We propose a new play activity intervention program for mothers and children. Our interdisciplinary program integrates four fields of child-related sciences: neuroscience, preschool pedagogy, developmental psychology, and child and maternal psychiatry. To determine the effect of this intervention on child and mother psychosocial problems related to parenting stress and on the children's cognitive abilities, we performed a cluster randomized controlled trial.Participants were 238 pairs of mothers and typically developing preschool children (ages 4–6 years old) from Wakakusa kindergarten in Japan. The pairs were asked to play at home for about 10 min a day, 5 days a week for 3 months. Participants were randomly assigned to the intervention or control group by class unit. The Parenting Stress Index (PSI) (for mothers), the Goodenough Draw-a-Man intelligence test (DAM), and the new S-S intelligence test (NS-SIT) (for children) were administered prior to and 3 months after the intervention period. Pre–post changes in test scores were compared between the groups using a linear mixed-effects model analysis. The primary outcomes were the Total score on the child domain of the PSI , Total score on the parent domain of the PSI , and the score on the DAM (for child cognitive abilities). The results of the PSI suggested that the program may reduce parenting stress. The results of the cognitive tests suggested that the program may improve the children's fluid intelligence, working memory, and processing speed.Our intervention program may ameliorate the children's psychosocial problems related to parenting stress and increase their cognitive abilities.UMIN000002265UMIN Clinical Trials Registry  Vygotsky regarded play as the supreme educative activity of the preschool years; play contains all developmental tendencies in a condensed form and play is, itself, a major source of development First, the play activities in the program were designed based on the standard cognitive tasks associated with prefrontal cortex (PFC) functions. This design was chosen because PFC functions are deeply associated with children's social and emotional development Second, we based the program design on the “zone of proximal development (ZPD)” and “scaffolding”, both concepts from preschool pedagogy and developmental psychology. Vygotsky defined the ZPD as “the distance between the actual developmental level as determined by independent problem solving, and the level of potential development as determined through problem solving under adult guidance or in collaboration with more capable peers” Third, we focused on the mother's emotional sensitivity to her child during the play activities. Our program was aimed at increasing positive mother–child interactions and reducing child and maternal psychosocial problems related to parenting stress. Parenting stress is not unusual; most parents experience it at some point Fourth, we made the program as undemanding on participants as possible. Bakermans-Kranenburg and colleagues We hypothesized that our program would improve child and maternal psychosocial problems related to parenting stress. Furthermore, we hypothesized that our play activities would increase the child's cognitive abilities. To test these hypotheses, we conducted a cluster randomized controlled trial.The study protocol was reviewed and approved by the Institutional Review Board of the Tohoku University Graduate School of Medicine. Based on the declaration of Helsinki, written informed consent was taken from each family.We recruited pairs of mothers and their children from a private kindergarten in Sendai, Japan. The inclusion criterion of this study was children aged 4 to 6 in the kindergarten and their mothers who consented on participating in this study. Two hundred and thirty eight pairs of mothers and children participated in this study. The children included of 115 boys and 123 girls, their ages ranging from four to six years old. The mean age of the children was 5.13 (SD = 0.586). The mean age of the parents was 33.78 (SD = 4.12). Fourteen children (8 children in the intervention group and 6 children in the control group) were raised in families where the father was absent. Two hundred and twenty four children were raised in dual-parent families. The exclusion criterion of this study was a current clinically severe illness or disorder which made it impossible to perform the intervention program. Additionally, no children in this study had histories of developmental disorders or psychiatric diseases.We ran the trial in accordance with the CONSORT statement The sample size of the present study was predefined as nearly the number of children in the kindergarten. The study was performed as part of the kindergarten curriculum, and we recruited children in the middle and the upper levels of Wakakusa Kindergarten.t-tests. We used a waiting-list control group design. After Assessment 2, the control group took the intervention program. This was done so that both of the groups could experience the program.Both groups participated in the same kindergarten curriculum and continued their usual daily lives at home. Only the participants of the intervention group were asked to participate in the play program for mother and child at home five days a week for the first three months. To measure the efficacy of our program, after pre-admission testing, there were two major assessment sessions identified as Assessment 1 and Assessment 2. The test battery, consisting of experimental cognitive tests for the children and questionnaires about parenting stress for the parents, was administered before (Assessment 1) and after (Assessment 2) the intervention group underwent the intervention program. Assessment 1 was conducted to confirm whether the two groups were equivalent before they participated in the program. We assessed the effectiveness of the program with the Assessment 1 – Assessment 2 changes between the two groups by the two sample The play program was made by the teachers of the kindergarten and the neuroscientists in our laboratory. The program consists of a set of play activities based on standard cognitive tasks used in previous neuroimaging studies. We intended to design the play activities to be associated with PFC as shown in the results of previous imaging studies. The contents of the play activities were updated monthly (four play activities per month).We made the program with consideration for the enhancing factors of scaffolding. Research showed that effective scaffolding has the following components and goals In order to become familiar with the activities, the children did the play activities of the program with their teachers and their classmates at the kindergarten before they played at home. After that, children were asked to take the initiative and teach their mothers how to do the play activities. Mothers were asked to play together with the children according to the children's initiatives. This program comprised four play activities each month. Those four play activities were selected so as to have different targets of the cognitive ability. Hand-outs of the play activities were also distributed to the mothers so they could perform the program correctly. In the hand-outs, the four play activities corresponded to four different colors; red, yellow, green, blue. The participants were given a calendar and 20 seals (i.e. 4 colors×5 times per one play activity) for each month. The children were asked to put the corresponding seal of a play activity on the calendar after they performed the activity. Every day the children were free to select the play activities they wanted to perform most out of the four. This calendar-seal system made it possible for the participants to perform the four play activities evenly every month. In addition, this system was performed to improve the participants' commitment to the program. However, we did not check the participants' calendars after this program.We made the load of this program as easy as possible on the participants since the meta-analysis of intervention studies for enhancing mother-child attachment revealed a lesser intervention load to be most effective We assessed child and mother psychosocial problems related to parenting stress and child cognitive abilities using the tests mentioned below.The PSI was used to assess child and maternal psychosocial problems related to parenting stress. The PSI is a self-reported questionnaire by parents and has been standardized with parents and children ranging in age from 1 month to 12 years in different cultures and is considered to be a reliable instrument across cultures The DAM is an international standard cognitive test for assessing child cognitive abilities. Children are instructed to draw a picture of man freely on a paper. Children's intelligence quotients are objectively assessed on the pictures they draw by the scoring system. This test was developed by Florence Goodenough under the assumption that individual differences in intellectual ability are reflected in the details included in a drawing of a human figure Vygotsky regarded cognition as a social phenomena The primary outcomes were “the Total score of the child domain”  and “the Total score of the parent domain” of the PSI . The secondary outcomes for child psychosocial problems related to parenting stress were the subscales of the child domain; Distractibility/Hyperactivity, Adaptability, Reinforces parent, Demandingness, Mood, Acceptability. The secondary outcomes for maternal psychosocial problems related to parenting stress were the subscales of the parent domain; Role restriction, Isolation, Spouse Competence, Depression, Attachment, Health).The primary outcome was Intelligence Quotient (IQ) in the DAM. The secondary outcomes were the subscales of the new S-S Intelligence Test (NS-SIT); “Understanding relationships”, “Understanding relationships between things”, “Counting and comparing numbers”, “Calculation”, “Completion of pictures”, “Working memory”, and “Processing speed”.At the kindergarten, we performed Assessment 1 and Assessment 2 for the children using a single-blind method. The subjects were assigned to 2 groups masked to the examiner of the assessments and to those who inputted the data and who rated the tests. During Assessment 1, two mothers from the intervention group and one mother from the control group who skipped some questions in the PSI were excluded from the analysis. One child from the intervention group was excluded for being absent from the assessment. Five children from the intervention group with defective answers in either the NS-SIT or the DAM were excluded (they went to the toilets or quitted to answer during the test). Three children from the control group with defective answers in the NS-SIT were also excluded . During Assessment 2, one mother from the intervention group and two mothers from the control group who skipped some questions in the PSI were excluded from the analysis. One child in both the intervention group and the control group was absent from Assessment 2. Two children who went to the toilets during the test in the NS-SIT were excluded. One hundred and fourteen mother-child pairs from the intervention group and one hundred and five pairs from the control group were analyzed for the assessments.We performed the fidelity assessment of this program for the intervention group in Assessment 2. We asked them, “How often do you perform this program?”. The participants selected one among the following alternatives, “1. Every day, 2. About once every two days, 3. About twice a week, 4. About once a week, 5. Less than once every ten days”.t-tests were performed. To assess whether there were any significant differences in the scores of Assessment 1 between the intervention group and the control group, two sample t-tests were performed. Changes in child and mother psychosocial problems related to parenting stress and in the children's cognitive abilities were assessed using linear mixed-effects models. The model analyses were constructed using the pre–post changes (i.e. the changes between Assessment 1 and Assessment 2) as dependent variables, group (intervention group and control group) as the fixed effect, and the kindergarten classes as the random effect. Statistical significance was set at p≤0.05. The effect size for between-group subscale changes was calculated using Cohen's d statistic To assess whether there were any significant differences in the children's and mothers' ages between the intervention group and the control group, two sample p = 0.28 and 0.86, respectively). None of the test scores showed a statistically significant difference between the two groups at Assessment 1  = 0.31 [95% confidence interval (CI): 0.18–0.45]). Another primary outcome, “Total score of the parent domain” showed no significant improvement in this program . The analyses of the secondary outcomes revealed significant improvement in the intervention group compared with the control group in the child domain subscales of “Mood” , “Adaptability to things” . In the parent domain, “Competence” showed significant improvement in the intervention group compared to the control group . The results of all subscales showed larger improvements in the intervention group than in the control group, with the exception of two subscales in the child domain, “distractibility/hyperactivity”  and “adaptability to people” ; and two subscales in the parent domain, “role restriction”  and “spouse” . According to these two subscales, the scores of the intervention group increased, and those of the control group decreased.“Total score of the child domain” which was one of the primary outcomes of child and mother psychosocial problems related to parenting stress showed significant improvement in the intervention group compared to the control group . In the NS-SSIT, the scores of the intervention group significantly improved in “Working memory”  and “Processing speed”  compared with those of the control group.Children's IQ in the DAM, the primary assessment of the children's cognitive abilities, was significantly enhanced compared with the control group  of the DAM. The IQ of the DAM is known to correlate highly with fluid intelligence The results of the NS-SIT showed that the scores of the intervention group significantly improved in “Working memory” and “Processing speed” compared with the control group.The improvement of WM in our program may have led to improvement of EF. This is because WM is one of the principal factors of EF. According to Miyake and colleagues, EF has three factors which correlate with one another: shifting of mental sets, monitoring and updating of WM, and inhibition of proponent responses The resulting improvement in “Processing speed” suggests that the program may enhance the children's processing speed (PS). PS heavily influences WM because memory processing and storage is time related The results of the enhancement of children's WM and PS in our program also lead us to surmise that the program may lead to enhance children's fluid intelligence. In Fry and Hale's model, ability change in PS increases the functional capacity of WM, which in turn facilitates fluid intelligence Children's play activities are greatly affected by their social and cultural background Van IJzendoorn revealed that child cognitive abilities are correlated with both attachment and communication p value of the statistical analysis revealed that the difference between the two groups was not significant.The scores of the control group improved more than did those of the intervention group in “Calculation” of the NS-SIT. However, the This program only takes about ten minutes per day. Without special training or education, mothers and children can enjoy the program. The load of performing this program is reasonably light. We believe that our program has the characteristics of a good public health program for improving child psychosocial problems related to parenting stress and thus preventing psychological and psychiatric problems and enhancing child cognitive abilities.There are many academic areas relating to children: brain science, preschool pedagogy, developmental psychology, child and maternal psychiatry, and so on. Each area has made remarkable advances. We think the integration of many academic areas is necessary for developing new viewpoints and stimulating progress in the various research fields relating to children. Such advancements would greatly benefit children and their families. As far as we know, this is the first investigation which examined a program for improving child psychosocial problems related to parenting stress and for enhancing child cognitive abilities using play activities by integrating brain science, preschool pedagogy, developmental psychology and child and maternal psychiatry.Although the play activities in our program were based on the standard cognitive tasks used in previous neuroimaging studies which are associated with PFC functions, we did not examine, using neuroimaging techniques, whether or not our program is really associated with PFC functions. Further investigations will be needed to demonstrate children's brain activities during participation in our program. It is also still unclear which factor contributed more to the effects of our program: the cognitive training or the positive parenting through the play activities. Our play activity program, which includes the characteristics of parents' sensitive emotional responses and cognitive training for children, can be regarded as an educational program package. Sensitive emotional response couldn't be excluded from our play activity program because it must exist in parent and child play activity programs from the viewpoint of preschool education. Therefore, sole examination of either the effects of cognitive training or parents' sensitive emotional responses could not be included in our present study.t-tests with 80% power at the two-sided significance level of 0.05, we determined that 158 pairs would be needed to detect a 0.45 standardized mean difference between the two groups in terms of the primary outcomes of Assessments 1 and 2. Because the mean number of children in this kindergarten class was 24.3, we used 24 as the mean class size for this estimate. Intraclass correlation (ICC) values are generally between 0.01 and 0.02 for human studies The participants in this study were recruited from the middle and the upper levels of a kindergarten, which determined the sample size. To arrive at a realistic estimate of the power of the study, we calculated the effect size to be 0.45 based on a previous meta-analysis The results of the assessment of participants' fidelity to this program revealed that about 20% of the participants performed the program at the frequency of once a week or less than once every ten days. Those participants can be regarded as having not performed the program. Since we did not ask the participants about their living conditions in the questionnaire, we cannot correctly discuss the reason why these participants could not perform the program. However, we guess that it is partly because some mothers work and could not set aside enough time for the program. How we can reach out to such people also should be investigated in the future.The present study involved multiple testing because the assessment tests used, the PSI and the NS-SIT, have several subscales. Multiple testing increases the risk of a type 1 error The measures of child and mother psychosocial problems related to parenting stress used in our study were based solely on the mothers' reports, and no independent observations were performed. It is not clear what aspect of the intervention was responsible for this program's effectiveness. We suggest, as mentioned above, that enhanced mother-child attachment and the cognitive abilities of children which were related to prefrontal functions played important roles in our results because those were the focuses of this program. Further investigations will be needed using measures of maternal sensitivity and behavioral changes, as well as observation measures.This emotional sensitivity focused program targeted solely on the mother–child relationship, and revealed the program effectiveness for the improvements of the child psychosocial problems related to parenting stress and parenting confidence. It can be regarded as a parenting support program. Previous studies indicated that parenting support programs involving fathers can impact on their parenting behaviors We developed this program using various types of play activities designed to enhance a variety of cognitive abilities rather than specific abilities. It is unclear to what extent this specific play activity intervention was responsible for the observed changes, or whether any daily 10-min play activity session would have been effective. Moreover, the preparatory run-through with teachers in the kindergarten may have been responsible for the changes. We proposed this program as an educational package, collaboration between the kindergartens and the families. Thus, we cannot distinguish between the contribution of the family and that of the kindergarten to our results. Further research is needed to identify which play activities were responsible for improving which cognitive abilities.The fidelity assessment suggested that only a minority of participants performed the intervention as planned (44% at least once every 2 days). However, the effect in terms of reducing parenting stress and enhancing the children's cognitive abilities was large. It may be that an improvement in emotionally sensitive parenting, rather than the daily play activities, was responsible for the reduction in parenting stress. Furthermore, performing the play activities daily in the kindergarten may be as important in increasing the child's cognitive ability as practicing them at home. The next step in our investigation is to identify the factors underlying the effectiveness of our program.The long term effects of the program are still under investigation. We intend to perform a two-year follow-up study. Our program was effective for typically developed children and their mothers. On the other hand, the effect of the program on mothers and children who have risk factors in their attachment to one another and in their mental health is still unknown. Further investigation should be conducted in the future.We propose a new play activity intervention program for mother and child integrating interdisciplinary areas for children, namely brain science, developmental psychology, preschool pedagogy and child and maternal psychiatry. To identify the effects of the program, we conducted a cluster randomized controlled trial. The results suggested that our intervention program may ameliorate children's psychosocial problems related to parenting stress as well as their cognitive abilities. It was also suggested that the program may help mother and child to develop a more positive attachment to each other and improve children's mood. In addition, the program may increase the mothers' self-assurance as parents. The present study reveals a new potential early childhood intervention using interdisciplinary knowledge to enhance child psychosocial development and to decrease parenting stress.Checklist S1CONSORT Checklist.(DOC)Click here for additional data file.Protocol S1Trial Protocol.(DOC)Click here for additional data file.Appendix S1The details of the program.(PDF)Click here for additional data file.Appendix S2The Parenting Stress Index mean score change in each class in the intervention and control groups.(PDF)Click here for additional data file.Appendix S3The Goodenough Draw-a-man Intelligence Test and the New S-S Intelligence Test mean score change in each class in the intervention and control groups.(PDF)Click here for additional data file.


Sport as a mechanism to build relationships across cultural boundaries and to build positive interactions among young people has often been promoted in the literature. However, robust evaluation of sport-for-development program impacts is limited. This study reports on an impact evaluation of a sport-for-development program in Australia, Football United®.A quasi-experimental mixed methods design was employed using treatment partitioning . A survey was undertaken with 142 young people (average age of 14.7 years with 22.5% of the sample comprising girls) in four Australian schools. These schools included two Football United and two Comparison schools where Football United was not operating. The survey instrument was composed of previously validated measures, including emotional symptoms, peer problems and relationships, prosocial behaviour, other-group orientation, feelings of social inclusion and belonging and resilience. Face to face interviews were undertaken with a purposeful sample (n = 79) of those who completed the survey. The participants in the interviews were selected to provide a diversity of age, gender and cultural backgrounds.Young people who participated in Football United showed significantly higher levels of other-group orientation than a Comparison Group (who did not participate in the program). The Football United boys had significantly lower scores on the peer problem scale and significantly higher scores on the prosocial scale than boys in the Comparison Group. Treatment partitioning analyses showed positive, linear associations between other-group orientation and total participation in the Football United program. A lower score on peer problems and higher scores on prosocial behaviour in the survey were associated with regularity of attendance at Football United. These quantitative results are supported by qualitative data analysed from interviews.The study provides evidence of the effects of Football United on key domains of peer and prosocial relationships for boys and other-group orientation for young people in the program sites studied. The effects on girls, and the impacts of the program on the broader school environment and at the community level, require further investigation. Australia accepts approximately 14,000 people either as refugees or on humanitarian grounds each year  - AustraPrevious studies have contended that sport may assist to build relationships across religious, ethnic and economic lines , as wellCoalter’s review of sport-for-development programs  found thThis article reports on the impacts reported by young people who participated in a school-based sport–for-development program, Football United, compared to those who did not participate, but attended schools in a similar setting . The stuThe Football United® program is a complex, multi-level football intervention targeted at young people in culturally diverse areas such as the western Sydney region with high levels of refugee settlement. The choice of football as the vehicle in this program was purposeful, as it is relatively inexpensive, is played in many countries, including those of many recently arrived young people with refugee experiences, and by both genders.The Football United program utilises a social-ecological framework, working with an awareness that heath and social behaviour is affected by, and in turn affects, the formal and informal social, cultural, physical and institutional relationships in which they are located -21. FootFootball United currently operates in a number of sites in Australia. There has been significant growth in the program’s reach and depth in recent years – it began in 2006 with one community park-based site and now has 13 program sites in New South Wales, with further sites in three other states in both urban and rural areas. The Football United sites evaluated in this study were based in Intensive English Centres (IECs) and Host High Schools where IECs are located in Western Sydney. IECs are part of the state school system and prepare newly arrived secondary aged students for study in an Australian high school by providing intensive English tuition. There are 13 IECs in Sydney, each attended by students from a broad geographic catchment area who are referred by their local high school. Students can spend up to five terms in an IEC before transitioning to their local high school.Students involved in Football United can play football after school at these sites, as well as access additional program components including training as football coaches, life skills and leadership development workshops. The program aims to promote participants’ health and well-being, social inclusion, connectedness, and cross-cultural engagement.The Football United program has four key focus areas:1. Football activities: Regular Saturday and after school training, school holiday camps, competitions and festivals are a central program activity. Mentorship between coaches, volunteers and players is actively promoted in all activities.2. Capacity building: Members of local communities participate in free training in coaching and refereeing, mentoring and life-skills, leadership and project management and apply their learning in the program. A significant proportion of young people who participate as players in the program continue with the program as volunteer or paid coaches and project coordinators.3. Building linkages: Linkages between program participants and partner agencies, including local football clubs, government, community and corporate sectors are a focus of the program.4. Creating awareness of Football United and issues for communities: This is achieved through advocacy, key partnerships and individual high profile champions.http://www.footballunited.org.au/Football United is coordinated by an overarching management team, with paid and volunteer coaches delivering the program at each of its sites and liaising with the community. Student participants who have completed coaching courses are eligible to coach junior participants on a voluntary basis. One or more school staff members act as coordinators and liaisons between the different sites, and the program management team. More details about the program can be found at This research study utilised a quasi-experimental mixed methods design and the methodological approach aligns with the socio-ecological framework underlying the Football United program. To effectively evaluate this program we needed to use a variety of measures at different levels of impact  and actiThe study was approved by the University of New South Wales Human Research Ethics Committee and by the State Education Research Approvals Process. This paper reports only on the data collected from young people. Relevant methods and measures are described below and details about the full study measures and approach have been published previously .The Football United study’s broad goal was to investigate the implementation of the program and to analyse processes and impacts on individual health and well-being, social inclusion and cohesion. The overall study had four aims and two hypotheses . The sinTo determine the impact of Football United on participants’ personal development, emotional health, resilience, social inclusion and peer relationships.Participants in the Football United Program will have significantly better emotional health, peer relationships and feelings of social inclusion than those who do not participate at all or who only participate minimally in the program.The study was a quasi-experimental design with treatment partitioning, which means the different groups compared in the study had a different level of exposure and involvement in the Football United program. This design was important to address the particular challenges of working with a study population that is always changing, with new Football United participants arriving regularly and moving locations, and with a program that had already been in operation for three years. These factors meant that a true baseline measurement was not possible and a study design with treatment partitioning represented the best approach to enable causal inference and protect internal validity . The appThe FUn Group comprised students from two IECs and their host high schools in Sydney, Australia who had participated in the Football United program prior to and during the study. The Comparison Group comprised recent arrivals to Australia who had attended an IEC or its host high school at two sites in demographically similar areas, and where Football United was not operating at the time of the study.All participants at the two Football United schools and all students at the two Comparison schools who had arrived in Australia as refugee or humanitarian entrants were eligible to participate in the overall research study. At Football United sites, the study was introduced to participants directly by IEC staff. At Comparison sites the study was introduced through staff and during school assemblies Particular attention was paid to align demographics as closely as possible between the two groups. For example, at one Football United site study participants included former IEC students who had entered Australia as refugee entrants who had transitioned to the host high school. The sample for the Comparison site was thus recruited accordingly to include some students who were now attending the host high school.The study population is vulnerable and some may have experienced trauma or persecution prior to arrival in Australia, sometimes in the form of governmental abuse. To be sensitive to this vulnerability, the research proceeded with an iterative model of consent that treated the process of ensuring consent as more complex than simply signing a form . This apThe complexity of the Football United program posed challenges for measurement and evaluation. Recognition that program impact is often not straightforward or linear  meant thhttp://www.footballunited.org.au/research/arc/research-questionnaire. The full survey was translated (and back-translated to assess accuracy) into Fasi and Dari, two key language groups represented among the study population. All three language versions were pilot tested with a small group of young people at Football United schools and found to be suitable for use with young people in IEC schools with little difficulty reported in completing the survey.A survey instrument comprising a composite of established measures was developed for the study . It measThe survey was administered with bilingual support as needed with the type of assistance recorded. After the first round of data collection with the FUn Group, the ethnic identity scale in the Multigroup Ethnic Identity Measure was removed from the survey . With wiA sub-sample of those who completed the survey instrument at all four schools also participated in an interview, often with one or more of their peers . The parThe study was enriched and strengthened by the use of two data sources: a survey and interviews as described above, and three different analyses: by group membership, level of participation, and qualitative analysis, each of which is described below. The findings of each analysis is presented in the results and then drawn together in the discussion. As suggested by the metaphor of triangulation, the confirmation of findings by two or more independent measurement processes greatly enhances confidence in the research findings .Descriptive quantitative analysis of the demographic characteristics of the FUn and Comparison Groups and univariate analysis of impact measures were undertaken. Two analyses were then undertaken to assess the impact of the Football United program. Firstly, an intention to treat analysis was undertaken to compare the outcome measures between young people enrolled at the participating intervention schools (regardless of whether they attended program activities or not) and those who completed the survey at the Comparison schools. Secondly, a treatment partitioning analysis was undertaken to explore the impact of no, lower or higher participation in Football United activities on the outcome measures. Analysis of Variance (ANOVA) was used for scale outcome measures and Chi-square tests for proportional outcome measures. In addition, factorial ANOVA was used to determine interactive effects of demographic variables on measured impacts.Qualitative interview data were transcribed in full with a unique identifier attached to each participant to allow comparison between survey and interview data. For each quote a brief descriptor is provided about the participant including whether they were from a Football United School (FS) or Comparison School (CS) and their gender. The quotes are taken from young people from a diverse range of countries, but country of birth has not been provided for each quote to protect anonymity. The overall qualitative data set was first analysed inductively and thematically with constant comparison undertaken, that is, comparison of the views of interview participants within and between schools . NVIVO 9Response rates to the survey for Football United schools’ were 76% site 1) and 54% (site 2) of all Football United participants in the survey year. At the Comparison schools the response rate was less important  as the sample was recruited to try to minimise difference in demographic characteristics between this sample and the FUn group, prioritising comparability over representativeness. The Comparison school sample frame was much larger than that at Football United schools as it included the whole IEC student population, versus a sub-set of IEC students at the Program schools who participated in Football United as the sampling frame. The larger sampling frame for the Comparison schools participants is therefore reflected in a lower calculated response rate. Participant demographic characteristics and immigrant experience are outlined in Table  and 54% Interviews were conducted with a sub-sample of participants in both FUn and Comparison survey groups. Interview participants ranged in age from 11–18, and had arrived in Australia from a diverse array of countries including Iraq, Iran, Afghanistan, Pakistan, Sierra Leone, Liberia, Sudan, Eritrea, Nepal, Burma and Thailand. The sampling focussed on selecting a diversity of students including girls. The FUn Group interview sample included 48 young people from 20 different countries of birth and included nine girls. The Comparison Group sample included 31 young people from 12 different countries of birth and included nine girls.24 = 9.5 p = 0.05). Only 13 young people in the survey sample completed the survey in Dari or Fasi with the remainder completing the survey in English. Most of the participants required little or no support with completing the survey, although bi-lingual support staff assisted 13 participants at the Program School and 18 at the Comparison School in completing the survey tool.Thirteen (13) young people from the Football United schools were recorded as not participating in any Football United activities  during the study year. Fifty (50) young people participated in at least one Football United activity during the study year (79.4%). On average, participating young people attended just over sixty percent (61.7%) of activities in each 10 week term for which they were registered as a Football United participant - regularity of attendance Table . During 2 = 0.31 p = 0.02; r2 = 0.32 p = 0.01 respectively). In interviews, participants in the FUn Group did not directly mention ‘feeling better’ since coming to Football United, but many talked about “having fun”  and “making friends” . The following quotes typify the kinds of comments made in interviews:The young people in the FUn group reported feeling better since commencing in the program Table , and repWhen I play soccer, I’m feeling like very nice, so nice. I can’t explain. Just that feeling’s so different. When I play soccer, I’m feeling so happy .Yeah, it helped me because I wasn’t know very much about football. I just go and they teach me how to play, and I got lots of fun for friends and playing, and jumping around, it’s so good And it’s fun like meeting new friends. People who we haven’t met before. The impact for all study participants, comparing young people from the FUn Group and Comparison Group, are outlined in Table 2,133 = 2.92 p = 0.004). This did not impact on group differences between the FUn and Comparison Group, however, due to the small number of girls in the FUn group, analysis of all impact was also conducted for boys only , boys mean 3.0 (SD2.3), t2,123 = 4.49 p < 0.001). This difference did not impact on differences between FUn and Comparison Group participants in impacts either overall or for male participants only.Outcomes were not significantly related to the number of countries the young people had lived in before Australia, the year they arrived in Australia, or having family, friends or people they know in the neighbourhood, either overall, for males participants only, nor when assessed for interaction effects with group membership, that is by FUn or Comparison Group. Reporting of emotional symptoms was related to refugee/asylum seeker experience, with those reporting refugee/asylum seeker experience reporting a higher score for emotional symptoms than those who did not (refugee/asylum seeker experience mean 3.6 (SD 2.4), no refugee/asylum seeker experience mean 1.8 (SD 1.5), tAnalysis was conducted using two forms of treatment partitioning to assess whether impacts were related to the total amount of participation in Football United or regularity of participation in Football United activities (or both). The three treatment partitioning categories of total participation were:a. No participation (n = 92), includes Comparison Group (n = 79) and FUn Group non-attenders (n = 13).b. Lower total participation (n = 25); total participation less than what would be received by a young person fully participating for 1.46 terms (14.6 weeks).c. Higher total participation (n = 25); total participation equal to or more than what would be received by a young person fully participating for 1.46 terms.The three categories of regularity of attendance were:a. No attendance (n = 92), as above.b. Less regular attendance (n = 25): average attendance in less than two thirds (66 percent) of the sessions per term for the terms in which the young person was registered in the Football United program. Each session is 2 hours meaning there are 20 hours of after-school playing activities offered per term.c. More regular attendance (n = 25): average attendance in equal to or more than two thirds of the sessions per term for the terms in which the young person was registered in the Football United program.2 = -0.18 p = 0.03). As above, analyses were also conducted for boys only. For boys, higher total participation had a significant linear association with lower (more positive) other-group orientation (r2 = -0.21 p = 0.03). More regular attendance for boys also had a significant linear association with lower scores (more positive) on peer problems and higher scores (more positive) on prosocial behaviour  other-group orientation .Yeah and it’s really fun, get to know people from other backgrounds, learn from them .I like to mix with different people. To know other things, what they do in their country and what they eat and stuff .Matrix queries in NVIVO found FUn Group interviewees, with lower and higher regularity of attendance, often talked about the value and benefit of mixing across cultures further supporting the findings around other-group orientation. Comparison Group and FUn group members interviewed who had not participated in any Football United activities didn’t talk much about other-group orientation, rather a number of them commented about being more comfortable with their own culture and language groups, for example:It’s a little bit hard because of the language, you know, we are not so good in speaking English like them so sometimes we find it difficult to make friends with them … so for now most of my friends from the same country .The FUn Group with no participation and some interviewees in the Comparison Group sometimes expressed a generalised sense of appreciation of a multicultural society:To me, the people, and you need to respect each other, countries, and where you're from, no matter where, who you are. You need to respect each other’s cultures and take that responsibility on yourself. Ensure you're not trying to change other people. Yeah .Some FUn Group interviewees also suggested that participation in Football United had prompted them to respect others as individuals, irrespective of their backgrounds. For example:Like we learn to respect other people no matter who they are .And it doesn’t matter who is it, where the player’s from you just play and have fun with him .Many interviewees in the FUn Group frequently referred to attendance at Football United as a means for them to find and make new friends and overcome peer problems, even those who didn’t attend regularly, as the following quotes demonstrate:We wouldn’t of made friends if we didn’t come to Football United .Yeah, before class they’d pick on us and stuff. But now from Football United we all come together .I think it was fun because when I first came here and I didn’t have friends and when I started soccer and that I get friends and more friends from high school .And it’s fun like meeting new friends. People who we haven’t met before. .The matrix query revealed a gradient in proactivity in peer relationships associated with regularity of attendance – those with low attendance in Football United speak of positive peer relationships, but do not report being as proactive in seeking and engaging in peer relationships as those with high regularity of attendance. The matrix query also revealed that peer problems were not very evident in FUn Group interviews – even amongst those with no participation providing some evidence that Football United’s presence at the school may have an impact on peer relationships at the school reflected in reduced reporting of peer problems.Comparison Group interviewees often talked about school as the main place that they had met friends. Some had made friends through playing sport at local parks as well as through attending church:I: Where do you meet friends? R: At school .I: Anywhere else?R: Probably just the school, and sometimes the park when we saw a lot of friend, because they want to play soccer and then come and just introduce us then we some friend there .There were a number of instances of Comparison Group interviewees talking about difficulties connecting with friends after school, as illustrated in the following excerpt:R: No, because I don’t go out of the home very much .I: Right. So you mostly just go from school to home?R: Yeah.A number of interviewees in both the FUn and Comparison Groups talked about bullying as a problem - their association with the IEC school and lack of proficiency with English were mentioned as catalysts for bullying as the quotes following show:Like everywhere is bullying, but here, people at high school always are fighting with us, and we don’t like to fight, so we are trying to find a high school where we are safe .Because they are like bullying, because we like in the IEC they think they can just bully us .Even though bullying appears to remain a problem in all schools studied, interviewees in one FUn Group interview observed that Football United had helped to improve the situation:They say when Football United haven’t start [school named] there’s always a fight between IEC students and the high school students but then when the Football United program started everyone started playing and started talking and try and make a friend, which is good stuff .In the interviews, a number of Football United participants reported enjoying helping and teaching others, especially those who had been in coaching roles, as illustrated in the first two quotes below. The value of student coaches from the participant perspective was also highlighted by some interviewees (last quote):R: It’s fun and when we learn good we can teach other people .I’d go coach the little boys. I really enjoyed that. It was nice, yeah. I had fun, too. I was laughing and – yeah, I think it was good that day .Student coaches, they learn more by like teaching other people [and] they know how it feels .An NVIVO matrix query revealed differences in prosocial behaviour between lower and more regular attenders of Football United with more regular attenders expressing prosocial behaviour in terms of leadership whilst less regular attenders talked more generally about helping and being helped as above. Regular attenders’ comments included life changing experiences and feelings, like those expressed in the following quotes:The most powerful experience I’ve ever had in my life is that leadership program, you know, that changed my life, that changed my thinking … you know, make good decisions… they give you a good opportunity for you to be a good leader in the community .I: You’re officially coaching … how does that feel for you?R: It feels amazing. I look after people, then the people listen to me in the game and stuff .There was some mention of prosocial behaviour in the interviews at Comparison schools, in response to more direct questions about how interviewees would help other new arrivals to the IEC school. The matrix query showed eight Comparison Group interviewees talked about being helpful, in general terms with only three students, who were student leaders in their schools, mentioning concrete examples of the types of prosocial behaviours measured in the survey. For exampleTo help them, when they arrived, I actually a student leader. So my job is to help the students, so when the other students come, I’m trying to be friendly for them .The resilience scale showed no difference between young people in the FUn and Comparison Group. In the qualitative interviews, participants were not specifically questioned about their response to change or adversity, and no experiences or feelings which showed ‘resilience’ in the way it was measured in the chosen scale were found in the data set for either Program or Comparison school interviewees.Young people in the FUn Group overall, and participating boys in particular, showed significantly more positive levels of other-group orientation than the Comparison Group, and some evidence (though lower in power and medium effects only) that the program positively impacted on peer problems and prosocial behaviour for boys. These quantitative results are well supported by the qualitative data from both groups and together the findings provide strong support for the effects of Football United on these key domains of peer and prosocial relationships for boys, and other-group orientation for young people in the program. The findings are of international significance as they show the positive impact of a sport-for-development program on important peer and social domains among young people using multiple triangulated methods .We did not find impacts on resilience, the reporting of emotional symptoms or hyperactivity. These non-significant findings are not illuminated by the interview data in which young people did not discuss these constructs in any detail. With a maximum score of five for resilience, both the Program and Comparison group samples have a high mean score on this scale, which may mean most of these young people already had a high degree of resilience given their experiences prior to arriving in Australia making this variable less open to change. In terms of emotional symptoms, we did find that girls reported a significantly higher score on emotional symptoms than boys, and the impact of the program on girls, including on emotional symptoms, is an area for further investigation given the small number of girls recruited for the present study.Treatment partitioning analyses indicated clear, positive, linear associations between other-group orientation and level of total participation in the Football United program, whilst reporting of peer problems and prosocial behaviour was associated with level of regularity of attendance. This is inherently logical if one considers attending regularly would be associated with fewer peer problems and better prosocial behaviour, but changing a person’s other-group orientation would require a large enough “dose” of positive exposure to other groups. Further, the greater the level of participation and regularity of attendance in Football United activities, the better participating young people reported feeling since commencing with the program. These linear associations suggest that the observed impacts are the result of the level of participation and attendance in the program, and not just the young people’s attendance at a Football United program school. It appears that the Football United program provides opportunities for many young people with a prosocial disposition to turn that disposition into actual behaviour – opportunities not generally available for the Comparison Group, except through things like school leadership programs which would only be available to a few newly arrived young people.In the published literature we found little robust evidence of the effects of participation in specific sport-for-development programs on the participants themselves, which echoes other researchers’ conclusions about the paucity of evaluation studies . We founEvaluation studies of sport-for-development programs focus almost exclusively on concepts such as social capital and often pay little attention to the effects on participants’ relationships with each other ,44. In tStudies of sport-for-development programs generally do not focus on evaluating prosocial behaviour as a specific impact, though programs may aim to foster these behaviours ,44. TherOther-group orientation has been much less studied as a concept than ethnic identity in adolescent and migrant studies in general . We founThe effects of Football United on the school environment in general, beyond just for those who directly participated in the program, is supported by some of our findings. In particular, a lack of peer problems was reported by some interviewees who were enrolled, but did not participate in any Football United activities. But there was also evidence that bullying was a problem at all schools. There is a need for further research to look at broader school level impacts of program such as Football United as school is a critical social field for young people in general and for early settlement .There was no evidence of impact on the general measures of neighbourhood social inclusion used in our study. The data from the FUn Group revealed that the students lived in a number of neighbourhoods, some very geographically distant from the IEC school they attended. The finding that there was no difference on social inclusion variables, which were focussed on the neighbourhood level, is therefore not surprising. The social inclusion variables may therefore be considered to better represent each young person’s broader experiences rather than a possible outcome of the program. These measures may still be useful in evaluating other programs if most of the young people in a sport-for-development program reside in close proximity to each other .Gender significantly impacted on reporting of emotional symptoms overall, with girls reporting a higher score than boys. Being more anxious and unhappy (the types of emotions we measured) may impact on girl’s engagement with Football United. Cultural barriers regarding girls’ engagement in sport in general, and with boys specifically, were noted as reasons for minimal female participation at the study sites and are prominent issues raised in the literature . HoweverThere were some study limitations and methodological changes made during the study conduct that are important to note. The power of the quantitative analysis of impacts was limited by the number of participants. The number of participants was limited to the number of young people participating in the Football United program at the sites chosen in the main study year - 2011. Further, study outcome data were only collected at one point in time, and program participation data for the one study year. Although treatment partitioning analyses were undertaken to assist in attributing impacts to participation in the Football United program, the time period for the study meant that it was not possible to determine whether other impacts (positive or negative) may result from longer participation in the Football United program, nor whether the impacts achieved would be sustained. As noted in the literature, many programs depend on “insecure and time-limited resources” (p133) . FootbalThe composite survey instrument was developed with significant attention to previous use of included instruments in Australia and among different language and cultural groups  and about the Football United program (for FUn Group only) could have been a factor. Specific techniques were used in interviews to lessen this effect and the finding that many qualitative comments supported the significant effects found using validated and reliable survey instruments gives more confidence that the interview comments reflected young people’s views and experiences not simply a desire to be liked and to say what may have been perceived as desirable. The triangulated methods also gives support to the accuracy of the assisted interpretations by the bi-lingual workers which occurred at some points during the qualitative interviews with a number of participants and was provided for some participants in completing the survey. The trust and rapport between bi-lingual staff and the participants (the staff work with these students daily to support them in learning English), was seen as a strength of the interview process. Trust and rapport with support staff would likely have enhanced the communication of young people’s experiences, moreso than would have been achieved with external translators who would not have an ongoing relationship with, or understanding of the experiences of the participants. A second interview was also originally proposed with the Football United students to examine experience of the program over time. However, this second interview was not undertaken for two key reasons. Firstly, the difficulty in arranging consent and scheduling a single interview which impacted on school staff time more than expected. Secondly, the data from the first interviews, which included students with a range of times of involvement in Football United, was judged by the team to have provided sufficient insight into young people with differing levels of exposure and time in the program.We agree with other scholars that no one program can address the broader macro structural factors which exclude individuals and communities from equal opportunity in sport and other life endeavours ,48. HoweThe impacts on reported peer relationships, prosocial behaviour and other-group orientation from the Football United study are of international significance and point to the need for other sport-for-development evaluation studies to include these variables in their measures. Further analysis is also needed to examine which program elements contribute most to these effects and how elements, such as specific training and mentoring, may foster these behaviours and attitudes. A specific focus on engaging girls in sport-for-development programs and evaluating these efforts is recommended. Much has also been learned through the research about appropriate approaches to evaluation that can help researchers capture the complexity of sport-for-development programs.ABB and TS were involved in program delivery in the study year. The other authors declare that they have no competing interests.SN, LK, ABB, CE and JM all participated in the study conceptualisation and refinement of the design and measures. JM, CE and SN were involved in data collection. ABB and TS were involved in program delivery in the study year. LK analysed quantitative data with support from TS. JM undertook initial qualitative analysis with support from SN. All authors participated in the refinement of the qualitative data analysis and presentation in the paper. SN, LK , JM and ABB drafted the paper with SN leading the drafting and revision process. All authors have read, commented and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/13/399/prepubInstruments and items chosen for survey and rationale for choosing.Click here for file


Early detection and intervention in schizophrenia are important in improving quality of life after treatment and are major issues in psychiatric care. Therefore, it is necessary to increase knowledge of schizophrenia among the general public. Among parents of junior and senior high school students in Japan, we compared rates of correct answers for items on knowledge of schizophrenia and ability to discriminate this psychosis from other disorders on questionnaires given before and after viewing a web-based education program.Questionnaires were distributed to 2,690 parents. The program was developed to help parents obtain a basic understanding of schizophrenia and to emphasize the necessity of early detection.P < 0.001 for all).Before the program, the rate of correct answers was 77% for items concerning basic knowledge of schizophrenia, 47% for "discrimination of schizophrenia symptoms," and 30% for "discrimination of prodromal symptoms." The program resulted in an improvement in basic knowledge of schizophrenia, discrimination of schizophrenia symptoms, and discrimination of prodromal symptoms (Our web-based education program was useful in helping parents acquire a basic knowledge of schizophrenia and discriminate correctly the symptoms of schizophrenia. Delayed detection of schizophrenia and the resulting prolongation of the duration of untreated psychosis (DUP) are viewed as serious issues in the mental health field -3. The mStudies have revealed a number of important factors related to delayed detection of schizophrenia -13. One Providing accurate information on schizophrenia is essential in preventing delays in diagnosis. In particular, parents of adolescents need to have sufficient knowledge of the disorder so they can identify an initial episode in their children. The onset of schizophrenia is typically between ages 15 and 25 years in males and between ages 25 and 35 years in females . HoweverIn recent years, several sophisticated educational programs have been developed to provide basic information, under appropriate conditions, on schizophrenia and its associated behaviours to various populations -17. HoweThe participants were extracted from a large database of 1,370,000 candidates that is administered by a Japanese private company specializing in questionnaire research. First, we extracted 44,000 parents of junior and senior high school students, all registered in the database. Second, gender and region were used as variables for stratified random sampling. Finally, 5,000 final candidates were extracted. Thus, the gender and region distributions of our sample were almost identical to those of the Japanese general population. Of the 5,000 candidates, 1,410 parents of junior high school students and 1,280 parents of senior high school students participated in this survey (the "first survey"). All respondents completed a questionnaire on an internet website that was newly developed for this study by the survey company. To evaluate the reliability of the first survey, we performed another survey of basic knowledge of schizophrenia and ability to discriminate it from other disorders in the same manner as the first survey. We used the same questionnaire for a different sample of 735 individuals who had not viewed our web-based education program (the "second survey"). All respondents were Japanese adults living in Japan. The study was approved by the medical ethics committee of Niigata University.Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria for schizophrenia and the PRIME Screen [The questionnaire used in the present study consisted of 3 sections. Section 1 collected demographic information on respondents including age, occupation, education attainment, and family structure Table . SectionE Screen . The PRIAfter the "before" questionnaire survey was conducted, all respondents were invited to view a web-based education program that had been developed to increase understanding of schizophrenia, after which the "after" questionnaire survey was conducted using the same questionnaire for the same respondents. The content of the education program consisted of 10 units: (1) characteristics of schizophrenia, (2) causes of schizophrenia, (3) symptoms of schizophrenia, (4) classification of schizophrenia, (5) course of the disease and its characteristic clinical features, (6) treatment of schizophrenia, (7) prognosis, (8) how to prevent progression and exacerbation of the disorder, (9) signs of progression, and (10) consultation facilities.The slide show included 12 slides with narration and required 13 minutes to complete. The media were delivered via the same internet website that was used for the questionnaire survey. The effectiveness of the education program was evaluated by the same respondents 1 week later.P < 0.05.All analyses were performed using the Statistical Package for the Social Sciences (SPSS) version 16.0. McNemar's test was used to compare the proportion of specific answers in paired data, that is, the results of the "before" and "after" questionnaires for each respondent. An unpaired t-test and analysis of variance (ANOVA) were used to compare the effect of the web-based education program on basic knowledge of schizophrenia and the ability to discriminate it from other disorders among several groups of demographic characteristics. The endpoint was the correct answer score, calculated by dividing the sum of the differences between the answers (correct = 1 and incorrect = 0) for the "after" questionnaire and those for the "before" questionnaire for all respondents by the number of items (i.e. 14). All statistical tests were 2-tailed, and statistical significance was defined as In total, 2,690 of the 5,000 individuals completed the "before" questionnaire, and 2,465 completed the "after" questionnaire after viewing the education program. Mean age ± standard deviation at questionnaire completion was 45.9 ± 4.7 years, and approximately 71% of the respondents were in their 40 s . Although the methods, participants, and results for education programs differ, many previous studies have shown that basic knowledge of schizophrenia is improved by such programs. Comptom et al. showed that a 40-hour training program for a crisis intervention team of 159 police officers in Atlanta resulted in a relative increase of 16%, from an average of 6.4 to 7.4 points, on a survey of general knowledge regarding schizophrenia [n = 114) of students scored 80% or higher on items related to basic knowledge. This improved to 78.8% (n = 260) of students on the post-test (P < 0.001). As in other studies, enrolment of subjects in the present study was limited. In previous studies, family advocates and mental health consumer groups participated in the education program. In addition, those studies used the real-life experiences of individuals with schizophrenia to illustrate the educational concepts, a method that differs from the one used in the present study.We attempted to measure participants' basic knowledge of schizophrenia. On the "before" questionnaire, the rate of correct answers for this section was 77%, indicating that the parents of junior and senior high school students were already knowledgeable about schizophrenia before viewing the education program. The education program resulted in a small improvement in basic knowledge, an increase of 3% . In the present study, the rates of correct answers for items on prodromal symptoms and symptoms of schizophrenia were 30% and 47%, respectively, on the "before" questionnaire. These rates are not high, indicating that Japanese parents of adolescents are unable to discriminate the symptoms of schizophrenia from those of other disorders. Most individuals who develop schizophrenia experience a prodromal stage. In this phase before the initial psychotic episode, many symptoms may be present, including depressed mood, anxiety, irritability, changes in volition, cognitive changes, physical symptoms, behavioural changes, impaired tolerance to normal stress, and attenuated psychotic symptoms. However, common early prodromal symptoms are generally non-specific  which foFinally, the present education program might be useful in testing parents of junior and senior high school students from other countries. Findings from such studies would aid in revising the questionnaire.Our web-based education program was useful in helping parents to acquire a basic knowledge of schizophrenia and discriminate correctly the symptoms of this disorder. The education program can be completed in only 13 minutes. Implementation of our program for parents could assist in early detection and subsequent intervention for schizophrenia.The authors declare that they have no competing interests.HY and KA designed the study and drafted the manuscript. YW, HK, and JC made significant contributions to the content of the paper and were responsible for the final editorial revision. All authors read and approved the final manuscript.1. The person is not able to take a train because of a racing heart, feeling smothered, dizziness, and/or cold sweats.2. During the third session, the patient becomes frightened, locks the door, and reports being chased by a spy.3. The person feels weak, has a fever and mouth sores, as well as a rash over their entire body.4. I think I might feel like my mind is 'playing tricks' on me.5. The levels of the person's shoulders are different.6. The person will not talk to their parents, takes a defiant attitude toward them, and seems to be hiding something.7. I believe that I have special natural or supernatural gifts beyond my talents and natural strengths.8. The patient has refused to eat for several weeks saying that the food may be poisoned.9. The person has complained for quite a long time, saying that the TV or newspaper is reporting something bad about them.10. The person is not able to feel enthusiasm because of depression and feels that life is hopeless. Also, the person is not able to sleep and has no appetite.11. The person is not able to make decisions without help and is intimidated by parents or teachers.12. The person persists in excessive dieting to decrease or maintain body weight.13. I have thought that it might be possible that other people can read my mind, or that I can read other's minds.14. The person suffers repeated abdominal pain or diarrhoea both while commuting by train to school and at school.15. During summer vacation, the person could be heard arguing, although no one else was present.16. The person has started coming home late and disobeying their parents.17. I think that I may get confused at times whether something I experience or perceive may be real or may be just part of my imagination or dreams.18. The person has started eating much more meat than vegetables.19. There is no validity in the above-mentioned items.We performed a retest of basic knowledge of schizophrenia in the same manner as the first survey. We used the same questionnaire for a different sample of 735 individuals who had not been exposed to our web-based education program. Demographic characteristics of the respondents and the rates of correct answers are shown in Tables The distributions of demographic characteristics are almost identical to those in Table The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/11/323/prepub


Based on the consolidated data with schools as units, results showed that participants generally had positive perceptions of the program, implementers, and benefits of the program. The subjective outcome evaluation instrument was found to be internally consistent. Multiple regression analysis revealed that perceived qualities of the program and the program implementers predicted perceived effectiveness of the program. The present study provides support for the effectiveness of the Tier 2 Program of the Project P.A.T.H.S. in Hong Kong.The Tier 2 Program of the Project P.A.T.H.S.  is designed to help students with greater psychosocial needs. This paper examines nine sets of subjective outcome evaluation data collected from 2005 to 2009 ( The Project “P.A.T.H.S. to Adulthood: A Jockey Club Youth Enhancement Scheme”  is a large-scale positive youth development program designed for junior secondary school students  in Hong Kong . There aBesides building up psychosocial competencies in adolescents via the Tier 1 Program, students with greater psychosocial needs are helped via the Tier 2 Program. Because research findings suggest that roughly one-fifth of adolescents need more help, the Tier 2 Program is provided for at least one-fifth of the students who display greater psychosocial needs at each grade  by the school social work service providers. The researchers deliberately avoid using the term “at risk” because the term is very stigmatizing in the Chinese culture, and it deters parents and students from joining the related programs. The Tier 2 Program (Selective Program) targets adolescents with greater psychosocial needs who are identified in the Tier 1 Program and/or via other sources. Students with greater psychosocial needs usually have special needs in the academic, personal , interpersonal, and familial domains. Information based on multiple sources, including objective assessment tools , teachers' ratings, student records, and other relevant quantitative and qualitative information based on systematic assessment, is used to identify students for the Tier 2 program.Services based on the Tier 2 Program were provided for students who were identified as having special needs. Some schools also involved the parents of these students. To create more flexibility for the workers with reference to the specific needs of the students in the unique school context, the applicants  had the choice of designing appropriate programs that target the needs of the students with reference to the 15 positive youth development constructs maintained in the project, as well as goals and objectives covered in this project . SeveralIn a pioneering study of the subjective outcome evaluation of the Tier 2 Program (Secondary 1 level) students in the Experimental Implementation Phase carried out in 2005/2006, the first author and colleagues  conducteIn the first year of the Full Implementation Phase (2006/2007), 10,255 participants (Secondary 1 level) from 207 schools joined the Tier 2 Program. Shek and Sun , a repliThe quality of the program and the workers implementing the program are important determinants of program effectiveness. Nation et al.  pointed Regarding the different modes of Tier 2 Programs, although previous studies showed that ABC and VTS were the two major modes involved –13, compThe second major mode of Tier 2 Programs is closely related to VTS. According to Clary et al. , there aThis paper presents and discusses the findings of a multicohort subjective outcome evaluation of the Tier 2 Program implemented in the Experimental and Full Implementation Phases of the P.A.T.H.S. Project. A total of nine cohort studies were implemented between 2005 and 2009 based on the perspective of the participants. Besides describing the profile of responses based on subjective outcome evaluation, the relationships between perceived quality of the program and program implementers and perceived program effectiveness were examined. Furthermore, whether participants who joined different programs differed in their evaluation of the program would be examined. It is noteworthy that although it is very common for social work agencies to design programs for adolescents with greater psychosocial needs , systematic evaluation and documentation of program evaluation have been rarely found in the local social work literature .From 2005 to 2009, the total number of schools that participated in the Project P.A.T.H.S. was 244. Since each school joined the Project for 3 or more years, the total number of “schools” as units of analyses was larger than 244. There were 669 schools in the Secondary 1 level, 443 in the Secondary 2 level, and 215 in the Secondary 3 level. Among them, 46.27% of the respondent schools adopted the full program , whereas 53.73% of the respondent schools adopted the core program . Altogether, 93,001 participants  joined the Tier 2 Program. Among these participants, 83,378 were student participants identified by teachers, parents, and/or self-administered questionnaires as having greater psychosocial needs, and 9,623 were their parents and teachers. The mean number of participants per school was 65.62 . The mean number of sessions used for implementing the program was 22.36 (range: 1–120). The basic characteristics of the participants in the different datasets can be seen in After completing the Tier 2 Program, the participants were invited to respond to a Subjective Outcome Evaluation Form (Form C) developed by the first author . In addiOn the day when the evaluation data were collected, the purpose of the evaluation was mentioned, and the confidentiality of the data collected was repeatedly emphasized to all of the respondents. The respondents were asked to indicate if they did not want to respond to the evaluation questionnaire . All respondents responded to all scales in the evaluation form in a self-administration format. Adequate time was provided for the respondents to complete the questionnaire.The Subjective Outcome Evaluation Form (Form C)  was usedparticipants' perceptions of the program, such as program design, quality of service, appropriateness of the program, and interaction among the participants (8 items),participants' perceptions of the workers, such as the preparation of the workers, professional attitude and knowledge, and interaction with the participants (8 items),participants' perception of the effectiveness of the program, such as promotion of different psychosocial competencies, resilience, and overall personal development (8 items),things that the participants appreciated most (open-ended question),opinion about the workers (open-ended question),things that the participants learned from the program (open-ended question),areas that require improvement (open-ended question).For the quantitative data, the implementers collecting the data were requested to input the data into an EXCEL file developed by the research team that would automatically compute the frequencies and percentages associated with the different ratings for an item. When the schools submitted the reports, they were also requested to submit the soft copy of the consolidated datasheets. After receiving the consolidated data by the funding body, the data were aggregated in order to “reconstruct” the overall profile based on the subjective outcome evaluation data by the research team. Only quantitative data based on the rating scale items were examined in this study.Percentage findings were examined using descriptive statistics. A composite measure of each factor  was created based on the total scores of each factor divided by the number of items. Pearson's correlation analyses were performed to examine if the program content and program implementers were related to the program effectiveness. Multiple regression analyses were performed to test if and how well each factor would predict the program effectiveness. All analyses were performed by using the Statistical Package for Social Sciences Version 17.0.The characteristics of the Tier 2 Programs implemented from the 2005/2006 to the 2008/2009 school year can be found in The quantitative findings based on the closed-ended questions are presented in this paper. Several observations can be highlighted from the findings. First, the participants generally had positive perceptions of the program . On the α = 0.99 for Secondary 1 through 3 participants), 8 items related to the implementer , 8 items related to the perceived benefits (α = 0.99 for Secondary 1 through 3 participants), and the 24 items measuring overall program effectiveness (α = 0.99 for Secondary 1 through 3 participants). Results of correlation analyses showed that both program content  and program implementers  were strongly associated with program effectiveness . Second, perception of program content was a stronger predictor for program effectiveness (β ranged from 0.59 to 0.65) than perception of program implementers (β ranged from 0.36 to 0.41). Third, the models explained a large amount of the variance toward the prediction of program effectiveness across grade levels.Regarding possible differences among the different types of programs on different measures of subjective outcome evaluation, results of MANOVA did not show any significant difference among the four types of programs on participants' views on the program, their views on program instructors, as well as their perceived effectiveness of the program. The mean scores of the key variables for the four different types of programs can be seen in The current study examined the Tier 2 Program of the Project P.A.T.H.S. in terms of participants' subjective perceptions of the program, the instructor, and effectiveness of the program based on nine datasets. There are several unique characteristics of the study. First, a large sample size was used. Second, several datasets collected over time were utilized. Third, a reliable measure of subjective outcome evaluation was employed to carry out subjective outcome evaluation. Fourth, this is the first known scientific study utilizing such a large sample to examine the perceived effectiveness of youth development programs developed for adolescents with greater psychosocial needs. Differences across cohorts were not specifically focused upon because there was nonindependence of observations across time.Several observations can be highlighted from the present study. First, results showed that the various measures derived from Form C were internally consistent. With reference to the comments of Royse  that theSecond, high proportions of the participants perceived the program in a positive light. Most of the respondents had favorable perceptions of the program and workers implementing the program; roughly four-fifths of the respondents perceived the program to be beneficial to their own development. These observations generally suggest that the Tier 2 Program was perceived positively by the program participants and they felt that the program was helpful to them. These findings are also consistent with those findings emerging from the separate analyses in the Experimental and Full Implementation Phases suggesting that the Tier 2 Program is beneficial to the program participants. Of course, these positive findings should be viewed together with the limitations of subjective outcome evaluation, such as demand characteristics and halo effect. If resources permit, studies attempting to examine the convergence of objective outcome evaluation findings and subjective outcome evaluation findings should be carried out.Third, consistent with our expectations, participants' perceptions of the program were positively correlated with perceived benefits of the program. Similarly, participants' perceptions of the program implementers were positively correlated with perceived benefits of the program. These findings basically suggest that the quality of the program and program implementers are intimately related to perceived benefits of the program. Because there are few studies examining the correlates of program effectiveness based on a subjective outcome evaluation approach in the Chinese culture, the present findings can be regarded as pioneering additions to the literature , 38, 39.The present findings give some insights into the differences in subjective outcome evaluation findings across different programs. The findings showed that there were no differences between the different types of programs in the Tier 2 Program. Although ABC has a long history in Hong Kong and it has been formally adopted as the major program theory for a huge social intervention program entitled “The Understanding the Adolescent Project” (UAP) to combat the problems among students identified as adolescent at risk from 2001 to 2004 in Hong Kong , 41, verFinally, the design and implementation of the Tier 2 program largely accomplished the six general characteristics of effective prevention efforts proposed by Flannery : (1) focIn the area of human services, subjective outcome evaluation is commonly used –45, and To sum up, the present study provided a general picture of the implementation and subjective outcome of the Tier 2 Program of the Project P.A.T.H.S. from the perspective of the participants based on a series of studies in the Experimental and Full Implementation Phases. The study evidenced the worth of the Tier 2 Program in that it is perceived positively by almost all the participants. In addition, both program content and program implementers were found to be predictors of perceived effectiveness of the program. Finally, program type was found to be unrelated to the different domains of subjective outcome evaluation findings. These findings have important implications for the design of positive youth development programs in the future. In conjunction with other evaluation findings , 47–50,