Coccidioides antibody and Meridian Premier Coccidioides, look for the presence of anticoccidioidal IgG and IgM in patient sera that are diluted 1:441. Per regulatory requirements, this dilution step must be verified with a dilution step control despite not being provided as a reagent in either FDA-approved EIA kit. Therefore, clinical laboratories collect and reuse patient sera in subsequent tests that had a positive result in a previous test. This is a nonstandard process, reinforcing the need for a consistent and reliable dilution control. Here, we evaluate the performance of a humanized IgG and IgM antibody as a dilution control in both EIA kits. Both humanized IgG and IgM work well in each EIA and meet the appropriate threshold for positivity.Coccidioidomycosis, also called valley fever (VF), is a fungal infection with endemicity in desert regions of the western United States as well as certain arid regions of Central and South America. Laboratory-based diagnosis of VF often relies on the composite results from three serologic-based diagnostics, complement fixation, immunodiffusion, and enzyme immunoassay (EIA). EIA is commonly performed in clinical laboratories because results can be obtained in a few hours. Two commercially available EIAs, IMMY clarus IMPORTANCE In southwestern and western regions of the United States, at least half a million diagnostic tests for coccidioidomycosis  are run annually. Enzyme immunoassays (EIAs) are blood tests which require precise dilution of patient serum prior to testing. To ensure patient serum is properly diluted, there is a regulatory requirement to ensure the dilution step is accurate. Two FDA-approved EIAs used to aid in the diagnosis of coccidioidomycosis do not contain controls for this dilution step, leaving clinical laboratories with the only option of using previously positive patient sera, which may not react in a reliable or predictable manner. Here, we evaluate a humanized monoclonal antibody against a coccidioidal antigen and its utility as a dilution control in both available commercial EIAs. The use of a humanized monoclonal antibody provides a standardized and well-characterized dilution control for use in serological assays that aid in diagnosis of coccidioidomycosis. Coccidioides spores , is a fungal infection endemic in dry areas throughout the Americas caused by the inhalation of s spores , 2. Dises spores –5. Those spores –, 7. LessCoccidioides or microscopic identification of the spherule form of the fungus in clinical specimens , and even in the case of confirmed coccidioidal meningitis, recovery from cerebrospinal fluid did not exceed 50%  and complement fixation (CF) antigens, against which immunocompetent VF patients form IgM and/or IgG antibodies  and clarus Coccidioides antibody EIA . In both test kits, patient serum is diluted 1:441 for screening per manufacturer instructions. It is a Clinical Laboratory Improvement Amendments (CLIA) regulation that clinical laboratories run a dilution control alongside patient serum to ensure correct operation  and truncations of rCTS1 have been tested to measure anti-CF antibodies in VF patient serum using an EIA format , 17, 18.peration . HoweverMeridian . This fiMeridian  in both Coccidioides antibody EIA at a concentration as low as 0.25 μg/mL, while P-4H2 IgM met the cutoff for positivity when used at a concentration greater than 1 μg/mL  P-4H2 IgG and P-4H2 IgM were shown to bind as predicted in the two commercially available EIAs that are used to aid in the diagnosis of coccidioidomycosis. Both EIAs are FDA approved; however, neither kit includes dilution controls for IgG or IgM so that laboratories can satisfy the CLIA requirement of diluting patient samples in the same manner as known IgG and IgM controls. To meet this requirement, clinical laboratories must collect and reuse patient sera that were previously IgG and IgM positive for use as dilution controls in subsequent runs. This may prove problematic not only because the stored serum is a limited and finite source but prolonged storage may lead to decreased reactivity on EIA and, subsequently, invalid results if the positive cutoff threshold is not met. Additionally, an error such as a misdilution  may be difficult to detect using patient serum as the dilution control since this would still produce a positive result. Inclusion of standardized dilution controls at a known concentration would result in an expected optical density range so that if the result falls outside that range, a dilution error may have occurred, and the test should be repeated. Ultimately, reuse of previously positive samples is a nonstandard practice and is not included in manufacturer instructions.Coccidioides EIA provides microwells coated with antigens that are used for both IgG and IgM detection, which are differentiated with the enzyme-conjugated secondary antibody used, either anti-human IgG or anti-human IgM. In contrast, the IMMY clarus Coccidioides EIA provides separate microwells coated with different antigens (termed “CF antigen-coated” and “TP antigen-coated” microwells) in addition to anti-human IgG and IgM enzyme-conjugated secondary antibodies for use only on their respective wells. The antigenic contents of the CF- and TP-antigen coated wells are proprietary; however, the lower reactivity of P-4H2 IgM on the IMMY TP antigen-coated wells suggests that there is less CTS1 present on these wells, as P-4H2 IgG and IgM bind specifically to CTS1/CF antigen.Our results showing that recombinant plant-produced anti-CTS1 humanized MAbs can serve as dilution controls for both IMMY and Meridian EIAs suggests that CTS1 is a major component of the antigen preparations used in the EIA kits. The Meridian Premier Coccidioides CFID and TPID antigens distributed by IMMY, while CTS1 was not detectable in Meridian’s Coccidioides “TP” immunodiffusion (ID) antigen  to CTS1, were cloned, sequenced, and genetically fused into human IgG and IgM Fc-containing plasmids to form a chimeric mouse V-region–human Fc region antibody construct, previously detailed . The chilsewhere , 24. TheCoccidioides EIA and IMMY clarus Coccidioides antibody EIA according to the instructions and reagents provided in each kit. Meridian’s EIA kit contains the same microtiter wells for both IgG and IgM screening, while IMMY’s EIA kit contains two types of microtiter wells, CF antigen-coated wells for IgG screening and TP antigen-coated wells for IgM screening. Briefly, 2-fold dilutions ranging from 8 μg/mL to 0.25 μg/mL of P-4H2 IgG and IgM were prepared in 1× specimen diluent and incubated in microtiter wells for 30 min alongside positive and negative controls provided with each kit. IMMY kits also contain a calibrator cutoff solution that is used to establish the cutoff signal used to calculate EIA units. Plates were washed three times with freshly made 1× wash buffer followed by addition of corresponding anti-IgG or anti-IgM conjugated antibody, also provided with each kit. After 30 min, plates were washed three times, and the substrate was added. The Meridian EIA was allowed to develop for 5 min before addition of stop solution, while the IMMY EIA developed for 10 min before addition of stop solution. Results of the Meridian EIA are reported as optical density at 450 nm (OD450) values, while IMMY results are reported in EIA units calculated using the provided CF or TP calibrator cutoff.P-4H2 IgG and P-4H2 IgM were tested in Meridian Bioscience Premier The amount of CTS1 in commercial antigen preparations used for immunodiffusion was quantified using our previously published assay  in order


The prevalence of childhood overweight and obesity among children is on the rise around the world. Meanwhile, comprehensive multi-sectorial approaches have been found to be effective in improving nutritional status among children. Ajyal Salima is a public–private partnership (PPP) school-based nutrition and physical activity intervention program implemented in six Arab countries. Its objective is to promote healthy eating and physical activity habits among 9–11-year-old students. The stakeholders, involved with the implementation of the program, comprised (1) local authorities, ministries of Education and Health, and non-governmental organizations (NGOs) as public partners, (2) The American University of Beirut (AUB) as the academic/regional scientific partner, and (3) Nestlé as the private partner. The Ajyal Salima program encompasses four coordinated educational components: classroom sessions, family involvement, food service intervention, and training of trainers. The program's educational material has been culturally adapted to each country's needs, as well as pilot tested. This paper describes the strategies used to build the PPP framework of Ajyal Salima, and the role of each stakeholder. The Ajyal Salima program is an example of a promising and sustainable comprehensive PPP program to address childhood obesity, that can be exported to other countries in the region and globally. The world is facing a progressive rise in the global prevalence of obesity, particularly childhood obesity that has increased from 31 to 42 million as reported by the World Health organization (WHO)  as “Health-E-PALS” to tackle childhood obesity in Lebanon through addressing nutritional and physical activity habits of schoolchildren . The firFollowing the pilot year, and with the scientific support of AUB, Nestlé set out to expand the program's implantation in the region, engaging with different stakeholders and authorities, disseminating learnings from the program, putting together proposals for PPP collaborations, as well as providing the evidence of its effectiveness in promoting nutrition knowledge and enhancing healthy eating in school children . The PPPIn the UAE, Palestine, and Bahrain, agreements were signed between governmental partners  and the private partner Nestlé Middle East FZE. The program was integrated into Palestinian strategic education and school health action plans. In Jordan and Saudi Arabia, the agreements were signed between Nestlé Middle East FZE and NGOs and agencies, the Royal Health Awareness Society (RHAS) in Jordan and Tatweer Education Holding in Saudi Arabia. The ministries in both Jordan and Saudi Arabia were also included in this collaboration framework. The role of each stakeholder is outlined in The Ajyal Salima program is a multi-component school-based intervention that relies on the Social Cognitive Theory, which goes beyond the acquisition of knowledge to include environmental modifications that support individual behavioral changes . The proThe Ajyal Salima intervention targets encouraging consumption of nutrient rich foods and specific energy balance-related behaviors such as physical activity, sedentary behaviors, and dietary intake that play a significant role in energy balance leading to weight gain in 9–11-year-old children , 21. SpeThe four intervention components included:Interactive classroom sessions: Culturally appropriate educational lessons, included fun and attractive material, designed to promote healthy eating, and physical activity, delivered by trained teachers. This component covered the personal and psychosocial determinants as outlined by the Social Cognitive Theory .Parental involvement: The intervention program was introduced to families to assist them in creating a supportive environment at home for healthy lifestyle behaviors. Take-home packets including nutrition and physical activity tips, as well as recipes were sent with the students. Additionally, parents were invited to health fairs organized at the school. This component covered the obesogenic environment at home.Food service intervention: This component covered the availability of food in the school environment and provided relevant recommendations to include a healthy list of snacks and drinks and exclude unhealthy choices for children in the school shop.Train the trainers (TTT) workshops: workshops were conducted in each country and consisted of a 2-day interactive face-to-face training of teachers, by a research team of dietitians, on all program components and hands-on coaching and role-plays on all educational activities. Teachers and health educators in each country were coached on the use of a complete tool kit, which consisted of a “Teacher's guide” with lesson plans and educational material  to ensure the delivery of the intervention exactly as designed. In addition, school-specific implementation plans were discussed and agreed upon with teachers and school administration along with hands-on exercises, illustrative of the program. The outlined PPP model was designed to be implemented across all six countries, with results used to further expand it to other countries. Collectively, the Ajyal Salima PPP brought together ten partners across six countries and reached 300,000 schoolchildren, their parents, and teachers. Given that this was a large-scale PPP, it was vital to monitor the program and evaluate its efficacy to expand it into other countries. The evaluation process included a pre-test 1 week prior to the start of the intervention and a post-test 1 week after the completion of the program (3–4 months duration) in all schools. These tools were developed by AUB as the scientific partner, which is the custodian of the data that will be later analyzed and shared with all partners. Evaluation and monitoring involved all partners and stakeholders to ensure program sustainability and success. Ethical approval of the study was granted by AUB's Institutional Review Board in Lebanon. Additional approvals were obtained by the Ministries of Health and Education in Jordan, the Palestine, Bahrain, and Saudi Arabia.This paper describes the Ajyal Salima regional program as a process and a model for implementing a PPP addressing childhood obesity and promoting healthy eating and physical activity in schoolchildren in different administrative settings. The Ajyal Salima program, which relied on the Social Cognitive Theory, is one of the first multi-component school-based interventions to be implemented in the Arab region that highlighted the importance of PPPs in addressing prevention of childhood obesity. It has been conceived as a gradual process involving development, piloting, adoption, rollout, and expansion through partnerships between different stakeholders from several Arab countries.Public–private partnerships, now commonly used in the health sector, have been shown to be effective in promoting sustainable health programs, by enriching the capacity, quality, and reach of public health services and allowing innovation in the dissemination of health-related messages .In the Ajyal Salima model, an integral part of the PPP was the research team at AUB as the academic partner responsible for all scientific aspects of the program, such as developing educational material and project tools, training of trainers, and monitoring and evaluation. A similar PPP is the Ensemble Prévenons l'Obésité Des Enfants (EPODE); a community-based program launched in France in 1992 involving an academic partner, as well as a public partner and NGOs . Four unIn all six countries that were included in the Ajyal Salima PPP model, there was a local public partner endorsing the program, mainly the local ministry of education or the ministry of health, or both simultaneously. Involving a public partner is important to ensure that the program is culture sensitive and abides by local rules, regulations, and local policies. Public partners have the authority and ability to mobilize large scale networks to secure implementation and sustainability of the program. For example, in the present PPP model, public partners secured schools' participation in the program and, in Lebanon and Palestine, embedded the model into their school curriculum. Similarly, the InFANT Program in Australia was adopted and endorsed by eight local governmental areas . LikewisAnother indispensable component of a PPP is the private sector, from which partners engage with stakeholders, create partnerships and program set-up for replication, mobilize resources, funds, and expertise to serve the program. The private partner in the Ajyal Salima model, Nestlé Middle East FZE, initiated and funded the program, and connected all involved partners from the region to achieve a common goal. Program communication was the responsibility of the private partner, which was also the case in the Change4Life PPP in which marketing agencies were recruited to create a social movement . SimilarMany PPPs started up as small-scale programs, such as the Food Hero and the Fuel Up to Play, later expanding to reach a wider audience , 12. TheThere had been various school-based interventions in the region that targeted childhood overweight and obesity. For example, in Lebanon, the “Jarrib Baleha” intervention aimed to decrease intake of soft drinks and increase intake of water through interactive sessions . Three oTo ensure a wider implementation of the Ajyal Salima program, a deep evaluation of the efficacy and acceptability of the program components has been conducted across different countries and contexts, with results of the full-scale data analysis to be shared at a later stage.In conclusion, this paper provided a detailed description for the implementation of a holistic school-based PPP intervention model addressing the food environment for the promotion and adoption of healthy eating and physical activity. Further expansion of the Ajyal Salima program may mitigate obesity and improve health of the Arab population; it could contribute to the existing body of literature espousing the possible success of multi-component intervention programs that include multiple partners and stakeholders from both the public and private sectors to prevent childhood obesity.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.CH-M and NH conceived the original idea and developed it, provided detailed feedback on the full manuscript, and contributed to revisions. CH-M wrote the original draft. All authors contributed to the article and approved the submitted version.This research was funded by Nestlé Middle East FZE without any further role in the scientific research design Grant number: 100119.This study received funding from Nestlé. The funder had the following involvement with the study: Contributed to the development of the PPP model as one of the program stakeholders. They led coordination efforts across the region to establish partnerships and supported the logistics of the program. All authors declare no other competing interests.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


MobileCoach Alcohol is a mobile app-based program for alcohol prevention that provides individualized coaching using a conversational agent. The current study tested the acceptance, use, and evaluation of this newly developed program and explored its potential effectiveness. Methods: Longitudinal pre–post study among upper secondary and vocational school students in Switzerland. Within the MobileCoach Alcohol prevention program, a virtual coach motivated participants to deal with alcohol sensitively, and provided feedback on alcohol use and strategies to resist alcohol for a period of 10 weeks. Information was provided in weekly dialogs, within contests with other participants, and interactive challenges. By means of a follow-up survey after the end of the 10-week program, indicators of the use, acceptance, and effectiveness of the program were examined. Results: Between October 2020 and July 2022, the program was advertised in upper secondary and vocational schools. Recruiting schools and school classes was difficult due to the COVID-19 containment measures in place during this period. Nevertheless, the program could be implemented in 61 upper secondary and vocational school classes with a total of 954 participating students. Three out of four students who were present in the school classes participated in the MobileCoach Alcohol program and the associated study. Online follow up assessment at week 10 was completed by 272 program participants (28.4%). Based on program use and evaluations by the participants, the overall acceptance of the intervention was good. The proportion of students who engaged in binge drinking was significantly reduced from 32.7% at baseline to 24.3% at follow up. Furthermore, the longitudinal analyses revealed decreases in the maximum number of alcoholic drinks consumed on an occasion and the mean number of standard drinks per month, whereas self-efficacy to resist alcohol increased between baseline and follow up. Conclusions: The mobile app-based MobileCoach Alcohol program proved to be an attractive intervention, in which the majority of students were interested when proactively recruited at school classes. It allows for individualized coaching in large groups of adolescents and young adults and is promising for reducing at-risk alcohol use.Background: At-risk alcohol use, particularly binge drinking, is widespread among adolescents and young adults in most Western countries.  Addictive behaviors, such as the use of alcohol, nicotine, and cannabis, or the excessive use of online media, are widespread in late adolescence and early adulthood. The results of a representative survey in 2021 among 15- to 19-year-olds in Switzerland show regular, i.e., at least monthly, use of cigarettes by 16%, e-cigarettes by 6%, cannabis by 9%, and alcohol by 52% of respondents [At-risk alcohol use among adolescents and young adults is associated with social and educational problems, accidents, damage to the liver , and, inAn important indicator of at-risk alcohol use among adolescents is binge drinking, which is internationally mostly defined as the consumption of four or more (for women) or five or more (for men) alcoholic beverages on one occasion . Binge dInterventions for reducing at-risk alcohol use among adolescents and young adults reviewed in international studies are predominantly based on motivational interviewing or normative feedback . HoweverBecause of the possibility of automated individualization of content as well as the strong use and high attractiveness of new communication technologies among adolescents and young adults, these technologies open up a promising route for conveying preventive information and counseling services . In addiMobileCoach Alcohol for the reduction in at-risk alcohol use in adolescents was implemented in Swiss upper secondary and vocational schools in 2012 [The mobile-phone-based program  in 2012 . The web in 2012 . The resWhile phone calls and communication via SMS were the most frequently used applications on cell phones until the early 2010s, they have been increasingly replaced by messenger-based communication via smartphone apps in recent years. Today, communication via messenger services  is the most frequently used cell phone function among teenagers in Switzerland .In parallel with the spread of smartphones, the question of whether to offer an app or SMS program to support health behavior change has been raised by several authors ,16,17. BMobileCoach Alcohol program was updated, optimized, and provided as mobile app-based program including coaching by a conversational agent. Within the current study, we (1) tested the acceptance, use, and evaluation of this newly developed app-based program version and (2) explored its potential effectiveness within a longitudinal pre–post study among vocational and upper secondary school students in Switzerland.Based on the potential advantages of mobile app-based programs and the changing digital communication behavior among young people, the Vocational and upper secondary schools in the Swiss cantons of Aargau, Bern, and Zurich were invited for participation via e-mail by prevention experts from collaborating regional centers for addiction prevention. Interested teachers at the individual schools were informed about the objectives of the program. Furthermore, its implementation and procedure in the school classes were discussed. The teachers reserved a period of 20–30 min within the regular school lessons for the program implementation.www.mobile-coach.ch (accessed on 10 February 2023). Students were asked to download the app on their smartphones and to complete online baseline assessment and study registration. The inclusion criteria for this study were a minimum age of 15 years and ownership of a smartphone. After being screened for the inclusion criteria and giving informed consent, study participants were invited to choose a username. Subsequently, they received coaching by the conversational agent for a period of 10 weeks (see intervention program). All participants were invited within the app to complete an online follow-up assessment after program completion, 10 weeks after their enrollment in the study.During the school lesson, reserved for program implementation, the students were informed about the program and the accompanying study by the prevention expert and invited to participate with the help of an introductory video available at The Ethics Committee of the Faculty of Philosophy at the University of Zurich, Switzerland approved the study protocol .MobileCoach Alcohol  is a mobile app-based program for alcohol prevention that provides individualized coaching by a conversational agent. The native app was developed for both iOS and Android and is available via the respective stores in Switzerland. A web-based administration program enables an overview of all realized coaching dialogs and messages, the administration of the participants’ data, and the answering of the participants’ personal questions during the program implementation.After choosing their language, participants could select a male or female coach to interact with. Subsequently, demographic variables (age and sex) and alcohol use were assessed in dialogue form by the coach.All participants from a minimum age of 15 years were then informed about the program within the app and invited to participate. Program participants were then asked for a username and invited to fill in some items on their drinking refusal self-efficacy. Sections of the registration within the app are shown in The intervention content was customized using data from the baseline assessment and program participants received individualized messages by the coach for a total of 10 weeks. An average weekly dialogue took between two and five minutes to process. The coach regularly contacted the participants via push notifications and guided them through the program. The coaching content was individualized based on age, sex, and alcohol consumption . The coaching was intended to (1) stimulate positive outcome expectations regarding low-risk drinking, (2) increase self-efficacy to resist alcohol consumption, and (3) stimulate planning processes to drink no or less alcohol in typical drinking situations. For participants who practiced binge drinking, the day of the week and time of day with the highest alcohol consumption were assessed in order to send push messages shortly before drinking situations, e.g., Saturday evening at 21:00 p.m., in order to promote low-risk consumption.The intervention elements of the coaching were based on the principles of social cognitive theory  , the socInteractive elements such as quizzes, challenges, and contests were designed to encourage cognitive engagement with the topic in a playful way. The contests were intended to establish a social connection with other program participants, and participants could upload pictures and messages on a beautiful experience without alcohol. These contributions were presented anonymously to the other program participants and could be marked with the help of a “like button”. The best contest contributions were then presented to all participants by the coach during a separate coaching session.By actively interacting with the coach, participants could collect credits. The more credits they had, the higher the chances of winning one of several attractive prizes , which were raffled off among all participants at the end of the program. Participants collected credits by completing the weekly dialogs with the coach, as well as by participating in the follow-up assessment. Screenshots of the intervention program are shown in In addition to the weekly dialogs, which were initiated by the coach by a push notification, participants had the opportunity to initiate and process dialogs on several topics themselves, e.g., on myths about alcohol, on the long-term consequences of alcohol consumption, or on how to avoid a hangover.Beyond the automated dialogs with the conversational agent, the program offered the option of posing individual questions on the subject of alcohol to an expert (Ask-the-Expert). Program users could pose their individual questions via chat within the app for a period of 3 weeks and received an answer within a few days from a prevention expert from the Swiss Research Institute for Public Health and Addiction.Binge drinking in the preceding 30 days, assessed by asking participants to report the number of standard drinks  consumed on the heaviest drinking occasion in the preceding 30 days. Binge drinking was defined as drinking at least five drinks on a single occasion in men and four drinks on a single occasion in women.Maximum number of alcoholic standard drinks consumed on one occasion in the preceding 30 days.Total number of alcoholic standard drinks consumed in the previous 30 days by multiplying the number of alcohol consumption days in the preceding 30 days by the number of alcoholic standard drinks consumed on a typical drinking day.Self-efficacy to resist drinking alcohol in different situations ((a) when going out, (b) when someone offers you alcohol, and (c) when friends drink alcohol) based on items from the Drinking Refusal Self-Efficacy Questionnaire .At baseline, we assessed the following individual demographic information: (1) age, (2) sex, and (3) migration background by assessing the country of birth of both parents. Additionally, characteristics of the schools and classes were collected. Both baseline and follow-up assessments included the subsequent alcohol-related measures:At follow-up, we additionally evaluated the acceptance of the program by asking the participants whether (1) they would participate in the program again, (2) whether it was fun to participate in the program, and (3) whether they would recommend the program to friends. Additionally, they should indicate whether the tips and information provided were (1) comprehensible, (2) helpful, and (3) relevant to their individual situation. Furthermore, program participants were asked to rate the program and different program elements using the response categories of very good, good, acceptable, and poor.MobileCoach Alcohol database.Beyond participants’ self-reported data, program use, operationalized by the number of completed weekly dialogs with the coach, was extracted from the log files of the 2 tests for dichotomous variables and Student’s t tests for metric variables were applied. For the attrition analysis (program participants lost to follow-up), we also used χ2 tests for categorical variables and t tests for continuous variables.To test for baseline differences between program participants and non-participants, Pearson χp < 0.05 on two-sided tests was considered statistically significant. All of the analyses were performed using R, version 4.1.2 .To assess the longitudinal course of the outcomes over the study period of 10 weeks, we used  linear mixed models ((G)LMMs). (G)LMMs take into account the dependence between observations caused by the clustering of data by participants, and allow for the number of observations to vary between participants . We usedAs a result of the measures to contain the COVID-19 pandemic in Switzerland during the entire project duration, recruiting schools and school classes for participating in the program proved very difficult. First, the containment measures led to a restriction of access of external persons, such as addiction prevention experts, to the school classes. Second, schools were organizationally strained during this period, and prevention services had low priority. Thirdly, the topic of alcohol consumption had less significance among young people during this period, due to the restrictions on going out and social life.Nevertheless, the program could be implemented at a total of eight schools  in 61 school classes from February 2021 to July 2022. The baseline characteristics for the study sample are presented in 2 = 10.4, p < 0.01), younger , and hada lower self-efficacy to resist drinking  than the non-participants.Compared with non-participants, the program participants were more likely to be female (χ2 = 14.2 p < 0.01), by students with higher self-efficacy to resist drinking alcohol , by those with a lower number of alcoholic drinks consumed per month , and by those with a lower number of alcoholic drinks consumed on one occasion . Regarding program use, it was found that those who participated in the follow-up assessment completed significantly more coaching dialogues within the program than those who did not . To account for this attrition bias, these variables were entered as covariates within the models that evaluated changes in outcomes between baseline and 10-week follow-up.Online follow-up assessments were completed by 272 (28.4%) of the 954 program participants. Regarding attrition, the analysis revealed that follow-up assessments were completed more by female than male participants . No dialogue was completed by 13.2% (n = 126) and one dialogue was completed by 31.9% (n = 304). Between two and five dialogues were completed by 23.3% (n = 222). The proportion of users who completed at least six of the ten dialogues was 31.7% (n = 302).In addition to the number of completed dialogues, the program usage time was calculated and operationalized as the time span between the first and last login to the program. This averaged 38.3 days (SD = 52.1 days). The proportion of users who used the program for at least half of the total program duration of 10 weeks, i.e., at least 5 weeks, was 44.7%.Follow-up data on program evaluation were available from 240 (25.28%) of the 954 program participants. When evaluating the program overall, 84.6% found the tips and information helpful, 100.0% found them comprehensible, and 70.8% indicated that they felt they were relevant to their individual situation. Furthermore, 76.2% indicated they would recommend the program to others, 89.1% would participate again, and 87.9% said they enjoyed the program.The “Ask-the-Expert” feature, the chatbot medium, and content, as well as the competition prizes, were rated as “very good” or “good” by around or over 90% of the respondent. The picture contests were rated as “good” or “very good” by two thirds of the participants .A total of 156 free-text responses were available to the questions “How could we improve the program overall?”, “Which topics or content should be given more attention?”, and “What additional media or functions would be useful?”.The most frequent response was that the program was good as it was and that there was no need for improvement, with a total of 23 responses. Another 53 responses referred to a deepening or broadening of the range of topics. Among these, 16 people suggested that the topics of dependence, addiction, and the consequences of addiction should be discussed in greater detail. Eight people wished for an expansion with regard to other drugs such as nicotine or cannabis. Twelve statements referred to a more differentiated presentation of the medical and biological basis of addiction. In particular, they wished for more facts and statistics, as well as information, on the topics of “intoxication” and “hangover”. Six people wished for more information on how to deal with colleagues/family members who drink a lot of alcohol, three suggested more tips on how to deal with peer pressure/compulsion, and another three wished for an expansion of the range of topics in the direction of mental health . Two respondents each referred to a more differentiated presentation of the triggers for alcohol consumption and adolescent consumption patterns (irregular but high consumption). In addition, two persons wished for a stronger consideration of adult target groups, and one requested more tips for a safe consumption.There were a total of 80 responses related to the technology, individual functions, and features of the program. For example, 22 respondents wished for greater individualization of the program, e.g., more answer options in the dialogs, the possibility of writing more free-text answers, and being able to freely choose the day and time of the coaching session. A total of 18 responses addressed the video clips within the program, of which seven wanted more videos, six wanted better videos, and five wanted shorter videos or a function to play the videos faster. Twelve people suggested integrating more interactive contests and challenges into the program, and five wanted more opportunities to interact with other program participants. Seven people wanted a consumption diary in which they could record their own alcohol consumption at shorter intervals. Three free text answers each suggested the integration of more quiz questions and the revision of the traffic light feedback. The elimination of technical difficulties when calling up links and uploading images was the topic of four responses. More frequent interaction with the chatbot was desired by three people. Another three people wanted fewer emojis in the dialogues with the chatbot.p < 0.01). Taking into account program participants with available follow-up data, the proportion of binge drinkers was 32.7% (89/272) at baseline and 24.3% (66/272) at follow-up.The GLMM analyses showed a statistically significant decline in the percentage of people with binge drinking in the previous 30 days between the baseline and follow-up assessment . Regarding program participants with available data at follow-up, the maximum amount of drinks consumed on an occasion was 3.2 (SD = 3.8) at baseline and 2.4 (SD = 3.0) at follow-up.Regarding the maximum amount of drinks consumed on one occasion in the last 30 days, GLMM revealed a statistically significant decrease between the baseline and the follow-up survey . Taking into account participants with available follow-up data, the average number of standard drinks decreased from 7.3 (SD = 13.9) at baseline to 4.5 (SD = 9.3) at follow-up.According to the GLMM analyses, there was a statistically significant decrease in the total number of alcoholic standard drinks consumed in the previous 30 days between the baseline and the follow-up assessment . Regarding program participants with available follow-up data, the mean number of standard drinks of program participants in a typical week was 4.8 (SD = 1.2) at baseline and 5.0 (SD = 1.0) at follow-up.Finally, the LMM analyses revealed a statistically significant increase in self-efficacy to resist drinking alcohol in different situations between the baseline and the follow-up assessment  Three of four students recruited in upper secondary and vocational school classes participated in program and the associated study, showing a high interest in the prevention program. (2) Based on program use and evaluations, the overall acceptance of the intervention was good. (3) The results concerning the initial effectiveness of this program derived from a pre–post investigation are promising.MobileCoach Alcohol program and the associated study. This participation rate of 75% is comparatively high given the program’s 10-week duration, the requirement that users had to download a separate app on their smartphone, and the potentially lower interest in the topic of alcohol drinking during the COVID-19 pandemic and its related restrictions on going out and social life. Although no data are available for Switzerland to date, a recent review on substance use among young people during the COVID-19 pandemic suggests that the prevalence of youth alcohol use declined during the pandemic [Personal recruitment in school classes, in combination with offering a mobile app-based coaching program, allowed for reaching three out of four of the present students for participation in the pandemic . The parpandemic .MobileCoach Alcohol was good. For example, the mean number of dialogues processed in the ready4life prevention program [MobileCoach Alcohol. Internationally, participant engagement and program use in app-based health interventions remain a challenge [MobileCoach Alcohol, it was 38 days.In comparison with other app-based prevention programs in school classrooms, program engagement in the  program , which ihallenge . For exahallenge . Among tMobileCoach Alcohol. In particular, the evaluation of the interactive contests lagged behind the other program elements. The free text responses on program optimization show that there were also more frequent technical difficulties in the contests, e.g., when uploading images. Overall, among the suggestions for optimization, greater individualization of the coaching dialogs, an expansion to other substances and topics, and the communication of facts, especially on the topic of addiction and the effects of alcohol, were mentioned most frequently.Despite the comparatively good program evaluations, there is still room for improvement with MobileCoach Alcohol version [Although the results on the effectiveness of the program should be interpreted with caution due to the study design without a control group, the present data show comparable effect sizes as in the earlier program version as well as the controlled study on the previous  version . In addiThe study’s main limitations include (1) a selective attrition with female participants, low-risk drinkers, and persons with high program use being more responsive. Therefore, a bias in the effectiveness and program evaluation results is possible. (2) The study was conducted in 2021/2022 during the COVID-19 pandemic, with varying restrictions that also influenced the social life and alcohol use of young people and accordingly the generalizability of the results of this study. (3) As we only included school classes that were willing to participate in the study, the results cannot be generalized to upper secondary and vocational school students in Switzerland.MobileCoach Alcohol program proved to be an attractive intervention, in which three of four students were interested when proactively recruited from school classes. Based on program use and evaluations, the overall acceptance of the intervention was good. It allows for individualized coaching in large groups of adolescents and young adults. Based on the presented initial results on the effectiveness, the program is promising for reducing at-risk alcohol use and increasing self-efficacy to resist alcohol. Based on these initial positive results, testing this interventional approach within a randomized controlled trial would be reasonable.The mobile app-based


Ambassadors are appointed by church leadership to lead the implementation of program activities. Data were collected concerning the levels of helpfulness, difficulty, usefulness, or utility of checklist activities and modifications and the ease of program implementation. The evaluation also assessed the COVID-19 pandemic’s impact on each church’s ability to implement activities and modifications. The survey results revealed that most required partnership activities and modifications were found to be at least moderately helpful. Some of the items (themes) that differed across church partners included barriers to implementing activities, the support provided and needed, and the use of program funding. This evaluation provides key insights to consider in developing and refining community-based, dementia-friendly communities (including faith communities). As implementation science expands and improves, the need to evaluate the implementation of programs continues to be highlighted. Our formative evaluation shed light on key areas in which modifications to our original programming would lead to program improvement and sustainability. Additionally, implementing the modifications identified in our evaluation will facilitate the achievement of the mission of Alter™ to improve the well-being of older adults affected by dementia and their families. Other programs would reap substantial benefits from engaging in similar formative evaluation efforts.Black churches have traditionally been a haven for Black American families; however, many churches do not currently have programs to support families living with dementia. Alter™ was established to assist faith communities in meeting the needs of these families and becoming a viable resource to promote their health and wellness. Alter™ achieves this aim through a three-pronged approach: (1) conducting educational sessions, (2) modifying Black churches to be dementia-inclusive spaces, and (3) providing ongoing support. The principal goal of Alter™ is to offer guidance to churches in adapting their community to reflect a supportive environment for families affected by dementia. Alter™ uses a partnership checklist to encourage activities that incorporate dementia education opportunities, environmental modifications, and dementia resources and support. This paper reports on a formative mixed-methods evaluation of church partners enrolled in Alter™. Church partner ambassadors within the faith communities participated in the evaluation survey ( In 2021, experts estimated over 6 million Americans were living with Alzheimer’s disease and other dementias ,4. BlackChurches have the capabilities to promote health within the community, communicate and disseminate health information, foster and maintain trusting, supportive environments for health, and offer relevant safe, culturally appropriate health prevention programs and care for the community without racial discrimination ,9. FurthBuilding dementia-friendly  communities is a growing priority to meet the educational and infrastructural needs of families affected by dementia . HoweverCurrently, there is a growing literature surrounding the science of implementation and sustainability strategies of health promotion programs ,18. As hAlter™ is a faith-based, dementia-friendly community program that equips Black churches with the tools needed to better support families affected by dementia . Alter™ n = 8), support (n = 6), community education and awareness (n = 4), and the worship experience (n = 6). Church partners agreed to implement at least 16 of the 24 suggested activities and modifications on the Alter™ partnership initiatives checklist over a 2-year period. The selection of activities to implement was performed by the respective church representative based on their ministry’s mission and strategic plan. The full list of activities included on the Alter™ partnership initiatives checklist is provided in Churches were recruited utilizing snowball and purposive methods. Purposive methods were used to focus enrollment efforts on under-resourced communities. During the enrollment process of the program, respective church representatives met with the program staff for an informational meeting. Upon enrollment to become a partner, churches received a welcome box accompanied by a memorandum of understanding and a financial contribution to assist with the implementation of partnership initiatives. The Alter™ partnership initiatives checklist was inclusive of dementia-related initiatives and environmental modifications, which provided church partners the framework to offer dementia support resources, dementia education, and meaningful worship experiences. The partnership checklist was divided into four domains: core  onto their corresponding evaluation questions. This process ensured that all data collected were valuable to answer the evaluation questions and addressed the overall purpose of the evaluation . The priProgram staff initially contacted church partners to inform them about the evaluation being conducted. The evaluation team contacted church partners with provided contact information to coordinate schedules and explain evaluation ethics, including that the survey and focus groups were voluntary and that responses were anonymous and would be kept confidential, and answered any questions from participants. The evaluation team then provided appropriate Zoom links for the survey and focus groups. The evaluator administered the survey, and their screen was shared with the participant using Zoom functionalities. All survey data were stored and secured on Qualtrics. An online survey was administered instead of a paper survey due to social distancing recommendations, thus eliminating the need for data entry. In addition, due to the guided nature of the survey, participants only needed to have an electronic device with Wi-Fi and Zoom capabilities. Focus group guides were developed based on preliminary results from the surveys in order to gain better insight into the overall experience of implementing Alter™ partnership initiative activities. All church points of contact participating in the evaluation survey were asked to schedule a time to participate in one of two focus groups. The program coordinator and program founder were also in attendance for both of the focus groups and helped guide the discussion. The focus groups occurred via Zoom and were led by the evaluation focus group guide and probes. Focus group sessions were transcribed verbatim, and all identifying information was removed.Data from the church partner surveys were exported from Qualtrics into an Excel spreadsheet. Team members (J.G. and J. T.) cleaned all data within Excel. Closed-ended and open-ended data from the surveys were organized into separate Excel sheets for data analysis. The evaluation team ran descriptive statistics on the quantitative data to obtain frequencies and percentages for categorical data. A content analysis was completed on the open-ended survey responses to understand the impact of COVID-19 on the church’s abilities to conduct program activities and modifications. Once all the descriptive statistics and frequencies were reported, the data from the survey were triangulated to extract salient themes. Transcribed focus group sessions were inductively and deductively coded to develop themes. First, an evaluation team member coded the transcripts based on previous knowledge. Then, the evaluator deductively coded, placing codes that align with the evaluation questions. The evaluator cross-analyzed the focus group data to formulate themes that were utilized during data triangulation. All codes and themes were presented to the other members of the program evaluation team and discussed for reliability. At the time of the program evaluation, nine faith communities were enrolled in the program (eight located in Georgia and one in Illinois). Of the nine church partners, eight completed the online survey. Church partners reported having majority Black congregations, and their congregant’s average socioeconomic status was middle income. Congregation sizes varied, as two reported having a small congregation (average weekly attendance of 50 or fewer people), five reported having a medium congregation (average weekly attendance of 51–300 people), and one reported having a “mega-church” size congregation (average weekly attendance of more than 2000). Overall, church partners described the age demographic of their congregation as the majority being older adults. Data were reported based on participants’ experiences implementing selected program activities. Program activities consist of Core Partnership Activities , providing support resources for families affected by dementia, providing community education opportunities to raise awareness about dementia, and implementing modifications to the worship service. Activities were assessed based on their level of helpfulness to the church becoming dementia-friendly, the difficulty of implementation, and the level of utilization (as appropriate). Church partners were required to select and attempt to implement all core activities of assign to a minister, building is well-lit, with large print signage, badges for support staff, physical support, quiet room/space, accessible pathways, and church leaders workshop. As part of the core activities, all church partners assigned the dementia-friendly initiative to a ministry at their church. However, other core activities had a 73% implementation rate. Participants reported 62% of core activities as being “completely helpful” to their congregants and assisting with their church being dementia-friendly. The majority of churches (91%) reported core activities being “not difficult at all (easy)” to implement . AdditioChurch partners were required to select and attempt at least three support activities. Four churches selected and implemented resource libraries and educational events, two churches offered support groups, one offered a respite care program, and one church offered social service coordination . AlthougChurch partners were required to select and attempt at least two educational activities. Six churches selected and implemented the provision of dementia resources and education on social media/websites, four churches offered a Memory Sunday, and one church offered dementia education with youth . AlthougChurch partners were required to select and attempt at least three worship modification activities. All eight churches shortened their service length to 75 min or less, six churches simplified sermons, five increased the amount of music, five modified worship service order of flow, and three included familiar bible verses. One church selected to have a support staff present but was unable to implement this activity . OverallChurch partners reported the COVID-19 pandemic as the main barrier to program implementation. Churches that were able to implement program activities reported conducting them before COVID-19 “stay at home orders”. Non-COVID-19 barriers were homogenous across most of the activities; therefore, we did not analyze barriers across activity types. The number of times a barrier was mentioned within the short answers of the survey was collected: the COVID-19 pandemic (f = 37); congregation members affected by dementia have not been identified (f = 7); lack of church personnel to conduct or lead activities (f = 7); unclear understanding of how to implement activities and modifications (f = 6); lack of marketing tools or knowledge of how to engage congregation members (f = 4); lack of space within the building to conduct activities (f = 3); perceiving the activity as not applicable for their church (f = 2); liability concerns (f = 1); not having enough funding to implement activities (f = 1).All church partners participated in at least one of the focus group sessions. Church partners were able to have more than one representative in the focus groups; thus, 11 participants across all churches participated in the 2 focus groups. Three themes emerged during thematic analysis: barriers to implementing activities, the support provided and needed, and the use of program funding. The themes describe findings related to church partners’ experience participating in Alter™.Participants expressed barriers to implementing activities while participating in Alter™. Barriers varied across churches; however, the COVID-19 pandemic presented as a significant barrier to implementing activities. Many church partners halted their implementation of various activities, as they were not able to be physically at the church. Participant 1 from focus group 2 expressed: “…once COVID came and then we shut everything down. So, we still have those things to do. You know? …, I think we would’ve been much further along had COVID not come.”Additionally, the COVID-19 pandemic presented other barriers, as it related to shifting the churches’ focus on prioritizing COIVD-19 information rather than disseminating information and resources related to dementia. “well, our organization have been so focused on trying to get back in the church as well as to bring education, ah, to their, ah, constituents, um, about COVID. And so, that’s been their primary focus and how they can, you know, really not lose their members during this time. … So, they have put the dementia back on the back burner, you know, during this time because that’s been their primary focus.”Participant 4, Focus Group 2Churches also expressed other barriers related to the implementation of activities and modifications, including lack of space within the church building for activities, not knowing how to find or approach those affected by dementia within their church congregants, and perceived liability issues with implementing a respite program at the church. Additionally, church partners expressed the need for the program at their church but were not sure if their efforts were reaching families affected by dementia because many families are not forthcoming with sharing their diagnosis. However, church partners remained positive in their preparedness to support families affected by dementia when they step into their church. “But right now, we just really don’t have that many, ah, people in the congregation, ah, who are actually dealing with, or living with dementia … I’m sure people will be coming or, you know, or things will be changing. So, that’s where we are in getting more things set up so that when, um, they’re needed, they will be available.”Participant 2, Focus Group 1Additionally, church participants noted there were activities they could have implemented, but they did not have a clear understanding of the activity. For instance, participant 2 from focus group 2 stated:“[W]hen we went through our survey [a] couple weeks ago, there were some things I think I could’ve implemented that I didn’t implement… I was like, “Oh, I… We could’ve did that.”Participants detailed their experience receiving support from program staff and provided suggestions for improvements. Due to the COVID-19 pandemic, the support provided by Alter™ staff was virtual . Many church partners expressed their appreciation to the program staff for the attentive support provided:“Keep on doing the good job that you’re doing in helping us to become, ah, great Faith Village [dementia-friendly] churches. Because, ah, it’s just a, it’s something that’s very much needed and, ah, the team has done an excellent job even, ah, with the COVID situation.”Participant 1, Focus group 1A participant recalled a time when an Alter™ staff member connected a family at a partnering church with dementia support resources.“Because the other day we had, um, someone and, and the, the father is member of our church. He’s, he’s older, but was doing very well, but has now moved back in with his daughter. And she had, um, she’s- she’s having to work from home and just some other things. But, ah, and I was able to, ah, connect her with [program staff], and it just really helped. Because we don’t know, well, let me speak for me. I don’t know all of the ins and outs and what may be available. I know with, with some of the information, but as far as talking to someone and seeing exactly where they are and what they need, then having her there has been just a tremendous asset.”Participant 2, Focus group 1Participants discussed the possibility of Alter™ incorporating a direct phone line, through which churches can call and receive dementia-related information for their congregation members. Participants agreed to have a point of contact who understands the needs of their congregations rather than someone who does not know the church well is vital. For instance, Participant 2 from Focus group 1 stated: “Because we’re dealing with people who—in most cases—are older.  “Okay, I’ve gotta dial a 1–800 number. What…?” The first thing that comes to their mind [is], “Okay, I may get in a loop… You know, it’s gonna be somebody who doesn’t necessarily care about me or whatever.” … but having you contact the sister the other day and being able to talk to her, letting her know you understood exactly what she was looking for, and I don’t even know if she found everything, but it was the fact that this is somebody who understands what’s happening here.”During evaluation focus groups, church representatives were able to exchange ideas and discuss challenges in implementing various activities. Participants appreciated being able to gather and discuss what each church has done for the dementia-friendly activities.“But I think it, it’s, you know, it’s good that we are talking and getting- getting to, to know each other… and or- or call or whatever and say, “Well, how did… how did this work for you? This is what we’re trying to do, but we’re running into a roadblock.” You know? And, and sometimes just-just having that, ah, because it’s just, it’s a lot we can do but then it’s a lot that we can’t do.”Participant 2, Focus group 1Alter™ provides a financial contribution to church partners to assist in the implementation of activities and modifications. Many church partners expressed challenges in spending the funding received. Although church partners have ideas about how to spend their funds, the COVID-19 pandemic presented a barrier due to many modifications not being able to be implemented.“Well, because of, ah, most of the churches been closed, ah, we haven’t used the money, ah, in The Alliance … So, um, it’s been beneficial, um, that, you know, we just hadn’t decided to use the money right now. We just doing, you know, we just doing what we do.”Participant 4, Focus Group 1Furthermore, participants expressed not spending their funds due to not being in the building and only focusing on activities that can be conducted virtually. “…but in the future. the church is not that big. Obviously, um, we do not have anything that we are doing that’s costing anything right now.”Participant 1, Focus Group 2Although many church partners expressed not being able to utilize program funds, one participant detailed their experience utilizing the funds to implement a caregiver support group and providing caregiver “support boxes” at their church. “And the toolbox had socks; it had, um, mints, nuts, um, a puzzle, a cross--no, word, word search puzzle. It had colored pencils for the colored, um, booklets. And just so happen, I went to the Dollar Tree, and they had those inspirational coloring books, and you could download the music, there was music to go along with the coloring books.”Participant 3, Focus Group 2Alter™ aims to provide a guiding light for faith communities in creating a dementia-friendly and inclusive environment. Informing Black churches of all sizes about the potential health needs of their communities, identifying church ambassadors and ministries who can implement health education initiatives, and providing churches with resources can be beneficial in building faith-based health programs ,23. Our On average, more than half of the churches implemented the core, support, and education activities and worship modifications listed in the checklist. We anticipated higher implementation rates; however, barriers, particularly COVID-19, deterred or delayed activities that required being in the church building, such as a quiet room or space for persons with dementia to worship, memory cafés, and onsite education events, including conducting education with youth. The Reframing Aging Initiative, a collaboration of aging organizations, encourages aging professionals to “innovate existing systems to reduce poor health outcomes during and after the pandemic” . Many AgHealth promotion programs seeking to address obstacles related to program sustainability would benefit from the development of an intake assessment tool measuring the need for their program activities and the capacity of their community partners to implement activities. Such a tool may ensure that community partners are able to implement selected activities to their intended extent. Assessing a community partner’s (Black church communities in the case of the Alter program) organizational readiness is essential for successful implementation ,27. An iThe level of helpfulness and usefulness of initiative activities perceived by church partners varied. Additionally, church partners expressed varying understanding of how to implement certain checklist activities and modifications. Thus, we believe providing community partners with a manual detailing how to implement program activities as well as expected outcomes may improve implementation efforts. For instance, a study assessing the impact of school-based education programs found successful interventions provided program implementors  with a program manual . AdditioChurch partners found value in the focus groups, as they could hear from other church partners about their challenges and successes. Similarly, designating structured time for program site leaders to discuss their experience in a program has been utilized within pediatric health interventions to guide individual site improvements . Thus, iUltimately, providing regular tailored support for community partners, and ensuring the organization is equipped with appropriate personnel such as health educators, is vital to a health promotion program’s success . Health The mixed-methods approach was a strength of this evaluation, providing an overview and detailed information. Additionally, the majority (83%) of participating churches in Alter™ completed the evaluation activities. However, the evaluation had notable limitations. One limitation of the structured interviews was participant bias when responding to survey and focus group questions. Several church partners were familiar with the principal investigator (F.E.), which may have caused them to refrain from offering harsh criticism upon answering specific questions. Participant recall bias was another limitation; however, due to administering the survey and focus groups at a similar stage among all participants, recall bias may have been minimized . AdditioTo enhance, expand, and sustain community-based programs, program leaders need to engage in rigorous evaluation of their community-based partners’ perceptions of the program’s implementation barriers and facilitators. Our evaluation of the Alter program revealed strategies to overcome identified barriers—namely, adapting health promotion programs virtually, assessing community organization capacity for programming, developing a program manual, conducting structured workshops for program implementors, and hiring health educators. These strategies will help ensure effective implementation for any program seeking to partner with a community-based organization.


Violence against children (VAC) is a major global issue with long-lasting negative consequences on individuals and societies. The present study presents a review of the literature on drivers of VAC and the core components of evidence-based violence prevention programs. Moreover, it analyzes the existing services and social infrastructure in Colombia to rigorously inform the design of the Apapacho violence prevention parenting program for families with children younger than five targeted toward Colombia. Findings indicate that (1) VAC in Colombia is a multidimensional issue with roots at the individual, family, community, and society levels, (2) evidence-based violence prevention programs share a common set of content and delivery strategies that could inform the components of the Apapacho program, and (3) there is an urgent need for scalable and flexible violence prevention programs for families with young children in Colombia. Considering existing evidence, the Apapacho violence prevention parenting program will be designed using ecological, developmental, and neuroscience-informed perspectives. This article concludes by presenting the initial components of the theory of change and discussing future directions for the design of the Apapacho program and other violence prevention interventions in LMICs. Violence against children (VAC) is a major human rights and public health issue that can lead to long-lasting negative consequences on children’s neural and skill development, physical and mental health, and well-being ,2,3,4. GThe purpose of this article is to present the conceptual foundations and design plan for the Apapacho (which means “to hug the soul” in the Nahuatl language) parenting program to prevent VAC during early childhood targeted toward Colombia, following guidance on the development of complex interventions. The specific objectives of the article are to (1) identify the core components of evidence-based parenting programs that have been effective in preventing VAC in LMICs, (2) understand the context of Colombia, including the drivers of VAC and existing services, programs, and social infrastructure related to violence prevention and parenting more broadly in the country, and (3) combine the core components and context to present an initial theory of change of the Apapacho program.The initial design of the Apapacho program will target Colombia. Colombia is an upper-middle income country with more than 48.2 million inhabitants, of which 8.4% are children younger than five. The country has endured a civil conflict for more than 50 years, which led to direct victimization and forced internal displacement of about 10% of its population. Regarding VAC, Save the Children recently ranked Colombia as the fifth country where children suffer the most from conflict and fourth regarding child homicide rates . FurtherIn May 2021, the Colombian National Congress approved a national law prohibiting all forms of violent punishment  in all settings, including the home. The Government also launched a national plan to reduce the high prevalence of VAC . The natParenting programs were identified as key strategies to promote the nurturing care of young children and prevent VAC ,16,17, aResearchers, practitioners, and policymakers sometimes transported and, in some cases, adapted violence prevention parenting programs developed in HICs to LMICs, such as Incredible Years  and TripAn alternative to fully transported or homegrown interventions is adapting “core components” of evidence-based parenting programs to the context of interest. Core components—or “active ingredients”—are fundamental principles and procedures that are thought to underlie the effectiveness of a given intervention ,36. ReceUsing evidence-based core components as a starting point, instead of starting from scratch or fully transporting an intervention, has at least three main relative advantages. First, identifying and using core components allows intervention developers to use all existing evidence to “distill” best-practice recommendations, instead of just employing the components from a single intervention or starting from scratch. Second, adapting core components, instead of transporting an intervention, can improve implementation outcomes, including acceptability, adoption, appropriateness, feasibility, fidelity, integration, and sustainability  see Tab, as wellGuidance on how to develop complex interventions comprises four major phases ,41. FirsWe respond to policy calls on the need for VAC prevention parenting programs in Colombia  by workiWe used three sources of information for this study. First, we searched PsycInfo (EBSCO), PubMed, and Google Scholar for literature on the theoretical basis and core components of programs to prevent violence against children and/or child behavior problems. We identified systematic reviews and meta-analyses of global evidence, as well as programs implemented in LMICs with experimental evidence. We focused on programs from LMICs to assess whether their core components are consistent with the core components identified in reviews. We searched for publications, facilitator manuals (when available/open), and other relevant information from the interventions implemented in LMICs. We also searched for literature on the predictors of VAC in the same sources.Second, we searched for and examined the operational manuals of the programs and services for children younger than five and their families provided by the ICBF. Finally, we complemented this review of operational manuals with conversations with staff from the ICBF to map all existing programs and services related to early childhood, families, and violence prevention in Colombia (the team who participated in these conversations are coauthors in this manuscript).This study received ethical approval from the Institutional Review Board (IRB) at Harvard University on 11 April 2022 (IRB Registration # IRB00000109) and received technical approval from the ICBF on 25 January 2022.We found six recent reviews and meta-analyses of parenting programs for caregivers of young children to prevent violence and child behavior problems ,46,47,48Overall, global reviews and the 11 programs suggest a common set of core components that might be relevant for violence prevention parenting programs. First, most programs use a cognitive–behavioral and/or social learning theoretical perspective. Second, most programs include content to promote (i) knowledge of children’s development and needs, (ii) caregiver engagement in play and other learning activities, (iii) emotional communication skills, and (iv) use of discipline strategies . Third, programs often include a focus on caregivers’ self-care, well-being, and stress management, for example, by introducing self-regulation techniques and less commonly dealing with a history of adversity . Finally, some programs include content to inform caregivers about the effects of violent punishment, e.g., , and oneRegarding delivery techniques, programs were delivered using group meetings, home visits, and a combination of both. Key components also include delivering content in positive, non-stigmatizing ways using positive and supportive feedback from facilitators, group discussion, and peer support to bolster caregiver self-confidence. Moreover, most programs used participatory and experiential approaches to promote knowledge and skills, including demonstrations and modeling from trained facilitators, role-playing and rehearsal/practice of behaviors, and homework to practice skills at home. Finally, most programs promote setting parenting goals and reviewing such goals and provide materials .Programs that were effective in preventing and reducing VAC and addressing drivers of VAC have shared core components, including content and delivery strategies, that could inform the development of the Apapacho violence prevention parenting program. Relevant content comprises knowledge and attitudes , emotional self-regulation (including emotion knowledge and regulation), family relationships , stimulation in the home (including child-led play), and adequate discipline techniques (including positive reinforcement and prevention of child behavior problems), among others. Regarding delivery, most programs used highly interactive and participatory strategies.Global research, including reviews ,59,60 anWe identified three studies of the drivers of VAC during early childhood—physical punishment specifically—in Colombia, using data from nationally representative surveys ,13,63. IAt the broader context, physical punishment was more common in neighborhoods with higher violent crime rates , in regions with higher levels of poverty and more exposed to the civil conflict (as measured by homicides rates and presence of guerrillas), and in rural areas ,63. FinaCollectively, global research and evidence from Colombia support a social–ecological perspective ,64,65, iThe ICBF is the entity of the Colombian state with responsibility for services for children and families, including child education and child protection from early childhood through to adolescence. The ICBF has a nationwide coverage but prioritizes at-risk families , and currently serves more than 8 million Colombians. The ICBF has six different divisions, but in the remainder of this section we focus on the Dirección de Primera Infancia  and Dirección de Familias y Comunidades , as they are responsible for services targeting early childhood, families, and the promotion of positive parenting.According to internal administrative data from the ICBF, the early childhood division serves around 1.7 million children younger than five and their families through four modalities of service provision, namely Institutional , Family , Community , and Ethnic and Intercultural modality . The objective of the Institutional modality is to promote early childhood development through holistic and structured early childhood care and education services . Its tarThe Family modality seeks to promote early childhood development and positive parenting at home, prioritizing children and families in rural areas and who do not have access to other early education and care services . The tarThe Community modality is a care and education service, which children attend every day of the week for about 6–8 h . This moFinally, the Ethnic and Intercultural modality was developed taking into account local traditional and indigenous perspectives to include social participation and cultural factors within service provision ,74. ThisThe early childhood division leads other initiatives targeting the prevention of VAC, including programs (1) to identify risk factors and actual cases of VAC in early care and education services (program Guardianes de la Niñez [Guardians of Childhood]), (2) to train ICBF staff, teacher and multidisciplinary teams in the detection and response to VAC, (3) to strengthen ICBF staff, teacher and multidisciplinary teams’ socioemotional skills [Sanar para Crecer], and (4) to provide ongoing support to families amid the COVID-19 pandemic (Mis Manos te Enseñan [My Hands Teach You] strategy).Besides services that target young children, the ICBF provides services for families with children and adolescents. One such service is Mi Familia , an indicated parenting psychosocial program that seeks to strengthen parenting capabilities to promote child and adolescent development and guarantee their protection . The proFor families with children younger than five, Mi Familia comprises nine home visits and four family meetings. In each meeting, the PAF follow methodological booklets to implement the session content. Broadly, the booklets include content on self-care, emotional regulation, assertive communication, conflict solving in the home, and positive parenting. A key feature of Mi Familia is that it is highly flexible and each PAF works with families to design an intervention plan that responds to families’ needs. To date, Mi Familia has not been evaluated.The ICBF has several different modalities and uses multiple delivery platforms to respond to different needs, territorial particularities, and cultures. To date, there are several universal programs aimed at promoting young children’s development and caregiver positive-parenting practices. Yet, there are fewer programs aimed at preventing VAC in the home, and besides notable indicated  programs, such as Mi Familia, there are no universal or selective programs with experimental evidence and clear theories of change and/or curricula aimed at preventing VAC. Considering that there is a solid social/service infrastructure and prior successful experience of integrating new curricula to improve service provision , there aIn this section, we combine evidence on the core components of parenting programs that were effective in preventing or reducing VAC, information on the drivers of VAC in Colombia, and the current services and infrastructure to support early childhood development and prevent VAC in Colombia to propose the conceptual foundations and objectives of the Apapacho program.We will employ a bioecological perspective ,65 as anA bioecological perspective allows us to operationalize some of the drivers of VAC in the Colombian context. First, some of the factors identified in previous research are proximal, malleable risk factors that could be targeted through a parenting program, such as Apapacho, including caregiver knowledge, attitudes, beliefs, self-regulation, and self-confidence. Second, other risk factors comprise past or ongoing experiences that require attention in the intervention content, including a history of violence in caregiver childhood or intimate partner violence. Third, some factors are more structural and could inform the targeting of the intervention, including household poverty, low caregiver education, teenage pregnancy, and high levels of contextual violence (crime or presence of armed groups). Finally, some risk factors suggest that the intervention must be designed to be sensitive to specific dynamics and needs, including family composition, the presence of fathers in the home, and regional and cultural differences within Colombia, among others.A developmental perspective indicates that early childhood is a sensitive period of development, when rapid brain and skill development occurs in response to experience . During A developmental perspective also highlights the need for the Apapacho program to be sensitive to the different needs and challenges that both parents and children experience throughout the first years of life see . For insTraditional models of training and support for caregivers largely rely on providing information , which could not meet the needs of caregivers, in particular of those facing past or ongoing adversity , and may not be effective in helping caregivers develop the skills they need for parenting . ExtensiThe development of the Apapacho program will use this neuroscience-informed approach to promote caregivers’ core capabilities to prevent and reduce VAC. We hypothesize that such an approach can increase the effectiveness of Apapacho for three reasons. First, there is evidence that the core skills that parents and caregivers require for parenting  can be strengthened with practice ,88,89. SPrevent violence against children younger than five by parents/caregivers;Promote caregivers’ core capabilities for parenting  and daily positive-parenting practices ;Promote young children’s executive function and self-regulation skills to support their overall development.Considering these conceptual foundations, the main objectives of the Apapacho violence prevention parenting program are to:Apapacho will be a parenting program based on ecological, developmental, and neuroscience-informed perspectives to prevent and/or reduce violence against children younger than five by promoting caregivers’ core capabilities for parenting and children’s executive function and self-regulation skills see . To achiThis manuscript describes the conceptual foundations of the Apapacho violence prevention parenting program targeted toward Colombia. We developed these foundations following recent guidance on how to develop complex interventions ,41, inteThe Apapacho program will incorporate content to promote parenting knowledge, positive attitudes, self-regulation, and well-being, among others. In general, this content seeks to build core capabilities for parenting  and, in The Apapacho program will also include delivery approaches based on experiential, participatory, and highly interactive strategies, including group discussions and support, demonstrations, practicing, joint problem-solving, and homework. These approaches are considered critical components of effective parenting programs in LMICs, e.g., ,38 and aWe used a “core components approach” to develop the conceptual foundations of Apapacho, instead of transporting an existing intervention with evidence on effectiveness. Using such an approach is advantageous in the context of Colombia, where the national plan to prevent VAC makes a call for scalable interventions that can be embedded into existing services or social infrastructure . By deveThe core components approach also allows us to develop a flexible intervention that responds to the specific needs and social infrastructure of Colombia and can be integrated into the different service modalities operated by the ICBF, maximizing its feasibility and scalability. Indeed, prior studies demonstrate that such an approach could strengthen existing services from the ICBF and have positive impacts on families and children. For example, a study showed that embedding a structured early stimulation curriculum into the existing HCB FAMI improved child development outcomes and maternal knowledge about child development, among other outcomes . TherefoThis article has some limitations that inform future directions for research. First, the article relies mostly on secondary data, so future studies should collect primary information to better understand families’, policymakers’, and potential facilitators’ needs and perceptions to adapt the core components. We will do this by collecting qualitative data and conducting rapid-cycle pilots in a process of ongoing adaptation and improvement. Such an iterative process will allow us to have an intervention that is more relevant to the local culture, context, and social infrastructure and that could be evaluated to inform its potential scalability. Second, there was scarce evidence on the drivers of VAC in Colombia, so additional work is needed to identify other factors that might inform the content or targeting of Apapacho and other violence prevention programs. Finally, this article focused on Colombia, but there is growing need for violence prevention parenting programs in other LMICs. Nevertheless, the rigorous identification of core components for the Apapacho program will inform future studies aimed at designing or adapting parenting programs in other LMICs.VAC is prevalent in LMICs and can undermine young children’s health and development. To date, most interventions to prevent VAC in the home were developed and evaluated in HICs, but there is a growing number of studies from LMICs in the last few years, e.g., ,38,49. I