The interior noise and vibration of metro vehicles have been the subject of increasing concern in recent years with the development of the urban metro systems. However, there still is a lack of experimental studies regarding the interior noise and vibration of metro vehicles. Therefore, overnight field experiments of the interior noise and vibration of a standard B-type metro train running on a viaduct were conducted on metro line 14 of Guangzhou (China). Both the A-weighted sound pressure level and linear sound pressure level were used to evaluate the interior noise signals in order to revel the underestimation of the low-frequency noise components. The results show that the interior noise concentrates in the low-to-middle frequency range. Increasing train speeds have significant effects on the sound pressure level inside the vehicle. However, two obvious frequency ranges (125–250 Hz and 400–1000 Hz) with respective corresponding center frequencies (160 Hz and 800 Hz) of the interior noise are nearly independent of train speed. The spectrum analysis of the vehicle body vibration shows that the frequency peak of the floor corresponds to the first frequency peak of the interior noise spectrum. There are two frequency peaks around 40 Hz and 160 Hz of the sidewall’s acceleration level. The frequency peaks of the acceleration level are also independent of the train speeds. It hopes that the field measurements in this paper can provide a data set for researchers for further investigations and can contribute to the countermeasures for reducing interior noise and vibration of a metro vehicle. In recent decades, the urban metro system has seen rapid development in eastern countries due to its fast speed, high efficiency, comfort, and environmental benefits, especially in China. According to recent statistics, the total length of China’s operating metro lines has increased from 112 km among three cities in 2000 to about 6000 km among 41 cities in 2019. The elevated metro has become an alternative rather than the general underground metro type due to its low cost and short construction period, especially in a metropolis with a well-developed metro network, such as Beijing, Shanghai, and Guangzhou. The total length of operated elevated metros in China accounts for nearly a quarter of the whole 6000 km ,4, afterThe interior noise inside a railway vehicle is composed of air-borne and structure-borne sound generated by exterior sources mainly including wheel–rail rolling effects, excitation phenomena due to the sleeper-passing frequency, and aerodynamic effects . Many acIn addition to the aforementioned theoretical and numerical investigations, many field measurements have also been conducted. Han et al.  investigAs there remains great concern regarding the acoustic environment of a metro vehicle, the lack of experimental studies about the interior noise and vibration of a metro vehicle, let alone investigations concerning a metro vehicle running on a viaduct, is noticeable. Moreover, with the trend of lighter trains and higher speeds, the increase of both air-borne and structure-borne sound will lead to the deterioration of the acoustic environment of a metro vehicle. This paper aims to determine the characteristics of the interior noise and vibration of a metro vehicle running on a viaduct. The measurements of vibration and noise were conducted in the standard B-type metro train on metro line 14 in Guangzhou (China). In order to analyze the underestimated effects of low-frequency noise components inside the vehicle, both the A-weighted SPL and linear SPL were adopted to evaluate the measured interior noise signals. The relationships between the interior noise and the vibration of the metro vehicle under various train speeds were investigated. The main noise sources of the metro vehicle were identified through the spectrum analysis of the measured vibration acceleration signals. The field measurements here can provide an available data set for researchers for further investigations, and could contribute to countermeasures for reducing interior noise and vibration of a metro vehicle.The main sources of interior noise can propagate by both air-borne and structure-borne paths, which includes rolling noise related to wheel and track characteristics and roughness and aerodynamic noise related to train speed and train type. The coupling effects of the train-track-bridge system may also affect the sources of interior noise when the metro vehicle is running on a viaduct . The datThe total sound pressure level is a simple and direct parameter to quantify the sound level, which is defined in terms of the time-varying sound pressure level, as follows:N represents the order number of each harmonic component, N = length [The fast Fourier transform (FFT) is one of the most important numerical algorithms and has been widely used in signal analysis. The original signals can be transformed from the time domain to the frequency domain by adopting the FFT. Then, the spectral characteristics of the signals can be extracted. The FFT could be expressed as (3)X(k)=Wheel–rail roughness, especially rail corrugation, is the main source of vibration excitation for the interior noise of the metro vehicle. One of the most effective and economic countermeasures to prevent rail corrugation is rail grinding, especially before the operation. The field measurement of Metro line 14 of Guangzhou was conducted two weeks before its operation, and the rails were pre-grinded before its operation, as shown in The running tests were conducted between overnight Dengcun station and Chicao station on metro line 14 in Guangzhou. The test section was an elevated metro line, which was mainly composed of 3 × 40 m concrete continuous rigid-frame box-girder bridge, as illustrated in The standard B-type metro train was used in the field test, which consists of four motor vehicles and two trailer vehicles, as illustrated in According to the Noise Limit and Measurement for Trains of Urban Rail Transit standard  and refeSince the combined effects of noise level and its frequency characteristics determines the acoustic environment of the vehicle, the total SPL and the spectrum characteristics of the interior noise are analyzed in this paper. The total SPL of each measuring point inside the vehicle with respect to different speeds is illustrated in The propagation path of noise in trains can be generally divided into the structural sound transmission and air sound transmission. The aim of vehicle vibration measurements is to reveal the relationship between the interior noise and the vibration of the metro vehicle. Field experiments of the interior noise and vibration of a standard B-type metro train running on a viaduct were undertaken overnight on the Metro line 14 of Guangzhou (China). Both the A-weighted SPL and linear SPL were adopted to evaluate the measured interior noise signals. The FFT method was applied to measure vibrations of both the vehicle’s floor and sidewall. The results show that the interior noise increases sharply with the increasing train running speed. However, the effects of the train’s running speeds on the acceleration levels of the floor and sidewall are not apparent, especially in the range of 40–80 km/h. There are two obvious ranges (125–250 Hz and 400–1000 Hz) in the frequency domain of the interior noise. Their corresponding center frequencies are 160 Hz and 800 Hz, respectively. These two frequency peaks are nearly independent of train speed. The spectrum analysis of the vehicle body vibration shows that the frequency peak of the floor corresponds to the first frequency peak of the interior noise spectrum. This indicates that the vibration of the floor contributes to the low-frequency noise components of the interior noise. There are two frequency peaks of the sidewall’s acceleration level, around 40 Hz and 160 Hz. The frequency peaks of the floor and sidewall are also independent of the train speed. This indicates that the characteristics of the vehicle itself dominate the frequency peaks of the acceleration levels of the floor and sidewall. The results show that different vibration reduction measures should be taken according to the characteristics of the floor and sidewall. Since field measurements of the interior noise and vibration of metro vehicles are quite rare in the literature, this paper can also provide an available data set and reference for researchers in further investigations.


Maternal and Child Health Journal supplement “Supporting Expectant and Parenting Teens: The Pregnancy Assistance Fund,” which draws together the perspectives of researchers and practitioners to provide insights into serving expectant and parenting teens through the PAF program. The articles in the supplement include examples of programs that use different intervention strategies to support teen parents, with programs based in high school, college, and community settings in both urban and rural locations. Some of the articles provide rigorous evidence of what works to support teen parents. In addition, the articles demonstrate key lessons learned from implementation, including allowing some flexibility in implementation while clearly outlining core programmatic components, using partnerships to meet the multifaceted needs of young parents, hiring the right staff and providing extensive training, using strategies for engaging and recruiting teen parents, and planning for sustainability early. The studies use a range of qualitative and quantitative methods to evaluate programs to support teen parents, and three articles describe how to implement innovative and cost effective methods to evaluate these kinds of programs. By summarizing findings across the supplement, we increase understanding of what is known about serving expectant and parenting teens and point to next steps for future research.Until recently, federal programs had not explicitly focused on improving the outcomes of highly vulnerable teen parents. Established in 2010, the Pregnancy Assistance Fund (PAF) aims to improve the health, social, educational, and economic outcomes for expectant and parenting teens and young adults, their children, and their families, through providing grants to states and tribes. This article introduces the  There is limited research on what works to support expectant and parenting teens and how to successfully implement programs to serve them. This introductory article highlights key findings and lessons learned from the supplement “Supporting Expectant and Parenting Teens: The Pregnancy Assistance Fund,” which provides insights into serving expectant and parenting teens through the Pregnancy Assistance Fund. Rigorous research shows programs can improve outcomes for teen parents. Key lessons learned from program implementation include allowing some flexibility in implementation while clearly outlining core programmatic components, using partnerships to meet the multifaceted needs of young parents, hiring the right staff and providing extensive training, using strategies for engaging and recruiting teen parents, and planning for sustainability.Expectant and parenting teens face immense challenges completing education, finding work, and earning family-supporting wages  within colleges helped to identify and recruit participants. Program administrators reported the program champion’s recruitment via word of mouth and his or her promotion of activities/services were most successful in reaching potential PAF participants (Askelson et al. Recruiting and engaging teen fathers is particularly challenging, in part because they are harder to identify. For example, although a school-based program like New Heights attracted 75% of all teen mothers in their schools (Asheer et al. In the context of limited funding and the substantial needs of teen parents, organizations must focus on sustainability to maintain services after grant funding ends Seifer . The PAFCommunicating regularly with key stakeholders, building partnerships, and other sustainability activities helped grantees to identify new funding sources, keep programming relevant, and build support for their programs (Amenumey et al. The studies in this supplement use a range of qualitative and quantitative methods to provide insight into serving expectant and parenting teens. In addition to more traditional research methods, some studies use innovative methods such as presenting Bayesian impact estimates alongside traditional impact estimates (Zief et al. The evaluation of the New Heights school-based program used a rigorous difference-in-differences design based on administrative data to determine effects on teen mothers’ educational outcomes (Zief et al. Participatory research methods can involve community members in analyzing and reflecting on information generated by the research process. Two articles present examples of using participatory methods to evaluate systems-level approaches to serving teen parents, which may be particularly challenging to evaluate because of their complexity. One article used ripple effect mapping to identify stakeholders’ perceptions of success through a participatory process (Workman and Browder This supplement makes important contributions to both research and practice related to serving teen parents. Two impact studies, one of which was a replication study, and a systematic review, which included other recent studies funded by the U.S. Department of Health and Human Services in addition to a broader range of studies, illustrate that there are effective programs for promoting positive outcomes for teen parents (Zief et al. In addition, the supplement articles demonstrate five key lessons learned from implementation, including allowing some flexibility in implementation while clearly outlining core programmatic components, using partnerships to meet the multifaceted needs of young parents, hiring the right staff and extensively training them, using strategies for engaging and recruiting teen parents, and planning for sustainability early. First, outlining core program components but allowing flexibility can assist programs to meet the complex needs of teen parents. Program developers and supervisors may wish to incorporate guidance on how program implementers can be flexible while maintaining fidelity to the core components. Second, partnerships are needed to support the multifaceted needs of teen parents. Program implementers should consider how to develop strong partnerships to meet the complex needs of expectant and parenting teens. Third, staff are crucial for strong program implementation. Programs should work to hire the right staff to serve teen parents, including teen fathers; they can do this by clearly defining expectations for staff. In addition, programs should expect that intensive support and guidance may be required to ensure program staff implement programs with fidelity, particularly when the program is new. Fourth, recruiting and engaging teens is challenging. Programs must focus attention on recruiting and engaging teen parents, particularly fathers. Strategies that may be effective to support recruitment and engagement include having a program champion to promote activities, offering teen parents social activities and support groups, building strong staff-participant relationships, providing concrete supports to teen parents, and using technology. Fifth, early and strategic planning for sustainability can help programs support teen parents over the long term.In addition to adding to the knowledge base on what works to support teen parents and lessons learned in serving them, the supplement also illustrates how a range of qualitative and quantitative methods can provide insight into serving teen parents. Using administrative data can help programs rigorously evaluate their outcomes in a more cost-effective way. In addition, more innovative, participatory approaches can provide useful tools for evaluating complex initiatives. Evaluators of programs serving pregnant and parenting teens should consider methods from the full research toolkit.Although these studies provide important insight into serving teen parents, additional research is needed. Only two studies provide rigorous evidence of program effectiveness. We need more rigorous research, including on what works to support groups who have received less attention such as fathers, college-age parents, and parents experiencing intimate partner violence. Programs are often small, which is a challenge for rigorous evaluation, but new Bayesian methods can be helpful for interpreting findings from small-scale evaluations. Next, program components research that examines how specific components contribute to outcomes would be useful because programs are often multi-component. We also need more systematic examination of partnerships to serve teen parents. Social network analysis may be a promising tool for understanding how partnerships strengthen over the course of program implementation, but rigorous research is needed to determine whether strengthening partnerships actually improves service delivery and teen parents’ outcomes. Finally, these articles provide suggestive evidence of how to recruit and engage teen parents, including fathers, but more rigorous research using rapid cycle learning methods to trial such tactics could help programs understand the most effective recruitment and engagement strategies.


Physical activity (PA) is a modifiable risk factor for postnatal depression (PND) and programs are needed to enhance PA amongst women at risk of PND. Key stakeholder involvement in informing development and implementation of such programs is vital. However, little research demonstrates key stakeholder insights to inform the design and delivery of PA programs for improving PND. The aim of this study was to explore key stakeholder perspectives on the design and delivery of a home-based PA program for mothers with PND symptoms to inform future real-world implementation and scale-up.n = 11). Interviews were conducted between September to November 2019 and explored stakeholder perceptions on the design and delivery of a home-based PA program for mothers with PND symptoms. The interview schedule was informed by both the Consolidated Framework for Implementation Research (CFIR) and the PRACTical planning for Implementation and Scale-up (PRACTIS) guide. Data were analysed thematically using both deductive and inductive coding.A descriptive qualitative study was undertaken whereby semi-structured interviews were conducted with representatives from various key stakeholder organisations involved in postnatal PA and/or mental health, public health and policy in Australia . Planned components of the program were suggested to align (i.e. relative advantage) with existing initiatives (e.g. equipment hire for nurseries scheme) and screening systems for PND . Perceived barriers to scale-up included logistics/cost of equipment, organisational capacity demands and safety risks/liability. Perceived enablers to scale-up included linking the program with ‘adjunct’ programs and services.The While the program was appealing and most organisations could see a role in endorsing and/or referring to the program, funding and delivery mechanisms still need to be identified.The online version contains supplementary material available at 10.1186/s12889-021-10394-8. Postnatal depression  , 10. AltStep 1) Characterise parameters of the implementation setting ; Step 2) Identify and engage key stakeholders across multiple levels within delivery systems ; Step 3) Identify contextual barriers  and facilitators to implementation ; Step 4) Address potential barriers to effective implementation   team, it is something that we recognise as being really important for women through pregnancy and then also postnatally. I would say we talk about it in every interaction we have with someone who’s pregnant or postnatal, whether that’s the inpatients, outpatients or group education sessions” .Most stakeholders indicated that physical activity promotion was a priority within their organisation, particularly those working in postnatal physiotherapy who articulated the physical and mental health benefits associated with postpartum physical activity.“… it’s not a priority to the extent that we would look to providing physical activity programs, but that said, part of that is because our brief is a national brief and it’s impossible to provide that kind of program on a national basis without obviously extensive resources and so we wouldn’t prioritise that” .However, one stakeholder stated that physical activity was not prioritised as their organisation simply did not have the resources to promote physical activity, due to competing priorities.“… it’s a strong focus. We have a number of programs which I guess you would categorise as enhanced services, so additional visits by the nurse, home-based visits by the nurse and there may be referrals to other services, both mental health services and early parenting services” .A handful of stakeholders reported that their organisation currently had existing programs supporting women at risk of postnatal depression. These programs/initiatives included scheduled screening appointments for PND, group-based social support programs and services from maternal child health nurses such as home-based visits to women at risk.“[The program] is a mother and baby program, we do singing and movement with mums. They all love that, and these are women with postnatal depression and anxiety. We’re using that mainly as a way of engaging with the baby and encouraging play and interaction, but the mums… from a physical activity point of view…they’re actually getting up and doing something so it’s quite nice” .Most stakeholders reported their organisation had no existing physical activity programs supporting women at risk of postnatal depression. However, one stakeholder reported that a yoga program and music therapy/ dancing program was offered to mothers experiencing PND and anxiety at their organisation. These programs were designed predominately to increase mother-baby bonding.Most stakeholders perceived the program as feasible for real-world implementation, although a few suggested that this may depend on factors such as cost of equipment  and whether the program is an adjunct to existing programs (see ‘Enablers of Program’ below).…I think it is absolutely brilliant because I know how hard it is as a new mum to exercise…There’s always something that stops you be it sleep time or nap time or it’s too hot or the baby might need to feed- so I think if you can do anything at home, it’s going to be significantly more accessible than outside of the home environment” .Most stakeholders suggested that the program was appealing as it breaks down the barriers postpartum women experience in relation to physical activity.“.. six to eight weeks would be a good starting point because it’s when people are at that point where they’re not as overwhelmed by the baby and they’re ready to invest a little bit in their own health” .A theme that emerged was the timing of the intervention which included both the time-point in the postpartum period that women would receive the program and the time of year the program was offered. Two stakeholders clarified that screening for PND occurred at 4 weeks postpartum, which could be an optimal time to refer to the program. One stakeholder stated that commencing the program at six to 8 weeks postpartum may be more effective than at 12 weeks postpartum as it would allow women to initiate physical activity and build their self-efficacy earlier post-childbirth.“I think particularly in the winter months, the clients would love it. I’m not sure whether in the summer months it would be as popular” .In addition, one stakeholder believed the feasibility of scaling up the program would also be dependent on the time of year the program was offered to participants.Both sub-themes included an “equity” focus, providing suggestions on how to reduce socioeconomic and/or cultural inequalities within the program design/delivery.“…there’s probably multiple solutions for people. …where some patients get the option of just getting the text messages and the park meet up but then you actually want the equipment at home so that’s a good program for you. .Two stakeholders suggested women could be provided with greater flexibility in the option of choosing the program components  they preferred, rather than providing all components to all women.This ‘multi-pronged approach’ was further highlighted by another stakeholder as a strategy to enhance equity across different socioeconomic groups, suggesting that the most socioeconomically disadvantaged women (e.g. low income) could receive the ‘full program package’ , whilst those who are of a higher socioeconomic position (e.g. high-income) may receive just certain elements (e.g. just the web-app and online forum).“We have a large Chinese and Indian Community here and quite a few of them adhere to cultural confinement too so they don’t leave the house for four to six weeks... so we visit them at home until they’re ready to come to a centre. But probably that would be too early to introduce the program to them” .The importance of cultural considerations in both the intervention design and content particularly in the web-app was highlighted by one stakeholder. Cultural confinement post-childbirth was one factor that could impact on participant recruitment and timing of the intervention.In addition, it was suggested that having the web-app content translated into other languages would make this program more culturally appropriate and reach women with or at risk of postnatal depression who are more likely to be socially isolated.“There was that walking one- this was a couple of years ago now, but it was pram-walking and that showed definitely, yeah, improvements in physical activity” .The majority of stakeholders reported they were not aware of any similar existing programs run by other organisations. A few stakeholders, however, mentioned hearing of pram-walking groups (without being able to provide specific details of these), although it was acknowledged that such programs required a different level of involvement from participants .Mums on the Move, suggesting that there is precedence of free hire equipment being made available to families of low socioeconomic position.“There are some related programs that focus, for example, on things like nursery equipment and so forth where we fund the provision of equipment but that’s not exercise equipment specifically” .Although not related to physical activity or postnatal depression specifically, one stakeholder described an existing program whereby nursery equipment is offered/provided to socio-economically disadvantaged families with babies, free of hire charge. That program strategy evidently aligns with that of “I think the only issue would be the logistics of getting the exercise equipment in the home but if that’s not a big issue, I don’t think it would be a problem at all. I’m tipping hiring the equipment is probably fairly pricey too so that could be an issue” .A handful of stakeholders expressed concerns about the reliance on equipment within the program and the logistics/costs associated with providing the exercise equipment, being viewed as potential barriers to the scale up of this program.“…we’ve got to put into context is all the budget commitments for the state in regard to maternal and child health. Everything from baby bundles, to first aid courses, to checking car seats, to information sharing, to family violence and the autism screening which has just been rolled out. I can tell you that most nurses will say this looks amazing, but I’ve got no capacity [to deliver the program]” .A few stakeholders mentioned they simply did not have the capacity to incorporate another program within their organisation as they lacked resources and were overloaded with additional programs.Mums on the Move. It was suggested that a signed document from participants would be essential to ensure organisations involved were not liable. Alternatively, one stakeholder suggested providing play pens with the exercise equipment, which would ensure young children are not at risk whilst the equipment is in use, could be one strategy to overcome this concern.Some stakeholders discussed the injury risks (for mother or baby) associated with the program and the potential liability of their organisation if they were involved in the scale up of Mums on the Move program to existing programs (i.e. ‘piggy-backing’) could facilitate program scale up. This could involve integrating the program within existing services, programs and referral systems.A few stakeholders believed that linking the A couple of the stakeholders (including those representing non-government organisations) stated their organisation could have a role in funding the program. However, most stakeholders felt their organisation would not be able to fund it due to budget restrictions and rather would be involved in scale-up in other ways . Those stakeholders further suggested that other funding bodies could include the Government , advocacy groups, community funding, sports owning bodies, grant funding and non-government organisations such as the Heart Foundation, Beyond Blue, YMCA.“So….it could be a number of different referral points or it could be GP’s in partnership with the state health departments” .Organisations already listed above as potential funders  were also suggested by stakeholders as being organisations that potentially could be involved in endorsing the program. In addition, some stakeholders stated that referrals to the program could come from primary health care professionals.Stakeholders were asked about organisations that could potentially deliver the program, however none were suggested.Key stakeholder analysis is a critical step to facilitating implementation of physical activity programs, ensuring programs are ready for real-world roll out. However, little research to date has explored key stakeholder insights to inform the design and delivery of physical activity programs, particularly home-based programs, for preventing and/or managing PND symptoms.Overall, most stakeholders suggested that the relative priority of their organisation in targeting physical activity and/or postnatal depression was high in line with a national focus on these issues. However, no physical activity programs specifically targeting women at risk of PND were identified by stakeholders, highlighting a major gap. Although the evidence linking physical activity to PND prevention and/or treatment is understood by such organisations, little action has been taken to develop and/or implement physical activity programs for women at risk of PND. This finding is in line with calls to action by researchers and professional organisations for the implementation and translation of feasible physical activity programs for mental health into routine practice .Mums on the Move program was perceived by stakeholders as appealing, particularly due to its ability to overcome major barriers to postnatal physical activity. This is consistent with the views of participants (i.e. women experiencing heightened PND symptoms) in the proof of concept study [The pt study , who sugpt study ), and 2)pt study ); and 3)Additionally, suggested adaptations/alterations took on an equity lense as they aimed to reduce socioeconomic and cultural inequalities within the program. This was via either offering a different program dose based on either 1) socioeconomic position ; or 2) ensuring the program content (particularly the web-app) was translated into various languages. The importance of women being able to choose which components of the program they wanted  was also highlighted. Given that PND is socioeconomically skewed  and thatMums on the Move aligned with other existing programs or initiatives in the postnatal space. This included a Government funded program, which provides large equipment free of hire (i.e. nursery equipment such as cots) to disadvantaged families. Given that the cost and logistics of exercise equipment hire was identified by stakeholders as a potential barrier to scale-up, this demonstrates that provision of free equipment hire for postnatal women already occurs within existing Government systems. Pram walking groups were also suggested by stakeholders to align with the Mums on the Move program. Although limited evidence has shown pram walking groups may improve PND symptoms in a research setting [Mums on the Move is able to . Yet, these groups could be used as an adjunct strategy within the Mums on the Move program . This could be particularly useful as a maintenance strategy for when the exercise equipment is removed after the initial 12-week ‘equipment’ period.Despite no existing similar home-based physical activity programs being identified for the prevention or treatment of PND by the interviewees, it was suggested that  setting , pram waMums on the Move. Finally, few organisations suggested they would be involved in the funding or delivery of the program and most would be referring organisations. Thus, more evidence of cost effectiveness of such programs is required before organisations might invest in this type of program.Another barrier to scale-up identified by stakeholders was organisational capacity/competing priorities. This finding is consistent with those of a systematic review investigating barriers to scaling up health programs . Most orn = 12) which may have limited the range of stakeholder perspectives and insights provided. For example, a couple of major mental health support organisations declined to participate due to not having capacity at the time. Further, the perspectives of maternal child health services located specifically in socio-economically disadvantaged neighbourhoods, as well as organisations with the potential to fund such a program may be underrepresented. The focus on one specific physical activity program may limit the transferability of the findings to physical activity programs offered to women in other settings and contexts. However, many of the issues identified such as the fit with existing programs, program complexity, appeal, timing, adaptations, cultural considerations, funding and referrals are likely to be important in the scale up of many physical activity programs. We acknowledge there is the potential for social desirability bias given the interviewer was also the designer / developer of the intervention, although steps were taken to minimise this (described earlier). Stakeholders (participants) were not known to MT, except for one. We acknowledge that some interviews were short in duration, and this may reflect the fact that some participants were in busy policy positions and had more limited time to contribute. A one-page brief of the project was however provided prior to the interview to provide necessary background information.This study has a number of strengths and limitations. Strengths include the recruitment of representatives from a broad range of stakeholder organisations relevant to physical activity and/or postnatal health/mental health, who were equipped to provide expert opinion on the potential scalability of the program. Further, the qualitative study design enabled rich and detailed insights on a previously under-studied research topic. The interview schedule and coding framework were guided by existing implementation and scale up frameworks for informing program implementation and scale-up of physical activity programs  , 18 ensuMums on the Move program, but also inform the broader researcher community on key program considerations, barriers and facilitators for implementing public health programs. Despite being appealing such programs should consider ensuring: 1) Programs address inequalities in health ; 2) Programs are designed with potential to embed within existing infrastructure, services and systems; 3) Organisations responsible for funding, endorsement and delivery are identified early on. Given that most stakeholders suggested that the potential role their organisation would play in scale-up and implementation of Mums on the Move would be in referral/endorsement of the program, further exploration of potential organisations as funding and/or delivery agents is needed.To date, limited implementation research in the area of physical activity and PND has been conducted. This study demonstrates the importance of working with stakeholder organisations in the co-design of physical activity programs to promote mental health in postnatal populations. Findings not only inform the scale-up and implementation of the Additional file 1: Table S1. Interview schedule and related CFIR and PRACTIS constructs


World Health Organisation (WHO) recommends that countries conduct comprehensive national immunisation programme reviews regularly to help them identify systems wide-barriers or gaps and monitor performance against the set targets.we reviewed reports from the latest national immunisation program reviews conducted in the 20 countries in the subregion in the course of 2012-2018. We generated descriptive analysis of the findings across the subregion.the 20 program reviews included field observations to the subnational levels as well as interviews with program staff and stakeholders. At the time of the reviews, only 11 countries had functional National Immunisation Technical Advisory Groups. Operational funding was inadequate in half of the countries. The reviews documented the cancellation of outreach services, supportive supervision visits and maintenance of cold chain equipment due to the lack of fuel or operational funding. Immunisation programs in 10 countries had major human resource gaps. Vaccine stock management tools were not effectively used in 10 countries, and stockout of vaccines and supplies was documented in 9 countries during the review. The full components of the Reaching Every District (RED) Strategy were implemented in only 3 of the 20 countries. Twelve countries reported challenges with the availability and accuracy of target populations. Four countries had documented the presence of vaccine hesitant groups at the time of the reviews.the reviews demonstrated challenges in various aspects of the programs in different countries. The implementation of the review recommendations should be built into the annual program plans, as well as into costed multi-year plans, in order to address the gaps and helps the program to attain the set targets. With the rapid evolution of the scope and complexity of the immunisation programs in recent years, countries should invest their efforts in building the capacity of their human resources as well as updating their logistics and data systems. In May 2012, the World Health Assembly (WHA) endorsed the Global Vaccine Action Plan (GVAP) -5. On thThe monitoring of vaccination service delivery data is done by recording the number of doses of antigen delivered in each health facility and aggregating it at the district, provincial and national levels. Administrative coverage is calculated by dividing the number of doses provided by the target population  for the particular catchment area. The target population is generated from census data or from projections made based on recent census data. Considering the challenge with the accuracy of numerator and denominator information, WHO and UNICEF generate annual estimates of coverage for each antigen for each member State using the provided administrative data, information from coverage surveys, logistics information and other programmatic data. These WHO estimates are only generated for the national level . Data quComprehensive Immunisation Program Reviews are cross-sectional program assessments that are conducted through the review of documents and data, the interview of immunisation program staff at national and subnational levels, as well as field visits to provinces, districts and to service delivery sites. The data from the program review is collected using standardised data collection tools developed by WHO AFRO, which are adapted to the individual country context. The tool includes sections that cover the following thematic areas: (i) Leadership, governance and coordination; (ii) Human resource management, capacity building and supervision; (iii) Vaccine supply quality, logistics and cold chain; (iv) Service delivery; (v) Data monitoring, immunisation quality and vaccine preventable diseases surveillance; (vi) Demand generation, social mobilisation and advocacy. At the end of a program review, the findings and the recommendations are compiled by the review team in a formal report and presented to the respective Ministry of Health. We reviewed the detailed narrative technical reports generated from each of the national immunisation program reviews conducted in the 20 countries in the subregion in the course of 2014-2018. We conducted a descriptive analysis of the findings from the review exercises and attempted to do a summary of the findings by thematic areas.Each of the 20 countries conducted at one national immunisation program review between 2012 and 2018 . These 2Leadership, governance and coordination: at the time of the program reviews, 16 of the countries (80%) had some sort of legislation promoting immunisation, and 13 (65%) had updated immunisation policy documents. All except one country had updated comprehensive multi-year plans for immunisation (cMYPs). Full government financing of the immunisation program was documented in the 6 countries while 14 countries (which were GAVI eligible) depended on complementary support from partners such as GAVI for new and underutilised vaccines and UNICEF for the purchase of traditional vaccines. Immunisation services were provided free of charge in public health institutions in all countries. In the area of coordination, only 11 countries had functional National Immunisation Technical Advisory Groups (NITAG), while 17 countries had National Regulatory Authorities (NRA) at the time of the review. The 6 self-financing countries did not have functioning Inter-Agency Coordination Committees (ICC), while in 10 of the remaining 14 countries, the ICC was playing a key role in the coordination of partner support to the national immunisation program. The level of coordination between the immunisation program and the unit responsible for disease surveillance was limited in 8 of the 20 countries. Operational funding was inadequate in half of the countries in the sub-region. The reviews documented the cancellation of outreach services as well as the regular conduct of supportive supervision and maintenance of cold chain capacity at sub national level in these countries, mainly related to the lack of fuel or funds to rent vehicles.Human resources management, capacity building and supportive supervision: ten (50%) countries had gaps in the number of staff and the skill mix required to run an efficient immunisation program at national and sub-national levels. These countries also lacked clear terms of reference or job descriptions for the assigned focal persons who were engaged in the day-to-day management of the immunisation program at different levels. Seventeen countries (85%) had clear plans for program supervision. However, supervisory visits to the subnational levels were inadequate or irregular in 4 of these 17 countries, due to limitations in funding and means of transport. Standardised tools for the supervision of immunisation services were available in only 14 of the 20 countries.Vaccine and cold chain logistics: vaccine stock management tools were not effectively used in 10 (50%) countries, with tools lacking or outdated or not used regularly to monitor vaccine stocks at the health facility levels. Stockout of vaccines and supplies at the sub national level, lasting more than 3 months, was documented in 9 (45.0%) countries during the review. It was documented that 4 countries had frequent power interruptions and inadequate backup generators. Five countries did not have an updated cold chain equipment inventory system and no cold chain rehabilitation/replacement plan at the time of the review. The cold chain capacity was considered inadequate according to the reviews in 4 countries mainly at the sub national level . At the time of the reviews, 14 countries (70%) did not have up-to-date operational level micro-plans for routine immunisation services. In addition, 9 (45.0%) countries were not able to organise outreach services as planned due to transport and field staff constraints. Five (25.0%) countries also did not have enough cold chain equipment to run outreach services. At the time of the reviews, three countries had not yet introduced AD syringes for use in their immunisation programmes. Defaulter tracing mechanisms were available in only 12 (60%) countries  out of the 20 countries. Besides, the review in ten countries detected gaps in the systematic use of data for decision making, especially at the district and health facility levels, linked mostly due to knowledge gaps and limited resources. Data quality review and data harmonisation meetings were held regularly in 13 (65%) countries. Seven countries reported major challenges with their monitoring systems. These included denominators projected from outdated census causing significant over or under-estimation of the real target population, too many monitoring tools, discrepancies in the data across different administrative levels, as well as limited time and capacity to analyse and use data for decision making  countries. In 5 countries, it was noted that communication efforts were well developed for new vaccines introduction and Supplemental Immunisation Activities (SIA) but quite weak in promoting routine immunisation and community surveillance. Four countries had documented the presence of vaccine hesitant groups at the time of the reviews. Four (20%) of the 20 countries did not have communication messages tailored to address specific groups.The findings in this summary have been aggregated and no specific country detail is given, since the main objective of the study was to demonstrate the challenges countries face in general. Moreover, since the reviews took place in the years 2012-2018, it is expected that any gaps have been addressed by the specific countries following the review exercise. While 12 of the 20 reviews were conducted in the last 5 years, 40% were conducted more than 5 years ago indicating the need for timely program reviews to steer the programs in the right direction. Immunisation program reviews cover a broad scope of program area but may not always achieve the necessary depth given the limited time allocated to the exercise . When inet al. have identified six common drivers of routine immunisation coverage improvement. These include the presence of a cadre of community-centered health workers, health system and community partnership, regular review of health workers performance, the delivery of immunisation services tailored to community needs, political commitment to routine immunisation, and the actions of development partners. The study claimed that the presence of all six factors together was found to have positive impact in terms of coverage improvements [The growing complexity of the immunisation area of work in the last two decades requires the presence of strong human resources with the necessary managerial skills and tools. Findings from the reviews show that half of the countries were experiencing limitations in their human resource capacity within the national program and at sub-national levels. Health worker training plays an important role in improving overall performance including vaccination coverage ,17. Otheovements . The finet al. have found that geographic inaccessibility of services, vaccine stock-outs and/or cold chain problems accounted for the majority of missed opportunities for the vaccination of children in many countries [It is well known that service factors and parental attitudes and knowledge are some of the most important reasons for non-vaccination. Among the service factors, Favin ountries . A lot oountries . The revountries ,28. The ountries ,30. Notiountries .Limitations of the study: these national immunisation program reviews were conducted using similar approaches and tools, but the review was conducted by different teams and using tools adopted for the national context. This may result in differences in the formulation of the review questions and interpretation of data. During these reviews, the sampling of subnational units was done purposively to strike a balance between urban and rural districts as well as strong performing and weaker districts. Therefore, all the results may not be comparable across the countries. In addition, it is expected that the countries will have acted upon the review findings and made the necessary program changes since the reviews, and so the results may not reflect the current situation at country level at the time of publication.The national immunisation program reviews in the sub-region have been useful tools to identify barriers or program gaps and generate recommendations for the national program and local partners to address the barriers or gaps. The reviews in the subregion have demonstrated challenges with regards to various aspects of the programs in different countries and unless addressed they will fail short to ensure provision of equitable immunisation service delivery. The follow up of recommendations to address the challenges and gaps constitutes an essential component of the review exercise aiming to enable them to attain the set targets. Countries should invest in continuous and systematic capacity building, in the context of the continuously evolving and expanding immunisation program. In this context, we also recommend that countries should plan for and conduct EPI program reviews at least every 4-5 years, preferably timed to provide inputs into program plans along with setting up mechanisms to regularly monitor program performance and address gaps, as well as to follow up and implement recommendations from review exercises. These EPI reviews may not constitute an in-depth evaluation of all program components, indicating the need to tailor the implementation of the reviews towards specific aspects of the program, based on the country context and preliminary findings. In addition, as necessary, countries may plan to conduct in-depth evaluations and root cause analyses.Comprehensive national immunisation program reviews are conducted once every 4 to 5 years in low- and middle-income countries, in order to identify program areas for improvement, realign program focus as necessary and prepare the program for the introduction of additional program elements;Comprehensive program reviews are complementary to reviews with in-depth focus on specific program components;Recommendations generated by program reviews help countries to focus their efforts to address major program gaps.With the rapid evolution of the scope and complexity of the immunisation programs across the Region, countries should build in methods to regularly review program performance and develop their strategic directions with the required investments for program sustainability and also invest in capacity building;A significant proportion of national immunisation programs in the subregion continue to have gaps in their implementation of the Reaching Every District Approach, in their human resource capacity, as well as in their logistics and data management systems;The follow up of the review recommendations will be critical to address the identified system-wide barriers or gaps in order to strengthen the immunisation program and enable it to attain the objectives.


Taiwan was the first Asian country to endorse patient autonomy, and advance care planning (ACP) has been highly promoted to improve quality of end-of-life (EOL). A mixed-methods pilot survey was conducted in northwestern Taiwan to investigate older community-dwelling residents’ (N = 52) ACP behavioral engagement, socio-demographical correlates, and their preferred intervention strategies. An interview subset  was purposely chosen for in-depth feedback and rationales behind their ACP decision-making. Rich information was obtained about perceived facilitators and inhibitors to initiate ACP and preferred intervention strategies in ACP programs. Consistent with previous literature, carefully designed ACP programs that incorporated family decision-making and met older subjects’ multiple needs would increase program acceptability and foster ACP engagement among older Taiwanese in the community setting. Advance care planning (ACP) is a process that aims to support patients’ medical decisions in the event of incompetency ,2. ACP hIndividuals’ ACP updates vary across settings and populations, between 7.8% and 60%, particularly higher among western mainstream cultures . DespiteACP uptake in Taiwan is between 10–12% ,14. TaiwAlthough efforts have been made by the government to support palliative care, the general stage of the Taiwanese’s readiness for ACP is still in its infancy. Results from a nationwide Taiwanese survey in 2010 showed that ACP was not commonly mentioned among oncology care physicians and nurses, and their own ACP engagement was largely influenced by knowledge and attitudes related to the Hospice Palliative Care Act . WhereasTo ultimately increase ACP uptakes, this pilot study made an initiative to assess readiness for ACP, discover significant socio-demographical correlates, and investigate program strategies preferred by older community-dwelling residents. A mixed-method design was employed in which both qualitative and quantitative findings collaborated to explore facilitators and inhibitors that possibly influence subjects’ ACP engagement.Approved by the Mackay Memorial Hospital Institution of Review Board , this descriptive study was part of the “Northwestern Taiwanese Residents’ Health Examination Survey” and an exploratory triangulation design   was emplOur data were collected from two government-contracted health examination centers in northern Taiwan. Potential subjects (≥65-year-old) were already in the national geriatric registry and recruitment flyers were posted with participation criteria at the time of free health check-ups. The inclusion criteria for this pilot study were self-identified Taiwanese in the community. Specifically, they were aged and above 65-year-old, currently un-institutionalized, legally competent for making life-support decisions, and communicable in Mandarin and/or Taiwanese about their current medical conditions and EOL preferences. Excluded were those who were critically ill, hospitalized, institutionalized (in nursing homes or hospices), legally incompetent for ACP decisions, and/or unable and reluctant to discuss ACP matters during the data collection period. Specific attention was paid for the influence of gender in this cross-sectional study, yet no evident patterns were found in the final sample. There was no noticeable gender difference in the interview subset as well.Older community-dwelling Taiwanese subjects eligible for this study were immediately approached, and those agreed to discuss their ACP engagement were invited to a separate waiting room. After they completed their annual health examinations, written information was provided about this pilot survey. The anonymous and voluntary (no participation fees) nature was verbally explicated before obtaining oral informed consents. All survey data were de-identified and separated from their health examination in the hospital database. While subjects’ risks for participating in this study were no greater than those who did not participate, the ethical approval was granted for an institutional data analysis in which subjects’ signatures were waived.Within the 6 months of data collection, sixty-six potential patients were approached. Among them, six (9%) were excluded due to their nursing home residency. Eight qualified individuals (12.1%) declined to participate, allegedly due to unavailability. None of these potential older community residents reported being offended by the survey topic. Each older Taiwanese in the final sample (N = 52) completed a bespoke type of questionnaire  establisBased on behavioral change constructs of Prochaska’s Transtheoretical Model (TTM) ,30, inquIn order to precisely identify each subjects’ readiness for ACP, a 7-item algorithm, rather than a summative scoring, was originally created according to the TTM stipulations to assess ACP behavioral readiness among Chinese-ethnic immigrants  Table 1Table 1. To account for older subjects’ education levels and survey burdens, questions were written in traditional Chinese at the fifth-grade literacy level, and survey readability was originally tested by two elementary school students. Older Taiwanese’s ACP engagement was on a theoretical basis, for example, if one has an AD legally completed more than six months ago and still continued to communicate his/her EOL preferences with family members, he/she would be placed in the most advanced stage of change, maintenance. On the contrary, if subjects had a lack of awareness , an avoidance , and/or a disbelief of such planning, they would be placed in the pre- contemplation stage. The final score of the stage of change measure ranged from “precontemplation (non-believers = 1 and believers = 2)” to “maintenance (6)”. The higher the stage score, the better the behavioral engagement. In this study, two nurse professors with palliative care expertise reviewed the algorithm scores and each subject was examined and manually positioned in one stage of readiness.p < 0.01), slightly higher than it was in the original older overseas population  [More than 1400 Taiwanese patients from different clinical settings have used this algorithm; older Chinese-ethnic Americans and Taiwanese in Asia both reported good clarity and ease of use. In this study, older Taiwanese generally completed the survey within 15 min without any confusion and the algorithm tool served well in distinguishing each subject’s readiness in one of the six stages for their ACP engagement. Good internal consistency was reported  .Our semi-structured interviews, a traditional form to collect qualitative data ,33, focuAll interview questions were open-ended which allowed the subjects to freely share personal stories and acquaintance with the EOL experience of others. Simple explanations of ACP concepts, such as life-sustaining treatment and ADs were introduced in a standard format in the guide to avoid medical jargons and possible distortion. For example, instead of using the term ACP, the interviewer explained this term by stating, “In Taiwan, people are encouraged to make life-support decisions about treatment and care when becoming seriously ill. There are clinics that you may pay for such guided discussions. We would like to know your plan should you become too ill to let others know of your preference at the time.” The final version of the interview guide consisted of the following sections: (1) an introduction section that allowed the researcher to get acquainted with the subject; (2) an assessment of ACP readiness, which included an understanding of their motivation status, pros and cons, and barriers specifically perceived related to ACP; (3) recommendations for ACP intervention strategies; and (4) reflections on the interview.All survey data were entered manually into SPSS Statistics for Macs, Version 19.0  for descriptive analyses. The final interview subset contained 6 males and 7 females whose answers were further clarified and coded, searching for the rationales behind ACP decision-making. Since the purpose of obtaining qualitative data from the older Taiwanese community sample subset was to support, clarify, augment, and possibly explain the quantitative survey data, in order to maximize variations, our interview subset (n = 13) was selected based on their demographical profiles and readiness .Qualitative data management analysis ,35 involAll fifty-two subjects resided within a 20-mile radius of the study site in northwestern Taiwan. One-fourth (N = 13) of them were purposely selected and individually interviewed for 25–40 min by one nurse researcher. The interview subset has a maximized socio-demographic variability to represent the whole sample .Each older subject was assigned to one of the six behavioral stages of readiness, according to their intentions for ACP, completion of advance directives, and status of EOL communication . Only twOur pre-contemplators also demonstrated lower self-efficacy than others in the communication aspect; they admitted being moderately to highly influenced by significant others whether to initiate ACP. While the Taiwanese cultural custom is a shared decision-making model within the family, the concept of family durable power of attorney for health (DPOA) is nonetheless strongly endorsed. “I definitely want my husband(wife) to decide for me.” However, many older subjects in fact reported their significant family members, unclear about their wishes, probably had no interest in serving as decision surrogates at this time point. Discouraging behaviors were also described during interviews, such as their EOL conversations being interrupted or stopped by their family members, “They think this topic is too negative… no need to mention this now.” Two were interfered by adult children with their wish to complete ADs. Subjects agreed that such discordant opinions in the family might have adversely affected their ACP engagement.p < 0.01) associate with ACP engagement. Household income and ACP engagement was weakly correlated , but this level of income was not significant in the six ordinal stages of readiness.To understand correlational relationships between subjects’ demographical characteristics and readiness for ACP , approprOlder Taiwanese subjects’ interest in the ACP program was quantitatively and qualitatively explored, along with preferred strategies that may facilitate their participation . The ideOlder subjects expected ACP sessions not longer than two hours (86.4%), and in order to gain fundamental ACP knowledge, 40% believed, “A one-time ACP 101 (introductory class) would be just sufficient.” Internet or computer learning was not popular in this age group due to technology limitations and computer unavailability. Among those highly educated and capable of accessing ACP information online, the self-learning mode was favored, “so I am not going to waste my valuable time sitting in a class.” One-on-one ACP sessions were popular since they tailor to individual needs, “I want to be taught by experienced social workers or nurse counselors.” ACP education is not to be offered by physicians because, “I am afraid that’s going to be too intimidating.” A small group of five persons (or fewer) was a recommended size , particuIn the multiple-choice section , though The major facilitator for older Taiwanese to engage in ACP was related to program characteristics. In fact, more than half of the written responses about program facilitators were subjects’ personal expectations and descriptions of an ideal ACP program. Reportedly, a carefully designed intervention would increase ACP readiness, such as resourceful lectures, a complete course agenda, an introduction about the speakers’ background and expertise, learning objectives, suggested readings, and events related to ACP. Rich information was also obtained about the program: older Taiwanese’s ACP engagement would be facilitated if a program was offered free of charge (or inexpensive), with a friendly atmosphere, in a comfortable learning environment, with a feeling of mutual trust between the lecturers and subjects, with a respect for privacy, and in a relaxing pace that they would not need to worry no homework or be forced to speak in the public. Program lecturers and developers were experienced physicians or professors good at teaching and currently practicing in the clinical field.A self-perceived availability for ACP was reported as an important facilitator, commonly described as, “when I have extra time”, “when I am not busy” or “when I become available.” In other words, subjects would better engage in ACP if “their time allows.” Another category of facilitators was older subjects’ physical condition, self-perceived appropriate to initiate ACP, “When I become older” or “I will have my ACP when becoming sicker.” Older subjects agreed that while they perceived no imminent needs, complicated with the medical uncertainty, it was natural “not to think about EOL now”. Last, older subjects’ willingness to participate in the ACP program rested largely on the availability and convenience of the program; in their words, “effortless.” Subjects admitted that they would “definitely commit better” if the program site was close to their residence or nearby MRT stations.Regarding the program inhibitors, the majority responded, “no comments”, “no idea”, or “no advice” due to a lack of ACP understanding. However, a pointless or abysmal program was reported to hinder subjects’ willingness to participate in ACP. Descriptions of such an “unworthy-to-go” program were mostly contrasting characteristics mentioned in the above facilitator section. Educational materials being excessively theoretical or too academic would also prevent participation. A continuing participation was determined by the success of the first meeting, “I have to say, the first impression about the program is important”.A category of reported hindrances of ACP engagement was again about subjects’ self-perceived unavailability (10.2%) and poor physical condition (6%). Interestingly, older subjects used the same reasons to rationalize their ACP decision-making. Six subjects  explained in their interview that being healthy was in fact a condition not suitable for ACP, “If I am being physically healthy, why would I go to ACP programs now?” A poor health status was also viewed as a situational inhibitor to prevent ACP, “If I cannot move around, I will not have energy to go to any health programs.” Older subjects resided in the suburban community, and most did not drive and came to the study site alone by public transportations without family members’ company. Although “poor access to the program site” was an inhibitor, transportation was not a general concern according to this relatively healthy sample. The Taipei metropolitan rapid transit was affordable and convenient for older Taiwanese to use in the community.To summarize, despite the general low readiness for ACP, older Taiwanese in this sample mostly well accepted and believed in the benefits of EOL planning in advance. The majority were interested in an ACP educational program, and specific and certain program strategies were preferred with rationales, such as the need for a short and useful ACP 101 lecture, the format of a small-group sharing and discussion, a self-learning method online, the preferred characteristics of the program contents, etc. The one-fourth interview subset provided details about an ideal ACP program with which they were unfamiliar, yet they anticipated, experienced developers/educators, practical program contents and effective teaching, and support for convenience and accessibility. Other than undesired program characteristics, inhibitors at the personal level included decreased physical functioning and stamina, a lack of awareness or inadequate knowledge, no sense of urgency, future EOL uncertainties, possible troubles and inaccessibility to the program site, and the difficulties of initiating EOL conversations, in particular with spouses and adult children in the family.Both qualitative and quantitative findings support that the majority of older community-dwelling residents are precontemplator-believers, potential for further ACP behavioral changes . RecogniExisting international literature shows multiple influencing factors to ACP uptake , includiIn addition to increased age, female gender is a common correlate of ACP discussions; particularly among urban, community-dwelling overseas Chinese immigrants ,38, beinLow awareness of ACP (never heard about ACP) is reported as one of the major ACP inhibitors . VariousOlder Taiwanese subjects’ little ACP comprehension and limited awareness are consistent with previous findings about ACP literacy among older community-dwelling Chinese-ethnic groups. Up to 2016, no ACP discussions were documented in China ,44, and Limited literacy presents a substantial barrier to ACP discussions , and forAcross a number of countries where is ACP is promoted, ethnic minority people’s ACP readiness is generally low : approxiEmerging literature shows that a shared decision-making model is desired among most racial and ethnic minorities, particularly in collectivistic cultures . The indHowever, family decision-making may be controversial if patients’ wishes cannot be respected and followed. Multiple concerns exist in the shared decision-making model, such as decisional regret, non-disclosure of the diagnosis, value conflicts, and proxy anxiety. Highly influenced by Confucianism beliefs, self-efficacy for ACP is often limited among older individuals of Chinese cultural heritage ,31,39 toThe reluctance of older Taiwanese’ family members to discuss EOL topics, regarded as a common ACP barrier among the older and frail group , is alsoIncorporating a familism value and cultural preferences into intervention programs will increase ACP discussions among diverse cultural groups, particularly in older Taiwanese. While the notion of familism is ingrained in Taiwan, family members remain important advocates to provide social and decisional support, facilitate communication with health care providers, and help overcome language barriers ,51. ACP What needs to be emphasized from our strategy findings are the implied challenges for program developers to design a practical and accessible ACP intervention in the community; in older subjects’ words, “something useful and worthy of my time.” Strategies older Taiwanese prefer are comparable to that of overseas Chinese Americans. A well-planned and structured educational program is considered the best facilitator of ACP behavioral change , and it An essential component of the program is to provide realistic guidance to maintain ongoing EOL communication within the Taiwanese family. With limited self-efficacy for ACP, a possible cultural taboo of death avoidance , and lowSince only very few health care professionals are formally trained to have ACP communication skills , a vast We believe “precontemplator-believers” is an appropriate readiness stage to increase ACP literacy , and comFor those older patients with symptomatic chronic, progressive illness, we believe community health care providers may utilize clinical scenarios to facilitate clients developing a more detailed advanced care plan, including a timely goal to complete ADs, identify health care surrogates, even appoint durable power of attorneys for health care (DOPAs). In a collectivistic culture, this is a good time to involve clients’ significant others in ACP discussions, and scripts and decision algorithms may be used to remind the whole family of the EOL goals ,55. We dRegarding the commonly mentioned ACP barrier, human being’s procrastinating nature ,57,58, oWe learned from our subjects that public media play an important role in shaping older Taiwanese’s death attitudes and impacting their awareness of EOL decision-making. Subjects reported EOL conversations usually occur in the family when watching life-support circumstances on TV or reading news about numerous deaths after natural disasters. Further market research will be valuable to understand what types of media older Taiwanese may be psychologically triggered to initiate ACP. Easy-to-access multi-media educational materials should be developed for older Taiwanese .In our experience, older Chinese and Taiwanese demand respect and generally do not want to be coerced ,18,22. WOur study lays the theoretical groundwork for future ACP program development. In this pilot stage, efforts that begin with subjects’ self-identified facilitators and barriers are appropriate, as suggested by a clinical framework for improving the ACP process . To faciDespite a modest sample size, findings from this study support our premise that the actual distribution of ACP engagement is highly skewed. Although evidence-based recommendations from the TTM research suggest dichotomizing the sample and focus on precontemplators, we recognize that the two groups do not fully represent the range of behavioral difference. Simplifying the ACP outcome reduces the outcome variance, leading to a possible lowering of correlation between ACP engagement and contributing factors. Larger community samples will statistically adjust this problem, and this is especially important when numbers in the advanced ACP stages (preparers and actioners) are expected to be low in Taiwan. In the future, interpretations of determinants should be taken into careful consideration if regressions analyses are to be performed.More research is required to validate and justify the six-month cutoff point for older Taiwanese subjects to progress forward to each stage ,30. Our Last, our descriptive study employs a mixed-methods design to combine both quantitative and qualitative results to gain insight into the readiness phenomenon ; elementWe recognize the inevitable bias of our non-probability, rather homogeneous sample; they are older, well-educated individuals physically transportable and accessible to the study site from a comparatively affluent metropolitan area in northern Taiwan. While not all eligible older Taiwanese had an equal chance to be included in this study, the selection bias limits the range and scope of our findings. In addition, significant effects explored from this modest-sized sample also attests to the robustness of our observed effects. For example, there may be correlational factors other than age and household income ,7,43.We strongly believe that minority groups’ voice should be heard , such asIn this pilot study, the relatively high level of openness in discussing death topics reflects only mainstream opinions or norms. While attained knowledge seems to be an important factor influencing ACP readiness , older TLast, since causal conclusions cannot be drawn by our cross-sectional study, longitudinal designs are needed to examine the influence of cultural beliefs, knowledge, and adult children’s surrogate decision-making on ACP engagement over time, as well as how these factors change in response to the changing communication landscape around EOL decisions. Despite these limitations, this pilot study made an initiative to understand community-dwelling Taiwanese’s ACP engagement when they were still physically and cognitively intact to access and well utilize health resource covered by national insurance.In conclusion, this mixed-methods study made an initiative to theoretically defined and assessed ACP engagement among older community-residing subjects in northern Taiwan. Socio-demographic correlates and influencing factors of program participation were explored, including facilitators, inhibitors, and useful intervention strategies preferred by this age group. In general, older Taiwanese of Chinese cultural heritage are at a fairly low stage of behavioral readiness; they perceived no imminent needs to proactively initiate ACP discussions and passively and infrequently communicated EOL decisions within the family. However, our results hold promise for older Taiwanese in the community to further engage in ACP. In contrast to the commonly known death taboos in Chinese culture, older subjects have openly discussed EOL decisions and provided rich information about ACP programs. Neighborhood out-patient geriatric clinics in Taiwan are potentials for conducting this type of community research, as well as for nurses to continue subsequent work to provide easy-to-access educational materials. Carefully designed interventions that apply “staged planning” principles, utilize clinical scenarios, and facilitate family-oriented ACP discussions will be essential to increase behavioral engagement and suit older Taiwanese’s multiple needs for ACP.


This study aimed to develop an education system using DVD video-based teaching materials or web-based learning to reduce sexual violence among teens in Japan.During the first stage, June 2018 to March 2019, an education program using DVD video teaching materials was carried out at three high schools and four universities with research consent from the director of the facility. From 1337 high school students and first- and second-year university students, subjects in their teen years were targeted for analysis. A survey was conducted at baseline and after the DVD video teaching. During the second stage, November 2019 to March 2020, web-based learning using improved video teaching materials was developed and carried out. From the adolescents who participated in the web-based learning, subjects in their teen years were targeted for analysis. A survey was conducted at baseline and after the web-based learning.In the first stage, 876 students consented to and participated in the education using DVD video teaching materials and baseline and after surveys (collection rate 65.5%). Among these, the number of respondents in their teens both baseline and after education was 705 persons . In the second stage, the number of respondents in their teens both baseline and after education was 250 respondents in their teens who received web-based learning using the improved video teaching materials . The improvement effect of the two programs was observed in attitudes that lead to physical violence, attitudes that lead to mental violence, attitudes that promote healthy conflict resolution, and dangerous attitudes that lead to sexual violence from persons in the community or through the Internet. The web-based learning program achieved an improvement of preventive attitudes toward sexual violence.The education program using DVD video teaching materials or web-based learning may help prevent sexual violence among teens in Japan. The World Health Organization (WHO) has recognized sexual violence as an important international health and human rights issue and recommends strengthening preventive measures . Sexual In Japan, the Domestic Violence (DV) Prevention Act was revised to allow protection orders to be issued also for cohabitating dating partners. Additionally, the Anti-Stalking Act was revised to regulate repeated sending of emails . In 2015In recent years, the percentage of adolescents with smartphones with daily access to the Internet has increased: approximately 70% of junior high school students and 97.5% of high school students . FurtherCohen and Felson proposed the routine activity approach, in which crime stems from three factors: a motivated offender, a suitable target, and the absence of a capable guardian . GottfreWhile group education to increase awareness of DV and promote respectful relationships has been carried out among junior high school students , there aThe objective of this study was to develop educational material for teens in Japan, using DVD video teaching materials and web-based learning, to prevent sexual violence, in particular, from intimate partners, persons in the community, or through the Internet. For the first stage, implementation of the program and assessment was carried out at junior high schools, high schools, and universities in some Japanese regions using DVD video teaching materials. Following the after surveys, the video teaching materials were refined by referring to comments and opinions from research collaborators. The objective of the second stage was to implement and assess education using a web-based learning program, which allowed users to improve their skills at their own pace regardless of location or time, through the use of improved and revised video teaching materials and personal computers or mobile terminals.To enhance the educational effects, this study used instructional design to build learning materials and processes through the introduction of the following: attention—“That seems interesting.”; relevance—“It concerns me.”; confidence—“I can do it.”; and satisfaction—“I’m glad I did it.” The theoretical concepts of the ARCS  model  and the In the first stage, the theme of the DVD video teaching material was determined to be “Hidden risks and enjoyment in relationships between you and me,” with a two-step learning structure. Viewing time was set at approximately 17 min for step 1 and approximately 21 min for step 2, for a total of around 38 min. Around 5 min was allotted for questions and answers at baseline and after learning.For the second stage, the web-based learning theme using improved DVD video teaching materials was set as “Hidden risks between you and me and a give-and-take enjoyable relationship.” Viewing time was set at approximately 15 min for step 1 and approximately 17 min for step 2, for a total of around 32 min. Approximately 5 min were allotted for questions and answers at baseline and after learning  Learning about diversity in sex—sex is one of our inherent characteristics. Some people may have a sexual orientation toward the same sex, and some may feel troubled due to a sense of discomfort with the mismatch between their physical appearance and sexual mindset. Students learn about diversity in sex and think about individual dignity and fair relationship with others. (2) Learning about sexually transmitted diseases—learn about the changes in the number of patients with sexually transmitted diseases in Japan, the routes of infection, and symptoms. Preventive methods are also presented. (3) Learning about dating violence—explore the status of male and female victims and understand the hidden risks in a person close by, by viewing videos of dating violence. (4) To think about a fair relationship—by watching a video in which both female and male avoid becoming a victim, students think about countermeasures to avoid becoming either an assailant or a victim of dating violence and become aware of the actions that should be taken in threatening situations. (5) Summarizing what students learned.Step 2 was “Learn about the risks in relationships, either face-to-face or through the Internet, and their prevention”: (1) To learn about sexual crimes in the local community—the characteristics of assailants of forced intercourse and indecent assault and the number of crimes involving male and female victims. Students are also expected to understand the local community’s current status through case studies of female and male victims. (2) Students consider the risk when information is transmitted to an unknown person via the Internet. The hidden risk of the Internet is explored through video case studies and countermeasures. (3) To learn how to prevent unwanted pregnancy—students learn about pregnancy and birth control methods to avoid pregnancy. Measures that can be taken in case of sexual violence are also discussed. (4) To summarize what they learned.In the first stage, for 3months, between June 2018 and March 2019, education using DVD video teaching materials was carried out at three high schools and four universities with research consent from the director of the facility, such as the school principal or president in region A. Among 1337 high school students and first- and second-year university students, subjects in their teen years were targeted for analysis.In the second stage, from November 2019 to January 2020, a web-based learning program was developed using improved video teaching materials, and an education program was conducted using these materials. From the 287 persons who participated in the web-based learning program, subjects in their teen years were targeted for analysis.t test calculation.The education using DVD video teaching materials comprised almost the same content but had an in-class format. In contrast, in the web-based learning program, students could perform iterative learning anywhere throughout the day using either the mobile web or an Internet home page. Subjects for the analysis of this study were restricted to teenage students who were within the scope of this education program. Accordingly, participants aged 20 years or older were excluded from the analysis. To calculate the sample size, G*Power version 3.1.9.7 was used. A total of 428 participants (214 participants per group) were required to achieve an effect of .35, power of .95, and a significance level of .05 for the In the first stage, schools were randomly selected from among junior high schools and universities in region A. A principal’s request form explaining the learning program using DVD video teaching materials, a teacher request form, consent forms, implementation guidelines and instructions, and user manuals and questionnaires for students were sent, and participating schools were recruited. Participation in the learning program was at the discretion of the director of the institution and that the institution could withdraw from the study at any time. At junior high schools and high schools, which had agreed to participate in the learning program and for which the principal had provided written consent, the program and the baseline and after survey were carried out with the cooperation of the teacher in charge of the class. At universities which agreed to participate in the learning program, the program and the baseline and after survey were carried out with the cooperation of faculty members, such as the Student Support Committee, Health Management/Lifestyle Guidance, and persons in charge of the academic year, curriculum, etc. according to the conditions at the university for which the President or Dean had provided written consent.In the second stage, the contents of the web-based learning for preventing adolescents from becoming perpetrators or victims of violence targeting persons in their teen years were introduced, and participants were recruited through the websites of organizations and academic associations related to the prevention of violence, and the university website. The web-based learning could be viewed individually or in groups. The educational effect was assessed with a questionnaire at baseline and after the web-based learning program.The following information was clearly written and requested in the student manual to explain the objective of this study and obtain participants’ understanding: This questionnaire aims to learn and understand thoughts and attitudes to “Hidden risks and enjoyment in relationships between you and me” and is meant to help you improve your learning. Please answer the questionnaire once before the educational program (front) and once after the educational program (back). The results from before and after the educational program will be compared to determine the program’s effect.The following contents regarding the question and answer methods were clearly explained in the teacher and student manuals: You are free to choose whether or not to answer any question. If you do not want to answer a question or do not know the answer, you do not have to answer. If you decide to answer a question, please circle your answer. There is no penalty for refusing to answer any question. If you agree to submit the completed questionnaire, place it in the collection bag.The following information regarding personal privacy was explained and distributed in the student manual: Personal secrets are completely confidential. You do not need to write your name, and individuals will not be identified at any point. Your family and teacher will not see what you have written. The answers provided will not affect your school performance. The results are summarized as numerical values.The following contents were clearly described on the website: As the use of the Internet expands, violence between friends and dating partners has increased. Sexual violence is taking place through both local life and the Internet. Therefore, let us learn about the hidden dangers in human relationships in our society in two steps using the web-based learning program, “Hidden risks and enjoyment in relationships between you and me,” with a video drama featuring university students, along with explanatory information. How to answer the questions: Please take about 5 min to answer the questions before and after watching the web-based learning program. Please access the questionnaire page in advance and answer the questionnaire using a computer or mobile terminal before watching the learning material (access by Q.R. code). When watching as an individual, you can use a personal computer or mobile terminal. After viewing, reaccess the questionnaire page and answer the questionnaire.The following contents are clearly described on the website: To match before and after questionnaires, please enter a 4-digit number such as “the last 4 digits of your mobile phone.” You are free to choose whether to answer a question or not. There is no penalty for refusing to answer any question. If you do not understand a question or do not want to answer it, you do not have to answer it. Please enter the answers that you think you can. If you want to submit the entered answer, please click the submit button. If you do not want to submit the information you entered, you do not have to click the submit button.The following contents were clearly described on the website: You do not need to enter any personal information such as your name. The study will not identify individuals. Personal information such as your email address is not collected when the entered contents are sent. The information entered will not be seen by your family or teachers. The information entered will not affect your school performance. The results are summarized in numerical values.When a group of many students watched the web-based learning course, the survey implementation was carried out at baseline and after the learning program using the same method used in the first stage to avoid congestion when multiple subjects accessed the Internet.At the start of either education program, DVD video teaching materials or web-based learning program, age was requested as an attribute using the following question: “Please circle your age.” Subjects were requested to select from three choices, 10s, 20s, or 30 years or older.(2)Attitudes that lead to violence and healthy conflict resolutionBefore and after the education programs, questions on the following three attitudes (items (2) to (4)) were asked.The scale developed by Ball was used to evaluate preventive education .A.Attitude that leads to the perpetration of violence“When spending time with your boyfriend, girlfriend, or close friend, do you think about taking the following actions toward the other person? Circle one from 0 (no) to 3 (yes).” was asked.B.Healthy conflict resolution(a) Attitude that leads to the perpetration of physical violence: “hit, throw things.” (b) Attitude that leads to the perpetration of emotional violence: “break the other person’s things, yell at or belittle the other person, tease the other person in front of others, blame the other person, threaten by saying you will date someone else, change tone of speech or express hostility, say something to offend the other person.”(3)Dangerous attitudes toward sexual violence(a) Empathy: “try to understand the other person’s feelings from his/her point of view, ask what the other person is thinking, listening while considering what the other person wants to say.” (b) Assertiveness: “explain your feelings to the other person, tell the person that he/she is important to you, can say no when needed.” (c) Discussion with other individuals: “calmly discuss problem-solving with the other person, suggest a solution that will make both you and the other person happy.” (d) Attack avoidance: “sometimes leave the room so you and the other person can calm down, sometimes you do not talk until you and the other person calm down.”(4)Preventive attitudes toward sexual violenceThe following original scale (5 items) created in the 2014-28 Grant-in-Aid for Scientific Research (C) “ICT-based adolescent education for coping with and preventing sexual violence in Japan targeting junior high school students ” was use(5)Free comments and opinions about the educationWhen holding a safety class in 2004 on attitudes to prevent violence in the region, the youth development section of the Tokyo Metropolitan Police Department and the Education Planning Department of the Tokyo Metropolitan Government created a safety slogan with an impact that would stick in children’s minds . A scaleAfter the education, students were asked, “If you have any comments or opinions about the DVD, please feel free to write them down.”p<0.05.The average scores for attitudes that lead to violence and for each category and the average scores for attitudes that promote healthy conflict resolution and for each category were compared and analyzed at baseline and after the education program. Dangerous attitudes toward sexual violence and preventive attitudes toward sexual violence were also compared at baseline and after the learning program and analyzed by analysis of variance (ANOVA). Two-way ANOVA was employed to assess whether there was a significant interaction between measures of the effect of intervention between the baseline and after surveys stratified by education using DVD video teaching materials and the web-based learning program. The Statistical Package for the Social Sciences (SPSS 25.0) was used for these analyses, and the level of significance was set at The number of persons who gave consent and participated in the survey baseline and after the education program using DVD teaching materials was 876 (collection rate 65.5%). Among these, 705 were in their teens both baseline and after education .t test, the average score of attitudes that lead to violence decreased after the education program compared to the baseline of the program (p <0.001). Among these, the average scores of both attitudes that lead to physical violence and attitudes that lead to mental violence decreased (p <0.001). The average scores for attitudes toward healthy conflict resolution increased (p <0.001). Among these, average scores for empathy, assertiveness, discussion with individuals, and attack avoidance increased, as well as the results such as a lower average score of dangerous attitudes toward sexual violence from the community or person through the Internet (p <0.001).According to the corresponding The web-based learning program, using the improved video teaching materials based on the opinions and comments of study participants and who responded both baseline and after the education in the second stage, was taken by 250 adolescents . They were in their teen years.p <0.001). Among these, the average scores of both attitudes to cause physical violence and attitude to cause mental violence decreased (p <0.001). Additionally, the average score for attitudes toward healthy conflict resolution increased significantly (p <0.001). Among these, empathy, assertiveness, discussion with other individuals, attack avoidance, and the average score of all attitudes increased. Overall, an improvement effect with the web-based learning program was observed, including a lower average score of dangerous attitudes toward sexual violence from persons in the community or through the Internet (p <0.001) and an increase in the average score for preventive attitudes toward sexual violence (p = 0.001). On the whole, the feedback provided by the students after the learning program showed a positive impression of the teaching program: negative impressions and opinions were not observed.The average score of attitudes that lead to violence significantly decreased after the web-based learning program compared to baseline (p = 0.002). The web-based learning program achieved an improvement of attack avoidance on attitude toward healthy conflict resolution and preventive attitudes toward sexual violence (p = 0.039). The mean scores of attitudes to cause violence, empathy, assertiveness, discussion with other individuals, and dangerous attitudes toward sexual violence did not show significant differences between the effect of web-based and DVD learning.A significant main effect between baseline /after and education using DVD video teaching materials/web-based learning program was noted with respect to the attack avoidance  was implemented to improve communication skills between men and women . ImproveImprovement in the dangerous attitudes that lead to sexual violence in adolescents was observed following the education program using DVD video teaching materials to prevent violence. This improvement effect was also observed for the web-based violence prevention learning program. According to the routine activity approach, crime stems from three factors: a motivated offender, a suitable target, and the absence of a capable guardian . The risPreventive attitudes toward sexual violence were strengthened in adolescents after the web-based learning program. A study suggested that women with low self-control experience more sexual violence . AdditioDuring the process to obtain study approval from the educational institution, the inclusion of a control group without any education program was not allowed. The Internet’s influence should also be considered, and it is conceivable that a web-based learning program might have been affected by the Internet learning environment and information from the Internet. Future studies should carefully consider interventional and assessment methods to minimize the potential influence of the Internet learning environment and information on the web. In terms of the research using DVD video teaching materials, there are limitations in the generalization of the results owing to the implementation of the questionnaire in a limited area. Further explanation of web-based learning programs and expansion to a wider range of subjects are needed. Consideration of the educational contents of the program and assessment methods that can be used both in Japan and overseas is required. In Japan and overseas, of the disruption that is being caused by the COVID-19, the development of a sexual violence prevention education program is needed.Implementation of an education program for adolescents using DVD video teaching materials and web-based learning to prevent sexual violence from an intimate partner, persons in the community, or through the Internet has been shown to improve the attitudes that lead to mental and physical violence and help them to cultivate attitudes that promote healthy conflict resolution. Improvement in the dangerous attitudes that lead to sexual violence was also observed. An education program using DVD video teaching materials or web-based learning may help prevent sexual violence among teens in Japan.