Internet-based cognitive behavioral therapy (iCBT) for child and adolescent anxiety has demonstrated efficacy in randomized controlled trials, but it has not yet been examined when disseminated as a public health intervention. If effective, iCBT programs could be a promising first-step, low-intensity intervention that can be easily accessed by young people.The objective of our study was to examine the feasibility and acceptability of a publicly available online, self-help iCBT program (BRAVE Self-Help) through exploration of program adherence, satisfaction, and changes in anxiety.This study was an open trial involving the analysis of data collected from 4425 children and adolescents aged 7-17 years who presented with elevated anxiety at registration (baseline) for the iCBT program that was delivered through an open-access portal with no professional support. We assessed the program satisfaction via a satisfaction scale and measured adherence via the number of completed sessions. In addition, anxiety severity was assessed via scores on the Children’s Anxiety Scale, 8-item (CAS-8) at four time points: baseline, Session 4, Session 7, and Session 10.d=0.87, children; Cohen d=0.81, adolescents), indicating a moderate to large effect size. Among participants who completed nine sessions, 57.7% (94/163) achieved recovery into nonelevated levels of anxiety and 54.6% (89/163) achieved statistically reliable reductions in anxiety.Participants reported moderate satisfaction with the program and 30% completed three or more sessions. Statistically significant reductions in anxiety were evident across all time points for both children and adolescents. For users who completed six or more sessions, there was an average 4-point improvement in CAS-8 scores (Cohen Participant feedback was positive, and the program was acceptable to most young people. Furthermore, significant and meaningful reductions in anxiety symptoms were achieved by many children and adolescents participating in this completely open-access and self-directed iCBT program. Our results suggest that online self-help CBT may offer a feasible and acceptable first step for service delivery to children and adolescents with anxiety. Half of all lifetime mental health disorders begin before the age of 14 years ,3. AlthoThe current Australian federal government recommendations encourage primary prevention and early intervention across the life span through easy-to-access first-line responses, particularly for children . They fubeyondblue and commenced in 2014, offering an evidence-based, open-access, online program free of charge to Australian young people and their parents. The self-help program was adapted from BRAVE-ONLINE, a 10-session, internet-based CBT (iCBT) program implemented with brief therapist support. The evidence base for the therapist-assisted program is strong  provided data that could not be accurately coded).beyondblue and youthbeyondblue websites. Through the beyondblue website, the BRAVE Program was listed as a direct referral for young people who completed an anxiety quiz and scored high on anxiety. In order to promote awareness of the program, introduction letters, flyers, and postcards were sent to schools and health and mental health organizations as well as private practitioners nationwide. The program was also presented at relevant conferences held for school counselors, psychologists, and teachers. Throughout the 2-year recruitment period, 28.67% (1269/4425) of participants were referred by school-based professionals, 13.36% (591/4425) by external health professionals, 10.85% (480/4425) by a parent or family member, 8.48% (375/4425) through beyondblue, and 9.94% (440/4425) through internet searching, with the remaining  participants finding the program through other means . With respect to the participants referred from health professionals, 13.96% (80/573) were referred by their general practitioner, 55.67% (319/573) by a psychologist, and 9.60% (55/573) by a social worker, with the remaining participants referred by other health professionals.All participants registered for the program through a website accessible only to Australian families. Then, participants were directed to the program in several ways through (1) self-referral and internet searching, (2) referral from health or education professionals, (3) links hosted on several Australian mental health information sites , and (4) direct links from the T-score ≥60 on the Children’s Anxiety Scale [CAS-8]; see below). The progression of participants from registration through the study, with reasons for exclusion is presented in To be included in this study, participants were required to have enrolled in the BRAVE Self-Help program between July 1, 2014, and June 30, 2016. We monitored the program progress for participants through to November 17, 2016. All participants (including those registered at the end of the recruitment period) were monitored over a 20-week period, which was sufficient to complete the ten sessions. Participants who were enrolled outside of the 2-year recruitment period were excluded from this study. As this online program is open-access, young people do not need a referral to register and begin the sessions. Besides, there are no set inclusion criteria for enrollment in and access to the program, and thus, users are able to access the program for prevention, early intervention, or treatment purposes. When registering, users are not required to demonstrate symptomatic levels of anxiety, and the program is completely open access and self-sought. In this study, however, participants were included only if they demonstrated elevated anxiety at the baseline above a predetermined criterion  was required prior to beginning the program, and it was obtained during the Web-based registration process. Participation was voluntary, and young people were made aware that they could cease using the program at any time, without consequence. The study protocol approval was obtained from the ethics committees of the University of Queensland (UQ), University of Southern Queensland, and Griffith University. Furthermore, data were stored on secure servers hosted by UQ. Participants were not provided with any reimbursements for participation.The BRAVE-ONLINE program for youth anxiety when delivered with minimal therapist assistance has been described elsewhere -12,16. FIn addition to the removal of any therapist contact, the following changes were made to the existing intervention. First, we created a new infrastructure to surround the existing program and provide clearer navigation to resources for users. This included additional home pages, new graphics, demonstration videos, frequently asked questions, and dedicated sections for resources and key program components . Second, we integrated relaxation activities into the program via the dedicated relaxation room, where users could live stream relaxation or download relaxation recordings (or transcripts) to add to their music libraries. Third, the exposure hierarchy (BRAVE ladder) was integrated into the new home page infrastructure in a dedicated section and additional tools were created to ensure that young participants were able to build their exposure hierarchy effectively without a therapist. This included easy creation of steps and rewards, the ability to move steps around, and the capacity to check-off steps when complete. Fourth, in addition to the already included automatic email reminders and session completion messages, the self-help program also included automatic alert messages that were sent to the users if they reported anxiety scores in the clinical range. Finally, we integrated a self-registration system into the program that required young people to register for the program and provide a contact email address and name or pseudonym. Registration also included the provision of consent and an explanation of the monitoring and reporting features included in the program. All users were able to first trial the program in a 20-minute guest access before registering. Young people were able to register for and complete the program on their own, via a personal computer or mobile device. Program sessions were conducted in a prescribed sequence, although participants could progress at their own pace. Furthermore, automatic email reminders were sent if participants had not completed the next session within 1 week.In this study, we aimed to disseminate the intervention as widely as possible on a national scale; thus, we implemented assessment procedures conducive to this goal. The advisory committee identified administering an exhaustive assessment battery as a potential deterrent for young people registering and completing the program in this self-directed manner. Thus, to minimize participant burden and the potential barriers to participation, we administered a limited assessment battery, including one brief measure of anxiety, along with basic demographic characteristics and a brief satisfaction scale.Demographic data  were collected when participants created their account to access the program. Postcodes were categorized according to the Australian Standard Geographic Classification system  and codeNever, 3=Always). The CAS-8 has demonstrated good reliability and provides population-level, gender-standardized norms for comparison =0.13; P<.001). In the adolescent sample, likewise, a statistically significant decrease was noted in anxiety from the baseline to Session 10 .The results for LGCMs confirm the findings of the completer sample and demonstrate that anxiety decreased significantly over time. Estimated means, SDs, and effect sizes for the CAS-8 in the child and adolescent samples are provided in The proportion of child and adolescent users demonstrating statistically reliable (gender-adjusted) improvement, deterioration, or no change according to sessions completed is presented in χ21,1095=21.64; P<.001).The proportion of child and adolescent users crossing the “elevated” and “clinical” thresholds at the different time points (and according to sessions completed) is provided in χ2=1.09; P=.30). As is evident in For those who initially demonstrated “clinical” levels of anxiety, 59.1% (309/523) demonstrated an improvement into the “nonclinical” range by their final recorded score. We observed no differences in the proportion of children  and adolescents  achieving this level of improvement . For adolescents, this number dropped to 39.8% (224/563) for those completing three sessions, 31.2% (64/205) for six sessions, and 29% (21/72) for nine sessions. For children, only 21.1% (112/532) received email alerts after completing three sessions, 14.5% (28/193) after six sessions, and 16% (15/91) after nine sessions.The proportion of young people receiving email alerts for the presence of clinical-level anxiety was higher among adolescents than among children across all four time points and showed reduction over time for both groups. At the baseline (registration), 59.96% (1770/2952) of adolescents and 38.15% (562/1473) of children received email alerts, with this difference being statistically significant . This study examined the feasibility and acceptability of this approach by evaluating satisfaction with, and adherence to, the program as well as changes in anxiety symptoms. Although there was no control comparison condition or trial methodology, the methodological approach to analysis was comprehensive, with data being collected on multiple occasions and the effects assessed using multiple methods of evaluating changes in anxiety. Furthermore, both satisfaction and adherence data provided further information about the acceptability of the open-access intervention.The BRAVE Self-Help program is extremely comprehensive as all specialist techniques are incorporated into the content and prominent examples and opportunities for skill rehearsal are integrated within and between sessions. In addition, the content is interactive, engaging, and age appropriate, and our previous research has demonstrated high consumer acceptability and satisfaction ,11. ThusQualitative feedback indicated that many users were able to obtain benefits from the program, and potential improvements were noted by others. In particular, the intervention might benefit from accompanying app-based features, either for the entire program or for specific intervention components such as exposure. Furthermore, when delivered in this self-directed format, sessions might need further refinement to decrease the length, increase the use of videos and acceptable graphics, and reduce monitoring and reminder systems . Interestingly, the need for sessions to be personalized was raised, despite the intervention being run as a self-help program without any professional contact. Thus, there are opportunities to implement innovative technology-based methods for achieving treatment personalization  in such open-access, self-help online interventions.Despite positive feedback and satisfaction with the program, there was a noticeable variation in the degree of program adherence across users. The fact that around 21% 958/4425) of participants did not go on to complete any of the sessions and a further 48% (2126/4425) completed only two sessions or less indicates that the program was either not acceptable or potentially not useful to a substantial proportion of people. These rates of session progression are not dissimilar to those found in other large-scale, open-access eHealth interventions such as MoodGym  [ of partiIn all likelihood, these results may suggest that services that are widely or publicly available attract users from varying contexts and backgrounds, who will subsequently engage very differently with the programs than those in strictly controlled RCTs. With respect to the BRAVE Self-Help initiative, given the significant change observed in users completing only three sessions, it is possible that several participants engaged in the program until they obtained the benefit they needed, which might have occurred early on in the program. For others, such as those who did not commence the program at all, it is possible that their expectations were not aligned with what the program had to offer and that this only became apparent after registering. For others still, it may be possible that a self-directed program with little guidance was simply not enough to sustain engagement. In this study, we were unable to determine the reasons for nonadherence, and this will be important for future studies. Nonetheless, while the program was acceptable, the low rates of adherence suggest that such approaches will not be sufficient for or acceptable to all.The results of this study demonstrate that self-reported anxiety decreased significantly over time, with effects being greater as the number of sessions completed by youth increased. These findings were confirmed through the completer analyses (N=1095) and growth curve modeling, which utilized all eligible participants registering for the program (N=4425). Improvements were evident for both children and adolescents, although adolescents showed slightly less improvement on some outcome indicators. Based on the assessment point at the beginning of Session 4, results showed that around 43% of children and around one-third of adolescents had recovered (no longer experienced elevated anxiety). For those with clinical levels of anxiety, over half (57%) of children and just under half (45%) of adolescents were no longer in the clinical range after completing three sessions . Importantly, even greater reductions were evident for child and adolescent users who completed more sessions, such that of those who completed nine sessions, over two-thirds (70%) were no longer in the clinical range  and almost half (47%) no longer demonstrated elevated anxiety . Furthermore, of all participants who completed nine sessions, around half (54%) achieved statistically reliable change as indicated by RCI. Thus, we observed substantial reductions in anxiety across multiple measures among users of a freely available, evidence-based online intervention.d=0.83-1.01) are similar to the effect sizes observed in previous RCTs  [Although not directly comparable, as diagnostic status was not determined by clinical interview in this study, the results can be compared with those of the previous RCTs of the therapist-assisted BRAVE-ONLINE program. The demonstrated effect sizes for reductions in anxiety from the baseline to Session 9 in this study  ,11. Furtd=1.22 on the full Spence Children’s Anxiety Scale from pre- to posttreatment, although it should be noted that this intervention was (1) delivered with substantial therapist support , (2) required both parents and children to complete sessions before subsequent sessions were unlocked, and (3) encouraged families to log in at least twice a week to respond to therapists [The effect sizes for BRAVE Self-Help presented in this study are somewhat smaller than those of a pilot implementation study (N=20) conducted very recently by Jolstedt et al . In theierapists . Thus, BIt is often argued that low-intensity interventions such as iCBT programs are only effective with professional support. However, the results of this study demonstrate that self-help online interventions may be effective for many young people if they complete at least three sessions of the program. Indeed, the improvements demonstrated by participants in this open-access, self-help program are significant and reveal that a meaningful change is feasible without therapist support. The finding that a substantial proportion of young people can achieve clinically meaningful improvements through such an intervention in a self-help format has significant implications for models of service delivery. In addition, substantial therapist time and cost savings may be afforded by such self-help interventions, contributing to an increase in the overall efficiency of youth mental health services. Furthermore, providing evidence-based services via online self-help may reach more young people at a far lower cost than face-to-face service delivery models. It would seem that if young people who would benefit from self-help programs are accurately identified, more costly resources  could be reserved for those young people who need them the most.Another implication of the findings relates to the treatment dose or magnitude of change in early sessions. Specifically, it is worth noting that the highest magnitude of change was evident following the completion of the first six sessions. Thus, the results of this study demonstrate that even a small dose of self-help treatment may be effective for some young people and would perhaps bring about a change equivalent to that from an extended program. These findings are also consistent with those of Chu et al  who demoThis open dissemination study has some design limitations. There was no control group against which to determine whether changes simply reflect spontaneous recovery, regression to the mean, or nonspecific intervention effects. In addition, there was no initial interview to confirm the clinical diagnosis, instead a single informant and a single measure was relied upon. Although this measure is unable to provide a comprehensive overview of anxious symptomatology type and intensity, it does allow for examination of the magnitude of anxiety symptom change, which was the objective of this study. Furthermore, it was necessary to minimize participant burden in an open trial of this nature where participation was completely voluntary and self-sought.We also note that some analyses in this study were limited to those individuals who completed at least two assessment points and, thus, had completed at least three program sessions. While this setting provides a fair evaluation of the outcome for those who completed at least a proportion of the program, it does not consider those who initially enrolled and decided not to continue at all with the program. Perhaps, such young people were not ready to participate in active treatment or they might require alternative treatment modalities. In fact, in this study, those who completed less than three sessions were more likely to reside in non-metropolitan areas, were older and had a higher anxiety severity. It is possible that low-intensity iCBT programs may be more accessible or preferred by youth who live in major cities. Also, younger children may be more likely than adolescents to complete iCBT programs with parental assistance, which may bring about higher adherence to the program. Furthermore, the finding that youth with lower levels of anxiety adhered more to the program is consistent with the objectives of low-intensity iCBT interventions and supports the notion that iCBT for youth could be useful as a first step in intervention.In terms of sample representativeness, all participants in this study demonstrated elevated anxiety > 84th percentile on the CAS-8. Thus, all participants were experiencing anxiety at a level that was interfering with their lives; however, only half of the participants demonstrated “clinical” levels of anxiety (>94th percentile). Thus, the sample was somewhat less severe than those examined in previous RCTs of iCBT for child anxiety ,11. PartDespite its limitations, the findings of this study are encouraging and certainly justify further research in an RCT or similar design to confirm the effectiveness of this type of intervention. Historically, there has been a lack of formalized approaches to the dissemination of iCBT interventions , yet theThis online, self-help program for anxiety has the capacity to reach greater numbers of young people compared with programs that require therapist contact. The results of this open trial demonstrate moderate to high program acceptability when delivered in this way and show its potential feasibility in bringing about clinically and statistically meaningful reductions in anxiety for children and adolescents. Greater reductions were evident for those who completed more sessions, although significant improvements were most evident in the first six sessions. Overall, self-help iCBT is a potentially feasible and acceptable approach for delivering evidence-based interventions through a public health delivery model.


Children with disabilities tend to be less active than typically developing peers and may therefore miss important developmental benefits. Class time physical activity (PA) programs can provide additional PA to children and have shown to contribute to numerous benefits in mainstream classrooms. However, it is unclear whether class time PA opportunities are provided in specialist education settings. This review aimed to identify and map class time PA programs that have been implemented in specialist schools and classes. Nine electronic databases were searched. Grey literature searches were also conducted. Programs were included if they were implemented in a primary/elementary specialist school or class, involved a PA component, were conducted during class time and involved more than one child from the class participating. Included programs were mapped and narratively synthesised according to activity type. Of the 2068 records screened, 34 programs were included. Programs involving dance/drama activities (k = 11) were most common and programs involving stretching activities (k = 2) were least frequently implemented. Twenty-three programs had been evaluated, of which only two were randomised controlled trials. More class time PA opportunities are warranted in specialist education settings. Further research is required to build the evidence base for these programs. Approximately 150 million children worldwide experience a disability . ExperieOne such protective mechanism is engaging in physical activity (PA) ,7. EngagA recent review by Jung et al.  found thThe large amount of compulsory time that children spend in education settings positions schools as a promising avenue for providing PA opportunities to children ,31,32. SThere are numerous opportunities throughout the school day to promote PA, including during physical education (PE), recess periods and even classroom time ,35. This®Take 10! and Energizers have been implemented in mainstream classrooms around the world [Classrooms are particularly well suited to facilitate PA programs, given children spend most of the school day in class instructional time . Numerouhe world ,45,46,47he world ,44. Othehe world ,45,46. Hhe world  identifihe world . Time bahe world ,48. Unsuhe world . TherefoTake 10! program indicates that participation in this program increased children’s PA levels, significantly reduced girls body mass index (BMI) z scores, increased primary school student’s attraction to PA and reduced student’s off-task and inattentive classroom behaviours [Previous studies have reviewed class time PA programs in mainstream schools and have reported positive effects for children ,51,52,53haviours . Other rhaviours ,52, and haviours ,51,53.Given this success, it is possible that class time PA programs may have a positive impact on the development of children with disabilities attending specialist schools . HoweverThe aim of this study is to conduct a systematic mapping review of class time PA programs that have been implemented in specialist primary schools and classes. Specifically, this review will identify what the programs have involved, what outcome variables have been evaluated after implementation and whether any programs are conducted specifically as a short break. This review will also comment on the ability of class time PA programs to produce positive outcomes  for children with disabilities.http://osf.io/q7smv/). This systematic mapping review was conducted from September 2018 to June 2019. A protocol was registered with the Open Science Framework on 24th July 2018 , intellectual , psychological , sensory , multiple, or other disabilities and special needs . Programs in inclusive or mainstream classes were excluded. Where school or grade level was not clear, programs were eligible if participants mean age was between 5 and 13 years. Programs implemented with middle and secondary school students specifically were excluded. Programs implemented with both primary/elementary and secondary students were eligible if results for each group were reported separately; however, only results from the primary/elementary group were considered. Programs that contained a PA component of any intensity and duration that were conducted during general class instructional time in the school day and involved two or more children from the same class participating were considered for inclusion. PA in this review refers to any bodily movement that results in some energy expenditure  includinStudies with and without a comparison were eligible for inclusion.Studies that evaluated any type of outcome after program implementation were considered. Studies without outcome evaluation of the program were also eligible. Documents using any design to describe the implementation of a class time PA program were eligible. Peer-reviewed and grey literature documents were considered. No restrictions were placed on date. Eight electronic databases  were searched via EBSCOhost to identify relevant studies. Embase was also searched. Literature was searched from the earliest date in each database to 7th September 2018. Grey literature was searched during September and October 2018 using ProQuest Dissertations & Theses Global and Google to identify additional programs. The first 50 results from 28 Google searches of Australian health sites, Australian state government and education sites, United States of America (USA), United Kingdom (UK), Canada, Japan, New Zealand, Singapore and South Africa federal education sites, United Nations Children’s Fund (UNICEF), United Nations Educational, Scientific and Cultural Organisation (UNESCO) and World Health Organisation (WHO) sites were reviewed. See The search strategies were developed with the support of an experienced librarian. For the electronic databases, truncation was applied to key terms see  which weThe Google search strategies included a series of key terms with the relevant Google operator to limit each search to one of the sites described above . De-duplicated results were imported into Rayyan for dual eligibility screening (CE and NP), first by title and abstract. Remaining results were reviewed in full-text independently by two authors (CE and NP). The same process was followed for the ProQuest Dissertations & Theses Global search. Two authors (CE and NP) conducted the Google searches and reviewed the first 50 results of each search simultaneously. The authors met to resolve any discrepancies throughout the entire selection process. If more information was required to determine the study’s eligibility, an attempt was made to email the author if contact details could be obtained. This was not always possible due to the age of the study. Studies were excluded if the author didn’t respond within one month. Data was extracted by one author (CE) according to a pre-planned form which included bibliographic information, study aims, study characteristics, sample characteristics, intervention characteristics, outcomes and results. A second author (NP) verified initial data extraction. To assess the risk of bias, the Effective Public Health Practice Project (EPHPP) tool  was usedFindings are presented in tables, maps, and are also synthesised qualitatively according to the type of activities in the class time PA program to describe this field of literature. Maps were generated using RStudio . Broad activity categories  were formed by authors after final program inclusions were decided to synthesise and map the programs. Variables that had been previously evaluated in the included studies were categorised by authors into broad outcome groups  for mapping purposes. Variables were mapped according to outcome group per study; therefore, studies that evaluated multiple variables of the same outcome type were categorised once per program. Evaluations of included programs were not considered if results weren’t related specifically to the PA component of the program. Given this review primarily aims to identify programs that have been implemented and a large amount of heterogeneity was found between intervention characteristics and outcomes, it was not appropriate to conduct a meta-analysis. This review identified 33 records that report on 34 class time PA programs see  that havTwenty-three programs included in this review had been previously evaluated; however, three of the evaluations ,64,65 wePrograms were subjectively categorised into broad activity groups to synthesise the type of activities involved. Some programs involved more than one type of activity and are therefore included in more than one category in the text described below and in the map figures. Refer to Class time PA programs most commonly included dance/drama-based tasks (k = 11), which involved activities such as theatre games, aerobic dance routines and acting exercises. These programs have been published since the 1960s and all were conducted in the USA. These programs have been least frequently implemented in classes of children with ASD (k = 1) and multiple disabilities (k = 1), and most frequently implemented in classes of children with ID (k = 4). Programs involving dance/drama activities were often implemented with small samples, with only one containing a total of more than 40 participants.Programs involving dance/drama activities were commonly implemented by a specialist subject teacher , researchers (k = 3) and classroom teachers (k = 3). Where location of implementation was reported, programs were slightly more frequently implemented in the classroom (k = 2) and school gymnasium (k = 2) than other school rooms (k = 1) or mixed locations . The shortest program was implemented for two weeks (k = 1) and the longest went for the entire school year (k = 2). Most involved 40–60 min sessions (k = 7), with only one program consisting of ≤10 min sessions. Three programs were implemented once per week, two were twice per week, one was three times per week and two were every school day. Seven programs involving dance/drama activities were evaluated, none of which were conducted as an RCT. A variety of outcomes were evaluated including academic (k = 1), physical (k = 3), cognitive (k = 1), psychological (k = 3), social (k = 2) and “other” outcomes . Results suggest that programs involving dance/drama activities may contribute to improvements in children’s physical fitness, psycholinguistic skills, visual perception skills and increased positive social interactions with typically developing peers. However, the overall evidence produced by these evaluations was consistently weak. Six studies demonstrated risk of selection bias by either consisting of a sample that is not likely to be representative of the target population (k = 5) or providing insufficient information to judge representativeness (k = 1). Only one used a strong study design. Additionally, risk of performance and detection bias is present, as blinding was either not used or reported in any evaluations. Nevertheless, valid and reliable data collection tools were used in some cases (k = 4) and most (k = 6) used appropriate statistical analyses. Studies also controlled for confounding variables where applicable (k = 3).Class time PA programs also commonly consisted of motor activities (k = 10), which involved a range of activities including balance, body awareness, locomotor and non-locomotor tasks. These programs were most commonly implemented in the USA (k = 6), with only one program each being implemented in Australia, Canada, South Africa and the UK. Two programs were published in the 1960s. Since then, there have been two programs each in the 1970s and 1980s, and four programs since 2010. Programs involving motor activities have been much more frequently implemented with classes of children with ID (k = 7) than sensory impairments (k = 2) or other special needs (k = 1). Sample sizes were generally small, with all studies involving ≤ 40 participants. Where the person who delivered the program was reported (k = 9), most were implemented by classroom teachers (k = 5) or researchers (k = 3). Of the six programs that reported location, three were delivered in the classroom, two in a different school room and one in the gymnasium. Program durations were dispersed, ranging from a minimum of eight weeks (k = 1) to a maximum of 15 months (k = 1). Sessions were generally quite lengthy, with most programs (k = 6) consisting of 30–45 min sessions and only two of ≤ 20 min duration. The majority involved regular sessions, with six programs involving sessions every school day. Six of the programs involving motor activities were evaluated; two used an experimental and four used a quasi-experimental design. Physical outcomes were most frequently evaluated (k = 5). Results suggest that class time programs involving motor activities may contribute to a range of positive effects including improved academic abilities, improved gross motor skills  and increased cardiovascular and muscular endurance. Although four of the six evaluations produced an overall weak evidence rating, there were many strengths. All evaluations used a moderate or strong study design. Furthermore, most studies (k = 4) reported a high participant retention rate and used appropriate statistical analyses (k = 4). Additionally, where applicable, studies either had no differences between groups (k = 2) or attempted to control for relevant confounders (k = 1). However, only half (k = 3) used valid and reliable data collection instruments, and most (k = 5) contained samples that were not likely to be representative of the target population. Additionally, many studies (k = 5) either didn’t report or utilise blinding. Other class time PA programs included games/play activities (k = 7), which involved activities such as interactive electronic games, imaginative games , the Hokey Pokey, Simon Says and tag. These programs were most frequently implemented in the USA (k = 3) and most commonly implemented since 2010 (k = 3). They have been delivered in classes of children with ASD (k = 3) and ID (k = 4), and generally involved modest sample sizes, with only one study containing more than 30 participants. Programs that included games/play activities were most frequently delivered by the classroom teacher (k = 3) or “other” personnel . Locations varied, with two programs being implemented in classrooms, one in the school gym, one in mixed locations, and one in a different school room . These programs ranged in duration from eight weeks to the whole school year. Session frequency varied between weekly and daily. One program involved 15 min sessions, whereas four involved 30–45 min sessions. Five of the programs that involved games/play activities were evaluated, only one of which was an RCT. Physical outcomes were most frequently evaluated (k = 3) and cognitive outcomes were least frequently evaluated (k = 1). Results suggest that programs containing games/play activities may positively influence children’s academic abilities, social functioning, arm strength and flexibility. While three overall rating scores indicate weak evidence for programs involving games/play activities, the studies included a number of domain-level strengths. All evaluations used a moderate or strong study design and most (k = 4) used appropriate statistical methods. Additionally, majority of studies (k = 4) used data collection tools that were both valid and reliable, and had few participants withdraw or drop out (k = 3). Evaluations that recruit more representative samples and use/report blinding processes may increase the quality of evidence.Multiple running programs (k = 5) have be implemented during class time in specialist schools and classes, all of which were in the USA. Most (k = 3) were implemented in the 1980s, with only one being implemented in the 2000s and one since 2010. Two studies involved children with ASD, one involved children with ID, and two involved children with other special needs. All involved few participants, with N = 12 being the largest sample size. Three programs reported who delivered the program, of which, either classroom teachers (k = 2) or researchers (k = 1) were responsible. Unsurprisingly, no running programs were conducted in the classroom. Those that described location were either conducted in school grounds , the gymnasium (k = 1) or a location categorised as “other” . It is unknown whether this track was on school grounds or external. Duration of the running programs varied from as little as three weeks to as much as seven months. Majority (k = 4) were conducted for between three and six weeks. Sessions ranged from 12 to 45 min. Where reported, session frequency ranged from twice per week to every school day. All running programs were evaluated, one of which was conducted as an RCT. Behavioural outcomes were most frequently evaluated (k = 3). Evidence suggests that running programs may have positive consequences including increased correct academic responses, increased academic engagement, greater attention span, improved classroom behaviour and greater fitness. However, the majority (k = 4) of the evaluations produced weak overall evidence. Evidence may be at risk of detection and performance bias due to infrequent use or reporting of blinding of outcome assessors and participants. Only one study reported blinding of outcome assessors. Selection bias may also be present, as studies frequently investigated samples that are not likely to represent the target population. Only one study contained a sample that was somewhat likely to be representative. While three studies employed a moderate or strong study design and two utilised valid and reliable data collection methods, improvements in these domains may strengthen the quality of evidence. Encouragingly, the evaluations generally had few participant withdrawals and drop-outs, and used appropriate statistical methods. Swimming programs appear to have been less frequently (k = 3) implemented during class time. All three were implemented in Australia, one of which was implemented in 2011. The other two records did not report when the swimming program was implemented but indicated that it was part of the ongoing curriculum. These programs have involved children with ASD (k = 1), ID (k = 1) and children with both ASD and ID (k = 1). While none of the records reported exactly how many children participated, each indicated that all children at the school were involved.One swimming program did not report who delivered the program. The remaining were delivered by specialist subject teachers, specifically and unsurprisingly, swimming teachers. While it is sensible to assume that each of these programs were conducted at a swimming pool, none explicitly stated whether they were conducted in a pool at the school or an external facility. One program involved lessons every school day for a two-week period. The other two involved weekly lessons for the entire school year. Session lengths differed, with one program not reporting an exact duration but indicating that lessons lasted from between 15 min to 1 h, another program involving 30 min sessions and the third program involving 45 min sessions.None of the swimming programs identified had been evaluated, therefore, it is unclear whether class time swimming programs contribute to positive outcomes.Class time PA programs in specialist schools and classes were least frequently based around stretching activities (k = 2). Programs that did primarily involve stretching activities included activities such as yoga, slow-motion movements, and tensing, flexing and releasing the body. Both programs were implemented in the USA, one in the 1970s and the other in the 2000s. One was implemented with children with emotional difficulties and the other involved children with multiple disabilities. Only one program reported sample size, which was very small (N = 5).Both programs were implemented by classroom teachers and delivered in the classroom. One program lasted 16 weeks, while the other did not report total duration. Additionally, one study involved sessions three times per week, while the other study did not report session frequency. Both programs contained brief sessions, with one involving 15 min sessions and the other consisting of no more than 10 min of stretching.Only one of the programs involving stretching activities was evaluated. Using a quasi-experimental design, this study evaluated the effect of the program on behavioural and physical outcomes. There was a significant reduction in children’s muscle tension following the program. Parents and teachers also noted a reduction in children’s inappropriate behaviours; however this was not statistically significant.The overall evidence from this evaluation is weak and possibly affected by selection bias, as the sample was not likely to represent the target population. The quality of evidence may also be impacted by the lack of reporting of the reliability and validity of data collection tools and blinding of outcome assessors and participants. This study did however utilise a moderate strength study design, appropriate statistical methods and was unlikely to be impacted by attrition bias, as there were no withdrawals or drop-outs.Three programs involved activities that did not fit the above categories. These include a TaeBo exercise routine , an outdoor education program  and a fitness program involving walking activities. One was implemented in Australia, one in Singapore and one in the USA. Two programs have been implemented since 2010 and one did not report the year of implementation. These programs were implemented with children with ASD (k = 1) and ID (k = 2). Sample size was rarely reported, however, one study reported that six children participated in the TaeBo activity.All of these programs were delivered by classroom teachers, however, location varied. One did not report where the program was implemented, one was in a school hall and one was in mixed locations . Programs ranged in duration from 30 days (k = 1) to the whole school year (k = 1). One did not report total duration. One program included 19 sessions over a 30 day period, while the other two were implemented weekly. Sessions were generally brief, with one program involving 10 min sessions and one involving 15–20 min sessions. One did not report the length of individual sessions.Only one of these programs had been evaluated. Using an experimental design, the study evaluated the impact of TaeBo activities on academic outcomes and found that performance on mathematics and language tasks improved on most of the days that children engaged in the program.However, the overall quality of evidence is weak. While statistical methods were appropriate and the study employed a moderate strength study design, the evidence is subject to selection, performance, detection, and attrition bias. Indeed, the sample was not likely to be representative of the target population, outcome assessors were not blinded to intervention status, and there was a lack of reporting regarding blinding of participants and withdrawals and drop-outs.Disability categories  were formed after record inclusions were finalised in order to synthesise the data. One disability category was assigned per record based on the participants and type of specialist class described. Refer to For classes of children with ASD, programs involving games/play activities were most common (k = 3) and demonstrated potential benefit for boys social functioning. This was followed by running programs (k = 2) which may contribute to increased correct academic responses and academic engagement. Programs involving dance/drama, swimming and ‘other’ activities were less common (k = 1 each) and were not adequately evaluated to understand benefits for children.For classes of children with ID, programs most commonly involved motor activities (k = 7), with some studies indicating that these activities may contribute to improvements in motor abilities, endurance and academic abilities. This was followed by programs involving dance/drama activities (k = 4), with studies suggesting improvements in physical fitness and dance skills, and programs involving games/play activities (k = 4) which may contribute to improvements in gross motor skills and flexibility. Programs involving running, swimming and ‘other’ activities were less common in this population. Nevertheless, studies indicated that running activities may contribute to increased fitness, and ‘other’ activities  may contribute to improved academic performance.Stretching was the only activity type used in a class of children with emotional difficulties. Results indicated that stretching activities  may reduce muscle tension in children with emotional difficulties.For classes of children with sensory impairments , two programs involved motor activities, with one study suggesting that these activities may contribute to improvements in locomotor development, performance development and practical reasoning development. Two programs also involved dance/drama activities; however these were not evaluated.Programs for children with multiple disabilities  have involved swimming (k = 1), stretching (k = 1) and dance/drama activities (k = 1). However, none of these were evaluated to understand the benefits of the program.For classes of children with other special needs , programs have most commonly involved dance/drama activities (k = 3), with one study suggesting that the activities may contribute to improvements in psycholinguistic and visual perception skills and another indicating a reduction in anti-social actions after participation. This was followed by running programs (k = 2), with studies indicating improvements in attention span and classroom behaviour, and a program involving motor activities (k = 1) which was not evaluated.Class time presents a promising opportunity in which to provide PA for children with disabilities. However, it is not currently clear whether children who attend specialist education settings have opportunities to participate in class time PA and whether these programs contribute to health benefits. This review aimed to systematically search for and map class time PA programs that have been implemented in specialist primary schools and classes. The results serve to identify avenues for further development and investigation of class time PA programs in school settings for children with disabilities.This is the first review to the authors’ knowledge that explores class time PA programs that have been implemented specifically in specialist schools and classes. Results identified few (n = 34) class time PA programs, which aligns with existing literature suggesting that more active opportunities are needed in specialist school settings ,35,37. NAccording to activity categorisations in this review, the identified class time PA programs most commonly included dance/drama activities. This is reasonable given research suggests that dance can be used to meet the diverse needs of learners in the school setting  and thatIt is also interesting to note that all swimming programs identified were implemented in Australia. This is perhaps unsurprising, given that swimming is part of the school curriculum in a number of Australian states ,102,103.This review identified few programs based primarily around stretching. It is possible that stretching activities may not be a first choice of PA if teachers decide to dedicate class time to maximising children’s energy expenditure. Additionally, characteristics such as poor attention are common among some children with disabilities  ,105, whiSimilarly, few running programs have been implemented in recent years, with the latest program being implemented in 2011. This could reflect support for a recent shift towards providing children with more play-based PA opportunities to achieve holistic benefits . The decEncouragingly, one-third of all programs were implemented within the last decade, and four (11%) in the last five years. This could be in response to calls for action to increase the amount of PA children engage in . AdditioTake 10! or Energizers) that have been successful in mainstream schools. This is despite the features of these existing programs likely being attractive to teachers in that they are often brief, require minimal training and equipment to implement, and can incorporate learning materials [Interestingly, none of the programs in this review utilised existing programs , of which, seven were conducted by classroom teachers. Time and implementation variables may have a large influence over whether teachers include PA during class time. Indeed, classroom teachers are increasingly under pressure to manage competing demands and therefore may be inclined to forfeit time for PA during instructional sessions if they are not invested or supported appropriately ,32,48. FPhysical outcomes were most frequently assessed by studies included in this review. Variables categorised as behavioural, cognitive and academic outcomes were also reasonably frequently evaluated. This is perhaps unsurprising, given these variables are proximal to the setting and type of program reviewed. That is, given class time programs implemented in schools were reviewed, it is unsurprising that academic and cognitive outcomes were targeted as these may reflect enhanced classroom performance—a valued result in schools. Similarly, behavioural outcomes may be frequently targeted in class time programs as problematic behaviour is less conducive to a supportive learning environment. Additionally, given PA programs were reviewed, it is unsurprising that many studies targeted physical outcomes. However, as aforementioned, no studies evaluated the impact of the program on children’s PA levels. This may suggest that PA programs in specialist education are targeted more towards advancing aspects of child development  than fostering increased PA engagement. Notably, this review identified a lack of studies investigating the impact of class time PA programs on psychological outcomes. Given children with disabilities have shown to experience higher rates of psychopathology  and prevResults suggest that class time PA programs may have the potential to yield a range of positive outcomes for children with disabilities. For example, there are indications of improvements in social functioning, classroom behaviour, academic performance, physical fitness, cardiovascular endurance and practical reasoning. This is in line with studies of class time PA programs in mainstream schools which report positive academic , behavioThe results of this review highlight the importance of considering disability populations separately when developing and evaluating class time PA programs. Indeed, the most common type of activity implemented with children with disabilities often differed between different disability populations, suggesting that a program appropriate for children with one type of disability may not be the most suitable for all children with special needs. Additionally, the impacts of the programs are likely to vary for children with different disabilities. This is perhaps expected given the heterogeneity of children with disabilities and aligns with a review by Rimmer et al.  which ouThere is a paucity of high-quality evidence from the evaluations of programs included in this review, with most (n = 17) receiving an overall weak rating. Only three studies produced moderate-strength evidence. None were rated as strong. A number of consistencies in risk of bias and several methodological limitations across the studies may contribute to this. For example, many studies were at risk of selection bias due to not investigating participants that are representative of the target population, or not providing enough information about sample representativeness. Many studies were also at risk of performance and detection bias, as blinding processes were infrequently utilised or clearly reported. Additionally, many studies did not clearly report on or employ intervention integrity processes. Indeed, studies rarely reported the percentage of participants that received the allocated intervention and whether participants were likely to be exposed to contamination or co-intervention, which could have compromised the impact of the program. Furthermore, very few evaluations utilised an RCT design. This is consistent with previous literature reporting few RCTs of PA interventions for people with disabilities ,113. ManThese consistencies in risk of bias may be due to factors such as the study age, study type , sample heterogeneity and constraints inherent to conducting research in schools. Indeed, several complexities inherent to the specialist education context  may make robust RCTs with large sample sizes difficult to conduct ,113. UndThis is the first study to the authors’ knowledge that reviews class time PA programs in the specialist education context. The review included a comprehensive and systematic search of peer-reviewed and grey literature sources and dual screening of results. However, this review is subject to limitations. Firstly, it is possible that programs akin or identical to those in this review have been implemented in other contexts without documentation and therefore were not found during the searches. Secondly, limiting search results to English may have neglected programs implemented in non-English speaking countries. Thirdly, it is possible that other identified programs could have been included if authors were contactable for extra information ,116. LasThis review has taken the first step towards understanding class time PA opportunities available to children attending specialist schools and has identified a dearth of programs that have been implemented and evaluated. PA programs have been successfully implemented during class time in mainstream schools ,50 and a


A Mw 7.4 earthquake hit Donggala County, Central Sulawesi Province, Indonesia, on 28 September 2018, triggering a tsunami and liquefaction in Palu City and Donggala. Around 2101 fatalities ensued and 68,451 houses were damaged by the earthquake. In light of this devastating event, a post-earthquake map is required to establish the first step in the evacuation and mitigation plan. In this study, remote sensing imagery from the Landsat-8 and Sentinel-2 satellites was used. Pre- and post-earthquake satellite images were classified using artificial neural network (ANN) and support vector machine (SVM) classifiers and processed using a decorrelation method to generate the post-earthquake damage map. The affected areas were compared to the field data, the percentage conformity between the ANN and SVM results was analyzed, and four post-earthquake damage maps were generated. Based on the conformity analysis, the Landsat-8 imagery (85.83%) was superior to that of Sentinel-2 (63.88%). The resulting post-earthquake damage map can be used to assess the distribution of seismic damage following the Palu earthquake and may be used to mitigate damage in the event of future earthquakes. On 28 September 2018, at 17:02 UTC + 7, a Mw 7.4 earthquake hit Donggala County in Central Sulawesi, Indonesia, as reported by the National Board for Disaster Management (BNPB) of Indonesia [According to a press release issued by the Indonesia Meteorological, Climatological, and Geophysical Agency (BMKG) in the ASEAN Coordination Centre for Humanitarian Assistance on disaster management (AHA Centre), up to 27 October 2018 at 07.00 (UTC + 7), 770 aftershocks were recorded, with maximum and minimum magnitudes of M 6.3 and M 2.9, respectively . For exaThe BMKG reported that a tsunami struck Talise Beach in the city of Palu, as well as beaches in Donggala . Some seIndonesia’s BNPB reported that the total loss and damage caused by this disaster amounted to USD 95 million (13.82 trillion Rupiah); this estimate is expected to increase, as the release included only temporal data. The loss and damage caused by the disaster’s impact span five developmental sectors, including housing, infrastructure, the productive economy, the social sector, and cross-sector, with the greatest loss and damage occurring in the housing sector [Historically, this region has hosted several large earthquakes, with the largest event being an Mw 7.9 earthquake in January 1996 at Toli-Toli city . RahmadaTwo predominant methods are available for obtaining accurate information of post-earthquake damage, as mentioned by Xu : field iTherefore, the aim of the present study was to map post-earthquake damage in the city of Palu, Indonesia, using ANN, SVM, and decorrelation methods as a basis for risk assessments, prioritizing evacuation, and mitigation efforts in Palu.The earthquake occurred near the city of Palu, Sulawesi Island, Indonesia a. Palu iSulawesi Island is located at the convergence of three plates: the Indian-Australian Plate, the Pacific Plate, and the Eurasian Plate . ConsequThe Palu-Koro fault zone separates the Sulawesi Sea from the Makassar Basin, dividing it into the North Makassar and South Makassar Basins . The PalBased on field data, the BMKG reported and shared photograph of the field conditions following the earthquake, as shown in In this study, a post-earthquake damage map was generated using two artificial intelligence techniques, ANN and SVM, as well as a decorrelation method. Landsat-8 and Sentinel-2 data were used to ascertain the pre- and post-earthquake conditions. The collected Landsat and Sentinel images were classified using two artificial intelligence models and ANN and SVM classifiers. The pre- and post-earthquake classification results were then calculated using the decorrelation method, as detailed by the flow chart in Satellite imagery from Landsat-8 and Sentinel-2 were obtained for use in this study to generate the post-earthquake damage map of Palu, Central Sulawesi, Indonesia. Two images from Landsat-8, consisting of eight multispectral bands with a spatial resolution of 30 m, were selected for the pre-earthquake a and posThe pre-earthquake image was captured on 16 September 2018, while the post-earthquake image was captured on 2 October 2018. Three multispectral bands were selected to generate the false color combination: shortwave near-infrared (SWIR2) (2.09–2.35 µm), thermal infrared (TIR) (10.40–12.50 µm), and near-infrared (NIR) (0.77–0.90 µm). A false color band combination was selected to easily differentiate the affected area from the area that unaffected by the earthquake during the classification stage.http://step.esa.int/main/toolboxes/snap/). Both the pre- and post-earthquake data from the Landsat and Sentinel imagery were covered by clouds in some regions, which could lead to misclassification and affect the final map result, particularly in the case of Sentinel images. However, cloud contamination in the Landsat image did not significantly cover the affected area, and both images were suitable for use.Sentinel-2A and Sentinel-2B MSI level 1C data were captured for both pre- and post-earthquake conditions on 17 September 2018 c and 22 ANN modeling is a reliable computational method for data classification that is applicable across several fields . ANN is i,xj) denotes the kernel function, and γ is the gamma term in the kernel function for the RBF kernel, and should be optimized in the modeling process. This study employed the RBF as the neural network architecture for its superior association with input data [The SVM algorithm is a useful classifier that is used widely for various types of classification because it works effectively with linearly non-separable and high-dimensional datasets ,47,48. Sput data , whereinDecorrelation is a method whereby the discrimination between areas of different coherence is increased, and the areas are then termed decorrelated areas . DecorreLandsat-8 images were used to classify the land-cover map of Palu before and after the disaster. ENVI Classic 5.3 software was used to process the classification, using both ANN and SVM models. The classification map was divided into five classes  based on the colors shown by the false color band combination from the Landsat-8 satellite images. To generate the classification result, a stratified random sampling method on a pixel-by-pixel basis was used. Fifteen random training samples (polygons) were created in each class, yielding a total of 75 polygons or training samples for the Landsat image. In the resulting pre-earthquake map, red shading shows the urban area before having been affected by the earthquake, while in the post-earthquake map, red shading shows the urban area affected by the earthquake, including tsunami and liquefaction damage. In the post-earthquake image b,d, partIn the pre- and post-earthquake SVM classification results, the urban or affected area classifications were indicated by red shading, as in the ANN classification. The urban area in the pre-earthquake image differed from that in the post-earthquake image, since the post-earthquake area was affected by the disastrous events associated with the earthquake, including the tsunami and liquefaction, in the densely populated area. Red shading was used in both SVM maps following the same premise as in the ANN classification: since the decorrelation method negated the same pixels, it was easier to generate the damage map.The results of the ANN and SVM classifications from the Landsat-8 images were analyzed using the raster calculator function in ArcMap 10.4 software. Using the raster calculator to subtract the post-earthquake image data from that of the pre-earthquake image, differentiation maps of pre- and post-earthquake images from the ANN and SVM classifications were generated, which could be considered as post-earthquake damage maps .2 or 881.46 ha. This result did not differ substantially from the total damaged area based on field data reported by the BNPB of 390.82 ha for the liquefaction area and 2976 houses; although there was no mention of the total area, the total damage to Palu could be assumed to have reached 850 ha. However, the results in The ANN decorrelation results a,b showe2 or 797.4 ha, which did not differ substantially from the total damaged area indicated by the field data. As with the ANN-derived results, some areas were erroneously categorized as damaged due to differences in cloud cover in the pre- or post-earthquake Landsat images.The SVM decorrelation results are shown in The generated map yielded similar results to the ANN decorrelation, where some areas were found to have changed as a result of the earthquake, tsunami, and liquefaction. Since the results based on SVM decorrelation were very similar to those based on ANN decorrelation, a post-earthquake decorrelation map was generated from the two post-earthquake classification methods (ANN and SVM) to differentiate the damaged area from the two classifiers see .Sentinel-2 false color combination images were used for classification with the ANN and SVM methods. The pre- and post-earthquake images were categorized into six classes: urban or affected area, sea and river, vegetation, bare land, clouds, and shadows . To prodThe SVM classification results for the Sentinel-2 images are shown in The ANN and SVM classification results from the Sentinel-2 imagery were analyzed using the decorrelation method. The pre- and post-earthquake classifications were subtracted to generate damage area maps . 2 or 11.150 ha; this was much greater than the damaged area estimated from the field data due to clouds that dominated the map. Both the pre- and post-earthquake Sentinel-2 images were cloudy, causing some areas to be detected as damaged area, and influencing the map’s accuracy in terms of its comparability to the field data.The post-earthquake damage maps from the ANN and SVM classifications showed the areas affected by the earthquake, indicated in red. However, in the results, differences in cloud position were also categorized as damaged area, which ultimately dominated the post-earthquake damage maps. The total area indicated in red in the ANN classification was 11,502,100 m2 or 31.941 ha, due to the inclusion of clouds that dominated the map. This area differed substantially from area estimated from the field data, due to the cloudy conditions.Decorrelation maps for differentiating the results of the SVM and ANN decorrelation maps were made using the post-earthquake results from the Landsat and Sentinel images . The mapFrom the Landsat images a, areas The same process was performed for the Sentinel-2 decorrelation maps to ascertain the differences between the ANN and SVM decorrelation pre- and post-disaster map results b. To disClassification maps using ANN and SVM classifiers generated from Landsat-8 and Sentinel-2 images were produced. Overall, there were eight pre- and post-earthquake classification maps, wherein all Landsat-8 imagery was classified into five classes, urban area or afected area, vegetation, sea and river, bare land, and clouds, while the Sentinel-2 imagery was classified into six classes, with the addition of shadow as the sixth class. There were some differences among the image classification results that were indirectly influenced by the image source and sampling methods used to determine the area of each class. These classification results were then analyzed by decorrelation to reveal the differences between the pre- and post-earthquake images. From the eight resulting classification maps, four decorrelation maps were generated, divided by classifier type (ANN and SVM classifiers) and image source (Landsat-8 and Sentinel-2 imagery). The decorrelation maps, which also included the results of the post-earthquake damage maps, were compared to the field data. For the Landsat-8 images, the results and total area were very similar, but for the Sentinel-2 images, the damaged areas were dominated by clouds rather than the actual damaged area, due to the image conditions. In this case, Landsat-8 yielded superior results for the post-earthquake damage map than did the Sentinel-2 images.The BNPB, Geospatial Information Agency, and National Institute of Aeronautics and Space of Indonesia have published field data, including distribution maps of the areas affected by the tsunami, earthquake, and liquefaction. In comparison to the field data map , the resFurthermore, Post-earthquake damage maps of the city of Palu, where the 2018 Mw 7.4 earthquake occurred, was generated. Two satellite image types were employed, Landsat-8 and Sentinel-2 images, and both satellite images were classified using ANN and SVM methods. The decorrelation method was used to generate damage maps from the pre- and post-earthquake ANN and SVM classification maps. The decorrelation map results were assessed to ascertain the correlations between the ANN and SVM methods, which yielded very similar results. Moreover, the analysis and verification results indicate satisfactory agreement between the post-earthquake damage maps and field data. Post-earthquake damage maps are an essential tool in post-earthquake hazard mapping. Therefore, the results of this study are expected to prove particularly useful in high-risk scenarios, such as that in Palu, Central Sulawesi, and throughout Indonesia, as a country with many active faults. The developed post-earthquake damage maps are beneficial to planners, engineers, and governments, and can help develop evacuation or mitigation strategies to minimize the number of victims, and determining the appropriate courses of action for further plans and developments. However, while the methods used in this study are valid for evacuation and mitigation purposes in areas with a history of disastrous occurrences, they are likely to be less useful for sites without any disastrous events on record. Further research should prioritize the application of post-disaster damage maps to other regions, particularly in Indonesia, which is highly susceptible to various natural hazards, including earthquakes, landslides, subsidence, tsunamis, and flooding.


W scale. The same worst-case scenario caused the casualties up to 49 000 people at night-time and 15 000 people at daytime. The result established that confined masonry building type conduces the highest value of economic losses and timber frame building shows the highest vulnerability to the earthquake disaster than other building types. Furthermore, in order to reduce the risk, we applied the hypothetical policy to build a simple earthquake-resistant house called Simple Instant Healthy House. The result indicates that this mitigation policy can effectively reduce both economic losses and casualties.Bantul regency in 2006 had experienced considerable earthquake and suffered many casualties. The factors such as high population density and lack of seismic design of residential buildings in Bantul besides its location in a high seismic region have increased its vulnerability to earthquake disasters that can lead to a widespread economic losses and casualties. This research aims to capture earthquake risk in Bantul towards economic losses and casualties by using risk curve. Risk curve is a combination of several sources from literatures containing hazard curve and vulnerability curve together with exposure. The result showed that the expected economic loss in 50 years for residential building is $647.22 million; however, the highest value of economic losses shows the value up to $7600m which occurs in earthquake of 7.15 M Indonesia is an archipelago country in Southeast Asia, with a population of approximately to 261.1 million people in 2016 . The risk curves show how often the occurrence of an event such as earthquake may have consequences towards the economic loss and casualties which indicate the level of loss with different return periods. The risk curve is generally applied by decision-makers such as physical planners and civil protection institutions that allow for the instant sum of risks involved in a particular effort, making it very easy to use as a decision-making tool Habegger .To captuThe first step to establish risk cure consists of hazard assessment to know earthquake situation by hazard curve and followed by identification of the element exposed by earthquake risk. The second step is exposure analysis which calculates earthquake probability of damage for each hazard scenario and for each building type. Then, the next step is vulnerability analysis based on vulnerability curve that is related to degree of damage for each type of building. The curves are generated from past event damage assessment. Furthermore, we multiply the replacement value of building damage and vulnerability to calculate losses, and then we sum up the building losses for the same hazard scenario to produce the risk curve.Hazard assessment is first established by hazard curve estimated by plotting annual rate of exceedance versus ground motion. It represents a correlation of occurrence probability of an incident in an area for a period of time. Hazard curve represents seismic hazard resulting from a combination of the ground motion relation and seismic hazard from fault sources: characteristic, Gutenberg Richter and seismic , RC low rice frame with masonry infill walls (RCLRFM), confined masonry (CM), RC medium rise frame with masonry infill walls (RCMRFM) and timber frame (TF). The total number of building in Bantul regency is 369.106. The highest number of building type is CM building, as depicted in Most of the building topology is residential building, because most of the population is farmer which is 25% of all population in Bantul regency. I) in European Macroseismic Scale (EMS-98) based on different sources. Vulnerability curves define the physical vulnerability as a function of the process intensity and the level of loss, reflecting some structural characteristics of the affected buildings , as depicted in The result indicates that CM buildings type conduces the highest value of economic loss which is approximated to $3123m for the worst-case scenario, as shown in There are two important results in this research. Firstly, CM building produces the highest economic losses followed by RCMRFM building type. It is because CM building is the most widely used building in Bantul regency, accounting for more than 50% of all building types in the area. RCMRFM building, which is the most expensive one, takes the third place of the building used in Bantul regency. Besides, TF building, which is the fourth highest, results in the economic losses because of the lowest price of the building; moreover, only 8.19% families in Bantul regency are using this type of construction.Secondly, in terms of casualties’ result, TF building conduces the highest value of casualties. Timber frame structures are earthquake-resistant because of the dissipative capacity of the joints and their ability to dissipate large amounts of energy  budget to rebuild the damage building after earthquake disaster. From This comparison indicates that Indonesia has not been applied the earthquake DRM effectively. Moreover, considering this high number of economic losses and casualties, the disaster risk needs to be reduced. Hence, this study intends to apply some policy to reduce the disaster risk as explained in the following section.To reduce the risk in future earthquake, we intend to simulate a hypothetical mitigation policy. As it was indicated in previous section, the numbers of CM and TF dwellings play a crucial rule to increase the risk. In this section, a policy containing replacement of a number of CM and TF dwellings to engineering-based reinforced concrete house called Simple Instant Healthy House (RISHA)  has been2 (type 36) is $6332.23. Residential Research and Development Centre claims that RISHA is resistance until eight richer scalars or eight in Mercalli Modify Intensity scalar. However, RISHA has still less public interest because of the lack of promotion; this is the reason why so many people do not know about RISHA. So far in Yogyakarta, the enthusiasts are still dominated by the government. In 2014, there were only 16 units, and it is increased only five units in 2015  of efficient sizes in order to be assembled into a large number of different products  feel that the area of RISHA building type 36 needs to be expanded and the openings and ventilation needs to be increased Heston . TherefoThe policy is applied to reconstruct the 10% of CM and TF buildings by RISHA. The economic losses and casualties are subsequently recalculated after 10% of CM and TF buildings are replaced by RISHA. The hypothetical policy consists of two procedures which are the reconstruction by the homeowner or by government subsidy. To engage a high degree of risk reduction to transform earthquake vulnerability to earthquake resistance in Bantul regency, a 100% subsidy by government to replace the damage building with RISHA has been applied.Later, the total cost of policy is compared to the economic loss reduction and number of decreased casualties after mitigation policy implementation scenarios. As shown in The area under risk curve which stands for expected loss in 50 years has been calculated and compared for both typologies before and after applying policy, as shown in In this study, the economic losses and casualties of Bantul earthquake in the future have been calculated and predicted. Our method using risk curve to capture earthquake risk in Bantul has resulted in how often the occurrence of Bantul earthquake has consequences towards economic loss and casualties; this indicates the level of loss with different return periods. The results established that the residential building is exposed the highest value of economic losses, CM building type conduces the highest value of economic losses and TF building shows the highest vulnerability to the earthquake disaster than other building types. Furthermore, we applied the policy to reconstruct the damage building with a simple earthquake-resistant house called RISHA to reduce the risk. The result indicates that this hypothetical mitigation policy is not only effective to reduce the economic losses but also affective to reduce the number of casualties.


Lnc10), which was highly expressed in the spermatogonia and spermatocytes of the testis, interacted with QKI-5. Furthermore, Lnc10 depletion promoted germ cell apoptosis via the activation of p38 MAPK, whereas the simultaneous knockdown of QKI-5 could rescue the apoptotic phenotype and the activation of p38 MAPK, which were induced by the loss of Lnc10. These data indicated that the Lnc10-QKI-5 interaction was associated with the regulatory roles of QKI-5 and that the Lnc10-QKI-5 interaction inhibited the regulation of QKI-5 on the downstream p38 MAPK signaling pathway. Additionally, we functionally characterized the biological roles of Lnc10 and found that the knockdown of Lnc10 promoted the apoptosis of spermatogenic cells in vivo; this suggested that Lnc10 had an important biological role in mouse spermatogenesis. Thus, our study provides a potential strategy to investigate the biological significance of lncRNA-RBP interactions during male germline development.Spermatogenesis is the complex process of male germline development and requires coordinated interactions by multiple gene products that undergo strict developmental regulations. Increasing evidence has suggested that a number of long noncoding RNAs (lncRNAs) may function as important regulatory molecules in various physiological and pathological processes by binding to specific proteins. Here, we identified a subset of QKI-5-binding lncRNAs in the mouse testis through the integrated analyses of RNA immunoprecipitation (RIP)-microarray and biological verification. Among the lncRNAs, we revealed that NONMMUT074098.2 ( This series of processes involves the coordinated interactions of multiple gene products that undergo strict developmental regulations in time and space3. Thus, identifying key regulatory gene products will potentially be useful in elucidating the molecular mechanism of spermatogenesis.Spermatogenesis refers to the complicated, yet highly ordered, process of continuous production of haploid spermatozoa from diploid spermatogonia, which proceeds through mitosis, meiosis, and spermiogenesis inside the testes4. Accumulating evidence shows that lncRNAs are emerging as important regulatory gene products in various physiological and pathological processes7. Over the past years, genome-wide transcriptome analyses of lncRNA repertoires have demonstrated that lncRNAs are highly organ-specific and preferentially expressed in testes8. Furthermore, recent studies have demonstrated the dynamic expression patterns during male germline development, which suggests potential functional roles for lncRNAs in spermatogenesis12. A testis-specific lncRNA, Tslrn1, is highly expressed during the pachytene stage, and Tslrn1 deletion does not affect normal male fertility but causes a significant reduction in spermatozoa number13. Additionally, lncRNA033862 controls spermatogonial stem cell (SSC) self-renewal and survival by regulating the expression of GDNF receptor alpha1 (Gfrα1)14. Despite these promising findings, most of the lncRNAs systematically identified in the testis have not been functionally characterized in vivo in a mouse model. One emerging theme is that lncRNAs may exert their functional role by interacting with specific target proteins and act as decoys, guides, or scaffolds16. Recently, an integrated analysis of large-scale high-throughput sequencing of immunoprecipitated RNAs after cross-linking (CLIP-Seq) and RNA-Seq datasets respectively identified 21,073 and 1662 lncRNA-RNA binding protein (RBP) interactions in humans and mice17. A schizophrenia-associated lncRNA, Gomafu, has been found to be involved in the alternative splicing of schizophrenia pathology-related genes through its direct interaction with Quaking (QKI) and serine/arginine-rich splicing factor 1 (SRSF1)18. Additionally, lnc-Lsm3b can compete with viral RNA in the binding of retinoic acid-inducible gene-I (RIG-I) monomers, which restricts the conformational shift of the RIG-I protein and prevents downstream signaling in the innate immune response19. These findings indicate that the function of many lncRNAs depends on the interaction with functional proteins. However, the biological significance of the interaction of lncRNA with RBP in spermatogenesis remains to be further investigated.Long noncoding RNAs (lncRNAs) are defined as transcripts that are longer than 200 nucleotides (nt) and have little protein-coding potential20. The Qki gene produces three major isoforms designated as QKI-5, QKI-6, and QKI-7, respectively22. QKI has been found to be involved in the regulation of precursor mRNA (pre-mRNA) splicing, mRNA stability, microRNA (miRNA) biogenesis, and circular RNA (circRNA) formation by selectively binding to QKI response element (QRE) located in the target RNAs25. It is well established that QKI is required for neural development and myelination by regulating oligodendrocyte and Schwann cell differentiation26. Since the ubiquitous expression profile of QKI, the interactions of QKI with multiple RNA species have been implicated in various physiological and pathological processes outside the nervous system. QKI is a critical regulator of the vascular smooth muscle cell (VSMC) phenotype by binding to Myocd pre-mRNA and regulating alternative splicing27. Recently, it has been reported that QKI binds upstream and downstream of circRNA-forming exons to promote circRNA formation during the epithelial-to-mesenchymal transition (EMT)28. Additionally, our previous study demonstrates the pivotal role of QKI-5 in regulating primary miR-124-1 processing via a distal RNA motif during erythropoiesis29. Despite the functional diversity of specific interactions of QKI with many RNA species, it is largely unknown if QKI can bind to lncRNAs and its functional importance during spermatogenesis.QKI belongs to the signal transduction and activation of RNA (STAR) family of the KH domain-containing RBPLnc10 exhibited a similar high expression pattern with QKI-5 in the testis. Furthermore, we unveiled that the binding of Lnc10 to QKI-5 suppressed germ cell apoptosis via inhibiting the activation of the p38 MAPK signaling pathway. Additionally, using a shRNA-mediated functional approach of lncRNA in vivo, we demonstrated that Lnc10 played a significant regulatory role in mouse spermatogenesis.In this study, we identified 5922 lncRNAs binding to QKI-5 in the mouse testis using an RNA immunoprecipitation (RIP)-microarray analysis. Among them, Qki gene, QKI-5, QKI-6, and QKI-7, are differed by ~30 amino acids in their C-termini  but was significantly increased in pacSC and gradually reduced in the rST and the elST  analysis. Notably, we found that the percentages of total apoptotic cells with QKI-5 knockdown (siQKI) and the normal control (siNC) cells both increased in response to treatment with etoposide in a time-dependent fashion, whereas the knockdown of QKI-5 led to a significant decrease of ~5–9% during 6–12 h compared with the normal control Fig. . Furtherhttp://rbpdb.ccbr.utoronto.ca). A preliminary QRE screening indicated that 13 lncRNA candidates (65%) contained one or more of the QREs , was mainly expressed in the mouse testis and exhibited a similar high expression pattern with QKI-5 , named I-5 Fig. . AccumulLnc10, we performed RNA pull-down assay in GC1-spg cells by antisense probes that were designed against endogenous Lnc10. A qRT-PCR analysis of the RNA species captured from the RNA pull-down assay revealed a significant enrichment of Lnc10  as well  according to an analysis with the UCSC Genome Browser  mouse testes, whereas both newborn and adult mouse testes expressed low levels  in GC1-spg cells and examined the effect of knockdown of Lnc10 on the regulation of the p38 MAPK and apoptosis. Notably, we observed a dramatic ~70% reduction in the expression of Lnc10 by ASO-mediated silencing  and the normal control (ASO-NC) both increased after treatment with etoposide in a time-dependent fashion, while the knockdown of Lnc10 caused a substantial increase of ~8.3–17% over 3–9 h compared with the normal control  to block protein translation had no influence on the expression level of QKI-5  were significantly lower than those in the normal control (pcDNA3.1) during 3–9 h; this indicates that the overexpression of Lnc10 inhibited the p38 MAPK and apoptosis, which was consistent with the loss of function roles of QKI-5 -mediated knockdown by adeno-associated virus (AAV9) via a seminiferous tubule microinjection. A qRT-PCR analysis showed that the expression of Lnc10 was reduced by at least 50% at 4 weeks after the microinjection with AAV9-shLnc10-RFP , a Sertoli cell marker, but detected no significant differences in terms of the localization and number of WT1lls Fig. . Given tive Fig. . CollectDrosophila to mammals, has diverse roles during physiological and pathological processes32. However, the precise regulatory roles of QKI in male germline development remain largely elusive. It has been reported that QKI-5 can selectively interact with multiple RNA species, such as pre-mRNA, microRNA, and circRNA, by binding to the QREs located in the target RNAs. Given this model, it is of great interest for us to ask whether there is a class of lncRNAs, including QRE, which can physiologically interact with QKI-5 and plays an important role in spermatogenesis. Through the integrated analysis of RIP-microarray and biological verification, we found that some lncRNAs contained one or more QREs, which were located in their primary RNA sequences. There were also some lncRNAs without a QRE, and these lncRNAs may not directly bind to QKI-5, but indirectly. To some extent, these observations illuminate the binding relationships between QKI-5 and lncRNAs.Accumulating evidence has documented that QKI, which is extremely conserved from LncmyoD33, LncTCF734, and Lnc-DC35. Given the lncRNA-protein interactions in association with protein functions, it is tempting to speculate that Lnc10 binding to QKI-5 may have an effect on the regulatory function of QKI-5. Of interest, we found that Lnc10 depletion promoted germ cell apoptosis via the activation of p38 MAPK, whereas the simultaneous knockdown of QKI-5 in part revert the effect induced by the loss of Lnc10. Indeed, lncRNAs that inhibit protein regulatory functions through competitive binding have been reported, such as Malat136, Gomafu18, and lnc-Lsm3b19. It is an attractive possibility that Lnc10 inhibits the regulatory function of QKI-5 through competitive binding, although further investigations are required to determine the precise mechanism. These observations of the Lnc10-QKI-5-p38 MAPK regulatory axis may broaden the known regulatory roles of QKI-5. Since QKI-5 is widely expressed in multiple tissues, involved in organ development, and the lncRNA-QKI-5 interaction is associated with the regulatory function of QKI-5, it will be of great interest to identify QKI-5-binding lncRNAs in other systems.A widely proposed hypothesis is that lncRNAs may exert their functions through specific interactions with functional proteins, such as Drosophila spermatogenesis37. Additionally, the knockout of an ultraconserved lncRNA, THOR, produces fertilization defects in zebrafish38. These findings indicate that lncRNAs may play similar functional roles in male germline development across multiple animal species. However, most lncRNAs have not been functionally characterized in vivo in mouse models. Thus, we performed a shRNA-mediated knockdown by AAV9 to investigate the functional role of Lnc10 in vivo39. Our study demonstrated that the depletion of Lnc10 caused spermatogenesis abnormalities by promoting germ cell apoptosis, which was consistent with the regulatory effects in vitro.In fact, a number of lncRNAs have been systematically identified in the testes of multiple species. A recent study has revealed critical functions of testis-specific lncRNAs in late Lnc10-QKI-5 interaction is associated with the regulatory function of QKI-5, which inhibits the downstream p38 MAPK pathway and germ cell apoptosis  was incubated with cells for the periods of time. Actinomycin D (5 μg/mL) was purchased from AMRESCO. Cycloheximide  was purchased from Sigma-Aldrich . SB203580 (10 μM) was purchased from Selleck Chemicals .The distinct germ cell types were isolated from the testes of ICR mice. GC1-spg cell lines were purchased from the American Type Culture Collection  and cultured in Dulbecco’s modified Eagle’s medium  supplemented with 10% fetal bovine serum  and 1% penicillin-streptomycin  at 37 °C with 5% COLnc10 was PCR-amplified and subcloned into pcDNA3.1 (+) vector using ClonExpress II One Step Cloning Kit (Vazyme Biotech), named pcDNA3.1-Lnc10.The cDNA of QKI-5 was PCR-amplified and subcloned into p3XFLAG-CMV™-14 EXPRESSION VECTOR using ClonExpress II One Step Cloning Kit , named Flag-QKI-5. The cDNA of Lnc10 and Smart Silencer control were transfected into GC1-spg cells using Lipofectamine RNAiMAX Transfection Reagent (Invitrogen).Plasmids were transiently transfected into GC1-spg cells with Lipofectamine 3000 Transfection Reagent (Invitrogen) according to the manufacturer’s instructions. The siRNA specific to murine QKI-5  and silencer negative control siRNA were transfected into GC1-spg cells using Lipofectamine RNAiMAX Transfection Reagent (Invitrogen). LncRNA Smart Silencer  specific to murine Total cell and tissues lysates were prepared in 1 × sodium dodecyl sulfate buffer. Cell or Tissue lysates were subjected to SDS/PAGE and transferred onto a PVDF membrane. The protein levels were quantified by densitometry using AlphaEaseFC software. The following antibodies were used for Western blotting analysis. The anti-QKI-5 (#AB9904) was purchases from Millipore Company . The anti-JNK (#9252), phospho-JNK (#9255), ERK1/2 (#9102), phospho-ERK1/2 (#9101), P38 (#9212), phospho-P38 (#9211), cleaved caspase-3 (#9664), cleaved PARP (#9548), TUBULIN (#2128) were purchases from Cell Signaling Technology .The testes dissected from mice was fixed in 4% paraformaldehyde for 24 h and then incubated in sucrose-PBS solution  at 4 °C. Frozen sections were cut to a thickness of 7 μm using the Leica CM1950 . Cryosections were washed in PBS and permeabilized with PBS containing 0.5% Triton X-100. The slides were blocked with 5% BSA and then incubated with primary antibody at 4 °C overnight. AlexaFluor™ conjugated secondary antibody was added for 1 h at room temperature. Finally, the slides were mounted with SlowFade™ Gold Antifade Mountant with DAPI (Invitrogen) and observed under LSM 780 confocal microscope  for fluorescent signal analysis.Total RNA was extracted from cell or tisue using Trizol reagent according to manufacturer’s instructions and quantified using the NanoDrop 2000 spectrophotometer (Thermo Scientific). Total RNA (1 μg) was reverse-transcribed to cDNA using RevertAid First Strand cDNA Synthesis Kit (Thermo Scientific). Quantitative real-time PCR was performed in Step One ABI real-time PCR System through PowerUp SYBR Green Master Mix . The primers used for qRT-PCR were listed in Supplemental Table 2, 0.05% NP-40, 1.5 mM DTT, 1× Protease Inhibitor Cocktail and 200 U/ml RNase Inhibitor). After the lysates were centrifuged at 12,000 rpm for 15 min, the supernatants were precleared with protein A beads  in lysis buffer. Then, the preclear lysates were used for RIP with anti-QKI-5 and rabbit isotype control IgG antibodies. RNA-IP was carried out for 4 h at 4 °C. The beads were washed four times with wash buffer, followed by extraction with proteinase K (20 mg/μl) master mix  at 55 °C for 15 min. The RNA for each RNA-IP sample was extracted with acid phenol/chloroform and was treated with DNase I. The RNA sample was used for a lncRNA microarray assay or a reverse transcription assay.The testes were homogenized in ice-cold PBS using a homogenizer and were resuspended in 800 μl lysis buffer , and the RNA integrity was assessed using an Agilent Bioanalyzer 2100 (Agilent Technologies). Sample labeling, microarray hybridization and washing were performed based on the manufacturer’s standard protocols, provided by the Shanghai Oebiotech Co Ltd . Briefly, the total RNA was transcribed to double-stranded cDNA, synthesized into cRNA and labeled with Cyanine-3-CTP. The labeled cRNAs were hybridized onto the microarray. After washing, the arrays were scanned by the Agilent Scanner G2505C (Agilent Technologies). Feature Extraction software  was used to analyze the array images to obtain the raw data. GeneSpring was utilized to finish the basic analysis with the raw data. The raw data were normalized with the quantile algorithm. Differentially expressed mRNAs or lncRNAs were then identified by their fold change. The threshold that was set for the up-regulated genes was a fold change >=2.0. The QKI-5 binding mRNAs were listed in Supplemental Table Lnc10 using an online design tool (http://www.singlemoleculefish.com/). Probes were synthesized and labeled with Biotin at 3′ end (Invitrogen). RNA pull-down assay was performed according to a previously published protocol40. The probe sequences used for RNA pull-down in GC1-spg cells are listed in Supplemental Table For RNA pull-down assay in GC1-spg cells, we designed 8 tiled antisense probes covering the sequence of For RNA pull-down assay in isolated type B spermatogonia and pachytene spermatocyte, we used the Pierce™ Magnetic RNA-Protein Pull-Down Kit (Thermo Scientific) according to manufacturer’s instructions.For GC1-Spg cell apoptosis detection, FITC Annexin V Apoptosis Detection Kit I  was used to stain cells according to manufacturer’s instructions. Apoptotic cells were determined by FACS analysis (BD Pharmingen).For cell apoptosis in the testicular sections, apoptosis was evaluated via a terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) assay using In Situ Cell Death Detection Kit (Roche) following the manufacturer’s instructions.6) were collected from the testis. Nuclear and cytoplasmic RNA fractions were isolated from Germ cells using the PARIS isolation kit (Thermo Scientific) according to the manufacturer’s instructions. Small nuclear RNA U6 and Actb were used as positive controls for nuclear and cytoplasmic RNAs, respectively.Germ cells  were injected into the seminiferous tubules using a glass microcapillary pipette with a tip diameter of 40 μm. One testis was injected with AAV9-shCtrl-RFP; the contralateral testis was injected with AAV9-sht-test (two-tailed) was performed to analyze the data. P-value of <0.05 was considered to be statistically significant.All experiments were performed at least in triplicate and the values were presented as means ± SEM. Student’s Table S1Table S2Table S3Table S4Supplementary figure legendsSupplementary Figure 1Supplementary Figure 2Supplementary Figure 3