The majority of STEM disciplines in Canada are male-dominated and there is a significant lack of programming available to girls. The Girls Get WISE program is a university-based program that is funded by the federal government, the university, and corporate sponsorship. This program is delivered in person by educational professionals, science students, and past participants. By engaging girls in hands-on interactive STEM activities in a safe and fun space, this program provides an opportunity for young women to showcase their talents and excitement for science-based topics. The features of this program and its evaluation over a 10 year period are described here. The Girls Get WISE programs began in 2011 at a university in Halifax, Nova Scotia, Canada. The city of Halifax has a population of about 450,000 people and is located on the East coast of Canada. The university that delivered the Girls Get WISE program has a long-standing reputation for the advancement of women. At the time when this outreach program was started, there was very limited STEM programming in the region, and only one other non-profit organization running STEM programming exclusively for girls, and that program was primarily focused on getting girls interested in Trades and Technology careers. The limited number of other STEM programs in the region are mixed gender and it was clear that, in most, the percentage of girls participating was 10% or less. The university itself had no science outreach programs.Statistically in Canada, the percentage of women working in STEM careers in Canada is low and is in stark contrast to the almost equal gender split in the labor workforce . This peThe career progression to achieving a STEM career starts with elementary and secondary school. In Canada, most public schools are mixed gender with the majority of students attending public schools. The Science curriculum across the country is varied with each province regulating and determining course content. Science is taught as a single subject from elementary through to junior high school in Nova Scotia, Canada. In high school (grades 10–12), students can select Biology, Chemistry, and/or Physics. Mathematics is required in each year of schooling from primary through to grade 12, however the amount of math (one to three courses) varies depending on the student’s interests. Science teachers have limited time and resources to conduct hands-on activities in the classroom, especially in junior high (Grades 7–9) and high school (Grades 10–12). Grade 9 of high school is when students begin to select courses for the following school year and this is when students are either selecting or not selecting science-based courses. The choices made in Grade 9 for Grade 10, dictate the science options available to them in Grade 11 and Grade 12. All Science degree programs in Canada require Science pre-requisite courses from high school. Therefore a student without science subjects in Grade 12, has to spend an extra year or two obtaining these course credits before they are accepted into university science programs. Furthermore, university education is very expensive in Canada and is not affordable to many students. Thus, girls who pursue STEM-based programs at university are often those who (i) are encouraged by science and mathematics teachers and/or parents; (ii) are from affluent families who can afford university tuition and tutors (if needed) during high school; and (iii) who are exposed to STEM careers through family members. Programming, such as the Girl Get WISE events, is needed because the STEM stereotype is heavily white male-dominated in Canada and is reinforced by the branding of toys, clothing for children, and the voices/images portrayed in the media e.g., . Thus, wThe two signature Girls Get WISE events described below are a one-day Girls Get WISE Science Retreat and Junior and Senior Girls Get WISE Science Summer Camps. These events are open to individuals who identify as girls . Both of these events feature hands-on STEM activities as well as an hour-long Role Model session. The hands-on sessions are always very interactive and ensure the girls are learning some aspect of STEM in a novel and fun manner. The hands-on activities are either developed in-house by a team of science-trained professionals or by others . In the latter case, all activities are thoroughly reviewed prior to accepting them into the program content (see Discussion). The Role Model session works round-robin style; five to six women working in different male-dominated STEM fields are invited to chat informally with small groups of participants about their careers for about 8 min, and then the girls switch to the next role model. Included with the recruitment of potential role models is a “Role Model Guide” guide document, which details how the session will run, as well as topics they are encouraged to cover such as their career pathways, what motivated them to pursue their careers, what their typical day is like, any setbacks they had along the way, etc. The girls are encouraged to ask questions, and question prompt cards are provided to them at the tables. Participants are informed that they can always reach out to the Program Coordinator to connect with specific role models if they have further questions after the session. It is important for girls to see people like themselves working in male-dominated fields to show them that these careers are possible.The one-day Girls Get WISE Science Retreat brings together 50–60 girls+ in grades 7–10 (ages ~12–16 years) together at Mount Saint Vincent University  to participate in two hands-on STEM sessions and a Role Model session. The day starts with a team ice-breaker activity, which is typically an engineering design challenge or STEM trivia, and then the girls are split into two random groups to participate in their first hands-on activity of the day which is typically an hour in length. There is a break for an hour lunch (that is provided), then they move to the second hands-on activity of the day, which is then followed by the hour-long Role Model session. At least one of the hands-on activities takes place in a laboratory setting each year, and the other session could be coding or Engineering related. The day ends with some reflection, an evaluation, and prize draws.From 2012 to 2016, one Girls Get WISE Science Summer Camp took place each year for 24 girls+ that were 12–14 years in age. In 2017, a second Science summer camp for older girls, 15 and 16 years in age, was added. Both camps are day camps; however, the Junior camp runs for a full 5 days, while the Senior camp runs 4 days a week and at reduced hours per day. The difference in length is because the younger girls are more likely to depend on parents or caregivers for transport to the camp, while older girls are more able to take public transport. Similar to the Science Retreats (described above), both of the camps feature an hour-long Role Model Session, as well as different hands-on STEM activities, some of which take place in the laboratory, while others take place outdoors. Danio rerio) are wonderful organisms to showcase to students as they are easily obtainable , they breed readily and produce hundreds of eggs per clutch, their development is external to the mother, and their embryos are transparent , that work in different STEM fields (to ensure a diversity of careers and career paths are showcased), and that come from diverse backgrounds . Invitations to participate are sent to five or six role models. Sometimes, the timing of the event does not align with their schedule, for example, and in these cases, our role model database is consulted once again. We found that it was extremely useful to have a database of role models we could call upon at any time since a number of repeat participants attend the events, and therefore, both the program content and the selection of role models need to be different in consecutive years.Delivery of the majority of the hands-on sessions is carried out by the Program Coordinator, part-time students and/or volunteers. Often experts are invited to discuss their research with participants and to then lead related hands-on activities, this typically occurs if the team is not familiar with a particular STEM topic. We also invite other STEM-related non-profit groups to host activities, such as the local Science Centre or Canada Learning Code. As noted earlier, it is important that the Program team reviews the activities to ensure that they are age appropriate.At all of these Retreats and Camps, evaluations are handed out at the end of the programming on the final day. These evaluations are primarily used to determine which sessions were well received and which need improvement. We also ask some program impact questions, although we acknowledge that these are leading questions. The past participants (from the last 10 years of programming) that completed program evaluations described below range in age between 12 and 16 years of age, they all identify as young women (girls+), and they come from varied socioeconomic backgrounds. The majority of respondents live in urban areas (roughly 85%). In total, 678 girls have participated in this program over the last 10 years and completed evaluation forms at the end of the events. Since these forms are handed out in the last few hours of the event, the response rate is high (95%). The data presented below is aggregated data from the last 10 years.F = 22.11; p < 0.005). To better understand if the Girls Get WISE programming has a lasting impact on participants, participants are asked: “Did attending this event inspire you to continue with science at school?” Participants could select from the following options: Yes, No, Maybe, Unsure. 93% of participants indicated that the event did inspire them to continue with science at school . Another question is: “How did attending this event affect your interest in science and engineering?” of which participants could choose the following options for their response: More Interest, Same Interest, Less Interest. Results from this question were as follows: 60.7% of participants indicated that the event increased their interest, while 36.9% indicated that their interest stayed the same . Based on these responses, the many emails we receive after events and participant comments, it is evident that this programming style is highly successful; the longer girls stay on this science path the more exposure they would have to science and engineering as a career.One of the questions participants are asked is “Did this science camp (or retreat) meet your expectations?” Participants could select from the following options: Exceeded, Yes, or No. From responses, 96% of participants indicated that the event met or exceeded their expectations  it is time consuming to develop new activities, and (ii) the activities the team wanted to run were not in their field of expertise. This approach is two-fold, participants are able to meet additional STEM experts and the activities are often more tailored on a particular topic. This approach comes with other challenges, however. First, just because someone is an expert in a particular field or topic, does not mean that they have the experience in delivering an activity to youth based on that knowledge. To address this challenge, an activity proposal sheet was developed in which prospective facilitators were asked to complete. This form asks them to detail their activity and provide all relevant materials that would go along with it. The program team then works with the facilitators to tweak the content if needed. This proved to be an effective way to develop quality and age-appropriate content for the program.Some lessons that were learned along the way in delivering all-girls STEM programming over the last decade are that it is important to create activities that are as hands-on and as interactive as possible, use the knowledge of local STEM experts to develop unique programming, and include them in the delivery if possible, including female role models as part of the programming is very impactful, and always strive to improve upon programming using feedback from participants . SpecifiWhile the school system curricula have remained largely unchanged over the last 10 years, there is a need to depend on other organizations to encourage the pursuit of STEM. Past research has shown that girls are influenced by their parents and guardians, teachers, and their peers e.g., . When spTo build on these programs in the future, we would recommend the creation of an ambassador’s program, where past participants become program ambassadors and through video and other social media content encourage their peers to participate in the program. Another program that would expand on the Girls Get WISE model would be to create a Girls Get WISE Leadership program, where past participants can get leadership training and then begin to volunteer with the programs. This helps to build confidence in the girls and would help to ensure a steady stream of ready and eager volunteers for STEM outreach programming.I just wanted to touch base to let you know that the camps had an impact on my academic direction. I have just begun my first year in a Bachelor of Science degree in Biology at .. I wanted to thank-you for the opportunities we had during the WISE camps to better understand the different aspects of science and its various influences. It opened my eyes to different career possibilities. I am enjoying my first month at … and wanted to reach out to let you know these wonderful camps do make a difference.”The longer-term impact of these programs on the STEM workforce or student enrollment into STEM programs is unknown at this time. However, some insight can be gained from some of these unsolicited emails that were received: In the words of one of our participants “My two daughters did the WISE Atlantic program a few years ago. My oldest has just been accepted to … University for Biology/Medical Sciences with a scholarship. I give great credit to your program for inspiring her to study and enjoy science. Many thanks for your program and the people who work to make it possible.”And another email from a father of a past participant: “The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.TF-O and SM designed and delivered the programming and wrote the manuscript. All authors contributed to the article and approved the submitted version.Funding was received from the NSERC Chair for Women in Science and Engineering (Atlantic region). This program is funded by the Natural Sciences and Engineering Research Council of Canada (NSERC), Mount Saint Vincent University, Lockheed Martin Canada.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Family-based lifestyle interventions (FBLIs) are an important method for treating childhood weight problems. Despite being recognized as an effective intervention method, the optimal structure of these interventions for children’s overweight and obesity has yet to be determined. Our aim was to better understand participants’ (a) implementation of behaviour strategies and long-term outcomes, (b) perceptions regarding the optimal structure of FBLIs, and (c) insights into psychological concepts that may explain the success of these programs.n = 53) and children  three months following their involvement in a 10-week, multi-component, FBLI involving education and activities relating to healthy nutrition, physical activity, and behavior modification. Using an interpretivist approach, a qualitative study design was employed to examine participant experiences.Purposive sampling was used to recruit participants. We conducted focus groups as well as one-to-one interviews with parents (We identified three higher-order categories: (a) participants’ program experiences and perceptions (b) lifestyle changes post-program, and (c) recommendations for optimizing family-based programs. Themes identified within these categories included (a) support and structure & content, (b) diet and physical activity, and (c) in-program recommendations and post-program recommendations. We identified several challenges that can impair lasting behavior change  following involvement in a FBLI. On optimizing these programs, participants emphasized fun, interactive content, interpersonal support, appropriate educational content, and behavior change techniques. Concepts rooted in motivational theory could help address calls for greater theoretical and mechanistic insight in FBLIs. Findings may support research advancement and assist health professionals to more consistently realize the potential of these interventions. Childhood overweight and obesity is recognized as a global public health crisis . In AustBehavioral and lifestyle interventions  aimThere exists a vast literature on frameworks and psychological constructs that may explain varied effects of FBLI programs. For example, in self-efficacy theory, there are four antecedents to an individual’s confidence in their ability to perform a behaviour, namely, performance accomplishments (whether a task is performed successfully), vicarious experiences , verbal persuasion  and physiological and affective states (such as stress or joy) , 38. In In discussing the merits of FBLIs, Berge and Everts  noted thNotwithstanding the positive outcomes for which family-based treatments may be responsible, however, there remain important questions to be addressed in this area. In a systematic review exploring the viewpoints of adolescents (12–17 years) who had attended overweight and obesity interventions, several of the key themes which emerged were: intervention tailored to the individual, active engagement and fun, longer term support, value derived from professional, peer and family support, and an emphasis on enjoyment from physical activity . FurtherIn this study, we sought to understand (aspects of) participant experiences during and following a FBLI for children’s overweight and obesity. In seeking to address the broad issues outlined above, we sought detailed feedback from parents and their children after they had completed a FBLI. More specifically, we sought information regarding participants’ (a) experiences in and perceptions of the program, (b) lifestyle changes following the program, and (c) recommendations for optimizing the effectiveness of programs of this kind. These three broad discussion areas were selected because they either mapped directly onto issues that we sought to better understand , or because they would likely enable us to make inferences about issues that may be considered too esoteric  to discuss directly with community-based participants .Grounded in our desire to capture parents’ and children’s lived experiences within a family-based intervention, we adopted an interpretivist approach to enquiry . The intn = 97) or one-to-one interviews (n = 6 parents). All children were classified, according to body mass index (BMI), as overweight (BMI > 25.0) or obese (BMI > 30.0) at entry into the program, and participants were drawn from the Perth metropolitan area.We aimed to recruit parents and their children who had completed a program and had returned to an extended period of ‘independent’  living so as to enable us to explore long-term effectiveness and lifestyle change/maintenance post-program. We primarily sought to obtain insight from parents and children who had received the full program ‘dose’, as those participants would likely have the richest experience upon which to reflect. For the sake of contrast and in order to capture more balanced data, however, we aimed to supplement these accounts with information from a sub-sample of parents who had withdrawn from the program . A total of 53 parents  and 50 of their children  participated in focus group interviews  and parents (n = 9 sessions) separately to ensure that the perspectives of children were freely explored. Six of the parent participants were those who had left the program early, and these parents were separately recruited (via email) in order to provide perspectives from program non-completers. One-on-one phone interviews were held with these non-completer parents to obtain the richest possible accounts from all of these participants.All program completers were invited to participate in the study. During a scheduled program follow-up assessment that took place three months after the end of a family’s involvement in the 10-week family-based program (see following section for program information), prospective participants  were approached by members of the research team (over 50% of those invited were willing to participate). Focus groups were used to provide an in-depth understanding of participant perception and identify barriers to change that cannot be addressed using quantitative methods  in a timIt is worth noting that some inter-patient and patient-interviewer dynamics likely affected the findings of this current study. For instance, prior to participation in interviews, participants became acquainted through participation in the FBLI program. There is little consensus in the literature on the impact of conducting focus groups with acquaintances. Some researchers , suggesThree members of the research team developed a semi-structured interview guide for parents and children prior to data collection. In line with the aims of this study, the interview guide included open-ended questions developed to explore parent and child (a) experiences within and perceptions of the program, (b) lifestyle changes during and following the program, and (c) recommendations for optimizing the effectiveness of programs of this kind. Probing questions were used to explore answers given by participants, concepts surrounding answers, and to gain further explanation regarding a belief or behavior. At the end of each focus group or phone interview, participants were invited to ask questions. Based on the nature of thematic analysis, there always remains an ability to generate alternate meanings from data, and as a result, data analysis may never truly be considered ‘complete’. Data collection continued, therefore, until members of the research team made an interpretive judgement that the data provided a faithful and detailed representation of participants’ experiences during and following the program . On averwww.betterhealthcompany.org/) provides a childhood overweight and obesity intervention called the Better Health Program  to families across Australia who, over the past 10 years, have shown statistically significant improvements in self-esteem, BMI, healthy eating habits and physical activity upon program completion. The program aims to have children build confidence, improve self-esteem, become fit, and teach parents the skills to ensure their children are healthy. The organization is reputable, well-known, and government funded; its program is based on best-practice programming guidelines and published research evidence . The 10-week multi-component program involves weekly, two-hour parent-and-child sessions—delivered by trained health professionals—focused on the provision of resources, education, and experiential activities relating to healthy nutrition, physical activity, and behaviour modification . The program targets children with overweight and obesity aged 7 to 13 years old, is cost-free for participants, and operates in venues such as leisure and recreational centers, community and school halls, and council facilities across multiple locations in Australia. Participants are recruited through community promotion  and referrals by health professionals. The Better Health Program—in terms of lifestyle modification aspects, behavior change content, expert delivery, and program length—adheres to many of the best-practice recommendations for family-based program content  finds herself in the middle of a group where they all have the same level of activity, so nobody is faster or stronger or better. That really helped her because, as a group, they all helped together through the same activities.” On a separate issue, another parent appreciated the supportive comments from peers, stating, “saying nice things about other [children] in the group, it builds other people up as well. I think that was helpful, and [the children] were quite proud of it, it’s something for them to hold on to”  the significance of practical and interactive components, (b) the inclusion of appropriate educational material, and (c) the importance of program features that support participant enjoyment.With respect to practical and interactive components, parents and children appreciated the ‘hands-on’ elements of program content. This practical approach allowed parents and children to develop their understanding (and competence) regarding, for example, nutrition-related skills. Specific strategies will vary program-by-program, but one example of this interactive approach in the present program was the use of food label reading sessions, and a ‘live’ visit to a supermarket. Discussing this component, one parent commented, “the best thing we did was when they took us to the supermarket and they actually showed us how to look for the labels… like, telling us ‘this is good, this is not good, this has too much fat, this one has a little bit of sugar’, it just gives us details on what to take away.” Children also appreciated these practical methods for delivering educational content. One child commented, “I liked it when we went to the shop and learned about the labels. We got to learn about the labels and what’s good for you, what’s bad for you, and what the best brands are.” Similarly, reflecting on ways in which program content could be improved, another child noted he would have appreciated “if we got to learn things in different ways, like doing activities, instead of sitting and… trying to listen.”As well as describing the importance of practical program elements, participants also expressed a desire for educational material—which was central to program content—that was considered ‘new’ or ‘fresh’. For example, the program afforded parents and children with the opportunity to learn new healthy recipes; one parent noted that “[the] program’s been really helpful in terms of recipe ideas and giving information about reading labels and all those kinds of things I didn’t know before.” Similarly, another parent commented, “A lot of the stuff… was all new for the kids, and the information was very accurate. They kind of gave you websites that you can look for, go and search for recipes, community activities and things like that.” It was noteworthy that children expressed the same sentiment. One child commented, “I learned that when you have lots of muscle, fat won’t be able to grow that much. And also, instead of using sugar, you can use natural sweeteners or healthy fruits. And instead of having white bread, you could have whole-meal bread. I found out that wheat is much better.” Whilst discussing educational material, parents expressed concerns when information was not considered to be ‘new’ or ‘fresh’. One parent, for instance, noted that “I think the program itself is good, but I don't think it was suited to my son. You know, they gave a lot of good tips and things, but it was nothing that wasn't already common knowledge.” A parent who did not complete the program added, “it’s all good to say ‘you need to stay away from junk food’, but we all know that already. It was based a lot on things that we already know… we stopped going because everything that we were learning was stuff that everybody knows.”Finally, participants emphasized the importance of program elements that support participant enjoyment. Many parents and children reported that they enjoyed the physical activity within the program sessions. One parent summarized, “the exercise, that’s the fun part. Because they’re all the same, they helped each other, and they had real fun, they loved it. The kids will go off with the instructors and get bright red, sweaty, and they absolutely loved it, and they would stay behind”. This enjoyment appeared to be derived from children being able to access a variety of different forms of physical activity, and ‘having a say’ (or some degree of autonomy) over their activity involvement and choices. Participation in different team or cooperative activities was perceived as enjoyable and as an opportunity to learn and develop competence in new areas. One child noted, “I liked the sports. We got together and worked as a team. And we got to run around and be free, have fun, and learn new stuff. Bouncing! And running! I liked getting to do the different exercises.” The same effect was described in instances when children felt that there was a lack of variety or autonomy. One child commented, for example, “I didn’t like having to do fitness, it didn’t really help me. We were just standing in circles for the whole thing, we didn’t run or anything. I thought we’d be racing and that stuff.” One parent echoed this sentiment, noting, “[my boy] kind of felt like it was a bit, like he had no choice with that side of it, that’s how he felt, that's what he said to me” , participants spoke broadly about two key health behaviors. Specifically, they described successes and challenges relating first to children’s diet, and second to children’s physical activity levels, which were grouped into two themes. In doing so, participants also described some of the reasons underlying those successes and challenges. In the material that follows  had successfully adhered to, or sustained, dietary changes brought about during the program. These ‘successes’ reflected an ongoing awareness—that had been provided through participation in the program—regarding (a) healthier choices, recipes and food substitutions, and (b) nutrition resources  and simple ‘tips’ or skills  that were considered valuable and sustainable.Speaking generally about making healthier dietary choices, one parent noticed, “we’re now eating more fruits and vegetables. We don’t have food goals, but we’re just eating more of the healthier stuff now.” Similarly, one child mentioned, “we make these cupcakes now, and we didn’t put any sugar on them at all. We do it healthier, the healthier version.” Another child highlighted that his family was still making healthier substitutions that had been introduced during the program, “now we use wholegrain bread all the time. And also wholegrain spaghetti, and wholegrain crackers”  of physical activity. First, parents highlighted that the withdrawal of the structure provided by the program  had made it difficult for them to continue to support their child’s physical activity. On this issue, one parent commented, “it’s hard for me—there’s not enough time. Sometimes, we [the parents] don’t have the energy. Sometimes, we have the time, but we get more tired than the children, they have energy, but it’s just us that doesn’t.” Another parent explained, “The program’s just really good, it’s just the challenge of having, of how to go on on your own, because it’s very goal oriented, that’s been so good, it is more of how you keep them motivated to carry on.” A different parent reinforced the same issue, “The exercise part for the kids is missing after you finish, so we had to fill the time, even if he does other things, it’s not the same, because if you’ve got something interesting, they get more into it I find. I think just not having the fixed times, that we knew that Thursdays four to six, that’s what we’re going to do.”In reflecting on the benefits of being with similar others during the program , some parents noted that integration into ‘regular’ community activity post-program was difficult. One parent explained that her child felt ostracized when she tried to participate in community-based sport following the program, “the people organising the activities don’t use your kids in games because they’re “fat” or they’re “slow”, and it’s adults saying that to kids.” Another parent shared, “when [my son] was doing the exercises, he was actually so confident and relaxed because everyone else was the same… it’s the interaction with other kids. It’s just different after [the program] when they go out and to do the sports on their own” , or those focused on the period following the program . Below, we detail key issues highlighted in these two themes  following the program, some parents suggested that longer programs (including a dedicated ‘transition’ phase at the end) may be beneficial. One parent commented, “I think it would be nice if programs were spread out, instead of having it in just one school term.” On the issue of a gradual transition out of the program and into self-regulation, another commented, “it would be nice to have a bit more continuity instead of just doing that one program and finishing.” One parent suggested that a transition phase could involve shorter sessions, “You could, you know, make those later sessions just a quick blast of activity. We’ve got what we need for information, but that could be a way of keeping things active for longer.”In terms of intervention content, it was apparent that children expressed a desire for prioritizing time toward (enjoyable) physical activity during the sessions. One child mentioned, “less talking, more playing. We normally do an hour of talking and a bit of sport, and then we’re coming back, and then we have to leave.” Similarly, another commented, “I want more games, I want to run more. If not, we do more mind things instead of active things.”Finally, some children raised noteworthy recommendations about sensitivity to grouping considerations. Although the majority of children observed likeness with others in terms of weight and health issues, age differences appeared to be a barrier to participation in some instances. One child mentioned, “I don’t know, maybe the age groups that they take in at one time should be smaller, because for me to come in was awkward, because I’m 13 and all of you guys are like 10.” Another child commented, “I kind of wished like the age groups were exactly the same for everyone. You won’t get a lot of teenagers wanting to join unless their parents force them into it.”Parents provided valuable recommendations for post-program strategies that could improve the maintenance of healthy dietary and physical activity behaviors learned during family-based programs of this kind. The overarching recommendation reflected the importance of maintaining connections—with the program and those with whom the families had completed the program.For example, parents endorsed the possibility of having formal ‘post-program support’ through occasional contact with the children. One parent explained, “to have someone like that [from the program] calling, you know, contacting you, asking how you’ve been, what you’ve been doing, what your goals are for the next month, I think that would just reinforce the message, and it wouldn’t take a lot of time.” Other parents felt that a continued connection between program and parent would help ensure children were able to maintain their newly-learned healthy behaviours. One parent said, “it’d be a good back-up, like a review or something. Maybe we should make it every 2 or 3 weeks, just to keep us motivated.”In addition to formal connections with the program, parents also indicated the benefits of facilitating continued connections with one another. Parents suggested that social media platforms could be used to create a lasting sense of community, allowing them to connect with similar others and organize social and physical activities. One parent summarized, “I think creating a Facebook group would be fantastic. You can connect with everybody together, you and the kids can meet somewhere, they can play in the park or walk around.” Another stated, “we started a thing online through Facebook, we sort of just join our own personal group to keep helping each other, and you know, we can add whatever we want to, and sort of check in on each other to see how we’re going, and that has helped.”Finally, one parent suggested utilizing gamification principles in this respect, “Like, a five-day challenge, you can do it on Facebook or Messenger. It comes through, post up what you had for breakfast, get everyone involved. It’s going along the nutrition lines, you’ve got your five days a week included, and another’s posting up all the meals you had in a day, and adults can get into that sort of thing, I think it’s a great idea to actually get people on track” . There Family-based programs of this kind are developed with the aim of modifying lifestyle behaviors during and following the intervention; two particularly prominent behaviors in this respect are physical activity and diet . Based Some of the barriers to lasting dietary and physical activity change (post-program) identified in our results such as cost, time, and competing priorities as barriers to physical activity and lifestyle change are well documented and understood . HoweveFrom a practical perspective, as well as being mindful of support strategies that are commonly recommended in this area , addressing specific stigma-related physical activity challenges might help programmers translate improvements in physical activity attitudes into sustained physical activity participation. In terms of methods for doing so, participants spoke about the benefits of end-of-program transition periods, and strategies aimed at ‘maintaining connections’ with one another (and with program staff) following the completion of a family-based program. The benefits of these continued connections  may not only provide opportunities and social support for physical activity , they maIt is often recommended that family-based programs accommodate themes of nutrition, physical activity, and lifestyle modification . WithSeveral of the issues identified by participants mapped onto elements of motivation theory, and in particular, self-determination theory . It was An additional element of self-determination theory with relevance to these findings is the notion of basic psychological needs . It was Aside from relatedness issues, we also obtained feedback relating to the importance of autonomy and competence development , and regarding the importance of variety, which has also been shown to predict autonomous motivation . It is pThere are many factors—such as socioeconomic issues To mitigate weight-related stigma impacting long-term change, families emphasized end-of-program transition periods and strategies to maintain connections with both program staff and participants. On optimizing the program design, participants highlighted a desire for autonomy in program activities, tailored, interactive and novel content, and their similarity to other participants. In line with self-determination theory, participants’ desire for autonomy, competence and relatedness suggested they were driven by autonomous motivation, which has the potential to bolster long-term outcomes. Other barriers to lasting behavioural change post-program included time and financial constraints and competing priorities. The focal program in this study is empirically grounded, accommodates many best-practice recommendations, and consists of elements common across programs of this kind. That being the case, it is reasonable to expect that the evidence reported in this investigation may be informative for other programs and researchers . It woul


Breast Cancer (BC) specialists need to acquire comprehensive knowledge, covering their own specialty and principles of related disciplines. Blended learning, the integration of online and face-to-face learning, is becoming more and more important in academic education and has added value during pandemics which limit face-to-face learning and residential training.In this context, the ESO-ULM Certificate of Competence in Breast Cancer (CCB) provides postgraduate multidisciplinary education and delivers an academic postgraduate title.The aim of this work is to investigate the degree of satisfaction of 42 participants to the first two editions of the programme and to assess if attending the programme entailed any professional gain.An ad-hoc questionnaire was developed exploring 4 areas: participants’ characteristics, administrative aspects, CCB Program syllabus and design, professional impact.The program was attractive for specialists of different disciplines from all over the world: > 90% of responders appreciated the curriculum set up and the quality of the teaching.Despite 64% of responders changed their clinical practice, only 33% could implement institutional changes. One third of the participants activated a collaboration with other colleagues and 64% used the CCB as a trigger to take part in other educational activities.Only 12% of the participants had the opportunity, after CCB, to visit other BC Units or to be involved in international research projects.More than half of the attendees profited from attending CCB in terms of promotions (16.7%), change of working institution (9.5%) or development of a more structured educational program at their home institutions (28.6%).Results provide interesting and stimulating considerations on the expectations and needs of training physicians and on what modern educational tools and formats can achieve. This paper can provide useful information to navigate through what the post-graduate training market is currently offering to develop a specific curriculum in modern multidisciplinary BC care but might not be applicable to other fields of multidisciplinary oncology.The online version contains supplementary material available at 10.1186/s12909-022-03414-7. Breast cancer (BC) management is a complex and rapidly evolving discipline which can no longer rely on generic, single specialty training. Evidence has shown that multidisciplinary specialized care improves patient outcomes : accordiMedical education is changing, and modern technology enables the learner to access didactic material, at any time, and at any location . BlendedIn 2014, the European School of Oncology (ESO), in co-operation with the Ulm University, developed a structured course, named “Certificate of Competence in Breast Cancer (CCB)”. It aims at providing BC specialists with multidisciplinary education and delivering an academic postgraduate title in the field. The Curriculum, built with the contribution of internationally recognized BC clinicians and scientists, provides, and enhances, clinical and scientific competencies, recognized by an academic postgraduate title. CCB provides a total of 381 hours of comprehensive learning (75 in-person and 306 of distance learning) corresponding to a workload of 13 European Credit Transfer and Accumulation System Points (ECTS) accredited by the Ulm University. The Program includes five modules and three attendance seminars with an overall duration of 13 months (Objectives and concept - European School of Oncology (eso.net ).The CCB program, with its academic endorsement, meets all the requirements to be part of the BRESO- Breast Surgical Oncology project, created in 2018 to enhance and harmonize breast surgery training across Europe , 15.CCB has now reached its fourth edition. Forty-two specialists were admitted to the first two editions of the program and have passed the final examination at ULM University, obtaining the academic Certificate of Competence (CCB). Twenty-five health professionals will participate in the fourth round (2021-2022).The acquisition of a multidisciplinary, highly specialized, structured CV, with academic qualification, should also enhance professional carrier opportunities.The aim of this work is both to investigate the degree of satisfaction of participants to the first two CCB editions and to assess if any professional gain, both on a personal and institutional level, was achieved by attending the CCB program. With this work we hope to aid trainees, seeking to develop a specific curriculum in multidisciplinary management of BC, to navigate through the offer of the market and make a more informed choice according to their career expectations.Participants’ background information Administrative aspects of the CCB Program and applicationCCB Program syllabus and designCCB Program outcome and professional impactAn ad-hoc questionnaire was developed by a specialist task force composed by a senior Breast Surgeon, a senior Oncologist, one young Gynecologist involved in post-graduate training in BC surgery, one professor from the Faculty of Communication at USI  and one ESO coordinator of post graduate training programs. The poll was then piloted on a different group of breast surgeons, oncologists, trainees, and administrative personnel to ensure content validity and usability. Minor modifications were made based on feedback: the definitive survey explored 4 domains:At the very end of the questionnaire, participants were asked to rate the overall quality of the course and were given the opportunity, by means of two open questions, to provide the organizers with personal suggestions to improve future editions.The final version of the survey was reviewed and approved by all members of the task force and then published online, using the GOOGLE Forms platform.All 42 participants from the first two cohorts of the CCB Program were invited to participate by an e-mail sent out from the central ESO office, which contained a link to the questionnaire.The survey was available online for 8 weeks, and two email reminders were sent out during this period, at the end of which a response rate of 100% was achieved thanks to the notable commitment of all CCB participants. The full questionnaire is available on Additional file After the survey was closed, spreadsheet data were exported for analysis: responses to the questions were extracted and summarized.). Interestingly a significant share (6 - 14.2%) was from low-middle income countries: 2 from Egypt, 2 from Georgia and 2 from Pakistan. All invited health professionals answered the survey.The cohort included 42 physicians Table , from 4 Mean age of the participants was 40.8 years (ranging from 31 to 61); 27 (64%) were females and 15 (36%) were males. All specialties were represented: 29 (69%) participants were medical oncologists, 7 (17%) gynecologists, 5 (12%) radiation oncologists, and 1 (2%) general surgeon. Eighteen (42.9%) respondents worked in a university hospital, 15 (35.7%) in a non-teaching public hospital and the remaining 9 (21%) in private clinics.The degree of training/professional position at time of enrollment varied significantly, ranging from post-doc/PhD students (3 - 7.1%) to chiefs of department (8 - 19.0%) and Professors (3 - 7.1%); consultants were the largest group (17 - 40.4%), the remaining being residents and fellows (11 - 26.2%).When asked about the main reason for applying to the CCB Program  most of the participants provided 2 answers, the most frequent being: 1) the need for up-to-date comprehensive knowledge in BC, 2) the search for a model of training focusing on multidisciplinary management.Other reasons included the opportunity to develop new international collaborations for clinical and research projects (networking and learning about BC treatment in other countries) and, not least, the wish to improve their CV to boost a career advancement.www.ESO.net) was informative and precise, the application procedure was clear, easy to follow and reasonably structured in terms of time allocation.This section of the survey aimed to explore participant’s opinion on the CCB administrative procedures. Overall, the vast majority (39–93%) of participants agreed that website information (n = 40) of responders believe that selection criteria for admission, based on personal CV and specific BC experience were correct, about 20% (n = 8) considered that final exclusion/inclusion decisions were not fully transparent.Over 95% (n = 13) of responders thought the application fee (5400 Euros) was somehow too expensive, despite a discounted fee available to participants from low, lower middle and upper middle-income economies. Interestingly, most participants were either from low-middle income countries (according to the Organization for Economic Co-operation and Development-OECD) and/or did not have a permanently paid professional position (students or residents), three outliers had stable professional positions in high income countries.Thirty percent , in a very updated and detailed manner (40-95%).Two aspects the participants would like to be improved are the opportunities for networking (13-30%) and the implementation of collaborative research projects among participants and possibly among home institutions (18-43%).To include periods of structured observer-ship (30-71%)To increase the time allocated to multidisciplinary discussions during seminars (27-64%)To increase the time spent in the hospital during seminar 3 in Ulm (24-57%)To increase the focus on loco-regional treatments (17-40.5%)To increase the opportunities of clinical research training (15-35%)When specifically asked for suggestions to improve the program structure , five aspects were highlighted:n = 27) were definitely in favor, 12% (n = 5) undecided, 24% (n = 10) against. It is of note that 20 (48%) medical oncologists and 2 (5%) radiation oncologists were in favor, underpinning the concept that one aim of BC professionals is to widen the horizons of their knowledge, in line with the goal to improve multidisciplinary skills.When looking specifically at the possibility to increase the knowledge on surgical and loco-regional treatments, the cohort felt divided. The responses have been variable: 64% (n = 27) declared to have implemented a significant change of BC management in their clinical practice consequently of what they learnt through the CCB Program.When investigating personal professional benefits, 64% of responders ; some felt to have improved team working skills and gained capacity to better organize teaching sessions for students and fellows.n = 28), upon returning to clinical routine, did not report any significant change in clinical guidelines or in the organization of the Breast Center at their home institution. Among the minority  who were able to implement some changes, update and innovations in internal protocols and guidelines are reported. Development or improved efficacy of MDMs is also a goal worth to mention. One responder (2%) stated to have set up a brand-new department dedicated to BC care, using the experience gained from the course and from his/her international colleagues.When shifting the attention to the institutional level, the landscape changed: 67% of respondents  of the participants were able to activate a collaboration with other colleagues which yielded two peer reviewed publications, several new research ideas, and international connections for networking and mentoring opportunities. On the other hand, 66% (n = 28) of the CCB fellows thought they had not achieved a significant networking advantage from attending the program, at least at the time of the survey.On an individual level, one third  had the opportunity for visiting other BC Units in foreign countries, for example through the ESO fellowship program. One responder was able to get his home institution on board a multicentric international research project with Breast Units from London and Paris.Seventeen responders (40.5%) took part in a publication on a peer-reviewed international journal, 2 (4.8%) co-authored a book chapter, 3 students (16.7%) took advantage of the CCB participation to develop their doctoral thesis and 7 (16.7%) have arranged an exchange plan for themselves or other students. One (2%) participant, originally from a low-middle income country, but employed in the USA, was invited to participate in the panel of experts to review the ASCO 2019 Meeting Educational Book, together with several renowned international BC experts.On the other hand, 3 responders (31%) said they had not gained any specific professional output from the CCB other than general multidisciplinary knowledge update.n = 40) reported an increased awareness of the relevance of, which paralleled their enhanced professional self-confidence. Their participation to MDMs discussions became more active and their clinical decisions established according to up-to-date knowledge. Finally, the survey scouted on specific changes in professional career that, directly or indirectly, derived from attending the Certificate: 7 participants (16.7%) reported a promotion consequent to the additional qualification achieved; 4 responders (9.5%), decided to change working institution; 12 (28.6%) implemented a new and better organized educational program at their home institutions.The main professional gain acquired from the certificate was related to multidisciplinary management of BC: 95% of responders (n = 27) of the attendees, used the CCB as a springboard to take part to other educational activities, e.g., preceptorships or formally organized Breast Cancer Fellowship programs.The majority : a widely endorsed attempt to enhance and harmonize breast surgery training across Europe by means of a structured, high-level, multidisciplinary training and certification [Similarly, on the surgical side, some of the major European societies involved in BC surgical training, research, education, and advocacy recently developed the fication , 15.E-learning programs can play a significant role facilitating distance learning, as they may overcome some of the difficulties seen with traditional learning and training by allowing flexibility in time, place, and pace, for both the clinically working trainee and educator. Several models can be adopted  and it iThe ESO-Ulm Certificate of Competence in BC is one of the very few academic programs specifically designed to meet the needs of professionals dealing with BC and has been incorporated and recognized by the BRESO certification. CCB has been designed to cover and fulfill knowledge needs and improve career trajectories of professionals coming from all specialties involved in BC management, at any level of professional experience, from fellows to chiefs of departments.n = 38) of responders appreciated the curriculum set up and the quality of the teaching. Nevertheless, several practical suggestions for improvements were made. Among them the most popular were: including periods of structured observer-ship (30-71%); increasing the number of multidisciplinary discussions (27-64%) and the time spent in the hospital during live seminars (24-57%); focusing more on loco-regional treatments (17-40.5%). The last proposal was supported not only by surgeons, radiation oncologists and gynaecologists but also by 69% (n = 20 out of 29) of the medical oncologists, demonstrating a diffuse interest, among different specialists involved in BC management, in widening the boundaries of their knowledge beyond their specialty of origin .The current survey, designed by the participants of the third CCB cohort, showed the program was attractive for specialists of different disciplines from all over the world: > 90%  of responders reported having personally changed their clinical practice as a consequence of what they learned through the CCB, only a few (14-33%) were able to implement institutional changes, such as protocols and guidelines update and innovations. Interestingly, though, among these were not only chiefs of department, but also consultants.According to the survey, despite 64%  of the attendees, used the CCB as a trigger to take part in other educational activities, e.g., preceptorships or formally organized Breast Cancer Fellowship programs.n = 5) had the opportunity, through the CCB attendance, to visit other BC Units in foreign countries or to be involved in international research projects. These domains were those the participants would like most to be strengthened, despite not being among the CCB objectives.At the Institutional level, only 12% of the participants (n = 23) profited from attending CCB in terms of their professional career, either in terms of promotions (7-16.7%), change of working institution (4-9.5%) or development of a more structured educational program at their home institutions (12-28.6%).More than half of the attendees , the results provide interesting and stimulating considerations on the expectations and needs of training physicians and the expertise and competence which can be achieved by modern education tools and formats. Both students and teachers need nevertheless to develop and acquire new specific skills to make the most of these evolving educational opportunities .One merit of this survey is to highlight the need to build a breast specialist career and the potential benefits of specialist and multidisciplinary training in breast surgery, which is on average poor and very heterogeneous across Europe, partly because breast surgery is currently just a subspecialty of either general or gynecological surgery.Blended learning has the potential to be widely adopted in higher education, prticularly now, due to the COVID-19 pandemic. Learning modalities will undergo a substantial change with a range of positive effects, such as engaging learners, increasing access and flexibility, reducing dropout rates, increasing attendance and satisfaction. Blended learning strategies can make students feel connected with others providing a strong sense of international community in the learning experiences. Another advantage is the affordance of this emerging learning strategy, as reduced travelling and operational costs improve cost-efficiency.Over pure e-learning, blended courses have the advantage of offering face-to-face sessions which allow for interactions and offer ample opportunities for discussions, enhancing learning outcomes and strengthening the sense of community among trainees and with faculty members.However, this new instructional strategy presents some pitfalls: technologies could hinder teaching and learning if not used properly, therefore sufficient training and timely technical support should be arranged. Moreover, as individual learning could lead to a lack of motivation, sufficient opportunities for interactions should also be carefully scheduled throughout the whole course, both during in person and online sessions.The CCB program is one of the few blended programs aiming to build a dedicated, up-to-date CV in BC management. The flexible format, applied also to other ESO certificates of competence, e.g., in lymphoma and lung cancer, may represent a valid model in other oncologic and medical fields, allowing also to overcome current barriers in medical postgraduate training, such as present and future pandemics and funding restrictions.Understanding the specific strategies and technology use will be critical to improve the CCB course and make the most out of the potentials of blended learning strategy. The optimal balance among face-to-face learning, the proportion of asynchronous or synchronous e-learning, overall duration and suitable evaluation tools, still need to be defined, but the present survey shows that quality and satisfaction are high; timely adjustments can be efficiently planned.In the absence of a reference standard in postgraduate teaching, it is essential to offer tools that allow trainees to make an accurate and informed choice to build a competitive curriculum according to the needs of modern multidisciplinary oncology. The present survey aims to satisfy this specific need in the field of BC care, recognizing adaptations would be required in other oncology fields.Additional file 1.Additional file 2.


BackTrack is a multi-component, community-based program designed to build capacity amongst high-risk young people. The aim of this study was to conduct a benefit-cost analysis of BackTrack, which was implemented in Armidale, a rural town in New South Wales, Australia. Costs and benefits were identified, measured and valued in 2016 Australian dollars. Costs were estimated from program financial and administrative records. Benefits were estimated using a pre-post design and conservative economic assumptions. Benefits included education attendance or completion; employment; engagement with health service providers; reduced homelessness; economic productivity; reduced vandalism to local infrastructure; reduced youth crime; reduced engagement with the justice system; and program income generated by participants. The counterfactual baseline was zero educational outcome, based on discussions with BackTrack staff and expert informants. We tested this assumption compared to the assumption that participants had a Year 8 education. There was evidence of significant quantifiable improvements in several outcomes: high school attendance or completion, vocational education attendance or completion, unskilled or vocationally qualified employment and economic productivity. Reduced homelessness, engagement with health services and acquisition of job readiness skills, as well as reduced local infrastructure vandalism and reduced crime were further quantifiable improvements. The net social benefit of BackTrack was estimated at $3,267,967 with a benefit-cost ratio of 2.03, meaning that every dollar invested in BackTrack would return $2.03 in benefits. BackTrack represents a viable funding option for a government interested in addressing the needs of high-risk young people. More specifically, BackTrack’s activities can be organised into five standardised core program components: (i) engagement, to optimise participation in the program; (ii) case management, to provide individual life skills management; (iii) diversionary activities, to reduce exposure to police and the judicial system and provide recreational opportunities; (iv) personal development, identity and team identity, to improve health and wellbeing; and (v) training and skill development, to increase opportunities for active participation in education or training that increases the likelihood of employment [BackTrack is a community-based program designed to build capacity amongst high-risk young people who typically have multiple and complex needs ,2,3. Theployment . Detailsployment ,2.For the majority of program participants, the key risk factors are criminal activity, school absence, lack of employment, high-risk of mental health issues (including suicide ideation), alcohol and other drug problems and lack of engagement with and utilisation of the health system . BackTraBenefit-cost analysis (BCA) is the appropriate economic analysis to capture the multiple social, health and economic outcomes arising from social programs like BackTrack . BCA comThe BackTrack program was implemented in Armidale, a rural town in New South Wales (NSW). Armidale has a population of close to 24,000 with a land area of 7818 square km, representing a population density of 3.77 persons per square km [The BCA adopted a societal perspective and covers a nine-year period, comprising of five years of program operation (March 2012–February 2017) and four years of additional projected benefits (March 2017–February 2021). All estimated cost and benefit values were converted to 2016 Australian dollars using the Australian Gross Domestic Product Implicit Price Deflator . Both con = 34) and their level of participation with the program, school, further education and employment. For the specified program investment period, program data accurately recorded participant status. For the post-trial projected period, a decay rate was applied per annum to reflect that in the absence of the program’s support, participants may not be able to sustain their involvement in education/employment and as a consequence, the beneficial gains  may not be sustained. The analysis assumed a conservative decay rate of 50%, implying that half of the participants engaged in the preceding year in school, employment or other activities would drop out in the following year. This conservative assumption is tested in the scenario analysis.For both the individual participants and their communities, the extent of change from pre-intervention to post-intervention was determined by a counterfactual analysis ,11. The The productivity benefits arising from education and employment used the human capital approach to value the progression of a participant from one status to another i.e., from school attendance to high school completion, from unemployment to employed. The human capital approach is an accepted method in economic analysis to estimate the social benefit arising from this progression. The projections in the absence of the program reflect the average productivity of males in Armidale, assuming that their income follows the average career trajectory for men with equivalent qualifications. The projections with the program apply the same approach, but were derived from males in Armidale with higher levels of qualifications/employment status. The projected productivity benefits incorporate proportional labour force participation and unemployment assumptions. In line with the conservative approach, participants were assumed to retire at 60 years, at which point no further benefits are realised. The basis for the specific crime projections is explained in detail below and in It is possible that participants may have realised productive outcomes without the provision of the BackTrack program, due to their innate capabilities. Previous research on the program suggests that the productive outcomes for participants dropping out of the program and for the community from which the participants are drawn are extremely low ,2. SimilA systematic literature review of economic evaluations of programs for high-risk young people was conducted to inform the potential costs and benefits arising from BackTrack . In accoThe costing model was developed from program financial and administrative records alongside discussions with the program manager and staff. Program inputs were included for the five core components of the program  , and comTo account for the costs associated with greater participant engagement with the health system, a corresponding cost for the provision of four consultations per annum with each program participant reporting higher health service engagement was incorporated. The costs corresponded to the number of program participants for whom a health benefit was conferred . The cosBackTrack provides education to improve participants’ basic literacy and numeracy skills. It is assumed that attendance at BackTrack for a minimum period of 12 months collectively is sufficient for participants to realise this benefit, the lowest education/employment outcome for which a benefit has been acknowledged. Therefore, all participants who attend the BackTrack classroom for 12 months receive the job readiness, literacy and numeracy skills benefit, valued at $4677 (AUD2016) as a one-off value, irrespective of whether they went on to realise further employment or education achievements . The high school education outcomes from the program fall into two categories: participants recommencing high school attendance, or participants completing high school stages. The additional annual cost of a full-time secondary student (classroom) is $21,149 and $622 in administration, a total of $21,771 AUD2016) . The hum . The huThe same human capital method was applied to the benefit of vocational education. The additional cost of a Certificate I/II Vocational Education and Training (VET) qualification (government and private) is $7763 AUD2016) . As per  . As perUpon entry to the program, participants were surveyed to provide a baseline measure of health service utilization . AnalysiIn June 2015, a residential site was made operational for BackTrack participants without secure accommodation. It was comprised of six permanent beds and two emergency beds. It was assumed that permanent would equate to three years, the usual time a participant would stay in BackTrack allowing him/her to develop sufficient life skills and reach an age where it would be possible to secure other accommodation and become economically productive to sustain that situation. The benefit for one year was valued at $14,961 (AUD2016) per participant [The economic productivity outcomes from the program fell into two categories: unskilled employment and vocational employment. The human capital method was utilised to estimate the productivity gain arising from the progression of male youth from a zero education baseline to unskilled or vocational employment. Adoption of the human capital method was consistent with the labour costs of program delivery. Median annual income was estimated using the count data for total personal income for ten-year age cohorts. The NPV for each participant was assumed to be realised after three years in the program. The productivity gains for a participant progressing, for example, from a zero education baseline to unskilled employment was assumed to reflect the difference in income profiles for these two cohorts. The NPV for each participant progressing to full-time unskilled employment or vocational employment reflected the discounted gains in personal income from age 18 for both unskilled employment and vocational employment to age 60. Employment income for part-time work was equivalent to 52% of full-time income. The NPV was modified for the innate talent assumption (5%), and a proportional attribution to the BackTrack program (50%) as opposed to vocational education alone.The Armidale Dumaresq Council Crime Prevention Strategy 2014–2018 identified that, in 2013, 50% of crime perpetrated by males  was carried out by 10–19-year-olds and 41% by 10–17-year-olds, the age cohorts supported by the BackTrack program [Criminal incident data related to Armidale were obtained from the NSW Bureau of Crime Statistics and Research (BOCSAR) for males aged 15 to 18 between 1 January 1999 and 31 December 2017. Segmented generalised linear models were used to model count time series data pre- and post-intervention implementation. The data suggested a statistically significant reduction trend after the respective intervention dates see . It was The Learning and Skills component of the BackTrack program was comprised of several work ready activities that generate income. For example: welding and the sale of metalwork sculptures or farm gates; farm work, such as fencing or firewood collection; and dog handling exhibitions. This program income is acknowledged as a benefit reflecting the social value of these services to the community.A Discrete Choice Experiment (DCE) was used to quantify, in monetary terms, the value that households in the BackTrack community placed on improving outcomes for young people with multiple and complex needs . DCEs inThe nature of BackTrack, its inherent flexibility and the number of participants passing in and out of the program, implies that there is limited information to inform the probabilities of any given cost or benefit. Consequently, it is not possible to conduct uncertainty analysis, such as bootstrapping, around the parameters included in the analysis. This limitation has been addressed by adopting a rational, but conservative, approach to all assumptions, and by conducting sensitivity analyses. Three types of sensitivity analysis were conducted: (i) parameter; (ii) discount rate; and (iii) deadweight loss (DWL). A multivariate parameter scenario analysis varied the assumptions associated with participant engagement decay rate, education completion rates, innate talent assumption, crime and economic productivity. These scenarios were based on a worst to best case analysis. Consistent with the NSW Government’s Treasury guidelines , the basAlthough the agreed counterfactual baseline for the population of high-risk youth in this BCA was zero educational outcome, we tested this assumption compared to the assumption that participants had a Year 8 education.The costs relate to the additional resources that were required to deliver BackTrack. Labour costs account for the majority of the operating costs. The costs included in the post-intervention period capture additional demands on the health service, arising from greater participant engagement with the health system.The economic benefits associated with employment accounted for over 75% of the direct benefits ($4.95 million). Reductions in crime resulted in an estimated benefit to society of $1.23 million, with higher levels of education accounting for $1.07 million.In the BackTrack DCE, participants were asked to choose between BackTrack and a policing alternative, with different costs and efficacies. The full methods and results of the DCE are published elsewhere . The resAs summarised in Consistent with the NSW Government’s Treasury guidelines , the basThe inclusion of a 27.5% DWL from the taxation revenue raised to provide the public investment in BackTrack contributed $236,771 in costs, reducing the net benefit to $3,053,950 or a BCR of 1.90.In addition to learning formal skills . A broad societal perspective was adopted to produce a comprehensive evaluation to better support informed decision making. Both primary and secondary sources were used to measure and value the costs and benefits of BackTrack over a nine-year time frame. Our analysis also explored the sensitivity of estimates to alternative assumptions about the counterfactual, discount rates and inclusion of DWL. Adoption of government evaluation guidelines also enhanced the methodological rigor and practical application of this analysis.BackTrack generated a positive return on investment, despite the conservative approach of the analysis and the fact that it is a social program with benefits that tend to have a longer-term impact. When interpreting the results of this BCA, several limitations should be considered. First, the requirement to translate costs and benefits into comparable dollar values naturally favours impacts that can be readily quantified, such as operational costs. This is a recognised concern in BCA because the major costs are often readily quantifiable and founded in the initial stages of a project, whereas the benefits are more likely to be difficult to quantify and typically extend into an uncertain future. Unquantifiable costs or benefits are sometimes referred to as intangibles. The NSW BCA guidelines  note thaPrograms that implement the same standardised components as BackTrack represent a viable funding option for governments interested in addressing the multiple needs of high-risk young people. The flexible implementation options of such standardised programs , along w


In this study, we evaluated the effectiveness and safety of bisoprolol, metoprolol, carvedilol, and nebivolol in the treatment of chronic heart failure. The results demonstrated that bisoprolol improved the prognosis of chronic heart failure in comparison with carvedilol, and carvedilol exerted similar effects as metoprolol succinate and nebivolol and better effect than metoprolol tartrate . Dear Editor,Initiation with a very low dose of β blockers and titration to the tolerated dose is recommended as the cornerstone in the treatment of chronic heart failure (CHF) with reduced ejection fraction, but which β blocker has the superiority over others remains unclear.Twenty‐six studies were deemed eligible for inclusion, including 14 RCTs and 12 observational studies Figure . The metp = 0.0002)  (Table p < 0.00001). However, bisoprolol and carvedilol had similar effects in decreasing heart rate  and hospital stay . No differences were observed in total drug−related adverse events , including worsening heart failure  and hypotension , but carvedilol caused fewer bradycardia  in comparison with bisoprolol (Table p = 0.02), but not in Caucasian patients ; bisoprolol decreased all−cause mortality in patients with mean LVEF < 40% , but not in those with LVEF ≥ 40%   Figure , but did3) Table . Compareol Table . Compare9) Table . Thus, bp = 0.82), repeat hospitalization (per 100 patient−years)  or LVEF  between the carvedilol group and the metoprolol succinate group  but not heart failure readmission in CHF patients  , but did not affect 6‐min‐walk distance (6MWD) , heart rate , or quality of life assessed by the Minnesota Living with Heart Failure Questionnaire score . Carvedilol reduced worsening heart failure in comparison with metoprolol tartrate , and no differences were observed in the incidences of total side effects and drug withdrawals between the two groups   Figure . Compare5) Table . Thus, cp = 0.62), hospital readmission due to heart failure  or drug‐related adverse events  between the carvedilol group and the nebivolol group  in CHF patients   Table .2+ overload and increases myocardial oxygen consumption and damage. Compared to the β1 receptor, α receptor‐associated cardiac remodeling is weaker due to its lower density in the heart. However, after α receptor activation, vascular smooth muscle contracts, peripheral vascular resistance and cardiac afterload increase, and heart failure progression are accelerated.Although 50%–60% of adrenergic signaling pathways are inactivated in patients with advanced heart failure, numerous receptors are still exposed to excessive catecholamines, resulting in cardiac remodeling and dysfunction. β1 receptor activation causes intracellular cAMP‐mediated CaBisoprolol, metoprolol, and nebivolol are selective β1 blockers with affinity ratios of β1 to β2 about 103, 74, and 321, respectively, and carvedilol acts as a non‐selective α1 and β blocker with β1/β2 selectivity almost 1:1.In summary, carvedilol exerts similar benefits as metoprolol succinate and nebivolol in CHF patients. Bisoprolol is considerably more effective than the other several β blockers, and the curative effect of metoprolol tartrate is worse than the above several β blockers Figure . There aBL, YZ and PH conceived the protocol and drafted the manuscript. BL, RZ, JX, YL, and PH collected the literatures, extracted and analyzed the data, and substantively revised the manuscript drafts. Data curation was performed by BL,RZ, AZ, GW, JX, and YL. All authors contributed to the final revision of manuscript drafts and approved this manuscript for publication.The authors declare that they have no conflict of interest.This work was supported by the Natural Science Foundation of Shandong Province , the Natural Science Foundation of Jiangsu Province (BK20200224).Not applicable.Supporting InformationClick here for additional data file.