Purpose. The aims of this in vitro study were to evaluate morphological changes induced by glycine powder air-polishing on titanium surfaces, biofilm removal, and biocompatibility. Material and Methods. Titanium grade IV discs were allocated into two groups: (1) discs without biofilm and (2) discs for Streptococcus mutans biofilm formation. Discs in each group were further subdivided into (a) no treatment and (b) air-polishing treatment with glycine powder. Discs were characterized by scanning electron microscopy (SEM), electron-dispersive spectroscopy (EDS), and confocal microscopy. Bacterial biofilms were quantified using a crystal violet dye-binding assay. Biocompatibility was evaluated by measuring the coverage and viability of L929 fibroblast cells cultured on the discs. Results. Air-polishing increased the roughness of treated discs (P < 0.05). EDS analysis did not show significant differences in the chemical composition of treated and nontreated discs. The amount of residual biofilm on treated discs was 8.6-fold lower than untreated controls (P < 0.05). Coverage of treated discs by fibroblasts was half that of untreated discs (P < 0.05) although both groups had the same cell viability. Conclusions. Air-polishing removed a significant amount of biofilm from titanium surfaces. The “polishing” was accompanied by increased surface roughness, but there were no changes in chemical and elemental compositions, nor the biocompatibility.  Peri-implantitis is an inflammatory disease that affects both the mucosa and the supporting bone around implants. Signs of peri-implantitis include crestal bone loss, deep peri-implant pocketing, bleeding on probing, suppuration, and, in advanced cases, implant mobility . In cont Porphyromonas gingivalis, Prevotella intermedia, Fusobacterium nucleatum, and Treponema denticola and streptococcal species, including Streptococcus mutans, are reported to be associated with peri-implantitis [ Fusobacterium and streptococcal species were found to be predominant in both peri-implantitis and periodontitis sites, whilst Parvimonas micra was only present at peri-implantitis sites [ S. mutans is not usually associated with active peri-implantitis, it is commonly found in the oral cavity and considered as one of the early colonizers of oral surfaces. The bacteria produce extracellular polysaccharide in response to dietary sucrose that firmly attaches the cells to surfaces and contributes to the biofilm matrix.Microorganisms play a key role in the initiation and development of peri-implant diseases . The miclantitis –5. Accoris sites . AlthougThe incidence of peri-implantitis is approximately 20% of implant patients after 10 years of placement. The prevalence of peri-implant mucositis is even higher. Almost 80% of implant patients in a long-term follow-up 9 to 14 years) reported to have this condition . However years re in vitro and in vivo studies, glycine powders are less abrasive than sodium bicarbonate powders; they are safe to use and effective in biofilm removal [ in vivo study suggests that glycine powders may inhibit, to some degree, bacterial recolonization of implant surfaces over a 24 h period [In air-polishing therapy, the biofilm is removed by abrasion at the implant surface caused by low-abrasive powders, water, and pressurized air emitted from the device. A range of abrasive powders are available including sodium bicarbonate, amino-acid glycine salt, aluminium trioxide, and calcium carbonate . Accordi removal , 17. A rh period .The results of many studies, however, are confounded by not controlling the device settings (air pressure and water flow rate) and treatment protocols . In addition, further research is needed to clarify any biocompatibility issues of implant surfaces with host tissues that may arise after the air-polishing treatment using glycine powder. Hence, the aims of this research were to evaluate the influence of air-polishing therapy on titanium surface morphology and its effect on biofilm removal and biocompatibility.The null hypotheses of this study are that (1) glycine powder air-polishing of titanium surfaces has no effect on surface morphology and (2) the powder air-polishing of titanium surfaces has no effect on biofilm removal and biocompatibility.Sterile titanium discs  were used. The discs had standardized enhanced moderately roughened surfaces (Sa = 1.43 nm) with the same surface topography and chemistry as those of Southern Implants. A total of 55 discs were used;  Streptococcus mutans UAB159  were streaked on blood agar plates using aseptic technique. These plates were incubated anaerobically at 37°C for 24 h. A single colony of S. mutans was cultivated anaerobically at 37°C in a sterile tube containing 10 mL of sterile Brain Heart Infusion . After 24 h, 200 µL portions of the culture were transferred to 14 vials each containing 10 mL of sterile BHI broth plus 0.5% sucrose. Two sterile titanium discs were added to each of these vials. The vials were then incubated anaerobically at 37°C for 72 h to allow biofilm formation on the discs. The medium was replaced daily by the aspiration of spent medium from vials and the addition of fresh medium consisting of 10 mL of sterile BHI broth containing 0.5% sucrose. Following medium replacement, vials were returned to the anaerobic incubator. The dense, multilayered biofilm formed after 72 h allowed evaluation of the efficacy of the air-polishing therapy on biofilm removal [Frozen (−80°C) stocks of removal . S. mutans (biofilm) or no biofilm. Then, discs of each group were further divided into either no air-polishing or the air-polishing group  was used to capture images of the disc surface before and after the air-polishing treatment. These images were used to examine any alterations to the titanium surface. Electron-dispersive spectroscopy (EDS) analysis was also carried out before and after the treatment to evaluate the surface chemical composition. Backscatter images were taken for the analysis of elemental compositional differences across the disc surface. For SEM and EDS analyses, images were captured at 3, 6, 9, and 12 o'clock positions, at a distance of 300 µm from the centre of the disc. One disc of each group was observed. CLSM images were analyzed using ImageJ software . The mean roughness parameter Ra was obtained using this software.To determine any changes in surface roughness of the titanium discs, a confocal laser scanning microscope  was used. Images were captured at 3, 6, 9, and 12 o'clock positions, at a distance of 300 µL of sterile distilled water. The biofilm was then stained with 500 µL of 0.1% crystal violet  for 15 min at room temperature. The discs were then washed gently three times with 1 mL of sterile distilled water. The bound dye was solubilized using 500 µL of 100% ethanol and the optical density (OD) of the solubilized dye was measured at 600 nm. The percentage reduction in biofilm caused by the treatment was calculated as follows: ((ODcontrol − ODTreatment)/ODcontrol) × 100.To evaluate the effect of air-polishing on biofilm removal, crystal violet assays were performed. Discs were first washed twice with 500 To evaluate the biocompatibility of the titanium surface, viability testing was undertaken using L929 fibroblast cells. Following the air-polishing treatment, discs were kept in sterile microtitre plate wells until cell viability testing was commenced to avoid microbial contamination. Sterile forceps and sterile gloves were used when handling these discs.α-MEM at a density of 4 × 103 cells/cm2 at 37°C for 30 min. Discs were then incubated in α-MEM (containing L-glutamine without antibiotics) supplemented with 10% fetal bovine serum  in 5% CO2 in a humidified cell culture incubator  at 37°C for 48 h. The viability of the fibroblasts was measured with a live/dead assay [µm from the centre. Quantitative analysis of the images was carried out using ImageJ software. Live cells have intracellular esterase activity and the polyanionic dye calcein is retained inside the cells, producing green fluorescence. In dead cells, EthD-1 dye enters through damaged membranes and generates red fluorescence. Live cells can pump out EthD-1 and so show no red fluorescence. Images were separated according to the color channels. The green and red channels were considered separately. The threshold for each image was determined manually and the area of selected threshold was measured with ImageJ software.Discs were seeded with L929 fibroblast cells in ad assay , 27. A Cα was set at 0.05 and P < 0.05 was considered to be significant.For biofilm quantification, the results were analyzed using the Mann-Whitney test, as the data were not normally distributed. For surface roughness and biocompatibility testing results, ANOVA was used to determine whether there was an overall difference across the groups, and then one-way ANOVA was used to identify where the differences were. Fisher's least significant difference (LSD) post hoc test was applied. For all statistical analyses, The treated discs displayed altered surface morphology when compared by SEM to untreated discs, under all three magnifications. The surface of the treated disc had a smoother profile with less rugosity. Both groups exhibited surfaces that appeared as irregular but well-defined troughs and crests . There wTitanium, oxygen, and aluminium were present in similar proportions in both treated and untreated discs . Both grRa), determined by CLSM, than untreated discs, and this difference was statistically significant . This represents an 88% reduction in the amount of biofilm on the air-polished discs.The amount of residual biofilm on discs was quantified by the amount of crystal violet dye released from stained biofilms (absorbance measured at 600 nm). The higher the absorbance, the more biofilm was present on the discs. The air-polished discs had significantly lower residual biofilm than untreated discs . The meaSEM images of treated and untreated discs also revealed changes in the amount of biofilm present . Images The areas of live and dead fibroblast coverage of titanium discs were measured and their proportions are shown in The fibroblasts on untreated discs displayed a slightly different morphology compared to those on treated discs . The maj S. mutans biofilms on titanium by air-polishing was reported by Schmage et al. [Successfully osseointegrated implants can fail if peri-implantitis is left untreated. Peri-implantitis occurs due to accumulation of a biofilm around the implant soft tissues and on implant surfaces, causing an inflammatory response. Once peri-implantitis occurs, it leads to destruction of supporting bone, undermining the stability of the implant . It has e et al. . S. mutans [ S. mutans is known to have multiple efficient modes of adhesion to various surfaces that enable colonization [ S. mutans, may well result in the reduction of less adherent species that are often associated with peri-implantitis.Many studies have investigated the colonization of different types of surfaces and materials, including titanium, by early colonizer. mutans –36. The . mutans , 38. Ournization . In contnization . From thS. mutans can tolerate acidic environments and has the capacity to secrete lactic acid as part of its metabolism causing a drop in the pH of growth media and the oral environment [2) film created in oxygen-containing environments. However, in the presence of lactic acid, hydrogen peroxide, and high concentrations of fluoride, TiO2 can dissolve, resulting in the release of metallic ions. Metallic ions leaching into surrounding soft tissues can cause inflammatory reactions [ S. mutans on titanium surfaces can reduce the anticorrosive properties of TiO2 [ironment . The titeactions . Recent  of TiO2 , 36. ThiSEM images showed the presence of polysaccharides and streptococcal remnants after the air-polishing treatment. Although there was a significant reduction in bacterial load which will help prevent an inflammatory response, it is not known whether the remaining bacteria were viable, which may allow recolonization of the implant surface and future clinical problems. Also, it is not known what the effect of the residual biofilm would be on the implant biocompatibility. More research is needed to investigate the extent of bacterial recolonization after the air-polishing instrumentation and the biocompatibility of discs with residual biofilm. AIR-N-GO PERIO is a relatively new device; consequently, data on its area coverage for decontamination is still lacking. Further research using different treatment protocols  may result in protocols that remove biofilms more effectively.Air-polishing treatment did not change elemental composition of the titanium surfaces significantly. Elements that are derived from glycine powders are oxygen, nitrogen, and silicone . Traces of nitrogen (less than 1%) were found in both treated and untreated discs. A slightly higher percentage of oxygen was found in the untreated group and silicone was not present in either group. As these percentages were only indicative values, statistical analysis could not be carried out. For the purpose of the current study (gaining a broad overview on the effect of air-polishing treatment), EDS analysis was sufficient. If more accurate elemental analysis were the main aim of the research, Laser Ablation Inductively Coupled Plasma Mass Spectrometry (LA-ICP-MS) could have been carried out. LA-ICP-MS enables highly sensitive elemental and isotopic analysis to be performed directly on solid samples .CLSM measurements indicated that the average roughness of the treated discs was greater than that of the untreated discs. To date, some studies have documented that increased surface roughness promotes more bacterial adhesion than smooth surfaces , 41–43. The live/dead assay with mouse fibroblast cell line L929 is widely used in biocompatibility testing . The via in vitro study, our findings indicate that 5 s air-polishing treatment using glycine powder significantly reduced bacterial biofilm load on titanium surfaces, although some bacteria and polysaccharide remained. This reduction in the amount of biofilm accompanied the statistically significant increase in surface roughness of the titanium disc surface. There were no apparent differences in surface chemical and elemental compositions following the treatment. Whilst the air-polishing treatment did not seem to affect fibroblast cell viability, the increased surface roughness appears to have reduced the adhesion and/or proliferation of the cells on the surface. This is an area of concern and warrants further investigation.To conclude, within the limitations of the present


Tobacco use prevalence rates are high among Spanish adolescents. Programming to counteract tobacco use is needed.p < .05) and CO ppm levels (p < .001), and lower consumption of cigarettes at last month (p = .03).The current study provides a one-year follow-up outcome evaluation of Project EX, an eight-session classroom-based curriculum. The intervention was tested using a randomized controlled trial with 1,546 Spanish students, involving three program and three control schools. Compared to the control condition, the program condition revealed a greater reduction in nicotine dependence (Long-term outcomes of the Project EX classroom-based program are promising for adolescent prevention and possibly cessation in Spain. Tobacco use has become a pediatric epidemic in Spain, because most new smokers begin at school age , and mosIn its clinic version, Project EX has shown positive 3-to-6-month outcome effects over three experimental trials and one multiple baseline single group trial –14. WhilThis paper focuses on the one-year self-reported behavioral outcomes of Project EX prevention/cessation program with Spanish adolescents. A previous paper reported on the implementation and immediate outcomes of the project . The proBefore proceeding with the recruitment of the sample, the study was approved by the IRB at Miguel Hernandez University. The education authorities were informed of the study goals, and authorization was requested. Once such authorization had been obtained, the researchers interviewed the head teachers and the school counselors, informing them verbally and in writing about the aim of the study, so as to obtain their permission and encourage their cooperation. Finally, parents were informed by letter and requested to provide written consent for their children to participate in the study. The written parental consent was provided for all minors participating.We used a convenience sample of 45 schools from 17 towns in the Province of Alicante. After the first in-person meeting with the school board of each school to present the objectives of the intervention, a total of six high schools from three cities , were recruited (recruitment rate = 13%). The reasons for non-recruitment were no response (72%), responded back to us after a first meeting with a statement of no interest (18%) and inability to be able to implement the study during the school day (10%). The schools recruited were randomly assigned to one of two experimental conditions: treatment or standard care (control); that is, there were three schools per condition (schools were carefully matched into pairs prior to assignment).The original version of the EX prevention/cessation curriculum was translated into Spanish by two translators. Two bilingual researchers working at the University Miguel Hernandez (UMH) checked the translation by reading both the English and Spanish versions. The feasibility of the Spanish version was assessed in one focus group, composed of 10 students at a high school before program implementation, which verified that the curriculum was clearly understood and culturally appropriate.The Project EX classroom curriculum is closely adapted from the clinic program , 18. TheIn addition to language adaptations, five changes were made in the curriculum to adapt it to Spanish culture. First, the original curriculum targets “tobacco” use including smokeless tobacco, pipes, cigars, and chewing tobacco. Spanish adolescents very rarely use other forms of tobacco other than cigarettes , 6, so tSD = 0.8), interested in implementing the program, spent eight hours studying and practicing the eight sessions of Project EX, including learning details of program delivery and how to deliver the material with fidelity. The training was provided by a researcher who had previously been trained by the program developer. All persons trained delivered the program to an average of two classrooms each.Between October and November of 2012, psychology graduate students at Miguel Hernandez University were given the opportunity to become a program facilitator. All volunteers received an introductory lecture about Project EX, which included a brief summary of the Project EX curriculum, its history, advantages of using the program, and the role of program facilitators. Seventeen Spanish graduate students , an average of 23 years of age . Among the 1,546 subjects that participated in the pretest survey, 965 (393 in the control condition and 572 in the program condition) also completed one-year follow-up questionnaires (62.4% retention rate). All adolescents who conducted assessments at baseline and 12 months follow-up were included in the analysis.An average of 12 classes was selected per school, with a range of 8 to 19 classes, across the six high schools. A total of 1,546 students were selected for participation in the study (716 in the control condition and 830 in the program condition), 57% of the total enrollment across these classes . The sample was 50.7% male; 91.8% were Spanish and 8.2% were other nationality . Further, 80.9% of the students lived with both parents and 36.1% of youths’ fathers and 36.6% of youths’ mothers completed high school. Approximately 32% of the participants smoked a cigarette sometime in their lives, 13.4% smoked in the last 30 days, and 7.9% smoked on the day of the pretest assessment.Participants varied from 14 to 20 years of age , gender, nationality , current living situation , and parents' education  .http://www.bedfont.com/ch/smokerlyzer/micro, accessed 4-19-2014). Participants who responded to our one-year follow-up survey  did not complete the CO readings.Smoking behavior was assessed with the fill-in-the blank item asking “How many cigarettes have you smoked in the last month (30 days)?” The level of nicotine dependence was assessed with the 8-item modified Fagerstrom Tolerance Questionnaire (mFTQ) , 20, 21.p value at the .05 level). Again, all relevant demographic and outcome variables were examined.To assess the potential sampling bias due to attrition at the one-year follow-up across conditions , we calculated a new variable called “attrition group” in which we included 965 participants that were surveyed at both time points and compared them with the 581 participants that were only surveyed at pretest. We used logistic regression analysis with “attrition group” as the dependent variable. Predictors included age, gender, nationality , current living situation, parents' education, assessment-last month smoking, level of nicotine dependence, and smoking intention. To assess the potential sampling bias due to attrition at the one-year follow-up as a function of condition , comparisons were made between the sample that was lost at one-year follow-up and the rest of the sample that remained in the study at one-year follow-up, as a function of condition. The comparisons utilized were chi-square or t-test models to indicate statistically significant differences . In addition, those followed-up in the program condition were more likely to intend to not smoke in the future than in the control condition  = 6.87; p < .05), and had less nicotine dependence than in the control condition  = 23.67; p = .001). Differences in these variables have been controlled for in the analysis.First, regarding the analysis of external invalidity, differences were only found on age, gender, and school see . Retainep < .05) and increased consumption of cigarettes (p = .03). Further, at one-year follow-up, the CO monitor repeated assessments revealed a significant decrease of ppm levels in the program group  while the control group showed a significant increase of ppm levels . However, one-year follow-up effects on smoking intention did not show a significant difference between the program and control condition (p = .30).As shown in p = .32). Intent-to-treat quit rates were 22.2% for program condition (22 quit and 78 assumed not to quit) and 15.2% for control condition (17 quit and 95 assumed not to quit).The intent-to treat quit rate comparison was in the right direction, but this comparison failed to approach significance  and the large sample size, along with changes observed particularly on level of 30-day smoking and CO levels, suggests promise of Project EX as a cessation/prevention program for Spanish adolescents. Furthermore, there are no well- evaluated cessation intervention programs for adolescent tobacco in Spain, so the results of this study provide evidence about the long-term effectiveness. It is possible that cessation programming should focus on smokers in a school-based clinic setting rather than in the classroom .


Reviewing program educational efforts is an important component of postgraduate medical education program accreditation. The post-graduate review process has evolved over time to include centralized oversight based on accreditation standards. The institutional review process and the impact on participating faculty are topics not well described in the literature.We conducted multiple Plan-Do-Study-Act (PDSA) cycles to identify and implement areas for change to improve productivity in our institutional program review committee. We also conducted one focus group and six in-person interviews with 18 committee members to explore their perspectives on the committee’s evolution. One author (MLL) reviewed the transcripts and performed the initial thematic coding with a PhD level research associate and identified and categorized themes. These themes were confirmed by all participating committee members upon review of a detailed summary. Emergent themes were triangulated with the University of Michigan Medical School’s Admissions Executive Committee (AEC).We present an overview of adopted new practices to the educational program evaluation process at the University of Michigan Health System that includes standardization of meetings, inclusion of resident members, development of area content experts, solicitation of committed committee members, transition from paper to electronic committee materials, and focus on continuous improvement. Faculty and resident committee members identified multiple improvement areas including the ability to provide high quality reviews of training programs, personal and professional development, and improved feedback from program trainees.A standing committee that utilizes the expertise of a group of committed faculty members and which includes formal resident membership has significant advantages over ad hoc or other organizational structures for program evaluation committees. Calls for the development of a systematic approach to program evaluation in post-graduate medical education (GME) abound –3. SeverMost of the existing literature within the post-graduate milieu has emerged in response to the United States’ accreditor’s  requirements . More spAs a result of the ACGME’s accreditation standards, continuous review processes for clinical care has been widely accepted within our academic environment , 10–12. The literature on postgraduate program evaluation is fairly recent and there is little information on how to develop the expertise of committee members who are able and willing to review the large amount of data created by the assessment of competence and quality metrics for post-graduate education. It is in this environment that we sought to answer the following questions: What are the conditions needed for the development of a highly functioning review committee? What can be done with, and beyond, accreditation standards to create an environment for thriving committee participants that see program evaluation for the institution as critical? In that vein, we questioned the University of Michigan Health System’s (UMHS) Internal Review Committee (IRC) on their motivations and career success to try to fully understand their commitment as well as probe the benefit to the institution . Lean thIn this paper we will describe the decade-long evolution of the Internal Review Committee (IRC) into the Special Program Review Committee (SPRC). This change was made using multiple quality improvement cycles as well as the members’ perspective on the transformation of the committee.To improve the program review process, committee members engaged in multiple PDSA cycles of continuous quality improvement from 2002 to 2013. The PDSA model advocates the formation of a hypothesis for improvement (Plan), a study protocol with collection of data (Do), analysis and interpretation of the results (Study), and the iteration for what to do next (Act) . The impTo understand their perspectives on the committee’s evolution, we held a focus group and individual interviews with 18 SPRC members: 11 faculty members, five residents, and two office GME staff. Members of the standing committee included some who had also participated during the ad hoc committee era. The focus group lasted approximately 2.5 h and the in-depth face-to-face interviews lasted 45–90 min each. All participants provided their consent, knowing that they were being recorded.Focus group data was analyzed using grounded theory methodology, which seeks to understand the manner in which an individual is impacted by a particular experience . One autHere we provide results of the PDSA process, support from ACGME feedback (via process outcomes compared to Residency Review Committee citations) and data from the focus group suggesting that a standing committee structure has benefit.Between 1999 and 2001, the institution developed a review process based on, and in compliance with, the ACGME requirements. In 2002–2003 we moved from an ad hoc to a standing committee model specifically convened to review individual training programs. Ad hoc committees would meet the same number of times per year and participants were solicited from over 50 program directors and their associated faculty via email. One hypothesis for this quality improvement project was that a standing committee would provide a comprehensive review and lead to career development opportunities for its members versus those in an ad hoc model.The intent of the standing committee model was to allow members to gain expertise and familiarity interpreting postgraduate requirements, and evaluating and critiquing training programs. By developing areas of expertise within the review process, members are able to recognize and address patterns of concerns across programs and within the institution. Members also began to learn and promote system improvements to education and they were able to transfer this expertise to the educational operations of their own department’s postgraduate medical training programs.This standing committee is comprised of 12 faculty (average 8.5 years of service) and 4 residents (one-two year terms) who, over a 14 year period, met 16 to 20 times during each academic year to review an average of 20 programs annually. The committee provides a model for consistency of program evaluation and assessment of compliance with program requirements. With an ad hoc committee, it was difficult for committee members to develop process expertise on various important aspects of accreditation. In addition, an understanding of local best practices can be missed due to variable measurement of compliance.Committee members are financially rewarded for their participation through their professional development accounts to use for travel, research, or support of junior faculty. The financial reward, which is less than the effort involved, demonstrates that the committee’s work is valued by the institution. As incentives waxed and waned, decreasing over time, the quality of review remained consistent; underlining the faculty’s commitment to the process.As mentioned above, the membership of the standing committee includes resident members. These members are responsible for coordinating interviews with fellow residents and collecting data on residents’ opinions about their educational program. Resident members serve as active participants on the committee, having a voice equal to that of the committee’s faculty. Inclusion of residents allows for the collection of valuable perspectives of the training programs’ residents, and they are better able (than faculty) to elicit honest feedback from residents who are interviewed, due to the peer-to-peer nature of these interactions.The move to a standing committee was partially successful. A natural outcome of that was for the committee to begin to use intentional recruiting for membership on the standing committee. Departmental leaders with a sincere interest in the integrity and excellence in the review process were pursued. Faculty for the committee were recruited from training program Assistant/Associate Program Directors and Program Directors, as well as others by recommendation. Residents have the opportunity to participate and are recruited by their peers or are recommended by their program directors. Selection is confirmed by the institution’s Graduate Medical Education Committee.Cumbersome binder process with numerous steps and unnecessary processes.High cost due to shelf storage and volume capacity, duplication and delivery of bindersExcessive effort of postgraduate and department program’s staff in assembling each program’s documentation.Due to the high demand of requests and collection of data the committee transitioned from a paper to an electronic format for both the committee meeting materials and program documentation. This change resulted in a substantial cost savings in paper and delivery fees. Prior to this, the review process involved:The transition to an electronic process came from requests from Program Directors, Program Coordinators and several committee members. This new streamlined documentation process was the essential element needed for the SPRC to be able to assess the educational components of a training program and for programs to decrease the effort and time devoted to the review process .The committee had established a well-functioning work flow. However, in 2012 the ACGME changed its accreditation standards as well as noting a need for continuous review at the individual program level as well. In 2013, the IRC became the GME SPRCwith an expanded role for providing oversight of the annual program reviews, reviewing GME special reviews, and performing internal reviews of new programs. Thus, the internal review protocol was modified into a structure that supported a protocol for annual reviews. The items reviewed did not change, however the mechanisms of review became focused on the program’s annual report of their own program evaluation and assessment.We realized that programs with two 5-year accreditation cycles and no changes in Program Director were preparing the same documentation as programs with fewer years of accreditation and multiple citations. The committee reconfigured the presentation of program materials from a long- to a short-electronic format to reduce the production of unnecessary documentation. After a review of the ACGME’s Next Accreditation System (NAS) requirements, programs with at least two 5-year accreditation cycles were no longer required to submit documentation in areas that they previously demonstrated accreditation compliance. This significantly decreased the volume of documentation received and need for storage, reduced the committee’s review to only key elements needed to assess the educational components of a training program, and saved the committee members and program staff time and effort.We are currently in the process of implementing a sixth cycle of improvement. Once again, in response to changes in the ACGME requirements there is no longer a need for internal reviews. We have adapted to be able to conduct “impromptu” special reviews for: (1) programs whose annual review submission does not meet the standards of the committee and (2) programs the institution feels are struggling either as a result of lack of resources or issues with learners or leadership. In this model we have moved from a regulatory mandating-based review to an institutional-based annual review program based on program improvement.The effectiveness of the Special Program Review Committee is supported, in part, by an institutional average accreditation cycle of 4.6 years (2010–2013) prior to the onset of NAS. Under the ad hoc model (2002), the average cycle was approximately 4.2–4.4 years. In addition, formal feedback was provided by Program Directors that the rigor of the review ensured an ‘easy’ ACGME site visit for them. ACGME site visits were less rigorous than their internal review and/or the program was adequately prepared as a result of their internal review. We considered this very helpful given the number of programs and the initial short cycle of new programs. This process has ensured a smooth transition to the NAS for our programs and can serve as a model for other institutions . The NASad hoc model there might [be] people that might be doing it (conducting interviews) and this will be the one and only time they’ll ever do it so they won’t get any expertise of what to look for or what standards programs should be held to. (Faculty participant #7)With the Committee members believed that a standing committee format offered numerous advantages over the ad hoc model.I have, for the last how many years, done the program requirements for each review, so I have read through almost every set of program requirements there are out there and it’s very interesting to see the differences and you start to see the big things that stick out almost every time with any program review you do. For me, it was program evaluation. (Faculty participant #1)With this format there is a committee of standing members who are very familiar with reviewing residency documents.I know that after being on the committee for a while and doing our own internal review…I didn’t try to buff up anything beforehand. I said here’s the program how it exists, tell me what’s wrong, knowing…even if I had there were still going to be changes recommended, why do the work twice. I waited…I was smart…I waited until I had the comments to go on and then made the changes. So I think our committee even goes beyond providing useful information it does some of the work quite frankly for some of these programs and just hands stuff to them. (Faculty participant #1)Committee members also commented that the standing committee facilitated the work of program directors, including those who were members of the committee. Because the committee members were aware of common pitfalls and areas for potential improvement, they noted their increased ability to assist program directors in the work they need to do to enhance or further develop their educational programs.[T]here’s been a huge benefit to my own residents, to the training program, and hopefully to the department as result of what I’ve learned here. (Faculty participant #8)Members of the committee frequently brought the expertise that they gained back to their own training programs. In a review of the procedures at Duke University, Andolsek and colleagues also noted that program director involvement in the internal review process often improved the educational content of their own programs . Our finSome of the program directors [are] not all defensive. They see us partnering [with them] much more than when we first started. (Faculty participant #9)The standing SPRC structure has demonstrated value over time creating faculty and residents who are skilled and committed to the review process. Committee members reported that the evaluation style of the committee evolved over time, and UMHS program directors were increasingly more likely to view the internal review process as helpful rather than adversarial. As a result, it appears that the SPRC became increasingly more effective as an educational tool for program directors as the committee members gained expertise.The committee continues to improve upon previous work. In addition to detailed reports, the committee adopted a modified color coded technique for annual program reviews from Duke University. This technique has aided the committee members by quickly identifying different levels of compliance: red (not-compliant), yellow (minimum compliance), green . The committee has also discussed how to decrease meeting frequency while maintaining efficiency. The committee is adaptable to change but change is challenging at times, even to those who embrace it. It is only through a culture of safety, as well as historical experiences with career and institutional benefits of PDSA cycles, that the committee continues to improve.The formation of a standing committee with minimal turnover has ensured great stability in the program review process; stability which was absent when ad hoc committees were utilized. This has allowed each member to gain considerable expertise over several years of service which has resulted in increased efficiency and depth of the reviews. Further, this format has led committee members to be able to effectively educate program directors to address deficiencies by exposing them to best practices identified from other training programs within the institution. Consequently, individual program directors have come to view the functions of the committee as beneficial rather than adversarial.Resident participation on this standing committee has been critical. Resident-to-resident interactions have been very effective in identifying certain problems within reviewed programs. Additionally, resident members place a heavy value on this unique opportunity to learn about the evaluation process, as well as to interact with faculty members as peers.The program review process is time consuming and requires personal sacrifices; features which are readily admitted by committee members. As a result, the institution has taken the unique step of rewarding committee members for their participation. This monetary reward is appreciated by participating faculty members and is perceived as indicating that the institution understands and values the sacrifices committee members are asked to make. Faculty and resident compensation has also likely contributed to greater stability in the committee membership, even though participating members readily admit that the compensation, in and of itself, is not of sufficient magnitude to lead to their decision to re-enlist year after year. Committee members universally expressed a deep sense of commitment to the educational mission of the institution.Finally, because committee members serve for multiple years, they are well-positioned to recognize areas in which the internal review process can be improved. This has included facilitating the transition to a paperless process, revising and improving institutional forms utilized in the review process, creating documents which can be adopted by each of the programs (such as examples of different policies), and streamlining the review process. Such improvements would be much more difficult or impossible for an ad hoc committee to identify.As residency programs move to the NAS, the committee, given its previous quality improvement efforts and ability to adapt quickly to a changing environment, developed a process to provide oversight to 103 programs (as of 2014). This process is electronic, using data already created by programs with a short 15 min questionnaire. The committee uses a red, yellow, green measuring criterion and is able to provide meaningful critiques and meet accreditation requirement in 4–10 meetings a year. Resident participation is continued. This process in the first year will continue to develop as well.Under NAS, the institutional GME office will have more responsibility for overseeing its training programs. Although formal site visits will be less frequent for individual training programs than in the past, establishing a standing committee to review programs at regular intervals was part of a logical transition to accomplish this requirement.


The aim of this study was to investigate the prevalence of posttraumatic stress disorder (PTSD) and its risk factors among survivors in a heavily-hit area five years after the Wenchuan earthquake in 2008, China.684 survivors from Beichuan county, the center of the Wenchuan Earthquake in 2008, were evaluated using the PTSD Checklist-Civilian Version (PCL-C) questionnaire in 2013.The prevalence of PTSD among survivors was 9.2% in 2013. Significant risk factors of PTSD included gender , age , occupation , education  and family member loss . Multivariate logistic regression showed that females, older people, farmers and those with family member loss were significantly more likely to develop PTSD.Posttraumatic stress symptoms remained relatively common among survivors five years after the “5.12” Earthquake in Beichuan county, China. It is important to provide psychological aid and social support for survivors to decease health burden from PTSD, especially for females, farmers, old age survivors and those with family member loss. On May 12, 2008, a major earthquake measuring 8.0 on the Richter scale hit Wenchuan country, Sichuan province of Southwest China. The “5.12” Wenchuan earthquake was the most violent earthquake in China since Tangshan earthquake measuring 7.8 on the Richter scale in 1976. During the earthquake, 69,227 people were dead and 374,643 got injured. The total property damages cost over 150 billion dollars [Many studies have detected a variety of psychological problems following the “5.12” Wenchuan earthquake, especially posttraumatic stress disorder (PTSD) . PTSD usWhen a large scale disaster such as earthquake happens, usually PTSD would also develop -8. AboutPrevious studies have shown that PTSD is a common problem of mental health among survivors after natural disasters. According to a study about the Taiwan 9.21 earthquake, the PTSD rate was 20.9% among survivors who experienced the disaster 2 years after the earthquake . The PTSIn this study, we assessed the prevalence and risk factors of PTSD among survivors five years after the Wenchuan earthquake. The prevalence of PTSD for survivors from the area of Beichuan was 12% about 2 years after the disaster in 2010 [All participants were recruited from Leigu Town with about 7,700 people. Most people in this community were originally native inhabitants of Leigu Town, a subordinate town of Beichuan County, which is the epicenter of the earthquake where 80% of the houses collapsed and more than 1,000 people died. Because Leigu Town was a severely afflicted area in the earthquake, almost all survivors received psychological aids after the earthquake. The survivors were the target population in this study, and were sampled from all household units in this community. A method of systematic sampling was adopted according to household unit doorplate number, and 730 families were selected. The sampling ratio was about 30%. Only one participant within a family was recruited for interview to ensure independence of study subjects, which is usually the household host if available. The inclusion criteria are as: (1) willing to participate, over 18 years old, clear consciousness and without language disorders; (2) experienced the Wenchuan earthquake in Beichuan county on May 12, 2008. The exclusion criteria include: (1) mental retardation, dementia, or any other major psychosis ; (2) Failure to be reached after three household visits or refuse to be interviewed. If a sampled individual was unavailable, the next available individual was sampled. We have inquired the participant about the mental health before the earthquake. If they had similar symptoms such as depression, anxiety or another psychological problem, they would be excluded.Since 2010, Community Health Service Center in China has set up a health care information system with data on all residents with major psychosis in the network of basic community public health care centers. The community health care information system maintains a list of residents with mental retardation, dementia, or any other major psychosis diagnosed by community doctors using questionnaires such as Mini-Mental State Examination (MMSE) and the General Health Questionnaire (GHQ-12). According to the list from the community health care information system, residents with mental retardation, dementia, or any other major psychosis were excluded.The study was approved by the research ethics committee of Panzhihua University in Feb, 2013(reference number: 2013026). Written informed consent was obtained from all study participants. More than 20 voluntary individuals who can speak local dialect received training by the study investigators on communication and interviewing skills before the data collection. They were divided into six groups and all interview groups have been provided a professional physician. At the same time, we paid a return visit by random sampling to monitor the volunteers [There were about 2300 families and 7700 people in this community. Systematic sampling by house doorplate number in three was conducted, and 730 families were selected. For the majority of families, there are three or more family members. Only one eligible resident in each family was recruited, usually a household host if available. We have chosen to recruit the first host we met for each family. If all family members were absent for one month or refused to be interviewed, the family with the next doorplate number would be selected as a replacement. If families with 2 or 3 consecutive doorplate numbers, all did not respond, the next ten doorplate numbers would be considered for recruitment. A total of 26 families refused to be interviewed, 20 families were not reachable within 1 month and 11 people that were unavailable because of mental problem. The final study cohort included 684 participants from Beichuan County who were representative of survivors in the heavily hit area.All participants were interviewed using a structured interview questionnaire to obtain data on socio-demographic characteristics  and earthquake related losses . Posttraumatic stress symptoms were assessed using the subscale of PTSD Checklist-Civilian Version (PCL-C), which is the internationally recognized screen tool for PTSD with high reliability and validity ,15. The The 17 items of PCL-C each is with a score from 1 to 5: 1 = not at all; 2 = a little; 3 = quite a bit; 4 = extremely; 5 = very extremely. The maximal total score for 17 items is 85. Participant with a score of 50 or greater was classified as having probable PTSD. With PCL-C score of 50 as the diagnostic cut-off, the sensitivity was approximately 80% . This cuAccording to the 4th edition of Diagnostic and Statistical Manual of Mental Disorder (DSM-IV) proposed by the Harvard Refugee Trauma Group , PTSD inAll data were analyzed by statistical software SPSS 17.0 . Descriptive statistics were computed for demographic characteristic variables. Chi-square test was used to examine differences in categorical variables between those who were suffered from PTSD and those who were not. Multivariate logistic regression was used to assess the risk factors of PTSD.Table As recommended by DSM-IV, total score over 50 was considered probable PTSD. The percentages of probable cases according to participants’ characteristics are shown in Table Table In Table According to previous studies of the Wenchuan earthquake, the PTSD rate among survivors was 45.5% two and a half months after the earthquake , and 13.We noted that the prevalence of PTSD seemed to decrease over time, but at a relatively slow pace. The declining prevalence may be attributable to self-healing capabilities, social support and psychological aid. Social support and psychological aid are shown to be associated with the quality of life in earthquake survivors . Since aSignificant risk factors for PTSD five years after the earthquake were female gender, old age (≥60 year), farmer occupation and family member loss. These findings are plausible. Our finding that the prevalence of PTSD was significantly higher among females 12.1%) compared with males (5.2%) is consistent with previous findings .1% compa,24. It sFarmers appeared to be more likely to be suffered from PTSD. The incomes of farmers are generally low. They perhaps had fewer resources in coping with the devastating stress from the loss of economic support and living means than people of other occupations. This may result in a higher PTSD rate in farmers.Survivors with family member loss may undertake more negative trauma, and have more economic and psychological pressure, which may result in a higher prevalence rate of PTSD .Among all 63 probable PTSD sufferers, the items “physiological reactivity to cues” (76.2%) and “intense psychological distress to cues” (73.0%) occurred most frequently, suggesting more mental interventions concerning these symptoms would be helpful. Additionally, the majority of common PTSD symptoms are different for probable PTSD sufferers and others, suggesting different psychological aid may be needed. Community-based mental health aid may be helpful .This study has limitations to acknowledge. First, in the current study participants with a score of 50 or above were classified as having probable PTSD without a clinical interview. This diagnostic criterion is often used when a clinical interview is not feasible . It is ePTSD remains a common mental health problem among survivors at five years after the 5.12 Wenchuan Earthquake in China. The major risk factors for such persistent PTSD included female gender, farmer occupation, old age and family member loss. Implementing psychological counseling for women, farmers, old age survivors and those with family member loss would be critical in mitigating the long-term risk of persistent PTSD.


Tuned In, a novel emotion regulation intervention that uses participant selected music to evoke emotions in session and teaches participants emotional awareness and regulation skills. The group program content is informed by a two dimensional model of emotion , along with music psychology theories about how music evokes emotional responses. The program has been evaluated in two samples of adolescents: 41 “at risk” adolescents  attending an educational re-engagement program and 216 students  attending a mainstream secondary school. Results showed significant pre- to post-program improvements in measures of emotion awareness, identification, and regulation . Participant ratings of engagement and likelihood of using the strategies learned in the program were high. Tuned In shows promise as a brief emotion regulation intervention for adolescents, and these findings extend an earlier study with young adults. Tuned In is a-theoretical in regard to psychotherapeutic approach and could be integrated with other program components as required.This paper presents an effectiveness study of  Tuned In program was designed to train young people in emotion awareness, labeling, and regulation, using music listening as an engaging and meaningful way of evoking emotions during sessions. An early trial of the program found it to enhance emotional clarity and regulation among young adults , and the current study extends on this work with an investigation of the effectiveness of Tuned In for enhancing emotion awareness and regulation of healthy and at-risk adolescents in educational contexts.Effective emotion regulation relies on an individual’s awareness of their own and others’ emotions, the development of a lexicon to label a range of emotional states, and strategies to modulate emotions to suit the context. These abilities develop throughout childhood and adolescence, although the rate of acquisition varies across emotions and stimuli. There is some evidence that the development of emotional skills slows down during the onset of puberty – at a time when young people typically experience intense emotions and when their regulatory skills are not yet fully developed. The Most pre-school children (aged 3 to 5 years) are able to correctly identify primary emotions in facial expressions, body postures and a combination of cues . StudiesRecognition of one’s own emotions doesn’t necessarily develop at the same rate as recognition of emotions in others. The development of a lexicon for affect labeling has long been considered a precursor for emotion regulation – particularly the regulation of negative emotions . The recEmotion regulation can be conceptualized as the ability to modify emotion in flexible and adaptive ways in response to social context . Those wThere are currently no interventions designed to specifically address emotion dysregulation in adolescents. Cognitive behavior therapy (CBT) is an evidence based treatment for a range of emotional disorders in children and adolescents . HoweverTuned In program, music listening is used as the method for evoking and experiencing emotions in session for the purpose of emotion psycho-education and skills building. Personalized music listening has been consistently listed by 18–25 year old Australians as their number one emotion management strategy in the annual national survey of Australians Stress and Wellbeing , and what type of music listening or other emotion regulation strategy would help them to reach their desired emotional state. For example, if a participant felt flat and unmotivated at the start of the session, they would locate this emotional state as low on the arousal dimension and on the negative side of the valence dimension. They might want to feel more energized, so they would indicate a spot higher in arousal and on the positive side for valence. The participant would be asked to nominate some music that would help them to achieve this energized state, and some other strategies they could use (such as exercise) if music listening was not suitable.Several participants’ songs are played in each session, and participants engage in three activities designed to focus their attention on the music in order to enhance their emotional responses. The first is an imagery task in which participants are instructed to draw any images that come to mind while they listen to the music. According to Tuned In was conducted amongst 50 dysphoric university students aged 18–25 years . Participants were randomly assigned to Tuned In or a wait-list control. Tuned In involved groups of around eight participants with two psychologist facilitators. Mixed repeated measures ANOVA results showed that Tuned In participants experienced greater improvement in emotional awareness and clarity and total emotion regulation scores than controls. Weekly ratings also indicated significant improvements in emotional awareness, ability to name emotions, and ability to regulate emotions. Ratings of engagement were high and the overall attendance rate was 98% . As such, preliminary data supports the efficacy of this program amongst a non-clinical sample of university students.A pilot study of a 6 h version of Tuned In among two adolescent samples in real world educational contexts: a sample of adolescents who had disengaged from school due to learning and psychosocial problems and were enrolled in an experiential learning program run by the non-Government organization BoysTown; and a sample of students at a mainstream girls secondary school in a suburb of a metropolitan city in Australia. It was hypothesized that:The aim of this study was to investigate the effectiveness of     (1) Participants’ ratings of emotional awareness, ability to name emotions, strategies for regulation and confidence in using their strategies would increase from pre to post intervention;    (2) Participants would show improvements from pre to post intervention on validated measures of emotion regulation; andTuned In to be an engaging program, as indicated by their ratings of interest and enjoyment in the program collected at the end of the program.    (3) Participants would find     (4) That the program could be scaled up from the original small group size of around 8 participants to an en masse school group of over 100 students while remaining effective and engaging.Mage = 14.83) were recruited from the BoysTown experiential learning program in a regional city in Australia. All consenting members of the program during the study period were recruited to the study. A majority of the sample was born in Australia (88%), with five participants identifying as Aboriginal and Torres Strait Islander and the remaining 12% hailing from New Zealand, the Philippines and Liberia. Participants in this sample experienced multiple barriers to learning and social inclusion resulting in their drop out or exclusion from formal secondary schooling. Furthermore, 18% were reportedly undergoing treatment for a psychological disorder at the time of this study. The sample mean on the K6 (see Measures) was 5.7 (SD = 4.9), which is in the normal range, with no participants falling over the cut off of 13 indicative of mental health problems. So although this was not a clinical sample of adolescents, they could be characterized as “at risk” of mental health problems. Less than a quarter of the sample (24.3%) had received a year or more of formal musical training.Forty-one participants , aged between 14 and 17 years old ; I felt confident that I could manage my strong emotions, I used music as a way of managing my emotions, and I have a range of healthy ways of managing my emotions. The internal consistency of the emotion variables in sample 1 was α = 0.83 at pre-program and α = 0.90 at post-program.At pre- and post-program, participants were asked to rate the extent to which five purpose-written emotion statements were true of them over the past week, on a 7-point Likert type scale from 1 = When I want to feel more positive emotion (such as joy or amusement), I change what I’m thinking about); and suppression . Longitudinal research indicates that use of emotional suppression is related to negative social connectedness and wellbeing while cognitive reappraisal is associated with positive social connectedness and wellbeing among young people . As the internal consistency for suppression was low in this sample, the results should be interpreted cautiously.The ERQ  is a widg people . ParticiNone of the time to 4 = All of the time, which are summed to a total score in the range of 0 to 24. A cut off score 13 and above is interpreted as indicating a clinical level of distress. The internal consistency of the K6 in sample 1 was α = 0.87.The K6 is a widely used six-item screen for mental illness designed by Tuned In; and the likelihood they will continue to use music to regulate their emotion. These were rated on a 7 point Likert type scale from 1 = Never True to 7 = Always True.Upon completion of the program, three additional items were included to assess responses to the program overall: how helpful participants found the program in helping them to regulate mood; how enjoyable and interesting they found Tuned In program as a component of their 2-days a week BoysTown experiential learning program. Participants from five different cohorts were recruited across three terms, with data collection spanning an 8-month period in 2014. Participants completed the online surveys prior to the Tuned In program and immediately following the completion of the program. Participants in the BoysTown program did not receive any other psychological intervention during this time, with the curriculum focused solely on literacy, numeracy and life skills. There was a 29% attrition rate during the 10 weeks term, with 29 participants completing the post-program survey (and some measures not being completed accurately). Attrition was due to a range of factors including that the young person started a vocational training program, had to appear in court, or experienced an increase in family difficulties that was associated with their disengagement with the learning program. The Tuned In program was facilitated by provisional psychologists enrolled in postgraduate clinical psychology internships at the University of Queensland under the supervision of the first author. Participants received $20 in vouchers for each completed survey as compensation for their time.Participants took part in the Mage = 13.6 years) attending an independent school. There were 117 year eight girls and 99 year nine girls. This was a convenience sample in which participants were given a brief survey to complete before and after an en-masse half day Tuned In workshop, so only a small selection of variables was assessed. No information was collected on psychological problems or musical training.Comprised of 216 female students aged 12 to 15 years .Figure 1. Repeated measures analysis of variance results showed a significant increase in participant’s self-reported emotional awareness from pre to post, preM = 4.03, SD = 1.59; postM = 4.83, SD = 1.26; F = 5.28, p = 0.029, η2 = 0.16. There was also significant increase in their ability to name their emotions: preM = 4.25, SD = 1.35; postM = 5.00, SD = 1.39; F = 6.32, p = 0.018, η2 = 0.19. Furthermore, a significant increase in participants’ confidence to manage their emotions was observed from pre to post, preM = 3.61, SD = 1.64; postM = 4.75, SD = 1.11; F = 12.43, p = 0.002, η2 = 0.32. The use of music to regulate emotions did not change significantly: preM = 4.84, SD = 1.90, and postM = 4.90, SD = 1.60. Finally, self-reported range of healthy strategies to regulate emotions improved from preM = 3.74, SD = 1.74 to postM = 4.56, SD = 1.53, however, this change did not quite reach significance: F = 3.882, p = 0.06 . According to scores on the Emotion Regulation Questionnaire, there was a significant decrease in the use of emotional suppression as a regulation strategy from pre- to post-program, preM = 4.53, SD = 1.02; postM = 3.88, SD = 0.97; F = 6.44, p = 0.018, η2 = 0.21. No significant difference was found for the use of reappraisal, preM = 4.27, SD = 0.86; postM = 3.77, SD = 1.1; F = 3.35, p = 0.08, see Figure 2.Sample 1 means on the emotion variables at pre- and post-program are shown in preM = 5.64, SD = 4.92; postM = 7.56, SD = 4.06; F = 4.16, p = 0.053. Participants rated Tuned In to be helpful in managing their emotions , they found Tuned In interesting and enjoyable  and reported that they were likely to continue to use music to manage their emotions .Depression and anxiety symptoms on the K6 were in the normal range for the majority of participants and although the sample mean increased slightly from pre- to post-program this did not reach significance, Figures 3 and 4. Repeated measures analysis of variance results showed a significant increase in participants’ emotional awareness from preM = 4.59, SD = 1.44 to postM = 5.59, SD = 1.23; F = 103.13, p < 0.001, η2 = 0.326. There was also a significant increase participants’ affective labeling of their emotions, preM = 5.70, SD = 1.10; postM = 6.11, SD = 1.02; F = 27.33, p < 0.001, η2 = 0.113. The use of music to regulate emotions increased from preM = 4.97, SD = 1.83 to postM = 5.76, SD = 1.43; F = 43.655, p < 0.001, η2 = 0.171. Furthermore, participants’ range of healthy strategies to regulate emotions improved from preM = 4.89, SD = 1.46 to postM = 5.68, SD = 1.31, F = 63.52, p < 0.001, η2 = 0.230. Confidence in regulating anger increased from preM = 4.97, SD = 1.55 to postM = 5.50, SD = 1.42, F = 30.76, p < 0.001, η2 = 0.128. Confidence in regulating sadness improved from preM = 4.73, SD = 1.52 to postM = 5.39, SD = 1.46, F = 55.187, p < 0.001, η2 = 0.204. Anxiety regulation confidence increased from preM = 4.55, SD = 1.79 to postM = 5.31, SD = 1.49, F = 52.36, p < 0.001, η2 = 0.199. Finally, confidence that they could be happy without negative consequences was rated preM = 5.37, SD = 1.52, and postM = 5.78, SD = 1.21, F = 22.067, p < 0.001, η2 = 0.094. The program was rated an average of 5.85 (SD = 1.26) out of 7 for enjoyment, 5.61 (SD = 1.42) for recommended to other students, and 5.86 (SD = 1.27) for likelihood of continuing to use the emotion regulation strategies learned.The mainstream secondary school sample means on the emotion variables at pre- and post-program are shown in Tuned In to enhance emotion awareness and regulation skills of at-risk and mainstream adolescents in educational settings. The at-risk adolescents were offered an eight session version of the program in groups of around eight participants and showed significant improvements in self-reported emotional awareness, affective labeling of their own emotions, and confidence in using a range of emotion regulation strategies. Interestingly, the use of music as a strategy for regulating emotions did not increase from pre- to post-program, however, scores were highest at pre-program for this variable. This finding is consistent with previous research showing that adolescents are high consumers of music and use music listening naturally as a way of managing their emotions  than in the at-risk sample , a significant improvement was also seen across all emotion measures in the mainstream sample. Of all of the primary emotions assessed, students reported the lowest confidence in regulating their anxiety at pre-program, and this was one theme that the program particularly attended to. Further research is required to ascertain whether this increase in anxiety regulation confidence at post-program might translate to decreases in academic anxiety around assignment and exam time, and improvements in performance across academic, sporting, and music domains where anxiety can be a barrier to performance . However, the participants may have found the scale difficult to understand due to the meta-cognitive nature of the items, e.g., “when I want to feel more positive emotion, I change what I am thinking about”. It would therefore be recommended that future research with at-risk adolescents use a different measure of emotion regulation that is less reliant on meta-cognitive awareness. Alongside of the measure of emotion regulation, future research would need to include broader measures of social and academic functioning – potentially including teacher and parent reports to address the issue of demand characteristics on participants’ self-reports.Overall, the findings of this study indicate support for the four hypotheses and provide a proof of concept that the Tuned In? Other research shows that individual factors such as reward sensitivity, emotional sensitivity to music and absorption in music contribute to its effect on listeners . Other mechanisms have been described in work by Questions that remain to be investigated include: what are the moderators and mediators of the effectiveness of isteners . Severalisteners . Music wisteners . In respisteners . It woulTuned In helps build emotional awareness and regulation amongst at-risk and mainstream adolescents, and results are consistent with previous findings in a young adult sample . Adolescence is a time of growth, change, and emotional upheaval during which individuals’ capacity for self-regulation of emotion is still developing. The Tuned In program is engaging and effective at enhancing participants’ emotional skills in small and large groups.The findings of this study show evidence that GD developed the intervention program, designed the study, set up the collaboration with the stakeholders of Sample 1, and took overall responsibility for the manuscript. JH set up the collaboration with the stakeholders of Sample 2 and was involved in facilitating the program with both Samples, data collection, and input into the written manuscript. AK was involved with facilitating the program with both Samples, data collection and analysis of Sample 1 data, and input into the written manuscript.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.


This letter is a response to commentary by Skinner et al. on an evaluation by Burke et al. of the HealthMPowers program, an elementary-school-based program developed to improve child health and wellness. In their commentary, Skinner et al. make the criticism that our results for changes in BMI-for-Age Z score were simply reflective of Regression to the Mean (RTM). In this response, we show that while some of our results are consistent with RTM, with adjustment we do still observe some small effects in BMI-for-Age Z score over the course of the school year. We conclude that while our evaluation was not definitive, we still believe that programs of similar design to HealthMPowers merit further rigorous study. We thank Drs. Skinner et al. for their comments and feedback on our article . RegressAs mentioned in the original paper, this analysis had the severe limitation of lacking a control group. This is an effect of the fact that the HealthMPowers program was not designed as a research study, and the paper itself was conceived as an evaluation of the program based on existing data from its implementation. As Skinner et al. explain, one-group designs are particularly vulnerable to the potential effects of RTM. Nonetheless, it would be incorrect to state that we found “no significant reduction in BMI [Body Mass Index] z-scores in the total sample”; in fact, analysis of the total sample indicated a highly significant (p < 0.0001), though modest decrease of 0.06 in BMI-for-Age Z score over the course of the school year. Significance was maintained (p < 0.0001), though the effect further attenuated to a 0.04 decrease, when constrained to children normal-weight at baseline. Generally, the high correlation coefficient (rho = 0.96) between pre and post BMI-for-Age Z score would suggest that the effect of RTM, and indeed any observed one-year effect of the program, should be modest. In response to this feedback, we also performed an analysis of the potential effect of RTM on the published results (a subset of obese children stratified on grade and sex), based on formulae in Davis . This anEven though the evidence may not conclusively support an effect of the HealthMPowers program on body composition as measured via change in BMI-for-Age Z score, we believe that programs of this design still have merit and warrant further rigorous evaluation. Our analysis was suggestive of improvements in student knowledge and behaviors, PACER performance, and self-assessed improvements in the school environment, all of which are important to holistically improving child health and wellness. We hope that our publication serves to inspire the development and evaluation of other similarly designed school-based programs that focus not only on student education and physical activity, but also on teacher and parent involvement. It is clear that more research is needed in this area, with special focus on randomized trials where possible, given the difficulties involved in obesity-prevention research. Our research team is currently in the initial stage of implementing a randomized controlled trial of the HealthMPowers program and its effect on the relationship between physical activity, physical fitness, and academic achievement. This planned research will help to more definitively identify whether and to what magnitude a comprehensive school-based program can effect change in student health and academic outcomes.


Dissemination and implementation (D&I) frameworks are increasingly being promoted in public health research. However, less is known about their uptake in the field, especially for diverse sets of programs. Limited questionnaires exist to assess the ways that frameworks can be utilized in program planning and evaluation. We present a case study from the United States that describes the implementation of the RE-AIM framework by state aging services providers and public health partners and a questionnaire that can be used to assess the utility of such frameworks in practice. An online questionnaire was developed to capture community perspectives about the utility of the RE-AIM framework. Distributed to project leads in 27 funded states in an evidence-based disease prevention initiative for older adults, 40 key stakeholders responded representing a 100% state-participation rate among the 27 funded states. Findings suggest that there is perceived utility in using the RE-AIM framework when evaluating grand-scale initiatives for older adults. The RE-AIM framework was seen as useful for planning, implementation, and evaluation with relevance for evaluators, providers, community leaders, and policy makers. Yet, the uptake was not universal, and some respondents reported difficulties in use, especially adopting the framework as a whole. This questionnaire can serve as the basis to assess ways the RE-AIM framework can be utilized by practitioners in state-wide D&I efforts. Maximal benefit can be derived from examining the assessment of RE-AIM-related knowledge and confidence as part of a continual quality assurance process. We recommend such an assessment be performed before the implementation of new funding initiatives and throughout their course to assess RE-AIM uptake and to identify areas for technical assistance. With concerns about the aging population and attendant growth of multiple co-morbidities , 2 suppoOriginally conceived in the late 1990s, the RE-AIM framework  was desiBuilding on early community-wide efforts to identify best practice programs for older adults through the aging services network, the United States Administration on Aging (AoA), a program division within the Administration for Community Living (ACL), has dedicated resources to the implementation and dissemination of state-wide evidence-based practices . This emIn 2006, the Atlantic Philanthropies and the AoA funded the evidence-based disease prevention (EBDP) initiative with the intention of supporting stronger linkages between State Aging Services and State Health Departments to address the health needs of the growing population of older adults. The overall goals of this initiative were to (1) develop the systems necessary to support the ongoing implementation and sustainability of evidence-based programs for older adults; (2) develop multi-sector community partnerships to enhance program accessibility and extend program capacity; (3) reach the maximum number of at-risk older adults who could benefit from the programs; and (4) deliver evidence-based programs with fidelity .Seen as an opportunity for fostering learning collaborative, the funders contracted for technical assistance to the 27 state grantees funded under the EBDP initiative. Since this was the first time RE-AIM was integral to health promotion program implementation activities for these partnerships, there was interest in exploring how well and in what ways the framework was being adopted and applied, especially since no systematic collection of this information existed. As investigators from three CDC Prevention Research Center–Healthy Aging Research Network (HAN) campuses charged with providing technical assistance to the funder and State grantees, we wanted to explore how translational research frameworks were being implemented in the real world settings by state-level aging services providers and their public health partners. This paper expands upon previously reported findings . Its purAs illustrated in Figure “Reach” is the extent to which a program attracts and retains the target audience. Measures of Reach include the number, proportion, and representativeness of participants. It is important to monitor Reach to determine if the desired audience is participating in the program, in what numbers, and whether there is program completion or attrition. This in turn, can help gage the success of marketing, recruitment, and retention efforts.“Effectiveness” refers to assessing the change in short- and/or long-term program outcomes, such as health behaviors and lifestyles, symptom management, health status, or health care utilization outcomes. Effectiveness indicators also monitor for other outcomes, whether negative or unintended that result from the program. It is important to monitor Effectiveness to provide the evidence as to whether the program is producing positive changes, which ultimately makes the case for the program’s value and return on investment.“Adoption” activities assess organizational capacity and partnership support. Measures include the number, proportion, and representativeness of staff and settings who adopt a program as well as tracking of the various ways partners contribute to program delivery. It is important to know if the supply of delivery staff and sites matches program demand and is located in areas where the target audience resides and whether there is capacity to bring the program to scale.“Implementation” is the extent to which the program is delivered consistently, as intended by the program developers, across all implementation sites by all instructors. Implementation measures also tracks program costs. It is important to monitor Implementation in order to identify areas of need for improvement in program delivery, assure participant results can be attributed to the program and identify return on investment for stakeholders.At the setting level, “Maintenance” refers to the extent to which the program can be embedded within the routine organizational practice. Some factors, such as “ongoing staff support,” “partnership with community,” “sufficient funding,” and “health marketing,” are all essential elements for organizational maintenance. At the individual level, “Maintenance” refers to the extent to which individual participants experience long-term benefits (longer than 6-months following program completion) and better quality of life from the health promotion interventions or policies. Attention to these elements helps inform strategies to ensure individual benefits are sustained over time and that the necessary infrastructure is in place to ensure a program will receive ongoing institutional or community support.Data were collected using internet-delivered methodology. The questionnaire utilized to collect data from respondents was developed by the HAN project team using online survey software. Electronic mail-based invitations to participate in the questionnaire were sent in January 2009 to designated project leads representing 27 states receiving funding from and participating in the EBDP initiative. The instructions requested that the questionnaire be completed separately by one state lead  and one state-level program evaluator. Other team members who played key roles in program implementation and/or evaluation  were also welcome to complete the questionnaire. Some of the items  were asked retrospectively. After completing the questionnaire, the respondents were invited to share their responses with their state team as a way of enhancing their planning and evaluation efforts. The initial survey requested that responses be returned within 2 weeks. Two follow-up emails were sent to state respondents to increase the survey response rate. This study received Institutional Review Board (IRB) approval at Texas A&M Health Science Center where data were collected and analyzed.Reflecting expertise in several health professions  and prior experience with the RE-AIM model and implementation research –29, the As there were no comparable questionnaires in the literature, the authors built the questionnaire around concepts deemed important to reflect implementation processes. The questionnaire was designed to collect information about the respondent’s knowledge, attitudes, and current practices related to different aspects of the RE-AIM framework as a whole as well as attention to its individual components. The questionnaire was pilot tested for ease of understanding and face validity with local community practitioners.The final questionnaire contained 47 multi-part items including close-ended and open-ended items, as well as checklists. Recognizing the importance of “survey fatigue” or attrition, the HAN project team was careful not to make the questionnaire too long. Therefore, close-ended items with Likert-type scaling were used to make it easy for respondents to respond to questionnaire items. Additionally, open-ended items were integrated into the questionnaire to allow for additional responses to give richer detail and context to close-ended items.www.re-aim.org) if they desired more information about the rationale for and measurement of each element.It was estimated that the online survey would take approximately 10–20 minutes to complete. Individualized links were sent through the online survey website to state leads that were identified through the AoA’s Technical Assistance Center. Respondents had unlimited access to the online questionnaire to enable them to complete the task at their convenience and as a means of increasing completion rates. The questionnaire opened with a brief definition of the RE-AIM elements, with directions to the respondents to go to the RE-AIM website .”Respondents were asked to rate their knowledge about “EBDP programs” and “the RE-AIM framework” at the start of the grant initiative (retrospectively) versus the current time. If respondents were not present at the initial stages of program implementation, they were instructed to mark the “not relevant” category.Self-efficacy refers to individuals’ beliefs in their ability to succeed in a given situation . These bRespondents were asked to share their attitudes about the application of RE-AIM for various tasks related to their grant efforts. Respondents were asked to rate the usefulness of RE-AIM applied to the following activities: “planning of this initiative,” “implementation of this effort,” “evaluation of this effort,” “planning efforts with our other aging programs,” and “implementation efforts with our other aging programs.” Respondents were also asked to report how valuable they believed RE-AIM was for different audiences. Participants were asked to respond to the following audiences: “providers,” “community leaders,” “policy makers,” and “evaluators.” Finally, respondents were asked to indicate if they would apply RE-AIM in their future projects.Respondents were asked to report how easy they believed RE-AIM was to use/apply and their preferences about monitoring RE-AIM elements. Respondents were asked to respond to seven statements about the RE-AIM framework as a whole as well as its component elements.Items were included to collect information about the respondents’ role on the AoA/Atlantic EBDP grant ; the year that the respondent started working with evidence-based programs ; and the type of evidence-based programs being delivered (from a list of 16 approved evidence-based programs).As previously reported , 40 quesIn terms of when they started working with EBDP programs for older adults, less than half of the respondents reported that they had worked with evidence-based programs before the onset of the current initiative. Of the 16 approved evidence-based programs, 15 programs were offered across the grantee states. The most commonly offered programs by grantee states included Chronic Disease Self-Management Program (CDSMP) (100%), EnhanceFitness (37.5%), A Matter of Balance (30.0%), and Healthy IDEAS (10.0%). There were no reported problems with understanding or answering any questionnaire items.Table Table Table Table This study presents a unique real world application of how the RE-AIM framework was embedded into a national effort by aging services providers and their partners to expand the dissemination of evidence-based programing for older adults. The application of RE-AIM and other implementation and dissemination frameworks can be encouraged or mandated by funding agencies as illustrated by a prior examination of the application of RE-AIM to funding applications . HoweverIn contrast to previous research that documents a primary focus on reach and effectiveness and excludes attention to maintenance , in thisAn important issue addressed in this research was the extent to which RE-AIM elements were seen as an indivisible whole versus the sum of individual parts. As indicated in the Section “While there was strong endorsement of the usefulness of RE-AIM for applying various tasks, the framework was seen as most useful for evaluators versus providers, community leaders, or policy makers. This may reflect the original origins of RE-AIM as an evaluation tool for public health research , or the Consistent with the growth of literature about RE-AIM , large iA few limitations can be noted. With only 40 responses, this research is best viewed as an implementation case study of the RE-AIM framework. While we had anticipated having two respondents per state to reflect both planning and evaluation perspectives, it became evident that not all states had state-wide evaluators. With the small number of respondents, we were not able to examine responses by respondent type, which in turn made us unable to assess differences in perceptions by whether the respondent was a state lead, a state-wide coordinator, or program evaluator. However, it should be noted that there was representation from each of the funded states and this type of data related to practitioner self-reported confidence levels about RE-AIM use is rarely evaluated and/or reported. With the intent of collecting data from stakeholders in 27 states quickly and inexpensively, we were restricted to survey methodology. Our questionnaire reveals interesting observations about the utility of employing the RE-AIM framework, which points to issues that can be followed-up about through more in-depth interviews in a particular state.Additionally, another potential limitation is that this current study examines a community grants program implemented at one point in time. Requests for respondents to reflect back on their familiarity and knowledge about evidence-based programs and the RE-AIM framework may be subject to recall bias or be affected by personnel changes. Hence, we recommend that implementation assessments be ongoing from the beginning to the end of the program period. Further, different intervention programs could have been implemented over time, thus, knowledge, attitudes, and practices about RE-AIM elements may be changing. Since this initial AoA EBDP initiative there has been a 2010–2012 ARRA initiative for further disseminating the CDSMP in 45 states, the District of Columbia, and Puerto Rico. However, no systematic data on the application of RE-AIM elements were collected, and the current study is the only national examination of the implementation and adoption of the RE-AIM framework in the aging services network.We offer our questionnaire as a pragmatic tool that can be used to assess implementation of the RE-AIM framework as a whole, or its constituent parts. We recommend attention to the full continuum of implementation processes from planning, implementation, evaluation, and sustainability considerations. Additionally, users of this questionnaire will need to consider in advance the most feasible administration  and ideal assessment points . For those interested in more comprehensive evaluation aspects, questions can also be added to determine what types of standardized outcome measures would be feasible to collect in the dissemination of EBDPs conducted outside of a research setting. Seeking such input from the field aligns with the recent emphasis on person-centered research, which stresses the importance of including major stakeholders in research .As the EBDP field has matured, there are several important implications for the future use of RE-AIM. The AoA’s guidelines for initiatives in evidence-based programing for older adults now embed RE-AIM within a larger CQI approach for QA. To carry out CQI, state agencies and their partners need to orient the team about the QA plan; agree upon RE-AIM performance indicators; specify designated roles, responsibilities, and timelines for all program partners; establish mechanisms for periodic review and standardize protocols for making corrective actions when necessary . We beliIn 2012, the U.S. ACL/AoA funded 22 states to continue to scale the evidence-based CDSMP and establish a sustainable infrastructure for EBDP program delivery . With QATo support these efforts, the NCOA Center for Healthy Aging , buildinWithin a relatively short period of time, evidence-based health promotion programing for older adults has evolved into a system change movement with the goal of embedding these programs into integrated community, long-term care, and health systems. According to the AoA , state aThe 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.This paper is included in the Research Topic, “Evidence-Based Programming for Older Adults.” This Research Topic received partial funding from multiple government and private organizations/agencies; however, the views, findings, and conclusions in these articles are those of the authors and do not necessarily represent the official position of these organizations/agencies. All papers published in the Research Topic received peer review from members of the Frontiers in Public Health  panel of Review Editors. Because this Research Topic represents work closely associated with a nationwide evidence-based movement in the US, many of the authors and/or Review Editors may have worked together previously in some fashion. Review Editors were purposively selected based on their expertise with evaluation and/or evidence-based programming for older adults. Review Editors were independent of named authors on any given article published in this volume.