Our study objective was to examine the feasibility of implementing a culturally congruent mentorship pilot program, Youth-First (YF), that targets behavior modification among elementary school-aged children with disruptive behavior and a history of school suspension. We hypothesize that it is feasible to implement the YF program to reduce disruptive behaviors and recidivism of level III/IV infractions in school settings among at-risk African American students.We assessed program feasibility based on the success of program acceptance by parents/guardians, study enrollment, and intervention compliance by students. A pre/posttest study design was used to examine whether the YF program reduced recidivism of disruptive behavior among enrolled at-risk African American elementary school children between September 2016 and January 2017. Generalized linear mixed models examined whether student behavioral scores improved over time and varied by program mentor. A McNemar test examined the reduction in cumulative incidence of level III/IV infractions pre-post YF program intervention.N = 24). Overall, student behavioral scores improved and plateaued over time ; a two-week period was associated with a seven-point improvement  in behavioral scores. Behavioral score improvements were class-specific, based on respectfulness behavior . No recidivism of level III/IV infractions was reported during and post YF intervention.Intervention acceptance, enrollment, and compliance were 100% , 100% (95% CI 86 to 100%), and 67% (95% CI 45 to 84%), respectively  in reducing disruptive behavior, level III/IV infractions, and school suspensions among at-risk children. Disruptive student behaviors that result in school suspensions are categorized as level III or IV infractions , 2. TypiThe etiology of school-related disruptive behaviors is linked to early childhood behavioral and emotional disorders including but not limited to attention deficit hyperactivity, oppositional defiance, autism spectrum, depression, anxiety, bipolarity, learning, and conduct disorders , 6. AlthThere is growing evidence showing that school mentorship programs that provide social support, social skills, emotional regulation, and problem solving skills lead to interconnected and sustained social-emotional, cognitive, and identity child development , 10, 11.Among elementary school children, the argument for preventing disruptive student behavior and consequently suspensions is compelling due to its adverse effects on the life course trajectory outcomes of students involved , 13. ThiSome studies suggest that the over-representation of minorities, especially African Americans, in school discipline incidents is due to cultural discontinuities that place them at a disadvantage in many public elementary schools , 4, 16. In Syracuse City School District (SCSD), one of the largest school districts in New York State with one of the highest cases of poverty within the nation; 85% of SCSD students are classified as economically disadvantaged . Out-of-To address school-related violence, multi-faceted prevention strategies that address factors at multiple levels: students with problematic and disruptive behavior, relations with other students, teachers and school personnel, and community are needed . CulturaBased on the above considerations, this study aimed to examine the feasibility of implementing a pilot program, Youth-First (YF), that targets behavior modification among elementary school-aged children with disruptive behavior and a history of school suspension. The YF program specifically targets disruptive behavioral problems most proximal to school suspensions using an eco-behavioral perspective that involves a dynamic collaboration between parents, teachers, and culturally congruent community-based mentors. In this pilot study, we hypothesize that it is feasible  to implement the YF program to reduce disruptive behaviors and recidivism of level III/IV infractions among at-risk African American students in elementary school settings.Pre/posttest study design with no concurrent control group.Elementary school X is located in Syracuse city in one of the highest gun clusters in New York State. Elementary school X has 650 students; 90% are of African-American or Hispanic decent; 93% participated in the National School Lunch Program, a federally assisted program for low-income families; and 22% have a diagnosed mental health disorder . Elementary school X is one of the lowest performing elementary schools in Syracuse City; 98% and 95% of students performed below proficiency level on the New York State grades 3–8 English Language Arts and Mathematics assessments, respectively. The school also had a staff turnover of 33% during the 2013/2014 academic calendar.Study inclusion criteria was based on receipt of three or more referrals for level III/IV infractions or failure to attend teacher referred school based behavior counseling between September 2016 and January 2017. We excluded children involved in school-based behavioral counseling.Acting as first respondersThe pilot of YF program components included mentors: (a) acting as a first responder; (b) conducting daily Check-In Check-Out (CICO); and (c) helping to build relationships between student, teacher, and the student’s family. YF mentor caseloads varied between five to six students in any given week during the five-month intervention period.b)Daily Check-In Check-Out (CICO)Teachers made calls to request for program mentors as first responders via a walkie-talkie device, if a student exhibits disruptive behavior in a classroom setting. Regardless of the infraction, a student is able to take a 15–30 min reset with their mentor to de-escalate before returning to class or before seeing an administrator. The de-escalation process involves practicing self-control and self-regulation techniques. Students also requested meetings with their mentor whenever they felt agitated during class. Prior to this accommodation, teachers requested the removal of a disruptive child from the class, often with the use of restraints.c)Helping to build relationships between teacher and parents/guardiansMentors conducted at least two daily CICO’s with each student (in addition to the first responder contact for those students who had a problem during the day) during the five-month intervention period. Mentors used CICOs as a means to engage with the student, gauge what type of day a student was having, and practice self-control and self-regulation techniques. Students earned prizes for scores above 27 on the CICO report. All students enrolled in the program also had lunch at least once a week in groups (based on grade level) with their program mentors . On average, each mentor dedicated between 30 and 45 min to each student each day depending on the number of student-initiated requests and/or their involvement in minor infractions .In addition to interacting with assigned students, during the daily CICOs, program mentors observed and documented a student’s behavior during different class sessions  while focusing on specific behaviors . Documented CICO reports included teacher perceptions. Program mentors provided teachers with a holistic context  of each student’s well-being on a weekly basis. Mentors used interactions with the student’s teachers to inform mentor-student activities that supported student academic improvement and behavioral change in collaboration with an education consultant (NS).Each student’s parent/guardian received a permission slip explaining the purpose of the program, the objective of the program, the team’s community affiliation, and ways in which the mentor would work with the mentees during regular school hours. Program mentors also requested and received parental permission to work with the student on weekends during extracurricular activities . Mentors made weekly calls to a student’s parent/guardian to update them on their child’s progress in the program.YF program mentors were four community members (ages 34–50 years) who prior to the pilot intervention worked as gang outreach workers. Briefly, mentor previous experiences involved responding to every community murder or gunshot injury to provide tension/conflict reduction and emotional and self-regulation support to grieved individuals and first responders. The program mentors had histories of overcoming their own lived experiences directly related to neighborhood conflict. All program mentors had certifications in trauma informed and mindfulness-based interventions using self-control and self-regulation techniques.The prevalence of program acceptance by parents/guardians, student enrollment, and intervention compliance by students was determined at the end of the study period (January 2017). Program acceptance by parents/guardians was determined based on the receipt of a signed permission slip consenting to a student’s program participation. The study threshold for successful enrollment was set at 90% for all eligible and contacted students and their parents/guardians. A student was considered intervention compliant if they had at least three training session contacts a month (for at least 15 contacts during the five-month intervention period) with their mentor (outside of first-responder and daily CICO contacts). During these meetings, mentors (a) explained the YF self-control and self-regulation techniques, (b) demonstrated techniques, (c) had students practice the techniques, and (d) provided students with corrective and positive feedback.Check-In Check-Out (CICO) measure: The CICO is a three-item scale that captures elementary school children’s behavior on three target domains: respectfulness, stay in class, and accountability. Respectfulness—focuses on how respectful the target child’s behavior is with adults and peers. Stay in class—documents the target child’s behavior in the classroom towards teachers and peers. Accountability—captures the target child’s perception of their problematic behavioral actions. A target child’s behavior on each of these three domains is rated on a three-point Likert scale of goals met  across six periods (or classes): (1) math, (2) social studies, (3) specials, (4) recess, (5) language arts, and (6) science. For each domain and period/class , three goals were determined on a weekly basis by the school administrator/teacher concerned  and the target child . Total possible scores on the CICO ranged from 0 to 36. For example, if a child met all goals on all three domains across the six periods, they received a total score of 36.Level III/IV infractions: Level III behaviors involved (a) repeated incidents of level II infractions ; (b) behaviors targeted at or targeting others; and (c) behaviors that compromised individual or other students’ safety. Examples of level III behaviors included fighting, threats/intimidation, extortion, sexting, theft or vandalism [involving property less than $500], substance impairment, and propping open secured facilities including the school bus. Level IV behaviors involved (a) repeated incidents of level III infractions, and (b) behaviors that involve safety issues. Examples of level IV behaviors included suspected substance use or possession, physical assault, and theft/vandalism [involving property more than $500].Given that this was a pilot study, we did not perform a sample size calculation for our primary outcomes  a priori. We aimed for 24 students because it was felt that a caseload of 4–5 students per mentor (anticipating a response rate of 80%) was manageable and large enough to inform us about the practicalities of intervention delivery. Additionally, this sample size choice was supported by the sample size calculation for our secondary outcome—mean change in CICO behavioral scores. In order to detect a mean difference of nine points, pre-post YF program intervention, a sample size of 18 students was needed to have a power of 90%  assuming a correlation of 0.5 between repeated measurements and a standard deviation of 6 and 12 for pre-post CICO points. With 18 students, we had approximately 89% power to detect a paired proportion difference (based on a one-sided McNemar test) of 40% in III/IV infractions among students pre-post YF program intervention.Generalized linear mixed models were used to examine changes in student CICO scores  over time and whether these changes varied by program mentor. We modeled each student and behavior change  as a random intercept and slope, respectively to account for individual level variation nested within mentor. Fixed time  and program mentor (including interaction terms) effects were estimated. A McNemar test examined whether the proportion of III/IV infractions decreased pre-post YF program intervention. We used SAS 9.4  for data analysis, and all statistical tests were set at a .05 level of significance.We calculated YF intervention acceptance, enrollment, and compliance prevalence (proportions) with 95% “exact” binomial confidence intervals. We met our study feasibility criteria goals with 100%  YF intervention acceptance by parents/guardians approached for study consent. All targeted children  were successfully enrolled into YF intervention activities. Of the 24 enrolled students, 16  were intervention compliant . Students had an average of 16 (95% CI 14 to 18) student/mentor contacts with a minimum of 10 and a maximum of 22 contacts. Program mentors received on average 20 (95% CI 17 to 23) calls per day that ranged from 5 to 10 contact minutes with students.2 effect: b = − 0.01, 95% CI −0.02, < 0.00); a two-week period was associated with a seven-point increase  in CICO scores. Changes in student CICO scores did not differ by program mentor (Time × Mentor effect: Mentor (1 vs. 4): b = − 0.43, 95% CI: − 0.73, − 0.13; Mentor (2 vs. 4): b = 0.19, 95% CI − 0.02, 0.41; Mentor (3 vs. 4): b = 0.06, 95% CI − 0.15, 0.27). Figure Overall, student total CICO scores increased  and plateaued over time  with no significant differences between program mentors (Mentor (1 vs. 4): b = − 0.16, 95% CI − 0.24, 0.55; Mentor (2 vs. 4): b = 0.10, 95% CI − 0.13, 0.32; Mentor (3 vs. 4): b = − 0.09, 95% CI − 0.32, 0.13). The stay in class CICO sub-scale scores did not change over time  or between program mentors (Time × Mentor effect: Mentor (1 vs. 4): b = − 0.06, 95% CI − 0.18, 0.07; Mentor (2 vs. 4): b = 0.07, 95% CI − 0.01, 0.15; Mentor (3 vs. 4): b = − 0.01, 95% CI: − 0.09, 0.07). In addition, accountability CICO sub-scale scores did not change over time : b = − 0.14, 95% CI − 0.27, − 0.01; Mentor (2 vs. 4): b = 0.05, 95% CI − 0.04, 0.14; Mentor (3 vs. 4): b = 0.01, 95% CI: − 0.07, 0.09).Similar to total CICO scores, the respectfulness CICO sub-scale scores increased and plateaued over time . Changes in CICO score also differed by program mentors during language arts (Time × Mentor effect: Mentor (1 vs. 4): b = − 0.09, 95% CI − 0.14, − 0.03; Mentor (2 vs. 4): b = 0.04, 95% CI < 0.01, 0.09; Mentor (3 vs. 4): b < 0.01, 95% CI − 0.04, 0.05) but not in other classes. During social studies classes, there was a marginal improvement in behavioral scores over time  but no improvements were observed during the special classes  and recess periods .Class specific CICO scores improved over time (with a plateau effect) for the math, language arts, and science classes  to implement a culturally congruent mentorship program (YF) with demonstrable reductions in disruptive behaviors and recidivism of level III/IV infractions among at-risk African American students in elementary school settings. This is evidenced by behavioral score improvements that are class-specific  and behavior-specific  and did not vary by program mentor. During the five-month study period, none of the intervention students were involved in level III/IV infractions.The acceptance of the YF program by parents/guardians is not new to this study and has been demonstrated before in other culturally congruent interventions that target school children , 5, 8. WIn addition to cultural congruence, some of the successes in enrollment, acceptance, and compliance may be due to the YF program’s setting of clear daily CICO expectations, focus on building trust and friendship, mentorship training, and prior experiences mentors had in community trauma response. These factors have been associated with successful mentor-mentee relationships involving children in existing literature , 9.Evidently, culturally competent mentors in collaboration with teachers and parents can intervene to decrease incidents of disruptive behaviors that result in school suspension. Pulling from their experiential vantage points, YF program mentors were able to identify the subtle signs, not obvious to parents/guardians, teachers, and school personnel, of impending disruptive behavior and instituted timely remedial measures to prevent follow-through by students involved. A mentor’s role is neither academic nor parental but engenders trust; cultural understanding; and accountability to a student, teacher, and parent. As such, a mentor has unique insights and rapport with students; this allows a student to confide in and build trust with him or her. As a function of a mentor’s exposure to the home, school, and community contexts experienced by a student, mentors can identify potential causes and conditions that lead up to disruptive behavior. With this knowledge, mentors can intervene, avert behavior escalation, and make referrals to address root causes of disruptive student behavior.Variations in class-specific (versus behavior-specific) behavior improvements suggest a potential behavioral modification effect linked to conditions of a class involving specific teacher influences and to a lesser extent specific behaviors . These teacher effects may be a function of teaching practices including but not limited to a teacher’s emotional support and classroom organization . In factIn the face of ever-growing teaching and student performance demands, it may be infeasible to expect teachers to shoulder the full responsibility of individual student behavior intervention. In this sense, collaboration with a mentor can promote preventive intervention that incorporates a broader holistic contextual understanding of a student’s family, school, and community environment and its influence on student behavior in school-settings.n = 4) did not allow for an examination of mentor characteristics that might have influenced their effectiveness. This and potential cross-level (student/mentor) factor interactions need to be examined in future studies.It is important to acknowledge a number of limitations of our pre/posttest study design. One, we cannot conclusively attribute pre/post behavioral changes to YF intervention since we did not have a concurrent control group. For example, students given behavioral tests may have been inspired to behave better than those who are not tested independent of YF intervention effects. On the other hand, behavioral testing alone cannot explain the 100% reduction in level III/IV infractions among students with prior infractions, a known risk factor of recidivism –9. Two, In summary, it is feasible to integrate culturally congruent mentorship in school-settings to reduce risk of disruptive behaviors among minority, African American students. Culturally congruent risk identification and intervention, as well as teacher training are needed to holistically address disruptive student behavior that result in school suspension and adverse downstream outcomes  for at-r


Total hip arthroplasty is an effective surgical procedure commonly used worldwide for patients suffering the disabling effects of osteoarthritis when medical therapy is unsuccessful. Traditionally pre- and postoperative information for patients undergoing a hip arthroplasty has been provided by paper-based methods. Electronic health  programs to support individualized patient education on preoperative preparation, in-patient care, and home rehabilitation have the potential to increase patient engagement, enhance patient recovery, and reduce potential postoperative complications.The aim of this study is to compare the addition of an eHealth program versus standard care for pre- and postoperative education on patient outcomes for primary total hip arthroplasty.One hundred patients undergoing a primary elective total hip arthroplasty will be recruited from a metropolitan hospital in Western Australia to participate in a 6-month parallel randomized control trial. Participants will be randomized to either the standard care group (n=50) and will be given the education booklet and enrolled to attend a 1-hour education session, or the intervention group (n=50), and will receive the same as the standard care plus access to an eHealth program titled “My Hip Journey.” The eHealth program encourages the patient to log in daily, from 2 weeks prior to surgery to 30 days postsurgery. The information on the platform will be aligned with the patient's individual surgical journey and will include exercises to be completed each day for the duration of the program. The primary outcome measure is the Hip Dysfunction and Osteoarthritis Outcome Score, version LK 2.0. Secondary outcome measures include the EuroQoL EQ-5D-5L, a 5-level 5-dimension quality of life measure, and the Self-Efficacy for Managing Chronic Disease Scale. Data will be collected at pre-admission (presurgery) and at 6 weeks, 3 months, and 6 months postsurgery. A patient satisfaction survey will be completed 6 weeks postsurgery and Web-based analytics will be collected 6 months postsurgery. A cost-effectiveness analysis, using the intention-to-treat principle, will be conducted from the hospital’s perspective.Enrollment in the study commenced in January 2018 with recruitment due for completion towards the end of the year. The first results are expected to be submitted for publication in 2019.The outcomes and cost of using an eHealth program to support a patient’s recovery from a hip arthroplasty will be compared with standard care in this study. If the eHealth program is found to be effective, further implementation across clinical practice could lead to improvement in patient outcomes and other surgical areas could be incorporated.Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12617001433392; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373657&isReview=true (Archived by WebCite at http://www.webcitation.org/6yzoTuggx).RR1-10.2196/9654 Osteoarthritis is a major disabling joint disorder worldwide, with the hip being the joint that is second most affected therefore resulting in pain, decreased function, and reduced quality of life . Total hFor patients undergoing a total joint replacement, pre-admission, pre-operative, and postoperative patient education is essential. The mode of education delivery currently includes one-to-one verbal conversations, patient group sessions, educational booklets, and educational videos . Many stAn alternative forum for delivering patient education is through electronic health . The World Health Organization defines eHealth as “the use of information and communication technologies for health” . The intThe aim of this study is to compare the addition of an eHealth program versus standard care for pre- and postoperative education on patient outcomes for primary THA. The hypothesis is patients who have access to the eHealth program will have better physical functioning post-THA compared to patients receiving standard care.A prospective randomized controlled trial (RCT) will be conducted comparing an eHealth program to standard care for THA. Ethics approval was obtained from the participating study site (HPH505) and the University where the researchers are employed (19065).Recruitment of the trial began in January 2018 and data collection is due to be completed within 12 months.The setting of this study is a private metropolitan hospital in Western Australia with a focus on orthopedic surgeries. In 2017, there were a total of 848 hip surgeries performed in the hospital by 24 orthopedic surgeons. As the hospital is a private hospital, the surgeries are mostly funded through patients’ private insurance.Patients undergoing a primary elective THA will be invited to take part in the RCT. Patients will be screened and recruited during the usual pre-admission phone call conducted by the pre-admission nurse. Inclusion criteria are as follows: (1) the patient is undergoing a primary elective THA, (2) the patient is able to provide informed consent, (3) the patient is aged 18 years or over, and (4) there is a minimum lead-up time of three weeks prior to surgery. Exclusion criteria include the following: (1) the patient is undergoing a THA revision, (2) a bilateral THA, or (3) THA following a fractured neck of femur, (4) had a previous THA, (5) unable to converse in written or spoken English, (6) has no access to a Web-based device, and (7) has a risk assessment and prediction tool (RAPT) score less than six. The RAPT uses pre-operative patient factors of age, gender, pre-operative ambulatory distance, use of gait aid, community support, and presence of a home caregiver to predict their need for extended care after a THA .One hundred patients will be randomized with a one-to-one treatment allocation to the intervention (n=50) or standard care (n=50) group at the time of consent. Allocation concealment in the order of recruitment will be conducted “off-site” after consent has been obtained. Permuted block randomization will be conducted to ensure an equal number of participants are allocated to each group per week. This will be conducted in weekly blocks of 10. Due to the nature of the research, blinding will not be possible for either the participants or the health care team. The researcher conducting the data analysis, however, will be blinded.The comparator for the trial, namely standard care, is an Enhanced Recovery Program based on an orthopedic recovery program established in The United Kingdom . It consThe intervention for the trial is standard care as described above plus the addition of the eHealth education program. The eHealth program was developed specifically for patients undergoing a THA by a multidisciplinary team of clinicians, researchers, and consumer representatives. It provides information about the care requirements during the journey of a hip replacement, advice on well-being, and an exercise program. The information in the eHealth education program is for patients, support persons, relatives, and community health professionals and gives information on what to expect pre-operatively, whilst in hospital, postoperatively, and postdischarge.Participants will access the eHealth program via a weblink after registration using a username and password. The program is designed to give participants continual access to information, at a time that suits them without them having to come to the hospital. It is recommended that participants use the program on a daily basis starting 2 weeks prior to surgery until 30 days postsurgery. However, the participants may have access to the program up to 4 weeks pre-operatively and will continue to have access until 12 months postsurgery. The eHealth program provides a suite of educational resources including fact sheets, videos, exercise videos, and email reminders about the pre- and postoperative care of a hip replacement. The resources are linked to the participants’ journey with a focus on personal wellbeing and its importance in the pre-operative and postoperative periods. Some examples of the resources included in the eHealth program are preparation for surgery, nutrition, pre- and postoperative exercise regimes, and medication management with additional information provided on walking aids and safety if living with pets. Each day, when the participant logs into their “My Program” window, it will display a list of videos and information as well as exercises that have been allocated for them to view or complete that day .Each exercise is allocated a specific number of repetitions and sets that the participant is required to perform, and this information is included with the information about the exercise for the participant. Participants have access to the health care team via the program’s email for 4 weeks postdischarge and can invite their regular health care providers  or support person to be part of the program. The health professional team at the hospital can personalize the participant’s program including the exercises by editing in number of sets and repetitions recommended for each exercise.Intervention fidelity will be assessed using analytics built into the website. After a participant watches a video or reads information, they will be prompted rate it. The program will then mark it as read and record information about how long the participant spent on that piece of information. In addition, after the exercise videos are completed by the participant, they will be prompted to mark them as complete. Automatically generated emails from within the program are sent on a regular basis to inform participants of the information available on the platform and provide instructions pre- and postoperatively. The health care team have access to the platform and can view the website analytics for each participant.Outcome measures will be collected at four time points, namely at pre-admission, 6 weeks, 3 months and 6 months after the surgery. The primary outcome is patient-reported evaluation of symptoms and function limitations related to the affected hip (the hip undergoing surgery). The measure of this outcome is the Hip Dysfunction and Osteoarthritis Outcome Score (HOOS) version LK 2.0. The HOOS is a validated 40-item questionnaire where patients self-assess their hip across 5 subscales: (1) symptoms and stiffness, (2) pain, (3) function of daily living, (4) sports and recreational activities function, and (5) quality of life .The secondary outcomes measures are quality of life, self-efficacy, patient satisfaction, and Web-based analytics. These will be assessed using the tools listed below.The EuroQol EQ-5D-5L assessment will be utilized in this study. It is a 5-level 5-dimension standardized assessment tool, used to measure health-related quality of life. The 5 dimensions include: mobility, self-care, usual activities, pain or discomfort, and anxiety or depression. The tool includes a visual analogue scale where participants are asked to rate their health on a scale from 0 to 100, where 0 means the worse health you can imagine and 100 means the best health you can imagine .The Self-Efficacy for Managing Chronic Disease (SEMCD), is a validated tool consisting of six items on a 10-point scale measuring a participant’s level of confidence in doing certain activities, 1 being “not at all confident” and 10 being “totally confident” .Patient satisfaction with the program will be explored using a patient satisfaction survey developed by the research team. The developed survey comprises of 6 closed questions and 2 open questions for participants in both arms of the trial. Participants in the eHealth program will receive additional survey questions on the usability of the app, consisting of 13 closed questions and 3 opened-ended questions.For participants in the eHealth program additional data on their utilization of the eHealth educational program will be collected through Web-based analytics. This will include information on the modules accessed, length of time spent on each module, and satisfaction ratings prompted within the program.A cost-effectiveness analysis comparing the developed eHealth program to standard care will be conducted from the hospital’s perspective on an intention-to-treat basis. Direct costs will include the service delivery costs associated with each program  as well as the cost of follow-up care . Cost data will be collected from pre-admission through to 6 months postdischarge using hospital medical records. Outcomes will include changes in HOOS and quality of life (measured using the EQ-5D-5L). Incremental cost-effectiveness ratios  will be calculated for HOOS and Quality Adjusted Life Years, and sensitivity analysis will be conducted on the key parameters.Sample size calculations were conducted based on the primary outcome, the HOOS. Existing data were used to determine the minimal clinically important improvement  and SD . Based oData will be reported in accordance with the Consolidated Standards of Reporting Trial (CONSORT). Mean (SD), median (interquartile range) and percentages will be used to describe the characteristics of the study group.t tests, tests of medians, nonparametric tests, and chi-squared tests on pre-to-post intervention changes across the range of outcome measures and patient satisfaction.An analysis of covariance will be used to assess the primary outcome. The covariables will include age, gender, type of surgery, length of stay, RAPT score, and other comorbidities. Treatment effects will be calculated on the pre-to-post intervention outcomes at 6 weeks. Further analysis will be performed on the posttreatment effects at 3 months and 6 months postsurgery. The clinical treatment effect of each intervention group will be further analyzed using independent Enrollment in the study commenced in January 2018 with recruitment due for completion towards the end of the year. We expect to achieve our goal of 100 participants. The first results are expected to be submitted for publication in 2019.The outcomes and cost of using an eHealth program to support a patient’s recovery from a THA will be compared with standard care in this RCT. If the eHealth program is found to be effective, implementation into clinical practice could lead to further improvements in patient outcomes. Additionally, the findings of the study will support further research in the use of the eHealth program for other orthopedic surgical procedures such as knee replacements. If the intervention is found to be cost-effective to the hospital, it could support resource efficiency.Patients scheduled for a revision of THA, a bilateral THA, THA following a fractured neck of femur, or those who have had a previous THA are not included in the trial as their outcomes are likely to be different from those receiving a primary elective THA. A potential limitation of the trial is that in addition to patient self-reported outcome measures, more objective measures of function may have benefitted the trial . These tests are not included in the study due to the difficulty of conducting these tests pre- and postoperatively, particularly with patients living a distance from the hospital.The findings from this study will contribute to the current body of literature on eHealth programs in orthopedic care and inform other health professionals on the outcomes of using an eHealth program.


For several years, many medical physics educational programs in the United States and Canada have been participating in a residency application matching program (MedPhys Match) in assigning graduates of CAMPEP‐accredited graduate programs to residency programs. Patterned after the National Resident Matching Program (The Match) for medical school graduates, the MedPhys Match is designed to maximize the satisfaction of the residency selection process for both the residency candidate and the residency program.Originally developed by Roth,Several problems have arisen in the application of this algorithm to the MedPhys Match. One problem is that the number of residents entering any given program is small. In 2018, a mean of 1.4 applicants per program began residency training.The problem, then, that must be solved is to determine the optimal number of programs to which a prospective residency candidate should apply. On one hand, applying to very few programs is desirable because of the lower travel cost, but undesirable because of the lower probability of being matched. On the other hand, applying to a large number of programs is undesirable because of the increased cost, but desirable because of the higher probability of being matched. The solution to this problem is not easy to find since the solution is likely to be candidate‐specific. The purpose of this paper is to present some factors that need to be taken into account in achieving a solution.Fundamentally, finding an applicant's optimal number of applications is a straightforward constrained maximization problem, in which the applicant compares the benefits and costs of additional applications subject to a budget constraint. The search should stop when the marginal benefit of an additional application equals the marginal cost . Presumably applicants would have a pretty decent sense of what their cost function looks like; the challenge would be in quantifying the benefit function since it is probabilistic. The marginal benefit of applying to the applicant's nth program is a function of the probability of getting a match with that program. As n rises, it is more and more likely that a match would already been achieved with a higher ranked program and thus the probability of a match with the nth program falls. The proof of this is as follows:ip is the probability of matching the ith residency on a student's list given that the student did not match with any his/her i‐1 other possible residencies. So for the second residency, the probability of a match, Pi, is the probability of not matching with the first residency times the probability of matching the second P2 = (1 − p1)p2. For a student considering interviewing with the ith residency on the list the probability of matching is:Imagine a list of possible residencies with the first being the student's favorite and the last being his/her least favorite. i rises, the probability of matching falls. Since the student's list is organized in order of preference, the benefit of the ith position is also falls as i increases. So the expected marginal benefit PiBi declines as the student interviews with additional residencies.Each of those terms is a fraction less than one, so as In recent times, the advent of electronic applications and online job‐matching platforms has lowered the marginal cost of applying almost to zero. This has led to huge increases in the number of applicants that hiring universities must review. For example, in 2005 a faculty vacancy in the Department of Economics at Trinity University attracted 64 applicants for that position. Last year the Department had 536 candidates apply. Because it is impossible for a hiring committee to give careful consideration to that many applicants, institutions are looking for ways to reduce the flood by, in effect, raising the marginal cost of applying. This can be accomplished by, for example, requiring candidates to provide answers to questions unique to that position. That seems to have helped a little. However, if the number of medical physics graduates seeking residencies is small, this may not be a useful solution.Because the problem of optimal applications is an economics problem, there has been a search for solutions and a developing literature on the subject. Balter et al.Another approach to a solution is "signaling." A program would be permitted to notify a small number (somewhere between three and five) of applicants prior to interviews that it is seriously interested in them. This gives the applicant useful information about his/her chances at that particular program and so makes the benefit function a bit less fuzzy. Because the problem in medical physics seems to be more at the interview stage than the initial application stage, some form of signaling by institutions offering residencies might help reduce uncertainty so that at least some applicants could focus on the places where they have good chance and pass on visits to some of their more marginal options.In conclusion, the problem of optimizing the number of residency programs to which a medical physics graduate should apply is a cost‐benefit problem. The incremental cost of applying to an additional program is essentially the cost of travel to that program for an interview; the benefit has yet to be quantified. Strategies for mitigating the cost of a large number of applications include limiting the number of programs to which a candidate may apply and/or allowing programs to notify candidates if they are seriously interested in them.


This paper reviews the efficacy of a community psychosocial arts program focused on building mental health capacity within post-Ebola Liberia. The aim of this paper was to evaluate the outcome effects of two groups using pre- and post-treatment data. We hypothesized that there would be a difference in symptoms pre- and post-treatment, and the longer program would yield more significant results.t tests and a mixed-model analysis of variance (ANOVA) were used to analyse pre- and post-psychological stress symptoms (PSS) for samples from both groups.There was a total of 870 child participants. Of 40 sites, 24 were selected for a 5-month treatment (TG1) while the remaining 16 sites received 3 months of treatment (TG2). Paired t test yielded significant results (p < 0.001) for the decrease of PSS. The mixed-model ANOVA found that there were significant differences in total pre- and post-test PSS and a significant difference in PSS means over time.Separately, treatment group 1 (TG1) and treatment group 2's (TG2) paired Results indicated that there was a statistically significant decrease in reported symptoms in both treatment groups pre- to post-intervention and a significant difference in total symptoms over time. However, the findings do not indicate that the longer programming was statistically different compared to the shorter programming. The study presented had gaps in data, largely due to limits in research during the crisis. However, this paper provides a unique case study for challenges that can be faced for project evaluation in emergency settings. By the end of the epidemic, there were over 28 000 cases reported and 11 310 known case-fatalities  and guidance and collaboration with the Liberian Ministry of Health and Social Welfare (MOHSW) and Ministry of Gender (MOGD), the American nonprofit, Playing to Live (PTL), and Liberian-based nonprofit, Renewed Energy Serving Humanity (RESH), a large-scale psychosocial expressive arts program was implemented to address the growing psychosocial and mental health needs of children affected by the epidemic. PTL is an American 501(c)3 organization whose mission is to build effective and sustainable psychosocial community-based expressive art programs targeting the psychosocial needs of children and communities facing mental health issues and trauma. RESH is a Liberian-based nonprofit that focuses on providing psychosocial support to individuals and communities experiencing traumatic events. This paper discusses the quantitative findings of a large-scale project implemented by PTL and RESH, which focused on building mental health and psychosocial support (MHPSS) capacity within the most affected communities. Additionally, there is a discussion on barriers faced in establishing the monitoring and evaluation system, lessons learned, and steps for the future. Decosimo et al.  describePTL's clinical team consisted of an art therapist, child life specialist, play therapist, and yoga therapist. The clinical team was tasked to identify best practices in their field and develop a training program for para professionals. The tools and techniques identified for the programming were carefully reviewed, through literature review and consultation with expressive therapy colleagues, to determine what techniques were ethical to teach non-clinicians  and youth (12–18) could easily understand and find enjoyment. An example activity is, ‘My positive future.’ This activity instructed children to use art, play, and storytelling to explore what they want for their future. The goal of this activity was to help children and youth to identify positivity within their current situation to help them build hope and goals towards their future  of the eligible participants, received 5 months of the program. Treatment Group 2 (TG2), which was 40% (N  =  337) of participants, received 3 months of programming and began 2 months after TG1 started. This design was implemented to highlight program differences through the variable of time (The program was implemented in two groups using a delayed treatment model. Treatment Group 1 (TG1), which was 60%  or 3-month (TG2) implementation period. Child participants were selected based on their residency in the PTL facilitator's community and their guardian's consent to have them involved. Children's symptoms were not screened for entry into the program, as the MOHSW wanted the program to be provided based on the child's exposure to EVD and not on psychological stress symptoms (PSS) that may or may not have initially been expressed.The study compared pre- and post-tests on the total of seven PSS, which were chosen by the MOHSW/MOGD based on items that were culturally and developmentally applicable for children in Liberia and would provide an indication of how the child was adjusting. The PSS were chosen based on existing literature and are further explained in the data collection section. The research hypothesis was that the children in TG1 would show a higher effect of decreased PSS than TG2 due to participating in programming for two extra months.There were 870 children (ages 3–18) enrolled in the PTL/RESH project. The project was conducted in 40 sites that were randomly selected from a comprehensive government list of nearly 100 hot-zone communities. In each of the selected sites, there were children who were Ebola-survivors, from Ebola-infected homes, or were living in an Ebola-affected community. The activities were inclusive to all children no matter their Ebola status, with the goal of supporting reintegration and decreasing stigma. Of the 40 sites, 60% (24) were randomly selected for a 5-month treatment while the remaining 16 sites received 3 months of treatment. The sites were randomly selected by the monitoring and evaluation specialist who blindly selected the sites out of a hat.et al., et al., et al., RESH collected the data, which included child interviews, with parental consent, on seven PSS, parental/guardian interviews on the child's PSS, and observations of household environmental conditions. Data collection was completed with a scorecard that consisted of a yes/no checklist, measuring key symptoms identified by the MOHSW/MOGD as the common symptoms among persons impacted by EVD . The final article was submitted to the National Ebola Survivors Network of Liberia, where it received formal approval for dissemination from the network's president.t test was used to analyse the effects of the two programs individually, and a mixed-model analysis of variance (ANOVA) between the pre-and post-symptom results for TG1 and TG2 was used to determine if there was statistical significance between the effects of the programming for 5 months compared to 3 months.SPSS software was used for the analyses. Descriptive statistics from TG1 & TG2 were analysed to evaluate whether the populations were comparable . The outn  =  233) had a mean age of 9.90 years old (s.d.  =  3.57), with 63.1% female and 36.9% male participants.TG2 (n  =  123) had a mean age of 10.20 years old (s.d. 3.87), with 73% female participants. All communities that received programming were in close proximity to Monrovia, Liberia and reflected similarities in geography and descriptive statistics. t tests were completed for each treatment group separately to analyse mean differences in PSS scores (range 0–7) pre- to post-intervention. s.d. = 0.93), with a post-treatment PSS mean of 0.77 (s.d.  =  0.73).Paired s.d.  =  1.45), and the post-treatment mean was 1.79 (s.d. = 1.392). t test, which was performed to test the significance between the two assessments. s.d.  =  0.96); t(232) = 8.74, p < 0.001)] and TG2  after the implementation of PTL.F = 69.46, p < 0.001   =  84.33, p < 0.001) (p  =  0.28).The ANOVA test showed that there was a significant difference between the two treatment groups on total symptoms pre- to post-program,  < 0.001 . This in< 0.001) . Howeveret al., There was a statistically significant decrease in reported symptoms in both treatment groups pre- to post-intervention and a significant difference in total symptoms over time. However, while those in TG1 and TG2 had different scores and there were changes in PSS scores across time points, the findings do not indicate that the longer programming was statistically different compared to the shorter programming. This finding does not provide a comprehensive indication that longer programming was more beneficial, but it does support the growing evidence that expressive art activities have short-term effects on the improvement of physical and mental health and social wellbeing (Morris et al., However, it should be noted that TG2 had a higher mean at pre-test of total symptoms than did TG1. TG2's pre-data were collected 2 months after TG1's pre-data, which indicates that PSS increased over 2 months after the end of the epidemic. It is unclear from the interview of key informants during the implementation time, whether a community-wide event could have impacted TG2's stress symptoms over the 2-month period, though since TG1's symptoms decreased over the 5-month time, it seems unlikely that an additional community-wide event caused increased stress symptoms. The demographics of both treatment groups were similar, and since selection of communities for the two treatment groups was randomized, this difference in the two pre-test symptoms suggests that symptoms rose due to not receiving mental health support immediately after the trauma, which could infer PTL programming acted as a barrier to further development of stress symptoms for TG1. It also highlights the need for sustainable programming for children who have experienced a traumatic event. Children's reactions to trauma are not immediate; at times they can appear weeks or months after the trauma event (Wethington v. using monetary and personnel resources for researching the program. From this guidance, PTL & RESH built a monitoring and evaluation process to capture the outcomes of the programming as best as possible given the limited resources available.During the process of piloting and implementing this program, PTL and RESH followed the Liberian Ministry's ethical and cultural guidance. Due to limited resources and the crisis at hand, PTL was instructed to focus on program implementation Despite those limitations, a strength in the data collection was the triangulation of data. The RESH and PTL employees were trained in culturally appropriate techniques of assessing and inquiring about PSS. By asking the child, the caregiver, and assessing through observation validity was enhanced in the decision to confirm or deny symptoms. A symptom was not recorded as a yes unless all three sources confirmed this to be true.Ethical considerations were taken into consideration when deciding on the timeline to collect data for the delayed treatment group, and it was decided by the partnership and Liberian guidance that it would be too difficult to collect data on the delayed group 2 months prior to actual implementation. This was to avoid the children becoming prematurely excited for programming.There were some key limitations to the data collection and analysis. First, baseline data collection included case files that had missing or inaccurate information, mostly explained by the challenge of collecting data within weeks of the Ebola crisis ending. Social and cultural effects from the crisis provided great challenges to the data collection team, and incomplete data were removed from this study. Some of these challenges included children moving away and fears of being infected if they engaged in community activities. Secondly, 510 participants were not included in this analysis because they were not assessed for post data collection. Due to limitations in data collection resources, the evaluation team randomly selected post-test recipients to represent the program and not all participants had post-test data collected. Despite randomization, there are still gaps in the research framework that could have missed cluster effects occurring in specific communities.Additionally, due to the absence of a midpoint assessment of stress symptoms and data for TG2 not being collected at the same time as TG1, this design is not a true delayed treatment design. The absence of having a control group creates gaps in knowledge and true reliability of the findings. A formal delayed treatment framework would include a pre, mid, and post evaluation structure, in which two nonequivalent groups received the treatment at different times and in a delayed sequence. This program design did not have the budget for a midpoint evaluation. This study analysed the two treatment groups as separate treatments to account for these limitations and to accommodate the recommendations and requests of the Liberian ministries. However, a true delayed treatment design would provide a stronger evaluation of the progression of two treatment groups.All of these limitations demonstrate the obstacles often faced by in-field evaluation teams in mental and psychosocial programming in developing countries, regularly compounded by high-risk, post-disaster settings. This project team worked closely with government and implementation partners to find solutions to these unanticipated challenges as they arose on the ground. Data collectors were operating in sites heavily affected by Ebola, and still under threat of another outbreak. Their dedication and bravery to establishing a baseline pretest so near the epicenter of the crisis is commended.et al., To truly understand the value of a program, it is essential to analyse if a program or project has a lasting effect and is sustained over time (Ager et al., There is a paucity of research on long-term art therapy programming in emergency settings Orr, , though A recommendation for future work is to establish an analytic and behavioral framework for similar programming prior to a crisis response. This implementation framework can be used as a theoretically-based foundation for program development and implementation. The framework should include essential steps needed prior to implementation that inform cultural significance and needs of the community, involvement of stakeholders, and how the elements of the program will influence outcomes. Additionally, program developers and partnered organizations should ensure that all appropriate ethics and community leadership are involved, consulted, and in agreement with the program implementation and evaluation plan. Many factors were faced by the local implementation team due to the public health emergency context and the multi-agency request for a timely implementation, therefore accessing and submitting to the local IRB was not achieved. In place of a formal IRB, the local team formed a group of representatives from the Liberian ministries to guide and oversee the development, monitoring and evaluation, and implementation processes. The authors of this paper later submitted the secondary data set for expedited IRB approval.Secondly, a framework for monitoring and evaluation and outcome measurements is also recommended. This study followed the recommendations from the Liberian ministries and focused on stress symptoms, where the data validity was strengthened by utilizing a triangulation technique that involved collecting data on seven potential stress symptoms from the child, caregiver, and facilitator/social worker. Additional measures on behavior, attitudes, knowledge gain, and perceptions would further inform the understanding of the program's outcome. The development of impact models specific to the different aspects of programming would provide a more in-depth understanding of how they influence change. This could include how therapeutic expressive arts impact childhood trauma symptoms, the impact of community support for children, the impact of community-wide knowledge gain on trauma and mental health, and the impact of psychosocial skill development among local leaders.This study highlights the impact a community-based psychosocial expressive arts program had on a child's stress response to the EVD outbreak. Support programming significantly reduced PSS symptoms post-program. This clinical implication suggests the urgent need for psychosocial support programming after a trauma. It is important to note that resources for data collection and program development can be severely limited during a crisis, and it is essential to follow the leadership of the local government and entities. Using low-cost techniques like triangulation during data collection can be an effective tool for building validity and the development of programming and evaluation frameworks prior to an emergency will provide a more thorough and efficient approach. Evaluation frameworks that include analytic and behavioral elements and impact models will provide a stronger understanding of how each component of development, programming, and implementation influence outcome effects.While further research is needed to show a more in-depth picture of the impact of expressive art therapy techniques in emergency settings like the Ebola epidemic, a growing number of reports are showing the effects of expressive art therapy on reducing trauma stress symptoms Orr, . The theet al. (For future programming, the development of impact models specific to the different aspects of PTL's program will provide a more in-depth understanding of how they influence change. The different aspects include how therapeutic expressive arts impact childhood trauma symptoms, the impact of community support for children, the impact of community-wide knowledge gain on trauma and mental health, and the impact of psychosocial skill development among local leaders. Qualitative data and process evaluations are also a key component of a thorough evaluation. Decosimo et al.  explainsThis evaluation builds a foundation for future investigation of therapeutic expressive arts programming and provides a key case study reflecting on potential evaluation obstacles to overcome when providing psychosocial programming in post-epidemic settings. Despite limitations in methodology due to issues with data collection and completeness, this study provides worthwhile information regarding children's PSS in the midst of a major infectious disease epidemic, which is unprecedented in the literature. Further, the study provides an impactful approach on how to successfully navigate implementation of a program to assist with long-term effects of an epidemic that caused high-levels of mortality in an already low-resource environment.


Electronic mental  health interventions can address mental health needs of different populations. Cultural adaptation of these interventions is crucial to establish a better fit with the cultural group and to achieve better treatment outcomes.This study aimed to describe the cultural adaptation of the World Health Organization’s e-mental health program Step-by-Step for overseas Filipino workers. We used a framework which posits that cultural adaptation should enhance (1) relevance, wherein the cultural group can relate with the content; (2) acceptability, where the cultural group will not find any element offensive; (3) comprehensibility, where the program is understandable; and (4) completeness, wherein the adapted version covers the same concepts and constructs as the original program. We aimed to have English and Filipino and male and female versions.Overall, 3 experienced Filipino psychologists provided their perspectives on the program and how it might be adapted for overseas Filipino workers. We then adapted the program and obtained feedback from 28 overseas Filipino workers from diverse industries through focus group discussions. We conducted 7 and 9 focus group discussions with male and female participants, respectively. Per discussion, cognitive interviewing was used to probe for relevance, acceptability, comprehensibility, and completeness of illustrations and text. Participant feedback guided iterative program adaptations, which were again shown to participants for validation and improvement.Several issues were raised by participants about the generic version of Step-by-Step. There were elements deemed irrelevant, like unfitting characters, lack of Filipino values, and unsuitable problems and activities. There were unacceptable components that were stigmatizing, political, inappropriate to context or subgroups, and too feminine for male users. Some elements were incomprehensible, unclear, or complicated. To address these issues, we made key adaptations. To enhance relevance, we adapted the narrative to match the experiences of overseas Filipino workers, incorporated Filipino values, and illustrated familiar problems and activities. To increase acceptability, our main characters were changed to wise elders rather than health professionals , political or unacceptable content was removed, and the program was made suitable for overseas Filipino workers from different sectors. To increase comprehension, we used English and Filipino languages, simplified the text to ease interpretation of abstract terms, and ensured that text and illustrations matched. We also used Taglish  when participants deemed pure Filipino translations sounded odd or incomprehensible. Finally, we retained the core elements and concepts included in the original Step-by-Step program to maintain completeness.This study showed the utility of a 4-point framework that focuses on acceptance, relevance, comprehensibility, and completeness in cultural adaptation. Moreover, we achieved a culturally appropriate adapted version of the Step-by-Step program for overseas Filipino workers. We discuss lessons learned in the process to guide future cultural adaptation projects of e-mental health interventions. The use of technology to deliver mental health interventions proliferated in recent years, with electronic mental  health interventions providing accessibility to needed mental health interventions ,2 for moE-mental health interventions that undergo cultural adaptation are more effective. Cultural adaptation is “the systematic modification of an evidence-based treatment (EBT) or intervention protocol to consider language, culture, and context in such a way that is compatible with the client’s cultural patterns, meanings, and values” . Culturag=.67. Furthermore, culturally adapted interventions are more effective than their original unadapted versions, with a medium effect size of g=.52. Another meta-analysis [Culturally adapted interventions are effective. A meta-analysis  of 78 stanalysis  of e-menanalysis  include It should be noted, however, that cultural adaptation does not equate with completely rewriting the program. In fact, a systematic review  on cultuCultural adaptation involves an integration of top-down and bottom-up approaches . The orieHelper may provide technical support and assistance in accomplishing program activities through phone calls or text messaging for up to 20 min a week.The World Health Organization is developing several evidence-based interventions—including transdiagnostic programs—designed to be scaled up to reach populations globally that lack access to needed mental health services . We adapIn places with more established services, Step-by-Step may be suitable for use within a stepped-care structure, where users who show mild-to-moderate levels of symptoms could be referred to higher-intensity services should they require it on completion of the program. The program contains text and stories with corresponding illustrations and 2 main characters. The first character is an expert who helps the second character by sharing behavioral techniques to overcome problems and by explaining the concepts behind the problems and the techniques offered in the program. The second character narrates their experience of using the Step-by-Step techniques to overcome depression, reporting their previous encounters with typical problems and psychological symptoms of the target population and explaining how they employed the program to reduce these problems.The original version already has 3 of the 4 desired features of effective e-mental health interventions, as it is based on the empirically tested theory of behavioral activation, it is structured, and it is interactive or experiential . The lasIn this study, Step-by-Step was adapted for overseas Filipino workers (OFWs). There are 2.24 million OFWs around the world . The majPrevious studies focused on the risks and challenges that OFWs and other labor migrants experience. OFWs’ primary reason for working abroad is the desire to escape poverty or to achieve socioeconomic mobility, mainly for their family, rather than individual aspirations ,21. HoweThis study aimed to culturally adapt the WHO Step-by-Step program for overseas Filipino labor migrants. We made English and Filipino and male and female versions. It was intended for use by OFWs engaged in different occupations.There were 31 participants, all of whom were selected through purposive sampling. We used a 2-stage approach refer to , first iThe intervention material was a generic version of the Step-by-Step program. The program starts with registration and introduction (session 0), followed by sessions 1 to 5. Each session is meant to be completed on the Web by the user once per week, with each session lasting between 30 and 40 min.In advance of the interviews with expert Filipino psychologists, we provided a summary of the program’s content, the complete intervention content, and examples of possible illustrations with instructions to review all materials before the interview. For the FGDs with OFWs, we made Microsoft PowerPoint presentations that showed the entire initial adapted texts and illustrations (after Filipino psychologist interviews). Each slide consisted of about 3 to 5 sentences, most with simple illustrations. We started only with the intervention text for sessions 0 to 2, as the illustrations were not yet ready. Eventually, we showed both texts and illustrations to the participants side by side for the remaining 3 sessions.We also utilized interview and FGD guides. The interview guide for the psychologist interviews consisted of questions about their opinions on whether or not the Step-by-Step program can address OFWs’ mental health needs, the type of OFWs that the program will be most or least suitable for , appropriateness of the content of the program, considerations we had to make with regard to Filipino culture and OFW culture, and challenges they foresaw in using the program. We added questions on which specific groups we needed to consider for content tailoring , suggestions on the characters in the story, and opinions with regard to the characteristics of the eHelpers.cognitive interviews  with a FGDs were conducted in English to adapt an English-language version and in Filipino to adapt a Filipino-language version. We matched the sex of the facilitator with the sex of the participants .We first gave participants consent forms to read and sign, and then, we introduced the interview or group discussion and the Step-by-Step program. We then proceeded with the interviews or FGDs. The first FGDs concerned developing the illustrations of the main characters. After this, once illustrations had been developed, further groups were conducted based on the remainder of the stories and activities. The entire adaptation process was thoroughly documented. We used note-taking, wherein we wrote participants’ feedback for each slide. We also used audio recording to review the sessions if any of our notes were unclear. After an interview or FGD, we (MRG and BJH) discussed what transpired and reviewed our notes. We decided on pertinent changes that needed to be made on each slide. Throughout the process, we used the approach of Manson  and van All changes in text and illustrations were documented using standard forms developed by the World Health Organization. We deemed making changes based on our notes sufficient because participant feedback on the slides was simple and straightforward , and participants provided us with concrete suggestions on what changes to make . Furthermore, each slide contained relatively short text and simple illustrations to begin with. The questions we asked them were also direct .Suggested changes to the illustrations were sent to a professional illustrator. He was the same illustrator who made the illustrations for the original Step-by-Step program and was familiar with the program and cultural adaptation process. Using the original illustrations as the starting point, we gave instructions on what changes to make  and at times accompanied instructions with sample photos taken from the internet to guide the development of new illustrations.Changes in illustrations and in stories were then shown to participants during subsequent FGDs. We reminded participants of their comments on the past illustrations and text and showed them the revisions made. We asked for their feedback on the changes and then their approval . If the changes were still unsatisfactory, we asked for more input from them, made necessary revisions, and then showed them the newly revised slides in the next FGD. For example, it took 3 FGDs to finalize the appearance and get participants’ approval for one of the characters refer to .Malikhaing Pagsulat or Filipino creative writing. We gave her a background of the adaptation process and informed her of the desired tone of the story and personality of the characters as per the interview and focus group feedback. We then edited the translated text to capture the OFW experiences better . The edited translations were then shown to female FGD participants during subsequent cognitive interviewing. Their comments and suggestions to simplify the texts, especially words that were too difficult to understand or lines that were too long, were then used to make additional translation edits. We then showed the revised slides during the next FGD for feedback and approval.After we conducted all the FGDs on the English and female versions and after revising the texts, we sent the texts to a professional translator. The translator was a Filipino fluent in both Filipino and English, with a BA in This study was conducted by a research group that aimed to improve the health of migrants globally and within the Macao SAR. As such, the implementing researchers (MRG and BJH) were familiar with the OFW context, through prior knowledge and interactions with the study population, and worked with organizations providing support to this community  for years, including those based in the Macao SAR. MRG is a native Filipino who speaks the Filipino language fluently and has a similar cultural background as the participants. During data collection, MRG was an OFW herself but was only involved in the project as an investigator but not a participant. BJH is from the United States of America and emigrated to China over 5 years ago. However, neither researcher is employed in the same sector as the participants. We also had higher educational attainment, occupational prestige, and socioeconomic status. Although we are migrants ourselves and have a rich understanding of the OFW context, our experiences are different from the participants’ and other typical OFWs. With this acknowledgment, we attended to our own beliefs by assuring participants their feedback on the materials were crucial in improving the program and that they were the experts when it came to OFW experiences. We also probed participants’ answers to get more information and asked them to confirm our understanding of their input. Furthermore, we presented to them the interim changes we made on the stories and illustrations for validation. They verified many of the changes, but at times, they provided clarifications and more details for additional changes. We also presented the findings to a group of stakeholders, which included Philippine Government staff , NGO workers, a Macao government official, Macao mental health professionals, and Filipino priests and nuns, for their feedback. They did not suggest changes in the adapted program and instead raised concerns regarding logistics and eHelpers.drinking alcohol because it is culturally normative for Filipinos to drink, especially when they are with their friends. Finally, some male participants mentioned that some text and illustrations looked too feminine . Due to strong traditional gender roles, it was important for them to maintain a masculine stance or at least not exude femininity, including emotional weakness.On the basis of key informant interview data and FGD data, there were 3 main issues with regard to the acceptability of the generic version of Step-by-Step. This includes stigma regarding mental health problems and mental health help-seeking in the Philippines. On the basis of interview data with experts, the use of a doctor pathologizes the users’ experiences and connotes there is something wrong with them. This would then serve as a barrier for the OFW population to use the program. This opinion is also backed by previous research . AnotherTo address these issues raised by participants, adaptations were then made to make Step-by-Step acceptable. These include reducing content that may increase the stigma associated with mental health and help-seeking, changing content that appeared political or potentially unacceptable to an OFW subgroup and depicted as negative when it is socially acceptable in the OFW’s context, and making considerations for the male version. These are explained below.To address the issue of stigma, we made 3 modifications. First, instead of stating the original program goal of “helping the user cope with difficult emotions and problems” explicitly, we changed it to “helping the user become a successful OFW, for their families’ sake.” The latter deemphasizes the focus on mental health and increases emphasis on positive goals and outcomes. The latter also still addresses the original goal but focuses on a common and integral OFW experience and value of working abroad to contribute to family’s expenses, at times as the family’s sole provider. Second, we developed the character that explains Step-by-Step concepts to the user  into an older OFW who has been successful in his or her work rather than a medical or mental health professional refer to . Changinbalikbayan box  to the Philippines and preparing to go to work  choosing appropriate names and appearance of main characters, (2) highlighting Filipino values, (3) using relatable problems, and (4) using relatable activities.Ate or Kuya before their names, which mean respected older sister or older brother in Filipino, often associated with being sensible and experienced. For the characters’ appearances , whereas the younger characters had more modern and American-sounding names (John and Leona), both of which are common naming practices that are related to the colonial and changing cultural context of the Philippines. We also ensured that the names had positive meanings  and were approved or chosen by the participants. For the older characters, we added the terms refer to , particikabayan or countryman, a common term used among OFWs, which denotes similarity and familiarity with fellow Filipino migrants. The older characters also acted as mentors or coaches to the younger characters and user. The younger characters called the user sis or bro to denote kinship. They showed eagerness to share their stories and emotions with the users and to learn and become better. Participants advised for all characters to offer encouragement or reassurance to the user, with lines such as “Keep up the good work!” and “You can do it!” They recommended matching these with illustrations where the characters gave warm smiles to welcome and bid the users goodbye and thumbs-up sign to show approval.We highlighted Filipino values in 3 ways. First, experts and participants advised adapting the personality of the program and characters to exude desirable Filipino values of family orientation, showing warmth and care for others, sociability, and positive thinking. Participants added changing the tone of the text to become more conversational and story-like to sound more engaging and realistic such that the characters seem to be talking to the users. Participants also recommended that the characters addressed the user as Second, the texts were changed to highlight that OFWs consider their family as motivation for going abroad and working hard, even making sacrifices for them. Participants suggested matching the illustrations by showing OFWs thinking of their families often and missing them. Furthermore, participants wanted to emphasize being with friends and family as crucial to one’s mental health and as culturally appropriate and expected. Participants proposed matching the text with illustrations of characters spending time and having fun with friends who were also OFWs and with family through Web-based communication.bayanihan and utang-na-loob in the stories. Bayanihan means working together to help someone, which we added in an activity where an OFW helped a main character in a task. Utang-na-loob means debt of gratitude, which we mentioned as a motivator for a main character to reach out to a friend who helped them in the past.Third and last, as suggested by all 3 experts during individual interviews, we mentioned additional Filipino values such as We adapted the content in terms of the problems the characters experienced to make them more typical, based on interview and FGD data. Examples of problems included leaving their family behind, having personal conflicts, and having too much work or having no break or day off.merienda or afternoon snacks with friends, visiting nearby historic sites, celebrating events with family using Web-based communication, and singing videoke (video karaoke) with friends  complicated. Finally, participants found that some texts and illustrations were not clearly linked. For example, one passage in the text was about isolating oneself from other people when one feels sad. Although participants understood the text, they mistook the illustration where the character is facing away from 2 other characters as friends gossiping about the character . When a term or an idea was too abstract, we changed the words or added extra words or lines to clarify what they meant. For example, instead of the abstract concept of social support, we used helping hands as suggested during an FGD because although participants understood what social support meant, they could not verbalize their understanding of the term.On the basis of FGD data, we also simplified the text in 3 ways to boost comprehension: shortening long sentences by removing words, dividing long sentences into 2 sentences, and using simplest words and phrases  because the word homesick is a common OFW term and is deeply tied to working abroad far from one’s family.All key concepts in the original version are intact in the adapted Step-by-Step for OFW. We also made sure that the English and Filipino versions were as similar as possible, so that if an OFW chooses to use the English version, they would have an equivalent program to the Filipino version and vice versa. For the Filipino version, instead of translating all English words to Filipino, we retained some English words because OFWs use these words to describe their experiences. The combination of Filipino and English  is an unofficial language  that is To our knowledge, this is the first study that culturally adapted an e-mental health intervention for the OFW population and Filipinos generally. We illustrated how the 4-point framework to improve acceptance, relevance, comprehensibility, and completeness is useful in navigating the process of culturally adapting the Step-by-Step program. It was a practical guide to both us, the researchers, and the participants as it enabled us to capture and flesh out crucial elements to make the finished product attuned and sensitive to the context and experiences of OFWs. In turn, we were able to make the program culturally specific for this group, which is essential among the 4 features of effective e-mental health interventions .For future cultural adaptations, we recommend that all illustrations and content be adapted at the same time. In our experience, participants were more engaged in the presence of visual stimuli . Furthermore, it was easier for them to understand the texts and key concepts while being able to see the illustrations.We recommend that the same set of participants be part of the FGDs from start to finish to avoid spending time explaining the program, the mechanics of the cognitive interviews and discussion, and details from previous sessions. We were able to do this with the majority of our FGDs, but scheduling limitations hindered participants from attending all sessions. Therefore, to accommodate the realities of the population, we allowed the FGDs to be open to newcomers. Some participants were more able to provide input than others. As in any FGD, it is important to select participants who are more open, less shy, and comfortable to freely share their thoughts. In the context of this adaptation study, norms of social hierarchy and harmony within the cultural group may have influenced how much people shared within the groups.Another limitation is the lack of standard and systematic evaluation on whether the inputs from members of the FGD represent the entire community. Further investigation is also recommended to determine which elements were most salient to the participants to more clearly know when adaptations are good enough for the cultural group.The methods and detailed results of formative adaptation work as described in this study are often not shared by researchers or program implementers in mainstream literature ,11. As iFollowing the Medical Research Council Guidelines for Complex Interventions and the WHO scalable psychological interventions program ,32, this


This article describes survey result on humanic clues and customer loyalty in selected hospitals in Lagos State, Nigeria. This paper obtains information from the customer experience management strategy in considering the techniques in which customer loyalty can be built. 365 copies of questionnaires were retrieved from the customers of the selected four private hospitals in Lagos State. The data gathered from the survey customers were subjected to inferential and descriptive statistics in order to ascertain the sum, mean, standard deviation and the relative importance index (RII). The retrieved copies of questionnaires were analysed utilising SPSS (22). Using the Categorical Regression CATREG analysis, the data article establish that humanic clues have positive influence on customer loyalty. The data collected is openly presented to enhance further analysis. Specification TableValue of the data•These article made available data on the influence of humanic clues on customer loyalty among healthcare customers of Nigeria. However, to enhance the generalization of result, other scholars may choose to replicate this study in a different context •Future studies can focus on the other variables of the customer experience management strategies •Looking at scarce data on how customer loyalty can be built. Further studies can focus on the functional and mechanic clues alongside the humanic clues 1w=The weight age of the respondentsA=1, 2, 3, 4, 5xi=The frequency of every respondentfN=Total number of respondents [8]The data encompassed the fresh statistical data on the influence of humanic clues on customer loyalty in the healthcare segment of Nigeria. The data show result of the descriptive statistics of the influence of humanic clues on customer׳s loyalty based on the views of the healthcare customers. Using the relative importance index or RII formula. The Relative Importance Index (RII) for each of the variables used to investigate the influence of humanic clues on customer loyalty was computed.According to several scholars, the standard deviations and mean are not dependable measurements for weighing overall ranking of the elements The result in 1.1From the result presented in β=.285) contribute mostly to explaining the influence of humanic clues on customer loyalty of healthcare services. This is followed by the body language of the healthcare service provider (beta=.215), the friendly actions of the service providers (beta=.202) and the caring expression of the service providers scale (beta=.172). This means that the healthcare customers of the organisations believe that the respect and courtesy of the healthcare service provider makes the strongest unique contribution to explaining the loyalty of customers. This findings corroborate Furthermore, the result of the model in 22.1The data for this article are quantitative in nature. The quantitative data are mainly the socio-economic characteristics of customers and healthcare experts sampled, as well as their perception of the extent to which humanic clues influence customer loyalty of the customers in the four hospitals sampled.2.2The data for this objective were derived from the selected private healthcare customers of the hospitals in Lagos, Nigeria. The data from the healthcare customers on the extent to which humanic clues affect the loyalty of customers were sourced via the administration of structured questionnaire.The copies of questionnaires were distributed to the healthcare customers of the four private hospitals during the working hours of the week days. Accidental or convenience sampling technique was adopted in dispensing the questionnaire to the healthcare customers during the waiting time of the week days. Although, four hundred (400) questionnaires comprising 100 questionnaires administered to the customers of each of the four private hospitals were distributed. However, 365 copies of questionnaires representing 91.25% of the questionnaire disseminated were salvaged.2.3The extent to which humanic clues affect the loyalty of customers was investigated by asking the respondents to indicate the degree of agreement with the statement relating to the objective based on a 5-point Likert scale, where 5=strongly agree, 4=agree, 3=undecided, 2=disagree and 1=strongly disagree. The data were subjected to descriptive statistics, and this was used to compute the sum, mean, standard deviation and the relative importance index of the variables used in assessing humanic clues. Tables were used to present the results, the frequencies and percentages to provide adequate understanding of the respondents’ characteristics and their view on the extent to which humanic clues affect the loyalty of customers. CATREG in SPSS was also used to investigate the influence of humanic clues on the loyalty of customers in the four private hospitals sampled.


Diario della Salute [My Health Diary] is a school-based program designed to enhance the subjective well-being and health of 12- to 13-year-old students. We hypothesized that providing students with the social and emotional skills to fulfill their potential and deal with common developmental tasks of adolescence  would result in improved well-being and health. The program comprises five standardized interactive lessons concerning common psychosocial and health issues in adolescence, and two narrative booklets addressed to both students and their parents. We evaluated the effectiveness of the program in terms of the students’ subjective well-being, aggressive behavior, and health behavior. Using a quasi-experimental study design, schools in the intervention group implemented the full program and those in the comparison group received their regular curriculum. We administered measures of the study’s objectives both before and after program implementation. Statistical analyses accounted for within-school clustering, potential socioeconomic and demographic confounding, and pre-implementation levels of these measures. We sampled 62 schools and allocated 2630 students to either an intervention or comparison group. Sociodemographic characteristics and baseline outcomes were balanced across study groups. Unexpectedly, respondents in the intervention group had 0.38 greater mean adjusted score of the WHO/Europe Health Behaviour in School-Aged Children Symptom Checklist instrument than respondents in the comparison group, indicating a reduction in subjective well-being. We did not observe any program effects on aggressive and health behaviors. The apparent reduction in subjective well-being reflected by an increased perception of psychosomatic complaints is suggestive of either increased emotional competence or, potentially, iatrogenic program effects. While greater emotional competence is positively associated with well-being over the course of life, the program in its present form should not be disseminated due to the possibility of adverse unintended effects. In the last decade, there has been increasing interest in the potential of interventions capable of promoting psychological well-being among adolescents. Although most adolescents deal successfully with the developmental tasks that are typical for their age , some may not achieve optimal functioning and positive psychosocial adjustment. Failure to cope with the developmental tasks occurring in adolescence may impair future well-being, social functioning, and health status  while reducing aggressive behavior.We conducted a cluster quasi-experimental study with two arms between January and May 2013 in two Northern Italian regions  and in three Southern Italian regions . The Ethics Committee of the Santa Croce e Carle Hospital of Cuneo, Italy, approved the study and we publicly registered it prior to its inception .We asked each participating region to enroll at least four middle schools and 20 classes of 12- to 13-year-old students . Schools participated in the study on a voluntary basis provided that they had a minimum of two classes of 12- to 13-year-old students, were state schools, and were not involved in other prevention programs. Eligible schools were given the choice of being in the intervention or in the comparison group, and underwent pairwise matching by number of students, an indicator of school-wide socioeconomic status, and geographical area to form two similar sets of schools. We assessed whether the distribution of the students’ sociodemographic characteristics and outcomes at baseline were balanced across groups. As the number of schools that chose the comparison group was greater than those that chose the intervention group, we discarded non-matching comparison schools. This procedure allowed us to retain all intervention schools while ensuring that the two sets of schools were as balanced as possible. Schools allocated to the intervention group implemented the full program, while those in the comparison group administered their regular curriculum and did not deliver any structured prevention activities that focused on the same outcomes as those that our program targeted.Diario della Salute [My Health Diary]Diario della Salute was developed to address some of the limitations in school-based prevention and health promotion, building adolescents’ competence and including components designed to promote the psychological and behavioral well-being of the young. The program employs an interactive approach and focuses on the active engagement of children as generally is recommended  implemented the program during the second year of the Italian middle school to students aged 12–13. The number of teachers is greater than the number of classes in the intervention arm (n = 76) because in Italian middle schools there is usually more than one teacher per class. Sixty-one teachers did not implement the program, mainly because of simultaneous work commitments.This intervention followed a “train the trainer” model. Members of the research group delivered five two-day training courses (one course per study center) for 125 health professionals working in the field of prevention and health promotion. Health professionals trained middle school teachers in their area, selected the schools to enroll in the study, managed program implementation, and administered study surveys. Altogether, 191 teachers were trained by health professionals for 12.5 h over a maximum of four sessions and received a detailed program implementation manual. During their training sessions, teachers were made aware that Unplugged, their specific activities were original. A brief summary of each unit’s aim, duration and contents is provided herein.Table Unit 1 ‘My emotions’ is planned to last 3–4 h and aims to improve the students’ capability to recognize and manage their own emotions, with the ultimate purpose to improve their well-being  critical thinking with the ultimate aim of reducing aggressive behavior Werle, , and (2)Unit 3 ‘Becoming men and women’ is planned to last 2–3 h and targets critical thinking and interpersonal skills to reduce aggressive behavior and to improve well-being , and 21 items (21%) were strongly or very strongly correlated (r ≥ 0.70). Cronbach’s alpha was 0.84, indicating good internal consistency.We validated the evaluation questionnaire with a test–retest study of 49 students living in Piedmont, one of the five regions participating to the evaluation study. Demographic characteristics of these students were similar to those in the main evaluation study in terms of age at baseline (mean 12 years) and sex (53% boys). In test–retest comparisons, 55 questionnaire items (54%) were moderately correlated (0.40 ≤ Pearson’s 1), i.e. past 30-d smoking  based on the findings of a life-skills program implemented in Italy and assessed with a randomized trial  and 80% power (zβ). We included an inflation factor (IF) of 1.9 to account for the cluster design. The IF was calculated assuming an intraclass correlation coefficient of 0.039 for past 30-d smoking, consistent with previous studies , categorical (l > 2) or continuous variable ; u0j is the random intercept, i.e., school, assumed to be normally distributed with mean zero and variance σu2; and  is an indicator function. Model 1 was nested within Model 2, which adjusted program effect for five potential confounders: outcome variable at baseline, sex, age, socioeconomic status, and nationality of parents. School-wide socioeconomic status was already accounted for by matching at the design stage.We used linear mixed-effects models to estimate adjusted program effects. Model 1 estimated the effect of the SD 0.54) and 50% were male. Approximately 45% had at least one parent with a university degree and 95% were of Italian descent.Students’ demographic and socioeconomic characteristics were balanced across study groups Table . Studentp < 0.001).Outcome distribution at baseline appears generally balanced across study group, with the exception of past 30-d smoking, which was 2.3% in the intervention group vs 4.8% in the comparison group (n = 56 out of 76 classes = 74%), and others reported implementing less units . Unit one was the most popular, implemented in 75 classes (99%), followed by unit two (97%), unit three (88%), unit four (82%), and unit five (78%). Although we did not require units to be delivered in a particular order and teachers were free to tailor the program to the needs of their class, the first units were those most closely related to the program main objective of improving well-being. Teachers reported on the lack of dedicated time and space as the main barrier to program implementation and prioritized the units deemed most appropriate to the needs of their students.Almost three quarters of teachers in the intervention group implemented all of the program’s five units  in the previous 30 d than did students not exposed to the intervention  was not sufficient to capture changes in these areas. The strict deadline enforced by the project funder for the completion of the study did not allow carrying out a further follow-up survey at a later time to detect later-onset program effects which are uncommon but possible.p = 0.001) of a positive association between number of units implemented and the WHO/Europe Symptom Checklist instrument , reflecting worse subjective well-being in a linear dose–response fashion. This suggests that although the freedom to tailor the program to the class needs is likely to result in different program effects, even the minimum implementation of the program (one unit) was sufficient to result in strong evidence of an effect on the main outcome. Although it is possible that heterogeneity in program implementation  may have influenced the size of the overall program effect, it is unlikely to have modified the overall interpretation of this study’s findings.The main limitation of the study concerns the lack of randomized allocation to study groups. In Italy, the evaluation of prevention programs is uncommon, randomized controlled trials are rare Coffano, , and schDiario della Salute was evaluated under real-life  conditions, the generalizability of our findings is maximized. Third, our study was conducted in five geographically and socioeconomically diverse Italian administrative regions, which increases the external validity of our findings. Our findings may also serve to show that the development and large-scale evaluation of a structured preventive program is feasible even in low-resource settings, provided that local health authorities and the education system and administrators are committed to the project.At least three key strengths may be noted for this evaluation study. First, because we conservatively based our sample size estimations on the least prevalent indicator  the study was sufficiently powered to detect changes in subjective well-being, which was the principal focus of the program, and adequately powered to capture changes in the other objectives. Second, our evaluation was conducted in real-life settings. A large part of the literature comprises efficacy studies of programs carried out in controlled research settings (Faggiano et al., Diario della Salute yielded an unexpected finding of reduced well-being as a result of program exposure, based on an increased perception of psychosomatic complaints among preadolescents. This could be explained by either an iatrogenic effect or an increase in emotional recognition skills that are positively associated with well-being over the lifespan. While higher emotional competence is associated with greater well-being, the program in its present form should not be disseminated due to the possibility of adverse unintended effects.In conclusion, our large multicenter evaluation study of