Evidence strongly suggests that orthogeriatric co-management improves patient outcomes in frail older patients with a fracture, but evidence regarding how to implement this model of care in daily clinical practice is scarce. In this paper, we first describe the implementation process and selection of implementation strategies for an orthogeriatric co-management program in the traumatology ward of the University Hospitals Leuven in Belgium. Second, we report the results of a multi-method feasibility study. This study (1) measures the fidelity towards the program's core components, (2) quantifies the perceived feasibility and acceptability by the healthcare professionals, and (3) defines implementation determinants.Implementation strategies were operationalized based on the Expert Recommendations for Implementing Change (ERIC) guidelines. In the feasibility study, fidelity towards the core components of the program was measured in a group of 15 patients aged 75 years and over by using electronic health records. Feasibility and acceptability as perceived by the involved healthcare professionals was measured using a 15-question survey with a 5-point Likert scale. Implementation determinants were mapped thematically based on seven focus group discussions and two semi-structured interviews by focusing on the healthcare professionals' experiences.We observed low fidelity towards completion of a screening questionnaire to map the premorbid situation (13%), but high fidelity towards the other program core components: multidimensional evaluation (100%), development of an individual care plan (100%), and systematic follow-up (80%). Of the 50 survey respondents, 94% accepted the program and 62% perceived it as feasible. Important implementation determinants were feasibility, awareness and familiarity, and improved communication between healthcare professionals that positively influenced program adherence.Fidelity, acceptability, and feasibility of an orthogeriatric co-management program were high as a result of an iterative process of selecting implementation strategies with intensive stakeholder involvement from the beginning.https://www.isrctn.com/ISRCTN20491828], International Standard Randomised Controlled Trial Number (ISRCTN) Registry: [ISRCTN20491828]. Registered on October 11, 2021.[ ApproTo prevent adverse outcomes in hospitalized frail patients, comprehensive geriatric assessment (CGA) has been introduced . CGA is Proactive geriatric co-management has proven to be a potential solution to tackle the limitations of the consultative model. Co-management is characterized by shared decision-making and shared responsibility between the geriatric and non-geriatric care team from admission until discharge. The beneficial impact of geriatric-surgical co-management on patient outcomes, such as in-hospital mortality and length of stay, has been repeatedly demonstrated –16. DespIn 2017, a geriatric co-management program was implemented in the cardiology wards of the University Hospitals Leuven in Belgium , this coWhile the effectiveness evaluation will be reported once data collection is finalized, the aim of this paper focusing on the G-COMAN implementation is twofold. First, we describe the implementation process including the selection of implementation strategies. Second, we report the results of a multi-method feasibility study, in which we (1) measured the fidelity towards the program's core components, (2) quantified the perceived feasibility and acceptability by the healthcare professionals, and (3) defined implementation determinants.2.2.1.This study was performed at the traumatology ward of the University Hospitals Leuven, a level one trauma center , in Belgium. Annually, around 53,000 patients are admitted to this hospital of which 22.0% are patients aged 75 years and older. In the traumatology ward, 30.5% of the admitted patients are older than 75. Daily care on the 56-bed traumatology ward is delivered by a multidisciplinary team. This team includes 5.45 full-time equivalents  surgeon-traumatologists, supported by eight FTE surgical residents. The ward is managed by two full-time head nurses, who supervise 32.2 FTE ward nurses and 5.6 FTE supporting healthcare workers . There are also four half-time advanced practice nurses (APN) specialized in trauma care. These master-trained nurses are clinical experts in traumatology nursing and medical care and ensure the continuity of care and treatment of the patients over the weekend. They also play a coordinating role in the implementation of quality improvement initiatives on the ward and a monitoring role in clinical pathways for fracture patients. Allied health professionals on the traumatology ward include physiotherapists , occupational therapists (one FTE), a psychologist (0.35 FTE), a speech therapist (no specific FTE), a dietician (0.40 FTE distributed over three wards), and a social worker (one FTE).2.2.Before the implementation of the G-COMAN program, usual care for older patients admitted to the traumatology ward consisted of care delivered by the multidisciplinary trauma team. The inpatient geriatric consultation team, including geriatric nurses  and occupational therapists (2.15 FTE) under the supervision of geriatricians, was available upon request from the surgical resident or traumatologist. The geriatric consultation team conducted a multidimensional evaluation and formulated tailored recommendations based on the geriatric problems identified. The traumatology team was responsible for implementing these recommendations without systematic follow-up by the geriatric consultation team.2.3.The G-COMAN program includes (1) proactive geriatric care with automated protocols for all patients aged 75 years and over and (2) a screening questionnaire for all patients aged 75 years and over to map the premorbid situation, followed by a multidimensional evaluation and multidisciplinary interventions with systematic follow-up  21)..21).First, all patients aged 75 years and older receive proactive geriatric care focusing on the functional, somatic, psychological, and social domains. To support this, various care plans are automatically programmed into the electronic health record. For example, three times per day the nurses receive a care plan for monitoring the bowel transit of the patient. Furthermore, urinary catheter removal is planned within 24 h postoperative, afterwards automatically a care plan to monitor the post-void residual bladder volume using a bladder scan is launched in the electronic health record.Second, the premorbid functional, somatic, psychological, and social status of the patient is documented via a screening questionnaire. This questionnaire is sent to the patient or his caregiver via the hospital's mobile application “mynexuz.be” upon admission to the traumatology ward. Alternatively, the questionnaire can be offered via e-mail, a QR-code, or interactive screens available in all hospital rooms. Subsequently, a more in-depth bedside multidimensional evaluation is performed by the multidisciplinary traumatology care team or the geriatric consultation team to identify potential geriatric problems. The results of the screening questionnaire and the multidimensional evaluation enable the development of a tailored interdisciplinary care plan through daily consultation between the G-COMAN traumatology nurse and the responsible ward nurse and during the weekly meeting with the multidisciplinary care team of the traumatology ward. This care plan, based on the individual patient's needs, is carried out by the multidisciplinary care team on the traumatology ward with the support of the geriatric consultation team and the geriatric resident. Two times per week, the surgical resident consults the geriatric resident to discuss acute medical problems or geriatric syndromes.2.4.Implementation of a new care program comprises a change in the current care organization and the behavior of healthcare professionals. For an implementation effort to be successful, implementation strategies are essential to tackle local barriers and contribute to the achievement of implementation outcomes . Based o2.5.2.5.1.To provide insights into the outcomes and determinants of the implementation, we performed a multi-method evaluation in the action phase of the implementation process. First, a quantitative evaluation of fidelity was done in a small patient cohort to determine how well the core components and care processes of the G-COMAN program were implemented (July-August 2022). Second, a survey was conducted to measure the perceived feasibility and acceptability of healthcare professionals (June 2022). Third, a qualitative descriptive evaluation using focus group discussions and interviews was done to capture healthcare professionals' experiences with the implementation and assess for implementation determinants (September 2022). This study was approved by the Ethics Committee Research UZ Leuven/KU Leuven (S65569).2.5.2.2.5.2.1.We recruited fifteen consecutive patients aged 75 years and older who were admitted to the traumatology ward and who were included in the G-COMAN program.2.5.2.2.2.5.2.2.1.Demographic variables included age, gender, and pre-fracture residential state . Clinical variables included body mass index (BMI), comorbidities based on the age-adjusted Charlson Comorbidity Index (CCI) , use of 2.5.2.2.2.We measured the fidelity towards the four core components of the program. The first core component is the completion of the screening questionnaire by the patient or his caregiver to map the premorbid status. The second core component is a multidimensional evaluation consisting of at least one evaluation in each of the following four domains: functional domain , somatic domain , psychological domain , and social domain . The third and fourth core component were the development of an individual care plan and systematic follow-up, respectively. Adherence to the core components in at least 80% of the patients was needed to consider the program as feasible . We also2.5.2.3.A research assistant recruited the patients upon hospital admission and immediately completed the baseline case report form after written patient (or proxy) informed consent was obtained. Fidelity indicators were assessed by daily checking the electronic health records of included patients. Categorical data were expressed as absolute numbers and percentages and continuous data were expressed as means with standard deviations.2.5.3.2.5.3.1.All healthcare professionals working on the traumatology ward, including nurses and allied health professionals, nurses of the geriatric consultation team, and geriatric and surgical residents, with at least four weeks of experience with the program at the time of data collection were eligible to participate.2.5.3.2.A 15-statement survey was used to investigate implementation targets, i.e., awareness, knowledge, motivation to change, perceived acceptability and feasibility, support, and belief in the benefit, value, and sustainability of the program. The survey statements were composed after a literature search and piloted internally by the nurses and clinicians of the G-COMAN project team See . Every s2.5.4.2.5.4.1.Seven semi-structured focus groups and two semi-structured individual interviews were organized targeting healthcare professionals with at least four weeks of experience with the program at the time of data collection. Participants were invited face-to-face and via e-mail. Since the program is a co-management program with all types of healthcare professionals, the focus groups were a mixed composition of healthcare professionals. The composition of the focus groups discussions was as follows: one focus group discussion with three geriatric residents, one focus group discussion with three surgical residents, one focus group discussion with four nurses of the geriatric consultation team, one focus groups discussion with two traumatology APNs and two head nurses of the traumatology ward, one focus group discussion with two traumatology APNs, one focus group discussion with two traumatology bedside nurses, one logistic employee, one occupational therapist, and one speech therapist, one focus group discussion with two traumatology bedside nurses, one social worker, one occupational therapist, two physical therapists, and one dietician, one individual interview with a nurse of the geriatric consultation team and one with the head nurse, resulting in a convenience-based sample of 30 healthcare professionals.2.5.4.2.An interview guide, based on the results of the 15-statement survey, was drafted and internally reviewed by members of the G-COMAN project team, including nurses and physicians. Expectations and goals, facilitators and barriers, feasibility and sustainability were key topics covered in the focus groups discussions and interviews. All focus groups and interviews were organized in a meeting room at the hospital lasting between 30 and 60 min. One independent researcher coordinated the focus group discussions (SJ) and a second independent researcher (CD or KS) took field notes. The interviews were coordinated by one researcher (SJ). The researchers involved could count on the expertise of an implementation science expert (MiD). All focus groups and interviews were tape-recorded and written out verbatim. The audio recordings were deleted afterwards. The transcripts were not returned to participants for comments. After each focus group and interview, a descriptive and methodological report was written to describe the conditions and quality of the interviews and to reflect on the interview guide, respectively. A qualitative thematic analysis was performed to select implementation determinants. After reading the transcripts, codes were inductively  given to relevant quotes. Subsequently, codes were mapped in a deductive way  to corresponding determinants from the contextual analysis framework by Flottorp et al. . This pr3.3.1.All implementation strategies linked with the targeted implementation outcomes are mapped per phase in ad hoc meetings with several stakeholders  all coordinated by the G-COMAN project manager to inform all stakeholders in order to receive feedback to further improve the implementation process. In addition, evaluative and iterative strategies such as the development of a detailed manual including geriatric care processes and protocols were used.In the pre-contemplation phase, stakeholder interrelationships were developed. This included the recruitment of a G-COMAN geriatric nurse, the organization of monthly meetings with the G-COMAN project team  and In the contemplation phase, a G-COMAN traumatology nurse was recruited. One of the responsibilities of this nurse was to adapt the detailed geriatric manual and tailor it into an orthogeriatric manual by merging it with the existing trauma care manual for older patients. Focus group interviews were performed with nurses and allied health professionals on the traumatology ward to evaluate current care practices before implementation of the program.In the preparation phase, stakeholder interrelationships were developed by organizing meetings with all allied health professionals of the traumatology ward. A step-by-step implementation process was used. This implied that one patient per week received the program by the G-COMAN traumatology nurse and G-COMAN geriatric nurse adding to the number of included patients each week until all admitted patients received the program.In the action phase, stakeholders were trained and educated. Every four to six weeks a new geriatric subject  was introduced during a meeting by the G-COMAN project team in collaboration with the involved allied health professionals. After each period, a feedback moment was organized to finalize the orthogeriatric protocols formatted as posters and pocket cards. Furthermore, tailored training was given to the existing geriatric consultation team to focus on coaching the traumatology care team instead of providing recommendations. Several interdisciplinary meetings were initiated by the G-COMAN traumatology and geriatric nurse: weekly meetings between the multidisciplinary traumatology care team and the inpatient geriatric consultation team to discuss all older patients as well as a daily briefing between the bedside nurse, physiotherapist, occupational therapist, and surgical resident to improve the efficiency of execution of proactive geriatric care.In the maintenance phase, focus group interviews were organized with the leadership team of the traumatology ward to discuss how the program can be continued after implementation. Subsequently, two APNs already working on the traumatology ward were designated to further monitor the execution of the orthogeriatric protocols by the traumatology team and be the main point of contact for the inpatient geriatric consultation team. To this day, every six weeks a meeting is organized between the traumatology APNs and the geriatric consultation team to discuss the specific needs of the traumatology team to further maintain the G-COMAN program.3.2.3.2.1.3.2.1.1.The study cohort of fifteen patients had a mean age of 84.2 years and had a 2-to-1 female-male ratio. Most of the patients were admitted with a proximal femur fracture (46.7%) followed by a distal femur fracture (13.3%) and a pelvic fracture (13.3%). Patients had a mean Katz index of 8.6, a mean Parker mobility score of 7.2, and a mean MNA of 10.6 .3.2.1.2.The adherence towards the core components of the G-COMAN program  was as f3.2.2.Of the 50 healthcare professionals who completed the survey (response rate = 58%), 98% were aware of the program, 88% indicated that they had theoretical knowledge about geriatric syndromes, and 78% of the healthcare professionals indicated that they knew how to prevent geriatric syndromes . The per3.2.3.The thematic analysis revealed implementation determinants in all seven domains of the framework for contextual analysis by Flottorp et al.  Figure . A detaiguideline factors. The healthcare professionals were satisfied with the availability of the orthogeriatric protocols (accessibility of the recommendation). They emphasized the need for adjusting the geriatric protocols to the trauma patient population (compatibility) since not all geriatric intervention components were feasible to execute in a traumatology setting (feasibility). The effort was perceived as minimal once they observed improvement due to their actions (observability). As a result, the execution of the protocols was no longer perceived as an additional workload (effort).The first domain for which important implementation determinants were determined was individual health professional factors. Before implementation, the healthcare professionals at the traumatology ward indicated their geriatric knowledge as limited and the need for improvement (domain knowledge). Awareness of and familiarity with the program among both people already working on the ward and new people starting during implementation and in the future were essential determinants of implementation. In addition, the intention and motivation towards the program of each individual was key to the implementation. Demotivation by colleagues was perceived as a barrier since this affected the motivation of the others. The healthcare professionals emphasized that the program needed to become routine over time due to frequently executing the protocols (nature of the behavior).The second domain contains patient factors, with patient needs as an important determinant. A barrier that came to light was the perception of patients' needs by the healthcare professionals which was not always in accordance with the actions of the program. For example, a fixed moment for micturition training was meant to be implemented, however, healthcare professionals felt this was a violation of the independence of the patient.The third domain covers professional interactions. Since the start of the program, communication between healthcare professionals of the geriatric and traumatology teams has improved, which has positively influenced adherence. The process of patient referral evolved positively during implementation. Hence, all disciplines worked more closely together and considered this to be a strength.The fourth domain contains incentives and resources. A barrier that was indicated by the healthcare professionals was that, when necessary, resources were not available to execute the intervention . The phased education of geriatric themes was appreciated by the healthcare professionals, as they indicated that implementing it all at once would be too much. In addition, they emphasized the importance of continuously reinforcing this knowledge.The fifth domain includes capacity for organizational change. Healthcare professionals agreed that a capable leader who is actively involved in the implementation process is needed during a period of change. The importance of a reference person from within the nursing team, who can motivate healthcare professionals and provide them with feedback, was pointed out numerous times.The sixth domain is the social, political, and legal factors. This domain includes important determinants that were indicated by the healthcare professionals such as legislation  and influential people .The last domain includes 4.Despite the strong evidence showing the impact of orthogeriatric co-management models on patient and organizational outcomes , 15, theIn contrast with these positive findings, we observed a low fidelity towards the first core component of the program, the completion of the screening questionnaire to map the patient's premorbid situation. This finding might be because we only offered digital self-assessment options to fill in this questionnaire. Although the use of e-Health technology to send out health questionnaires to older adults has increased and is perceived as an added value , 37, sevThe high fidelity towards the other three core components is likely a result of the high perceived acceptability by all healthcare professionals. During each phase of the implementation, we intensively involved all stakeholders. Early and continuous stakeholder involvement creates ownership and has been proven to increase acceptability and uptake ultimately leading to the embedding of a new intervention in practice . In contWhile 65% of the healthcare professionals believed in the sustainability of the program, only 35% of the healthcare professionals had the feeling that the program was integrated into their daily clinical routines. The percentage of healthcare professionals believing in sustainability is surprisingly low as we did pay particular attention to including sustainment strategies as reported by Hailemariam et al. . As statSeveral methodological considerations need to be mentioned. First, we used the electronic health records of the patients to assess the fidelity indicators. This was based on registrations of the healthcare professionals which can be an under or over-registration of actual care performance. Second, it is possible that only the highly motivated healthcare professionals participated in the focus group discussions and filled out the 15-statement survey. Lastly, perceived acceptability and feasibility by healthcare professionals were measured only once during the action phase. This should be repeated to monitor changes over time and to have a better understanding of the program's sustainability. Fidelity indicators will be reevaluated as part of the ongoing effectiveness evaluation.5.In conclusion, this paper reports essential information on the implementation process of a CGA-based orthogeriatric care model that can guide other clinicians and researchers. The iterative process of selecting implementation strategies with intensive stakeholder involvement from the beginning to address several determinants of implementation was the key to the success of implementation. This is translated into the high acceptability and feasibility perceived by healthcare professionals. The fidelity towards three out of four of the core components was high as well. The successful implementation of the program allows us to evaluate the effectiveness of the program. We hypothesize that this program will have a beneficial impact on patient outcomes and inpatient costs. The evaluation of the effectiveness of the program is ongoing.


Findings evidenced improvements in quality of life amongst distressed PEER participants, mediated by increases in psychological flexibility and self‐compassion, and reductions in distress. Peer support and mindfulness were not significant mediators. Together, this suggests that the psychosocial benefits of PEER observed for highly distressed adolescents are linked to the specific therapeutic approaches used in the program, rather than being non‐specific effects of peer connection or recreation. Findings from this evaluation provide further evidence for the efficacy and mechanisms of the effect of PEER for supporting distressed adolescents impacted by cancer. The study also demonstrates the viability and utility of the therapeutic approaches  used, showing that they have psychosocial benefits for this population.PEER is a four‐day residential program for adolescents impacted by their own or a relative's cancer, with both psychosocial  and recreational components. This study aimed to determine whether previously observed improvements in quality of life amongst highly distressed participants were mediated by improvements in processes targeted by psychotherapeutic elements of the program . Adolescents attending PEER completed surveys assessing the quality of life and proposed mediator variables at pre‐program, post‐program and two‐month follow‐up. Adolescents experiencing high/very high levels of baseline distress ( Acceptance and Commitment Therapy (ACT) and self‐compassion show promise in facilitating adolescents' adjustment to their own or their parent/sibling's cancer.PEER is an ACT‐ and self‐compassion‐based program developed for adolescents impacted by cancer.Highly distressed participants have been shown to experience greater improvements in quality of life after participating in PEER.Highly distressed PEER participants experienced improved quality of life from baseline to two‐month follow‐up, mediated by changes in therapeutic processes .The benefits of the PEER program are linked to the specific therapeutic approaches used, rather than peer connection or recreation.ACT and self‐compassion have demonstrated psychosocial benefits for distressed adolescents impacted by cancer.1For adolescents, a personal or familial cancer diagnosis can cause significant psychosocial disruption at an already dynamic developmental life stage. Just over 40% of young people diagnosed with cancer experience clinical levels of distress  programs have been identified as a promising format of psychosocial intervention for adolescents impacted by cancer, as they combine the chance to ‘escape’ the immediate cancer situation with opportunities for peer connection, support and learning coping strategies  delivered to groups of 3–10 adolescents by two facilitators trained in ACT and experienced in providing support to this population. These sessions were interspersed with group recreational activities  impacted by their own or a relative's cancer, which draws from ACT and self‐compassion in its therapeutic approach. The program involves seven psychosocial sessions  observed amongst PEER attendees who presented with high or very high levels of distress at the beginning of the program, as this group was previously noted to derive the greatest benefit from program participation , the person with cancer was more likely to still be in active treatment (p = 0.033), and on average that person had been diagnosed more recently (p = 0.018). There was no difference in participant age, cancer experience category , ethnic background, employment status or length of engagement with CanteenAs previously reported, the 2017 evaluation of PEER involved 148 adolescent participants who attended the program and completed the evaluation at two or more time points , the end of the program (T1) and 2 months following program completion (T2). This survey included demographic questions2.32.3.1very sad/unsatisfied to very happy/satisfied), with scores ranging from 0 to 10). This item is derived from the Personal Well‐being Index‐School Children , with scores summed to produce an overall distress score (range 10–50). Following Australian Bureau of Statistics guidelines, scores are categorised as indicating low (10–15), moderate (16–21), high (22–29) or very high (30–50) distress  using a 5‐point Likert scale  to rate how often they have felt supported by peers; total scores range from 11 to 55. Preliminary work with this measure has established its validity and reliability with young people attending therapeutic/recreational programs  using a 5‐point Likert scale . Total scores range from 0 to 32. The AFQ‐Y8 has been demonstrated to be more psychometrically robust and more accurate at classifying clinical depression and anxiety than the original 17‐item measure . Total scores ranged from 5 to 25. The full scale has demonstrated reliability, validity and theoretical coherence, including in adolescents  was for them, using a 5‐point Likert scale . Total scores range from 0 to 40, with higher scores indicating lower mindfulness. The CAMM has demonstrated reliability and confirmed single‐factor structure with adolescents  and satisfaction, as previously reported . As missing data was minimal (maximum 3% for each item), values were not imputed for incomplete items.2.4.1A mixed linear model was used to examine whether distressed participants' QOL improved across the three time points , with regression coefficients treated as random variables. Three models were tested: (1) a linear effect of time on QOL with no additional covariates or factors; (2) a quadratic effect of time on QOL with no additional covariates or factors; and (3) a quadratic effect of time on QOL, with demographics  included as additional covariates or factors.2.4.2The mediation analyses were conducted using the MEMORE (MEdiation and MOderation for REpeated measures) macro for SPSS, which allows testing of mediation effects in repeated measures designs with two occasions of testing , psychological flexibility  and self‐kindness . Participating in PEER is associated with reduced distress and increased psychological flexibility and self‐kindness (significant path As); changes in these mediating variables are linked to improved QOL (significant path Bs). The overall change in QOL over time (path C) was significantly altered after accounting for the indirect effect of each mediator (path C′), indicating significant mediation effects for these variables. The results show that peer support and mindfulness did not significantly mediate the effects of program participation on QOL. Together, these results suggest that the observed improvement in distressed participants' QOL after participating in PEER was specifically linked to improvements in distress, psychological flexibility and self‐kindness.Figure 4This study explores the mechanisms underlying benefits of PEER for distressed participants, with results indicating that increases in the therapeutic processes underpinning the program—particularly psychological flexibility and self‐kindness—are linked to improvements in QOL following participation. Reduction in distress also mediated this change, whilst mindfulness and peer support were not statistically significant mediators. This builds on findings from the previous process evaluation of PEER which identified that the program resulted in clinically significant improvements in QOL and distress for some participants, with those who reported high and very high levels of baseline distress appearing to benefit more from the program (Patterson, McDonald, Kelly‐Dalgety, Luo, & Allison, The evidenced mechanisms of the effect of the PEER program provide further evidence to support the use of ACT and self‐compassion as therapeutic approaches when working with adolescents impacted by their own or a family member's cancer, particularly those experiencing higher levels of distress. Whilst previous literature evidences the benefits of these approaches for young people (Bluth et al., Interestingly, neither mindfulness nor peer support was significant mediators of the improvement in QOL in this study. That mindfulness did not mediate this change suggests that the observed impacts of ACT for adolescents impacted by cancer are not solely attributable to this therapeutic component; that is, the six elements of ACT in combination appear to offer greater psychosocial benefit than mindfulness in isolation. Likewise, that peer support did not mediate improvements in QOL suggests that program benefits for distressed participants are not purely due to opportunities for peer support and connection. However, qualitative testimonials from participants evidenced the clear value adolescents found in connecting, sharing experiences and exchanging support with peers (reported in the previous PEER evaluation paper (Patterson, McDonald, Kelly‐Dalgety, Luo, & Allison, Finally, improvements in QOL were also mediated by reductions in distress—perhaps unsurprisingly, as these participants were experiencing high to very high levels of distress at the beginning of the program. The effect sizes for this mediation were the largest of all mediators, although caution is required when interpreting this comparison, as the relatively small sample precluded entering multiple mediators in a single analysis.4.1It is important to note that the results of this study are only true of a subset of participants: those adolescents with clinically elevated levels of distress at baseline (Australian Bureau of Statistics, 4.2The findings of this study not only confirm the benefits and underlying therapeutic processes of the PEER program; they also demonstrate the viability and impact of ACT and self‐compassion for adolescents who are experiencing high levels of distress as a result of their own or a family member's cancer. Improvements in QOL amongst distressed adolescents were specifically mediated by increases in psychological flexibility and self‐kindness, suggesting that therapeutic interventions can improve these processes in this population, with resulting psychosocial benefits. The finding that mindfulness and peer support did not mediate improvements in quality of life suggests that incorporating ACT and self‐compassion as part of therapeutic intervention may be more effective than programs based solely on peer support and/or mindfulness. Whilst further research comparing different interventions would be needed to confirm this, healthcare providers and community organisations may want to prioritise programs and services that incorporate ACT and self‐compassion when considering the most appropriate referrals to make, or support services to offer, distressed young people impacted by cancer.Canteen is a registered charity supported by government funding and donations from individuals, corporations, trusts and foundations. The evaluation of the PEER program received no specific funding.The authors would like to acknowledge Dr Richard Tindle for his contribution to the statistical analysis, the Canteen staff who conducted the PEER program, and all the young people who participated in the evaluation. Open access publishing facilitated by The University of Sydney, as part of the Wiley ‐ The University of Sydney agreement via the Council of Australian University Librarians.All authors on this paper are affiliated with Canteen, which owns the intellectual property rights to the PEER program; there are no other conflicting interests associated with this project.


Social determinants of health (SDH) are intricately intertwined with various social and economic factors. Reflection is essential for learning about SDH. However, only a few reports have focused on reflection in SDH programs; most were cross-sectional studies. We aimed to longitudinally evaluate a SDH program in a community-based medical education (CBME) curriculum that we introduced in 2018 based on the level of reflection and content on SDH in students’ reports.Study design: General inductive approach for qualitative data analysis. Education program: A 4-week mandatory clinical clerkship in general medicine and primary care at the University of Tsukuba School of Medicine in Japan was provided to all fifth- and sixth-year medical students. Students underwent a 3-week rotation in community clinics and hospitals in suburban and rural areas of Ibaraki Prefecture. After a lecture on SDH on the first day, students were instructed to prepare a structural case description based on encounters during the curriculum. On the final day, students shared their experiences in a small group session and submitted a report on SDH. The program was continuously improved and faculty development was provided. Study participants: Students who completed the program during October 2018–June 2021. Analysis: Levels of reflection were categorized as reflective, analytical, or descriptive. The content was analyzed based on the Solid Facts framework.We analyzed 118 reports from 2018–19, 101 reports from 2019–20, and 142 reports from 2020–21. There were 2 (1.7%), 6 (5.9%), and 7 (4.8%) reflective reports; 9 (7.6%), 24 (23.8%), and 52 (35.9%) analytical reports; and 36 (30.5%), 48 (47.5%), and 79 (54.5%) descriptive reports, respectively. The others were not evaluable. The number of Solid Facts framework items in reports were 2.0 ± 1.2, 2.6 ± 1.3, and 3.3 ± 1.4, respectively.Students’ understanding of SDH deepened as the SDH program in the CBME curriculum improved. Faculty development might have contributed to the results. Reflective understanding of SDH might require more faculty development and integrated education of social science and medicine.The online version contains supplementary material available at 10.1186/s12909-023-04320-2. Social determinants of health (SDH) are non-medical factors that influence health outcomes, including environments where people are born, grow, work, live, and age . SDH havThe importance of teaching about SDH in undergraduate medical education has been widely recognized , 5, 7, bIn our previous studies, we reported on SDH program evaluation in the community-based medical education (CBME) curriculum in upper-year medical students from a university in Japan  by evaluThe purpose of this study was to show the continuous program improvement process in an SDH education program for medical students and to longitudinally evaluate an SDH education program in a CBME curriculum by evaluating levels of reflection in students’ reports.The study used a general inductive approach for qualitative data analysis of the program annually for 3 years. It evaluated SDH reports of medical students who participated in an SDH program in a CBME curriculum. The general inductive approach is a systematic procedure for analyzing qualitative data, one in which the analysis is likely to be guided by specific evaluation objectives. Its purpose is to enable the emergence of research outcomes from frequent, dominant, or significant themes inherent in the raw data, without being predetermined by structured methodologies .The participants of the study were fifth-year and sixth-year medical students in the University of Tsukuba School of Medicine who participated in a mandatory 4-week clinical clerkship in the CBME curriculum either between September 2018 and May 2019 (2018–19), September 2019 and March 2020 (2019–20), or October 2020 and July 2021 (2020–21).The structure of the 4-week CBME curriculum is comparable to those in our previous studies , 14. TheThe structure of the SDH program in the CBME curriculum followed the structure of those in our previous studies , 14, witWe continuously modified the SDH program and provided faculty development since it began in 2018. At the beginning of the program in 2018, the core faculty members who designed the program provided a faculty development lecture to other faculty members who would take part in the SDH program. The first faculty development lecture was on SDH and having sociological perspectives in clinical settings.After the 2018–19 program, we held faculty development meetings to discuss and confirm the program’s goals and modified the program accordingly. For the 2019–20 program, which took place from September 2019 to March 2020, we introduced a facilitator guide, evaluation sheet, and evaluation rubric for faculty facilitators for the small group presentation of SDH cases on the final day. After each set of small group presentations, we conducted a group interview with faculty facilitators to reflect on the program.In the third-year program from September 2020 to June 2021, we conducted faculty development sessions to discuss goals for the SDH education program using the final report. We made minor revisions to the final report assignment and its evaluation rubric . We alsoAs a method for deriving important and frequent themes inherent in the reports, we evaluated the levels of reflection in the description of SDH and extracted the Solid Facts factors that were mentioned. Since reflection has been considered as a form of education and program assessment in a previous review , we deteThis study was approved by the University of Tsukuba medical ethics board (No. 1434–2).In 2018–19, 2019–20, and 2020–21, a total of 118, 101, and 142 students participated the SDH program, respectively. There were 35 (29.7%), 34 (33.7%), and 55 (37.9%) female students, respectively.Figure The percentage of SDH factors described in the reports is shown in Fig. We introduced the SDH education program into the compulsory CBME curriculum for upper-year medical students and presented the results of a 3-year program evaluation by assessing the levels of reflection about SDH in the students’ reports. After 3 years of program introduction and continuous program improvement, most students were able to describe SDH and explain some SDH factors in their reports. On the other hand, only a few students were able to write reflective reports about SDH.Compared to 2018–19, the proportion of analytical and descriptive reports gradually increased and non-evaluable reports markedly decreased in 2019–20 and 2020–21, which might have resulted from improvements in the program and faculty development. Faculty development is essential for the SDH education program , 9. We pAlthough the number of SDH factors mentioned in reports increased, the frequency of their appearance varied based on the factors, which may have been related to the characteristics of the practice setting. The high percentage for social support was unsurprising given frequent contact with patients already connected to medical care. Transportation was also frequently mentioned, which may be due to the fact that the CBME sites were located in suburban or rural areas, where students actually experienced inconvenient transportation conditions and had opportunities to interact with people in such environments. Stress, social exclusion, labor, and food were also mentioned, which more students could have encountered during their practice. On the other hand, the impact of social disparities and unemployment on health might have been difficult to understand during this short training period. The SDH factors that students can experience during their practice might also be influenced by the characteristics of the practicing field.Our study was valuable in that we continuously evaluated the SDH program within the CBME program, which we provided to upper-year medical students, through assessment of the level of reflection in student reports. Upper-year medical students, who have been studying clinical medicine for several years, have a medicalized perspective. Therefore, they have the potential to learn by relativizing the social scientific perspective required by the SDH program and their own medical perspective . Thus, pAlthough overall levels of reflection among students improved markedly throughout the study period, the proportion of students who wrote reflective reports remained low. Cultivation of more sociological perspectives might be needed for further improvement. The assignments in the SDH program required students to integrate sociological and medical perspectives, which had a different type of complexity compared to that of the medical model . As we mThe study had several limitations. First, the study setting was limited to a single medical school in Japan, with the CBME setting limited to one region of Japan in sub-urban or rural areas, as in our previous studies , 14. We We conducted a longitudinal evaluation of an SDH education program for upper-grade medical students in a CBME curriculum. We showed that the students’ understanding of SDH deepened as the program improved. SDH program improvement might take time and effort, but faculty development to deepen the faculty’s understanding of SDH might be effective. In order to further enhance students’ understanding of SDH, it might be necessary to design the program in a way that integrates social science and medicine more longitudinally.Additional file 1. 4-week final report (2020–21).Additional file 2. Rubric for evaluating the 4-week report on SDHs (2020–21).


Fellowship accreditation is crucial to ensure adequate clinical education for physicians in training, yet there is limited data on use of accreditation survey results for program quality improvement. The Accreditation Council for Graduate Medical Education (ACGME) administers annual surveys to trainees and core faculty to monitor education and identify potential non-compliance with ACGME accreditation standards. Our purpose is to describe the creation of an internal program review process for program improvement based on results of nationally implemented accreditation surveys.We collected data from standardized ACGME survey responses administered to core faculty and fellows at our academic Infectious Diseases fellowship program. The identification of areas scoring lower than 20% in comparison with national average prompted creation of a Special Program Review (SPR) committee comprised of a program director, a program coordinator, and a trainee from programs outside of the program under review. This committee met separately with core faculty, trainees, and program leadership to compile an assessment of each survey component and opportunities for improvement. This review process of survey results was completed annually from 2020-2022.Between 2020-2022, surveys were completed by 100% of fellows (7/7 or 8/8) and up to 92% of core faculty (11/12). Key findings raised concerns involving clinical education, faculty supervision, patient safety, and teamwork. Actions taken in response to the SPR included the creation of: an updated backup and weekend coverage system, new didactic curricula, a morbidity and mortality conference, documentation limits, informal fellow/faculty dinners, opt out counseling, and a division culture committee.A non-punitive internal review process mimicking accreditation standards is valuable for program assessment and improvement as means to identify areas of risk for accreditation issues at a national level. This review process is generalizable, as all accredited programs complete the survey annually. The quality improvement interventions taken will differ depending on survey findings and areas to be addressed.All Authors: No reported disclosures


Despite the well-recognized risk poor maternal mental health poses to early child development, it is still rarely addressed in global health programming, especially in humanitarian settings where access to health and mental health infrastructures may be limited. Recognizing the critical role of maternal psychosocial wellness in addressing the health and development of children in conflict, Action contre La Faim/Action Against Hunger (ACF) developed the Baby Friendly Spaces (BFS) program. BFS is a holistic, evidenced-based psychosocial support program that aims to enhance mothers’ wellbeing, internal resources, and child caring skills in order to create a buffer against the deleterious health and developmental impacts of conflict on children.In Bangladesh, we sought to evaluate the effectiveness of a psychosocial support program for Rohingya refugee mothers and their malnourished children under two years old living in Cox’s Bazar’s camps.For this study, we used a matched pair randomization, where ten BFS program sites were allocated to either continue providing services “as usual” or to an “enhanced BFS program” after re-training and providing continuous supportive supervision of the BFS staff throughout the trial period. 600 mothers and their children were enrolled in the study and attended psychosocial stimulation activities related to child care practices and care for women. Data were collected at baseline and 8-week follow-up. Primary outcomes included maternal distress and wellbeing, functioning, and coping. For implementation purpose, a survey was administered on confidence at work for all BFS staff and a fidelity observation assessment was conducted.Relative to “as usual” sites, mothers in enhanced implementation sites reported greater reductions in distress (B=-.30) and improvement in wellbeing (B=.58). These differences were small, but marginally significant  with standard estimation; There was no significant difference between the two groups for daily functioning and coping. BFS providers in “enhanced BFS program” reported higher confidence in service delivery than their colleagues (p=.01). Fidelity varied widely across different components, with some very high and some very low adherence. There tended to be better adherence to procedures in group versus individual sessions and for some specific activities across domains, for enhanced versus standard BFS.Findings highlight the value of innovative study approaches for real-world evidence generation. Small but feasible adjustments to implementation can both improve program delivery for maximizing impact. Consequently, low-intensity psychosocial support activities holds potential for reducing distress and improving subjective well-being of conflict affected mothers.None Declared


Project Towards No Drug Abuse (TND) is an effective, evidence-based, drug abuse prevention program that has provided favorable effects in 7 out of 7 cluster-randomized controlled trials . FergusoThis was an immediate outcomes evaluation of adapted program content with a novel population (location and age group) and revised implementation schedule of Project TND. While the authors mentioned that no behavioral effect was observed , one should not expect a behavioral impact at an immediate posttest. All one can successfully measure in an immediate outcome evaluation of a prevention program for youth is program implementation fidelity, including dosage, adherence, quality of program delivery, participant responsiveness or acceptance, and knowledge gains from the program . In factn = 30) and extremely low retention rate were also major limitations. The sample size needs to be large enough to allow for sufficient statistical power to conduct meaningful efficacy analyses  in Ferguson et al. study , and Sessions 7 and 9  were condensed into 1-hour session periods, and the study evaluation measures (pretest and posttest) were added as part of the program, which turned the 12-session, 4-week TND program into an adapted 14 session, 3-month program. This is not the original implementation design of the Project TND program  to an older population with programming content adaptations, this can destroy the evidence-base. In fact, the Project TND website provides guidance on program implementation, stating minimum delivery is 2 sessions per week (over a 6-week period) for favorable results, and specifically that one session per week is not recommended .There was no explicit use of a systematic adaptation approach in the process described in the Ferguson study. The authors could have referred to systematic adaptation frameworks like the ADAPT-ITT framework , which iIn conclusion, it is quite clear that fidelity of programming being demonstrated in this study is lacking for the variety of reasons presented. While the authors of the article were complimentary to the TND program in some ways, they made speculations far above what the data collected could provide, particularly considering the vast limitations. Making any claims about preventive alcohol, tobacco, or other drug use (ATOD) behavior based on their methodological design is simply not possible. Future work should be careful to be more cautious of any potentially causal statements made.All authors took an active role in the manuscript. SS drafted the manuscript. AG and LM provided critical revision to the manuscript. All authors approved the final submitted manuscript.


Although international guidelines state that psychoeducation to caregivers should be provided systematically, it remains insufficiently available in psychiatry. This study reports the development and evaluation of an original training course aimed to provide participants with the knowledge and skills to implement “BREF,” a psychoeducational program for caregivers.n=467) completed a post-course questionnaire (n=341) and a cross-sectional questionnaire (n=56). Quantitative data on satisfaction, learning, and behavior changes following the course were collected equating to levels 1, 2, and 3 of Kirkpatrick’s model.The BREF program training course, a free, 1-day course incorporating peer role-play was developed. In addition to psychiatrists, nurses, and psychologists, caregivers were involved as preceptors. Participants were mental health professionals and volunteer caregivers. Participants to the first 28 sessions of the course  with no significant effect of course session. At cross-sectional evaluation, 73% of responders reported improvements in skills related to providing psychoeducation to caregivers, 64% stated that the BREF program was implemented/under implementation, and 66% stated that their department had connected with a family association.Training course sessions alone can increase psychoeducational programs for caregivers and network establishment. The BREF program training course demonstrates a high level of participant satisfaction and is a promising method to disseminate psychoeducation to caregivers, thus addressing a major shortage in mental health organization. Family caregivers fulfill multiple roles in the care of individuals with a severe mental disorder (SMD) such as schizophrenia, bipolar disorder, or major depressive disorder. In this regard, family caregivers are indispensable actors promoting recovery for individuals with a SMD . While cPsychoeducation to caregivers (PEC) aims at increasing caregivers’ knowledge and understanding of their relative’s illness and treatment. PEC also provides caregivers with skills to best support their relative and coping strategies to maintain their own well-being. PEC is associated with substantial beneficial outcomes on both individuals living with a SMD and their caregivers , 7. It iDespite international and national guidelines advocating PEC as one of the most effective treatments for SMD, such programs remain scarce . Only 3%The present paper describes the development and evaluation of the BREF Program Training Course (BPTC) aimed to provide mental health professionals and volunteer caregivers of family associations with the knowledge and skills required to implement the BREF program in their psychiatry department.The BPTC was designed with the aim to provide course participants with the knowledge and skills required to implement the BREF program in their psychiatry department. Additionally, the course aimed to (i) raise participants’ awareness regarding caregivers’ experience and needs, (ii) update participants’ knowledge on the efficiency of PEC in psychiatry, and (iii) encourage partnerships between psychiatry departments and family associations. On a broader level, the course was intended to help disseminate the BREF program nationally, therefore addressing shortages within the French mental health system. To our knowledge, no such training is currently available in France.Mental health professionals lack basic knowledge regarding interventions to caregivers , 13. IncTwo distinct groups are eligible as course participants: direct providers of the BREF program and other key actors promoting recovery for individuals with a SMD.As direct providers of the BREF program, nurses, psychologists, and volunteer caregivers of family associations are the natural audience of the BPTC. Including caregivers as course participants is critical since the BREF program is provided by mental health professionals together with volunteers of family associations. Indeed, the involvement of a peer co-leader is a key factor to improve effectiveness of PEC . MoreoveAdditionally, other key actors are eligible as course participants such as medical residents, senior psychiatrists, chief nurses, social workers, social educators, and medical secretaries. Although they do not provide the BREF program themselves, they are an appropriate audience for the BPTC because, as prescribers, managers, and/or essential actors supporting individuals with a SMD, they need to update their knowledge about PEC efficiency. Moreover, providing them with a clear understanding of the BREF program helps to implement it in their psychiatry department, thus promoting early and systematic PEC prescription.All course directors  were experts in providing PEC and trained in family therapy. In addition to the course directors, a core group of course preceptors has been formed. This multidisciplinary group is composed of psychiatrists, nurses, and psychologists. Volunteer caregivers were also included in the group of course preceptors to take advantage of their experience, knowledge, and skills.Consistently with the literature on consumer as teacher , 16, invTo be included in the group of course preceptors, three requirements had to be fulfilled: (i) being a former participant of the BPTC, (ii) having provided the BREF program for 1 year at least, and (iii) co-providing the BPTC with an experienced preceptor. Although being trained to family therapy was valued, it was not compulsory to become a course preceptor since such professionals remain rare in the French public mental health system. Two to three preceptors were required to teach a BPTC session. It was essential to have enough course preceptors since we aimed to teach the BPTC frequently in order to disseminate the BREF program nationally.All the course directors were involved in the design of the BPTC. The course content was conceived in accordance with recommendations on medical education curriculum regarding caregivers in psychiatry , 18. TheCommon misconceptions explain mental health professionals’ reluctance to provide PEC. Indeed, PEC is wrongly seen as a complex intervention, requiring a high-level expertise and therefore not falling within mental health professionals’ competence. A peer role-play module was incorporated within the BPTC to overcome such misconstructions. Our intention was to have participants rehearse usual situations to improve their coping abilities before providing PEC . Course Many mental health professionals fear that providing PEC could lead to a breach in professional secrecy. To overcome this common misconception, a substantial amount of time throughout the BPTC was allotted to exchanges and debates between participants and preceptors. Questions about medical secrecy were systematically encouraged and addressed. We hoped that such a content and interactive format would help participants feel able to provide PEC and convince them that early and systematic provision of PEC is an essential duty for any mental health professional.as course preceptors would be engaging for the course participants and would encourage them to provide PEC, establish partnerships with, and refer caregivers to family associations. Secondly, we hoped that including caregivers as course participants would promote a sense of partnership between caregivers and mental health professionals. Engaging caregivers within the education process and care provision could improve the referral to family associations, thereby increasing the number of caregivers receiving peer support.Not only mental health professionals have little knowledge about caregivers’ needs and experience, but they are not aware of the resources and support interventions provided by family associations. Two choices were made to address these issues. Firstly, we believed that involving caregivers Adequately referring caregivers after the BREF program is of crucial importance since some interventions such as systemic, cognitive-behavioral, or medical family therapies although highly efficient remain rare in France. To this end, we designed an interactive exercise based on the Pyramid of Family Care . This moThe lack of knowledge about PEC efficiency and the limited funding explain the low priority currently given to PEC trainings in France. In this challenging context, we believed that a free, 1-day format would improve the admissibility of the BPTC, allow us to teach it frequently, and, ultimately, help disseminate the BREF program nationally.The BPTC was assessed in accordance with Kirkpatrick’s 4-level training evaluation model, one of the most widely used frameworks to evaluate health education programs . Under tFollowing the BPTC, course participants were asked to complete two questionnaires. Participants’ informed consent was sought prior to data collection, and information was provided on researchers’ contact details, anonymity, and right to withdraw. Hence, in accordance with French regulations on educational research, Le Vinatier Hospital Center Institutional Review Board (IRB) Office determined the project was exempt from IRB review.The post-training course questionnaire, an anonymous, self-administered questionnaire, was completed by the participants immediately after the course. Five questions assessed participants’ satisfaction level using a 3-point Likert scale with 1 being “satisfied,” 2 being “neutral,” and 3 being “not satisfied.” Two additional questions explored participants’ confidence and commitment.The cross-sectional questionnaire was sent on the 5th of January 2021 to participants who provided their mail contact. Using Framaforms , this ann; %). Quantitative variables are presented as the mean and standard deviation (m ± SD). Proportion comparisons were performed using the chi-square test. Significance threshold for the statistical tests was fixed at p<0.05.JASP software (JASP Team (2019), JASP (Version 0.14) [Computer software]) was used to perform statistical analyses. Categorical variables are presented as the number of responders and percentages , professional activity , and type of employing-organization  between the two groups of responders.The post-training course questionnaire was returned by 403 (86.3%) of the 467 participants who underwent the BPTC. After discarding 61 unusable questionnaires (blank questionnaires), 341 responders were included in this study. The 341 responders were mostly women (81%) and belonged to 56 different employing-organizations, 90% were mental health professionals, and the remaining 10% were volunteer caregivers of family associations. The cross-sectional questionnaire was completed by 56 (16.4%) of the 341 participants who completed the post-training course questionnaire. Responders were mostly women (73%) and belonged to 56 different employing-organizations, 89% were mental health professionals, and the remaining 11% were volunteer caregivers of family associations. There was no difference in gender .χ216=18.9; p=0.27). Analysis of the cross-sectional questionnaires showed that 73% of responders reported an improvement in their ability to provide PEC following the training course. Moreover, responders deemed that the BPTC had a very positive impact on their professional practices with a mean score of 7.9/10 (± 1.7).Analysis of the post-training course questionnaires showed high levels of confidence and commitment. Following the BPTC, responders’ confidence to implement the BREF program was high with a mean score of 7.9/10 (±1.4). Consistently, 81% of responders intended to implement the BREF program in their psychiatry department. Remarkably, the effect of course session on the confidence to implement the BREF program was not significant . Regarding network establishment, 66% of responders reported that their psychiatry department had connected with a family association following the training course.The results of the present study have five important implications regarding the development of educational initiatives around PEC.Firstly, the course participants reported a high level of satisfaction regarding the various characteristics of the training course. Notably, 100% of responders would recommend the course to other mental health professionals. To date, we are unaware of any research of similar size assessing participant satisfaction of a training course about PEC. Furthermore, 98% of responders deemed to be satisfied with the preceptors’ lectures, suggesting that no resistance arose from the involvement of caregivers as course preceptors. Such a high satisfaction level strengthens the interest of engaging caregivers within medical education initiatives .Secondly, our findings support the value of the BPTC for improving participants’ skills, confidence, and commitment in providing PEC in the short and medium terms. Immediately after the training course, very satisfactory data regarding responders’ confidence and commitment to implement the BREF program were observed. At cross-sectional evaluation as well, the majority of responders reported an improvement in skills related to PEC provision. This is in accordance with the efficacy of a short interprofessional training course in improving clinicians’ confidence and abilities in working with families of individuals with a SMD .Thirdly, the present study indicates that the BPTC helps mental health professionals overcome their reluctance in working with caregivers. Indeed, despite the clear benefits in providing interventions to caregivers , 29, resFourthly, the BPTC was enough to implement the BREF program which was the main goal of the course. Immediately following the course, responders reported a high level of confidence to implement the BREF program in their psychiatry department (mean score ± SD: 7.9/10 ± 1.4). Furthermore, although some participants attended the BPTC only 3 months before the cross-sectional evaluation, 64% of the cross-sectional questionnaire responders stated that the BREF program was implemented or under implementation and 66% that their psychiatry department had connected with a local family association. Responders deemed the BREF program implementation as moderately easy with a mean score of 6.2/10 (±2.3). Further evaluation is ongoing to identify the main barriers of the BREF program implementation.Our data confirm that a 1-day format is enough to implement the BREF program. To date, no study evaluating a short training course aimed to develop PEC knowledge and skills is available. However, our results are consistent with previous reports that 1-day courses are effective in improving knowledge, skills, and confidence regarding key non-pharmacological treatments in gerontology  or psychTo address providers’ misconceptions regarding PEC, we incorporated a peer role-play module (a simulation-based training method) within the BPTC. Although our evaluation data did not assess the specific effect of peer role-play in the global impact of the BPTC, our results raised the question whether it is a key factor in the effectiveness of our training course. Indeed, simulation-based training is now considered a core educational strategy in mental health , 35. It Fifthly, the BPTC alone led to an increase in the structures providing the BREF program and to network establishment in France. Indeed, at cross-sectional evaluation, 64% of responders stated that the BREF program was implemented/under implementation and 66% that their department had connected with a family association. This is consistent with the previous report that a 1-day training workshop is an effective method to disseminate cognitive stimulation therapy  in dementia services . FurtherAlthough created in France, the present model could prove relevant in other countries. Indeed, both the BREF program and the BPTC were conceived in accordance with international recommendations , 18, 22.In interpreting the findings of this study, a number of limits need to be considered. Firstly, some advanced skills related to PEC provision could not be included in the course content. Indeed, although communication skills, problem solving approaches, or cognitive-behavioral techniques are key elements in psychoeducational programs, teaching them to the BPTC participants was not compatible with a 1-day course format. To compensate for this missing content, complementary e-learning modules are in preparation and will be made available to all former course participants.Secondly, only post-course questionnaires were used to assess the BPTC. To better identify specific achievements and shortcomings of the course, a comparison of performance levels of individual students before and after course participation is needed. Furthermore, prior knowledge and skills were not explored. Such an assessment allows a more accurate evaluation of learning improvements after the BPTC since participants may have differing performance levels when entering the course. Finally, while we explored satisfaction, skills, and behavior improvement, we did not evaluate changes in knowledge following the BPTC. Given these limits, since April 2021, new evaluations are ongoing to further assess the BPTC. We designed new pre- and post-course questionnaires exploring knowledge and skills. Additionally, the pre-course questionnaire allows participants to self-assess their prior knowledge and skills.Thirdly, we used self-administered questionnaires which are widely used in health training research , althougFourthly, the quantitative measures used in the post-course and cross-sectional questionnaires were specifically developed for the evaluation of the course; they were thus not validated. In the absence of existing validated instruments to assess the BPTC , the couLastly, 61 of the 403 returned post-training course questionnaires were discarded because they were unusable (blank questionnaires) and only a subset of the course participants completed the cross-sectional web questionnaire. Our results can thus be subjected to sampling bias since low-performing students are less likely to participate in online evaluations as compared to their high-performing peers [In conclusion, in addition to showing a high level of participant satisfaction, our 1-day training course helps overcome resistance in working with caregivers and is sufficient to implement the BREF program. BPTC sessions alone can lead to an increase in psychoeducational programs for caregivers and network establishment between psychiatry departments and family associations. In this regard, the BPTC is a promising method to disseminate PEC, thus addressing a major shortage in mental health organization.


This study evaluated the impact of a semi-structured diversity education program on young adolescents, which included five 45-min sessions facilitated by schoolteachers using an instructors’ manual. The study compared changes in knowledge and attitude related to diversity, self-esteem, and mental health among participants before and after the program. The participants were 776 junior high school students. Self-esteem and mental health conditions were assessed with the Rosenberg Self-Esteem Scale (RSES) and Kessler 6-Item Psychological Distress Scale (K6). The ratio of those who answered the knowledge and attitude questions correctly increased significantly for most questions, while the ratio decreased significantly for two questions. The RSES scores improved significantly after the program, but the difference was very small. Mental health, as measured by K6, became significantly worse after the program. A logistic regression analysis indicated that lower K6 scores before the program and worse academic grades had significantly higher odds ratios; being a girl, not having a disability, and having close friends were associated with worse K6 scores after the program. Further, this indicates the importance of developing processes based on evidence and the “nothing about us without us” principle. Diversity and inclusion have become global priorities in various international agreements. In particular, the United Nations 2030 Agenda for Sustainable Development and the Sustainable Development Goals have adopted the “leave no one behind” and “reach the furthest behind first” as foundational principles and made diversity and inclusion one of the top global priorities . FurtherEducation plays a key role in increasing individual and societal awareness and nurturing inclusive cultures and systems to protect and promote diversity and inclusion. Research has been conducted with various foci to examine the effectiveness of diversity education. For example, early studies (from the 1950s–60s) examined school-based educational interventions to improve attitudes toward race . RegardiThere have also been studies on educational interventions related to disabilities. A meta-analysis was conducted on the effects of 20 school-based interventions to improve disability awareness and attitudes from kindergarten to secondary school in the Republic of Korea. The study found that contact-based interventions, use of materials, role-playing, and human rights interventions were effective factors in achieving such improvement . In addiHowever, few studies with strong designs and large sample sizes have examined educational interventions to reduce the stigma against persons with mental health conditions or psychosocial disabilities. A narrative review  found thA limited number of studies on educational interventions to ensure the diversity and inclusion of students have been reported in Japan. A study targeting medical university students indicated that a one-hour educational program demonstrated positive attitudinal changes related to distance from persons with mental health conditions or psychosocial disabilities, approaches to psychiatric services, and perspectives on human rights, including the importance of independence in social life . HoweverConcepts and terminologies related to diversity and inclusion evolve over time. Taking the rights of persons with disabilities as an example, models have changed from the charity model, which considers persons with disabilities as vulnerable objects of charity, to a medical model that often views disability only from a medical lens, such as requiring prevention and treatment. The current social model is based on human rights and views environmental, institutional, and attitudinal barriers as key factors and targets for interventions related to disability . In the This study evaluated a semi-structured education program on diversity and inclusion in four cities in Japan. The program was developed based on experience and good intentions but with limited reference to evidence, new concepts and terminologies, and the voices of stakeholders with diverse backgrounds.A total of 776 students from four junior high schools in the four suburban cities of Japan participated in the education program. Study participants who responded to a question on gender included 210 students from city A (boys: 108 (51.4%), girls: 95 (45.2%), others: 7 (3.3%); age range: 12–14 years; mean [M]: 13.29 years, standard deviation [SD]: 0.59), 99 students from city B (boys: 50 (50.5%), girls: 49 (49.5%); age range: 12–14 years; M: 12.86 years, SD: 0.38), 129 students from city C (boys: 75 (58.1%), girls: 52 (40.3%), others: 2 (1.6%); age range: 12–13 years; M: 12.82 years, SD: 0.38), and 235 students from city D (boys: 129 (54.9%), girls: 106 (45.1%); age range: 12–13 years; M: 12.66 years, SD: 0.48). A total of four junior high schools, one from every four cities, consisting of seven classes from the school in city A, four in city B, four in city C, and 11 in city D, participated in the study. A teacher from each class presented the educational program to each class. In other words, the teachers who implemented the program differed from class to class but based on an instruction guide. The vendor who developed this program requested the participation of schools with which it had prior relationships; four schools agreed to participate in this study. Demographic DataDemographic data, including age, gender, academic grade, the experience of being bullied, whether they performed regular exercise, and the existence of close friends, were obtained before the program. In addition, the Washington Group Short Set on Functioning  was admiSelf-EsteemThe Japanese versions of the Rosenberg Self-Esteem Scale (RSES) (α = 0.81) ,19 were Mental HealthKessler 6-item Psychological Distress Scale-K6 (K6) (AUC Index = 0.94)  was usedKnowledge and AttitudeParticipants were also asked original questions before and after the program on their knowledge and attitude toward diversity based on the current United Nations Human Rights Framework. These questions were developed in collaboration with academic experts on diversity and human rights, public health experts, mental health experts, a United Nations human rights advisor, representatives of organizations of persons with disabilities, and young people. At the end of the questionnaire, questions on existing social support and successful coping strategies were asked to assess positive resiliency. Participants were requested to answer the questionnaire one week before the program and one week after the program.The program was created by a vendor with experience developing exploratory educational programs. This was a pilot diversity and inclusion education program for junior high school students in Japan implemented between December 2021 and February 2022. It involved five 45-min sessions on diversity with a special focus on “pain.” The vendor developed an instruction guide for teachers, and teachers in junior high schools implemented the program based on this guide. The program has an active learning style and is structured as follows:Session 1: Students share “the pain that I know” among group members and map the pain based on its intensity and commonality. The goal is to understand diversity in the perception of pain among members.Session 2: Students share what was discussed in each group with the class as a whole and watch a video regarding pains that they did not know about.Session 3: Students have a group discussion on the value of realizing pains that they did not know about and do homework to find the “invisible pain” (to which they had not paid attention thus far) in their daily life.Session 4: Each student to select one pain that they want others to know about and think about a message to deliver.Session 5: Students share the selected pains and messages in groups and reflect on the program.Before data collection, all procedures and questions were discussed with the school principals and teachers to ensure that the questions were relevant and not intrusive. Informed consent forms were distributed to the parents of the students. The researchers explained that there would be no negative implications even if their children did not participate in the study, and all the data would be stored safely with individual data coded and statistically analyzed as groups. If the parents agreed, they were requested to sign the consent form. Students were also informed that their responses would not affect their academic grades, and teachers would not know their individual answers because all the data would be coded and statistically analyzed.The procedures for this study were approved by the Institute of Human and Social Sciences Ethics Committee of Kanazawa University (2021-53).2 analysis was used for the comparison of categorical variables, and a Wilcoxon signed-rank sum test was used for continuous variables. In addition, a logistic regression analysis was employed, where whether or not the K6 score worsened after the program  was set as an outcome. The pre-program K6 score and gender, as well as whether the participant has a disability, close friends, and a regular exercise routine, were set as independent variables. Statistical analysis was conducted using SPSS version 28.0 J for Windows . Statistical significance was set at p < 0.05.The χFurther, 126 students (16.2%) reported that they had experienced being bullied, 398 (51.3%) reported that they exercised regularly, and 609 (78.5%) answered that they had close friends. t =−1.06, p = 0.30). However, their pre-intervention K6 scores were almost double that of participants without disabilities . According to the previous literature, social support, personal background, and educational environment may affect the mental health conditions of adolescents. These factors were chosen as independent variables for the linear regression model. This study evaluated the impact of a diversity education program on young adolescents by comparing changes in knowledge and attitudes related to diversity, self-esteem, and mental health before and after the program. Regarding knowledge and attitude related to diversity and inclusion, the ratio of correct answers increased from before to after the program for all but two questions. However, the ratio of those who answered correctly remained as low as 20–40% even after the program for about half of the questions. Therefore, this result could not be understood as a meaningful improvement in terms of knowledge and attitude. In addition, in two questions on the importance of listening to the voices of minorities and what is required to understand the feelings and needs of others, the ratio of correct answers decreased. Listening to the voices of marginalized populations and consulting with them are foundational aspects of promoting diversity and inclusion. If the program decreases the number of students who correctly understand the importance of these aspects, the program’s effectiveness in terms of basic knowledge and attitude toward diversity and human rights is doubtful. The current human rights standards recommend listening to the voices of every person to understand their real needs; this is because preferences, contexts, and surrounding environments are different for each person at each time, and decision-making based on stereotypes without consulting the relevant persons could be harmful.Self-esteem generally improved after the program, although the degree of change was small. However, when we examined students who were susceptible to marginalization, such as students with disabilities, no significant improvement was detected between before and after the program.Overall, the mental health scores of the students deteriorated after the program. This might be associated with the fact that the program attempted to examine diversity and inclusion through “pain.” The worsened scores after the program do not necessarily mean poor mental health since many of the changes occurred within the non-clinical range, and the long-term sustainability of the deterioration is unknown. However, there is evidence that debriefing in a group immediately after a crisis situation increases the symptoms of posttraumatic stress disorder; therefore, such debriefing is not recommended . Given tThe development process of this educational program may have affected these results. The development team mostly comprised men who were older than 30 years. Although they had organized intensive consultations with schoolteachers and principals, they did not involve experts on diversity, organizations of persons with disabilities, women, or young people, even though a famous writer who uses a wheelchair engaged in several consultations and appeared in the video material. Moreover, the vendor had only a brief online consultation with a representative of an organization of persons with mental health conditions or psychosocial disabilities upon the request of the organization that hired the vendor. These factors might have negatively affected the program. Further, the results led to the following key lessons:First, since educational programs involve human interventions, especially when children or young adolescents are the participants, it is important for program developers to involve experts. In this way, the interventions will be based on evidence as well as the outcomes and lessons learned from past studies, including meta-analyses ,8,11. ThToday, the importance of key stakeholder participation based on the principle of “nothing about us without us” is increasingly being understood and implemented widely . This prIn this study, many students did not provide correct or desirable answers to questions on knowledge and attitude toward diversity, even after completing the program. This could be because the program was developed without consultation with experts, persons with diversity, and young people themselves; therefore, the program did not include the current and dynamic concepts of diversity and disability. For example, the vendor utilized “pain” as a keyword to explore the world of diversity; this approach may have been effective if it had been based on evidence, good practices, and dialogue with persons with disabilities in consideration of the principle “nothing about us without us” adopted in international guidelines regarding disability policies . Naively2 is low (0.09), and the result and discussion based on logistical regression analysis may have some limitations. In other words, many other factors contribute to the deterioration of mental health among young adolescents, and this study only shows a part of it. Therefore, the interpretation of the results should be cautious. Further empirical studies are desirable.This study has several limitations. The program outcome was evaluated only once, immediately after the program, and the long-term effects are unknown. The evaluation was based on originally developed questions on knowledge and awareness, self-esteem, and mental health. The inclusion of more dimensions and perspectives may be useful. Furthermore, during the study period, while the classes in secondary schools in Japan were conducted normally, there were some COVID-19 restrictions regarding extracurricular activities and traveling across the prefecture. Additionally, fears around the pandemic and the high death rates may also have negatively affected the mental health condition of the participants. Naglkerle RThe findings suggest the importance of scientifically evaluating diversity and inclusion education throughout the development, implementation, and follow-up phases. As diversity, including gender and disability, is closely interlinked with identity, relationships, and mental well-being, education programs can negatively increase stigma, discrimination, and bullying based on social barriers. Efforts to ensure that the education program is based on current knowledge and methods so that it does not deliver incorrect information, increase stigma, and result in harmful practices, must be part of the development process. Diversity-related interventions should include scientific evaluations, mainstreaming the participation of key stakeholders, including persons with disabilities, an evidence- and good practices-based approach, and the “do no harm” and “nothing about us without us” principles as the standard.This study evaluated the impact of a diversity education program on young adolescents. The ratio of those who answered the knowledge and attitude questions correctly increased significantly for most questions, while the ratio decreased significantly for two questions. Self-esteem scores improved significantly after the program, but the difference was very small. Mental health became significantly worse after the program. A logistic regression analysis indicated that lower K6 scores before the program and worse academic grades had significantly higher odds ratios. This indicated the importance of developing processes based on evidence and the “do no harm” and “nothing about us without us” principles.