One-third of US veterans receiving care at Veterans Health Administration (VHA) medical facilities are obese and, therefore, at higher risk for developing multiple chronic diseases. To address this problem, the VHA designed and nationally disseminated an evidence-based weight-management program (MOVE!). The objective of this study was to examine the organizational factors that aided or inhibited the implementation of MOVE! in 10 VHA medical facilities.Using a multiple, holistic case study design, we conducted 68 interviews with medical center program coordinators, physicians formally appointed as program champions, managers directly responsible for overseeing the program, clinicians from the program's multidisciplinary team, and primary care physicians identified by program coordinators as local opinion leaders. Qualitative data analysis involved coding, memorandum writing, and construction of data displays.Organizational readiness for change and having an innovation champion were most consistently the 2 factors associated with MOVE! implementation. Other organizational factors, such as management support and resource availability, were barriers to implementation or exerted mixed effects on implementation. Barriers did not prevent facilities from implementing MOVE! However, they were obstacles that had to be overcome, worked around, or accepted as limits on the program's scope or scale.Policy-directed implementation of clinical weight-management programs in health care facilities is challenging, especially when no new resources are available. Instituting powerful, mutually reinforcing organizational policies and practices may be necessary for consistent, high-quality implementation. In 2006, the Veterans Health Administration (VHA) issued a policy directing implementation of an evidence-based weight-management program to help reduce obesity rates among veterans receiving care from VHA . CreatedNCP took several steps in designing and disseminating MOVE! to ensure rapid adoption and implementation . First, By 2009, nearly all 98.7%) of the 155 medical centers in VHA reported having MOVE! programs in place  with 15 years of experience conducting qualitative research, interviewed 68 MOVE! representatives. He asked each VHA facility to identify the MOVE! coordinator, the program's physician champion , the facility manager directly responsible for overseeing the program, an opinion leader in primary care, and 3 or 4 members of the program's multidisciplinary team . Of the Analysis proceeded in 3 steps. First, we used Atlas.ti version 5.0 qualitative data analysis software  to code the data. Using a codebook informed by the conceptual framework, 2 investigators independently coded the transcripts, compared their coding, and reconciled coding discrepancies through discussion until consensus was reached. Second, we conducted a within-case analysis of facilitators and barriers for each facility. We generated reports of all text segments for each code and wrote memoranda in which we assessed the degree to which the construct emerged in the data (its "strength"), identified themes in the coded data for the construct, and assessed the degree to which the construct positively or negatively affected implementation . We then created a checklist matrix to visually display the construct valences and support the identification of patterns within medical facilities . FinallyAll 10 VHA medical facilities encountered facilitators and barriers as they implemented MOVE! . AlthougAll facilities either had an existing weight-management program or had participated in the pilot phase of MOVE! before issuance of VHA policy. Moreover, all facilities knew that the VHA central office would soon hold them accountable for their obesity screening rates (a key factor leading to increased demand for MOVE! treatment). However, preexisting weight-management programs at 3 facilities provided limited preparation for MOVE! because they focused primarily on healthful eating and offered only group education. In 1 facility, previous programs were perceived as failures, which undermined organizational readiness. Even with pilot-phase experience, 2 facilities struggled to offer the full range of tiered treatment options of MOVE!. Delaying accountability for obesity screening gave facilities time to implement MOVE!; the delay, however, had the unintended effect of reducing the sense of urgency during the interim period, leading to slower MOVE! implementation than interview participants at 2 facilities had desired. Finally, obesity screening rates were added to an already long list of performance indicators at 2 facilities, which may have diluted the motivational effect of such accountability.Interview participants often, but not always, characterized the facility's senior managers  as supportive of MOVE!. In 2 facilities, senior managers allocated resources for hiring staff or purchasing materials during the pilot phase or immediately after the national launch. However, in 4 other facilities, senior management support did not translate into resource allocation until facilities became accountable for their obesity screening rates. Moreover, the support of service-line chiefs for MOVE! was highly variable, ranging from enthusiasm to passive acceptance to skepticism.  Service-line chief support varied as a function of where the MOVE! program was based administratively. In 2 facilities where MOVE! was based in nutrition service, for example, support from the primary care service-line chief was sometimes tepid. In 3 facilities, interview participants attributed variable service-line chief support as a barrier to creating and sustaining a multidisciplinary team approach to MOVE! program delivery.In several facilities, interview participants cited limited resource availability as a significant barrier to MOVE! implementation. Three facilities praised the toolkit that NCP developed for MOVE! implementation and delivery. The national program launch, however, provided no additional funding for facilities to implement MOVE!. With no additional funding, 5 facilities launched MOVE! by assigning existing clinical staff the additional duty to implement and deliver MOVE!. When facilities became accountable for their obesity screening rates, facility managers at 2 facilities proved more receptive to requests to hire full-time staff for MOVE!. In all 10 facilities, however, MOVE! relied heavily on the staff who were personally committed to supporting and delivering the program in addition to performing their other clinical or administrative duties. Four facilities coped with limited staffing resources by involving psychiatric residents, psychology interns, and nutrition students from nearby universities. Interview participants generally reported that MOVE! is understaffed in their facility and that the understaffing limits the number of veterans served, the range of tiered treatment options, and the multidisciplinary approach. In 5 facilities, for example, interview participants reported little or no staff support in physical activity disciplines . Five others reported shortages in behavioral health disciplines .VHA policy required all facilities to assign a physician champion for MOVE! In most facilities, interview participants reported that the physician champion was actively engaged in MOVE! and served as a respected ambassador for the program among primary care physicians and an influential advocate for additional resources. In 2 facilities, however, the physician champion was described as uninvolved in MOVE! or passive as a spokesperson for the program. In these facilities, interview participants sometimes identified the MOVE! coordinator or another MOVE! staff member as an innovation champion. These people, however, did not have the position, prestige, or influence of the physician champion.Primary care physicians are expected to screen patients for obesity, counsel them about the health risks and consequences of obesity, and refer them to MOVE! if they seem interested or ready. Interview participants at 7 facilities noted that primary care physicians strongly believe in the value of prevention and perceive weight management as necessary for reducing illness among their patients and to VHA as a health care system. As a comprehensive, multidisciplinary weight-management program that offers tiered treatment options tailored to patient needs and interests, the MOVE! program fits the values of many primary care physicians. However, interview participants at 4 facilities noted that some primary care physicians doubt the program's efficacy to produce and sustain enough weight loss to make a noticeable impact on patients' health. This skepticism, plus the urgency of patients' more pressing medical issues, led to less support from some physicians.All 10 facilities attempted to tailor MOVE! to better fit their organization's capacity to implement it. These modifications included adding or removing clinical reminders for obesity screening, tailoring procedures for enrolling patients, and offering various levels of the MOVE! program at a facility. Eight facilities noted that primary care nurses and physicians felt that tasks associated with MOVE!, such as the clinical reminder to screen for obesity or attending multidisciplinary meetings, were time consuming and burdensome to already heavy workloads. Two facilities decided to remove the clinical reminder altogether.Enrolling patients in MOVE! was challenging for some facilities. One facility reported patient reluctance to participate in a weight-loss program. Additionally, 4 facilities had difficulty motivating patients to practice behavior changes, such as exercising and eating healthfully, outside of the MOVE! classroom. Implementation of the most basic treatment option — self-management supported by frequent telephone contact — varied among facilities. Four facilities discontinued this level because they had difficulty reaching people by telephone and it was time consuming for staff and volunteers to make calls. One facility could make initial telephone calls but noted that staff availability limited the number of follow-up calls. Another found this level was more convenient for patients living farther away.Organizational facilitators and barriers played a salient role in the implementation of MOVE! — the only nationally implemented, evidence-based weight-management program that focuses on reducing obesity rates among US veterans receiving care at VHA facilities. Of the 6 organizational factors examined in this study, organizational readiness for change and innovation champions were the most consistent facilitators of MOVE! implementation. Management support, resource availability, innovation-values fit, and innovation-task fit either acted as barriers to implementation or exerted mixed effects on implementation.Our findings contribute to a limited body of research on the organizational context of innovation implementation in health care settings ,18. A stThis study had several limitations. Case study research emphasizes depth over breadth and insight over generality ,15. Ten We suggest 2 directions for future research. First, the theory and practice of the multilayered complexities of management support need to be understood. Senior management support is often cited as necessary for innovation implementation ,25-29, bWe also learned 2 practical lessons that may help other health care or public health systems to implement new programs amid competing organizational priorities and a lack of new resources. First, organizational leaders directing implementation of new programs must put into place powerful, mutually reinforcing policies and practices that make implementation expected, supported, and rewarded. Such policies and practices include setting measurable goals for implementation, instituting a realistic schedule for meeting those goals, monitoring progress against goals, recognizing those who meet goals, and holding accountable those who do not. These policies and practices must be clearly and consistently communicated, and they must command the attention of those charged with implementation. Second, the policies and practices must cascade throughout the multiple levels of organizational hierarchy to form an aligned, interlocking implementation strategy. Otherwise, an implementation gap arises between top management and the front line of service provision to veterans.


Yoga is one of the most common forms of complementary and alternative therapies utilized for weight loss. This mixed methods study included quantitative surveys and interviews of participants of a 10-week, bi-weekly yoga and Ayurveda-based weight loss program designed for overweight and obese women. The program involved training in yoga poses, breathing, and philosophy as well as eating mindfully, cultivating relaxation, and compassion.This analysis focuses on the subject interviews which occurred both pre and post program and covered the topics of: (1) hopes and found benefits of the program, (2) anticipated challenges and lessons learned, (3) subjects’ relationships with food pre and post program. Analysis was directed by a grounded theory approach. The interview notes were double coded independently by the two authors. Any disagreements in coding were addressed in discussion. Coding consisted of searching for sought themes and emergent themes in each transcript as well as condensing responses to each topic across the sample.Thirty-seven overweight and obese participants were enrolled  with mean age of 48.3 years. Most were yoga naïve and had tried weight loss programs in the past. The qualitative findings support the trial’s quantitative findings of statistically significant improvements baseline to post program in BMI (p<0.05), and a number of psychosocial variables. Pre-program, subjects reported that they were drawn to the yoga-based program to achieve greater clarity, structure, and security in their lives in addition to losing weight. Post program, subjects reported greater sense of security, self-confidence, self-compassion, and insight into their behavioral motivations. Useful program tools mentioned are: breath work, mindful eating, focus on self-care, relaxation.Our data suggests that participation in a 10-week yoga and Ayurveda-based weight loss program is associated with improvements in reported psychosocial health immediately following program completion.


The Project P.A.T.H.S. is a positive youth development program which attempts to promote holistic development of junior secondary schools in Hong Kong. It is ground breaking in terms of the number of schools participating in the project and financial resources injected into the project. Based on the experiences gained from the implementation of the project and evaluation data collected from 2005 to 2011, several issues pertinent to the development of positive youth development programs in the Chinese culture are discussed. These issues include complexity of program development, importance of training, identification of factors governing program implementation, need for evaluation, and promotion of sustainability of the program in the long run. With the intensification of adolescent issues, increasing effort has been paid to the development of adolescent prevention and positive youth development programs in the global context. With specific reference to Hong Kong, there are also growing adolescent problems such as substance abuse, bullying, and suicide . In respThe basic arguments for having positive youth development program are that many adolescent developmental problems have common origins and that adolescents have potentials and they are resources to be developed. Furthermore, one attractive feature of positive youth development programs is that instead of having many prevention programs for adolescent problems, one single positive youth development program may be enough to tackle different types of adolescent developmental tasks. As the evaluation papers in this special issue and elsewhere clearly demonstrate, the Project P.A.T.H.S. is effective in promoting the holistic development and reducing risk behavior of adolescents in Hong Kong.Shek and Yu  pointed  conceptualization which involves the identification of personal resources  and environmental supports and their combinations that promote social competence in specified domains and/or prevent mental health problems based on theories, research findings, and intervention experiences. The second stage is design in which developmentally and culturally appropriate programs with application of effective classroom teaching principles are designed. The third stage is implementation where the program is adapted to the ecology of the school setting and that mechanisms are used to monitor the program integrity. The fourth stage is evaluation where the researchers examine whether the program is implemented effectively and the program improves the personal resources of the students. The fifth stage is maintenance and dissemination where issues of sustainability of the program and dissemination are considered. In the present paper, discussion and personal reflections with reference to these steps would be carried out.Generally speaking, there are several steps in the development of positive youth development programs. According to Weissberg et al.  there arIn the education and welfare sectors in Hong Kong, there are many “home-baked” youth development programs as if such programs can be easily designed. One common example is that there are life skills or life education programs in many schools which are simply based on arm-chair theorizing and workers' professional judgment. While workers' judgment must be treasured, there is no guarantee that the related knowledge is beneficial to the students in the long run. Therefore, the intervention program to be developed must be guided by research findings and an evidence-based approach is called for. In the Project P.A.T.H.S., the following assertions are maintained in the conceptual model underling the proposed program.Based on ecological models, adolescent developmental outcomes are determined by personal factors  and environmental factors in different systems in the school, family, peers, community, and cultural contexts .Based on the ecological perspective, changes in adolescents and their developmental contexts would be necessary to promote positive youth development .Based on models on holistic health, existential theories, and transpersonal literature, it is important to consider adolescent development in the physical, psychological, social, and spiritual domains and to examine how such factors are related to adolescent development .Based on life span developmental theories, there are different developmental assets to be developed by an adolescent . In connection with this, adolescents have to learn different skills in their developmental trajectory.Risk factors in different ecological systems impair adolescent development .Protective factors in different ecological systems help an adolescent to cope with the negative impact generated by the risk factors .Besides focusing on the reduction of youth problem behavior , focus should also be expanded to developmental potentials of adolescents .Based on the literature on positive youth development, there are constructs that promote positive youth development .An integration of the positive youth development approach and the prevention science approach would be desirable .Existing theories, research findings, and available successful programs will be used to guide the conceptualization, design, implementation, and evaluation of the project .In future, several questions should be carefully considered as far as program development is concerned. Is positive youth development program a panacea to different kinds of adolescent developmental problems? Are different positive youth development constructs equally effective in solving all adolescent developmental problems? What are the theoretical and empirical bases of the developed program? Is the proposed program based on the best available evidence in the field? Ideally speaking, a well-conceived program should specify the theoretical mechanisms that are conducive to the program effects  and underlying the teaching and learning processes, cultural factors that may affect the program design and outcome, and the relationship between the program to be developed and the best available evidence. In addition, multidisciplinary collaboration among different professionals in designing and implementing the program is regarded as the ideal scenario.A review of the literature shows that training plays an important role in the smooth implementation and positive outcomes of positive youth development programs. As such, great effort was spent on training programs in the project, with 20 hours of training required for the potential program implementers at each grade. The following principles were adopted in the design of training programs.It is important for training program designers to be conscious of the theoretical and conceptual bases of the training program.The training program should equip potential implementers with the necessary basic knowledge in these areas.To be an effective program implementer, the worker must know the program well. In particular, the sequencing details involved in different units of the curriculum should be made known to the potential program implementers.To be effective program implementers, potential program implementers must possess appropriate teaching skills, such as communication techniques, varied teaching styles, active participation skills, and open discussion skills.As positive youth development programs emphasize the importance of self-reflection of the program participants, potential program implementers should be helped to cultivate self-reflection skills regarding the implementation process and experiences of the program participants.It is expected that program implementers of positive youth development programs have a strong influence on the program participants through their own experiences. As such, program implementers should be encouraged to serve as role models for the program participants to follow.As there are research findings showing that motivation of the program implementers is instrumental to program success, training programs should promote the willingness of potential program implementers to implement the program.As there are research findings showing that self-efficacy of the program implementers is instrumental to program success, training program participants should be helped to cultivate the belief that they possess the necessary competence to implement the program.To enable potential program implementers have actual personal experiences about the program to be delivered, demonstration with the participation of the trainees is important.To enable potential program implementers to acquire adequate knowledge about adolescents and the designed program as well as to help them develop the qualities mentioned above, adequate training time should be provided for the training program.Cultural adaptation and indigenization must be taken into account in developing the related program. Similarly, the related issues should be taken care of in the development of training program.As good intention alone does not guarantee program effectiveness, evaluation of training programs via different evaluation methods would provide a triangulated picture about the effects of the training program.In the Project P.A.T.H.S., evaluation of the training programs generally showed that the program participants were satisfied with the program, worker and effectiveness of the program , 6. We bIn the Western literature, various factors governing the quality of program implementation have been identified. In the Project P.A.T.H.S., cross-case analyses revealed several conclusions . First, In future, program developers should ask the following questions when they identify the possible process variables that may affect program implementation quality: how would principal support and interdisciplinary collaboration influence the quality of the implementation? What is the extent of program adherence and program fidelity in the implementation process? Is the morale of the program implementers high? If not, how can we promote the morale of the program implementers?For adolescent and positive youth development programs, one crucial issue is whether the programs can really benefit the program participants. In the Project P.A.T.H.S., the following principles are used to govern the evaluation of the project.Objective changes in the participants via objective outcome indicators, including self-report rating scales are important areas considered in the evaluation.The use of multiple objective outcome indicators would give a more complete picture about the program effects.Participants' perceptions of the program  via client satisfaction survey are important data to be considered in the evaluation.The views of the stakeholders, including those of the program developers, program implementers, administrators, and clients, are taken into account.Program implementers' views  of the program are important data to be considered in the evaluation.To adequately understand the program effects and the related contexts, qualitative data are collected.Both quantitative and qualitative evaluation methods can give a more complete picture on the program effects.Both process evaluation and outcome evaluation are included in the evaluation framework.Triangulation of data collected from different sources by different methods would give a more in-depth picture of the program effects.Validated measures are used to assess changes in the program participants.Existing guidelines governing the evaluation of positive youth development or prevention programs of adolescent problems are observed.Evaluation of the program is a continuous and ongoing process.Based on the above principles, different evaluation strategies including objective outcome evaluation, subjective outcome evaluation based on both program participants and implementers, qualitative evaluation based on program implementers and participants, interim evaluation, process evaluation, and personal construct evaluation were adopted in the P.A.T.H.S. Project. In future, the following questions should be considered: what evaluation paradigm should be adopted to evaluate the program? In view of the existence of different strands and methods of qualitative evaluation methods, what qualitative evaluation methods can be used to assess the program? How can we triangulate evaluation findings based on different sources and different methods? How can we promote the workers' awareness of the importance of evaluation in the implementation of positive youth development programs?http://www.paths.hk).There are several impacts of the project. First, the project has impact on secondary schools in Hong Kong regarding holistic youth development curriculum. It provides a useful and practical framework with roughly half of the secondary schools participating in the project. In addition, more than half of the participating schools have included the program in the formal curriculum. Second, evaluation based on multiple methods, multiple data, and multiple informants showed that different stakeholders of the project perceived that the project is beneficial to the program participants and the randomized group trial showed that students participating in the project showed better development than did the control participants. Third, the project is regarded as an important youth enhancement program by the government. It has been regarded as (a) an anti-poverty initiative by the Poverty Commission, (b) a key youth enhancement initiative by the Social Welfare Department, Government of the Hong Kong SAR, (c) a key adolescent prevention program , and a program that can be used for antidrug education in schools (Resource Kit for Teachers on Anti-Drug Education). Fourth, the project has impact internationally. The project has been adapted and implemented in Shanghai and Macau. In addition, more than 100 international refereed publications have been generated from the project. The list of publications can be seen in the website of the project , expectation about the quality of psychosocial preventive initiatives  is not high. While the notion of primary prevention is endorsed by the general public, it seems that it is primarily confined to physical illnesses than psychosocial problems.Obviously, it is a long road to popularize child and adolescent prevention programs and widely adopt them in children and adolescent service contexts. Looking into the future, there are several areas of work that prevention scientists and positive youth development researchers should focus on. The first area is “youth vision” of the government. Government officials must appreciate the importance of primary prevention programs in children and adolescents which will eventually reduce health spending and social costs. Furthermore, without policy support, implementation of children and adolescent prevention programs, particularly school-based programs, would not be possible. As political processes and cultural ideologies strongly affect the policies, development, and implementation of adolescent prevention programs, more attention should be paid to politics and the “political will” involved in advocating for youth prevention programs.The second direction relates to the “dissemination of knowledge about effective programs” is another direction to work on. Dissemination of research on effective programs for professionals working with children and adolescents is important to engage professionals to use the developed programs. Similarly, strengthening the communication between the government and prevention scientists is a key to the development of prevention-focused policies. Furthermore, educating the public (particularly parents and adolescents themselves) about the value of prevention will promote the use of such programs. In the long run, credible databases documenting exemplary and promising programs are also important. It is noteworthy that there are no such credible databases in different Chinese communities, including Hong Kong.Finally, “When we take the first letter in these three areas , the acronym is “pyd” . Definitely, joining hands with the government, other allied professionals, parents, adolescents, and the general public, prevention and positive youth development scientists have to work out strategies that can promote children and adolescent prevention work at the national, regional, and global contexts, particularly in different Chinese communities.


To explore the feasibility and implementation efficiency of Nutritional Report Cards(NRCs) in helping children make healthier food choices at school.Pilot testing was conducted in a rural New York school district (K-12). Over a five-week period, 27 parents received a weekly e-mail containing a NRC listing how many meal components , snacks, and a-la-carte foods their child selected. We analyzed choices of students in the NRC group vs. the control group, both prior to and during the intervention period. Point-of-sale system data for a-la-carte items was analyzed using Generalized Least Squares regressions with clustered standard errors.NRCs encouraged more home conversations about nutrition and more awareness of food selections. Despite the small sample, the NRC was associated with reduced selection of some items, such as the percentage of those selecting cookies which decreased from 14.3 to 6.5 percent. Additionally, despite requiring new keys on the check-out registers to generate the NRC, checkout times increased by only 0.16 seconds per transaction, and compiling and sending the NRCs required a total weekly investment of 30 minutes of staff time.This test of concept suggests that NRCs are a feasible and inexpensive tool to guide children towards healthier choices. A healthy diet is a key component of child health and development. Yet, many American children have poor diets, consuming too many calories In this article, we evaluate whether the “Nutrition Report Card” may be a low-cost, scalable intervention providing parents with information about which foods their child orders at school. Despite its name, the Nutrition Report Card (NRC) does not provide a grade or evaluation of food choices, but rather, simply records which foods are selected over a given time period. For example, it could list how many fruits, vegetables, starches, and snacks were selected and if white or flavored milk was chosen. Even without any action on the part of parents, the NRC could positively influence food choice through the child's perception that parents were observing those choices The NRC is based upon electronic purchasing records and could be e-mailed regularly to parents at little cost to the school. Research suggests that even passive feedback and follow-up increases success of weight loss and weight maintenance in adults The NRC is similar in concept to the Body Mass Index (BMI) Report Card that Arkansas schools initiated. Since 2003, the Arkansas schools have clinically measured and weighed students annually and sent a BMI Report Card to parents After obtaining Cornell University Institutional Review Board approval, a letter was mailed to all parents in a rural school district in New York inviting them to enroll their child in the study. Physical letters were used because the school district did not maintain an e-mail list for parents. The letter explained that the study would examine child nutrition, but did not specify the nature of the intervention until they enrolled their child. Interested parents were directed to a website to enter their e-mail address, their child's information, and consent to the specifics of the study. Due to limited time available for the study, no reminder or follow-up contacts were made and no incentives were offered for participation. This led to a relatively small number of participants. Our sample includes students (n = 35) ranging from grades K-12.Most schools in the United States use computerized point of sale (POS) systems to record student purchases and maintain account balances. While POS systems record purchases with varying specificity, almost all systems are capable of outputting per-item data with student, date, and cost identified. Data recorded in this format would enable schools to generate NRCs similar to those created for this study. While some POS systems are already configured to record meal components, most indicate only if a reimbursable NSLP lunch was purchased. An important step in implementing NRCs is learning which lunch components a district already records and which one the district has the capacity to record.In the study school district, computer systems were configured to record reimbursable meals and the specific names of a-la-carte items prior to our intervention. For the purposes of this study, cash register keyboards were reconfigured by adding three virtual buttons to track selection of fruit/vegetable items, starchy sides, and white milk. These three components were recorded whether purchased as a la carte items, or as part of a reimbursable meal. However, these three buttons were added at the same time as the NRC was implemented. Thus, difference-in-difference style results could only be calculated for a-la-carte items. Cashiers were trained to identify fruit/vegetables and starchy sides (e.g. tater-tots and French fries) within each meal and to press the corresponding virtual buttons. Programming additional transaction keys into POS software systems is a simple task, generally taking less than one hour. In some cases, however, it may be complicated, time-consuming, or even impossible. Even in cases where reconfiguration is simple, adding keystrokes for purposes of data collection increases the time it takes cashiers to conduct each transaction. Thus, to avoid lengthening the lunch payment process, there should be a limited number of food categories that cashiers are asked to identify and record. For this reason, we recorded fruit and vegetable selection in a single category. Additionally, we measured transaction times before and after keys were added to assess the impact of the NRC intervention on transaction times.For the five weeks of the study, purchase data for all students were recorded for analysis. Purchase data for students enrolled in the study were compiled in a Nutrition Report Card sent weekly to their parents by e-mail. The NRC did not grade the student's food choices in any way, but simply noted what had been purchased. For each day of the week the NRC listed 1) whether the student had purchased an NSLP meal, 2) whether the meal included fruits/vegetables, starchy sides, white milk, flavored milk, and 3) each a-la-carte item. The school district's POS system was programmed to record a-la-carte items by name  due to the item-specific variation in price. Thus, the NRC could provide a precise list of a-la-carte items purchased, whereas items included in the NSLP could only be roughly categorized. The NRC did not indicate if the student had purchased food from vending machines or other food outlets within the school grounds but beyond the lunchroom.Data for this study include grade-level, transaction time for each student purchase, a-la-carte purchases, and meal components selected for each student in treatment (n = 35) and control . The grade distribution of students (grades K-12) was similar between treatment  and control . Data for each transaction included a time stamp that identified the day, hour, minute, and second of the purchase. Transaction times were computed by measuring the time, in seconds, between purchases within a school. To avoid mistaking infrequent purchases for slow transaction times, we focus on transactions taking fewer than 20 seconds (84% of both pre-post POS key-change transactions). A-la-carte purchases of cookies, ice cream, and chips were recorded both before and after key changes and NRC treatments and are summarized in To analyze the impact of changing POS systems on transaction times, we compare transaction times in the weeks preceding and following the system change. Analysis of the impact of the NRC on children's food selection, however, is less clear. One should note that parents who chose to enroll their children in the NRC may be different from those who did not enroll their children. Reports of differences in purchasing behavior based upon the NRC are only suggestive and cannot be interpreted as in a true controlled experiment. Our preliminary analysis of the relationship between enrollment in NRCs and a-la-carte selection was examined by using difference-in-difference ordinary least squares (OLS) regressions with standard errors clustered by student.The first objective of the Nutrition Report Card was to investigate whether providing information to parents about the components of their child's school lunch holds any promise of improving what students select for their lunch. A second objective was to investigate the implementation feasibility of the NRC and its impact on transaction times.Despite the small sample size, A post-intervention survey (n = 22 of 35 surveyed) indicated that the NRC encouraged some parents to have nutrition conversations with their children and that they increased children's awareness that their lunch selections were being observed. In open-ended responses, parents expressed appreciation for knowing what their children were eating and reported that the NRCs altered what they served at family meals. Some parents used this as an opportunity for nutrition education . Other parents were interested for economic reasons .A second objective was to investigate the impact of the NRC on transaction times. In the first week, transaction times increase from 6.93 seconds to 7.63 seconds. However, the difference in transaction times decreased steadily over the six-week period to the point where transactions took only 0.16 seconds longer in the fifth week after the change. These findings suggest that adding keys to generate detailed NRCs added only 16 seconds of staff time per 100 students, after five weeks. Additionally, a total of about 30 minutes of staff time each week was required to process data, generate report cards, check quality, and send to parents.This pilot study underscores that a NRC intervention is feasible and efficient. Additionally, while this study was not designed to test the effectiveness of NRC, preliminary results provide hope for their capacity to improve children's food selection. Although the results are preliminary, they suggest that NRCs may be helpful in nudging children towards more healthy, less expensive options and away from less healthy, more expensive ones and to do so at little cost to the school district. Future research should use random assignment and full pre-treatment and post-treatment data collection to rigorously test the effectiveness of NRCs in various types of schools  and at various grade levels .The results of our study related to effectiveness must be cautiously interpreted. Because parents selected their child into the treatment condition, differences in behavior between treatment and control groups may be due to differences in the types of families that would opt into a NRC and those that would not. Thus, our results may overstate the impact of the NRC. This is less of a concern for a-la-carte items for which we have baseline consumption data. This baseline allows us to use a difference-in-differences approach, which can mitigate some of the potential selection bias. Nonetheless, a true test of effectiveness should involve random assignment to treatment. Finally, it should be noted that some families-particularly those of low socio-economic status-may not have access to e-mail at home. This would limit the effectiveness of NRCs to reach some of the primary cohorts of at-risk children.If proven effective in a larger-scale randomized trial, the NRC could be easy and cost-effective for schools to implement. For schools with POS systems ready to output student lunch data and communicate with parents via e-mail, implementing a NRC would require minimal programming and ongoing management. Another attractive component of a NRC is the scalability of such an intervention. Because data processing, report card generation, and email sending are each automated, increasing the number of NRCs a school sends would require little, if any, additional time for NRC administrators. A district providing NRCs for some of its schools could easily add other schools, provided that their data could be formatted similarly. Along with ease of implementation and scalability, NRCs have the attractive feature of engaging parents in their child's decision-making process. This could be especially beneficial to younger children, who are learning to make independent food decisions and can be helped and guided by concerned parents.While NRCs show promise in positively influencing the dietary choices of children, it is worth noting some concerns. One concern is the possible psychological impact of observing and reporting students' eating behavior to parents. Recalling the BMI Report Cards of Arkansas, overweight students did report being embarrassed by measurement. Nutrition Report Cards, while less incendiary, could still make some students feel uncomfortable.Another possible area of concern is strategic student response. If NRCs focus on healthy items taken, such as fruits and vegetables, students may take more healthy items but not actually eat them. Such a reaction by students would undermine the effectiveness of the report card and increase costs to school lunchrooms. While responding strategically to less healthy items on a report card would be more difficult, students could find other means for acquiring less healthy items, such as vending machines or school stores. Being aware of these possible strategic responses can inform research design for future implementation. Despite these challenges, the NRC holds promise for creating an effective and cost-efficient way to involve parents in their child's school nutrition behavior.Appendix S1Sample of a Nutrition Report Card.(DOCX)Click here for additional data file.Appendix S2Sample Code (STATA) to Program Food Service Computer to Send Weekly Nutrition Report Cards to Parents.(DOCX)Click here for additional data file.


Time discounting refers to the fact that the subjective value of a reward decreases as the delay until its occurrence increases. The present study investigated how time discounting has been affected in survivors of the magnitude-8.0 Wenchuan earthquake that occurred in China in 2008.Nineteen earthquake survivors and 22 controls, all school teachers, participated in the study. Event-related brain potentials (ERPs) for time discounting tasks involving gains and losses were acquired in both the victims and controls.vs. non- earthquake) × task (gain vs. loss) interaction for the N300 amplitude, with a marginally significantly reduced N300 for gain tasks in the experimental group, which may suggest a deficiency in inhibitory control for gains among victims.The behavioral data replicated our previous findings that delayed gains were discounted more steeply after a disaster. ERP results revealed that the P200 and P300 amplitudes were increased in earthquake survivors. There was a significant group  and less rational thinking (System 2) in terms of a dual-process model of decision making. The implications for post-disaster intervention and management are also discussed. Disasters have a large impact on cognition and decision-making processes Intertemporal choices – decisions involving tradeoffs among outcomes occurring at different points in time To our knowledge, up till now, only quite a few studies have investigated the effect of disasters on intertemporal choices. By studying the same participants before and after the 2008 Wenchuan earthquake, our previous study Time discounting is considered as a bias deviate from rational choices etal. Furthermore, researchers have recently proposed that there are two distinct systems underlying the decision-making process On May 12, 2008, an earthquake measuring 8.0 on the Richter scale shook Wenchuan, China's Sichuan Province, leaving 69,227 people dead, more than 374,000 injured, and approximately 5 million people homeless . Based on the finding that victims are still influenced by a major earthquake for two or more years after the event The study was approved by the ethics committee of Beijing Normal University and informed consent was obtained from all participants. A written agreement was signed during the recruitment procedure and all participants verbally reconfirmed their consent to participate before the experiment. Specifically, with the assistance of a local teacher, two members of the study team went door-to-door in the selected school to recruit participants. Each teacher was presented with a one-page recruitment sheet that illustrated the ERP study, informing them of the goals, procedures, study criteria, potential risks (including discomfort), research sites and payment, etc. In addition to the verbal description, there was also a picture of a girl wearing an ERP cap on the recruitment sheet to illustrate the ERP method more clearly. After being fully informed about the study, teachers who met the study criteria and agreed to volunteer were asked to write down their names and contact numbers on the recruitment sheet. In addition to the prior signed agreement on the recruitment sheet, all participants verbally reconfirmed their consent to participate before the experiment began.The selected experimental site was the Bayi Middle School, which is located in the town of Yinghua in the rural city of Shifang, Sichuan Province. This school was selected because it was a rebuilt school that accommodated teachers and students from four schools that were severely damaged by the Wenchuan earthquake. There were more than 200 students and approximately 18 teachers died in the tremendous earthquake, with even more injured. A comparable rural middle school located in a town out of the earthquake area was selected as the control school.The participants in the experimental group were 19 teachers from Bayi Middle School who experienced the major earthquake but were not injured. The participants in the control group were 22 teachers recruited from the control school who did not experience the earthquake.The two towns are comparable in their natural/social economic environment; both towns are located at the foot of a hill, and the living/consumer price levels are approximately the same for the two towns. Although there is, to our knowledge, no current data on the Consumer Price Index for the two towns, the descriptions of prices for goods and services when the experiment took place in 2010 may be helpful to illustrate the living/consumer price levels. For example, in both towns the price for a haircut was about ¥20 and for a carwash was about ¥10. The prices of meat, vegetables and fruits were also similar. Financial officials in the two selected schools reported that almost all the teachers earn a monthly salary of ¥3,000 to ¥4,000. There were no significant differences in demographic features between the experimental and control groups see .All participants were healthy and right handed with normal or corrected-to-normal visual acuity. They were paid for their participation after the experiment. The study was performed from September to October 2010, approximately 2.5 years (29 months) after the earthquake.The participants performed the experimental tasks in quiet hotel rooms adjacent to the schools.vs. LL) alternatives at different times (today vs. a month later or 1.5 months later)  See . For eacThe two alternatives for each choice were presented on either side of the screen. Participants were instructed to press the “F” or “J” key on the computer keyboard to indicate their choice.The electroencephalogram (EEG) was recorded from 64 scalp sites using electrodes mounted on an elastic cap , with an online reference to the left mastoid. The horizontal electroencephalogram (HEOG) was recorded with two electrodes placed laterally to the right and left eyes. The vertical electroencephalograms (VEOG) were recorded with electrodes placed above and below the right eye. All inter-electrode impedances were maintained below 10 kΩ. The EEG and EOG were amplified using a 0.01–100 Hz band-pass and continuously sampled at 500 Hz in each channel for off-line analysis. All EEG signals were re-referenced off-line to the average of the left and right mastoids. The EEG data were low-pass filtered below 30 Hz (24 dB/oct) and were corrected for eye movements and/or blinks with the Gratton and Coles' method as implemented in the Brain Vision analysis software . Trials containing EEG sweeps with amplitudes exceeding ± 100 μV were excluded.For each stimulus, epochs of 1000 ms duration including a 100 ms pre-stimulus period were extracted from the continuous EEG record. Because the P200 and P300 components are components commonly found in decision-making processes, we analyzed the P200, P300 and N300 components.In each trial, participants indicated their preferences for SS or LL by pressing the corresponding key. The percentage of SS gain/loss choices in the earthquake-devastated and non-devastated areas are illustrated in p<0.05), suggesting that delayed gains were discounted more by earthquake victims than by the control group. Additionally, fewer trials involving an SS loss were chosen in the earthquake-devastated (72.8%) than in non-devastated (75.4%) area, but this did not reach statistical significance (p>0.05).A chi-square test revealed that the SS options involving gains were chosen more in the earthquake-devastated compared with non-devastated areas (p>0.05).There was no significant difference in reaction time between groups for both gain and loss tasks (vs. loss) as a within-participants factor. Another within-participants factor was the electrode, which included Fz, F3, F4, FCz, FC3 and FC4 for the P200 component; Pz, P3, P4, POz, PO3, PO4, CPz, CP3 and CP4 for the P300 component; and Fz, FCz, C z for the N300 component. These electrode sites were chosen based on the literature Repeated measures analyses of variance (ANOVAs) for each ERP component were conducted with group (earthquake vs. non-earthquake) as a between-participants factor, and with task (gain p<.05). The P200 amplitudes for the earthquake-devastated group were larger than those for the non-devastated group. No other effects were significant.The P200 amplitudes was measured as the average amplitudes of the waveform in a window from 180–220 ms. ANOVAs indicated that the P200 amplitudes differed significantly between the earthquake and non-earthquake groups   = 4.471, p<.05). The P300 amplitudes for the earthquake-devastated group were larger than those for the non-devastated group. No other effects were significant.The P300 amplitudes were measured as the average amplitudes of the waveform in a window from 250–350 ms following stimulus presentation. P300 amplitudes showed significant main effect of group   = 4.288, p<.05). Further simple effects analyses revealed that, for gain tasks, the N300 amplitude was marginally significant smaller in the earthquake-devastated group compared with the control group (p = 0.059). With regard to the N300 amplitude for loss tasks, there was no significant difference found between groups (p = 0.555). In addition, the N300 amplitude for gains and losses showed a marginally significant difference (ps<.1) in both the earthquake and non-earthquake groups.The N300 amplitude was calculated as the average amplitudes of the waveform in a window from 280–320 ms following stimulus presentation. For the N300 amplitude, a significant interaction was found between group and task   = 6.562, Repeated ANOVAs for the P200, P300 and N300 were also conducted with group (earthquake vs. non-earthquake) as a between-participant factor, and with choice (sooner vs. later) and electrode as within-participant factors. The Greenhouse-Geisser correction for non-sphericity was applied when necessary. Only participants with at least 20 trials in either condition (sooner and later) were taken into account. Finally, there were 20 participants  included in the analysis. Only the results for gains are presented in detail because there were insufficient data (too few participants) for losses to allow for a meaningful ERP analysis.p>.05; P300, F  = 0.530, p>.05; N300: F  = 0.008, p>.05) nor the effect of choice   = 0.17, p>.05; P300, F  = 1.432, p>.05; N300: F  = 2.4, p>.05) were significant. It is worth noting that the group effect was significant in the group (earthquake vs. non-quake) × domain (gain vs. loss) × electrode ANOVA. Therefore, the insignificance of choice effect might be due to one of these two main factors: (1) insufficient number of participants and (2) imbalance number of epochs between the sooner and the later choices, which is likely to influence the amplitude of the averaged ERP.ANOVAs revealed that neither the effect of group   = 0.03, Source analysis was performed for components that differed between the groups using standardized low-resolution brain electromagnetic tomography (sLORETA) As shown in In the previous study vs. control) and task (gain vs. loss).The ERP data were of particular importance in specifying the influence of the earthquake on intertemporal decision making. The time discounting task elicited larger P200 and P300 amplitudes in earthquake survivors than in the control group. Furthermore, there was an interaction for the N300 amplitude between group  revealed significant hyperactivity for the earthquake group in the insula (BA 13), cingulate gyrus (BA 31), precuneus  and inferior frontal gyrus . This pattern of findings indicates more activation of emotion-related areas including the insula and cingulate gyrus Our results provided convergent evidence that post-disaster decisions may be less rational, involving more emotional thinking (System 1) and less rational thinking (System 2) in terms of a dual-process model of decision making. First, the behavioral findings that the immediate gains were chosen more by the earthquake survivors than by the control group implies a more irrational tendency among victims, because discounting future gains is viewed as an irrational decision bias which “ought to be resisted” One limitation of the present study is the relatively small number of participants included in the ERP analysis distinguishing between immediate and delayed choices, which may lead to the argument that the statistical approach was not sufficiently robust to produce clearly significant results. Further research is needed to clarify this issue.The findings of the present study highlight the lasting influence of the Wenchuan earthquake and its neural mechanism. The results indicate that immediate gains were more preferred by the earthquake survivors than by people who did not experience the earthquake. It might be inferred from the results that a major natural disaster could cause people to have less inhibitory control and to evaluate future gains as more risky, leading to more shortsighted decisions involving intertemporal tradeoffs. The current data behaviorally and electrophysiologically suggest that post-disaster decisions may be less rational. As mentioned above, time discounting plays an important role in many everyday life problems, such as decisions about investments and savings, dieting, education, marriage, alcohol and drug use/abuse, etc. The current findings can then also be related to theoretical and policy implications for a better understanding of post-disaster behavior and for effective intervention and management in the aftermath of a disaster.


MixtureTree v1.0 is a Linux based program (written in C++) which implements an algorithm based on mixture models for reconstructing phylogeny from binary sequence data, such as single-nucleotide polymorphisms (SNPs). In addition to the mixture algorithm with three different optimization options, the program also implements a bootstrap procedure with majority-rule consensus.http://math.asu.edu/~scchen/MixtureTree.htmlThe MixtureTree program written in C++ is a Linux based package. The User's Guide and source codes will be available at The efficiency of the mixture algorithm is relatively higher than some classical methods, such as Neighbor-Joining method, Maximum Parsimony method and Maximum Likelihood method. The shortcoming of the mixture tree algorithms, for example timing consuming, can be improved by implementing other revised Expectation-Maximization(EM) algorithms instead of the traditional EM algorithm. Theibutions . Unlike ibutions  was doneibutions  and 8]))a mixtuributions . In our ixtures . Any user uses the program needs to cite the MixtureTree website and the papers listed there.The MixtureTree construction project and source codes can be found in the link SC implemented the computational model, carried out the simulations and drafted the manuscript. MR implemented the computational model and biological interpretation. BL participated in summarizing and interpretation the simulation results and revising the manuscript. All authors read and approved the final manuscript.


To the Editor: Roehrig and colleagues described the long-term persistence of immunoglobulin (Ig) M antibody in patients with West Nile virus (WNV) infection, as tested using an in-house Centers for Disease Control and Prevention (CDC) enzyme immunoassay (EIA) (ay (EIA) . This reFifty patients who were WNV IgM positive by 2 commercial IgM kits  during the fall of 2003 were contacted. Sera were recollected and tested for IgM and IgG antibodies to WNV with current kits from these 2 companies. Sera were also tested for hemagglutination-inhibiting (HI) antibodies to WNV (Of 39 serum samples from 38 patients, 28 were positive, 5 were indeterminate, and 6 were negative with the Focus IgM kit. Twenty-one were positive, 3 were indeterminate, and 14 were negative with the Panbio IgM kit. All had WNV IgG antibodies detected by Focus and Panbio IgG kits. We detected HI antibodies to WNV in all patients, and titers in 12 were ≥320. The time course for IgM index values for the Focus IgM kit used in 2003 and 2004 is shown in the These data show that when tests are conducted with newly available kits, as with the CDC in-house test, IgM antibody to WNV persists for ≥8 months in most patients. A single high HI titer is not helpful in identifying recent infection. In addition, the IgM test cannot differentiate between recent and past infections. Interpreting a positive IgM result in WNV-endemic areas will be complex because a positive WNV IgM result could indicate a current acute infection or a previous WNV infection even in a person with a different acute illness.


To present preliminary data from LEAPS into IM, the Leadership and Education Program for Students in Integrative Medicine, an innovative program designed to foster the development of the next generation of medical student leaders in Integrative Medicine (IM). Medical students selected from across North America engaged in hands-on and didactic IM education, leadership skills, self-care, and community building curricula with leading experts serving as teachers/mentors. Our goal was to evaluate LEAPS impact on several IM related behaviors in participants immediately following and several months after the program.Allopathic and osteopathic medical students who completed the LEAPS into IM program in 2010 (N=20) and 2011 (N=30) were surveyed at the conclusion of the week-long program and quarterly thereafter via an anonymous IRB approved survey. Questions explored participants’ utilization of Integrative Medicine resources in self-care and IM referral for family, friends, and patients. Satisfaction with medicine was also measured. Additional questions included other exposure to integrative medicine educational material over time.Students exhibited increased utilization of yoga, group activities, exercise, and healthy nutrition a year after conclusion of the program. A significant drop in group support activity at 6 months correlated with a drop off in return of follow-up surveys and an apparent reduction in satisfaction with standard medical education. Comparison across years showed similar results.The LEAPS into IM Program appears to be effective in enhancing student utilization of select Integrative Medicine resources and referrals. A significant correlation exists between continued engagement with Integrative Medicine and the support given by groups of like-minded individuals.


Although rare, popliteal artery aneurysms form the majority of peripheral arterial aneurysms and are generally asymptomatic. They usually cause embolic events such as extremity ischemia. In this paper, we present a patient successfully treated with endovascular stent grafting for bilateral popliteal artery aneurysm.A 67-year-old woman presented to our clinic with pain at the back of bilateral knee joints. Physical examination showed manually palpable distal arterial pulses and a pulsatile mass at bilateral popliteal fossae. Arterial Doppler ultrasonography revealed bilateral popliteal arterial aneurysms. Multislice computerized tomography showed an aneurysm starting from distal femoral artery and involving entire popliteal artery at the left side and aneurysmal dilatation in both popliteal artery and proximal segment of the anterior tibial artery at the right side. Screening tests failed to show any additional aneurysms at other sites.Both popliteal artery and right tibial artery aneurysms were successfully treated with stent grafts at one month interval. The patient was discharged with full recovery after an uneventful postoperative course.Management of popliteal artery aneurysms are very important because the complications threaten both limb and life.


A well-tested comprehensive Chinese positive youth development program (Project P.A.T.H.S.) developed in Hong Kong has been modified and adapted for use in Macau. This program aims to help adolescent school children develop positively and to be better prepared for their future. The present study investigated the effectiveness of the Tier 1 Program of “P.A.T.H.S.” for Secondary 2 students of two pilot schools. Since there were “repeating” and “transferring” students joining the program, the effectiveness of the program on these particular groups of participants was also examined. The subjective outcome evaluations including participants' perceptions of the program, program instructors, benefits from the program, and overall satisfaction were positive. Although the longitudinal data from the objective outcome evaluation did not show any notable improvement, the overall effect of the program was found to be positive to the new comers in the junior secondary years. The existing evaluation findings suggest that the Secondary 2 program is especially effective to those newly joining the program. In view of the paucity of youth studies in Macau, the present study can contribute to evidence-based youth work and provide baseline data for the program to be evaluated in the Secondary 3 periods in the future. Macau is a small city located near Hong Kong in South East Asia, famous for tourism and an increasing gaming industry. In 2010, the estimated population of Macau was 542,400, and it has a comparatively young population with those aged between 10 and 24 years contributing 22 percents to the total population . This reA well-structured local youth program can potentially help adolescents develop positive growth and ensure that they are better prepared for future challenges in life. At present, youth studies and theoretically sound and comprehensive programs for adolescent positive growth and development in Macau are lacking. , 6. HongMacau has a history of a 15-year free nontertiary education system with direct promotion from primary to secondary school without any public examination. Individual admission examination is required after secondary school education for entry into local universities. Consequently, there is a rather relaxed and less competitive learning atmosphere in the education system. It is not uncommon to see students repeating their studying in some classes in the primary and secondary schools if they find their academic performances unsatisfactory. It is roughly estimated that about 20% of students may repeat their studying in the junior secondary years in many schools . In thisThe study participants included all Secondary 1 students in the two chosen schools, totally 232 starting from year 2009, these were followed up for three years up to Secondary 3. When this group of students was promoted to Secondary 2 year, 43 of them dropped out of their classes and 79 new students either repeating in Secondary 2 or transferred from other schools had joined the program. Data was collected at two time-points during each year. Firstly, before the program started, pretest self-reported questionnaire was completed within 1-2 weeks after the start of the school year. The second data collection time-point occurred after the students finished the program at the end of that academic year. The pretest data Wave 1 (W1) and posttest data Wave 2 (W2) of Secondary 1 had been collected and analyzed [t-test were performed to examine the pre- and posttest differences between the scales, providing an objective outcome measures for evaluation. After completion of the program each year, an evaluation questionnaire was also completed by the participants to assess their satisfaction with the course and perceived benefits of the program, providing subjective outcome measures for evaluation.At pre- and posttests, the participants were invited to complete a valid and reliable questionnaire including measures of positive youth development, life satisfaction, school adjustment, adolescent problem behaviors, and demographic information. An identical questionnaire was used in the pre- and posttests, the paired-samples The two sets of questionnaires which were used in Year 1 were used again when the students were promoted to Year 2. The components in these questionnaires are described below.The Chinese Positive Youth Development Scale (CPYDS) is a self-administrated questionnaire developed by Shek et al. . It consLife satisfaction is another important indicator of positive youth development . The fivThe five-item scale was used to assess the adolescents' behavioral intention to engage in problem behavior, including drinking, smoking, taking drugs, having sex with others, and participation in gambling. The scale has a good reliability  . The CroThe school adjustment measures include three items. Two items assess the participant's perception of his/her academic performance. The third item assesses the participant's perception of his/her conduct. Previous studies showed that these measures were temporally stable and valid , 18. TheThe Subjective Outcome Evaluation Form (Form A) was designed by Shek and Siu . The Forμ ± SD = 15.08 ± 0.87) was higher than that of the old group (μ ± SD = 13.87 ± 1.11). Details can be seen in In total, there were 268 and 244 students who participated in the Wave 3 pretest and Wave 4 posttest, respectively. Out of 268 Secondary 2 students, almost one-third of them, 79 (29.48%) were students who were new to the program. Once invalid questionnaires were discarded, mainly due to missing data, 236 questionnaires were appropriately completed for analysis. There were 173 old participants and 63 new participants . Resultst-test to compare the W3 and W4 data of the program, revealed that there was a nonsignificant decrease in the score of CYPDS, SA or increase of LIFE. Besides, there was a significant slight increase in the score of BI (t-test to compare the W3 and W4 data of the new participants, results showed that there was significant improvement in EC, CC and ID subscales, LIFE, and SA scores. However, there was a significant decrease in BO subscale and an increase of score of the BI scale.The overall evaluation of all Secondary 2 students, using the paired re of BI . To assere of BI . As therIn this study, the participants' perception of the program and their program instructors were evaluated positively. With regard to their perception to the effectiveness of the program, and the overall satisfaction, results provided a positive feedback. Overall, subjective outcome evaluation generally supported positive perceptions to the program, program instructors, benefits from the program, and overall satisfaction with the whole course, these findings are consistent with those reported in Hong Kong , 21. HowWith regard to the objective outcome evaluation, our findings showed no significant improvement in the Secondary 2 program at posttest, which is inconsistent with findings in Hong Kong . There mHowever, when the W3 pretest data of the old participants were compared with those of the new inexperienced participants, the findings generally showed that the old students performed better than the new ones. This was evidenced in terms of the global positive youth development and school adjustment indicators. Even with control for age, results still revealed that there was an improvement in positive identity subscale and life satisfaction scale. This comparison may demonstrate the effectiveness of the Secondary 1 program. Furthermore, when comparing the W3 and W4 data of this new group of students, significant improvement in different youth subscales, life satisfaction, and school adjustment measures was noted. This evidence supports the effectiveness of the Secondary 2 program in this group of students. One possible explanation may relate to the nonacademic nature of the program, so it may be more receptive to those whose academic performance is of average or below academic standard. As this group of students is older than the students who were promoted from their original schools, most of them are probably of average or lower standard. Another reason may relate to the fact that this is a new program and may attract their interest more than the older students. Conversely, the decrease in bonding score could be attributed to taking more time for them to develop new friendship, because of the repeating in Secondary 2 or adapting to a new school. More attention and further study are warranted in relation to the behavioral intention of alcohol consumption in this group.Subjective outcome evaluation highlighted positive results from all participants. Although the longitudinal data from the objective outcome evaluation did not support any improvement, the effect of the program was found to be positive to the new comers in the junior secondary years. Therefore, in conjunction with the previous findings and based on the objective outcome evaluation, the Secondary 2 program is effective, particularly for new comers of the program. There are several limitations of this study. Firstly, only two schools are involved and the sample size was relatively small, raising the potential for sample bias, and it makes any generalization of the findings difficult. Secondly, the present study is based on a one-group pre- /posttest design which may not be the most appropriate. Other approaches such as the randomized control trial which can provide a more rigorous design to give more insight on the effectiveness of intervention program could have been considered. Thirdly, a comparative portion of students dropped out of the program which may affect longitudinal observation and observation of long-term effects. Finally, if the program is more beneficial to those with below average academic performances, and if some of them may have to repeat studying in Secondary 1 and lose the chance to be followed up, the evaluation of the program will be incomplete. Nevertheless, with the current paucity of youth studies in Macau, the present study can contribute to the understanding of the potential benefits of evidence-based youth work and provide further baseline data for evaluation of Secondary 3 periods in the future.