Interviews wereconducted using the Participation in ACTivities and places OUTside the Home forolder adults (ACT-OUT) instrument. Participants still visited 16(Median) places out of a possible total of 24, and they had abandoned 5(Median) places. Neighbourhood was the place most participants stillvisited, whereas 50% of them had stopped going to a Sports facility, with no significantdifferences between country samples regarding how many participants had abandoned thatplace . There were significantdifferences between country samples in the frequency of present participation andabandonment of the Hospital, Dentist’s office, Cemetery, Garden, and Forest . Although the participants still visited avariety of places, they had stopped going to places previously visited, which indicatesreductions in participation, posing an inherent risk to well-being. The similarities anddifferences across samples from the four countries suggest that healthcare services andaccess to public transport may contribute to the complex interactional process ofout-of-home participation for people living with dementia. The findings highlight the needfor initiatives targeting specific types of places to support continued participation insociety, especially places at a higher risk of abandonment such as places for recreationand physical activity.Social participation in out-of-home activities is important for people living withdementia, yet little is known about such participation. The aim of this study was toexplore and compare out-of-home participation among people living with dementia in fourcountries by assessing different types of places of participation visited or no longervisited. A cross-sectional design was used to gather self-reported experiences concerningout-of-home participation among people with mild stage dementia living in Canada( The Convention on the Rights of Persons with Disabilities  states tParticipation in activities and places outside home is known to be an important contributorto the social health of people living with dementia . ThroughParticipation inACTivities and places OUTside the Home for older adults (ACT-OUT) survey tool,and this was simultaneously done in three languages  using apre-defined method to foster internal validity , Sweden(n = 35), Switzerland (n = 35) and the United Kingdom. Shared inclusion criteria were to have a diagnosis of mildto moderate stage dementia and to live at home. The one exclusion criterion was theinability to communicate during an interview, for example, due to language barriers orsevere hearing or vision impairment that was not compensated by aids. The participantswere recruited through a dementia screening centre (Canada), memory clinics , Swiss Alzheimer’s association (Switzerland), National Health Service centres(the United Kingdom). Complementary information considering participants in each countryis found in In total, 163 participants were included from Canada (p < 0.01). However, there were only two significant post hoc tests;Sweden had a significantly higher rate of granted public transportation service thanexpected, whereas Switzerland had a significantly lower rate (both p <0.001 with Bonferroni correction).No significant differences were found between the country samples based on gender, ageand whether participants had someone who could help them. Significant differences werefound for the variables level of education, living alone or together with someone, drivinga car or not, and if they had been granted a public transportation service or not  survey tool designed to examine the out-of-homeparticipation of older adults (with or without dementia) in relation to places over time.In the development of the ACT-OUT, questions were trialed with older adults without aswell as with dementia (n= 6), B) Places for medical care (n = 5), C) Social,cultural and spiritual places (n = 6) and D) Places for recreational andphysical activities (n = 7). Part 1 consists of yes/no questionsregarding present, previous, and anticipated future participation in activities at theplaces listed. In Part 2, more detailed questions are asked about a couple of places ineach domain, for example, related to activities undertaken in the place, frequency ofvisits, distances and modes of transport. In Part 3, questions about attitudes torisk-taking are asked. In this study, only data from Part 1 were used because our aim wasto investigate participation in places at present and in the past across the fourcountries. In order to harmonise the data collection, all interviewers at each sitefollowed the same procedures by paying close attention to the user manual of the ACT-OUTand they could raise any questions to the research group who constructed the ACT-OUT, Mann–Whitney U test  or Fisher’s exact test . The significance value was set conservatively,*p < 0.01, to reduce the risk of Type 1 errors, and Bonferronicorrections proceeded from that.Similarities across countries were descriptively narrated. Differences between theparticipants from the four countries were significance tested with non-parametricstatistical methods since data either were nominal or ordinal that did not show the sameshape of distribution for each group. Depending on the level of data, number of groups,and assumptions fulfilled, analyses were made either with Kruskal–Wallis H test (withOffice of ResearchEthics at Simon Fraser University (2017s0052) for the Canadian sample, theRegional Board of Research Ethics (2015/77-31-5) for the Swedishsample, the Commission cantonale d'éthique de la recherche sur l'être humain inLausanne (protocol 452/15) for the Swiss sample and the Health ResearchAuthority  for the samplefrom the UK.Information about the study was given verbally as well as in writing before informedconsent was obtained. Each participant’s capacity to give informed consent was carefullyassessed by the experienced interviewers before the interviews. Measures were taken toensure that participants felt safe during the interviews. All participants were informedthat their participation was voluntary and that they could opt out at any time, withoutany explanation. Interviewers were alert to notice any indication of a participant gettinguncomfortable or tired. Ethical approvals were granted by the N = 163) visited was 16 (0–22). In χ2 (3) = 19.03, p < 0.01, with a mean rank of 107.57 forparticipants from Sweden, 80.81 for UK, 79.71 for Switzerland and 56.52 for Canada.Pairwise comparisons showed no significant differences, except for a significantly highernumber of places visited in the Swedish sample (Mdn = 18) compared to theCanadian (Mdn = 13), U = 209.50, z =−4.04, p < 0.001, r = −0.50. The effect measure rindicates a large effect size accounting for 25% of the variability.Of the 24 places outside home included in the ACT-OUT, the median number of places allparticipants  were found between samples from thedifferent countries for the places Doctor’s office, Hospital/Health centre , Dentist’s office, Day care, Senior centre/Social club (hereinafter namedSenior centre), Building for worship, Cemetery/Memorial place (hereinafter namedCemetery), Garden and Forest/Mountain/Lake/Seaside (hereinafter named Forest). Post hoctests were performed with adjusted residual values for the places where Fisher’s exacttest had shown an overall statistically significant difference between samples fromdifferent countries. Post hoc analysis showed no statisticallysignificant differences, with Bonferroni correction, for the places Day care, Seniorcentre and Building for worship, all p > 0.001. Only probabilityvalues that differed significantly from the null hypothesis with Bonferroni correction(p < 0.001) are presented for the places Doctor’s office, Hospital,Dentist’s office, Cemetery, Garden and Forest: Within country, the Swedish sample hadstatistically significantly fewer participants than expected, 26%, going to the Doctor’soffice. In the UK-sample on the other hand, there was a significantly higher rate thanexpected, with 98% of participants going to the Doctor’s office. The Swedish sample had asignificantly higher rate (94%) of participants going to Hospital. The UK-sample had asignificantly lower rate (61%) of participants going to the Dentist’s office. The Swedishsample had a significantly higher rate (83%) of participants going to the Cemetery,whereas the Canadian sample had a significantly lower rate (32%). The UK-sample had asignificantly higher rate (88%) of participants going to the Garden, whereas the Canadianhad a significantly lower rate (48%). Finally, the Swedish sample had a significantlylower rate (31%) of participants who were going to Forest.χ2 (3) = 6.81, n.s, with a mean rank of 91.94 for participants fromCanada, 78.94 from Switzerland, 75.34 from the UK and 60.41 from Sweden.The median number of places the participants had stopped going to were five (min -max:0–18). A Kruskal–Wallis H test showed no statistically significant difference betweensamples from different countries, p <0.01) were found for the Hospital, Dentist’s office, Cemetery, Garden and Forest. p > 0.001. The Swedish sample had a significantly higher rate ofparticipants than expected (31%) who had stopped going to Forest, p ≤0.001. No other countries’ probability values differed significantly from the nullhypothesis. All five places where there was a significant difference between countrieswith regard to the rate of abandonment also had a significant differencebetween countries with regard to present participation in that place.Looking into each place, Fisher’s exact tests were utilised to investigate anystatistically significant differences regarding the number of participants who hadabandoned each place by country sample. Significant differences , Restaurant (Domain C),Friend/family member’s place , Mall (Domain A) andDoctor’s office (Domain B). No statistically significant differences were found acrosscountries for any of these five places. Participants visiting these five places isconsistent with previous research which has indicated the importance of going to theneighbourhood and shopping , and alsAlthough the participants still visited several places, they had stopped going to placespreviously visited. No significant difference was found between the samples from differentcountries regarding the overall rate of abandonment. Looking into each domain, the samepattern emerged as for the presently visited places; a statistically significant differencewas only found for Domain B and C. Participants from the Swedish sample had abandonedsignificantly fewer places for medical care (Domain B) compared to the UK-sample, with amedium effect size. For social, spiritual and cultural places (Domain C), participants fromSweden had abandoned fewer places than participants from Canada, with a medium effect size.A pattern emerges, suggesting that people with dementia living in Sweden may experiencefacilitators to access various places. Another explanation may be sought withintransportation and the journey to and from a place.A specific barrier for people living with dementia is the eventual loss of drivingprivileges. This can increase dependence on others for transportations to destinations oralternative modes of transport. The consequence is decreased participation in non-essentialout-of-home activities compared to those that are considered more essential, for example,medical appointments, or household, for example, grocery shopping . The StoA wide range was noted in the number of participants who had abandoned a place: less than1% had stopped going to a Doctor’s office, but 50% had stopped going to a Sports facility.The places fewest people had abandoned were a Doctor’s office (Domain B), Neighbourhood(Domain D), Day care (Domain B), Restaurant (Domain C) and Garden (Domain D). The placesDoctor’s office, Neighbourhood and Restaurant were also among the top five most frequentlyvisited places presently. The coincidence of high participation in the present time and lowrate of abandonment may indicate that several people living with dementia across countrieswant to, are able to, and have access to visit these places.On the other hand, places with the largest rate of abandonment were Sports facility (DomainD), Cottage (Domain D), Bank (Domain A), Forest (Domain D). The places Sports facility andCottage were also found at the bottom of the hierarchy of present participation. Thedifference between previous and present participation was large; only 40 participants wentto a Sports facility presently, but 81 did go there before. The large rate of abandonmentindicated that either the participants once had more interest in going there, or that theyhad lost access to these places. Previous data from Canada highlighted that places morefrequently abandoned by people living with dementia should be examined closely when strivingto make communities more dementia-friendly . Our finImportantly, we do not claim to generalise the findings to the countries where data havebeen collected. Rather, our ambition is to shed light on the topic of participation inout-of-home places among people living with dementia across a variety of environments thatare both similar and different. A cross-national perspective and understanding ofdestinations in people’s everyday routine seem timely and relevant given the globalemphasis on creating dementia-friendly communities and enhancing community participationamong people living with dementia. Yet, the samples are small and unmatched, and forseveral demographic aspects, the groups of participants differ significantly from eachother across the countries. This discrepancy includes two important variables:transportation, namely, if participants are driving a car themselves, and whether they usea public transportation service. It has earlier been pointed out that driving cessationfollowing dementia usually has consequences for the persons’ participation in placesoutside home . The avaWe need to also acknowledge that there are weaknesses in the ACT-OUT tool that might haveinfluenced the findings. For example, when we ask about the past, we did not define thetimeframe for ‘past’, hence there might be variations in how ‘past’ was understood byparticipants. In addition, we did not ask about frequency of visits to places in the pastversus the present, so such changes might have escaped under our radar .Furthermore, there are variations in access to healthcare services across the fourcountries in terms of the location of services in the community and the affordability ofthe services depending on private or public healthcare systems. Socio-environmental orexternal factors, such as social deprivation of the living environment, may be of moreimportance in influencing the number of places a person goes to, compared to the influenceof individual or internal factors . Future The study showed that participants from samples in Canada, Sweden, Switzerland and the UKvisited a variety of places outside home, despite also having abandoned several places. Tosupport quality of life for people living with dementia through independent and safemobility and access to places in nature and in the community, it is important to identifyplaces that tend to be abandoned, such as sports facilities, where there is a need to takemeasures to facilitate continued participation in out-of-home activities. In this endeavour,the views of people living with dementia should be a guiding principle. This relates to thefundamental objective of developing dementia-friendly and inclusive community initiatives byvarious municipalities in the four countries and beyond through dementia education,appropriate social programmes, service options and built environmental interventions. Thecross-country comparison elucidates that besides environmental factors, public sector areas,for example, healthcare services, and access to public transport, including concessiontravel passes, could be important contextual factors that influence the level of out-of-homeparticipation among people living with dementia.


With the reduction in access to polymerase chain reaction (PCR) testing and changes in testing guidelines in Australia, a reduced number of people are seeking testing for coronavirus disease (COVID-19), limiting the opportunity to monitor disease transmission. Knowledge of community transmission of COVID-19 and other respiratory viruses is essential to better predict subsequent surges in cases during the pandemic to alert health services, protect vulnerable populations and enhance public health measures. We describe a methodology for a testing-based sentinel surveillance program to monitor disease in the community for early signal detection of SARS-CoV-2 and other respiratory viruses.A longitudinal active testing-based sentinel surveillance program for respiratory viruses  will be implemented in some regions of Queensland. Adults will be eligible for enrolment if they are part of specific community groups at increased risk of exposure and have not had a COVID-19 infection in the last 13 weeks. Recruitment via workplaces will occur in-person, via email and through online advertisement. Asymptomatic participants will be tested via PCR for SARS-CoV-2 infection by weekly self-collected nasal swabs. In addition, symptomatic participants will be asked to seek SARS-CoV-2 and additional respiratory virus PCR testing at nominated COVID-19 testing sites. SARS-CoV-2 and respiratory virus prevalence data will be analysed weekly and at the end of the study period.Once implemented, this surveillance program will determine the weekly prevalence of COVID-19 and other respiratory viruses in the broader community by testing a representative sample of adults, with an aim to detect early changes in the baseline positivity rate. This information is essential to define the epidemiology of SARS-CoV-2 in the community in near-real time to inform public health control measures and prepare health services and other stakeholders for a rise in service demand. By 29 August 2022, SARS-CoV-2 had infected more than 596 million people, caused over 6 million deaths worldwide , and indReduced public health measures and waning vaccine immunity against infection increases the spread of SARS-CoV-2 in the community. Initial public health and social measures that successfully controlled the rapidly rising numbers of SARS-CoV-2 cases have been gradually removed. Although COVID-19 vaccination coverage in Australia is high, with over 95% of adults fully vaccinated , studiesSentinel surveillance programs have been used for early detection of other respiratory viral illnesses, including influenza and Respiratory Syncytial Virus (RSV). They have provided reliable and timely data, sometimes pre-dating the increase in positive laboratory samples by two weeks –10. HoweConcerningly, the incidence of other winter respiratory viruses in 2022 could be much higher than in previous years due to waning immunity and reduced circulation of these viruses in the last two years. Given the easing of public health restrictions and reduced number of people seeking testing for SARS-CoV-2, a diagnostic sentinel surveillance program for respiratory viruses, particularly in the lead up to winter, is important to predict another wave of COVID-19, influenza, and other respiratory pathogens. This will also allow vulnerable settings  to take necessary measures, including increased infection control and public health measures during sustained community transmission, to protect their populations and reduce the risk of outbreaks.Targeting a selected population with an increased SARS-CoV-2 infection risk early in an outbreak may allow earlier detection of another ‘wave’. For example, the first surge in case numbers in Queensland occurred in December 2021 after the state borders were opened, with the 18–39-year-old age group among the first to see case numbers rise. Several international analyses found the early warning population included those who work in occupations unable to be performed from home and in environments where physical distancing and effective control measures are challenging –21.This project will implement a testing-based sentinel surveillance program for SARS-CoV-2, influenza, and RSV in local areas over winter. Monitoring trends may help further characterise the epidemiology of SARS-CoV-2. In addition, it may detect signals of increasing case numbers for respiratory diseases, consistent with a new surge that may impact hospital admissions. This would also help establish whether self-collected nasal PCR swabs by untrained individuals have a role in testing-based sentinel surveillance.Longitudinal active testing-based sentinel surveillance program for SARS-CoV-2 with additional influenza and RSV testing for symptomatic participants only.This program will be implemented in collaboration with several Public Health Units (PHUs) in Queensland, Australia. Each PHU will recruit participants from a range of age groups and occupational backgrounds to capture those who may be most at risk of infection.A time-space sampling strategy will be used focussing on location-based populations that may be at risk of contracting a respiratory virus earlier. This probability-based strategy will allow recruitment of members from target populations that congregate at specific locations and times –24. RespThe sample size will be calculated to detect a change of 1% from a hypothesized percent positivity rate based on a 95% confidence interval for each population.≥18 years of agePart of a select community group within Queensland likely to be at increased risk of exposure, for example hairdressers, healthcare workers, police officers, paramedics, supermarket/retail workers, hospitality staff, theme park employees, university and vocational students and schoolteachers.<18 years of ageInability to give informed consentDiagnosis of SARS-CoV-2 infection within previous 90 days. This period was chosen to be reasonably confident that a new detection of SARS-CoV-2 reflects an actual new infection , rather Community groups whose employees/members may be at a higher risk of SARS-CoV-2 infection early in a wave will be identified and approached to participate in the program. This may be through in-person contact, by email or online advertisement. Information about the program will be provided to promote the program within the community group with a link to an electronic registration form. Participant details and consent will be collected as part of the registration form .Participant numbers are expected to decline throughout the program due to withdrawal, loss to follow-up and participant exclusion with diagnosis of SARS-CoV-2 infection (primary endpoint). Therefore, rolling recruitment is expected to be required to retain appropriate study power to detect statistically significant changes in case positivity rate.Participants can withdraw from the program at any time by contacting the surveillance program team directly or completing an online survey (the link will be provided in the welcome pack information). Unless specifically requested otherwise, data collected before a withdrawal will continue to be used in the analysis. After the program, arrangements will be made to gather participants’ feedback.Participant testing will be based on the presence of symptoms and categorised into two streams—asymptomatic participants and symptomatic participants.Asymptomatic participants. Participants will be provided with a welcome pack that includes pre-filled pathology request forms specifically coded to identify inclusion in the surveillance program, pre-labelled nasal swabs for testing use and an instruction sheet detailing the nasal swab self-collection method. Participants will self-collect a nasal swab unobserved once per week for the duration of the program and deposit their swab in a designated collection box at their workplace or other designated site on a pre-determined day. A PHU employee will collect and transport these swabs to the pathology laboratory for SARS-CoV-2 PCR testing. A reminder text message and email will be sent to participants weekly to maximise ongoing participation in the program.Symptomatic participants. Participants who become symptomatic will be asked to attend a COVID-19 testing centre with a ‘symptomatic’ pathology form. This pathology form will be pre-filled with participant details requesting a specific respiratory panel  in addition to SARS-CoV-2. It will be specifically coded to identify inclusion in the surveillance program for data download purposes. Additionally, detailed information on seeking urgent and appropriate medical care for acute symptoms will be provided.Participants who have SARS-CoV-2 detected will be considered to have completed the program and will not be required to provide any further swabs. Those with another respiratory pathogen detected will remain in the program until SARS-CoV-2 is detected on their specimen, or until the program concludes; whichever is earlier.Changes in the proportion of cases of COVID-19 and other pathogens in participants compared to previous weeks, to detect a significant rise in cases.Weekly prevalence of asymptomatic and symptomatic COVID-19 infections amongst participants selected from specific community groups.Weekly prevalence of symptomatic respiratory virus infections  amongst participants selected from specific community groups.Tables Planned data analyses. Missing data will be coded as such. Data will be analysed weekly  as the program will be a quality activity and part of routine public health surveillance.Recruitment of participants will commence in March with weekly testing beginning in April. The Sentinel Surveillance Program will continue for six months from April until September (cooler months in the southern hemisphere). Recruitment will be ongoing until September. New data will be analysed weekly for primary and secondary outcomes. Data analysis will be conducted in October after the end of the program.In this paper, we describe an active testing-based sentinel surveillance program to detect and monitor respiratory viruses, including SARS-CoV-2, in a selected early warning cohort of community groups within a local area. The program aims to report the weekly prevalence to monitor trends in respiratory viruses over winter with the intent of early signal detection of SARS-CoV-2 and specific respiratory viruses . This information will help better understand the epidemiology of SARS-CoV-2. In addition, it may be used to guide public health action and prepare health services for a possible increase in service demand because of increased infections in the community. The surveillance program will be concurrently run over several geographical areas by different PHUs working closely together to ensure consistency in program implementation.The project is a novel active testing-based sentinel surveillance program supporting surveillance objectives of PHUs at the forefront of pandemic and outbreak responses. It will generate accurate local information on disease transmission and epidemiology to allow more measured public health responses with early communication to healthcare systems for improved planning and preparedness. This will help achieve essential care continuity, reducing disruption and improving health outcomes for the population. An evidence-based approach also reassures the community that the public health response remains proportional to risk. Government officials and decision-makers often seek assurance that reported case numbers reflect the true level of disease in the community. However, this cannot be reliably established from the current passive surveillance systems but should be provided through this program.The data generated by the program could contribute to national influenza sentinel surveillance programs, providing additional data at minimal cost to help capture the disease burden of RSV–important as RSV has recently been made notifiable in Queensland.There are several limitations to this study design. First, the program’s design hinges on a large sample size to provide statistically significant data. Workplaces are the target sites, but positive results of SARS-CoV-2 could impact the workforce. This may limit the number of organisations and individuals interested in participating leading to selection bias in the sample population. This program was not intended to be a surveillance system to calculate the burden of disease in the whole population but to detect an early change in a baseline rate of case numbers. People under 18 years were excluded from the study due to ethical considerations around the invasive nature of the procedure. Their exclusion should not impact on the objectives of the program.Testing of symptomatic participants will be crucial but as they are unable to enter their workplace with symptoms, facilitating testing is a challenge. The designated COVID-19 testing centres are an option for this cohort but with limited centres, this may be a barrier to testing. Participants may seek testing outside of this program, for example rapid antigen tests or private pathology laboratories.The gold standard investigation for SARS-CoV-2 infection is clinician-collected nasopharyngeal swab for PCR. However, utilising this method could substantially reduce participation due to the impost of having to attend a testing centre weekly. Given the target sample size, the logistics of clinicians attending workplaces weekly for nasopharyngeal swab collection from participants is difficult. Therefore, self-collected nasal swabs will be used to still achieve reasonable test reliability with few barriers to participation; compared to rapid antigen tests or saliva tests.Studies have looked at the reliability of self-collected swabs for SARS-CoV-2 compared to those collected by healthcare workers. One study found that self-collected nasal and throat swabs were a reliable alternative with concordant results and little difference in results for E-gene and N-gene . AnotherCompared to clinician-collected specimens delivered to a testing laboratory in a timely manner, our methods will result in specimens being transported and stored in uncontrolled environments for possibly extended periods. A study showed that dry swab samples for SARS-CoV-2 are stable at room temperature for 24 hours , but degLastly, testing for all common respiratory viruses on all participants (whether asymptomatic or symptomatic), would provide a much richer data set and contribute to better understanding the clinical significance of asymptomatic infections. However, this protocol has been developed to maximise both utility and cost-effectiveness, so testing regimes are streamlined into two pathways depending on whether the participant has symptoms. This is also to protect laboratory capacity given the anticipated high rates of community testing for respiratory viruses as winter approaches.A weekly summary of de-identified prevalence results with trends will be distributed to all participants during the program. Health service executives will have access to these weekly summaries so that local hospitals can receive timely notification of any signal event through the hospital communication team. Executives from other services involved  will also receive the regular summaries on trends so they can consider tailoring their services accordingly. An overall summary of findings will be presented at the end of the program with a view to publish in relevant peer-review journals and presented at national and international conferences.Throughout the program, team members will have regular meetings to assess the program and discuss amendments to the protocol as required. Any modifications to the program, such as changes in eligibility criteria or testing schedules, will be communicated to participants.The program will be terminated in September 2022 after the end of winter. The program duration may be shortened if a new SARS-CoV-2 wave is detected, given the limited continuation utility after the program achieves its primary purpose. Conversely, the program may be extended if ongoing surveillance is required, for example emergence of a new variant.A formal evaluation will occur after the program to identify strengths and opportunities for improvement. This will enable future programs to adapt procedures towards more efficient and effective practice.


Financially vulnerable consumers are often associated with suboptimal financial behaviors. Evaluated financial education programs so far show difficulties to effectively reach this target population. In our attempt to solve this problem, we built a behaviorally informed financial education program incorporating insights from both motivational and behavioral change theories. In a quasi-experimental field study among Dutch financially vulnerable people, we compared this program with both a control group and a traditional program group. In comparison with the control group, we found robust positive effects of the behaviorally informed program on financial skills and knowledge and self-reported financial behavior, but not on other outcomes. Additionally, we did not find evidence that the behaviorally informed program performed better than the traditional program. Finally, we discuss the findings and limitations of this study in light of the financial education literature and provide implications for policymaking and directions for future research. A growing number of studies show the occurrence of suboptimal financial behaviors among low-income, low-educated, and unemployed consumers. These behaviors range from undersaving  to excesHowever, the literature is not conclusive whether financial education is an effective policy program, both in general and in targeting the financially vulnerable. Literature reviews are inconclusive, either suggesting the effectiveness of financial education e.g.,  or conclThe purpose of our study is to investigate the impact of a behaviorally informed financial education program (BI program) targeting financially vulnerable consumers in comparison to both a control group and a traditional financial education program . Several studies suggest that effective financial education programs require a combination of transfer of knowledge, skill-building, and increasing motivation to create the desired changes in behavior . The traIn collaboration with five Dutch local government and debt counseling organizations, we conducted a quasi-experimental study including financially vulnerable individuals. Using a difference-in-difference design, we compared the BI program with both a traditional program and a control group. We collected data both before the start of the program (baseline) and 6 months later (endline). We estimated the effects on five groups of outcomes (indices): financial skills and knowledge, financial-psychological indicators, financial behavior, financial well-being, and financial situation. In addition, we collected data during the last program session to gain insight into the program-related outcomes. The main finding of our study is that the BI program had a positive impact on self-reported financial skills and knowledge and financial behavior but not on financial well-being and financial situation. Also, the BI program was not more effective than the traditional program.Our work contributes to the existing literature in two ways. First, by developing a financial education program based on behavioral insights and investigating whether such a program could be (more) effective in targeting financially vulnerable consumers. Prior studies have shown that offering the program on teachable moments  and adjuThis paper proceeds as follows. In “Design of the financial education programs,” we discuss the design of both the traditional and the behaviorally informed program. “Materials and methods” describes the quasi-experimental design and sample. In “Data and empirical strategy,” we describe the data and empirical strategy. “Results” discusses our results. “Discussion” concludes with a discussion of our findings and provides some advice for policymakers.In addressing suboptimal financial behaviors and outcomes, financial education programs have traditionally focused on financial literacy as primary determinant. These programs build on human capital theory applied to financial behavior , assuminWe designed a behaviorally informed financial education program using insights from both motivation and behavioral change theories and elements of the traditional program. Similar as for the traditional program, the purpose of the BI program was to foster healthy financial behavior. However, the intended mechanism to reach this goal differs. In designing this program, we assumed that improving financial knowledge and skills is insufficient to foster healthy financial behavior. Individuals often face ambivalence, internal and external barriers, and problems with self-regulation that may prevent behavioral change. Furthermore, the financial problems faced by financially vulnerable consumers may tax their mental capacities required for financial decision-making . For theThe set-up of the BI program differs from the traditional program in three respects: (1) approach, (2) role of the trainer, and (3) assignments  and are easy to recall and to implement. In other respects, the set-up of the BI and the traditional programs are similar. Before roll-out, we tested the BI program in a field setting and improved the program materials. Thereafter, we instructed the trainers of the BI program regarding the foundations, design, and key elements of this program during a full-day training session. Trainers taught either the BI or the traditional program, not both.via their professionals. For field partner 5, some clients participated in the program to complete their budget management trajectory. For field partner 4, most participants enrolled in a financial education program as part of their debt reduction trajectory. We classified the participants as financially vulnerable, considering the recruitment process (mainly among debt service clients and welfare claimants) and the baseline sample characteristics .Participants were recruited from September 2017 to December 2018. We implemented several program rounds for each field partner during the study period and recruited participants before each program round,All potential participants were informed about the purpose of the study, assignment procedures (if applicable), expected efforts (completing surveys), incentives for completing the survey, anonymous processing of the data, and the voluntary character of participation in the study. If people agreed to participate in the study, they signed an informed consent form. A total of 277 participants signed the consent form and completed the baseline survey, while 174 participants also completed the endline survey.We applied different procedures in assigning participants to the experimental conditions. For effect study 1, we planned to randomly assign participants to the experimental and control conditions as much as possible. However, this was not feasible in practice, mainly because in several program rounds, our field partners recruited too few participants to split them into both a treatment and a control group. In these cases, we assigned the main part or all participants to the BI program group to ensure that the program could start with a minimum number of participants. Holding our key principle that all control group participants would be willing to participate in a financial education program, we applied three methods to create a control group. First, some participants were randomly assigned to the control group . Second, we asked potential participants who were willing to participate in the program but could not start directly  to participate in the control group (10 participants). Both these and the randomly assigned participants were invited to participate in the program after completing the endline survey. Third, we recruited an additional group of participants beyond the standard recruitment process. Using a mailing and face-to-face recruitment, we asked people from a similar target group  to participate in the study. To hold our key principle for the control group, we included an additional question in the baseline survey: “Are you willing to participate in a financial education program if you were able and had the time to participate?” We included only participants who answered “yes” to this question in the control group . From the final sample, four participants participated twice in the study; first in the control group and thereafter in the BI program group. Overall, the control group consisted of 33 participants.For effect study 2, we assigned participants to one of the two program groups using the following procedure. For field partner 4, we asked potential participants for their preferred day part (afternoon or evening) to follow the program and assigned them accordingly. To prevent selection bias, we rotated the day part of the programs . For field partner 5, we mainly randomly assigned participants to one of the two program groups. A few participants were assigned according to their preferences for a particular program time. We note that none of the field partners informed potential participants that the programs for the different day parts differed in content. If two or more members of the same household participated in the study (effect study 1 or 2), we assigned them to the same experimental condition. In “Sample information and balancing,” we compare the conditions for both effect studies on background characteristics and outcomes.We collected survey , administrative, observational, and interview data. The baseline survey was completed before or at the start of the first program session. A small number of participants completed this survey before the second program meeting. Participants of both program groups completed the midline survey at the end of the final program meeting. This survey contained different outcome measures than the baseline and endline surveys and focused primarily on evaluating different aspects of the program . The endline survey was administered about 6 months after the start of the program.The main survey mode for all survey rounds was CAWI (Computer Assisted Web Interviewing). A small number of participants completed the surveys using paper and pencil. Thereafter, research assistants digitalized and checked the data. Participants received a cookbook or a gift card of 5 euros for completing the baseline survey and a gift card of 10 euros for completing the endline survey.z-score, for effect studies 1 and 2 separately, by subtracting the control group  mean at the corresponding survey round and dividing by the corresponding control  group standard deviation. Then, we created five groupings of outcomes, each reflecting a specific domain, and averaged the z-scores. Again, we standardized it against the control  group’s mean and standard deviation. As a result, the estimators could be interpreted as effect sizes in standard deviation units relative to the control  group. Below we briefly discuss the indices, underlying individual outcomes, and used covariates We measured this variable using a one-dimensional scale (r = 0.586). Financial-psychological self-evaluation included three items (α = 0.838) measuring financial self-efficacy  measuring to what extent the respondents keep track of their financial affairs. The consuming-consciously scale included three items (α = 0.844) about consciously spending money.The index of financial behavior consisted of three different scales: budgeting, keeping track, and consuming consciously. We measured budgeting using four items developed by α = 0.939), reflecting different stress symptoms related to one’s financial situation. General financial stress was measured by a single item: “In the last month, how often did you experience stress due to your financial situation?” We used the abbreviated scale (α = 0.727) of the This index consisted of three outcomes: chronic financial stress, general financial stress, and a financial well-being scale. Chronic financial stress was measured using a six-item scale , gender , educational level , migration background (dummy variable), partner, children (dummy variable), net household income (log),The midline survey provides insight into the differences between both programs as perceived by the participants, with respect to three categories of outcomes.α = 0.932) and (2) adaptive teaching and activating learning (α = 0.909).Building upon the validated teaching behavior scale of α = 0.821) and (2) overall satisfaction with the program (single item). See We measured two aspects of participant’s evaluation of the program: (1) perceived usefulness of (elements of) the program (α = 0.887), (2) improving financial-psychological indicators , and (3) providing and implementing implementation tools  designed for the BI program. We expected similar scores on the first and higher scores for the BI program on the second and third aspects. See Participants were asked whether the program contributed to (1) improving financial management , differences in baseline characteristics were more pronounced, specifically for income, professional assistance, and income from (self-)employment. To control for these imbalances, we decided to include the above-listed variables as covariates in our regressions. Additionally, we performed a robustness check in which we matched subjects on all background characteristics .We observed non-compliance for effect study 1 see  and non-To estimate intention-to-treat (ITT) effects, we used a difference-in-difference (DID) approach. For the ITT analysis, we compared participants assigned to the BI program group to those assigned to the control group (effect study 1) or the traditional program group (effect study 2), irrespective of whether they received the treatment or not.via treated individuals . Following the guidelines of For effect study 1, we additionally estimated local average treatment effects (LATE) in a two-stage least squares (2SLS) framework which adequately addresses potential selection effects caused by non-compliance. This model assumes that all effects operate In the second stage, we used the following equation to estimate the treatment effects:The parameter of interest is ysis see  and addiFor effect study 2, the 2SLS-apprach was not feasible due to non-take-up among both financial education program groups. As an alternative solution, we estimated a treated-only model in which we compared educated participants of the BI program with educated participants of the traditional program.actual treatment status  added covariates and (2) including/excluding the participants of particular field partners. Additionally, we performed a propensity score matching difference-in-difference model to measure ITT and treated-only effects. In estimating the propensity score, we used a rich set of control variables see  that migThe statistical power of our study may have been reduced by three factors. First, our final sample was relatively small, despite intensive recruitment and survey response campaigns. Second, among those who were assigned to either the traditional or BI program group, some did not complete any of the financial education sessions see . FurtherTo estimate the effects on evaluation scores of program elements , we applied propensity score matching using a set of control variables measured in the baseline survey. We performed these estimations using psmatch2  without We used observational and interview data to evaluate the implementation of both financial education programs. The traditional program was largely implemented according to its design. The trainers of this program discussed all main topics of the workbook more or less in the same order. Sometimes, they discussed additional modules provided in the course materials like “varying income,” “money and children,” and “money and relationships.” As part of their homework, the trainer asked the participants to keep track of their earnings and expenditures during the program period. We found differences across traditional program trainers in teaching the set-a-goal assignment (not taught vs. more prominent role) and seeking interaction with participants (more vs. less prominent role). The trainers involved in our study were experienced and had already run this program for several years.Most elements of the BI program were implemented according to its design. Indeed, trainers paid much attention to the “design-your-program” assignment. The participants’ main chosen topics were budgeting, book accounting, financial administration, and resisting temptations. Furthermore, we found that trainers indeed discussed the stages-of-change model, applied elements of the  interviewing techniques, and discussed the goal-action-plan assignment. Some deviations from the program design were observed. First, during the “design-your-program” assignment, some trainers steered participants to choose topics they found relevant . Second, most trainers did not deliver the rules-of-thumb assignment, possibly due to time constraints. Additionally, both programs regularly had fewer than eight participants. Overall, these deviations from the planned implementation in both programs might have attenuated the differences between both programs, thus limiting the experimental manipulation for effect study 2.p = 0.003) and financial behavior . Thus, offering this program improved the financial skills and knowledge with 0.54 SDs and financial behavior with 0.41 SDs. These results hold under all specifications. In contrast, we did not find significant positive ITT effects on psychological outcomes, subjective financial well-being, and financial situation.p < 0.001), financial-psychological outcomes , and financial behavior . Thus, the effect on financial-psychological outcomes was significant under the LATE-model, but not under the ITT-model. In line with our expectations, the size of the LATE effects was larger than the ITT effects.We conducted the following analyses to check the robustness of our ITT and LATE results: (1) applying a propensity score matching difference-in-difference method, (2) dropping participants of field partners that did not implement a control group, (3) dropping household income as covariate , (4) including two dummy variables for professional assistance , and (5) dropping participants who participated both in the control and BI program group. Our results were robust under these alternative specifications.p = 0.006; LATE = 0.426, SE = 0.179, p = 0.017) mainly have driven the effect on financial behavior. The effects on the other aspects of financial behavior (keeping track and consuming consciously) were also positive, but not significant, as reflected in p = 0.009) were the main driver of the LATE effect on financial-psychological outcomes. We did not find robust significant ITT or LATE effects on other individual outcomes.We conducted exploratory analyses to investigate the ITT and LATE effects on all single outcomes. We found that positive effects on budgeting  alternative specifications (same as for effect study 1), (2) the ITT-model, and (3) treatment assignment based on three or more sessions attended. We exploratively analyzed the effects on all 13 individual outcomes. We did not find robust effects on any of these outcomes.We conducted additional analyses to find out why we did not find differences between the BI and the traditional program. First, we explored the treated-only effects of participating in the BI program on evaluation scores of program elements (using the midline survey) compared to participating in the traditional program see . We expeSecond, we investigated the role of teaching experience as a potential determinant of evaluation scores on program elements. The rationale is that the BI program trainers did not have experience in teaching this program, while the traditional program trainers did have that experience. A lack of BI teaching experience might have negatively affected the BI program scores explaining the non-results for the comparison between both programs. To examine this potential explanation, we considered two types of teaching experience that might have played a role. First, we considered ex-ante teaching experience. We analyzed whether BI program trainers with previous experience in teaching financial education did obtain higher scores than teachers without this experience. Second, we considered on-the-road teaching experience. Trainers taught multiple program rounds and consequently became more experienced in teaching the BI program. We investigated whether BI program trainers obtained higher scores in later program rounds. Overall, we found that neither ex-ante teaching experience nor on-the-road experience in teaching the behaviorally informed program significantly affected participants’ evaluation scores on the program elements.This study aimed at designing a behaviorally informed financial education program targeting financially vulnerable consumers and investigating its impact compared with both a control group and a traditional financial education program. Below, we discuss the main findings, implications, and limitations of our study.offering the BI program improved financial behavior with 0.41 SDs (ITT effect) while the improvement for compliers was 0.56 SDs on average (LATE). Additionally, we found a significant treatment effect of 0.54 SDs (ITT), respectively, 0.76 SDs (LATE) on financial skills and knowledge. For financial-psychological outcomes, the treatment effect was only significant under the LATE-model (0.54 SDs). These results are held under several robustness specifications. Explorative analysis suggested that the effect on financial behavior was mainly explained by a positive effect on budgeting. In terms of program intensity, target population, and study design, our study is most comparable to Our study shows three main findings. First, the behaviorally informed program had a positive effect on financial behavior as compared with the control group. We found that α = 0.05, β = 0.2, and the estimated standard errors the post-hoc minimum detectable effect sizes (MDE) for these outcomes were.66 and.74 SDs, respectively. Furthermore, we should expect smaller effect sizes for the latter two outcomes because these are indirectly related to the financial education program and may require more time and education to develop. We note that financial behavior is positively associated with both financial well-being  and financial situation . This is in line with the literature that predict and find a positive impact of financial behavior  on financial well-being and financial outcomes  differences between both programs. Furthermore, the traditional program already obtained high scores from participants, thus leaving little room for improvement. As a consequence, we cannot provide a final answer as to whether the new elements contributed to the effectiveness of the BI program.We discuss some shortcomings of our study. First, the evaluation period of 6 months between treatment and measuring outcomes is short. We recommend future studies to implement a longer evaluation period, preferably of at least 18–24 months, to pick up possible indirect effects on financial situation and financial well-being. Second, we report a low reliability for the commonly used financial attitude measure. Third, we faced difficulties with the implementation of the field study. We were not able to fully randomize the allocation of participants to the treatment groups. As a consequence, we cannot rule out all potential threats affecting selection, despite our efforts to increase the credibility of the common trend assumption. Additionally, we may have faced a lack of statistical power due to difficulties with recruiting participants, attrition, and partial compliance. An ideal solution to solve these problems is to run an RCT including a substantially larger sample. However, both our study and via professionals) of our field partners in reaching the target population, we faced low take-up and considerable drop-out rates. These issues may reflect a low demand for financial education. Furthermore, not participating can be rational as financial education does not benefit everyone : https://doi.org/10.17026/dans-27y-s77z.The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found below: Codes and data are available (upon request) Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.TM designed the behaviorally informed financial education program. E-JB and TM collected the data. E-JB performed the analyses and wrote the manuscript, while GA and TM provided feedback. E-JB, GA, and TM contributed to the design of the study. All authors contributed to the article and approved the submitted version.This work was supported by ZonMw (535.002.001) and by the Netherlands Organization for Scientific Research (023.005.060 to E-JB).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


This symposium traces the nearly 30 years of development projects, trials, and transformations that continue to occur in efforts to make an evidence-based psychoeducation program (Savvy Caregiver) available to family members and friends who provide care to community-dwelling persons living with dementia illnesses. Savvy seeks to enhance caregivers’ knowledge and skills for providing care and to enhance their competence and confidence (sense of mastery) in being able to guide their persons through days that are as safe, calm, and pleasant as possible. Over this period of time, Savvy has clarified its target participant group (focusing on primary caregivers rather than larger family groups), moved from having concurrent sessions for caregivers and persons living with dementia, continued to develop strategies that enable broad implementation while maintaining program fidelity, demonstrated the effectiveness of a synchronous/asynchronous online version that extends program reach (Tele-Savvy), and is currently exploring in an ongoing pilot how best to deliver a fully asynchronous version of the program that employs continuing education principles (Tele-Savvy@Home). The individual presentations will describe the main developmental milestones  and the structural adaptations that enabled them. Particular emphasis will be placed on design decisions linked to maintaining a psychoeducational orientation and to program emphasis on developing or strengthening caregivers’ self-efficacy for providing effective day-to-day care. Savvy’s experience may help investigators in designing new interventions, particularly online interventions or in considering augmentation or delivery platform change of established interventions.