The organized colorectal cancer (CRC) screening program in the canton of Vaud, Switzerland offers citizens the choice of the faecal immunochemical test (FIT) or colonoscopy via a visit with a family physician (FP). Given the central role of FPs in the program, this study aimed to compare their self-reported preventive practices with the objectives of the program, namely to inform patients about CRC screening and present the choice of colonoscopy and FIT, and to identify factors associated with presenting a choice of tests.Mixed-methods study using an online survey and semi-structured interviews. Participants were FPs from the canton of Vaud who had included ≥1 patient in the screening program. We used multivariate logistic regression to compare FPs offering only colonoscopy to those who offered a choice of tests or FIT.n = 86, 33%) was the principal reason cited for not informing patients. Regarding the screening methods, 20% (n = 36) of FPs prescribed only colonoscopy, 13% (n = 23) only FIT and 65% (n = 115) both screening methods. Predictors of offering only colonoscopy rather than a choice of screening tests included: first, FP reporting that they chose/would choose colonoscopy for themselves ; second, being > 20 years in practice ; and third, seeing 300 or more patients per month . When asked what could improve the program, 17% (n = 31) wrote that patients should be informed in advance about the program by postal mail and a large-scale communication campaign.The participation rate was 40% (177 respondents / 443 eligible). Most FPs (68%) reported informing more than 75% of eligible patients about the program. Lack of time (The majority of FPs reported CRC screening practices consistent with the objectives of the program. However, to ensure that patients are well informed and to save time, all patients need to be systematically informed about the program. Further, FPs should be encouraged to offer a choice of tests. The burden of colorectal cancer (CRC) in Switzerland is substantial, with 4100 new cases per year . PopulatA screening program using semi-quantitative faecal immunochemical testing (FIT) and screening colonoscopy was implemented in canton of Vaud, Switzerland in 2015 . The aimIt is widely recognized that, in addition to having an essential role in primary prevention, FPs are key partners in screening programs, especially CRC screening. The active participation of FPs increases the successful implementation of a screening intervention . They arThe role of FPs in the CRC screening program deployed in the canton of Vaud is critical to its success. Given that no study had been conducted on their actual involvement in this public health intervention 3 years after its launch, we conducted an evaluation of their role and level of satisfaction. The aim of the present study was to compare the preventive practices of FPs involved in the CRC screening program with the objectives of the program, specifically “informing patients of the program” and “presenting the choice of colonoscopy and FIT”, and to explain the convergence or non-convergence between program objectives and current practice.We performed a mixed-methods assessment of FPs’ involvement in the CRC screening program in the canton of Vaud using quantitative data from an online survey and qualitative data from semi-structured interviews. Ethics approval is not required in the canton of Vaud for anonymously collected data of health professionals . HoweverParticipants were FPs from the canton of Vaud who had included at least one patient in the CRC screening program since 2015. In 2016 there were 512 FPs registered to practice in the canton of Vaud . At the surveygizmo.com (supplementary files). The internet link was sent on 08 June 2018 to each FP’s professional e-mail address through the FVDC with a 20-day deadline to reply. A reminder e-mail was sent on 19 June 2018. Our primary outcomes were FP’s responses to the question “What proportion of your patients aged 50 to 69 do you inform about the screening program during their first 3 consultations?” and “What screening method do you offer?” We also collected information about FP’s views of the program, patients included to date, personal prevention practices, and FP’s practice characteristics. The final question in the survey was whether the FP agreed to be contacted again for an interview. If they agreed, they could give their e-mail address. The survey was closed on 29 June 2018.The survey consisted of 28 questions and was created on To evaluate whether the objectives proposed by the program had been achieved, we defined a priori the minimum target to be reached to fulfil the program objectives: more than 50% of FPs inform 75% or more of their eligible patients; and more than 50% of FPs offer both screening methods. The 35 FPs who provided their e-mail address during the online survey were contacted for an interview. Ten face-to-face meetings were scheduled during July 2018. The remaining 25 FPs were not interviewed due to non-response on their part or unavailability during the time provided. Semi-directive interviews, lasting ~ 20 min were conducted using an interview grid . We asked about: general preventive practices, response to a vignette of a 55- year-old male who was going to his doctor for back pain due to osteoarthritis, who smoked one pack a day and had no high risk criteria for CRC; information about the program; approach to CRC screening and screening methods used; and finally, their opinion about the program.surveygizmo.com platform to Stata. Data are presented as numbers and percentages. First, descriptive analyses were used to present FPs’ characteristics. Univariate and multivariate logistic regressions were used to find associations between FPs’ characteristics and first, whether they informed > 75% of their patients, and second, whether they reported offering only colonoscopy vs. a choice of screening tests. We chose to dichotomize these variables in this sense because proposing both screening methods or FIT alone can improve participation, as opposed to recommending colonoscopy alone, which can reduce adherence to CRC screening ); second, being > 20 years in practice ; and third, seeing 300 or more patients per month  were significant  were satisfied with the overall organization of the program and 71% (n = 125) were satisfied with the procedure for including a patient in the program regardless of the method used . 87% (n = 155) of FPs believed they play an important or very important role in the implementation, specifically in the conduct of the program. As for the free-text question about improving program implementation, 19% (n = 31) of respondents indicated that patients should be better and more informed in advance through postal mail and large-scale communication campaigns.Most of the FPs  physicians interviewed proposed the two methods, however 2 (20%) of them influenced the patient to turn to colonoscopy. Finally, 3 (30%) FPs only offered colonoscopy “I’m more in favour of encouraging people to do a colonoscopy right away and not necessarily go through the FIT, because I think as long as they’re thinking about getting screened, you want to have the most effective screening possible right away”. One of the explanations given for this choice of method, colonoscopy, was the perceived low sensitivity of the FIT test. A FP aged over 50 said: “I am very for colonoscopy, I think that’s how we were “raised”. Before, we only had Guaiac for blood in the stool and they were really bad.” All but one of the FPs interviewed didn’t use decision aids during their consultations. The one using it said, «Yes I use it. It saves time ».n = 1, 10%), that sometimes they just forgot  and a lack of time .FPs were also asked about their role in the CRC screening program of canton of Vaud. All participants responded that their role was to inform patients about the program. The factor that made it easier to inform a patient for 6 (60%) FPs was if patients were informed of the program in advance of their consultation. Various obstacles were raised, such as the availability of gastroenterologists  were more likely to have patients reporting enough time to discuss CRC with their FP . But, a Lack of time was the major factor that influenced the differences between FP practices and the objective of the program to “inform patients of the program”. Regarding this barrier, the majority of doctors noted that it would be appropriate for all eligible persons to be systematically informed of the existence of the program through a postal letter or a large-scale communication campaign. This recommendation, also raised during a survey on colorectal cancer screening in Geneva , would aThe implication of these results for the CRC screening program of canton of Vaud is that FPs should be trained in both screening methods and shared decision-making consultations so that the FP’s personal opinion has less influence on his or her method proposals and so that FPs with more years of experience can become familiar with the FIT test.The strong point of this study was the response rate to the online survey, which was 40%, a relatively high rate compared to other similar surveys conducted in the Canton of Geneva (19.4%), Neuchâtel and Jura (29%) and Valais (36%) . In addiHowever, some limitations of this study should be noted. First, since participation was voluntary, we may have a selection bias as FPs’ interest in prevention in terms of colorectal cancer screening might have been a driving force for participating in the survey. Further, we limited our sample to the 89% of FPs registered with the program; however, even if we assume that the additional 11% do not inform 75% of their patients, we would still have greater than 50% of FPs informing 75% of the patients, our pre-determined threshold. Some results are likely to be overestimated due to desirability bias, especially as we relied on FP reporting and not actual practice. However, regarding this desirability bias, the FPs interviewed were very direct and honest. Another limitation of this study was that the survey was conducted with variables in dichotomous categories, limiting precision. If we had conducted this survey with continuous variables such as age, we might have had stronger associations with the outcomes of interest. Finally, differences between physicians may be confounded by differences in the composition of their patient panel, as patients’ conditions, illnesses, patients’ demographic condition, and population characteristics may affect FPs’ choices.In conclusion, FPs report taking their role in this program seriously and providing care consistent with the program objectives. In order to ensure equal information and to gain time, patients should be systematically informed in advance by postal mail and large-scale communication campaign. It is planned that the information brochure will be sent to the entire eligible population. However, at present, coverage is not complete. The program starts gradually over 5 to 7 years and the mailings are done in a segmented way. In addition, in order to increase the participation rate, it would be important for FPs to offer both screening methods to patients. To encourage this, physicians should be trained in both screening methods and in the shared decision-making that allows the patient to make a free and informed choice. Finally, in order for FPs to have more time available for patients to explain the two screening methods, better reimbursement could reduce pressure to see high volumes of patients.Additional file 1. Survey questions, survey questions on surveygizmo.com used for the quantitative results.Additional file 2. Interview guide.


The incidence of melanoma increased rapidly throughout the last decades, with overexposure to ultraviolet (UV) radiation being an established risk factor. Due to their intensive sun exposure, many student athletes (SAs) have an increased risk for skin cancer. The Clever in Sun and Shade Program (CSSP) aims at enforcing positive attitudes toward UV protection (UVP) and at supporting sports schools in establishing UVP strategies.n = 20), teachers (n = 5), school administration (n = 2), and coaches (n = 5). Materials were then adapted. Program acceptance and feasibility were tested at two further schools (convenience sample 2) with PPP groups of students (n = 95) and school administration (n = 2). Content analyses and descriptive statistics were conducted.CSSP was developed in 2019 using participatory program planning (PPP) as well as following WHO recommendations for UVP at schools. After drafting first material, within a PPP groups were conducted at a partner school (convenience sample 1) with students  used predominantly positive adjectives such as “important” and “positive” to describe the completed videos and the behavior self-check poster.German Olympic Sports Confederation and German Cancer Aid in 2021.PPP process has greatly influenced concept and materials of CSSP for sports schools. Integration of future program participants has proven to be an important component in creating a fitting and feasible program. CSSP for sports schools is a program free of charge that enables sports schools to integrate UVP into their daily routine. It will be disseminated in cooperation with  The incidence of skin cancer has increased substantially throughout the last four decades. In Germany, the incidence for malignant melanoma has more than quintupled since the 1970s. In 2016, around 23,000 people developed malignant melanoma and 230,000 people non-melanotic melanoma for the first time . Many heTherefore, the demand for UVP in young competitive athletes who practice outdoors frequently is high.Interventions to promote UVP should follow WHO recommendations  . FurtherCSSP aims at supporting sports schools in establishing UVP strategies and at enforcing positive attitudes toward UVP. The paper describes CSSP development using participatory program planning (PPP) as well as following WHO recommendations for UVP at schools.Participatory program planning (PPP) includes target group members in the program planning process and changes program development from a top-down to a rather shared approach. The likelihood of a program to succeed will rise with a better fit to individuals’ needs and experiences .In developing CSSP, one part of the PPP group was psychologists and public health professionals organizing the PPP process and preparing program material. To include future program, participants’ views and experiences, another part of the PPP group were potential program participants. Relating to sun protection for young athletes in sports schools, different target groups have to be regarded, starting not only with young athletes but also with coaches, parents, teachers, and school administration.PPP consists of components that, when considered correctly, not only improve program development and implementation but also its future evaluation . The PPPBefore target groups were included in program development, a concept for design and materials of CSSP was drafted based on purpose and goals as well as program theory Table .Deutscher Olympischer Sportbund).For developing a UV-protection program for sports schools via the PPP approach, a convenience sample of three schools was chosen out of the 43 “elite school of sports” that is supported by the German Olympic Sports Confederation , 498 students are taught by 41 teachers plus 9 sports teachers/coaches. At partner school 2 , 240 students are taught by 17 teachers plus 8 sports teachers. At partner school 3 , 482 students are taught by 53 teachers plus 9 sports teachers.At partner school 1 . In January 2019, three PPP group meetings were conducted with members of the potential participating group of students (n = 20), teachers (n = 5), and coaches (n = 5). School administration (n = 2) were also part of the meetings as representative stakeholders. Participating teachers were teachers of biology, German, physics, art, and social studies. The need for UVP in young athletes as well as the purpose of a UVP program for sports schools were presented to group participants and in succession discussed, also in regard to survey present UVP behavior as well as barriers for UVP in training and competition. Within the meeting with coaches, options for promoting sun protection during training were discussed. Within the meeting with teachers, options for addressing sun protection as a topic in class were highlighted. First drafts of CSSP materials were then assessed in all PPP group meetings, especially focusing on acceptance. Students answered a short questionnaire about the 14 video drafts: acceptance was surveyed with the question “How do you like the idea for the video?” and measured with a four-point Smiley Face Likert scale . Identification with the videos was asked with the question “What video can you identify with?”. Students could then apply adhesive dots at printed drafts of the videos according to their identification with the video idea. Observations as well as the spoken word of the PPP group meetings and the interviews were recorded. UVP behavior-frequencies from students and coaches were subsequently analyzed. Based on the four-point Smiley Face Likert scale, frequencies of acceptance were analyzed as well as medians and interquartile ranges for each video draft targeting SAs. Regarding identification with program material, frequencies of dots adhered to printed drafts of videos targeting SAs were also evaluated. Descriptive analysis was conducted with Microsoft Excel 2016. Content analysis of the PPP group meetings’ records were conducted and opinions and statements of the participants were extracted.Program concepts and materials were evaluated at n = 21), trainers (n = 2), one teacher, and one parent as actors.Based on the results of PPP-group meetings in sample 1, posters, drafts for the videos, and further material were adapted. The video spots were produced in May and June 2019, at partner school 1, including students (Sportoberschule Dresden (partner school 2) and Sportgymnasium Dresden (partner school 3) which are also supported as “elite schools of sports” by DOSB. Feasibility was examined via structured interviews with the two school principals before and after conducting CSSP. In four PPP group meetings with students of grade 5, 7, 9, and 12 (n = 95), UVP behavior and acceptance of videos and posters were surveyed. All students were asked to indicate their identification with the videos, applying up to five adhesive dots at printed images of the five produced videos answering to the question “What video can you identify with?”. Regarding the acceptance of videos and poster, SAs were asked to select adjectives to describe their impressions, e.g., “important,” “positive” “moving” “boring” “irritating.” Three out of the four PPP groups  selected up to 5 out of 15 positive and 11 negative adjectives for the videos as well as the behavior-check poster. Observations and interviews in partner schools 2 and 3 were also recorded. In a first step of data analysis, frequencies of selected adjectives were calculated. Frequencies are depicted in word clouds. In a second step, it was examined whether students chose more positive than negative adjectives. Therefore, the differences  between positive adjectives (x_ki) and negative adjectives (y_ki) were calculated for each video (k1-k5) and the poster (k6). Based on the differences, a dichotomous variable “predominantly positive adjectives selected” was calculated for each video and for the poster with the values “yes”  and “no” . Subsequently a new variable was calculated, summarizing results of the videos. The variable indicates whether more than half of all rated videos were described with predominantly positive adjectives (“yes” if (∑p_ki/2)>2; “no” if (∑p_ki/2) ≤ 2; i = 1-5). Identification with videos targeting students was analyzed by calculating absolute and relative frequencies of adhered dots. Descriptive analysis was conducted with Microsoft Excel 2016. Analog to content analysis in sample 1, records of PPP group meetings were analyzed by extracting opinions and statements.In September 2019, CSSP was piloted at The application of the PPP components introduced by Nichols  in regarThe theories underlying CSSP (7th component) are the health action process approach  and SocPurpose of CSSP on the organizational level is to support sports schools in establishing UV protection strategies. CSSPs’ conceptual design is a project kit free of charge that enables easy implementation of UVP into sports schools’ daily routine, providing easy-to-use instructions for activities and materials. In the process, schools can document their participation and apply for the Clever in Sun and Shade award. On the individual level, CSSP wants to enforce positive attitudes, intentions, and behavior toward UV protection.Including organizational and individual level, CSSP material was drafted, covering wording to incorporate UVP into house rules, award criteria, a behavior self-check poster, and short videos on UVP targeting teachers, coaches, parents, and students. Drafts of CSSP material are presented in Table To illustrate the changes made following the PPP group meetings in partner school 1, the results of steps 2 and 3 will be presented together. First, results in relation to attitudes toward UVP, UVP behavior, and barriers to UVP will be reported, followed by reports on adaption of program material.Sportgymnasium Neubrandenburg (sample 1). Participants of the PPP group meetings were members of the potential participating group of students , teachers , and coaches  as well as school administration  and social worker . Teachers of biology, art, physics, English, and German participated. Students were in grade 9 (n = 3), 10 (n = 6), and 11 (n = 11). Among the participating students and coaches were canoeists, soccer players, track and field athletes, and triathletes.In January 2019, three PPP group meetings were conducted at Being asked about their attitudes toward UVP, 4 of 5 coaches (80%) reported a positive attitude, emphasizing statements such as “it’s important to regard UVP.” One coach described sun protection as “more than just relevant.” In addition, another coach reported a negative attitude toward tanned skin, because it “draws so much energy” that athletes need for their performances. When looking into actual UVP behavior, no coach reported adequate UVP behavior according to recommendations  for themselves as well as not emphasizing UVP behavior for their athletes. Some coaches stated their responsibility toward their athletes whereas others emphasized individual responsibility of SAs.n = 2) reported to meet UVP recommendations. Track and field athletes reported that, if anything, they protect themselves with sunscreen in the stadium, whereas baseball caps and sunglasses are rarely used. SAs also report a desire for tanned skin as well as a use of UVP only when the weather is especially hot and sunny. One student said that he only protects himself “when the first sunburn has arrived.”Of 20 SAs taking part in the PPP groups of sample 1, less than 50% agreed to the importance of UVP and that their attitudes toward UVP are positive. Regarding their present UVP behavior, only 10% of the students , predetermined times for training, obstruction by UVP in performing , and the lack of shade at training facilities . Ideas to overcome barriers have been mentioned by the coaches, for example, rubbing hands with sand after applying sunscreen, adapting time, and location for training if possible, e.g., for triathletes, using rules to support UVP behavior . Students affirmed their willingness to accept behavioral rules set by their coaches.Students of sample 1 examined the behavior self-check poster and required more directive UVP messages  instead of questions as well as images of negative consequences of missing UVP like skin cancer or sunburn on the poster. They also stated to prefer photos to a drawing and icons of UVP, especially if they have recognition value, to ticks or thumbs up/thumbs down. The poster has then been adapted to the needs of SAs and was adjusted by gender to target females and males , scope 2 “planning a UVP strategy” and scope 3 “reactivating UVP in the following year.” The manual also describes barriers according to literature and PPP group discussions. Furthermore, a website  was crean = 12). In preparation of step four, the first versions of the videos were uploaded on the project website.The videos were produced in May 2019 at partner school 1 Fig. . In JuneSportoberschule and Sportgymnasium Dresden in September 2019. The interviews were conducted with a male (partner school 2) and female (partner school 3) principal. The PPP groups (n = 95) with students of grades 5, 7, 9, and 12 consisted of 58% male students. Fifty-seven percent of the students performed soccer, triathlon, track and field, canoeing, rowing, and tennis (n = 54), 43% (n = 41) performed indoor sports such as speed skating but also conducted endurance training outdoors.The fourth PPP step comprised piloting CSSP at n = 64; grade 7, 9, 12) is shown in Table Data on acceptance of each video targeting SAs and the behavior self-check poster from students  could identify themselves with the video “For team players,” followed by “For the clever” and “For the ambitious,” varying with class level  in September 2019. Program posters were placed in the schools’ entrance halls and in the cafeterias. The behavior self-check posters were placed in corridors, locker rooms, and above washbasins in the student restrooms. Both schools informed about participating in CSSP on their website. In partner school 2, the principal informed teachers and coaches personally or with a notice including a reference to the video messages about CSSP and UVP. Students were informed by teachers or written notices and invited to watch the CSSP videos. Furthermore, teachers showed video messages in class. Partner school 3 planned to inform students, teachers, and coaches by email, but due to technical difficulties in the mailing system, the target groups were informed with written notices.Both principals gave positive feedback on CSSP after implementation of the program. They assessed UVP to be an important topic for sports schools, the program easy to carry out, and well-thought-out materials. They reported that spots targeting parents, teachers, and coaches were shown to members of the respective target groups and were appraised very positively. Administrations of both schools explained their plans for a sun protection strategy (CSSP scope 2): partner school 2 included UVP in the school’s prevention concept. To sensitize students to UVP behavior, the school also plans to establish UVP as a topic in every grade. One idea was to implement a lesson on UVP in biology, 5th and 6th grade, and to take up further aspects in later grades . Partner school 3 wanted to gather information about funding for measures to create additional shade such as solar panels for the schoolyard.Both principals stressed the importance of involving parents into CSSP and to provide information for them on UVP, e.g. with material for parent-teacher conferences. They also planned to pursue CSSP the following year (CSSP scope 3).To improve the recognition of the sunburn pictured on the behavior self-check poster, the color contrast was set higher due to the students’ comments of sample 2.Written notices as ways to inform about the program and the video messagesWording for a sun protection policy within the school programIncorporation of additional organizational measures for schoolsIncorporation of additional measures for coaches in training and competitionIncorporation of additional proposals for covering UVP as a topic in classIncorporation of additional information on handling UVP barriersFurthermore, the manual was enhanced, taking results of CSSP pilot testing in partner schools 2 and 3 as well as the accompanying PPP group meetings and interviews with the principals into account. Chapters on how to conduct CSSP were adapted, including the following:The changes made resulted in additional material such as handouts and presentations for parent-teacher conferences, and led to the current CSSP material package displayed in Fig. This manuscript reports the development of the Clever in Sun and Shade Program for sports schools (CSSP) that aims at supporting schools in establishing UV protection (UVP) strategies and to enforce positive attitudes toward UVP in student athletes, coaches, teachers, parents, and school administration. In line with the definition of health-promoting programs , CSSP waTo effectively address these target groups, the authors followed WHO recommendation to place a UVP program at the school setting . In our Regarding relevant resources and assets as well as the ecological environment, research has shown that coaches and parents play an essential role in the development of young athletes and in maintaining athletes’ health , 31. In The “participatory input” as well as the “stakeholder check-in” provided valuable input to enhance acceptance and feasibility of the program. One coach in sample 1 underlined the need for athletes to show good performances and therefore to stay healthy, which can be used as a strong argument for a UVP strategy in SAs and coaches. The statement of tanned skin hindering optimal performance (“it draws so much energy”) is in line with the finding that UV radiation suppresses the immune system in multiple ways . Since iEspecially, videos and the behavior self-check poster thus regarded the concepts of enhancing self-efficacy, risk perception, and outcome expectancy to support motivational and volitional processes toward a positive attitude for UVP and showing actual UVP behavior. Beside others, theories expect the perception of a certain risk, i.e., for the development of skin cancer, to be necessary to build an intention in favor for a particular health behavior, i.e., sun protection . HoweverThe reported good reasons, barriers and suggested solutions for sun protection as well as statements regarding content and layout of materials were taken into account in the final materials. All potential future program participants were addressed with targeted UVP messages that were conveyed with the various adapted materials such as videos, posters, and emails.Ratings on acceptance of and identification with videos and behavior self-check poster of the participating student athletes have been used to modify program material and to adapt it to the needs of this target group. Results of sample 2 show that at least 4 out of 5 students  selected predominantly positive adjectives to describe the videos (80%) and the behavior self-check poster (86%). The adjusted material was mostly described as “important”  and “positive” . Most of the students reported to identify themselves with the video “For team players,” followed by “For the clever,” and “For the ambitious,” varying with class level. This is in line with the values and attitudes common to athletes, such as being performance oriented and assertive –26. The With respect to the organizational level, interviews and group discussions with coaches, teachers, and school administration helped to identify aspects that support the implementation of CSSP into school structures and processes. Such aspects comprised offering strategies to handle barriers for UVP in training and competition and recommending wording for integrating UVP into school policy. In addition, it incorporated giving examples on how to integrate UVP into school routine including material to address UVP in class, in parent-teacher conferences, and material to draft a UVP strategy for the school.In summary, participatory program development may sometimes force the researcher to face some unexpected but difficult decisions, for example, participants proposing the use of fear appeals. Combining top-down and bottom-up processes may impose a challenge. Though, when comparing program materials at step 1 of CSSP development with the completed program kit, CSSP greatly benefited by the PPP approach. Including potential future participants into the process not only enhanced program material but also broadened the program. CSSP now offers material for education on UVP in class, material for application in parent-teacher conferences, in training and competition, as well as material about handling of barriers and the development of a UVP strategy.This study is limited by the small number of teachers and coaches participating in the PPP process. Because of being involved in class and training, many coaches and teachers canceled PPP group meetings. Parents also have not been part of the PPP process. The sample was not chosen randomly.German Olympic Sports Confederation have not been involved in the development of concept and materials of CSSP.The target groups were primarily involved in the development of the concept, content, and materials of CSSP. Concerning PPP component “Program goals,” the target groups could have been involved even more into wordings of goals and objectives. Even though the program takes HAPA into account, the focus of the program is still on promoting positive attitudes toward sun protection among students, teachers, coaches, and parents. By addressing maintenance self-efficacy and recovery self-efficacy, volitional processes could be supported even more. Results of interviews with school administration and of PPP groups may be biased by social desirability. Validity and reliability have not been sufficiently examined. Further stakeholders like the ministries of education and cultural affairs and the In following WHO recommendations for UV protection at schools as well as using participatory program planning, the authors developed the Clever in Sun and Shade Program that aims at enforcing positive attitudes toward UV protection and supporting sports schools in establishing UV-protection strategies. PPP has shown to be an effective and valuable method in constructing CSSP to meet sports schools’ needs. CSSP now consists of a project kit free of charge containing videos with tailored messages targeting students, coaches, teachers, and parents, as well as posters and a manual about UVP and recommendations for implementing UVP in sports school settings.German Cancer Aid and German Olympic Sports Confederation .Summative evaluation that is also founded on the PPP components will be conducted in a subsequent study, followed by program dissemination in cooperation with


The Scholarly Concentrations program was established at Johns Hopkins University School of Medicine in 2009 with the aim of instilling passion for scholarship.Our study aimed to determine whether the Scholarly Concentrations program achieves positive changes in medical student self-efficacy in conducting research and, if so, whether this results in future career aspirations toward scholarship.We used the Clinical Research Appraisal Inventory-Short Form (CRAI-SF) to assess changes in self-efficacy among students completing the Scholarly Concentrations program between 2014 and 2017. We calculated composite mean scores of six domains. We included outcomes on whether students published a manuscript, overall program perceptions, and likelihood of future research careers. We analyzed relationships between CRAI-SF scores and outcomes using paired t-tests and multivariable-adjusted logistic regression.A total of 419 students completed the Scholarly Concentrations program. All 6 CRAI domain scores showed significant improvements in self-efficacy between the pre-Scholarly Concentrations and post-Scholarly Concentrations ratings . We found significant associations between post-Scholarly Concentrations self-efficacy ratings and course satisfaction  and mentor satisfaction , as well as students’ intent to conduct future research . These results were robust to sensitivity analyses, and pronounced in the group of students without prior research experience.Our findings suggest that a Scholarly Concentrations program is associated with an increased self-efficacy for research, and these changes in self-efficacy are associated with higher satisfaction in the scholarly experience and increased likelihood of pursuing scholarly work. Other medical schools could use such a tool of self-efficacy to both investigate the overall Scholarly Concentrations experience and understand factors that may increase interest in future physician-scientist pathways. Career choice for medical students, and whether this includes an academic career, continues to be high a priority area for research and advising ,2. BanduThe development of research interest through Scholarly Concentrations (SC) programs has increased across U.S. medical schools. These programs are based on the premise that human agency is essential in career development, and fostering self-efficacy and passion for research will help expand academic medicine ,10. ProvJohns Hopkins School of Medicine first established their SC program in 2009. In this paper, we review longitudinal data exploring the changes in student self-efficacy for scholarship that occur during the SC program, and whether these changes then translate into inspiring students both in their course experience and in their pursuit of future scholarly activities.The SC program has been described previously ,15. BrieFor our study population, we included all students at the Johns Hopkins School of Medicine who completed the Scholarly Concentrations program. Although the program began in 2009, our first cohorts using the survey instruments described below completed the course between 2014 and 2017. We included data on these cohorts and follow-up data on these cohorts through medical school year 5  or post-graduate year 1. Because participation in the SC program is a required component of the preclinical M.D. curriculum at Johns Hopkins, all eligible study participants were enrolled in their first and second years of the M.D. program. M.D.–Ph.D. program students are excluded from the Scholarly Concentrations program and this analysis.The Clinical Research Appraisal Inventory (CRAI) was developed as a tool to measure self-efficacy for conducting research among physician-scientists in training . It conta priori based on the factors we determined may be most important in impacting medical students’ experiences with scholarly work. The final choice of scholarly concentration category was one such variable. Options for this included Basic Science, Clinical Research, History of Medicine, Humanism & Ethics in Medicine, and Public Health. Another variable selected a priori included whether students had published scholarly work prior to starting the SC program; further descriptions of publication abstraction are provided below. Finally, we included students’ average scores on all CRAI domains prior to starting the SC program.We also investigated other student factors that may influence self-efficacy and/or interest in the future scholarship. We selected these variables We included five primary short- and long-term outcomes reflecting Kirpatrick’s trajectory from satisfaction to behavioral change . The firTwo additional outcome variables included whether students were authors on any published scholarly work after completion of the SC program, and whether they specifically were the first author on a manuscript. We collected the data for these variables by abstraction from the search engines, PubMed, Scopus, and Google Scholar, using students’ names and cross-referencing with ‘Johns Hopkins’, prior undergraduate institution, or subsequent residency institution. We made no distinction between different types of publications, such as case reports versus hypothesis-driven research. These publications were abstracted by the course administrator , with weekly review for clarification and discussion with the senior author (SS). Due to the granularity needed to search for prior and future publications, we limited this search to those students who already provided this information in graduation materials, Doximity, LinkedIn, and other publicly available sources . For each student, we recorded the numbers of publications and numbers of first author publications as continuous variables. We then transformed these into dichotomous variables, comparing at least one publication (or at least one first-author publication) with no publications (or no first-author publications).Finally, to understand whether students were interested in the future research, we asked in the post-SC course survey, ‘How did your experience with your scholarly project impact your plans for future research or scholarly work?’ Students responded with ‘More likely’, ‘Less likely’, ‘Same’, and ‘Unsure’. We compared those responding ‘More likely’ to all other responses.We used prior literature to help determine that these variables would adequately capture both short-term and long-term validity measures in assessing satisfaction with the program and long-term interest in scholarship .We used paired t-tests to compare the difference between composite pre- and post-SC program mean scores from the CRAI-SF, with t-tests and ANOVA to compare the baseline variables’ associations with change in each CRAI-SF domains score. We used multivariable logistic regression to assess whether there was an association between mean domain scores after SC program completion and students’ perceived satisfaction and future research success and aspirations, as captured by the five outcome variables. We used a stepwise model-building approach, with unadjusted model results first examined, then a minimally adjusted model, and finally a fully adjusted model. The minimally adjusted model included students’ SC area. The fully adjusted model added publications prior to SC and ‘Pre-SC’ average CRAI score.We used stratified logistic regression models to investigate whether self-reported interest in research modified the impact of final self-efficacy on outcomes. Results were stratified based on self-reported interest in research using the question: ‘When you started medical school, did you plan to conduct research or other scholarly work?’ Students chose between the responses: ‘Yes, definitely’, ‘Yes, probably’, ‘Unsure’, and ‘No’. We then aggregated the data into a dichotomous covariate, with the ‘Yes, definitely’ compared to any other response. We then included an interaction term in the fully adjusted model to examine whether any effect measure modification existed between the mean post-SC program CRAI domain scores and this dichotomous variable.In sensitivity analyses, instead of capturing the exposure variables as mean CRAI-SF Post-SC program scores on a continuous scale, we dichotomized this exposure variable to those who achieved the three highest domain scores , versus those who achieved any other score, to examine ceiling effects. We utilized a change variable capturing the difference between ‘Post-SC’ and ‘Pre-SC’ mean domain scores as the exposure instead of using the ‘Post-SC’ score as the primary exposure. We also examined the course satisfaction, mentor satisfaction, and publications during SC variables in their original continuous forms rather than categorical forms to determine whether the same patterns of significance were retained.We performed analyses using Stata 15.0 . A p-value <0.05 was considered significant. The Johns Hopkins Institutional Review Board approved this investigation (IRB00103412).Four hundred nineteen students completed the SC program between 2014 and 2017. Baseline characteristics of the study population are summarized in Three hundred twenty-one students completed both the pre- and post-course CRAI-SF survey, a 77% response rate. On the CRAI-SF taken before starting the SC program, the lowest mean domain score (4.8) was in the ‘Protecting Subjects & Responsible Conduct’ domain, while the highest score (6.5) was in the ‘Organizing a Study’ domain. We depict comparisons between CRAI domain scores ‘Pre-SC program’ and ‘Post-SC program’ in We show unadjusted, minimally adjusted, and fully adjusted analyses of the post-SC average CRAI score across domains on the outcomes in In terms of the satisfaction variables, adjusted regression models demonstrated that the higher the achieved self-efficacy score, the more likely students were to report satisfaction with the course  and their mentors . However, self-efficacy achievement was not found to be associated with either of the publication measures in final models ; the first author published during SC: OR 1.13, ). Though the unadjusted and minimally adjusted models generated some significant results for the ‘First Author Publications during SC’ outcomes, results became less significant as additional covariates were included in the models, and no significant association remained with the publication outcome variables in the fully adjusted model.A higher average post-SC CRAI score was also significantly associated with student plans to conduct future research in the fully adjusted model . In Supplementary Table 1, we observe that the specific domains in which this significant association was seen were ‘Reporting a Study’, ‘Organizing a Study’, and ‘Collaborating with Others.’ This was similar to the domains found to be significantly associated with ‘Satisfaction with Mentor.’In terms of potential effect modification, we found the highest baseline level of interest to be significantly associated with higher course satisfaction ratings , while other baseline interest levels were not . We did When we dichotomized the CRAI variables to include the three highest domain scores versus all other scores (rather than retaining them as continuous exposure variables), we noted the same associations remained significant as in the original analyses. We show these results in Supplementary Table 2. When we examined the domain variables as the difference between the ‘Post’ and ‘Pre’ scores rather than the ‘Post’ scores alone, we observed the same significant associations. We show results for this analysis in Supplementary Table 3. When we examined the continuous outcome variables in their original continuous rather than dichotomous forms, we found significant positive relationships remained between high post-CRAI scores and the course and mentor satisfaction outcome variables. We did not detect significant association for the publication outcome variable. We depict results for this analysis in Supplementary Table 4.Students completing the SC program at the Johns Hopkins School of Medicine reported significant improvements in their scholarship self-efficacy, with improvements in self-efficacy seen within each domain assessed by the CRAI. In addition, higher final scholarship self-efficacy was significantly associated with satisfaction with the course and mentor, and increased the likelihood of pursuing research in a student’s career. In minimally adjusted models, we observed an association between higher self-efficacy and publications. Our results remained robust to sensitivity analyses, demonstrating that the findings are significant even after accounting for other explanatory factors. This suggests that an SC program is associated with a student’s self-perceived research skills, which may ultimately translate into short- and long-term outcomes useful for medical school programs. Our results are also particularly meaningful because they both track a student’s sense of self-efficacy, and utilize various levels of Kirkpatrick's educational outcome variables, spanning a trajectory of outcome levels from student satisfaction to behavioral change . We, theThe most common themes for SC courses are the important value of ownership and strong mentorship in catalyzing and cultivating a passion for future scholarly endeavors. A program similar to the Johns Hopkins SC curriculum was developed at the University of California, San Francisco with the aim of teaching students and trainees the skills needed for a medical education scholarship. Participants specifically identified exposure to and interaction with role models and mentors as a particularly influential component of the experience that inspired them to pursue future career paths in academic medicine . AnotherOne limitation of the current study is that we conducted it at a single institution with a research-intensive mission and many students wishing to pursue subspecialties and academic careers. Therefore, the results observed in the SC program at this sort of institution might differ from those seen at one with a stronger focus on primary care or that self-selects for students wishing to pursue primarily clinical careers with more limited research and academic goals. In addition, we do not have data on long-term outcomes nor could we completely account for all threats to internal validity, such as selection bias. For instance, other studies found that the number of publications was higher after graduation for students who had competed an SC or similar program ,24. BecaTo date, our study is among the first to utilize the change in self-efficacy to explore the success of a Scholarly Concentrations curriculum. Self-efficacy for research has been shown to increase between matriculation and graduation of medical school, and self-efficacy at graduation correlated with interest in pursuing future research careers . HoweverQualitative data from multiple institutions do exist to provide general guidelines for how successful SC programs are structured. For example, one study identified a focus on developing rigorous critical thinking, analysis, creativity, and synthesis skills alongside the establishment of longitudinal mentorship as hallmarks of a strong SC program . Others A medical school SC program is one possible way to increase a student’s self-efficacy in conducting scholarship. Higher achieved self-efficacy also may translate to increased satisfaction with the experience and increased likelihood to pursue research. Other medical schools could use such a tool of self-efficacy to both investigate the overall SC experience and understand factors that may increase interest in future physician-scientist pathways.Click here for additional data file.


The Preschool Situational Self-Regulation Toolkit (PRSIST) Program was developed as a low-cost and embedded approach for educators to foster pre-schoolers’ self-regulation and related abilities . This study reports on a cluster RCT study with 50 Australian pre-school services to evaluate the effectiveness of the PRSIST Program for improving children’s self-regulation, executive function and school readiness, compared to current routine practice. Pre-school centers were recruited to reflect the breadth of geography, pedagogical quality, and socio-economic catchment areas across the early childhood education and care sector. All children identified as in their final year of pre-school education at these centers were invited to participate, resulting in a sample of 473 3-5-year-old children at baseline. Centers were randomly assigned to groups after baseline data collection, and data collectors were blinded to group assignment throughout the study. It was hypothesized that engagement in the PRSIST Program would improve children’s self-regulation, executive function and school readiness, over and above normal age-related rates of development. Results indicated small but significant improvements in executive functioning for the intervention group, after adjusting for cluster, baseline results and key covariates. All other outcomes were descriptively in favor of the intervention group but failed to reach significance. Levels of use of the program remained high by most educators throughout the intervention period, suggesting its acceptability and sustainability within these contexts. Together, results show promise for this approach to self-regulation development. Opportunities that might further strengthen this approach are discussed. This study was registered with the Australia and New Zealand Clinical Trials Registry (ACTRN12617001568303) and study protocols published in advance of commencement. Funding for this study was provided by the Australian Research Council’s Discovery Early Career Researcher Award research grant scheme. For many parents, early childhood educators and professionals, the term self-regulation evokes episodes of exactly the opposite – a child’s dysregulation, which requires their attention and intervention to restore calm to the child and situation . EffortsStrategies to foster self-regulation, however, should not begin and end with instances of child dysregulation. For one, efforts to return a dysregulated child to stasis will do little to aid the self-regulation of children not overtly dysregulated and those who “fly under the radar.” For instance, research highlights pervasive gender differences in the manifestation of behavior problems, with girls inordinately channeling this into internalizing problems , while boys more often engage in externalizing behaviors , average and higher self-regulation ability. Indeed, any-cause improvements in child self-regulation have been found to be associated with improvements in later-life outcomes even for children initially at average or high levels of self-regulation  Program was developed in response – in consultation and collaboration with early years educators and service providers – as a freely and widely available collection of professional learning, supportive adult practices, and child activities that can be embedded within existing pre-school routines. This manuscript reports on a cluster randomized controlled trial (RCT) evaluating the efficacy of the PRSIST Program for the first time.To support and promote genuine gulation . This imAlthough there are numerous definitions of self-regulation , one conThere is compelling research supporting the value of ‘earlier’ interventions in forecasting lasting, stable and cost-effective change . ConsideParalleling the diversity in characterizations of self-regulation, there are similarly diverse approaches for attempting to foster children’s self-regulation. One prominent approach to self-regulation intervention derives from a seminal study that reported 4-year-old’s performance on a delay of gratification task – in which the child would receive an enhanced reward if they were able to resist eating a marshmallow for a few minutes – which robustly and longitudinally predicted self-regulation outcomes . On the In contrast to this approach, and expanding on These intervention approaches, which target educator practices and classroom curricula, have arguably shown greater promise for improving children’s self-regulation and outcomes . Indeed,Another curriculum-based approach for supporting and enhancing self-regulation is the preschool adaptation of the Promoting Alternative Thinking Strategies PATHS:  program.The Chicago School Readiness Project CSRP;  takes yeCurricular approaches seem particularly promising, not only in their ability to generate immediate self-regulation improvements, but also sustained and flow-on impacts after program completion. However, approaches in this tradition are often plagued by time, inflexibility and cost constraints that are prohibitive for many pre-school services and educators . This may be a source of their mixed results, as comprehensive and prescriptive programs may not suit all contexts and educators (thereby impacting program adherence), and effects would not be expected where adherence to program requirements is low .Another possible explanation for the modest effects of some approaches is their focus on only some elements of self-regulation, which is exacerbated by resource-related barriers to effective, consistent and sustained program implementation . Curricular approaches, for instance, often neglect the role of cognitive control processes for successful self-regulation . Although this model of self-regulation has yet to be empirically evaluated, it may explain why many existing interventions yield limited transfer to children’s real-world outcomes. That is, while each approach creates conditions necessary for improvement in those abilities , as well as fostering strategies and opportunities for children to select goals and experience success in self-regulation . To leverage children’s interests and motivation, experiences should be fun and playful. Further, to enhance the likelihood that these experiences yield real-world and everyday improvements, they should be embedded in children’s social contexts. Minimizing the burdens of program induction and implementation – while maximizing program flexibility, educators’ choice and agency, and alignment with current practices and routines – would support implementation and maintenance of the program with minimal additional burdens or resource requirements. Lastly, scalability requires a program that is free, accessible without barriers and can be implemented by those who spend the majority of the time with the children .From this proposition emerges an approach that acknowledges both the cognitive and socially mediated mechanisms of self-regulatory change. In aiming to foster children’s self-regulation in its social context, this approach should identify those environments, routines and practices that engage and extend (or provide an opportunity to engage and extend) children’s Programs exist that combine at least some of these elements. For instance, the Red Light, Purple Light Circle Time Games Program  organizeYet the absence of some of the aforementioned criteria may constrain consistency or size of program effects, and/or possibility for widespread program uptake. For instance, given their different theories of self-regulatory change, some theorized components of self-regulation  are not explicitly targeted through educator practice or child activities. The constrained number and context of self-regulation-promoting situations further limits the everyday situations  in which children are given an opportunity to practice and extend these abilities. In terms of accessibility, this approach often requires delivery or face-to-face training by a master interventionist, and/or ongoing coaching, which present barriers to access and implementation. Given the successes of this approach and opportunity to empower those who have amongst the greatest opportunity to influence children’s early trajectories, the PRSIST Program was designed to adopt a similar approach but also address these additional criteria.To address limitations in current pre-school self-regulation intervention approaches, the PRSIST Program was designed with this theory of change in mind. Specifically, the PRSIST Program provides educators with: online professional development, to foster practices that set conditions for optimal self-regulation  with typical practice (control group). Fifty pre-school centers in metropolitan and regional areas of Australia were recruited to be broadly representative of population proportions for geography (84% metropolitan), socio-economic decile for their catchment area , and statutory quality assessment rating . Australia’s early childhood education and care (ECEC) sector includes a range of pre-school provision  that is delivered by not-for-profit, for-profit or state providers. While there is no state or national curriculum for the Australian ECEC sector, all pre-school services are required to follow the Australian Early Years Learning Framework, which outlines expected outcomes of children from birth to age 5. For this study, participating pre-schools: were structurally equivalent in terms of being long-day care services providing care to children aged 2–5 years, up to 5 days/week; were run by community or not-for-profit providers; and had at least one Bachelor-qualified educator (or government waiver).This study was a 6-month, 2-arm cluster randomized controlled trial comparing a pre-school self-regulation program . One-hundred and sixty-one educators participated in the study. Characteristics of these educators were broadly consistent with those in the sector: a majority were female (98.8%) and full-time (59.0%); had an average of 10.48 years of experience in the industry (range = 0–36 years) and 4.29 years at their center (range = 0–20 years); and were diverse in qualifications .SD = 0.38, range = 3.20–5.33), with a relative balance of boys and girls (48.2% girls). Children who were identified as of Aboriginal or Torres Strait Islander descent comprised 7.2% of the sample, which is in line with population estimates for this age group  and protocols were published prior to the trial’s commencement . The stuPreschool Situational Self-Regulation Toolkit (PRSIST) Program aims to engage, challenge and extend young children’s self-regulation in ways that are playful, low-cost, routine, and target each of the aspects required for successful self-regulation . The PRSIST Program is a collection of professional learning, adult practices, play-based child activities, and home-based resources to support the development of children’s self-regulation. The PRSIST program was designed to be compatible across a range of early learning contexts, but in this study was implemented by pre-school educators. Educators were inducted into the program through hard copy program materials, a program website1, and monthly 1-h teleconference calls to highlight different aspects of the program and discuss educators’ experiences and challenges. All program materials are freely available on the program website for inspection, replication, revision or adoption of program elements.The In previous phases of this research, all program elements were piloted, evaluated and revised on the basis of feedback from early years educators . In line with this feedback, the program was developed so that it can be flexibly implemented for varying durations, intensities, and using different combinations and sequences of elements.For the current trial, however, educators were asked to implement the program over the course of 6 months, implementing each of the program’s four core elements described below. While all program elements were made available on completion of baseline assessments, the program elements were explicitly introduced and emphasized in a staged manner, to ensure sufficient foundations for implementation. Specifically, the first month focused on completion of online professional development, the second month on child activities, third month focused on formative assessment and fourth month focused on increasing challenge in child activities. Minimum expectations of engagement in the program were communicated to educators, which are outlined in relation to each program element below.Educators were asked to engage with the program’s nine accredited online professional development videos within the first 2 months of the program. These videos, which were drawn from the self-regulation components of the evidence-based Fostering Effective Early Learning (FEEL) professional development , introduIn addition to the adult practices, a collection of 28 play-based activities were provided to extend children’s self-regulatory capacity. These activities were developed from: practices already occurring in high quality pre-school services; minimal modification of existing practices  in high-quality centers, which were identified as high quality in the FEEL study ; or newlDisciplined Dance is one such activity done routinely in early childhood contexts, in which children dance whenever the music plays and stop when the music stops. A common tendency in this game, however, is to either eliminate a child who does not “freeze” (thereby giving the least amount of practice to children who perhaps could benefit most) or ignore that the child continued dancing. In our variation of this activity, all children continue to play the game throughout, but children who do not freeze are aided by removing some of the body parts from consideration. For instance, if a child does not freeze at the first stoppage of music, they kneel for the next round (removing their legs from consideration). If they are unable to freeze again, they sit. Upon successful freezing, the child returns to an earlier position. To make this activity even more challenging, educators reverse the sequence – children must be still when the music is playing, and dance when the music is turned off.All activities included instructions for implementation, how to increase the challenge of the activity as children became more proficient, how the abilities required for the activity relate to children’s everyday self-regulation, and links to Australia’s national Early Years Learning Framework. The program was designed so that the timing, intensity, selection, and sequence of child activities is flexible; however, within the current trial educators were asked to complete a minimum of three activities of their choosing per week. While educators were free to select the activities that they and the children enjoyed best, they were encouraged to complete activities of various types and categories each week. Fidelity of this intensity requirement was evaluated through monthly wall-calendar sticker charts, returned to the research team, that showed the date and frequency of each activity.To appropriately plan for and support children’s self-regulation development, information about their current developmental progress in this area is essential. To support this understanding, participating educators were given access to online training for the PRSIST formative assessment tool. This tool involves observation of children as they perform everyday activities, but structures this observation to: (1) focus on key areas of self-regulation; and (2) provide actionable data based on a child’s current developmental progress. Use of this tool was optional, but if used it was recommended that each child be assessed at least twice during the intervention period to support tailoring the complexity of the child activities to children’s current developmental needs.While the trial did not explicitly focus on parental involvement, intervention centers were provided with monthly parent newsletters designed to support the sharing of information and practices with the home. Each of the six newsletters, which were one double-sided page in length, presented information relating to what self-regulation is, its importance in the early years, observing their child’s self-regulation and ideas for supporting self-regulation development in the home.Directors and educators from intervention centers were invited to join 1-h teleconferences run monthly, at the end of the first, second, third, and fourth months of the program. Participants were invited to participate in any one of three repeat sessions in a given week. Educators who were unable to attend these sessions were offered a one-to-one debrief with a member of the research team. The aim of each teleconference was on: highlighting a particular program element to commence or focus on over the following month; facilitating discussion of educators’ current experiences, challenges and needs in relation to the program; and creating an opportunity for educators to share with each other ideas and opportunities that arose from their engagement with the program. This was also an optional component of the program but had a high level of participation .The control group continued with their existing program, which included structured and free play time. Given the prevalence of self-regulatory concern amongst ECEC educators, it is likely that some of these activities targeted self-regulation. Further, it is expected that at least some of the educators would have attended professional development during the trial, and some of this might have concerned self-regulation. However, all of this can be considered current routine practice and represents an appropriately active control condition.Disciplined Dance), and were not designed to approximate the outcome measures, results can be interpreted as near transfer to untrained contexts. The one exception to this was the PRSIST Assessment, which was made available to the educators as part of the program. However, for the purposes of program evaluation this was administered and scored by a trained researcher (rather than educator), and performance indices were not concerned with proficiency in the game per se (thereby limiting practice effects).Outcomes were measured at the child level and pertained to self-regulation and related abilities . Given the child activities resembled those routinely enacted in early childhood contexts  Assessment (rs ranging from 0.50 to 0.63) and school readiness measures (rs between 0.66 and 0.75) (sessment  is an obsessment . To ensund 0.75) . ReliabiChild Self-Regulation & Behaviour Questionnaire , with three trials at each level, until the earlier of completion or failure on three trials at the same level of difficulty. Working memory was indexed by a point score that estimates working memory capacity, calculated as: one point for each level, from the first, in which at least two of three trials are performed correctly; and then one-third of a point for each correct trial thereafter  and withhold responding on the “no-go” trials (“avoid sharks”). The majority of stimuli are “go” trials (80% fish), thereby generating a pre-potent tendency to respond that children must inhibit on “no-go” trials (20% sharks). After instruction and practice, 75 test stimuli were presented across three 1-min blocks (separated by a short break and reiteration of instructions). Each trial involved presentation of an animated stimulus  for 1500 ms, each separated by a 1000 ms inter-stimulus interval. In line with protocols of Card Sort task, which asks children to sort cards  first by one sorting dimension , then switch to the other sorting dimension . The task begins with a demonstration and two practice trials, after which children begin sorting by one dimension for six trials. In the subsequent post-switch phase, children are asked to switch to the other sorting dimension. For all test items, each trial begins by reiterating the relevant sorting rule and then presenting a stimulus for sorting. If the participant correctly sorts at least five of the six pre- and post-switch stimuli, they then proceed to a border phase of the task. In this phase, children are required to sort by color if the card has a black border or sort by shape if the card has no black border. Cognitive flexibility was indexed by the number of correct sorts after the pre-switch phase  and reliability with children of this age (rs from 0.16 to 0.30) were similar to those previously reported (rs from 0.27 to 0.42).Individual EFs were indexed by measures of working memory, inhibition, and cognitive flexibility selected from the iPad-based box EYT; . Specifithis age . Inter-treported , as wereBracken School Readiness Assessment ; child’s sex ; identification as Aboriginal or Torres Strait Islander; home language ; a quality of home learning environment (HLE) index from the EPPE Study , which aAll tasks were administered to children in a quiet area of their pre-school center in five sessions across the same day, to maximize children’s attention and minimize fatigue. Measures were administered in the same order to all children, as follows: (1) BSRA; (2) PRSIST curiosity boxes and HTKS; (3) Mr Ant and Go/No-Go; (4) PRSIST memory; and (5) Card Sort. Each session took 10–20 min to complete and were done near the start of children’s final pre-school year (March–April 2018). These assessments were again conducted near the end of the year (October–November 2018), also in a quiet area of the child’s pre-school. All fieldworkers involved in follow-up data collection were kept blind to cluster assignments.To evaluate the effect of the PRSIST Program intervention, data were analyzed using a linear mixed model with a random effect for clustering by center. Unadjusted models and models with sex, age, SES category , HLE index, identification as Aboriginal or Torres Strait Islander  and language (English or language other than English) are presented. Baseline by group interactions, and interactions between group and sex and group and age were considered for all variables. Data were analyzed using the mixed models procedure in IBM SPSS Statistics .Adherence to intervention participation thresholds was evaluated in terms of educators’ completion of the online professional development modules and having engaged children in a minimum of three child activities per week. Engagement with optional program components  was also captured. Educators’ engagement in the online professional development was captured via log in and tracking functionality of the professional development modules. Of the 25 intervention centers, 20 services (80%) had at least one educator complete the professional development within the first 3 months of the intervention period . Type and frequency of child activities each month was captured through a custom-designed activity sticker calendar, which was returned monthly to the research team. On average, six of the program’s self-regulation activities were facilitated with children each week across the intervention period, ranging from none per week to 22 per week. Further, the charts indicated the suggested diversity of activities was met by most centers in most weeks, and certainly over the duration of the program (by centers who engaged with the child activities).Use of the formative assessment tool was not required, but educators at 16 of the centers completed the online formative assessment training module and successfully completed inter-rater reliability checks. Seven of these centers reported using the tool, while nine reported they had not yet used the tool. Five centers attempted the online training module but did not achieve the required level of inter-rater reliability and had not yet re-attempted the training. Four centers did not attempt the formative assessment training. Attendance at teleconference calls also was not mandatory, yet all except three centers joined at least one of the monthly teleconference calls .n = 1); substantial illness, maternity leave or turnover of key staff that precluded participation (n = 2); or low- or non-participation for undisclosed reasons (n = 2). Two of these five centers did not participate in any program elements. The other three centers did not engage with professional development modules or induction teleconference call yet completed child activities. Overall, there were good levels of adherence to the program, especially amongst those centers without significant sector-imposed impediments to participation.Based on these patterns of participation, 20 services (80%) were deemed to have met or exceeded the minimum threshold of participation . Those that did not participate in the program were a result of: preparations for government assessment and rating (ps ranging from 0.101 to 0.834). Interactions between group and gender to determine whether effects differed by child gender (ps ranging from 0.121 to 0.937), and group by age to determine whether effects were conditioned by the child’s age (ps ranging from 0.123 to 0.770), were not significant for any of the models (The Intra-Class Correlations (ICC) for all outcome measures were small – HTKS ICC = 0.02; PRSIST ICC = 0.08; CSBQ ICC = 0.08; EF ICC = 0.01; Bracken ICC = 0.05 – yet still advocated adjusting for nested data . Unadjuse models . All outThis program of research sought to design, implement and evaluate a program to support young children’s self-regulation development, the product of which was the PRSIST Program. The PRSIST program was developed by reconciling insights from interviews and observations of educators with research-based understandings about the nature, development and change in self-regulation. After pilot and revision of intervention components with educators, the current cluster RCT evaluation of the program over a 6-month intervention period indicated small but significant improvement in EF for the intervention group. All other outcomes  also showed descriptively greater improvement for the intervention group, although these changes did not reach significance. In the context of the short intervention period, during which the program was incrementally introduced, implemented and mastered, this pattern of results suggests promise and future enhancements for the PRSIST approach to fostering children’s self-regulation in the pre-school context. Fidelity data further demonstrated that educators were willing and able to implement each of the program’s components over a sustained period of time.The small but significant positive effect of this intervention on children’s EF – over and above the already rapid development of these abilities in the pre-school years  – is conWhile the primary outcome for the evaluation was child self-regulation, and there was a descriptively greater improvement in self-regulation in the intervention group for all indices, results for this outcome were non-significant. This contrasts other curricular approaches, which have successfully achieved improvements in indices of self-regulation after similar or longer intervention periods . There wIn relation to the PRSIST Program, there are a number of possible explanations for this result. First, given self-regulation develops rapidly in the pre-school years , the proSecond, it is possible that insufficient quality of implementation generated an estimate of program effectiveness , rather than efficacy . This was an explicit decision from the outset of this study, given the goal of identifying low-cost, accessible and sustainable approaches that can be employed by pre-school educators. While it might be the case that effects would be more pronounced if the program were implemented with fidelity by members of the research team visiting centers, this would render the approach expensive and difficult to scale. A compromise between these options, however, could involve mentoring and coaching, which may expedite and strengthen educators’ self-efficacy and fidelity in implementation. Indeed, there is ample evidence for the effectiveness of mentoring and coaching when attempting to influence the practices of the current educator workforce , and thiThird, it may be the case that children require greater duration and intensity of exposure to the program’s components to detect a self-regulation effect . In the Inability to conclusively and exclusively provide evidence for one of these possibilities, however, highlights limitations within the current study. That is, although the evaluation was rigorously designed and executed according to CONSORT guidelines, funding considerations limited the roll-out and intervention period to only 6 months. It is possible that a full year of program implementation would yield stronger program effects . The specific promise of this approach is further highlighted by its compatibility with pre-school contexts and routines. The flexibility of the program permitted educators to engage with online professional learning at their convenience, implement adult practices aligned to their specific needs, and select and scale child activities that were best enjoyed by children in their center. Acceptability of the program was evidenced by high levels of educator adherence to minimum program requirements – often exceeding these requirements – and, in cases where centers did not engage with the program, this was due to known sector-related issues . The PRSIST Program is not intended to be a complete collection of practices and activities that could support children’s self-regulation, but rather serves as a stimulus from which educators can expand these options. The accessibility and acceptability of the current approach creates a unique opportunity for embedded practices that yield benefits for young children, including those in less-advantaged contexts that are often most in need of support .stevenh@uow.edu.au.The dataset for this manuscript is not publicly available because ethics approval was not sought or granted for such use. Requests to access the dataset should be directed to SH at The studies involving human participants were reviewed and approved by the University of Wollongong, Human Research Ethics Committee – Social Sciences. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.SH conceptualized the study, secured funding for the study, designed the child activity aspects of the intervention, oversaw data collection, was involved in data analysis, and led writing of the manuscript. EV aided in conceptualizing the study and design of the intervention, managed data collection and entry, and contributed to drafting of the manuscript. MB contributed to evaluation design and planning, led data analysis, and contributed to drafting the manuscript. CN-H led the pedagogical aspects of intervention design and delivery and contributed to drafting of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.