The long-term sustainment of bullying prevention programs has rarely been investigated. This study addresses this gap by identifying facilitators and barriers to the systematic implementation of KiVa antibullying program in real-life conditions, after an evaluation trial. The study is based on focus group interviews with teachers from 15 Finnish primary schools implementing the KiVa program. The schools were selected based on the annual KiVa survey data, with the criteria of long-term involvement in delivering the program and reaching successful outcomes in terms of decreasing trends in bullying and victimization. By utilizing thematic analysis, we identified program-related, organizational, and contextual facilitators and barriers to sustainability. The results stress the importance of organizational factors in promoting program sustainability. Bullying at school, defined as repeated negative actions directed at a physically or socially less powerful person Olweus, , has recHowever, program efficacy alone does not ensure program sustainment and schools typically do not deliver all of the program components over time. For instance, the KiVa antibullying program developed in Finland has been shown to be efficacious in reducing bullying and victimization  framework . The program was developed at the University of Turku, Finland, during 2006–2009  sustained program implementation over the years, (2) ongoing participation at the time of the recruitment, and (3) overall success in reducing the prevalence of victimization and bullying across time. Moreover, we decided to focus on primary schools . Furthermore, we restricted the sample to schools identified as Altogether 15 focus group interviews were conducted in spring 2017 by the first three authors . The focus groups included (1) a staff member, who had been actively involved with the implementation of KiVa from the very beginning on, (2) former and/or current active KiVa team member, and (3) a staff member currently responsible for the program coordination in the school. Depending on the school, 2–5 staff members participated in the interview during regular school hours. Most of them were classroom teachers, but also special education teachers and one school social worker participated. Each participant was offered a free KiVa teacher manual, and the school staff was also given reduced admission to upcoming national KiVa training days organized by the program developers. The permission for the focus group interviews was granted by the schools’ headmaster, or in few cases by the municipal board, and all participants provided an informed consent.During the focus group interviews, the participants were asked to describe freely the implementation of KiVa across years. Clarifying questions were presented on the way . Also, several questions were posed on sustainability specifically . The interviews were kept as informal and conversational as possible. The interviews were recorded and transcribed verbatim. Their length varied from 1 h 1 min  to 1 h 36 min .The data were analyzed using thematic analysis  usability, (2) instructional capacity, (3) support from program developers, and (4) realistic expectations and recognition of program boundaries as program-related factors affecting program sustainability.According to the teachers, systematic program structure facilitated program delivery in various ways. It offered a solid background for antibullying work, promoted program delivery in everyday life, “strengthened” the actions taken, and lessened the tendency of individual teachers to “act haphazardly.” In addition, one teacher pointed out that clear guidelines on how to address acute cases of bullying can lower the threshold for intervening and increase teacher’s confidence to intervene. Furthermore, another teacher explained that also the allocation of resources, such as time for anti-bullying work, increased in their school along with the adoption of a systematic approach. This teacher specifically stressed the importance of clear program structure when tutoring new staff members:… And then we have clear steps in our school for how to intervene. It makes it really easy. We are able to tell that this is the intervention model we use, to a newcomer, for example, and they can familiarize themselves with it.  User-friendliness was considered as a necessity for program delivery — “the easier the program is to use the more it will be implemented” stated one of the participants. In this discussion, the participating teachers declared fast and in unison what in their opinion promotes program implementation:Teacher 1: Good materials.Teacher 2: Good materials.Teacher 3: Materials being updated.Teacher 2: Yes, materials being updated.Teacher 1: Materials being easy to get the hang of.Teacher 2: Materials being available.Teacher 1: In my opinion, the good thing about KiVa is that the materials are not only available in paper but also online. (School 7)Thus, teachers valued materials which were user-friendly. It is important to notice that the schools participating in this study were preselected among the ones that had managed to keep up with the program delivery over time. However, barriers for sustainability were also recognized and reflected upon during the interviews. For instance, utilizing electronic services were regarded as difficult by some respondents  and this was seen to risk the continued use of them.The participants noted that a bullying prevention program “needs to be flexible” in order to be delivered and one teacher pondered that fidelity is expected but supposedly “some adaptations are allowed.” Furthermore, the rich and versatile lesson material was described to enable the setting of various educational goals depending on the needs of the students, the teaching styles of the teacher, and the framework set by current curriculum. Nevertheless, although the importance of program adaptability was raised up, the teachers also made references to program fidelity. For instance, one teacher mentioned that starting by following the instructions precisely was one of the key factors in adopting the program and eventually finding the ways to “fit the program to the everyday life at school.” In another school, the teachers described KiVa to be the most solid program they had been following in the school for several years. Thus, the importance of both, program adaptability and program fidelity, were mentioned in connection to sustainability.But maybe, the KiVa program also opened the teachers’ eyes, brought some courage to intervene. So that it is not only about the bully and the victim, but also about looking more broadly at the role of everyone else [in the classroom].  At best, interventions can carry significant instructional capacity which in this case refers to the educational potential of a bullying prevention program. As such, an intervention can have the capacity to inform the practitioners about bullying as a phenomenon and offer practical tools for prevention, facilitating sustainability. This came up in some cases: Understanding the program foundations and implementing the program in practice led to some profound realization. First, few participants pondered upon how the program implementation might have influenced the understanding of the bullying phenomenon in general  as this quote illustrates:Second, some participants described that through KiVa, they had understood more in-depth the importance of preventive work: “Then it is not only about fighting the fire when something happens but preventive work instead.” Third key learning for some was that addressing acute bullying cases is not about punishment or accusations, but rather about helping children to improve their social skills and enabling behavior change. Thus, it appeared that implementing a bullying prevention program also served as a way for educators to learn more.A few participants explicitly pointed out that they valued the program being evidence-based, nationally implemented, and being investigated scientifically instead of being a set of procedures invented by a single teacher. Furthermore, the teachers acknowledged the support from and contact with the program developers to be important. Specifically, they longed for new materials, trainings, meetings, and specific campaigns organized by program developers. Such events were experienced as refreshing and described as motivating. Also being connected with the program developers was seen as a motivating factor: “ … The motivation is higher if there is the connection to the program developers, the ones that have designed the program. If the connection is strong, I think that is the key.”During the interviews, teachers shared stories about challenging bullying cases they had faced, thus expressing the limitations of the program in erasing all bullying. The challenging cases typically included several parties, were long lasting, and took plenty of resources. In many cases, it was evident that the students involved needed professional help other than the school alone could provide. Also, family-related problems were mentioned . Co-operation with various stakeholders, such as parents and multiprofessional working groups, was seen to be important when dealing with such cases.Thus, it was clear that KiVa program did not solve all bullying cases, and although the program’s good reputation was mentioned as an important facilitator of delivery during the first years, this reputation was brought up as a double edged sword when failing to solve challenging bullying cases. Specifically, teachers pointed out to the unrealistic expectations towards the program among school personnel, parents, or in some cases raised in public  discussions. Most often the teachers referred to parents expecting the program to remove all bullying from the school. As one teacher quite aptly stated, “KiVa is not about miracles but rather about common sense.” Such realization may be crucial in order to maintain the practices despite facing problems.The organizational features identified were connected to the following broad sub-themes: (1) Motivation to continue program delivery, (2) Administration and organizational development enhancing long-term sustainment, and (3) Organizational culture supporting sustainability.Some teachers emphasized that bullying prevention was inherently meaningful for them; bullying prevention was said to be “a calling” and a few teachers described “being in their vocation.” This teacher described how strongly she felt about the program from the very beginning on: “It somehow came in the training, we were so excited, we got to do some acting and. So we had a passion for it, so I have to say it was close to my heart to implement it and still is.” Furthermore, participants stressed the importance of shared values. The importance of children’s and community’s well-being was emphasized in almost every focus group interview, and the interviewees considered student well-being, safe school environment, and/or bullying prevention to be essential part of the school values. As one teacher put it: “Bullying prevention is a priority in our school.” Overall, understanding how important the well-being of students is and how being bullied jeopardizes their healthy development were seen essential elements in facilitating commitment and motivation to continue program implementation. In some interviews, the teachers, nevertheless, pointed out that not all teachers share the same values and this should be accepted. Also, resistance to change was mentioned during the interviews: New things are not always well-received.Indeed, commitment was mentioned often in the interviews as being an essential part of sustainability: If the teachers are not committed, bullying can take longer to solve, delivery of program components may be at risk, and the program does not become an integral part of the everyday life at school. One interviewee explained how the behavior of a teacher who is not fully committed can decrease the quality of program delivery: “And especially if the teacher is not committed, delivers the lessons begrudgingly, and does not stand behind the ideas, well then, the children will notice that this is not such an important thing.” Importantly, the teachers stressed that it is not enough that a few staff members, such as the KiVa team members, are committed. The program needs to be adopted by the majority of teachers in order to be sustained in the long run. Finally, financial compensation in terms of the employer paying for one extra hour per month or giving exemption from common duties such as recess monitoring was often mentioned in connection to commitment. Teachers regarded compensation as a signal of support and recognition from the school management that antibullying work is valued.The results emphasize how important and motivating it is for teachers to notice the benefits of program delivery in their daily work. According to the teachers, program implementation had the potential to influence everyday life at school in many positive ways. Bullying prevention was seen to be connected to increased well-being of students, better functioning classrooms, feelings of relief after a successful intervention, increased trust, and being rewarded after successful intervening. One teacher explained that it can be seen on the faces and appearance of the students that they feel safe at school. For her, this was the best sign of success in bullying prevention. Furthermore, positive student feedback and enthusiastic participation and profound discussions during KiVa lessons were described to promote further lesson delivery. In addition, noticing that the skills practiced during the student lessons transferred to real life, for example, when a student intervened in bullying situation, was considered motivating. The rewards in the form of successful outcomes were seen as reasons to continue with the program and they were at times described to be very emotional moments as this teacher describes:Of course those moments can be very impactful when you see the situation unravel and, in the best case, the children begin to recover when the bullying stops. [It happens] both in the victimized child and in the one who had been doing the bullying, and those moments can be very emotional. At times I have also had tears in my eyes. Also the results provided by the annual KiVa survey were seen to facilitate program delivery. In some cases, the results were seen to build up within time: over several years of persistent preventive work, the efforts taken started to carry out positive results in the form of decreased level of being bullied and bullying others. As one teacher stated, the results “tell something about the effectiveness of the program, working culture of the school, and about our own success.” The survey results were utilized in evaluating schools bullying prevention work and they were seen to offer valuable information on actions taken. In one school, for instance, the survey results yielded an increase in the student reported bullying prevalence along with the decreased level of program implementation. This information led to improved delivery of the program and “getting our act together,” as described by teachers. In some schools, the program implementation was evaluated yearly, for instance, by selected KiVa team members, school’s student welfare team, or local education and culture committee. Nevertheless, the survey results were considered as an underused resource — the results could be utilized more when planning and evaluating antibullying work.do this [italics added].” Some teachers stated that if the staff members do not share the same view on how to deliver various program components in practice, the motivation for implementation may decrease. Taken together, from the sustainability point of view, it is important to plan well how to deliver the program and also communicate this to all staff members.Teachers described the school level coordination being a necessity for sustained implementation of a complex prevention program. In some schools, coordination was more frequent and involved several staff members, whereas in others, the responsibility laid on the shoulders of one person, sometimes for many years. In any case, the teachers emphasized the role of active staff members. They often kept encouraging others, invited colleagues to participate, and coordinated program implementation. One teacher even described the way of informing others about the KiVa surveys being available for students in a very strict and straightforward way: “There is x amount of time left, book the time slot in this calendar, One of the biggest obstacles for sustained program delivery seemed to be lack of resources — especially time. Typically, teachers stated that they struggled to find time to prepare and deliver the preventive student lessons and to handle the acute cases of bullying: “And actually, of course there are exceptions and special cases that need to be agreed on, they are, like, like we have such a little time here at school, so then the lack of time becomes the problem.” But also solutions were described. For instance, scheduling monthly preventive lessons at the school level, choosing KiVa team members wisely , utilizing the help of assistant and resource teachers, and having a fixed time slot to handle acute cases of bullying were described to be well-functioning practices for promoting sustainability. Along with time and personnel resources, teachers mentioned recently introduced program-related annual costs as a potential risk for program continuation. They were pondering upon what would happen if the funding was cut down. In general, allocating enough resources — time, personnel resources, and financial support — was seen vital and failure to provide the teachers with these resources seemed to form a considerable risk for sustainability.Support from the headmaster was described to be a cornerstone of program sustainability. The role of the headmaster was seen crucial in resource allocation and in offering important backup for the KiVa team with challenging bullying cases like this respondent describes:What really enables it [implementation] is the headmaster’s support. The fact that the headmaster says it is OK to have a substitute teacher when you have to take care of an acute bullying case and also the feeling of having a back-up is also important. Also, the headmasters were described as the ones informing and reminding the staff members of the importance of bullying prevention  and giving appreciation for the work accomplished. Interestingly, teachers also pointed out that direct orders are at times necessary, otherwise nothing happens: “So, if we are not told to do something, well, then we don’t do anything.”Human resource management was brought up as a prerequisite of sustainability: New staff members need to be aware and part of the bullying prevention practices and key staff members need to be rotated every now and then in order to make sure the program does not get too personified or too heavy to carry on. Rotating teachers in key positions was also seen to increase commitment, involvement, and learning over time. In some schools, the program delivery had suffered greatly due to staff turnover, especially if the key persons had left the school with a short notice. Thus, according to the teachers, there needs to be a right balance between competent and experienced teachers and newcomers in key positions. These two participants reflect on the current situation with staff turnover and orientation for the new staff members:Teacher 2: But, this changing of staff has become to the picture during the past years…Teacher 1: [interrupts]: Yes, it messes things up.Teacher 2: It messes things up, like we have had no time to brief newcomers or so. (School 6)Need for training was highlighted in the interviews. One teacher declared that the trainings had brought “more flesh on the bones,” and another participant explicitly stated that training may increase commitment: “Training for as many as possible. It is easier to commit to a program if you understand the basic principles and the philosophy behind it. Just briefly hearing about it in a teacher meeting might not lead to commitment.” The teachers also stated that participating in training does not change anything if actions are not taken in practice. Understanding the basis of the program thoroughly and learning to deliver the lessons and organize the KiVa team discussion were described to take some time. Furthermore, the teachers emphasized that a single teacher participating in a training, although very committed and enthusiastic, cannot change the whole school community. Thus, the need for several teachers to be trained was highlighted, since it facilitates discussion, commitment, and planning of future activities.Teachers considered various symbols being essential in creating a unified antibullying culture in the school. Simple acts such as wearing recess supervisor’s vests, having posters on the walls, singing KiVa songs , and various get-together events organized by the KiVa team were considered important in strengthening the antibullying culture. Talking about KiVa and reminding students that we are a KiVa school where bullying is not tolerated seems to have a crucial role in raising awareness among students. According to the teachers, this should be done regularly in order to strengthen the key messages. This teacher describes how also children notice these symbols:One concrete example, how it [KiVa program] has become a part of life in our school are the research supervisor vests which are a visible sign of KiVa also for children. So, when there was a substitute [teacher] out there without a vest, a first grader reported that maybe they did not tell that man that in our school he is supposed to wear the vest. A generally warm and genuine school climate was perceived as promoting bullying prevention, and well-functioning work community was seen as a great source of support in the long run. One participant evaluated their own work community to be a place where everyone can share their problems and find solutions together. Another teacher described her work community by saying “there is no need to pretend anything” and “in our teachers’ lounge you can ask everything.” Thus, for teachers, it seemed to be important to be able to rely on colleagues and get support when facing problems. Teachers also mentioned some best practices that supported program delivery ; these examples highlight the importance of collegial support.The participants made references to the existing school structures and practices. One teacher, for instance, noted that a bullying prevention program “has to fit in the school” in order to be sustained, and another one emphasized that it was easy to start with KiVa because the program aligned with the already existing values of the school. Thus, a program needs to somehow fit to the current school structures in order to be adopted in the first place. In the long run, the integration of the program to the everyday life at school seems to become an essential for program longevity. Indeed, the participating teachers made references to KiVa becoming established, or “a natural part of the school culture.” Interestingly, teachers were also pondering upon what happens when the program is being routinized: In one interview, the teachers discussed whether the program should be more visible since it had become a part of everyday practices but was not that often referred to in different occasions. The teachers wondered to which extent the students recognized KiVa and realized being in a school where bullying is not tolerated. In another school, KiVa lessons were integrated into different subjects but were no longer called KiVa lessons. Consequently, the program was part of the everyday practices, but the adaptations made it also somehow invisible: KiVa was not that often talked about or present in happenings and in everyday talk in classrooms. These examples reflect the need for raising awareness and promoting antibullying values over time.During the interviews, also contextual factors facilitating program sustainability across years were referred to. More precisely, teachers described (1) national core curriculum, (2) school’s bullying prevention plan, and (3) media attention, as facilitating sustainability but also setting barriers to it at times.The nationwide dissemination of KiVa started in 2009. As one teacher stated, there was “room for a program like KiVa” in schools at the time. There was a need for a program offering tools for bullying prevention and socioemotional learning during those years. Since the program had become very well-known publicly, teachers did not want to miss their chance to get familiar with it, and many reported that they had taken part in the initial training days which were offered free of charge . The national core curriculum for basic education , Teacher 4: … Or then there are parents attacking you sharply that nothing has been done although their child has been bullied for years and in those cases teachers’ hands are totally tied.Teacher 1: No chance to defend oneself.Teacher 4: Or like, we cannot defend ourselves, no, we cannot tell anything, we are bound by confidentiality. (School 8)The last contextual factor described by teachers was media attention. Over the years, the KiVa antibullying program had received a lot of media attention in Finland — both positive and negative. More recently, the program had been discussed publicly when severe bullying cases were dealt with in the social media or in the news. Even though the teachers, in general, told that they try not to let the bad news or criticism affect them too much, some of them reported being frustrated at times about people’s way of generalizing schools’ (in)activity in preventing and tackling bullying, for instance, in social media. Due to professional confidentiality, they felt it was not possible to equally engage in discussion and respond to, for instance, accusations as the following discussion on social media influence points out:In such cases teachers often felt that the criticism was unjustified and wrong, considering all their efforts to promote the well-being of students at school. Corroborating prior research  and adaptations . The importance of program fidelity has been stressed in previous studies . Such theoretical and research-based understanding on the phenomenon could increase teachers’ motivation to use and maintain evidence-based prevention and intervention practices. Third, developing understanding and acceptance of the program being a tool, not a solution for all problems, seems to be important for sustaining a bullying prevention program (see also Coyle, Our results demonstrating the importance of organizational factors corroborate with previous studies in the bullying prevention field highlighting the need for commitment, coordination, adequate resources, support, training, human resource management, and supportive school climate in bullying prevention (Ahtola et al., In a broader societal picture, the legislation and policies directing schools towards high quality bullying prevention can promote sustainability. However, national level policies, legislative guidance, curriculum contents, or societal discourse alone cannot create the most important thing: a well-functioning school-level policy to prevent and intervene in bullying with enough resources that is sustained in everyday life at school over time. In addition, bullying taking place online has created new challenges for bullying prevention: Teachers find it difficult to recognize and intervene in online bullying (Bruening et al., In light of the broader literature on implementation, it is important to notice that this study focuses on teacher perceptions of the sustainment of a bullying prevention program, and the results should be understood as such. We did not aim to elaborate on how implementation influences outcomes, but rather to shed light on how teachers experience the factors influencing sustaining a bullying prevention program over several years. It is more than likely that the identified factors are intertwined in complex ways: Some of them might be more influential than others, and in some cases, the presence of more than one facilitator is needed in order to sustain the program. For instance, resources do not really help if there are no committed staff members to actually utilize those resources. In general, implementation processes are contextually embedded, which may further add complexity to how these factors are apparent in one context but may not be influential in another.The current study has used previous research and conceptualization coming from health interventions (e.g., Scheirer, To our knowledge, studies on bullying prevention have not utilized the EPIS framework in conceptualizing sustainment. The results of this study suggest that similar features can be found whether sustained implementation is studied in the context of a school-based bullying prevention program, or evidence-based practices in public sector services more generally. We examined the sustainability phase of implementation (see Aarons et al., The strength of this study lies on its design. The schools were invited to participate based on their success in implementing KiVa program; we knew already before the focus group interviews that they had implemented the program across several years and been successful in reducing bullying. Consequently, the interviews were rich in content, and the participants were able to elaborate vividly on program implementation and produce detailed information on facilitators and barriers to sustaining bullying prevention practices, a feature often highly valued in qualitative studies. However, since the schools were pre-selected from among the ones being successful in program delivery, the results may represent the most positive experiences on implementing a bullying prevention program. Schools that have been struggling with implementation, have not followed the guidelines, or have not been able to reduce bullying may have different kinds of experiences on facilitators and barriers to program sustainment.Another limitation is the restriction to primary schools. In Finland, lower secondary schools have a very different structure compared to primary schools, and also the KiVa lessons are organized differently in primary and lower secondary schools. Moreover, the results of this study reflect the situation in Finland, and possibly cannot be generalized across countries and school systems. Notably, the results illustrate the teacher perspective, but from the headmasters’ point of view some other factors might fuel or hinder the sustainment as suggested in previous studies in the bullying prevention field (Bruening et al., In this study, we examined implementation sustainability drivers and barriers in schools that had succeeded in implementing a bullying prevention program under real-life conditions up to 8 years. A clear next step would be to examine the schools failing to implement the program over time. This approach would unravel the relative importance of the facilitators and barriers now identified, and possibly reveal new ones. In addition, this approach could provide knowledge on possible factors explaining less optimal outcomes.As previous studies suggest, some bullying cases remain unresolved (e.g., Johander et al., Also, there is a clear need for studies examining program sustainment and how it relates to program effectiveness and factors predicting high implementation fidelity in the long run. Such studies would need to focus on the connection between the implementation fidelity and the outcomes, given that the implementation often varies across years (Herlitz et al.,


Foot-and-Mouth Disease (FMD) and Avian Influenza (AI) frequently occur in South Korea, resulting in high levels of occupational stress among quarantine workers forced to partake in massive livestock killings. This study explored the usefulness of Equine Assisted Learning (EAL) in improving these workers’ psychological and emotional functioning. A total of 51 FMD/AI control workers participated in 16 sessions of an EAL program facilitated by therapeutic riding professionals and trained horses. Results showed significant changes in their stress level, coping style, and overall quality of life-related to health, most notably increased vitality, enhanced emotional and social functioning, greater problem-solving, and less social avoidance after EAL participation. The usefulness of equine-assisted activities and the association between more significant stress coping ability and improved functioning in various areas of life are consistent with previous research findings. Implications for EAL application are discussed. Little is known regarding the experiences of FMD/AI control workers; however, based on previous research findings on stress and trauma related to disaster work, we may assume the stress levels among these professionals. Disaster relief work is associated with high-stress levels, possible lingering mental health problems, burnout, and quick turnover rates . When peFurthermore, the likelihood that Korean FMD/AI control workers’ will seek the professional help of their own free will is quite slim, not to mention there are few professional services to choose from nationwide . HoweverThere are currently few specialized methods to help with their occupational distress. The present study aims to gain a deeper understanding of the mental health statuses of FMD/AI workers who participated in an EAL program and to test for changes in their stress level, coping skills, and overall health. The rationale behind using Equine Assisted Learning (EAL) for this population in this study is that equine-assisted activities are suggested to improve participants’ various levels of physical, emotional, psychological, and social needs ,8,9,10. Epidemic control workers belong in the same group as any other disaster workers, including firefighters, police officers, medical personnel and paramedics, search and rescue workers, transport and recovery personnel, mental health and social services personnel, and volunteers who assist with high-risk situations . The natRecently, the National Human Rights Commission of Korea appointed the Seoul National University Institute for Social Development to examine the psychological health status of 268 public officials and veterinarians who participated in the killing of animals while performing FMD control. Using an 11-point scale of severity of difficulty/discomfort, the mean score was 9.02, indicating that the labor intensity of the work was relatively high. In addition, 76% of participants exhibited a clinically diagnosable level of PTSD. These findings are assumed to be associated with 43 accidents that transpired between 2000 and 2017 when FMD was aggressively taking place . Given tFundamentally, FMD/AI control work is far more severe than ordinary office “work” because the job description is shocking . ParticuWhen faced with difficult or stressful situations, how people process stressors is critical in determining whether trauma—or the level of stress resulting from critical events—will be experienced. According to various stress hypotheses, it is relatively easy to overcome if an individual can deal with stressful situations through good coping skills and a healthy support system ,16. For Stress coping can be learned in overcoming challenging situations to regain a more stable emotional state, hence a critical behavioral approach in counseling and therapy. In neuroscience, this process is associated with serotonin function, where the difficulties of human emotions are regulated through hormonal balance. Interestingly, serotonin release can be manipulated by conditioning our brain into peaceful or healing situations, such as listening to soothing music or thinking about enjoyable images or landscapes, known as “greenness effects” . In addiEAL is a form of Equine Assisted Activities and Therapy (EAAT) that aims to help individuals cope with personal emotional and behavioral problems through a learning-based program . AlthougThe trained horse is generally considered the teacher, and a human facilitator helps guide the participants during the process of learning and understanding. Horses have a significant advantage over other animals in that they are more sensitive to the emotional state of humans and the movement of their external environment than any other animals used for mediated therapy . Horses Research shows that EAL is effective for reducing trauma symptoms ,31, promThis study incorporated a non-randomized pre-and post-test design using a single treatment group of 51 voluntary study participants. Recruitment flyers were sent out to public officials (whose job specification includes FMD/AI control work) with the help of the Korean Ministry of Agriculture, Food, and Rural Affairs. Prospective participants then registered with a nearby contracted Therapeutic Riding Center. These centers run the same EAL program curriculum so that participants are provided the same program throughout Korea. We originally anticipated at least 40 voluntary participants with a maximum of 80 subjects. Before the first session, the study purpose and methods were thoroughly explained, and a written consent form was provided, outlining a free-of-charge program, voluntary participation, anonymity, and collection and use of personal information. Moreover, the current study was approved by the Institutional Review Board of Jeonbuk Horse Industrial Complex Center. The questionnaire for our pre and post-test was conducted via an encrypted online survey link sent individually to participants and required a password and smartphone. A printed version of the questionnaire was distributed, sealed, and passed to the primary investigator for coding and analysis in a few cases where the individual could not use a smartphone. The collected data file was encrypted, stored under lock and key, and was shared only with the researchers responsible for the coding, cleaning, analyzing, and writing documents. The entire program was free of charge, and no physical or psychological discomfort occurred during data collection. Any person with a current mental health diagnosis was excluded from the study.The EAL program we implemented in this study was specifically developed by a multidisciplinary research team affiliated with the Therapeutic and Healing-Riding Center at Korea Racing Authority (KRA) and with the advice of PATH Intl’s licensed international experts. The same program was previously applied to and evaluated the effectiveness and usefulness among Korean probation officers and firefighters. The use of EAL program on Korean firefighters has been supported by a recent study  and otheThe EAL program used in this study consisted of eight weeks of a total of 16 sessions, six sessions of unmounted (ground) activities, and ten sessions of mounted (riding) activities. Ground activities included observing horse behaviors, grooming, leading, desensitizing, and harnessing. Instructors were all trained and licensed professionals  with at least 5 years of experience in therapeutic riding. EAL programs were conducted as group sessions with 2–3 participants per instructor. Although assigned horses may change during the course of the program, the same instructor remained from start to finish of the program.The main goal of the riding activities was to help participants acquire independent riding skills by getting on the back of a horse and gradually learning to walk and trot. In addition, these activities aimed to increase self-control, accomplishment, and problem-solving ability. See Health and mental health domains related to characteristics of the high-risk stress jobs of FMD/AI control workers were our primary interest, including the perceived stress level, coping strategies, and overall health statuses. Demographic questions included age, gender, marital status, highest education level attained, religion, length of employment in current service, hobby, participation in one or more livestock killings, and severity of emotional pain.We used the KPSS to examine our participants’ perceived stress levels and observe changes before and after participating in the program. The KPSS, standardized by  and prevWe used the K-SCI, originally developed by Amirkhan  and tranThe SF-36 health survey  has beenp < 0.05.In addition to a descriptive analysis of demographic information of 45 program participants , a paired t-test was performed to observe any changes in the main variables of interest after the EAL program was completed. An analysis of covariance (ANCOVA) was also conducted to determine whether there were differences in quality of life —after the EAL program was completed—across age, length of service, and massive culling experience. All quantitative analyses were performed using Predictive Analytics Software (PASW) 18.0. The significance level for the study was set to The mean age of the participants was 41.2 years (SD = 10.5), with the majority of program participants being male (84.4%) and having attended university or a higher level of education (82.2%). The mean length of employment in the current service was approximately 119.1 months (SD = 124.4), or ten years. Half of the participants  had less than five years of employment, and about 22.2% (n = 10) were employed at the same workplace for more than 20 years.Of our 45 participants, 75.6% (n = 34) of respondents had one or more livestock killing experiences. When responding about the difficulty of the killing incident, almost everyone  recalled the massive culling experiences as difficult, with 1 out of 3 reporting  that it was ‘very difficult.’ When asked about any psychological help they had received in the past to cope with the emotional pain associated with their trauma, only a few participants  reported receiving any treatment. However, this treatment mostly consisted of medical attention related to physical injury  and was not associated with psychological trauma. Of the 34 respondents with one or more such experiences, only one had received professional counseling and had taken prescribed medication previously for anxiety and lack of self-control for the past three years. These results indicate that very few of these control workers sought professional help, despite their self-report of experiencing emotional difficulty from reminiscing about the killing incidents.p < 0.01, 46.0% improvement after EAL program participation) and vitality (energy and fatigue) , followed by general mental health  , social activities due to physical or emotional problems , usual role activities due to physical health problems , and general health . Based on effect sizes, the vitality domain had the greatest level of improvement (Cohen’s d = 1.00), followed by general mental health (0.83), limitations in usual role activities due to emotional problems (0.78), social activities due to physical or emotional problems (0.61), general health (0.45), and usual role activities due to physical health problems (0.47).The ANCOVA showed a difference in the post-test mean on physical activities due to health problems and vitality after controlling whether participants had one or more massive culling experiences in the past. More specifically, individuals with one or more enormous culling experiences  showed lower levels of physical activities due to health problems compared to their counterparts with no tremendous culling experience . Likewise, individuals with one or more massive culling experiences  showed lower vitality levels than their counterparts with no tremendous culling experience . In addition, the ANCOVA results indicated that participants with five or more years of employment in current service  showed lower general health levels at post-test than those under five years of a career .p < 0.001). When assessing across stress level categories, there was a 17.8% decrease in participants requiring clinical assessment for their depression or anxiety after program participation . Although only four participants (8.9%) were in the normal stress range  before program participation, there was a 15.5% increase from 4 to 11 participants (24.4%) in the normal stress range after participation. Among the 22 participants (48.9%) who exhibited high-stress levels before program participation, 13 (59.1%) showed improvement.The ANCOVA revealed a significant difference in the post-test mean scores on stress level after controlling for whether participants had one or more massive culling experiences in the past. More specifically, individuals with one or more massive culling experiences  exhibited a higher stress level than their counterparts with no massive culling experience .See In summary, (1) the overall stress levels of our participants were significantly reduced after participating in the EAL program; (2) participants’ tendency to pursue problem-solving based strategies and social support improved while using less avoidance-oriented strategies; and (3) positive changes were observed in various life domains, including both mental health and physical aspects . Differences in quality of life, depending on whether participants had one or more massive culling experiences in the past, especially in terms of stress level, physical activities due to health problems, and vitality, were also essential findings. For example, although the mean stress level score decreased after program participation, individuals with one or more massive culling experiences remained at a higher stress level than those without such experiences. This finding may indicate the unresolved nature of such traumatic experiences, and these workers likely require additional professional help to cope with their psychological and/or emotional issues.The observed changes in coping styles were our most important finding. Participant avoidance tendencies diminished, while problem-solving and help-seeking behaviors improved. We may explore how this occurred by examining the program components and the uniqueness and strengths of equine-assisted activities, especially building resilience. Resilient people tend to deal with stress without falling apart or running away (as in fight-or-flight response) and seek healthy solutions for overcoming stressful situations. High resilience can be learned in overcoming frustration, whereby individuals encounter various experiences that allow them to regain confidence and maintain a stable emotional state.Frederick, Hatz, and Lanning  showed eAlthough using EAL may be considered controversial, given that the high stress of FMD/AI control workers involves killing animals, our findings suggest that if used correctly by trained professionals, this equine intervention helps reduce stress and improve the coping skills of these individuals. Although our participants are not representative of all psychological states experienced by similar workers, as our sample size was too small to represent the whole population, we did find improvement in the lives of one of the most high-risk occupational stress groups.Epidemic control work is a professional effort to prevent and decrease the risk of developing or spreading disease. However, this task is inevitably performed by humans who must brutally kill livestock, resulting in significant negative physical, psychological, mental, and social impacts on individuals and communities involved in the process. These negative impacts include extreme stress, anxiety, and moral confusion, to name a few; therefore, it is a “disaster” for everyone.In the present study, we explored the usefulness of an EAL program to improve various life domains of FMD/AI control workers in South Korea. According to our findings, EAL effectively improved stress and increased healthy coping styles in program participants. In particular, positive changes for coping with stress were a significant outcome, as it is related to resilience, which is the ability to cope with future stressors healthily. Despite statistically significant findings of the study, caution needs to be taken in making definite conclusions about the impact of the occupational environment that lead to high stress levels and the effectiveness of the EAL program on improving stress levels and quality of life. Moreover, given that this study was conducted in more of a pilot form and did not follow up on the subjects after the program, there is little evidence to suggest that their increased coping skills had a long-term effect. However, given the results, we have gained some understanding of horses’ use in helping humans become mentally healthy in stressful situations. Equine-assisted approaches such as the EAL program used in our study may be adopted by different countries regardless of differences in culture or language because horses have their unique ways of non-verbally yet efficiently communicating and coordinating with human behaviors. Future studies should include greater sample sizes, conduct follow-up studies, and explore other mental health needs, such as alcohol or drug use, as these are two common comorbidities alongside PTSD, anxiety, and depression. Comparison with a control group would be necessary to rule out any external factors that may explain the effectiveness of the EAL program. In terms of future research from a strength perspective, it may be valuable to investigate protective factors  and determine how EAL reinforces protective factors to improve well-being.


Nano- and microplastic particles (NMP) are strong environmental contaminants affecting marine ecosystems and human health. The negligible use of biodegradable plastics and the lack of knowledge about plastic uptake, accumulation, and functional consequences led us to investigate the short- and long-term effects in freshly isolated skin cells from mice. Using fluorescent NMP of several sizes (200 nm to 6 µm), efficient cellular uptake was observed, causing, however, only minor acute toxicity as metabolic activity and apoptosis data suggested, albeit changes in intracellular reactive species and thiol levels were observed. The internalized NMP induced an altered expression of various targets of the nuclear factor-2-related transcription factor 2 pathway and were accompanied by changed antioxidant and oxidative stress signaling responses, as suggested by altered heme oxygenase 1 and glutathione peroxide 2 levels. A highly increased beta-catenin expression under acute but not chronic NMP exposure was concomitant with a strong translocation from membrane to the nucleus and subsequent transcription activation of Wnt signaling target genes after both single-dose and chronic long-term NMP exposure. Moreover, fibroblast-to-myofibroblast transdifferentiation accompanied by an increase of α smooth muscle actin and collagen expression was observed. Together with several NMP-induced changes in junctional and adherence protein expression, our study for the first time elucidates the acute and chronic effects of NMP of different sizes in primary skin cells' signaling and functional biology, contributing to a better understanding of nano- and microplastic to health risks in higher vertebrates.The online version contains supplementary material available at 10.1186/s12989-023-00513-1. Several downstream targets of Nrf2  pathway was affected in our primary skin cell model Fig. a. We obsrf2 Fig. c are mainer Fig. c. In thiner Fig. d. Additiner Fig. f. Additiner Fig. g.Fig. 5ACTNNB1) gene and protein level, and a slight increase in E-cadherin (CDH1) expression after acute NMP exposure, in contrast to chronic treatment , CTNNB1 is not ubiquitinated but accumulates in the nucleus, where it acts as a coactivator for transcription factors of the T-cell/lymphoid enhancer-biding factor (TCF/LEF) family. In the absence of Wnt ligands, glycogen synthase kinase (GSK) 3β promotes the phosphorylation of β-catenin at key Ser/Thr residues [GSK3β but an increase of LEF1 mRNA in single-NMP-treated skin cells. After prolonged NMP exposure, GSK3β was comparable between NMP-treated cells and controls, whereas LEF1 mRNA was increased in the NMP-treated skin cells  δ is widely distributed in the nucleus of epithelial lineages from keratinocytes in the skin [VEGF) mRNA, were significantly elevated in NMP-treated skin cells  mRNA. Additionally, gap junctions, as channels for intercellular cell–cell communication (GJIC), are mainly formed by connexin (Cx) 43. We found a marked and modest upregulation for Cx43 in dependence of single or repeated NMP treatment, respectively, indicating a general effect of NMP on GJIC , which is found in keratinized structures of the epidermis, was dramatically enhanced after prolonged treatment. In contrast, keratin 14 (KRT14) was identified to be downregulated  and epithelial-to-mesenchymal phenotype (EMT) as well as to a deposition of ECM proteins Fig. a, we quaNMP Fig. b, hintinNMP Fig. c. While NMP Fig. b.Fig. 8EITGA1/2/5/6 and ITGB1, were significantly differentially expressed between experimental groups compared to untreated control. However, the expression of integrin ITGB1 was increased  in the body is a potential health threat. Among the different entry routes, humans are exposed to NMP via the skin. However, the consequences of acute or chronic NMP exposure in skin cells are unknown. This is particularly important for chronic NMP exposure, as present in our environment. To this end, this study's major aim was to determine several biological responses, such as cellular uptake, accumulation, and biological effects of NMP in primary skin cells after both single-dose (acute) and repetitive  exposure, respectively.stratum corneum (SC) layer of the skin [, a continuous penetration and enrichment of topically applied nano-sized particles for skin tissue and epidermal cells were also shown [In several previous studies, the plastic particles were relatively large (at 0.5–1 mm)  comparedthe skin , the prethe skin . Althougthe skin . In addiso shown –45. Geneso shown , 46, 47,so shown . Howeverso shown –52. Our so shown , served so shown . NMP expso shown . Our datso shown , 56.A potential problem with NMP uptake is the possibility of toxic effects by elevated intracellular reactive oxygen species (ROS) levels, as shown for NMP exposure in marine organisms and human epithelial cells , 58. MicHIF1A) expression after single incubation has reversed with increasing duration of NMP exposure, indicating a regulation through a redox-sensitive mechanism [Generally, data on NMP-induced apoptotic responses in primary mammalian cells are scarce. However, in human alveolar epithelial cells , NMP-indechanism . On the echanism . The B-cechanism . In lineechanism . As highechanism . Accumulechanism , 69. AlbCAT) and glutathione peroxidase (GPX) 2 were diminished in the NMP-treated skin cells in a time-dependent manner, which was similar in marine organisms [Exposure to polystyrene NMP causes ROS generation and, subsequently, oxidative stress in vitro , affectirganisms , 80. It rganisms . In respThe dual-function protein β-catenin is involved in regulating cellular adhesion of E-cadherin complex and in gene transcription, where it acts as an intracellular signal transducer in the wingless (Wnt) signaling pathway . In rodeOne important role of the actin cytoskeleton is regulating the β-catenin / E-cadherin complex between adherent cells. The actin cytoskeleton maintains and changes the cellular shape and structural stability of cells and is involved in cell–cell and cell–matrix adhesion . IndividResident fibroblasts proliferate reactively in response to the microenvironment's external stimulation by secretion of excessive extracellular matrix (ECM) components like collagens. An excessive or prolonged collagen synthesis leads to abnormal scar formation in the skin , fibrotiThere are many different subgroups of keratins, representing a critical intermediary filament in keratinocytes. Krt1 is crucial for maintaining skin integrity and participates in an inflammatory network in murine keratinocytes suggesting a functional link between Krt1 and human inflammatory diseases . Its expIn summary, our results suggested that NMP uptake in primary murine skin cells promotes intracellular ROS production at low cytotoxicity while highlighting mechanistic pathways and modulation of transcriptional patterns of apoptosis-related genes. In addition, NMP treatment modulated the secretory profile. It activated Nrf2-driven antioxidant defense responses, accompanied by altered β-catenin signaling in the skin cells Fig. . MoreoveAdditional file 1:  Table S1. Murine gene-specific primer used in qPCR.; Figure S1. Expression of HO-1 in skin cells following NMP uptake. Representative images of 0.2 µm (a), 1.0 µm (b), 2.0 µm (c), and 6.0 µm (d) NMP uptake in skin cells in brightfield and fluorescence channels. The cell nuclei were stained with DAPI (blue). Scale bar is 50 µm; Figure S2. Expression of HO-1 in skin cells following NMP uptake. Distribution and expression of HO-1 after nuclear Nrf2 translocation and activation were observed after NMP uptake using immunofluorescence labeling in skin cells. The cell nuclei were stained with DAPI (blue). Scale bar is 50 µm; Figure S3. Effects on β-catenin signaling in skin cells following NMP uptake. Expression and distribution of β-catenin after chronic exposure to 0.2–6 µm and mix NMP. The cell nuclei were counterstained with DAPI (blue). Scale bar is 50 µm.


Translation of an effective research intervention into a program able to be implemented in practice typically requires adaptations to ensure the outcomes can be achieved within the applied setting. User centred design (UCD) methodologies can support these iterative adaptations, with this approach being particularly well suited to peer-led interventions, due to a focus on usability. We describe and reflect on the UCD approach that was applied to optimise an online, peer-led workplace health promotion initiative (BeUpstanding: ACTRN12617000682347) to be suitable for wide-scale implementation and evaluation. Optimisation was aligned against the indicators of the RE-AIM  framework, with UCD methodologies  employed to enhance the program according to all RE-AIM dimensions. The core team  worked closely with policy and practice partners and end users  to iteratively develop and test across the RE-AIM indicators. This description and reflection of the process of applying UCD and the RE-AIM framework to the optimisation of BeUpstanding is intended to provide guidance for other behaviour change research adaptations into practice. Adaptations of evidence-based health practices or interventions are almost always needed to maximise and maintain outcomes within applied settings ,2,3. AltA user-centred design approach was used for the optimisation of the evidence-informed BeUpstanding program and accompanying BeUpstanding Champion Toolkit to ensure it was fit-for-purpose for a national implementation trial. The BeUpstanding program is a workplace health initiative designed to support work teams to sit less and move more for their health and wellbeing . The proFrom its inception, the BeUpstanding program was designed with wide-scale uptake and implementation in mind; employing an iterative, phased process of development and adaptation ,16,17. TStand Up Australia program of workplace intervention research  survey because they feared what would happen to their data”Champion 121To address this tension between the needs of the researchers to collect detailed and validated data, and the workplace concerns identified, education on the need and usefulness of surveys was incorporated, in line with the suggestion from champions. Champions were also provided with the opportunity to view the survey prior to sending the survey link to staff.“Maybe a little summary at the beginning of the survey on what the survey was aiming to achieve and goals at the end of the survey”Champion 126Managers and champions also reported wanting more access to engaging data insights to assist with further scale out across other work teams within the organisation and/or repeat rollout of the program. Incentives for data completion were added to help address this issue.”…need for feedback on the activities that were put in place…we did not get outcomes”Champion 102Incentivising survey completion: Incentives were added to the toolkit to encourage completion of key self-report surveys including more detailed real-time data insights at baseline and follow-up survey times displayed for the champion /Tailored target response rates and feedback were also added . A new, customisable poster and a 9-page downloadable bespoke data report available at program end, following completion of the core evaluation elements, were also developed and integrated into the toolkit. Decisions around the data to present in the bespoke report were informed by the feedback from champions and management. Here, the research team had used custom-generated Powerpoint slides to iteratively trial how to present the data collected in ways that were meaningful and appropriately interpreted by the end-users .To enhance and more readily track the adoption of the BeUpstanding program, three changes to the design of the toolkit were identified: clear presentation of the business case; clarification of the champion journey; and, streamlining onboarding. The need for targeted recruitment pathways was also acknowledged.Clear presentation of the business case: Champion and management feedback highlighted the importance of presenting program outcomes that were of relevance to management when deciding to adopt the program in their organisation/team.“need to be able to promote it more…to get management on board”Champion 102Expected key program outcomes, such as behaviour change  were important, but so too were work outcomes including employee satisfaction, productivity and reduction in sick days. Consequently, the user’s onboarding journey included free downloads  and an engaging short animation to help potential champions present the ‘business case’ to management to take part in the program and facilitate uptake.Champion journey: Management and champion feedback indicated that they were keen to know exactly ‘what they were signing up for’ in delivering and evaluating the program. Management also wanted additional resources outside of the program information sheets to help recruit champions. A colourful two page and one page version of a ‘champion journey’ infographic  to complete the form before accessing the toolkit.Establishing targeted recruitment pathways: For the program to be adopted at a national level and across all the sectors identified as priority targets, it was necessary to develop recruitment targets and referral pathways in collaboration with policy and practice partners. Planning sessions were held with each policy and practice partner to determine key audiences and potentially appropriate channels to promote the program. A tailored promotions and marketing plan with associated content and collateral was developed for each partner. Engagement with the partners was led by the implementation scientist (AG) and business strategist (MF).Overall, champions found the toolkit and supporting materials easy to use and helpful to supporting implementation, but several elements were identified as not fit-for-purpose for either supporting or evaluating the program . To addrDevelopment of additional assets and dashboard changes: Champions often liked the supporting materials provided to help them implement the program, but commonly asked for additional collateral, particularly posters and tips sheets including ideas for strategies to keep messages ‘fresh’ and enhance staff engagement with the program.“I have been using many of the posters available and think some more would be good, as I am rotating them around so they don’t become part of the furniture. I think it’s more useful for the posters to have a tip  instead of a general statement ”Champion 168In line with what was described for reach, new weekly posters and associated email content were developed and organised in a week-by-week guide to make it easier for champions to implement the main program messages. The “champion journey” asset (as mentioned above) was used to roadmap the main tasks involved in the implementation trial see . The num“We are a small dynamic team, in a small office and already had all the equipment necessary. We could have jumped a few of the steps in the program.”Champion 422Design features were added to the well liked ‘push button’ design layout to encourage champions to complete tasks, check that they had completed them and stay on track . Visual cues  were added to the dashboard to encourage champions to complete the workplace audit tool, which was a key planning step in the program.Enhancing implementation data collection and feedback: A new champion-completion survey was added to the end of the program. This survey was designed to capture both champion and staff engagement and experiences with the program components and program costs. This data, coupled with other evaluation data, was used to generate a bespoke team performance report that the champion could then share with their team and management (see Effectiveness). To provide an incentive to complete the evaluation components, the report was only made available once there was sufficient evaluation data collected .The toolkit version used by early adopters (during the soft launch phase) did not include any measurement of program maintenance. Sustainability of program outcomes was a key consideration and concern for many organisations, with maintenance also a key indicator of the RE-AIM framework. To address this gap, additional data capture elements were built into the toolkit.Additional data capture: A staff survey with associated real-time feedback for the champion on team level data  was added to the toolkit to assess sustainability. Like the pre- and post-program surveys, champions could monitor the number of responses (with tailored target response rates) and the data responses in real time. This sustainability staff survey became unlocked and visually highlighted  after the completion of the post-program survey. This design feature was intended to reduce the visible number of tasks and avoid incorrect data entry . A sustainability workplace audit was also included for the champion to complete. Both the staff survey and the audit included informational text about the benefits of evaluating long term changes at both the organisational team and individual level.This study described the application of a user-centred design process to optimise a peer-led behaviour-change program to be suitable for delivery and evaluation in the context of a national implementation trial. It provides insight into a thorough and iterative way of redeveloping an evidence-informed and usable online workplace health program delivered by workplace champions, using a “train-the-champion” approach. The champion dashboard, toolkit and associated collateral were redesigned to better meet the needs of workplace users, but also researchers and policy and practice partners who helped fund the program. Involving multiple stakeholders and end users, including experts from design and behavioural science, workplaces and industry was necessary to increase the likelihood that the program would be successfully implemented and evaluated during the next planned national implementation phase. The resulting minimal viable product or intervention adheres to UCD principles and best practice in behaviour change, and has been optimised for success according to all five RE-AIM dimensions.Peer- or champion-led interventions offer a beneficial way of scaling evidence-based health behaviour programs delivered in the workplace ,30. If tDespite the ground breaking work of the Expert Recommendations for Implementing Change (ERIC) study  that higUse of the glossary of user-centred design strategies for implementation science by Dopp and colleagues (2019)  helped tRE-AIM provided the other key framework that informed the redesign. To our knowledge, this is the first study that has integrated UCD methodologies to enhance RE-AIM indicators. Mapping design changes against this well-established framework ensured that changes made were going to meet the needs of the implementation trial. Our experience shows that RE-AIM can be used to organise redesign efforts, providing balanced focus particularly to issues of design that impact adoption and reach.A critical element that informed the redesign was the iterative input gained from multiple sources , using multiple data collection techniques. This occasionally conflicting feedback needed to be considered in the context of other considerations, including alignment with research aims and budgetary, technological and timeline constraints. Consequently, not all feedback was considered equally. Recently developed tools, such as the House of Quality for Behavioural Science , can be While the formation of a multidisciplinary expert design team and involvement of stakeholders is a critical strength of UCD, the coordination of a large (10–15 person) team across diverse disciplines and holding distinct perspectives and needs was challenging. Relatedly, UCD involves a process that can sometimes be ambiguous, involving tolerance of differing opinions, pivots and repeated prototyping . This prThe redesign was used to optimise the BeUpstanding program and toolkit to be fit-for-purpose for the national implementation trial. This process highlighted the value in multidisciplinary expertise in helping to specify user and program needs, and make and test modifications. The trial will be completed in late 2022, and a similar UCD process is now been deployed to integrate the learnings from the trial to enable both scale out as well as scale up of the program. The core team are exploring the viability of the program through market research to ascertain funding models and potential commercial avenues to support the sustainability of the program in practice.This paper described how UCD methodologies were applied to redesign an online, peer-led workplace health initiative to ensure it was fit-for-purpose for a national implementation trial. It highlights the multiple perspectives and data sources that were considered, and the personnel that were required, to ensure that the redesigned elements meet both the user needs and the research needs, according to the indicators of RE-AIM. These findings and reflections are intended to provide guidance to inform the design of other behaviour change research adaptations into practice.