Evidence suggests that Internet-delivered cognitive behavioral therapy (CBT) may be as effective as face-to-face delivery for depression, but attrition and engagement rates remain a challenge.This service-based study aimed to evaluate an online, therapist-supported, CBT-based program for depression. The program was specifically designed to address engagement issues, most notably by integrating online therapist support and communication within the platform.Participants were 80 adults who were registered university students. Participants used the modular online program over 8 weeks, supported by a therapist. Engagement information was gathered automatically by the online system, and analyzed for all participants. Severity of participants’ self-reported symptoms of depression were assessed preintervention and postintervention using the Beck Depression Inventory-II (BDI-II). Postintervention measures were completed by 53 participants.P<.001) decrease in self-reported depressive symptomatology from preintervention (mean BDI-II 25.47) to postintervention (mean BDI-II 15.53) with a large effect size (d=1.17) was also observed.A high level of engagement was observed compared to a previous study within the same service, along with extensive use of a range of program features. A statistically significant (The results indicate the potential of unintrusive and easily provided online support to enhance engagement with online interventions. The system described in the paper also illustrates how such online support can be tightly integrated with interactive online programs by using a range of design strategies intended to improve the user experience. Many adults experience depression in their lifetime, but a relatively small number seek or receive effective or evidence-based treatment for their difficulties . This maThe integration of computerized interventions into mainstream mental health services offers a number of benefits, including the means to increase capacity in mental health services, reduce costs, and improve convenience to therapist and client ,5. In adThe first theme relates to the actual clinical efficacy of the computerized intervention. This line of enquiry seeks to ascertain if completion of the intervention leads to any significant increase in well-being or decrease in distress for the user. Typically, this manifests as an outcome study that assesses symptomatology and other clinically relevant variables preintervention and postintervention. Results are promising; in a comprehensive meta-analysis of the effectiveness of Internet-based psychotherapeutic interventions, Barak et al  reportedThe second theme of enquiry relates to the issue of how engaging computerized interventions are and how willing clients are to use them as they are intended. Related to this, researchers have also begun to examine the characteristics of the individuals most likely to both engage with and benefit from a computerized intervention ,17,18. AWe can see from the literature that the efficacy of online programs can vary as a function of delivery and context, and that difficulties remain surrounding engagement and attrition. This motivates development and exploration of innovative strategies for improving engagement in realistic service environments. To this end, we present an initial clinical evaluation of a highly interactive therapist-supported Internet-based intervention for depression, namely the Mind Balance program. We report the engagement patterns of clients using the therapist-supported program, and outcome data on changes in self-reported depression symptomatology following use of the program.Mind Balance is a 7-module online CBT-based intervention for depression, delivered on a Web 2.0 platform using media-rich interactive content. The structure and content of the program modules follow evidence-based principles of a traditional CBT program, incorporating ideas from mindfulness. The content of each module is described briefly in The Mind Balance program employs a number of innovative engagement strategies for improving the user experience, described subsequently. These features are also presented in the SilverCloud Platform Overview video . The desThe client has their own secure home page , which iThe program includes a number of interactive elements and graphical exercises  with their therapist see . This shAlthough group therapy and peer group support are well established, introducing contact with other clients within any online system raises a number of ethical concerns regarding the possibility for unhelpful or negative content or communications. As a first step, the client can see anonymous indications of other people in the system. The intention is to reassure clients that they are not alone in experiencing difficulties and that many other people have experienced similar problems and overcome them. Users can respond to content by indicating that they “like” it, and can see how many other people liked it, helping to reduce the sense of isolation. More detailed shared content (such as tips and ideas) is subject to therapist moderation.A key innovative aspect of the program is the way in which these different strategies are combined within the overall design. For example, the interactive features of the program generate content which can be shared with the therapist , and in some cases with peers (further enhancing the experience of other users).A service-based design was used to assess engagement with the Mind Balance program delivered by the mental health service of an Irish university . As a first exploratory trial, it was felt that a service-based design would be informative regarding the potential of the program to engage clients, provide initial evidence regarding the potential effectiveness of the treatment, and establish the feasibility of incorporating low-intensity online therapist support in a real-world environment. Part of the appeal of the program to this population was expected to be the relative anonymity of the online mode of delivery; therefore, face-to-face contact was not required to sign up for the program. The protocol for use was kept as close as possible to the actual practice for use of online interventions within the service; this degree of fidelity was borne out by the subsequent incorporation of the program into the day-to-day practice of the service following the same protocol. Client log-ins and use of program features were automatically monitored. Changes in symptoms of depression were also assessed through measures taken before and after use of the program. Ethical approval was secured from the Research Ethics Committee of Trinity College prior to the study.Participants were recruited in 2 ways as the program was rolled out, in parallel with the usual practice of the counseling service.Recruitment began in January 2011, with all first- and third-year students emailed through the university emailing system to inform them of the opportunity to receive this online intervention as part of a research study. In September 2011, all fourth-year and postgraduate students were similarly emailed. Finally, in January 2012, all first years were again emailed to inform them of this opportunity. This rolling recruitment model was used to manage the numbers of students simultaneously availing of the intervention because of limited therapist resources. Specific-year groups were chosen at various times based on existing records of service engagement patterns in the student counseling service. Participants were informed that they would be required to register with the student counseling service in order to avail of the program. Interested students were instructed to follow a Web link embedded in the text of the email and were directed from there to the sign-up page. Students could also access this Web link from the University’s online mental health portal. Once an individual had navigated to the sign-up page, they were presented with a comprehensive information sheet and an electronic consent form. Following confirmation of informed consent, students were required to complete the preprogram measures electronically and were then free to explore the online program as they wished. Postintervention measures were sent out automatically after completion of the final review.A number of participants were referred directly to the program by staff in the counseling service. Those receiving face-to-face therapy in conjunction with the program were excluded from the research sample.Participants were 80 students who identified themselves as having an existing difficulty with low mood, mean age 23.29 years (SD 4.84) and 69% female, who were all part of the population supported by the student counseling service. All of the participants were registered students. Demographic details for the main and subsample are detailed in Inclusion criteria were as follows: (1) at least 18 years of age, (2) having at least self-reported mild symptoms of depression with a Beck Depression Inventory-II (BDI-II) score ≥14, and (3) have received no face-to-face therapy since program commencement. A breakdown of how this final sample was reached through exclusions from the initial sample is provided in Telephone and email contact details for support services  for crises or out-of-hours emergencies were provided to users in the “help now” section of the website, which was visible at all times regardless of the page the user had navigated to. Any individual who scored 29 or more on the BDI-II or who scored 2 or more on BDI-II item 9  in their online screening was automatically alerted that a counselor would get in touch with them. They were telephoned within 1 working day to invite them for an interview, and contacted by email if they could not be reached by telephone. The screening interviews were carried out by a counseling psychologist and focused on the client’s own description of the problem, including duration of the problem and their understanding of the causes, their psychiatric or mental health history, current alcohol and drug use, current health and functioning , and current support network. A clinical decision was made on the basis of this assessment in relation to whether the client could go ahead and use the online program on a standalone basis. Alternatively, it was recommended that they attend face-to-face counseling instead of or in conjunction with the online program. Three clients declined to attend for interview and were excluded. Three others chose not to use the program following the interview and were excluded. Those receiving face-to-face therapy combined with the program were not included in the research sample presented here. Although the primary concern was client safety, the approach taken was one which would be applied in the normal practice of the service.The online system collected anonymized descriptive information relating to engagement and usage. Data collected included the number of sessions completed, mean time spent on the program, average number of sessions per client, and average length of a session. A session was defined as an instance when a client logged on to the system. Session time estimation will always be an imperfect calculation because users may be interrupted or take breaks within a session, and may not formally log out of the system. All client activity within the system, such as reading a content page, saving a journal entry, or updating an activity, was logged with a time stamp. Starting with the log entry of the client logging on, the total time was calculated by adding up the time that elapsed between each subsequent log record. On its own, this yields a result vulnerable to overestimation of session time. To avoid counting periods when the user was not actively engaged with the system, any interactions taking longer than 30 minutes were counted as 1 minute. Any period of inactivity longer than 3 hours started the count on a new session, rather than extending the time of the current session. Use of different program components was also measured. Data related to therapist reviews were also collected. In the interests of examining engagement and usage patterns in a fair and meaningful way, all 80 participants were included in that analysis regardless of whether or not they had completed the BDI-II postintervention. Dropout is analyzed in terms of the last time a participant used the system.The BDI-II was used to assess the severity of self-reported symptomatology of depression preintervention and postintervention. Cut-off scores suggested for the BDI-II are minimal symptoms: 0-13; mild symptoms: 14-19; moderate symptoms: 20-28; and severe symptoms: ≥29 . ReliabiAll data were collected and stored electronically on a secure server.Following initial sign-up, clients were assigned a therapist who would support them online. This happened automatically and randomly in the case of those clients recruited via self sign-up. In the case of those who signed up following a recommendation by a face-to-face therapist, the same therapist was assigned as their online supporter. While the program suggested that clients complete 1 module per week, clients were free to dictate the pace and order of their work. Therapists were asked to provide 7 weekly reviews of each client’s work. Allowing for 1 final session for the client to consider the final review, this corresponds to a target of 8 sessions per client, and also matches the target of 8 sessions in the program previously used within the service evaluated in Richards . The serViewing the engagement data by BDI-II category , clientsUsage of different program features is illustrated in t tests of difference.The reliability of the BDI-II was assessed using Cronbach alpha and was found to be in the acceptable range for both the overall sample (N=80) and the subsample (n=53), being Cronbach alpha=.78 and Cronbach alpha=.79, respectively. This indicates satisfactory internal reliability for the BDI-II for the present sample. P<.001) decrease in symptomatology of depression, as assessed by the BDI-II, from preintervention to postintervention. Cohen’s d was calculated as d=1.17, suggesting a large pre-post effect size for BDI-II [t test revealed no significant difference between preintervention BDI-II scores of those who completed postintervention measures (n=53) and those who did not (n=27), t78=–0.382, P=.70. As illustrated in r BDI-II . An indePoor treatment adherence and dropout have been repeatedly highlighted in the literature as significant issues to overcome in the delivery of Internet interventions ,21. LookOn the demographic breakdown, we must note that this is a relatively homogeneous population compared with what may be seen in other environments. The student population supported by the service has a majority of women (59% in 2010/2011), and the greater number of women signing up for the program mirrors the use of the service generally. The incidence of depression also differs by gender. The size of the sample for male participants precludes us from making any statements regarding the lower number of males completing the target, but this issue would be worth investigating in future studies.We can see from The primary aim of online interventions is to maintain clinical gains while reducing the amount of therapist time required per client. It is worth reflecting on the precise nature of the support needed to maintain an optimum pre-post clinical effect as well as satisfactory completion rates . A numbeThe nature of the support given by the therapist also deserves further exploration. Taking persuasive technology as encompassing both direct interaction with a computer system and computer-mediated communication , there id=1.17. This concurs with the current body of literature, which does suggest a reasonably robust pre-post outcome effect size for online CBT-based interventions [d=0.61 and d=1.0 in meta-analyses by Andersson and Cuijpers [A main focus of the development of the program was to improve client engagement; therefore, the outcome data are encouraging, with a significant reduction in depressive symptomatology following program completion, with a pre-post effect size estimate of ventions  point ouCuijpers  and SpekRecruitment for the study also illustrates the appeal that online interventions may have for some clients. All students are eligible for free face-to-face treatment, but the offer of online treatment led many people with clinically significant symptoms of depression to make contact with the service for the first time. This suggests that therapist-supported online interventions, such as Mind Balance, may attract people who are reluctant to engage with face-to-face treatment; hence, improving access to psychological interventions for those in need of them.The findings of the study are promising, but they should be interpreted with caution. Although the results were statistically significant, the modest sample size motivates continued long-term data gathering. Further replication of the research is also needed. Similarly, the absence of a control group does not allow us to draw specific conclusions with regards the efficacy of the program in relation to spontaneous symptom improvement . As a reThe study did not automatically exclude potential participants who reported symptoms of depression in the severe range. Although this results in a sample that may differ from that in several comparable studies, it mirrors a service-based pattern of use. The level of engagement with the program exhibited by this group was high, and together with the positive outcome data, suggests that clients along the full span of the symptom severity spectrum may benefit from supported online programs. This service-based study provides an example of how online interventions may be used and fit in with existing mental health services in this setting. The program is now embedded within the day-to-day practice of the service, following the same procedure described here, illustrating the ecological validity of the deployment within the study. Knowledge gained through the study has also been fed into the development of a more detailed treatment manual for supporters to be used in future trials. All data related to time spent on the program, modules viewed, exercises completed, and so on were collected electronically. This ensured a high level of accuracy in determining the level of system usage because there was no reliance on self-reports of time spent on the program.In this paper, we have presented a study of a new and innovative program for online CBT integrating a range of features intended to increase client engagement. Both client and therapist users were able to use the system successfully, and they made use of a range of program features. The findings suggest that a low level of asynchronous online therapist support is a promising avenue for the development of online interventions, when appropriately integrated into the delivery of the online intervention. As a new mode for delivery of online guided self-help, it contributes to the exploration of the optimum level and nature of therapist input needed to achieve clinical gains in an accessible manner and provides an indication of the many possibilities within the design space for such systems. It strongly motivates exploration of issues of clinical efficacy within a service-based randomized controlled trial and of the potential effectiveness of this form of interactive delivery for other types of intervention.


Following the 2010 earthquake in Haiti, infant and young child feeding was identified as a priority nutrition intervention. A new approach to support breastfeeding mothers and distribute ready-to-use infant formula (RUIF) to infants unable to breastfeed was established. The objective of the evaluation was to assess the implementation of infant feeding programs using RUIF in displaced persons camps in Port-au-Prince, Haiti during the humanitarian response.A retrospective record review was conducted from April–July, 2010 to obtain data on infants receiving RUIF in 30 baby tents. A standardized data collection form was created based on data collected across baby tents and included: basic demographics, admission criteria, primary caretaker, feeding practices, and admission and follow-up anthropometrics.Orphans and abandoned infants were the most frequent enrollees (41%) in the program. While the program targeted these groups, it is unlikely that this is a true reflection of population demographics. Despite programmatic guidance, admission criteria were not consistently applied across programs. Thirty-four percent of infants were undernourished (weight for age Z score <−2) at the time of admission. Defaulting accounted for 50% of all program exits and there was no follow-up of these children. Low data quality was a significant barrier.The design, implementation and magnitude of the ‘baby tents’ using RUIF was novel in response to infant and young child feeding (IYCF) in emergencies and presented multiple challenges that should not be overlooked, including adherence to protocols and the adaption of emergency programs to existing programs. The implementation of IYCF programs should be closely monitored to ensure that they achieve the objectives set by the humanitarian community and national government. IYCF is an often overlooked component of emergency preparedness; however to improve response, generic protocols and pre-emergency training and preparedness should be established for humanitarian agencies. Exclusive breastfeeding of infants up to six months of age provides the best nutrition and immunologic protection for the promotion of healthy growth and development in non-crisis and crisis settings. The priority approach to feeding these infants should be through relactation with their own mother or breastfeeding through a wet nurse. Haiti presented a complex set of challenges for addressing infant and young child feeding (IYCF) in the aftermath of the 2010 earthquake, including sub-optimal feeding practices prior to the earthquake as demonstrated by an exclusive breastfeeding prevalence of 21.7% in Port-au-Prince. Based on the large-scale displacement into makeshift shelters with significant issues of crowding; poor sanitary conditions, including limited excreta disposal; limited cooking facilities; the cessation of pre-existing weak public health services; and an increased risk for the spread of communicable diseases; the humanitarian community, in collaboration with the Ministère de la Santé Publique et de la Population (MSPP), identified the need to address IYCF, including the provision and management of BMS as a part of the nutrition response. Specifically, Ready to Use Infant Formula (RUIF) was identified as the safest option. RUIF is a commercially produced (Codex Standard 72–1981) hygienic, pre-mixed liquid infant formula that is consumed directly from the container or a cup, avoiding the use of water, bottles and teats. RUIF was already in use on an individual basis in select hospitals for the care of premature infants.Points de Conseil en Nutrition pour Bébé (PCNB) or ‘baby tents’ in most tent cities throughout Port-au-Prince, Leogane and Jacmel. The baby tents provided a safe place for mothers to breastfeed and caregivers to receive IYCF counseling. The intent was to provide RUIF in some of these tents through strict criteria to targeted infants. The National Nutrition Cluster (NNC) in Haiti, chaired by MSPP and UNICEF, was responsible for the procurement, management and administration of RUIF. The NNC non-governmental (NGO) partners established Baby tents were focused on providing a quiet place to breastfeed; promote and maintain breastfeeding; give psychosocial support; support relactation; and, screen for growth faltering and acute malnutrition. The baby tents adhered to the national guidelines developed by the NNC during the initial weeks following the earthquake. Operational Guidance on Infant and Young Child Feeding in Emergencies, admission criteria were defined as: infants under 12 months of age living in areas directly affected by the earthquake with no possibility of being breastfed based on one of the following situations: In line with the Mother absent or deadCritically ill motherRe-lactating mother until lactation re-establishedInfant rejected or abandoned by motherMother survivor of sexual violence not wishing to breastfeedInfants of known HIV-infected mothers who were not breastfed prior to the earthquake and were currently exclusively fed on powdered infant formulaInfants who were artificially fed prior to the earthquakeInfants were discharged from the program at 12 months of age or to treatment if they became acutely malnourished. The NCC ensured adequate RUIF for all infants enrolled until they reached 12 months. Enrollment of new infants into the program ceased in August, 2010.Infants were offered the following services at the baby tents: anthropometric assessment , referral for management of severe acute malnutrition, and referral for health care. Additionally, the program guidance stated that if an infant less than 6 months weighed less than 3 kg, they should be referred to the Centre Nutritionnel Supplementaire for inpatient treatment of acute malnutrition and not receive RUIF. Caretakers were offered assessment of current feeding practices and counseling on age-appropriate feeding of the child, including optimal breastfeeding positions and attachment, expressing breast-milk, feeding frequency, and advice on moving to exclusive breastfeeding if other liquids and foods were fed to infants younger than 6 months, relactation and complementary feeding. During the feeding assessment, non-breastfed children were identified and their eligibility for RUIF determined; caretakers were then counseled and trained how to feed RUIF using the cup. Depending on the implementing NGO, caretakers returned on a daily or weekly basis to collect additional supplies of RUIF and for follow-up of the infant. The objective of this evaluation was to assess the implementation of the infant feeding programs in response to the 2010 earthquake in Haiti.A retrospective record review was conducted from 14 to 27 July, 2010 to obtain data on infants receiving RUIF in baby tents. Selection criteria for baby tents included: 1) the baby tent was operational in April 2010 in Port-au–Prince, 2) the baby tent was enrolling infants at the time of sample selection (June 2010), and 3) the baby tent planned to continue services through December 2010. A standardized data collection form was created based on data collected across baby tents and NGOs and included: basic demographics, admission criteria, primary caretaker, feeding practices, and admission and follow-up anthropometrics. Age of the infant was collected from the caregivers; the majority was able to provide a date of birth for the infant. Food intake was assessed through a 24 hour recall for each infant. Based on the specific NGO program, beneficiaries received RUIF either daily or weekly; therefore the records for each infant receiving RUIF differ in terms of the number of visits and anthropometric measurements.Thirty baby tents administered by six NGOs were included in the evaluation. Trained enumerators extracted data from 590 individual infant records of infants admitted between April 1 and June 29, 2010. There were 16,946 individual visits recorded among these infants during this time period. Of the 590 infant admitted, 493 (83.6%) were included in the analysis. Infants were excluded for the following reasons: missing data , implausible weight-for-age at admission, age was outside of the admission criteria (i.e greater than 12 months of age), enrollement start date was prior to April as defined by the protocol, or if the infant only attended the baby tent one time. The majority of exclusions (44.3%) came from infants only visiting the baby tent one time. Sixty-eight percent of infants included in the analysis were between 0 and 5 months of age at admission with a median age of 4 months. There were similar numbers of boys and girls, 249 (50.5%) and 244 (49.5%), respectively.Nelson Textbook of Pediatrics, however it was not possible to assess weight gain of infants as a result of low data quality. Analysis was limited to records of infants who met the following criteria: date of birth recorded; sex recorded; younger than 12 months of age at enrollment; more than one visit to the baby tent recorded; weight recorded at admission and at least one subsequent visit; and plausible weight-for-age at admission. NGOs did not consistently measure length at admission or subsequent visits. The majority of measurements were rounded to 0.0 cm or 0.5 cm, therefore reliable weight-for-length and length-for-age were not assessed. Weight gain was assessed based on the difference between two weights divided by the number of days between the weights. The weight gain by age was assessed using the approximate daily weight gain by age in the t-test for comparing two group means. A P<0.05 was considered significant.Data were entered into Epi Info version 3.5  and analysis was completed in SAS version 9.3 . The study was reviewed and approved by the Division of Nutrition, MSPP. The Institutional Review Board of the Centers for Disease Control and Prevention determined that the activity was not human subjects’ research and that the primary intent was public health practice. Caregivers provided verbal consent to participate in the baby tent program. Enumerators not involved in the implementation of the program collected data from infant cards and data collection did not involve interaction with beneficiaries. Personal identifiers were deleted from the datasets once data were entered and cleaned.Infants were admitted for varying reasons. The most frequent reason was the infant was orphaned (41%), followed by HIV-infected mother (15%) . Among oForty-eight (9.7%) of infants in the program were erroneously admitted because they weighed less than 3 kg at younger than 6 months of age and, according to program guidelines, should have been referred for inpatient treatment of acute malnutrition. None of these infants were referred for treatment; four defaulted.Mothers were the most frequent (38%) caregiver present at the time of the infants’ admissions, followed by aunts and grandmothers . Of note, 11% of caregivers were male: 10% fathers and 1% uncles .Forty-five infants, all less than 6 months of age, only received breast milk prior to admission; however, 86.7% of them were admitted within 1 week of their birth into the NGO program specific for infants with HIV-infected mothers. The majority of infants under 6 months of age  were receiving foods in addition to or in replacement of breast milk at the time of admission. All children aged 6 months and older were consuming food other than breast milk. Across age groups, the use of powdered infant formula and powdered milk (not intended for infant feeding) was quite high .WAZ were calculated as the primary anthropometric indicator of nutritional status. At admission, the mean WAZ of all infants was −1.41 (SD 1.82). Younger infants had a significantly lower WAZ upon admission compared with older infants, −1.80 versus −1.23 (p = 0.001), respectively. Among orphans, the mean WAZ at admission was −1.37 (SD 1.82). There was a significant difference in the mean WAZ at admission between NGO’s , with one NGO having a mean WAZ of −2.31.t test, t = 0.55, p = 0.58) nor in the prevalence of underweight  of orphans compared with non-orphans at admission, respectively.There was no significant difference in mean WAZ  compared with moderately underweight (WAZ >−3 to <−2) . Within Seventy-four (15%) infants exited the program before the end of June; 27% of exits occurred among children who “aged” out of the programs at 12 months of age and 6.0% of exits were a result of death. Defaulting accounted for the majority of exits, 36 (49%). There was no further information on defaulters or deaths. Only two infants exited to breastfeeding programs through successful re-lactation programming.t-test p = 0.005).The number of visits each infant made to the PCNB varied significantly, ranging from 2 to 102 visits (mean 30). Measurements were not taken at each visit; the average number of visits with a measurement was 14 (range 2–99). Older infants (6–12 months) made more visits to the baby tents (median 25.5) than younger infants (median 17) , 8,787 infants received RUIF in 89 baby tents during the response.Designing a new programmatic approach to IYCF in the midst of an emergency poses many challenges. A balance must be struck between providing services while maintaining quality of the program and adhering to the program guidance. NGOs appeared to have difficulty adapting the emergency baby tent program to their existing programs and mandate. Admission criteria were altered to meet the objectives of the specific NGOs; for example, admitting all infants of HIV-infected mothers regardless of the feeding status of the infant prior to the earthquake or only admitting orphans. Additionally, NGOs did not abide by some of the programmatic policies due to inexperience with IYCF in emergencies, as well as logistics constraints to even physically access and staff the baby tents (data not presented). One of the challenges in the aftermath of the earthquake was transport of referrals. The location of inpatient treatment services was mainly in hospitals that were sometimes difficult to access, overcrowded and poorly functioning.There must also be a balance between providing services and collecting data on individual infants. Discrepancies in data, specifically weight measurements, question the use of data to monitor an infant’s progress. A key objective of ICYF is to support and promote ideal feeding practices to achieve optimal growth and development. In addition, the lack of referral of low-weight infants (less than 3 kg) at the time of enrollment highlights the limited use of weight data to monitor an infants’ overall health. Critical attention must be given to the growth trends of the infant receiving RUIF or any other service in the baby tent, particularly for the 20% of infants who were severely underweight at the time of admission. If this cannot be achieved within the baby tent itself, it is crucial that this program be linked to a growth monitoring program and/or programs for the management of acute malnutrition in infants. This type of robust monitoring also underscores the need for skilled staff and accurate scales and measuring mats, particularly for those infants less than 6 months of age. Additionally, basic interpretation of data is needed. Sixty percent of admissions for one NGO were underweight and 35% were severely underweight. This is highly unusual and requires further investigation if this is a true anomaly reflecting varying socio-economic status within Port-au-Prince or simply poor data quality. The proportion of severe underweight to moderate underweight infants was skewed. Typically, there are more moderate cases than severe. Older infants (6 to 12 months of age) came more frequently to the baby tents compared with the younger infants. While frequent visitation and the chance to interact with caregivers are beneficial at any age, it is particularly beneficial for the youngest infants. This age group is particularly vulnerable when consuming RUIF and should be closely monitored and provided clear messaging on appropriate infant feeding. Additionally, 11% of caregivers were male. This is an important programmatic consideration when designing programs and messaging on feeding as these are primarily targeted towards mothers and women.The proportion of infants reported to be orphaned or abandoned (49%) was exceedingly high. Prior to the earthquake, 20% of children were in this category, which indicates that there was a pre-existing problem in Haiti linked to abandonment. Responding to infant feeding needs in emergency contexts continues to present a challenge. Since 2010, RUIF has not been used on a large scale as subsequent emergencies have not presented the same context as Haiti. The floods in Pakistan in 2010, the Horn of Africa crisis of 2011, the Sahel emergency of 2012 and the ongoing displacement of Syrians have all resulted in unsolicited donations and continue to highlight the need to control donations and minimize the inappropriate use of BMS in a more coordinated manner. While quantitative data, such as weight gain, may not be available as evidence that the baby tent program was successful, the experience in Haiti did provide knowledge and experience for IFE response in subsequent emergencies. Since 2010, IYCF counseling and support have become increasingly prominent components in emergencies, including in the Syrian crisis, where similar baby ‘caravans’ are being operated in refugee camps of Jordan and relactation is more successful. A scaled up interest in IFE has been noticed, including revisions of standard operating procedures for the handling of BMS, new assessment methodologies and development of appropriate and feasible indicators for assessment.If the baby tent program with RUIF model is to be implemented as a component of IYCF emergency programs, specific actions must be taken by the IYCF in emergencies community. A generic protocol should be drafted and readily adapted to the context of emergencies which require IYCF interventions. This protocol should contain: admission and discharge criteria, standardized infant records forms and guidance on monitoring infant growth, minimal program monitoring and evaluation package, training package, appropriate numbers of staff, logistics components which address procurement, warehousing, transport and waste disposal issues. An IYCF toolkit encompassing these areas is underdevelopment. Training NGOs on the baby tent/RUIF model for IYCF in emergencies should be a mandatory part of preparedness activities. Special attention should be paid to NGOs with longstanding programs in emergency prone areas, and how short-term emergency IYCF programming can complement their programs. A stockpile of suitable and precise scales and length mats should be maintained for rapid deployment. Finally, it is important to remember that the use of BMS is only a small part of an overall IYCF program, albeit a very intensive one. It is easy to lose sight of the overall support for breastfeeding mothers given the added complexity and demands of the BMS component, but programs should still focus on the broader aspects of IYCF: support for breastfeeding mothers and appropriate complimentary feeding of older infants.


Parents and teachers of children with developmental challenges and special learning needs face unique social-emotional challenges in caregiving. Stress associated with their roles has been shown to impact parents’ and special educators’ health and well-being, as well as the quality of their parenting and teaching. In this paper, we report results of a pilot study conducted to investigate the efficacy of mindfulness based training program (MT) in facilitating improvement in caregiver mental health. Using a RCT waitlist design, 70 parents and educators of children with special needs were randomized to participate in a 9 session, 36 hour group-based MT program called SMART (Stress Management and Relaxation Techniques). This program, based on MBSR, included content on emotion theory and regulation, forgiveness and compassion, and application practices specific to caregiving/teaching.Participants completed a battery of standardized measures at three time points: baseline, program completion and two months follow-up. The measures included several indicators of mindfulness, distress, positive affect, compassion, well being, and caregiving competence. In addition, we explored the impact of participant demographic and lifestyle and characteristics , health status, and role (teacher vs. parent). The influence of several intervention parameters on outcomes were also examined within the MT group .Study findings provide strong preliminary evidence for the benefits of MT in reducing stress and anxiety, improving mindfulness and psychological well-being, and facilitating hope and gratitude in both parents and teachers. Medium to large effect sizes were shown on several measures upon program completion and at follow-up.MT is an effective intervention for facilitating well-being in teachers and parents of children with special needs whether delivered in weekly or biweekly program format.


Positive self-esteem, emotional well-being, school achievements and family connectedness are considered protective factors against health-compromising behaviors.In Favor of Myself, on the self-image, body image, eating attitudes and behavior of young adolescents. A preliminary cohort study was conducted among 972 program participants who did not take part in the controlled trial. Over 75% of participants said they would recommend the program to their friends.This study examined the effect of an interactive, community-based, media literacy and dissonance wellness program, A controlled trial was conducted to evaluate program acceptability, efficacy and effectiveness among 259 participants (210 in the intervention group and 49 in the control group), aged 12–14 years, who completed questionnaires during at least two assessment times. Program materials were provided, along with leaders' training, in order to ensure quality program delivery and creation of a wide network of committed program leaders.The program significantly reduced drive for thinness and self-worth contingent upon others' approval, the gap between current body figure and ideal figure, and the impact of mood on girls' self-image. Superiority was found among those participating in the intervention group with respect to recognizing media strategies, the influence of media on desire to change, and the influence of appearance on self-confidence and drive for thinness.In Favor of Myself shows promising results for strengthening adolescents' ability to cope with the challenges of their life stage. Suggestions for improving In Favor of Myself are presented. Adolescence is a critical life stage for the development of self-confidence and self-image Low self-esteem and negative self and body image have been reported as the most important factors for risk-taking behavior There are three factors, known as prospective predictors, which are considered common to many adolescents and thus targeted in health promotion programs; these are: self-image, body image and self-esteem. Development of a healthy self-image is the result of self-image change, a process which occurs over a lifetime, and starts with learning self acceptance and being liked and accepted by others.Body image is determined by a series of individual and socio-cultural factors common to Western society. Negative body image is a widespread concern among college age females and often results in dieting behaviors, which can perpetuate the risk of eating disorder development. Body image dissatisfaction is increasingly being recognized as an important target for public health action The third factor, self-esteem, is a widely used concept which refers to an individual's sense of his or her value or worth, or the extent to which a person values, approves of, appreciates, prizes, or likes him or herself There is growing evidence that effective health promotion interventions for a specific risk or protective factor (a prospectively identified mediator or moderator of a risk process) are likely to have direct effects on a range of health outcomes According to Neumark-Sztainer et al While most programs have focused on girls Factors that may influence the effectiveness of prevention programs include program format, participant risk status, age of participants, type of intervention and number of sessions In Favor of Myself is an interactive  and universal program . It is delivered to mixed gender groups and aims to promote development of a healthy self-image and body image among adolescents to prevent later symptoms of hazardous behaviors (including eating problems). In contrast to other programs, its objectives are the enhancement of global issues such as promoting self-care, stronger ‘self’ and better immunization to harmful external influences (rather than focusing on preventing eating disorders), thus it was assessed among healthy early-adolescence participants. It is a multi-component program with multiple target areas, including positive self-esteem, communication, media literacy and dissonance health education, to promote a positive attitude towards growing up, sense of self and self-esteem, body image, and communication among adolescents. The program aims to promote the ability to filter external media and culturally inappropriate messages about diversity of beauty and attractiveness. The program includes structured supervision and has the potential for high generalization due to its wide dissemination across various setting  as well as different socio-economic groups. It takes into consideration the impact of ethnic background, religion and the intersection of gender on body image and eating problems Three hundred adolescents were recruited for the research study from the same grade level in a primary school with mixed gender and socio-economic populations . Two claIn Favor of Myself is an innovative, interactive educational outreach program, developed and implemented by a group of professionals aiming to empower adolescents to promote their growth and development by teaching a range of coping strategies to help adolescents resist media-based and culturally inappropriate messages and promote the diversity of beauty and attractiveness.The program focuses on the promotion of adolescents' knowledge of normal development including the different courses of puberty among different groups, as well as the myriad of changes that take place during adolescence and their impact. It also aims to increase awareness of media strategies and literacy among youth as a way to help lower unrealistic expectations and decrease concerns with appearance. It teaches participants to identify and counter prejudice and socio-political structures that contribute to the development of body preoccupation. By helping youth gain the skills necessary to critically evaluate strong societal messages for both males and females vis-à-vis self-esteem, happiness, ideal body type or image, the program aims to help mitigate the effects of these messages.The program contains a kit with introductory material as well as a detailed guide for facilitators and material for eight interactive sessions (see enclosed photo). The guide includes eight structured sessions  each of The satisfaction from the program was evaluated in a cohort study  by an independent researcher with all adolescent who participated in the program during its first 6 months (972 subjects). Participants were asked to rate their satisfaction: 754 (77.8%) scored it as good or excellent, 91(9.3%) scored it as moderate and 127 (13%) did not like it.The program was delivered by teachers, school counselors and master program's students in nutrition – all supervised by the first author.Leaders' training is provided to ensure quality program delivery and create a wide network of leaders who are committed to delivering the program. Each leader participated in a 6-hour introductory training which included 2-3 sessions. Such a participatory approach, as suggested by Neumark-Sztainer et al The study protocol was approved by Tel Hai institutional review board. Parents of all participants, in the intervention and in the control groups, received information about the study and the intervention and provided a written informed consent. The program was delivered in a course of eight, 90-minute sessions, given approximately one week apart and integrated into a regular school coping skills curriculum. Groups of 15–20 participants were assigned 1 leader and groups of 21–35 participants were assigned two leaders. Twenty trainers and teachers were trained to deliver the program and the task of data collection was assigned to research students. Each participant was given an identification number to ensure confidentiality and anonymity.The impact of the intervention was assessed with a non-randomized, controlled experimental group design. To assess the impact and outcome of the intervention, all participants in the research and control groups completed the study questionnaire at pre, post (8 weeks later) and 3-month (after post) follow-up assessments. Process evaluation, which assesses program dissemination, attendance and relapse rates, as well as assessment of participants' satisfaction, was performed at the end of the program.Demographics, including personal and familial details, were obtained from each participant at baseline. Self-report measures are described in To assess program impact on knowledge and influence of media, participants were asked to identify several media strategies that promote consumption and internalization of stereotypes. They were also asked to rate media influence on their desire to “fix” their appearance. Further questions included use of comparisons to peers, family members and admired celebrities, as well as use frequency of positive and negative communication with peers and siblings. In order to evaluate change in awareness, perception of the changes occurring during adolescence and promote positive attitude towards them, subjects were asked to respond to the comment: “As I get older I feel that a) I am more influenced by the media b) life seems to be are more complicated c) life seems more interesting & exciting.” Test-retest evaluation was performed on the extended inventory with 30 students prior to administration of the questionnaire in order to assure its consistency with repeated completion .Participants were clustered in 9 program-groups. In order to take into consideration the unit treatment additivity the intraclass correlation coefficient (ICC) was calculated for each variable. Due to reasonable ICC (range of 0.03–0.07) the analyses were performed with all data set together.One way analysis of variance (ANOVA) and chi-square tests were utilized to assess comparability of the groups on baseline measures. One way MANOVA with repeated measures and univariate ANOVA were used to assess program impact on participants in the intervention group by measuring the differences between baseline, post-intervention and three months follow-up.2×3 MANOVA (groups X time) with repeated measure on time was used to assess the difference between groups in changes over time. The change in scores over time was analyzed after the intervention (pre->post) and over the 6 months study (pre->3 months follow-up).Statistical analysis was conducted only for those who completed the questionnaire in at least two assessment times, including 210 participants in the intervention group and 49 participants in the control group . No differences were observed in baseline variables between those who filled the questionnaire on two or three occasions and those that did not (filled only on baseline).2 , where 0–0.05 constitutes a small effect, 0.059–0.1 a medium effect and above 0.10 a large effect Effect size is described using partial ηNo statistically significant differences between the intervention and the control groups were revealed in the assessed variables, but there were many more girls (2-fold) than boys in the control group.The process evaluation with the controlled study population revealed that 78% evaluated the program as good or excellent while 12% did not like it. On a scale of 1 to 4, mean satisfaction with the program among participants was 2.93±0.9. 52% of participants attended all eight sessions, 14% attended 7 sessions, 18% attended 6 sessions, 16% attended 5 or fewer sessions.The effect of the intervention on the following group of measures at conclusion and at 3 months follow-up, in comparison to baseline, is reported in One way MANOVA with repeated measure revealed significant difference between the three measure times in respect to the intervention group participants awareness of the myriad of changes that take place during adolescence . Univariate ANOVA revealed significant effect of time on the three measures .The means and standard deviations of each measure and the paired comparisons' ANOVA results are presented in MANOVA also revealed significant difference between the three time frames in respect to the use of positive and negative communication with siblings and friends . Univariate ANOVA revealed significant effect of time on the two measures . Participants in the intervention group reported on increased use of positive communication skills, as well as a reduction in negative communication with peers .One way MANOVA with repeated measure revealed significant effect of time on media literacy, pressure from media and the wish to fix appearance . Univariate ANOVA revealed significant difference between times in respect to media literacy  = 5.76, p<0.041, η2 = 0.05), pressure due to media influence  = 10.4; p = 0.002, η2 = 0.09) and effect on the wish to fix appearance ). Paired comparison tests  showed iMANOVA revealed significant differences between pre, post and follow-up in respect to eating disorders' features which were measured by EDI-2 subscales: drive for thinness and body dissatisfaction . Univariate ANOVA revealed significant effect of time only on drive for thinness  while body dissatisfaction (EDI-2) did not change significantly from baseline among program participants . Paired comparison revealed that drive for thinness (EDI-2) decreased significantly among program participants, with a medium effect size of 0.09 at program conclusion and no further change at follow-up .EAT-26 scores indicated that the population had, a priori, a healthy mean score with respect to disordered eating and attitudes, thus it was not surprising that MANOVA revealed no significant differences among assessment times .MANOVA revealed significant differences between assessment times in respect to participants' self-worth contingent upon others approval and upon appearance . Univariate ANOVA revealed that self-worth was significantly less influenced by others' approval  with large effect sizes at both program conclusion and follow-up. They also reported a reduced impact of appearance on self-worth at program conclusion [F = 4.0, p<0.02, η2 = 0.03 . The impAt baseline, there were no significant differences between the intervention and the control group in measurements. Over time, mixed results were found in measurement differences between the intervention and the control groups. The means, standard deviations of the changes in measures and the results of the 2×3 (group X time) ANOVA are presented in Significant interaction effects of group X time were found in respect to: awareness of adolescents to life complexity; improvement in use of positive and negative communication, ability to identify media strategies, decrease desire to fix appearance due to media influence, decrease in drive for thinness as well as in self-worth contingent upon others approvals and upon appearance. A large effect size (>0.1) have been demonstrated both in adolescents' awareness to complexity of life and in reduced self-worth contingent upon others approval . Change Since self-esteem is considered a risk factor for hazardous behaviors, a one way MANOVA analysis was performed with repeated measures (time) and self-esteem as the independent variable, in order to examine if the program has a different influence on those with low self-esteem compared to those with high self-esteem at baseline. The analysis showed that those with higher self-esteem at baseline, reported greater improvement with respect to awareness of media pressure  = 8.72, p = 0.004; Partial η2 0.09), and showed greater reduction in influence of appearance on self-worth  = 6.07; p = 0.016; Partial η2 0.07).In Favor of Myself, a widely disseminated media literacy and dissonance health education interactive universal program. The program aimed to promote positive attitude towards growing up, sense of self and self-esteem, body image and communication among adolescents. The program also aimed to promote the ability to filter external, media and culturally inappropriate messages about diversity of beauty and attractiveness.The current study aimed to evaluate the efficacy of At post-test, the intervention group presented with a statistically significant advantage compared with the control group for awareness to changes during adolescence, recognizing usage of media strategies, usage of positive vs. negative communication, self-worth contingent is less relied on others approval and appearance, and lower drive for thinness and desire to fix appearance. An important outcome is the evidence that the program did not reveal any iatrogenic effect for the intervention group. No changes in the intervention group or differences between the groups were found for self-esteem, body dissatisfaction or eating attitudes and behaviors (measured by EAT-26). The lack of changes in these variables reflects the baseline status of our research population. When comparing the mean values of EAT-26 and the EDI-2 body dissatisfaction subscale to those published by others Support for the effectiveness of prevention intervention strategies designed either to prevent or ameliorate body dissatisfaction or reduce risk factors for eating disorders, is very mixed. Recently, González et al The failure to demonstrate change in self-esteem is not well understood, mainly in light of the high correlation between self-esteem and self-worth contingent upon others' approval and appearance. Still, those with higher self esteem at baseline, reported a greater improvement with respect to awareness of media pressure and showed a greater reduction in influence of appearance on self-worth, which might give some indication about the suitability of the intervention for this population. For example, it may be that participants with low self-esteem need more intensive intervention.A number of limitations in this study must be acknowledged. First, the results must be interpreted with caution, as randomized allocation to intervention and treatment groups was not possible due to timetable conflicts imposed by the school. The lack of random assignment to group conditions might reduce the external validity of this study. Second, the control group was smaller than the intervention group. The research group was balanced with respect to the proportion of girls and boys (55% girls and 45% boys) but the control group was not. (67% girls and 33% boys). This difference might have introduced bias in the comparison between the research and control groups. Third, in this study we used self-report questionnaire thus the answers are subjective and conclusions must be drawn cautiously. In addition, owing to limited resources, longer-term follow-up with the current population was not possible.Limitations should be considered in the context of the strengths of the study, including the low attrition rates and the high response rate over the three assessment points (82%). Although 256 adolescents filled out the baseline questionnaire, 210 completed the questionnaire during all three-assessment times. Those who did not complete them all, did not drop-out but rather missed school that day or simply did not feel like completing the forms.More strengths of the program are the use of multiple tools to assess change in perceptions, the examination of both negative and positive outcomes and the use of follow-up assessment to examine the medium-term effects of the intervention. The study included all 3 components of evaluation: process, impact and outcome on knowledge; targeted risk and protective factors, as well as resulting behavioral effects.To increase the chances of the intervention producing a positive effect and a more consistent impact, the program targets multiple risk factors. .initial indication that In favor of myself may produce effective impact on promoting healthy self- perception. It has a well- established manual and a structured training and supervision program for those who deliver it. The program includes inherent observational and other methods to verify and ensure fidelity in its implementation. The participatory approach increases program generalizability, as well as leaders' sense of ownership. It increases incentive and motivation to continue, because of the vested interest in its success and effectiveness. The program can serve either as a universal or as selective program to promote adolescents' physical and emotional well-being.This study provides Given that these promising findings are preliminary, future research is needed and should include greater numbers of ethnically diverse individuals, use of random assignment to both intervention and control groups and plan a longer follow-up. Future research may also benefit from use of extensive qualitative data in the form of semi-structured in-depth interviews. Such data have the potential to reveal much about the subjective impressions of the program with regard to both process and outcomes.To increase the program's impact, it is suggested that this program be applied with ongoing training, professional development of teachers and feedback from evaluation. Moreover, repetition of its topics every year, (if it is delivered via school-based setting), may be suggested in order to address the developmental stage of youth and build a solid foundation of health promotion activities to increase the sustainability of the intervention.