Health care providers do not routinely carry out brief counseling for tobacco cessation despite the evidence for its effectiveness. For this intervention to be routinely used, it must be brief, be convenient, require little investment of resources, require little specialized training, and be perceived as efficacious by providers. Technological advances hold much potential for addressing the barriers preventing the integration of brief interventions for tobacco cessation into the health care setting.This paper describes the development and initial evaluation of the Computer-Assisted Brief Intervention for Tobacco (CABIT) program, a web-based, multimedia tobacco intervention for use in opportunistic settings.The CABIT uses a self-administered, computerized assessment to produce personalized health care provider and patient reports, and cue a stage-matched video intervention. Respondents interested in changing their tobacco use are offered a faxed referral to a “best matched” tobacco treatment provider . During 2008, the CABIT program was evaluated in an emergency department, an employee assistance program, and a tobacco dependence program in New Jersey. Participants and health care providers completed semistructured interviews and satisfaction ratings of the assessment, reports, video intervention, and referrals using a 5-point scale.Mean patient satisfaction scores (n = 67) for all domains ranged from 4.00 (Good) to 5.00 . Health care providers completed satisfaction forms for 39 patients. Of these 39 patients, 34 (87%) received tobacco resources and referrals they would not have received under standard care. Of the 45 participants offered a dynamic referral, 28 (62%) accepted.The CABIT program provided a user-friendly, desirable service for tobacco users and their health care providers. Further development and clinical trial testing is warranted to establish its effectiveness in promoting treatment engagement and tobacco cessation. For a tobacco intervention to be implemented routinely in most health care settings—especially fast-paced settings like a hospital emergency department or a busy primary care clinic—it must be brief, convenient, and require little specialized training ,2. TradiComputer programs have the potential to make tobacco screening and cessation more convenient, tailored to the individual patient, and uniformly applied, while taking less provider time and requiring less provider training to implement properly. Prior research supports the feasibility and effectiveness of a variety of technological components useful for tobacco assessment and intervention, including computerized assessments -13, videTo our knowledge, there are currently no programs that blend these features into one integrated program that can be used in busy health care settings. For this reason, we created the Computer-Assisted Brief Intervention for Tobacco (CABIT) software, which is designed to facilitate brief tobacco cessation treatment and referrals during or immediately after a health care visit. It was designed to be used even in time-demanding settings like a hospital emergency department. This paper describes our development of the CABIT, its functionality, and our initial pilot testing and evaluation.Using the published literature ,13,20-22The CABIT is a web-based program comprised of 4 integrated modules: (1) a computerized assessment of tobacco use and related psychosocial variables, (2) a stage-of-change-based video intervention, (3) a referral generator, and (4) a report generator. Theoretically driven, each CABIT module was informed by principles derived from Motivational Interviewing (MI) , the TraThe CABIT software’s response-adaptive programming logic ensures each participant is presented with questions appropriate to his or her situation and previous responses. For example, a patient is asked, “Which tobacco products have you ever used?” A patient is then only asked about current use for types of tobacco that he or she indicated ever using. Further, assessments specific to type of tobacco use were chosen and the general wording of remaining assessment items were tailored to type of tobacco use. Based on a commonly used staging algorithm ,25, eachUpon completion of the assessment, the CABIT cues the appropriate stage-matched tobacco education video. Three already available educational videos tailored to 4 stages of change  were used. Although not ideal from a tailoring perspective, patients in both the contemplation and preparation stages viewed the same video. This 6-7 minute video was professionally produced and used appealing graphics to reinforce and illustrate important points related to tobacco use and cessation. For example, videos provided information about the stages one progresses through when getting ready to quit, consequences of tobacco use, benefits of quitting, and tips on quitting and available resources.The referral generator uses technology developed in a previous study called the Dynamic Assessment and Referral System for Substance Abuse (DARSSA) . In addiThe report generator produces 3 reports based on information the patient provided through the CABIT assessment: (1) Patient Tobacco Feedback Report, (2) Health Care Provider Report, and (3) Tobacco Treatment Referral .The patient received a personally tailored report written at an eighth-grade reading level. It was crafted using principles of Motivational Interviewing  and gainThe one-page counseling guide for the health care provider summarizes the tobacco use information that we deemed most important for clinical decision making based on our focus groups and in-depth interviews. It uses responses patients provided in the CABIT to provide evidence-based guidance for counseling the patient based on the NCI’s Five As  . The AskThis report, faxed to the “best matched” provider for patients who choose a dynamic referral, provides patient contact information and a summary of the patient's assessment. In particular, this report provides information on the patient’s tobacco use, level of addiction, tobacco-related illnesses or symptoms, past attempts to quit, methods used to quit, and readiness to quit. It also included personal factors related to poor prognosis and the patient’s readiness to quit ruler. See The CABIT program was implemented in three settings in a large hospital system in New Jersey : the Emergency Department; the Employee Assistance Program serving employees of the hospital system; and the outpatient Tobacco Dependence Program associated with the hospital. The Emergency Department is an academic, urban, Level I trauma center serving a catchment area of approximately 2 million people. The annual census is approximately 47 000 visitors, 20% of whom are admitted to the hospital. The Emergency Department and Employee Assistance Program demonstrate the CABIT’s utility across environments with different paces, procedures, staffing, patient characteristics, and foci of care. The Tobacco Dependence Program, with its specialized focus on tobacco treatment, yielded a cohort of smokers, recent quitters, and tobacco treatment counselors who were able to provide topical advice on the program.The recruitment protocol in the Emergency Department was similar to our published studies -32. ReseAfter the prototype of the CABIT finished laboratory testing, we completed a pilot test with 20 patients recruited from the Emergency Department. This pilot test was designed to assess global functionality, gain experience with the CABIT in a clinical setting, and reconcile problems with the software. Following resolution of problems, the CABIT was fully administered with updated components in the Emergency Department, the Employee Assistance Program, and the Tobacco Dependence Program during 2008. This was referred to as the Field Evaluation Study because the intent was to assess how feasible it was to fully integrate the CABIT into these clinical field settings. This research was approved by the institutional review boards for Cooper University Hospital and Polaris Health Directions, Inc.Patients were verbally asked to participate in the study if they agreed to answer screening questions and were eligible to participate based on their responses. This involved describing the study and the risks and benefits of participating to potential participants, and advising participants that they may withdraw from the study at any point in time. Written consent was obtained from all participants who verbally agreed to participate.The assessment was self-administered and research assistants were available to answer questions and to solve problems, if needed. Following completion of the patient assessment and viewing of the stage-matched video, research assistants reviewed feedback reports with the patients. Research assistants then conducted a satisfaction assessment following completion of the CABIT program to obtain impressions from participants in all settings and from the participant’s health care provider  in the Emergency Department and Tobacco Dependence Program. Since participants from the Employee Assistance Program were recruited directly, they essentially did not have a provider to evaluate the program.n = 5; video intervention, n = 5; tailored patient feedback report, n = 5). After patients completed the program, they were asked the satisfaction assessment questions and additional open-ended questions about the randomly assigned CABIT components. These interviews were recorded for later review and analysis for themes.To gather more detailed evaluations, 15 of the 67 pilot test participants completed an in-depth interview pertaining to a particular component of the CABIT program . Domains assessed with participants included those related to the different components of the CABIT. For the assessment domain, participants were asked about clarity of instructions, ability to read words on the computer screen, ease of responding to questions using the keyboard, understandability of how to return to the previous question, length, comfort in answering honestly, and appropriateness of questions. For the video, participants were asked about length, understandability and usefulness of information presented, ability to maintaining interest, and effectiveness in changing attitude regarding tobacco use. For the Patient Tobacco Feedback Report, participants were asked about understandability and usefulness of information, effectiveness in changing attitude regarding tobacco use, and usefulness of resources. These domains were patterned after published work on the Dynamic Assessment and Referral System for Substance Abuse (DARSSA) [In addition to the quantitative ratings, participants who completed the depth interviews were asked open-ended questions about a randomly assigned CABIT component . This included questions to help participants further elaborate their feedback on the domains from the satisfaction assessment, overall impressions of the program, and allow for suggestions for improvement.For participants enrolled in the pilot test through the Emergency Department or Tobacco Dependence Program, the participant’s treating physician, nurse, or counselor provided satisfaction ratings of the CABIT process and the Health Care Provider Report, including: understandability and usefulness of information, length, overall format, provision of information not assessed, effects on how provider would manage the patient, and whether the patient would have received a referral if he or she did not participate in the CABIT program.A priori, we choose a target mean satisfaction rating of ≥ 4.00 on the 5-point scale for each domain assessed by the end user. The domains failing to meet this goal would need to be modified and reassessed prior to the Phase II efficacy trial. Since the present study is a proof-of-concept study designed to assess the functioning, usefulness, and acceptance of the CABIT, treatment initiation and abstinence were considered secondary outcomes.Nonparametric summary statistics, including means and standard deviations, were calculated for all variables, including the end-user satisfaction ratings, completion time for the assessment, and 4-week outcomes. n = 40; Employee Assistance Program, n = 24; and Tobacco Dependence Program, n = 3)  see . ReasonsM = 4.48; SD = 0.70). Satisfaction ratings on all categories for the assessment, video intervention, and patient feedback reports were above our goal of a mean ≥ 4.00 (Good),  were integrated into the Master Theme Summary. Themes included in the Master Theme Summary were those endorsed by at least 3 respondents. Themes for the assessment included: the questions were understandable; instructions were clear; it was clear how to navigate the screens; the assessment length was appropriate; and it would be practical to administer this during visits to an emergency department, tobacco dependence program, or employee assistance program. Regarding the educational videos, the themes included: the video had good information; the video was not as useful as it could be; the situations portrayed in the videos are universal to all smokers; the videos were the appropriate length to hold your interest; the video format was useful; and the video was easy to understand. For the tailored feedback reports, the themes included: the report was informative; nothing should be changed with the report; the report was useful; the report was tailored to the participant; the report was the appropriate length and well-formatted; the report was understandable; and the report increased motivation to quit.M = 4.31, SD = 0.62), including: understandability , usefulness , length , and overall format . Providers indicated that the assessment gave them information not gathered during their standard evaluation for 34 out of 39 patients (87%). Additionally, 35 out of 39 patients (90%) received a referral that would otherwise not have been provided during routine clinical care.Of the 43 participants who completed the CABIT in the Emergency Department or Tobacco Dependence Program, 39 (91%) had a physician, nurse, or counselor complete satisfaction ratings of the Health Care Provider Report. Mean ratings exceeded our goal of 4.00 (Good) across all domains (The median completion time was 22 minutes (IQR: 14-26 minutes). This time for the assessment alone included interruptions by providers, which were impossible to quantify, so the recorded completion times overestimate the true administration time by an unknown amount. The educational videos, which were 6-7 minutes in length, were not included in the time it took to complete the assessment.Of the 45 participants not currently in treatment who expressed interest in changing their tobacco use and were offered a dynamic referral, 28 (62%) agreed to have their information sent to a best-matched tobacco treatment provider. While we did not assess the reason for not accepting a dynamic referral, we suspect these patients were not ready to quit or not interested in getting assistance to quit.Of the 64 participants who were followed , we successfully contacted 44 (69%) for the follow-up assessment. We did not follow-up with patients from the Tobacco Dependence Program because they were already enrolled in treatment. Based on the follow-up information from the 44 participants contacted, combined with follow-up data obtained from the tobacco treatment sites where dynamic referrals were sent, we determined that 6 out of 64 patients (9%) had initiated tobacco treatment within 8 weeks of their baseline assessment. Of these 6 patients, 5 had received a dynamic referral and 1 had received a passive printed referral at the completion of the CABIT. Reasons for not entering treatment included not being ready, disliking the programs, living too far away, other appointments, transportation problems, and medical problems or surgery.Of the 44 participants interviewed for the follow-up assessment, 21 (48%) reported going at least 24 hours without smoking even a puff in the past 4 weeks , and 4 (9%) reported abstaining from tobacco use in the 7 days prior to the follow-up phone call .While research supports the effectiveness of provider-based interventions for improving tobacco cessation ,48, clinIn the Emergency Department, of the 426 patients approached to be screened for the study, and of those who were eligible, 43 were enrolled in the study. Twenty-four participants responded to emails to participate in a tobacco treatment intervention through the Employee Assistance Program and 3 patients who were in a Tobacco Dependence Program agreed to participate in the study after being asked by counselors. Three patients failed to complete the program in the Emergency Department because they were discharged or sent for testing or a procedure. Overall, there were 67 participants who completed the CABIT program.Clinicians found the program to be useful. They rated the understandability, length, usefulness, and overall format of the Health Care Provider Report between 4 (Good) and 5 (Excellent) on a 5-point scale. Additionally, the CABIT proved to be useful to clinicians by providing information not obtained in the standard clinical assessment for 34 of 39 patients (87%). Providers indicated that 35 out of 39 patients (90%) evaluated would not have received a referral to a tobacco cessation program if the CABIT had not been administered.For automated interventions to be widely disseminated into clinical practice in medical settings, they will need to be brief so they do not impede clinical flow. Our early end-user input from a range of health care providers suggested that the entire intervention, from start to finish, should be completed within 10 minutes for the majority of patients. The CABIT fell short of this goal, with a mean time of 22 minutes. It is important to note that this estimate is contaminated by down-time arising from interruptions from health care providers, especially in the Emergency Department setting. Additionally, we were overly inclusive in our assessment instruments, which included considerable redundancy. Eliminating the redundancy would undoubtedly shorten the assessment. Additional work will have to be done on the CABIT program to shorten the length of administration before efficacy testing can be completed. In developing computerized clinical interventions, a careful balance must be struck between obtaining enough information to be useful to individuals using the system and the strong demands to have a simple, efficient system that does not impede clinical flow. However, despite the shortcomings, the result of only 3 out of 43 patients in the Emergency Department failing to complete the assessment due to discharge or clinical care supports the feasibility of a program like the CABIT and the willingness of patients to participate even in a fast-paced environment.Participants rated all aspects of the CABIT assessment, stage-matched video intervention, Patient Tobacco Feedback Report, and treatment referral locations between 4 (Good) and 5 (Excellent) on a 5-point scale. Connecting individuals with specialized tobacco treatment is an important goal of the CABIT program, considering the evidence that smokers who quit with assistance are more likely to succeed . The dynLimitations to the study included sample selection bias, which may have been present for those who were illiterate or not able to read at an eighth-grade level and for those who were computer illiterate despite our effort to assure patients that no computer knowledge was needed. Additionally, sample selection bias may have been present for those we excluded due to reasons of being too sick, not speaking English, and concerns about cognitive limitation. The sample size was relatively small, though this is mitigated by the proof-of-concept nature of the study. Follow-up limitations were possible with the 4- to 8-week follow-up window, which may have been too brief to catch all patients initiating treatment. Lastly, patient tobacco cessation at follow-up was based on patient report and not validated through biochemical means. Since this was not an efficacy trial, tobacco cessation was a secondary analysis.The CABIT proved to be an innovative and usable program that assisted providers in identifying tobacco users, providing brief individualized treatment with the stage-matched video intervention and feedback reports, and providing an automated referral to a tobacco treatment specialist. The program was highly accepted, easily implemented, and elicited a high level of satisfaction. Phase II of the CABIT will address the creation of a more user-friendly program, including a shorter assessment and production of videos that are more engaging and motivational. Lastly, future clinical trial testing is warranted to assess efficacy in promoting treatment engagement and tobacco cessation.


Risk-taking behavior is a leading cause of injury and death amongst young people.vs. 57% after). Using data from the Western Australia Police and Department of Health, the incidence of subsequent offences and injuries of all juvenile justice offenders was assessed. The incidence of subsequent traffic or violence-related offences was significantly lower for those who had attended the program compared to those who did not , as were injuries leading to hospitalization  and alcohol or drug-related offences . In the multivariate analysis, only P.A.R.T.Y. education program attendance  and a higher socioeconomic background  were associated with a lower risk of subsequent traffic or violence-related offences.This was a retrospective cohort study on the effectiveness of a 1-day youth injury awareness education program  program in reducing risk taking behaviors and injuries of juvenille justice offenders in Western Australia. Of the 3659 juvenile justice offenders convicted by the court magistrates between 2006 and 2010, 225 were referred to the P.A.R.T.Y. education program. In a before and after survey of these 225 participants, a significant proportion of them stated that they were more receptive to modifying their risk-taking behavior (21% before Participation in an injury education program involving real-life trauma scenarios was associated with a reduced subsequent risk of committing violence- or traffic-related offences, injuries, and death for juvenille justice offenders. Injury is the leading cause of death among young people, responsible for two-thirds of deaths in those under the age of 24 in Australia Injury is also associated with a significant number of hospitalizations, disability and costs. In Western Australia, about 2,500 to 3,000 hospitalizations each year are related to injuries from motor vehicle accidents A significant proportion of assaults and motor vehicle accidents in many developed countries including Australia are related to risky behaviors involving alcohol and drug use. Recreational drugs were detected in the blood of more than 45% of those presenting to a major Australian trauma center following a motor vehicle accident Health promotion strategies including economic and retailer interventions, alcohol taxation, reducing alcohol availability, legal and legislative strategies, and strategies addressing the servers of alcohol have been shown to be effective in reducing driving under the influence of alcohol The P.A.R.T.Y. (Prevent Alcohol and Risk-related Trauma in Youth) program is a one day youth injury prevention program developed in 1986 by the Regional Trauma Centre at Sunnybrook and Women's College Health Sciences Centre in Toronto, Canada. The program provides relevant information to young people to improve their awareness of injury-producing situations, make informed prevention-oriented choices, and adopt behaviors and actions to minimize risk of injuries.The P.A.R.T.Y. program has been successfully operating at Royal Perth Hospital, the state of Western Australia's designated major trauma center, since 2006. Traffic-related juvenile justice offenders (aged between 14 and 18 years old) and high school students (between grade 10 and 12) spend a day following the admission of an imaginary major trauma patient. After attending talks on pre-hospital care and the vulnerability of the brain and spinal cord to injuries, participants visit the Emergency Department, Intensive Care Unit (ICU), and Trauma wards. The participants are shown why and when a serious injury is more likely to occur and are given the opportunity of talking to trauma patients about their experiences and attempting to mobilize using a wheelchair and crutches.In a recent study involving high school students, P.A.R.T.Y program attendance was associated with a reduction in the incidence of alcohol-related driving offences, hospitalizations due to traumatic injuries and deaths We hypothesized that this injury education program is effective in reducing risk-taking behaviors and injuries in young people who have committed traffic- or violence-related offences, and conducted a retrospective cohort study to assess the effect of this education program on the attitudes of participants and their risk of subsequent injuries after attending the program.This study was approved by the Ethics Committees of Royal Perth Hospital (EC2008/071), Department of Health of Western Australia (2011/2), and Western Australia Police (00000FV001). Informed consent was waived by the ethics committees because of the extreme difficulty in obtaining direct contact with juvenille justice offenders and their families, observational nature of the study and the use of deidentified data. Due to the uncertain effectiveness of this education program, magistrates currently only refer some juvenile justice offenders to the P.A.R.T.Y. education program on an ad hoc basis. When a juvenille justice offender is referred to the P.A.R.T.Y. injury awareness education program, it is considered as one of the many elements of the whole action plan for the offender. There is no set criteria for this referral other than that the overall action plan have to be agreed by the magistrate and juvenille justice offender.After a short welcome and introduction to familiarize all participants of this education program with the Emergency Response Procedure, a pre-P.A.R.T.Y. program questionnaire was distributed to the participants to ascertain their baseline attitudes and knowledge relating to risk taking behaviors. A second questionnaire on the participants' opinion of injury prevention and evaluation of the P.A.R.T.Y. program was collected at the end of the program to assess whether the participants had changed their perception of risk-taking behaviors.The study period was March 2006 to December 2010 and included all young people between 14 and 21 years old in Western Australia. Data was obtained from the Western Australia Police for all traffic, alcohol or drug, and violence-related offences. Data obtained from the Department of Health of Western Australia included all hospitalizations related to traffic accidents or violence. The incidence of subsequent offences and injuries in those who had attended the program was compared with those who had not attended the program. The censor date to assess injuries and offences of this study was 1 May 2011.Categorical and continuous variables with skewed distribution were compared by Chi-square and Mann-Whitney tests, respectively. Multivariate logistic regression analyses were used to identify factors associated with a reduced risk of committing subsequent violence- or traffic-related offences for all juvenile justice offenders. The factors initially analyzed in the multivariate analysis included age, gender, ethnicity, number of prior offences prior to the study period, and IRSD. Variables were removed in a step by step fashion if their associated p-value was >0.25 until only variables associated with a p-value <0.25 were retained in the final model.We used a propensity score, representing the probability of juvenile justice offenders being selected for the injury education program, to adjust for potential ‘selection’ or ‘referral’ bias. The propensity score for each subject was based on age, gender, ethnicity, number of offences prior to the study period, and socioeconomic background as defined by Index of Relative Socioeconomic Advantage and Disadvantage (IRSD) at a post-code level Sensitivity analyses were conducted by (i) excluding all individuals who had any committed any offences prior to the commencement of the study, (ii) including only Aboriginal juvenile justice offenders, and (iii) including only subjects from lower socioeconomic background (IRSD<median IRSD of the whole cohort) to tackle the possibility of ‘confounding by indication’ due to selection bias. All statistical tests were two-tailed and performed by SPSS for Windows . A p-value<0.05 was taken as statistically significant.During the study period, there were 8869 hospitalizations and 113 deaths due to violence- or traffic-related injuries among those aged between 14 and 21 in Western Australia. The mean, median, standard deviation, interquartile range (IQR) and range of their length of hospital stay were 4.6, 1, 12.3, 1–3 and 1–310 days, respectively. A total of 320 patients (3.6%) needed ICU admission with an average length of stay in ICU of 6 days.vs. 57% after, p<0.001). Many written comments from the participants of the program were also very positive about the education program (see Supporting Information file). Court magistrates selected significantly more males, subjects without prior offences, and European or Aboriginal subjects to attend the injury prevention program , as were injuries leading to hospitalization  and alcohol or drug-related offences  (The median follow-up period for the whole cohort was 33 months (IQR: 17–44 months). The incidence of subsequent traffic or violence-related offences was significantly lower for those who had attended the program compared to those who had not (3.6% 9%–2.9%) Figure 1In the multivariate analysis, only P.A.R.T.Y. education program attendance  and a higher socioeconomic background  were associated with a lower risk of subsequent traffic- or violence-related offences Table 2.The results remained unchanged after excluding individuals who had offences prior to the commencement of the study. P.A.R.T.Y. program attendance  and a higher socioeconomic background  were the only factors significantly associated with a lower risk of subsequent traffic- or violence-related offences. Similarly, the results also remained unchanged when including only Aboriginal subjects  or those from lower socioeconomic background (IRSD<median of IRSD of the whole cohort).This study showed that attendance of the P.A.R.T.Y. youth injury awareness program was associated with a change in the attitudes of the juvenile justice offenders about risk-taking behavior and significantly reduced their subsequent risk of injuries and committing traffic- or violence-related offences.Trauma among young people remains as a major public health problem in many developed countries despite public health education and promotion Second, our study showed that a program designed to change attitudes to risk-taking behaviors (57% vs. 21%) can successfully empower young people, reducing their subsequent risk of committing violence- or traffic-related offences, injuries and death. Third, this education program is relatively simple and inexpensive and should be able to be implemented widely, potentially changing the lives of many young people and their families. Furthermore, the average costs of each traffic-related fatality, serious injury, and minor injury in 2003 were US$1.8 million, $400,000 and $15,000, respectively, in Western Australia The final consideration is the limitations of the study. First, this study involved only a cohort of juvenile justice offenders and whether this education program is equally effective for young people who have not committed an offence remains uncertain. The results of the Canadian study on high school students are very encouraging In summary, this study showed that participation in the P.A.R.T.Y. youth injury awareness program was associated with a very significant reduction in subsequent risk of committing violence- or traffic-related offences, injuries, and death for juvenille justice offenders. However, due to the design of the study, hidden or unmeasured selection biases might have, in part, contributed to the dramatic beneficial effect of this education program on the study participants. Our results strongly support an increased implementation of this education program for junvenile justice offenders as part of their rehabiliation program.File S1Some of the written comments of the participants of the education program.(DOC)Click here for additional data file.


Mind-body medical approaches may ameliorate chronic disease. Stress reduction is particularly helpful, but face-to-face delivery systems cannot reach all those who might benefit. An online, 3-dimensional virtual world may be able to support the rich interpersonal interactions required of this approach. In this pilot study, we explore the feasibility of translating a face-to-face stress reduction program into an online virtual setting and estimate the effect size of the intervention.Domain experts in virtual world technology joined with mind body practitioners to translate an existing 8 week relaxation response-based resiliency program into an 8-week virtual world-based program in Second Life™ (SL). Twenty-four healthy volunteers with at least one month's experience in SL completed the program. Each subject filled out the Perceived Stress Scale (PSS) and the Symptom Checklist 90- Revised (SCL-90-R) before and after taking part. Participants took part in one of 3 groups of about 10 subjects. The participants found the program to be helpful and enjoyable. Many reported that the virtual environment was an excellent substitute for the preferred face-to-face approach. On quantitative measures, there was a general trend toward decreased perceived stress, (15.7 to 15.0), symptoms of depression, (57.6 to 57.0) and anxiety (56.8 to 54.8). There was a significant decrease of 2.8 points on the SCL-90-R Global Severity Index (p<0.05).This pilot project showed that it is feasible to deliver a typical mind-body medical intervention through a virtual environment and that it is well received. Moreover, the small reduction in psychological distress suggests further research is warranted. Based on the data collected for this project, a randomized trial with less than 50 subjects would be appropriately powered if perceived stress is the primary outcome. William Cannon first described the concept of “fight or flight”, also known as the stress response, over 80 years ago Widespread use of the relaxation response is handicapped by the teaching method. It has traditionally required significant face-to-face interaction with clinician-teachers. These face-to-face teaching sessions, delivered weekly for up to 12 weeks, require time and travel. Those with limited mobility have difficulty taking part. Costs, the clinical model, and concerns about privacy in the group teaching model, provide additional hurdles to participation. Fortunately, the Internet has provided a conduit for reaching out to those with limited mobility who may also wish to maintain a certain degree of anonymity even while taking part in a group encounter. While many health interventions have been presented using the Internet A virtual environment offers many advantages not available in a typical Internet based application. Individuals create representations of themselves, give that representation unique properties to reflect their emotions or feelings and can interact with others in a rich, shared space. One extremely successful application is that of Second Life™ (SL). The free software allows users to interact in a persistent virtual world represented as a character referred to as an avatar. Stock avatars are predominantly human and come with free “animations” that communicate basic body language such as laughing, waving, falling or flinching. While anonymity is not guaranteed, it is difficult to determine the true identity of a user if they chose not to share it.People have been quick to employ SL for health related purposes. Self-organizing patient collectives were the first to develop, usually with expert patients at their core. However, the last few years have seen an increase in formal organizational involvement In this pilot study we aimed to determine if it is feasible to teach people to elicit the relaxation response using SL as the clinical teaching medium and to determine if there is an impact on perceived stress and other psychological symptoms. If successful, this approach could make it possible to reach a wider audience of individuals who could benefit from this mind body approach to health.The project was designed as a pilot study to find out if it is logistically feasible to teach stress reduction in an online virtual world and if so, to determine the effect size. The data could be used to design a larger, randomized trial of the program. It was an open trial with no blinding or randomization. The target for recruitment was 20–40 healthy volunteers. This number of patients was selected based on the experience of clinicians at the Benson-Henry Institute with face-to-face groups where a small aggregate effect was seen in groups of 15–20 participants. We hypothesized that the virtual program would be less effective and adjusted our target to 20–40 subjects divided into 2–3 groups.The project was reviewed and approved by the Partners Human Research Committee (PHRC) which serves as the Institutional Review Board of Partners Research Management. During the review of the Project, the PHRC specifically considered (i) the risks and anticipated benefits, if any, to subjects; (ii) the selection of subjects; (iii) the procedures for securing and documenting informed consent; (iv) the safety of subjects; and (v) the privacy of subjects and confidentiality of the data. Informed consent was obtained from all participants in the study, in person by a member of the research team. Each participant was given an opportunity to read the consent form at their leisure and to ask questions prior to signing the form.Patients were recruited by word of mouth in virtual world communities, through advertisement kiosks in the virtual world, through contacting local SL users groups and through a presentation at the Boston Linden Lab office. A local newspaper article in the Boston Globe about the project also raised awareness and was helpful for recruitment.The inclusion and exclusion criteria are shown in The virtual program was developed by drawing on the expertise of clinicians and team members with experience in SL. A group of 2 mind body trainers (MAB and MTM) and 2 developers (DAL and MS) met bi-weekly with facilitation by the PI and project manager (HEB), to share their knowledge. This division of expertise permitted the clinical team to focus on the conversion of their practice to SL while allowing the technical team to best understand how to best recreate the face-to-face experience in this virtual environment.. Although the face-to-face teaching area is somewhat austere, the virtual space was designed to be comfortable and welcoming, but without too many distractions.The team integrated standard web technology into the environment to simplify the development. By using external links to standard web sites for streaming video or online surveys the team could focus on the unique technical opportunities offered by this virtual world. Representative pictures of the virtual environment are shown in The participants were given some limited ability to modify the virtual environment. We felt thatif the groups could make the virtual space more personal, it would promote greater group cohesion. Mature content and software that would interfere with or slow the function of the environment were not allowed.Each subject completed baseline questionnaires including an intake history and pre-training survey as well as psychosocial self-assessment instruments. The latter were chosen because of ongoing experience with the impact of teaching the RR on these measures The groups were facilitated by the same clinician (MAB). The clinician had over 20 years of experience teaching mind body medical interventions at the BHI. She is a nurse practitioner with a Masters in Nursing and specialty training in cognitive applications of positive psychology and contemplative meditation. Each group gathered in the virtual meeting area with the clinician twice per week for 8 weeks. The content of each of the 8 weeks is given in Five different techniques for eliciting the RR were taught: 1) breath awareness, 2) mental repetition of a word, sound, phrase, or prayer, 3) mindfulness meditation, 4) guided body scan and Hatha Yoga, and 5) guided imagery. These 5 techniques are commonly used for eliciting the relaxation response and were used in previous studies of patients and healthy volunteers. The availability of more than one technique allows for individuals to explore several approaches and to avoid overuse of a single technique which may become tedious and a barrier to adherence. Instructional audio files of 20-minutes in length on each of these techniques were provided to subjects through SL for practice throughout the study. The other exercises described in The first meeting of each week lasted approximately an hour and was an overview of the principals of mind body interventions, the nature of the relaxation response, and an opportunity to learn and practice several methods to elicit the relaxation response. The second meeting each week lasted 20 minutes and was offered to answer questions and reinforce the teaching present at that week. Subjects were instructed to elicit the RR every day for 20 minutes either in front of the computer with their avatar (representation of themselves) in the virtual teaching area, or in any other quiet setting. A relaxation audio recording was available at specific locations in the virtual world, activated by guiding the avatar to that area at any time. Participants were not allowed to download the audio file for use off line.Subjects reported on their engagement in the program weekly using an online survey. The survey asked them to report the number of days they practiced for 20 min or more, methods they used for practice, the number of “mini” breathing relaxation exercises they used daily, and to report on symptoms they may have experienced.The areas of interest for this pilot study included three scales on the Symptom Checklist 90-Revised (SCL90-r) and the Perceived Stress Scale (PSS). The scales for the SCL90-r that were examined included the Global Severity Index (GSI) which measures overall psychological distress, the depression scale which measured symptoms of depression (DEP) and a scale for anxiety-related symptoms (ANX). Statistical analysis was performed using STATA on these measures that were obtained before and after taking part in the program. Since this was a pilot program in which a small number of individuals took part, we were unable to stratify by potential covariates such as gender, age and educational level.A total of 55 individuals were screened to enroll 28 subjects. The only reason for ineligibility was inexperience with SL. A complete data set for analysis was obtained in 24 of the 28 volunteers, because 4 subjects met the objective drop criteria of the study and were not included in the final analysis. . Since the study was designed as a feasibility pilot, and was not powered for statistical significance, we have excluded their data comletely. A description of the 28 participants is given in A total of 24 of the 28 subjects completed both pre and post program surveys. Scores on the Perceived Stress Scale and all 3 of the scales of the SCL90-r were normally distributed and compared pairwise. There was a trend toward improvement in each measure. Change on the Global Severity Index of the SCL 90-r reached statistical significance as shown in The individuals taking part in this study were extremely positive about the experience although most did not attend all of the sessions in SL. Two of the best accepted components of the traditional, face-to-face program: guided imagery and single pointed focus, were reported by a majority of our subjects to be “the best aspects and best takeaway from the program”. Thus, there is some consistency in the reaction to the program presented in the virtual world and face-to-face.Many participants reported that were it not for the convenience of remotely logging in for the one hour session, they would not have been able to commit to the program schedule. In addition, some felt that the subject matter was more approachable and digestible due to the anonymity. Several direct quotes from participants demonstrate this feature well:“I would probably not go to a study like this with strangers in the real world… the virtual space felt like a very safe environment….you can control what you reveal about yourself…. There is no way I would have done this if I had needed to participate in class physically, plus think about the travel time.” (participant 407)“I liked the fact that we could sit for hours doing these guided mediations together and stand up and not be stiff - doing this via SL in my comfortable chair made it easier to not focus on bodily aches and pains.” (participant 202)The goals of this pilot study were to determine if it is feasible to convert a face-to-face mind body program into one that can be delivered in a virtual setting, and to estimate the effect size in this setting for the design of a larger clinical trial. Both goals were achieved, and important lessons were learned.Although somewhat challenging, providing the program in a virtual environment is feasible and it would not require an unusually large sample to definitively test the efficacy of the program. The perceived stress scale would be a reasonable choice for primary outcome in such as study. It has excellent face validity and is easy to understand. Additionally there is a wealth of information about the perceived stress scale because “stress” is a common complaint in the general population and in clinical practice and Cohen and his collaborators have recently compared perceived stress in a relatively large sample of individuals Several important lessons were learned in the course of this study. First, although it is indeed feasible to present this type of program in a virtual world, the user interface is problematic. Recruitment was limited to individuals with prior experience in SL since the interface was known to be a barrier to entry. Even with such inclusion criteria, some of the less experienced users had problems that likely affected their participation. Prescribing this type of technology to individuals at large, with no experience in SL, would only be possible if some type of face-to-face tutorial or training program was also offered.There are several important limitations to the use of a virtual environment as described in this report. First, the healthy subjects we recruited were relatively young and exceptionally well educated. Since much chronic illness, especially that which limits mobility, is found in the older population, a virtual environment could be very difficult to use without significant technical support. Further, in the absence of remote sensing technology, it is very difficult to know if the participants are taking part in the exercises or succesfully eliciting the relaxation response. However, improvements in access to ease of use of technologies may moderate both these concerns.Technology changed significantly even in the short span of this study. When we initiated the project, the audio capabilities of SL were markedly unreliable. We decided to use Skype™ for the audio component. However, shortly after our study began, Linden lab improved SL “voice” and it is now adequate for this type of program. There is still an advantage to a separate audio technology, discovered as an unanticipated consequence of our design. If one system fails, the other persists and communication is intact.A final limitation due to the unique profile of our subjects is that of stress level. In comparison to the normative data recently reported by Cohen Providing care in a virtual world such as SL also presents a number of theoretical, practice-related challenges. Most malpractice is alleged due to negligence and proving negligence requires four elements: duty of care, breach of duty, injury and proximate cause. Further, one of the tenets of successful provider risk management is clear, caring communication with the patient. In a virtual world such as SL, challenges may arise in the clear establishment of duty, communication of a breach, and in documentation of injury or proximate cause. Likewise, great challenges around communication arise when the vehicle for communication is an avatar and exchange of text messages. Cues that are used to sense the clarity of communication such as eye contact and body language are missing. The anonymity associate with the virtual world can cloud all aspects of the provider patient relationship. The cues that one uses to confirm an individual's identity in a face-to-face meeting are lost. It is easy to masquerade as another individual in the virtual world since most contact occurs via text communication, albeit our use of voice helps. Working in a virtual world would place additional burden on a clinician to be clear about availability  in order to avoid allegations of negligence. It must be emphasized that these concerns are indeed theoretical, as no case law has emerged on what is both a nascent and low-volume activity.There are good reasons to continue to devise and investigate methods for widely distributing stress management programs like the one presented in this study, in spite of the challenges described above. The American Institute of Stress estimates that from 75 to 90% of primary care visits are to some extent related to stress. Face-to-face mind body interventions have been shown to be beneficial for many stress related conditions. However it will be difficult to make these self care strategies available on the scale necessary for effective primary, secondary and tertiary prevention, especially because mind body wellness approaches are not sufficiently reimbursed by 3rd party and governmental payers. With this in mind online web-based programs and cell phone applications will be of key importance in mind body public health and clinical efforts. Furthermore a segment of the public that is difficult to reach with face-to-face and with web-based programming–namely the socially phobic, those with post-traumatic stress disorder, autistic spectrum populations, and those with any illness that limits mobility will benefit from the use of virtual world mind body programming.Future research in this area faces several interesting challenges. The technology is rapidly evolving. SL, in particular, has changed significantly since the completion of this study. The company has reduced some services, eliminated nonprofit/educational pricing and made little effort to improve user security. Additionally, the client-server approach employed by Linden Lab is being supplanted by distributed virtual environments like jibe developed by ReactionGrid. The interface to these virtual worlds is changing rapidly, becoming more intuitive but also more powerful. The rapid pace of these changes means that clinical programs developed using this technology may be obsolete by the time a comparative effectiveness trial can be completed.The rapidly changing technological landscape also makes the choice of an appropriate comparison group difficult. A reasonable approach would be to compare a virtual intervention for stress reduction to the standard of care, which is a face-to-face intervention. However, since the human-computer interface is so critical to the intervention, an additional comparison of experienced computer users to those with little online experience may also be warranted.Research into the provision of health interventions in virtual environments should continue in spite of these hurdles. The population is living longer with a variety of chronic diseases that can limit mobility. More and more healthcare will take place at the patient's home and on line. Fortunately, even the aging population is becoming increasingly comfortable with on line commerce, social network and and personal interactions.


In the United Kingdom, non-medical prescribing (NMP) has been identified as one way to improve healthcare quality and efficiency. Healthcare organisations are charged with overseeing the clinical governance of NMP and guidance recommends the identification of a lead director to be responsible for its implementation. While over twelve million items are prescribed each year by the 50,000 qualified NMPs its uptake is inconsistent. Several studies have explored the barriers to NMP at a practice level, however little is known about the role the NMP lead and the implementation of NMP from an organisational perspective. The aim of this research was to explore the role of the organisational NMP lead across a range of practice settings within one Strategic Health Authority (SHA) and consider the development of NMP from a multi-organisational perspective.Semi-structured telephone interviews with 28 NMP leads across one SHA were undertaken by a trained qualitative researcher. Interviews addressed the purpose of the role and difficulties encountered; audiotapes were transcribed, coded and themes were identified.The NMP lead role comprised of four main functions; communication, coordinating, clinical governance and support. Factors hampering progress in overseeing the safe development of NMP included lack of clarity about the NMP lead role and responsibilities, strategic support and a lack of protected time. The extent to which clinical governance systems were in place across organisations was inconsistent. Where a strategic approach to its development was adopted, fewer barriers were encountered and NMP was more likely to become embedded within organisations.The significant contribution that NMP leads play in embedding NMP within organisations should be acknowledged by clearer national guidance for this role and its responsibilities. Greater standardisation and consistency is required of clinical governance systems if quality and safety is to be ensured given the expanding development of NMP. The extent to which NMP is in place worldwide differs. However, our findings will be of interest to policymakers in other countries involved in the development and implementation of this role. As part of the modernisation of the United Kingdom (UK) healthcare workforce, prescribing authority has been extended to nurses, pharmacists, allied health professionals (AHPs)  and optometrists ,2. AlthoIndependent Prescribing (IP) and Supplementary Prescribing (SP) are two different forms of prescribing. Through IP, nurses and pharmacists may assess, diagnose and prescribe independently any licensed or unlicensed medicines with the exception of controlled drugs (CDs). Under current legislation , nurses Learning on the NMP programme is often between nurses, pharmacists and AHPs (optometrists undergo separate training). The programme comprises 27 taught days  and 12 days in practice with a designated medical practitioner (DMP) who is responsible for the assessment of practice [There is evidence available that NMPs can improve the quality of care patients receive and provide services that are both flexible and accessible to patients. For example, patients value the interpersonal skills of nurse and pharmacist prescribers and the longer consultations they offer -14. ImprUnsuccessful implementation of NMP is potentially costly in terms of the time and expenses for training individuals to prescribe  and failGuidance  refers tA qualitative design was selected, using semi-structured telephone interviews and framework analysis.All NMP leads across the SHA (n = 44) were contacted via email (with a reminder two weeks later), and invited to participate.A two-part interview schedule was developed based on previous work in the area ,30 and cInterviews, held at mutually convenient times and lasting between 25-45 minutes, were conducted between August 2009 and December 2009.NHS and University Ethics Committee approval for the study was obtained. NMP leads who were interested in participating in the study were provided with an information sheet and given the opportunity to ask the researchers any questions. Participants were informed that the interview would be conducted in two parts with part 1 recorded on paper, and part 2 audio-taped, transcribed and anonymised. Consent was obtained prior to interviews and participants were free to withdraw from the study at any time.SPSS version 17 was used for data entry and analysis of part 1 of the interview. Data was summarized using descriptive statistics. Qualitative data generated in part two of the interview were analysed using a form of framework analysis . InterviTwenty eight (64%) of the 44 NMP leads across the SHA agreed to participate. They worked in hospital, primary care and mental health trusts and were responsible for varying numbers and types of prescribers. Characteristics of the leads and their role are summarised in table Participants reported that their role had four core elements  to be a conduit so that information coming into the organisation gets to all the NMPs because they're all so diverse and in so many different little pockets and silos. I see my prime responsibility is to make sure that they're kept up to date with any change. If I get access to information about prescribing practice nationally or, the East of England, I see that it gets to them.'[to them.'Promoting and co-ordinating NMP within the trust was also considered to be a key aspect of the lead role as was working to integrate and expand NMP into service planning.'It's actually making sure that we are driving this agenda, giving nurses opportunities, looking at new ways of working, trying to improve patient care and giving you know patients, you know benefits to prescribing.'[cribing.'A number of leads felt that in order to raise the profile of NMP in less developed areas, for example pharmacist prescribing, that their involvement in decision making at a strategic level was necessary. Liaising with higher education providers to ensure the NMP programme met the learning needs of their employees was also considered to be an important aspect of the leads role by several participants.'to inform the pharmacy networks on regional NMP initiatives, to provide input from a pharmacy perspective about where pharmacist prescribing can fit into care pathways as an alternative provider and to ensure that the pharmacy workforce  is not forgotten as potential prescribers for particular care pathways in different sectors.'[sectors.'Ensuring that clinical governance systems were in place and up-to-date was felt to be a critical part of the role by the majority of leads as described in the quote below:"..from an organisational perspective that we are assured that the organisation provided a safe environment for the prescribers to prescribe in and that ...we have systems and processes in place that would fulfil the accountability role, the support role, the development role." [t role." All but one lead held an electronic database in which they recorded the details of NMPs i.e. type of prescriber, work setting, and whether or not the prescriber prescribed. However, the extent to which this information was recorded by NMP leads varied  of the participants provided support and training directly to NMPs.Barriers and facilitators to the development and support of NMP reported by leads are detailed in table The amount of difficulty encountered depended upon the strategic approach of the trust towards NMP and the involvement of the NMP lead. The extent to which organisations had a clear strategy varied. Where a consistent strategic approach to developing NMP was in place, greater consideration was given to processes including workforce planning, the selection of candidates for prescribing training, the provision of clinical supervision, ongoing support, continuing professional development, and organisational preparation for the role in terms of procedures for registering as a prescriber and initiating prescribing. For example, it was a requirement by some specialist services, that those delivering the service had the prescribing qualification. New staff appointed to that service were therefore automatically put forward for prescribing training:'.....thinking more around some specialist services we have like x condition it's written within the service specification that whoever is delivering that service requires the prescribing qualification and so I've just had a new person come into that team and they've now put forward to go on the prescribing course.'[ course.'The extent that individuals were involved in the various lead role activities varied, but greater involvement was instrumental in alleviating many of the barriers. For example, involvement in the selection process ranged from no input to stringent interviewing of all candidates. Procedures for developing NMP varied: some candidates self-selected, some were selected by their manager, and some via strategic workforce planning . Selection criteria also varied (e.g. some trusts set a minimum job banding and three participants were uncertain if criteria were in place).'it varies across the Trust because it varies according to the area initially it was a case of nurses who were interested in going forward for the qualification would apply and then if it was appropriate they'd be assessed, is it appropriate for their role, were they going to be able to work to the academic level required and then it would be... would the service actually able to free them up for the training  but what we've done in community nursing is that because we've reviewed the education pathway we're now making independent prescribing an essential component of the specialist training so in the future all nurses going forward who come out at the other end as a Community Nursing Sister , will have the independent prescribing qualification.' [cation.' However, leads who discussed prescribing role expectations with potential NMPs, and followed criteria to select individuals with the appropriate skills and experience, said this helped identify and address problems at an early stage and so reduce barriers to prescribing once qualified. Providing support or requiring completion of additional courses  pre-empted problems during and post training. Problems securing ongoing support, finding a DMP, and defining NMP roles were alleviated where leads provided support and discussed expectations with new DMPs, NMP candidates and managers.Lack of strategic vision to develop NMP reflected a lack of organisational support, making it hard for individuals to justify the need to train. Equally, an overly restrictive selection procedure presented barriers to expanding NMP, especially within new areas of practice. Difficulties were reported in gaining approval to develop NMP for candidates without a defined specialty. Five (19.2%) participants reported they were unaware whether NMPs had an agreed scope of practice. Defining scope of practice was particularly difficult for community pharmacists:'If there isn't a commissioned service available, the primary care trust (PCT) will not provide the prescriber with an NHS prescribing patch. If the training was part of that process (commissioning), they would obviously have less of an issue about that. But if they were doing it off their own back, they would have to write a business case and persuade the PCT to support that pathway.' [athway.' Agreement was easier for individuals who worked within well-defined areas within general practice or in specialist practice areas. In these instances, NMPs were said to be well supported and actively prescribed.Despite the lack of designated time for the role, leads generally reported to be well supported within their organisations, with the exception of two leads who felt there was a lack of strategic support for NMP within the trust. Although a lack of guidance and support at a local and strategic level, misunderstanding of the NMP role by clinicians, managers or trusts acted as barriers to the NMP lead role  data information and analyse as to what people's prescribing patterns are like so that we can, you know, analyse it and then discuss it, you know groups and individuals as to you know, what the issues are with prescribing and also the prescribers can phone the Pharmacy Advisors in the PCT and ask for support and information in practice when they are prescribing'. [ribing'. This study is the first to specifically explore the role of the NMP lead from a range of practice settings and consider the development of NMP from a multi-organisational perspective. We acknowledge that the study is limited to participants from one SHA.The findings demonstrate the important role that the NMP lead plays with regards to supporting and overseeing the development of NMP within NHS trusts. However, a lack of consistency and clarity about the function of the NMP lead role, coupled with poor strategic support for NMP within some organisations, hampered progress. While some worked at directorate level, others had a clinical or educational remit. A lack of dedicated time for undertaking this role, inconsistencies in responsibilities, and large variations in coverage were reported. The number of NMPs and size of area covered impacted on the amount of time required to carry out the role, however these factors did not appear to have been considered by trusts when allocating lead roles. It is evident from our findings that the NMP lead role comprises several core functions including information and communication, promoting and coordinating NMP, clinical governance and support and training. Guidance is required from managers with regards to these functions and sufficient time dedicated to the role in order that they can be successfully achieved. Those factors which support leads in their role including good relationships with colleagues, knowledge and experience of NMP and trust wide issues, guidance from the SHA, and established policies and procedures should also be borne in mind.Patient safety and quality care is a priority for all health care professionals. NMPs provide a broad range of services enabling patients' easier access to medicines and increase choice in accessing medicines. It is essential that this is conducted safely and effectively within robust clinical governance frameworks . ClinicaFactors reported as acting as barriers to NMP including justifying a need to prescribe, finding a practice supervisor, preparation for the role, on-going support once qualified, and practicalities and legalities are in-line with those identified previously -35. ConsThe significant contribution that NMP leads play in embedding NMP within organisations should be acknowledged by clearer national guidance for the role, its responsibilities and workload. While procedures and policy for monitoring NMP are in place within NHS trusts, greater standardisation and consistency is required of clinical governance systems if quality and safety is to be ensured given the expanding development of NMP. The extent to which NMP is in place worldwide differs. However, our findings will be of interest to policymakers in other countries involved in the development and implementation of this role.The authors declare that they have no competing interests.MC was responsible for the study conception and design. NC performed the data collection and analysis. KS helped with the data analysis. All authors participated in the drafting of this manuscript and have approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/11/142/prepub


The recent U.S. Congressional mandate for creating drug-free learning environments in elementary and secondary schools stipulates that education reform rely on accountability, parental and community involvement, local decision making, and use of evidence-based drug prevention programs. By necessity, this charge has been paralleled by increased interest in demonstrating that drug prevention programs net tangible benefits to society. One pressing concern is precisely how to integrate traditional scientific methods of program evaluation with economic measures of “cost efficiency”. The languages and methods of each respective discipline don’t necessarily converge on how to establish the true benefits of drug prevention. This article serves as a primer for conducting economic analyses of school-based drug prevention programs. The article provides the reader with a foundation in the relevant principles, methodologies, and benefits related to conducting economic analysis. Discussion revolves around how economists value the potential costs and benefits, both financial and personal, from implementing school-based drug prevention programs targeting youth. Application of heterogeneous costing methods coupled with widely divergent program evaluation findings influences the feasibility of these techniques and may hinder utilization of these practices. Determination of cost-efficiency should undoubtedly become one of several markers of program success and contribute to the ongoing debate over health policy. These costs manifest themselves in criminal justice system expenditures, legal defense, and costs to victims. The Office of National Drug Control Policy reported in 2004 that substance-abuse related criminal justice costs in 2002 totaled US$35.3 billion, legal defense totaled US$647 million, and property damage to victims totaled US$206 million . An earlre costs . It is pre costs . Additiore costs ,82,83. Tance use ,84,85. IThe United States economy experiences large losses in gross domestic product due to substance use and abuse. The losses in productivity are due to underemployed or unemployed labor resources, and represent the costs involved in hiring someone to perform the services that cannot be performed due to substance-abuse related sickness, disability, incarceration, or death. Estimates of these costs have steadily increased over time; US$82 billion in 1992 , US$98.5Substance abuse in adolescents has also been linked to poor school performance, early exit from school, and lower levels of college attendance and completion . Severalet al. have recommended in their Guiding Principles that social welfare costs be excluded from analysis [i.e., the taxpayer has met their burden without recourse to hold back money intended for the Treasury).Substance abuse has been tied to increased social welfare costs in the United States. Drug and alcohol abuse leads to higher expenditures in programs such as Medicare, Medicaid, Social Security Supplemental Security Income & Disability Insurance, unemployment insurance, Aid to Families with Dependent Children, and procuring food stamps. Tabulation of substance abuse-related costs is difficult due to limited data on drug usage. Non-health social welfare expenditures were estimated at US$17.3 billion in 1994 . This fianalysis . While aClearly stating a perspective for economic analysis in terms of space and time helps to ensure that the costs and benefits considered are relevant to the study sponsor. Costs may differ depending upon the perspective selected for analysis . For exaProgram developers following the societal approach have the incentive to include the widest range of possible benefits in their economic analyses, because it increases the estimated return on investment and makes their programs appear more attractive. Alternatively, an overly thorough researcher may attempt to include the widest range of potential costs. However, the inclusion of more costs benefits may add extra time, cost, difficulty, complexity to the analysis without significantly affecting the results. Enthusiastic researchers must temper their desire to cast as wide of a net as possible and determine if the addition of extra benefits will have a meaningful impact on the results. If certain costs/benefits are especially difficult to determine and aren’t expected to change the results, researchers may rightfully consider their exclusion from the analysis.et al. conducted a sensitivity analysis that tested the differences in program benefits if reductions in substance abuse lasted through high school, mid-life, or death [The costs of a substance abuse prevention program are often immediate yet the benefits frequently accrue later (often much later) in time. However, research shows that it is fairly uncommon for programs to collect the type of long-term follow-up data that can effectively inform economic analysis. In a meta-analysis of prevention programs targeting children and adolescents, fewer than 7% of studies measured outcomes up to one year . The lacor death . More reFurthermore, costs and benefits that occur in the future must be discounted to a base year using an appropriate discount rate. For costs, the discount rate represents the rate of return that could have been achieved if program funds had been invested in the private sector. For benefits, this discount rate represents the social rate of time preference; goods and services received at an earlier date are valued more highly than those received at a later date . The selet al., for instance, suggested using a 4% real discount rate because it is “typical” or commonly used [For one thing, economists differentiate between the real and nominal discount rate. The nominal discount rate incorporates not only the society’s time preference but also inflation, while the real discount rate excludes inflation. A careful inspection of the existing literature reveals application of widely different rates. Caulkins nly used . Others nly used ,69. Mostnly used ,37,77. Petc. The marginal cost of capital would provide the most conservative discount rate and may be a truer approximation of a program’s opportunity cost of prevention. The marginal rate represents the cost of the last dollar of capital raised, and represents the market rate that a private firm would face if it sought additional funding.In many respects, using the interest rates on government bonds is justified because this approach matches the government’s borrowing rate; however, these funds are drawn from the private sector through taxation. The government rate is lower than the private rate of borrowing and thus does not fully capture the opportunity cost of those funds. The average interest rate for the private sector may also be too low because it includes industries that receive supranormal returns, monopolies, However, economic efficiency is not the sole criterion for determining the appropriate discount rate. The selection of a discount rate may have profound effects on intergenerational equity ,91,92. Tet al. included multipliers that account for more focused and effective drug enforcement, reduced peer pressure, and reductions in other substances that are theorized to occur due to the program’s effect on use of a particular substance [i.e., drug use is no longer perceived as socially acceptable). Caulkins et al. also theorized that a reduction in usage of one drug may correspond with reductions in other drugs that were not directly addressed by a particular drug prevention program [Some studies have used multipliers to increase the calculated benefits of programs. For example, Caulkins ubstance . The enf program . This is program .et al. accounted for more than two-thirds of the total calculated value of reductions and delays in substance use [Alternatively, other studies have included multipliers to decrease program benefits. For instance, scale-up multipliers may represent the expected degradation of effectiveness in a school-based prevention program as it increases in size ,38,39,97ance use . Researcet al. used Monte Carlo simulation to model the uncertainty of their estimates [et al. developed low, medium, and high estimates for individual cost drivers, and then created a computer simulation to randomly select one of the three estimates for each. The model simulation was run 16,000 times (with randomly drawn samples), providing the likelihood of particular cost scenarios instead of a single point estimate for program costs [et al. and Chatterji et al., both of which employed extreme-scenario analyses to describe the best and worst case cost estimates [It should be clear from this brief review that economic analyses of drug prevention include a great deal of uncertainty. Estimates of the economic implications of drug abuse yield precise values; however, these should be viewed as order-of-magnitude approximations. Data is usually gleaned from secondary sources and collected without economic analysis in mind . These sstimates . This meam costs . An altestimates ,49. The While the examples provided in this section limit their analysis to program costs, extreme-scenario analysis and Monte Carlo simulation could be extended to the benefits and the choice of an appropriate discount rate. In practice, researchers could potentially conduct extreme-scenario analyses first to determine if uncertainty has a significant impact on their results, and if so move on to Monte Carlo or alternative methods to account for the uncertainty inherent in their cost and benefit estimates. These methods provide results akin to confidence intervals for estimates of cost-effectiveness or return on investment. Decision-makers and other end-users may use the additional information provided by the confidence interval on results to make their resource allocation decisions.This article shows that despite their different orientations economic analysis and standard program evaluation of school-based drug prevention programs share numerous common threads. The experimental comparison between treated and “treatment as usual” or control groups, the collection of relevant data fueling program evaluation, tracking youth or cost outlays over time, and the need to precisely demonstrate some level of program “effectiveness” are all hallmark characteristics of both disciplines. Where the two evaluation arms differ is that program efficacy evaluation emphasizes accountability in terms of behavioral program objectives whereas economic analysis emphasizes accountability and efficiency in terms of resource utilization, both monetary and otherwise. For constituents faced with allocating scarce resources both approaches provide much needed information.treatment construct validity” [forward looking” approaches that deal with anticipated beneficial outcomes. In the former case the emphasis rests with investment opportunity costs (what the money spent on prevention would have yielded if spent in other ways). In the latter case the emphasis rests with anticipated program effects on behaviors that portend tremendous societal savings .Program evaluations of school-based drug prevention have made significant inroads with regard to traditional manipulation checks reinforcing “alidity” ; in othealidity” . With thTo date, economic analyses of school-based drug prevention programs provide clear evidence these programs benefit society by avoiding future costs  and have a high return on investment. Of the handful of cost benefit analyses, most show sizable returns from relatively modest dollars spent. In the case of five efficacious programs delivered entirely in a school setting—Life Skills Training, Project Northland, Project STAR, the Good Behavior Game, and the Project towards No Tobacco Use—the return on investment ranged from US$5.29 to US$55.84 per every dollar spent. Alternatively, the estimated annual costs of the D.A.R.E program range from US$99 to US$270 per student ,100; howrates” in economic terms reflecting monetized costs for each participant and for behavioral analysis the concomitant reduction in drug use . Furthermore, the economist is interested in ratios that reflect benefits to costs or cost per unit of outcome . As a corollary, the behavioral component of program evaluation seeks to establish rates of program success based on lowered incidence of new users following exposure to the intervention and reduced use among those already using drugs at the beginning of the program.There are other important parallels to the different approaches to program evaluation. Both disciplines test models with alternative albeit, plausible representations using adjustments that may influence (or confound) outcomes. Economists use sensitivity analyses and simulation procedures to objectively determine the robustness of their methods, whereas program evaluators test covariate adjusted models to avoid mis-specified models, confounding or suppression effects . Cross-vet al. and French et al. have been effective in creating guidelines for economic analysis in healthcare and drug treatment [Even with these noted similarities, widespread variation in techniques and evaluation design exists not only between economists and program evaluators, but also within each discipline. This may hinder progress because each field fails to inform the other. Researchers are required to make numerous design decisions when conducting economic analysis, and these decisions may significantly impact their findings. This has led to disparate groups within and between each discipline extolling the virtues of their respected methods without achieving an acceptable consensus. This dispersion of methods is problematic both in terms of the validity of the estimates produced, but also in comparing the results of one economic analysis to another. Gold reatment ,61. Howereatment  as a frareatment . There avs. behavioral change) in an effort to obtain a more refined view of process. One process involves actuarial applications as youth grow into young adults while the other monitors psychological maturational phenomenon. While the breakdown of how each discipline computes their net effect differs tremendously, the intended goals remain consistent and there is much to be gained from an interweaving of the two approaches. Economic analysis is entirely dependent on information gleaned from traditional program evaluation in order to estimate a program’s effects and benefits [et al.,) and the more recent integrated data analysis [effective” takes on a broader mandate when economic analysis is blended with traditional program evaluation, in a way that may redefine what is traditionally considered evaluation science [The success of both disciplines also rests with their ability to disentangle information (cost allocation benefits . Traditibenefits ,105 Toblanalysis  (Curran  science .