First responders report elevated rates of mental disorders, including posttraumatic stress disorder (PTSD), yet many are reluctant to seek care. Preventative resilience training programs attempt to proactively address this issue, and there is evidence showing promise for programs targeting cognitive processes. However, these programs rarely address the physical health conditions associated with PTSD. There is emerging evidence of mind-body exercise training improving PTSD symptoms as well as its associated physical health symptoms. However, the feasibility and acceptability of delivering a web-based mind-body resilience training among first responders are not yet known.This study aimed to evaluate the feasibility, usability, and acceptability of a web-based mind-body tactical resilience training program designed for first responders. In addition, we explored the preliminary effectiveness of the training program on mental health outcomes, adaptive cognitive strategies, and work productivity.A total of 42 first responders based in the United States enrolled in the web-based training program. Participants were administered web-based surveys before enrolling in the 6-week web-based program and at the end of the program. The primary outcomes of feasibility were measured using the number of training hours, program adherence rates, and self-reported data on frequency of practice. Acceptability and usability were measured using self-reported data. Secondary outcomes were symptoms of PTSD, psychological distress, emotion regulation, stress mindset, psychological preparedness, and work performance.t11=−3.898; P=.002). All other secondary outcomes were not significant. However, the secondary outcomes were exploratory only, and this study was neither designed nor powered to adequately assess efficacy.Overall, the training program was feasible based on the median number of training hours spent on the web-based program , and 55% (23/42) of the enrolled participants completed more than half of the program. Although acceptability, usability, and frequency of practice were rated as high, this was based on only 29% (12/42) of the respondents who provided follow-up data. Secondary outcomes showed a significant improvement in the adaptive cognitive strategy of the stress mindset, with a mean difference of –5.42 (SD 4.81; 95% CI −8.475 to −2.358; These findings suggest that a mind-body tactical resilience training program delivered in a web-based format is feasible and acceptable among first responders; however, further refinements may be required to improve adherence rates. Further research using a larger, more rigorous trial design is warranted to examine the effectiveness of this type of training as a possible prevention or treatment strategy for this population. First responders are regularly exposed to trauma and report elevated rates of mental health morbidities, including depression, suicidal thoughts and behavior, heavy alcohol use, and posttraumatic stress disorder (PTSD) -3. CurreA type of training rising in popularity in many first responder organizations is resilience training. This training seeks to prevent the development of psychiatric illnesses by equipping individuals with adaptive coping skills that would enable them to maintain psychological health despite exposure to adversity . The conTo date, promising evidence has been found for preventative resilience training targeting cognitive processes in military settings, another high-risk occupation group. A randomized controlled trial (RCT) on Israeli infantry soldiers examining the impact of a preventative attention bias modification training found that participants who received 4 sessions of attention bias modification training delivered before combat deployment had a significantly lower PTSD rate following combat exposure compared with those who did not receive the training. Another RCT on military cadet officers compared the effect of 2 other types of resilience training, one involving the use of a single session on coping skills using arousal training and adaptive thinking styles and the other involving multiple sessions of guided self-reflection that targeted maladaptive cognitions by reframing the experience of stress using more adaptive cognitive strategies such as growth and stress-is-enhancing mindsets . The resA type of physical activity intervention that uniquely integrates both psychological and physical health strategies is yoga training, a type of mind-body exercise that combines breathing techniques, controlled physical movement, and mindfulness practices simultaneously . PreviouIndicative evidence has also been found for programs that include mind-body approaches using a web-based format ,31. A reA novel web-based mind-body tactical resilience training program was developed specifically for first responders to address these research gaps. The primary aim of this study was to ascertain the feasibility, acceptability, and usability of a web-based mind-body tactical resilience training program that is culturally informed and job-specific to first responders. In addition, the study explored the secondary outcomes of the preliminary effectiveness of the web-based training program in (1) reducing symptoms of PTSD and psychological distress; (2) modifying mindsets about stress, emotion regulation, and perceived psychological preparedness; and (3) improving work productivity.The Online 6-Week Tactical Resilience Training program  to 4 is If you were participating in an online yoga training program, which learning tools would you prefer?When using an online training program, how many days a week would you be able to commit?When using an online training program how much time per day could you commit?Would you be interested in participating in this online training program when it is launched? Adjustments were made to the training content based on the feedback received wherever appropriate.As part of the modeling phase, first responders based in the United States were previously surveyed on the relevance of techniques and sections as well as web-based content preferences to determine the feasibility, acceptability, and usability. This consultation phase was not part of the research study and was conducted by the YFFR program developers before the development of the web-based program. To consult with first responders, YFFR placed an advertisement in their regular web-based newsletter to their local first responder network asking for feedback on the development of a web-based training program. Interested first responders were directed to a web-based survey as part of the advertisement. A total of 78 first responders answered this anonymous web-based survey, half of whom  had attended a previous YFFR training. Questions were asked on general interest in a web-based mind-body resilience training program; current yoga and meditation practices (if any), including frequency and place of practice; preferences for a web-based program, including time commitment and preferred time of day; helpful reminder cues; learning tools; use of technology; preferences for live classes; and strategies to encourage training participation. Examples of the questions include the following: The web-based program was based on the YFFR in-person training protocol, which was designed to provide proactive resilience training specifically for first responders. It is primarily based on the principles of traditional Hatha yoga, which involves regulation of breathing using synchronized movements and postures, as well as trauma-sensitive yoga, a trauma-informed approach designed with trauma survivors in mind to cultivate a safe environment . These yAlthough the web-based training program was intended to be self-paced, participants were expected to complete the course within a 6-week period, with automated weekly reminders sent to prompt program adherence. The 6-week time frame was based on the expected time commitment of 1 week per module; however, participants were given an additional 2 weeks to catch up on any materials missed. The program was mobile-responsive, which made access easy using a desktop, laptop, tablet, or mobile phone.This study aimed to examine the feasibility, acceptability, and usability of the 6-Week Tactical Resilience Training program and explore the preliminary effectiveness of a web-based mind-body tactical resilience training program specifically designed for the needs of active-duty first responders. The study was conducted with a small group of first responders where all participants were allocated to receive the intervention. Participants comprised first responders located throughout the United States with no previous training or relationship with YogaShield YFFR.Participants were recruited through email advertisements that were circulated to YogaShield’s first responder networks located across metropolitan and regional areas throughout the United States. Using snowball sampling methods, these networks then distributed the email advertisements to their social and professional networks. First responders with no previous YFFR training were invited to participate in the study. Participants met the inclusion criteria if they were current active-duty frontline first responders, specifically firefighters, police, and paramedics, and dispatchers who were either in paid employment or in a volunteer capacity. Participants also had to currently reside in the United States, be aged ≥18 years, and speak English. The recruitment advertisement described the purpose of the study and what would be involved and contained a link to the study website as well as the participant information sheet and consent form. The advertisement also emphasized that participation in the study was voluntary and not a requirement of their job. Study recruitment occurred in February 2021 for approximately 3 weeks.Each participant completed their own informed consent form by indicating their agreement with a declaration statement. By agreeing to take part in the study, participants declared that they had read and understood the participant information sheet, could ask any questions they may have, understood the risks and benefits, and knew that they were free to withdraw at any point throughout the duration of the study without penalty or consequences. Agreement was expressed by checking a box and providing their name and email address. Participants were also informed that the study data would be deidentified before analysis. Compensation was not provided for participation. Ethics approval was obtained from the Human Research Ethics Committee and the University of New South Wales before the commencement of the study (HC200707).Eligible participants who consented to the study were directed to complete the baseline assessment on the web. Upon completion, participants were provided with a hyperlink to register for the web-based training program by entering their name and preferred email address. Log-in credentials were automatically sent to participants’ designated email address. The web-based training program was made available at the end of the recruitment period on February 22, 2021, after which all the registered participants were able to commence the course. The web-based program was designed to be completed within a 6-week period, with an additional 2-week “catch-up” period. Although participants were encouraged to complete the program within 8 weeks, the program was still available for those who were unable to complete the web-based course within that time frame. Automatic email reminders were sent before the start of the web-based program, as were weekly reminders to continue working through the program. Web-based follow-up surveys were distributed upon completion of the web-based training program or at the end of the 8-week study period for those who had not yet completed the program within that time frame.The baseline and postintervention surveys were collected electronically via the REDCap  platform ,38 hosteDemographic information, including age, gender, occupation type, employment status, length of service, previous yoga or resilience training, and help seeking, was collected at the start of the baseline survey. Participants were also asked to indicate the approximate number of critical incidents that they had attended since becoming a first responder. The first 2 items on serious injuries and fatalities were based on a previous study on the impact of cumulative exposure on first responder mental health . A totalThe feasibility of the web-based program was based on the number of hours spent on the program as well as program adherence data obtained from the hosting platform. On the basis of a previous feasibility study for web-based delivery of a similar mindfulness-based training with active-duty first responders, we established at least 50% of participants completing more than half of the program as the cutoff benchmark for feasibility . To obtastrongly disagree to strongly agree. In addition, participants were asked to rate how useful they found key components of the course. This included the 4 main modules  as well as the type of learning materials, including video or audio lecture recordings, interactive exercises, prerecorded yoga videos, and live Zoom classes (if attended). Participants were asked to indicate the degree of usefulness using a 5-point Likert rating scale ranging from not at all useful to very useful. Items rated as useful or very useful were indicative of usability. Acceptability was measured using a 5-item scale adapted from the same previous study [strongly disagree to strongly agree. Items that were rated as agree or strongly agree were indicative of acceptability. In addition, participants were asked if they would recommend the training program to their coworkers. Upon completion of the final module, participants were also given the opportunity to provide optional qualitative feedback on the overall course using a free-text typed response through a separate and anonymous Google Form that was embedded in the web-based program.The web-based follow-up assessment also contained measures of usability and acceptability, which were adapted from a previous study on a web-based mental health training program for first responders and construction workers . Usabilius study  to accesnot at all to 4=most of the time). The cutoff criterion for likely PTSD was established through a combination of at least one symptom with an item score of ≥3 from each of the 3 PTSD symptom clusters. The summed score provides the score for symptom severity. Good internal consistencies, as measured by the Cronbach α, were achieved in previous trauma-exposed samples of accident, sexual assault, and disaster survivors  [The preliminary effectiveness of the secondary outcomes was assessed at baseline and at the 8-week follow-up time point. Symptoms of PTSD were measured using the PTSD-8 . The PTSctively) .none of the time to 4=all of the time) [Psychological distress was measured using the 6-item Kessler Psychological Distress Scale (K6) . The K6 he time) . Particihe time) ,47.strongly disagree to 7=strongly agree). Internal consistencies for both the cognitive reappraisal (Cronbach α=.89-.90) and expressive suppression (Cronbach α=.76-.80) subscales were high in various community samples [Emotion regulation was assessed using the Emotion Regulation Questionnaire, a 10-item scale designed to measure respondents’ tendency to regulate their emotions through cognitive reappraisal or expressive suppression . The cog samples .strongly disagree to 4=strongly agree). Negatively worded statements are reverse scored. Higher scores represent a stress-is-enhancing mindset. Internal consistency was high, with a Cronbach α of .87 [Mindsets on stress were measured using the Stress Mindset Measure , which aα of .87 .not true of me to 4=exactly true of me).Psychological preparedness was measured using a modified version of a previously validated subscale of psychological preparedness for natural disasters  and adapWorst performance to 10=Top performance). For sickness absence, participants were asked to indicate how many sick days they had taken in the previous 4 weeks and, if so, how many of these were because of mental health or emotional problems.Work performance was assessed using a single item from the Health and Work Performance Questionnaire and 2 additional items pertaining to past-month sickness absence . For wort tests. The outcomes considered included symptoms of PTSD and psychological distress, emotion regulation, stress mindset, psychological preparedness, help seeking, and work performance. All statistical analyses were conducted using SPSS  [Descriptive statistics were used to demonstrate participants’ responses to the feasibility, acceptability, and usability of the Online Tactical Resilience Training program. Differences in the mean scores for each of the outcomes between baseline and the 8-week follow-up point were assessed using paired-sample 2-tailed BM Corp) .P=.32), gender (P=.55), baseline PTSD (P=.28), or K6 cutoff scores (P=.61) between those who provided follow-up data and those who did not.A total of 57 participants consented to the study, of whom 52 (91%) completed the baseline survey. All 52 participants were invited to register for the web-based training program, of whom 42 (81%) registered and enrolled. P=.09), gender (P=.41), baseline PTSD (P=.59), or K6 cutoff scores (P=.89) were able to predict which participants were more likely to complete the program. The total number of hours spent on the entire program varied considerably, with a median of 7.57 hours. The median number of hours spent on the web-based modules was 5.45, and it was 1.35 for the homework yoga videos, which could be accessed either via the web-based program or via a separate app. App use was not tracked as part of this study. Less than half  of the participants who enrolled in the tactical Resilience Training program completed all 6 modules of the course. More than half  completed >50% of the program, meeting the benchmark for feasibility. Half  of the enrolled participants completed >80% of the program. Of the 12 participants who completed the follow-up assessment, 10 (83%) completed the web-based program, whereas 2 (17%) did not—of these 2 noncompleters, 1 (50%) completed only 2 modules and the remaining participant (50%) completed 4 modules. Both respondents cited time constraints as the reason for noncompletion, with one of the respondents adding the program not being user-friendly as another reason for noncompletion. Respondents to the follow-up assessment indicated a high frequency of practice, with all respondents practicing the breathwork techniques at least 3 to 4 times weekly, most  practicing yoga sequences at least once or twice weekly, and 83% (10/12) practicing meditation and cognitive declaration techniques at least once or twice a week.Analysis examining baseline predictors of program completion found no evidence that age  agreed that it was easy to find the information they needed and that the main modules of the course were useful. Although most also rated the lecture videos , interactive exercises , and yoga videos  as useful or very useful, some respondents did not find the discussion forums  or live Zoom classes  useful.Acceptability was high among those who responded to the follow-up survey, with most respondents  agreeing that the course was engaging and interesting and met their expectations and that they would recommend the program to their coworkers. All respondents  rated the overall course as useful and believed that it helped improve their overall well-being.The qualitative feedback received on what participants learned from the training was primarily positive. Some examples of comments included the following: “It felt good to do them, I learned something new,” “I felt so much better and the days I didn’t do my yoga I felt not so focused,” and “I learned that it is okay to put myself first, and that I can control my mindset.” The only major negative feedback regarding the course was the length of time required to complete it, as described by a participant: “Course material was more than expected and took more time, this not allowing time for homework.”t11=−3.898; P=.002). Total PTSD symptoms showed a nonsignificant trend toward reduction, with a mean difference of 1.58 . All other secondary outcomes were not significant. Following their use of the web-based Tactical Resilience Training program, participants reported significantly higher stress-is-enhancing mindsets compared with the baseline, with a mean difference of –5.42  of the respondents who provided follow-up data. Analyses of secondary outcomes showed a significant improvement in mindsets on stress, whereas no other significant changes were found for any of the other secondary outcomes. However, the findings on secondary outcomes were exploratory only, and our study was underpowered to assess effectiveness. To the best of our knowledge, this is the first time that a web-based mind-body tactical resilience training program designed specifically for first responders has been developed and tested.The total number of training hours provided an indication of feasibility; however, this varied considerably between participants, with a median of 7.57 hours for the overall web-based program. A median of 5.45 hours was spent on the web-based modules, whereas a median of 1.35 hours was spent on the homework yoga videos. However, homework videos were only tracked via access through the web-based program. Access via the separate app was not tracked as part of this study as this was only intended to supplement participants’ learning and homework videos could only be accessed upon completion of the accompanying module. It is possible that the actual use of the homework videos was higher as a result. Program adherence for the web-based delivery of the mind-body resilience training surpassed the benchmark based on a previous mindfulness-based feasibility study on first responders , with haSecond, the web-based self-guided format for this type of program may not have met the needs of some first responders who may have preferred the presence of an instructor. Previous reviews have demonstrated the superiority of guided web-based interventions to unguided web-based interventions in improving completion rates and symptom reduction, likely because of the provision of human support, feedback, and encouragement in completing the intervention and applying newly learned skills in practice ,61. It iOur study also experienced low retention rates in the follow-up assessment. Although it is not known why this high loss occurred, this may have been due to several factors. First, it is possible that the follow-up assessment, which comprised multiple questionnaires, was too lengthy. The lack of incentives to complete the assessments may have also contributed to this high loss. Furthermore, as the research team was based overseas, there was little opportunity to communicate the benefits of the research program other than via email. Improving follow-up procedures and expanding methods of contact such as the use of social media and better recruitment procedures through first responder agencies may help improve retention rates in future studies. Finally, it is also possible that retention rates for the follow-up assessment and program completion were affected by the COVID-19 pandemic, an unprecedented time in history and a particularly demanding one for first responders because of the nature of their roles. The study trial occurred in the middle of the COVID-19 pandemic, and although it is not known if retention was directly affected by the uniqueness of the time, it is possible and understandable that adherence to the follow-up assessment and web-based program was not a priority for many first responders during this disruptive time of ongoing uncertainty.Although our study was underpowered to detect measures of effectiveness, our significant finding on the stress mindset shows that it may be possible for this type of program to modify important perceptions of stress. Evidence is emerging on the influence of stress mindsets on perceived stress, physiological health, and mental health outcomes. Specifically, adopting a stress-is-enhancing mindset has been found to mitigate the development of depression and anxiety symptoms among college students with high levels of stress  and was Our work adds to the limited studies on high-risk occupations  and presOur study has a number of important limitations, most notably the small sample size and high study attrition rate, where only 29% (12/42) of the enrolled participants completed the follow-up assessment. Although high dropout rates for program completion are common for many web-based interventions , as prevPreliminary findings from this study suggest that this tailored web-based mind-body tactical resilience training program appeared to be feasible and acceptable among active-duty first responders. The use of mind-body exercises to integrate both psychological and physical strategies in a web-based format appears to be well received; however, further refinements to the existing program, implementation, and follow-up study procedures may be required to improve program adherence and follow-up assessment response rates. More research is required on the optimal duration and frequency of this type of program to better inform feasibility, as well as on the inclusion of social support via guided and group-based formats and social media. Given the low rates of help seeking among this population , there i


The purpose of this study was to develop a self-transcendence enhancement program and examine its effect on self-transcendence, spiritual well-being, and psychological well-being in elderly women who live alone. A self-transcendence enhancement program was developed through theory, literature review, and in-depth interviews. The theoretical framework came from the Psychoeducational Approach to Transcendence and Health intervention model based on Reed’s middle-range theory of self-transcendence. The program consisted of multiple modalities in a structured, theory-based program lasting for eight weekly sessions. Using a single-group pretest-posttest design, the program was tested on a group of 40 elderly women aged 75 to 84 years living alone in Daejeon, South Korea. Participants completed self-reported study questionnaires before and after the program at the elderly welfare center. Data were analyzed using SPSS version 24.0, with significance level set at .05. Paired t-test was used to compare mean differences before and after the program. p<.001), overall spiritual well-being , religious spiritual well-being , existential spiritual well-being , and positive affect  than they did before the program. They also reported lower levels of depression  and negative affect . The mean age of the study participants was 79.1 years. After completing the program, the participants showed higher levels of self-transcendence (t=8.78,  The self-transcendence enhancement program developed in this study may be effective for improving the level of self-transcendence in elderly women living alone and helping them to attain spiritual and psychological well-being. In terms of well-being, elderly women who live alone appear to be a more vulnerable group than other demographic groups in South Korea  ,2. AccorSelf-transcendence is the core concept of self-transcendence theory, which was developed by the nursing theorist Reed . It refefirst, elderly women living alone who participated in the self-transcendence enhancement program would have a stronger sense of self-transcendence than they did before participating in the program; second, elderly women living alone who participated in the self-transcendence enhancement program would have greater spiritual well-being than before; and third, elderly women living alone who participated in the self-transcendence enhancement program would have greater psychological well-being than before. Specifically, decreased depression and increased life satisfaction, positive affect, and negative affect were anticipated.This study was based on Reed’s self-transcendence theory , which dEthics statement: This study was approved by the Institutional Review Board of Chungnam National University (201907-SB-106-01). Informed consent was obtained from the participants.This study is a single-group pretest-posttest experimental study.The participants of this study were elderly Korean women living alone. The researcher (first author) selected two senior citizens centers using convenience sampling based on a report on the current status of elderly women living alone, issued by the Ministry of Health and Welfare . ParticiThe effect size of the self-transcendence variable (d=.70) and the effect size of the depression variable (d=.45) suggested by Kim and Kim’s  self-traInterventional studies that applied Reed’s concept of self-transcendence  were selIn-depth interviews and qualitative content analysis were conducted to select a program theme that reflected the specific aspects related to self-transcendence among elderly women. In-depth interviews were conducted with nine women who voluntarily participated, using the same inclusion criteria. These women were independent of the larger study and interviewed twice (over 2 weeks) from November 2 to 16, 2019. The questionnaire items included in the in-depth interviews focused on the four dimensions of self-transcendence  for elderly women living alone . One-on-The qualitative analysis involved applying the three stages of inductive content analysis devised by Elo and Kyngäs —open codBased on the eight meaning clusters, intervention activities were devised and concrete activities were created. The themes of the program were based on the eight meaning clusters related to the self-transcendence needs of elderly women living alone, with a focus on the expansion of temporal boundaries . The intTo ensure the validity of the program, this study was revised once and supplemented after receiving advice from a nursing professor and geriatric and psychiatric advanced practice nurses. A preliminary survey was conducted during an 11-day period with six elderly women who lived alone in a senior citizen center in Daejeon, Korea, regarding the program’s procedures to verify the completeness of its content and composition and to identify any unexpected problems. As a result of this preliminary survey, only body scan meditation in the sitting position was included in the final program due to the survey respondents’ opinion that the basic yoga movement included as a mindfulness activity could cause strain on the joints of program participants .The self-transcendence enhancement program for the well-being of elderly women living alone was conducted across eight sessions . In the first session, participants were divided into small groups of 6 or 7 people, with each group given a name, and an introduction was provided to foster a comfortable and intimate group atmosphere. From the second session onward, the participants shared their impressions and encouragement about homework and weekly home activities, which were designed to introduce topics and activities from the next session to capture participants’ interest. First, body scan meditation was performed for 5 minutes, followed by specific activities for 35 minutes. The theme of the first session was “expressing and respecting oneself.” The second session’s theme was “focusing positively on life in the present free from negative feelings about regrets from the past.” The theme of the third session was “caring for oneself,” followed by “forgiving people in the past to focus on life in the present” in the fourth session. The theme of the fifth session was “maintaining intimate relationships with people with a heart full of gratitude for others,” and the theme of the sixth session was “living an unselfish life of helping others.” The seventh session’s theme was “having a good death” and the eighth session’s theme was “having purpose and meaning in life.” Activities were carried out individually or through interaction and participants’ experiences were shared. At the conclusion, the facilitator summarized the topics and activities of each session, and the participants shared their feelings about the activities. At this time, participants were given assignments to review concepts and themes related to the activities. For family activities, one theme was chosen among the following activities; reading, observing, religious activities, encountering nature, and meditation. The selected activity was to be practiced by participants to maintain self-transcendence activities during the week .The measurement tools used for data collection in this study were approved for use by the original authors.The Korean version of the self-transcendence scale by Reed , of whicThe modified Korean version of the spiritual well-being scale  by Lee  was usedPsychological well-being is a subjective psychological state of health, which includes one’s ability to experience subjective satisfaction, euphoria, or general emotions and emotions when responding to environmental stimuli in daily life . TherefoKee’s Korean version  of the gKwak’s Korean version  of the sJeon’s Korean version  of the pThis study was conducted from December 31, 2019 to February 23, 2020. The procedures and methods are described below.The research assistants included two nursing students. They received education about the purpose of this study, the design and content of the program, research procedures and precautions, and the roles of research assistants. To keep the participants comfortable and safe, a welcoming indoor environment with sitting desks that could accommodate 20 people was prepared, risk factors related to falls  were rearranged, and regular safety checks were conducted. Protocols to protect study participants from coronavirus disease 2019 (COVID-19) were designed and followed. Researchers and assistants wore masks that covered their mouths and noses, remained at least 1 meter apart from others, washed their hands often with soap and water, and avoided crowds and poorly ventilated indoor spaces.A pretest survey was conducted after the researcher explained the purpose and method of the study to the 40 initial participants. The preliminary investigation period was from December 31, 2019 to January 2, 2020. The study participants gathered at the same time and filled out questionnaires for about 1 hour. The selection criteria required participants to be able to read, write, hear, comprehend, and express themselves in words, so there were no difficulties completing the questionnaires themselves; however, the participants had difficulties comprehending the response method. One researcher and two research assistants helped them with explanations.The eight-session program was conducted across 8 weeks from January 3, to February 21, 2020, at two senior citizen centers with 40 participants. This period was prior to COVID-19 outbreaks in the area and infection protocols were not as rigid. Safety protocols were maintained as sessions were conducted, once per week for 1 hour each.A posttest survey was conducted from February 22, 23, 2020, after the completion of the 8-week program. The same measurement tools used in the pretest survey were used except for general characteristics, which were not collected in the posttest survey. This study followed the Transparent Reporting of Evaluations with Nonrandomized Designs (TREND) statement  to improThe general characteristics of the participants were analyzed by frequency and percentage, mean, and standard deviation. To analyze the effect of the self-transcendence enhancement program, the paired t-test was conducted to analyze pre- and postintervention values. Statistical analysis was performed using IBM SPSS Statistics ver. 25.0 .The average age of the 34 participants was 79.10 years, 23 (67.6%) did not graduate from elementary school, and the average period for which they had lived alone was 10.08 years. The average monthly income of the participants was 497,400 Korean won (439 US dollars), and 25 people (73.5%) answered “poor” or “very poor” for their perceived health condition. Twenty-eight participants (82.3%) said their children were their guardians, while 4 (11.8%) listed relatives and 2 (5.9%) listed neighbors as their guardians. Fourteen participants (41.2%) were contacted by their guardians once per month, and 15 (44.1%) were visited by their guardians once per month. For leisure activities, 22 participants (64.7%) reported not having hobbies or participating in leisure activities, and 23 participants (67.6%) reported not being religious .p<.001). The participants’ overall spiritual well-being after the program increased significantly, from 56.52 points to 64.29 points , and both the religious and existential spiritual well-being subareas also improved. The average religious spiritual well-being score increased from 27.76 points to 29.70 points after the program , and the average existential spiritual well-being score increased from 29.55 points to 34.58 points . Thus, the first and second hypotheses were accepted.Participants’ self-transcendence, spiritual well-being, and psychological well-being increased after the intervention program . The selp<.001), and the average negative affect score decreased from 34.11 points before the program to 30.26 points after the program . In addition, the mean positive affect score rose from 30.41 points to 32.00 points . The average life satisfaction score also increased from 14.14 points to 14.97 points, but it was not statistically significant . Therefore, three out of the four components of the third hypothesis—decreased depression, increased positive affect, and decreased negative affect after the program—were accepted. However, the hypothesis that life satisfaction would increase was not accepted.Positive affect increased, and depression and negative affect decreased. The participants’ average score for depression decreased from 8.73 points to 7.00 points after the program , moving to another city (n=1), and not meeting the attendance criteria (n=1). In addition, there were no incidents related to the participants’ health or safety such as hypoglycemia, dehydration, or falls.The improvement of the average self-transcendence score after the program is consistent with the results of another study  in whichThe average scores for the spiritual well-being of elderly women living alone were similar to those of underprivileged older women living alone  and highThe average depression score reported by elderly women living alone in this study was higher than that found in another study of elderly women living alone ,38, and The average positive and negative affect scores after the program were 3.37 points and 3.10 points (out of 5 points), respectively. The average positive and negative affect scores were lower in this study than in a study of community-dwelling elderly people . The proHowever, the intervention program did not significantly affect participants’ life satisfaction. This is contrary to another study , which fThere is a limitation to generalizing the present results to other regions and countries since we recruited elderly women living alone in a particular region. However, their physical, economic, and social demographic characteristics can be generalized. In addition, this study used a single-group pretest-posttest experimental design to evaluate the applicability of the program. The ability to evaluate the effectiveness of the program was also limited by the inability to control for confounding variables and maturation issues. Lastly, the researcher and two research assistants conducted and analyzed the program simultaneously. Therefore, the validity of the study is limited. In future studies, single-blind randomization should be used to generate more credible results by establishing both a control group and an experimental group.The self-transcendence enhancement program for the well-being of elderly Korean women living alone developed in this study had a positive effect on spiritual  well-being and psychological well-being , and also enhanced participants’ sense of self-transcendence. Through this study, it was confirmed that this program could be safely conducted with other groups of elderly people. In addition, this study contributed to the body of evidence-based nursing knowledge related to promoting self-transcendence in elderly women living alone through the application of an intervention program based on nursing theory. The safety of this program was confirmed, and the attendance rate of the participants was satisfactory. Therefore, it is highly recommended that this program be conducted for small groups of people in the same age group at other institutions. Furthermore, nurses working in local communities should utilize connections between senior citizen centers and public health centers to implement this program for elderly women living alone.


Access to club sports is still not a given for children with ID. Parents and children report numerous structural and social barriers to accessing mainstream sports. Sports clubs, on the other hand, want to include this group of people, but often do not know how to do it. Using a community-based approach, children with intellectual disabilities (8–15 years) and their parents were given the opportunity to participate in an 8-week sports program in four mainstream clubs organized by a self-help organization for people with intellectual disabilities. Focus groups were conducted with all participants  before and after the program and evaluated by means of a thematic analysis. The children rated participation very positively and only very occasionally reported that they had been excluded. The parents confirmed this experience, but were nevertheless more critical in their assessment. Outside the research context of this study, the sports clubs hardly provided good support, which can also be deduced from previous negative experiences of the parents. The sports clubs themselves received valuable information about what their failings were: sufficiently available and qualified staff, better access to sports facilities, and a wider range of inclusive groups are needed. On the other hand, there was hardly any prejudice on the part of the non-disabled club members towards the new members with ID, which was evaluated extremely positively, albeit surprisingly, by the sports clubs. Regular physical activity (PA) is an important determinant of health benefits for all. The positive effects of PA on a wide range of physical, social, and mental health are well known and widely recognized . NumerouUnfortunately, people with disabilities are the group with the lowest regular participation in PA ,8,9. A mOnly a very few studies  focus onPeople with ID are interviewed less frequently on the motives and barriers to participation in sport. One of the few studies on this subject  showed tParticipation in organized sport can be beneficial for social, educational, cultural, and health reasons , but a rFor the reasons outlined above, the following questions guided the present study.What are parents’ positive and negative experiences with their children’s participation in organized sports? What do they expect? What are they afraid of?What do the children with ID expect? What positive and negative aspects can be identified?What is the view of the sport clubs? What conditions must be met for them to open up to people with ID? What benefits and what responsibility do they see in this area?What are the implications for all stakeholders if people with ID participate in organized sports?Fifteen families with children with ID took part in the study. They all were recruited during a community-based approach on participation in PA organized by a local agency of the German Self-Help for people with ID and their families . The ageThe four mainstream clubs offered a various array of sports, including team sports  and individual sports  in the near community. All clubs did not have special sport groups for people with ID nor other disabilities but were basically open for all and felt responsible for social inclusion, as stated on their websites.Ten female students from the local university studying special needs education, supported the families and the clubs during the program as facilitators. All students had long experience in mainstream sports (as athletes and/or coaches) as well as in supporting children with special needs (ID and other disabilities). The rationale for engaging them was not just for practical purposes but was also built on the approaches known to be helpful in creating inclusive settings such as in supported employment or in schools. They were not intended to act as a personal coach or a caretaker, but to foster an inclusive and equal participation of all members of the sport clubs.The Self-Help agency offered an eight-weeks sports program in which the participating families could choose one or more types of sports within the offer of the four cooperating sport clubs. They were open to try different opportunities with the aim of finding one or more types of sport which fit with the demands of the children with ID and/or the family as a whole. During the eight weeks, most of the children found a suitable sport. The sports were chosen by interest and availability in the clubs and covered handball, gymnastics, swimming, equestrian, and soccer.Two families dropped out after three weeks of participating. One family reported problems in getting their child to the clubs. The distance from the living area to the sport facilities was too far, so the effort was not manageable. The child of the second family indicated that she was bullied by the non-disabled kids on the team. Although parents, the coach, the facilitating student, and the author had serious discussions with the kids, no solution was found to convince the girl with ID to continue her participation. She did not want to continue in this group and was not motivated to try again in another group.Supplementary to the sports program, the families and the sport clubs representatives took part in two rounds of focus groups, one at the beginning of the program in week one (t1) and another at the end of the program, after week eight (t2). The complete process of the study is shown in Focus group interviews were chosen because this method enables a process of sharing ideas and comparing them between all persons interviewed in an interactive way, thereby leading to a co-constructing of meaning by the participants . At t1 aAn ethical approval for the study was obtained by the local university. Information sheets about the evaluation aims and consent forms were given to all participants, using an easy language format for the children with ID. For the children who were not able to read, the documents were read to them by the assisting students, who were familiar in interacting with children with ID.After obtaining consent forms and introducing the purpose of the program evaluation, the interviewers used semi-structured interview guides with predetermined topics see . DespiteThe second focus group round at t2 lasted around 12 min (children with ID), 21 min (club representatives), and 26 min (parents) and had the aim of summarizing the feelings and experiences after the eight-week program. For this purpose, the questions were adjusted as seen in The focus group sessions were audio-recorded and verbatim transcriptions were made. As the main goal of the study was to search for patterns across the different interviews rather than within a single case, thematic analysis  was usedThe thematic analysis revealed several themes, which were related to the experiences, expectations, and wishes from all stakeholders. The following section will describe these themes broken down by time (before (t1) and after (t2) the program) and group . The final thematic maps with main themes for all stakeholders can be seen in the All parents reported a great importance of physical activity for their kids. The perceived child’s need for motor skills training and psychosocial support was the main motivator to join the program. In contrast to motor therapies, which most of the children went through several times in their life, sport offers better possibilities for “real life” training together with other kids. A mother described these aspects in the following words: “I mean, for him [8-year-old son], it’s so important to train his body. He does not move much in his life. I wish him to be more active and have fun while doing so. In his therapy he is more passively moved than acting by his own. I hope, that he will enjoy the sport activities together with the other kids in his age”.The former experiences with taking part in mainstream sport were very negative. Out of the 15 families taking part in the first focus group, 10 had tried to be active in a mainstream sport club, some for several times. The anticipated positive aspects motivated the parents to try a membership in the clubs, but most of them did not feel welcomed and reported of unprepared club structures, not qualified coaches, and—sometimes—unwillingness to include their kids in the running of the programs. A father stated: “At the beginning, all went quite good in the club. I am a member there for five years and all knew about my daughter, and this was never a problem, as long as she was not participating. But when she started to join the regular swimming program, the situation changed rapidly. The other kids were not very kind, some of them were mocking about her, some seemed to have fear or just were overwhelmed. That is ok for me, they are young kids. But I expected the coach to act. She didn’t do. She just wasn’t able to handle the situation, which really disappointed me”. A mother of a 12-year-old girl added: “That’s exactly the reason why we are here. We tried to include her in the local soccer team, she loves kicking. But the coach didn’t know how to handle her. She needs a little more time, ok, but she is able to follow the rules and tries to give her best. He [the coach] was not able to adapt his training to her abilities”.On the other hand, there were some positive aspects as well, especially concerning the attitudes of the other, non-disabled children in the sport groups. “My son felt very well in his handball team. He was the only member with ID, but the other kids didn’t mind. They treated him like all the others, and the coach was very engaged with learning how to adapt the training. All went well, until they get into competition mode. My son wasn’t good enough to compete against the other teams. When it came to win or lose, there was suddenly no place for him. He didn’t get the ball any more, was just standing at the edge of the playing field and lost the motivation to take part”. The last argument of a mother reveals an important topic. Even when participation in a regular sport program is working, which is rare enough, competition seems to be a fundamental problem. Including people with ID in a system where performance is the limiting factor seems to be a contradiction. A lot of sport groups take part in some kind of competitive league, and there are only a very small number of inclusive teams at this level.The arguments stated echo reports in the literature . MainstrThe 15 children with ID discussed the same topics as the parents. The answers were shorter but the general direction was comparable. The importance of sports was presented very impressively. Being active, training muscles, and getting in good shape were motivators on the physical side, along with the aspect of learning new skills and general health. “I love to do sports. I can strengthen my muscles during weight-lifting or get more stamina through running. It’s very healthy as well”.Despite being intrinsically motivated to do sports, support from significant others, like family, friends, and teachers, seems to be crucial in starting to be active for children with ID. This leads to the second topic of the focus group, the motivation to join the program. Some of the children did not really know what the program was about, but some were very well informed and gave their comments on it. A 15-year-old boy summarized it as follows: “My parents asked me if I want to try it. It’s about joining normal sport groups in normal clubs. Not only with other kids with limitations. I really would like to do it. I want to play handball, and that is not possible where I live, there is no club for me. And I want to find new friends in the club. Maybe there is someone who is living nearby”. The aim of finding friends, of getting into social contact, was often mentioned by the children (as with the parents). This touched on another motivation for doing sports in general. Besides the physical aspect (see above), the psycho-social benefits of doing things together and the wish of finding friends and getting into contact with kids of the same age without disabilities was very pronounced.Approximately half of the children (N = 7) talked about previous experiences with mainstream sport. The experiences were very similar to the statements of the parents. Even though some had positive memories of acting together in a team, most remember negative aspects like being left out or even bullied. The contact to the coaches was reported as insufficient. A girl of 11 years remembered her time in an equestrian group: “They laughed about me from the beginning. I was not as thin as the other girls and I was not as good as them. The coach was nice first but later on she asked me to look for another sport. My mum got into dispute with her and we never came back”. The children had very few specific wishes for the participation in the program. They were curious about the different sport groups and were hoping that the kids without disabilities were nice. All in all, it seems like the parents were the driving factor behind the participation of the children.The motivation of the participating children and parents is one important aspect in creating an inclusive sport setting. At least equally important is the view of the providers of the sport programs. The motivation to join the project was centered around social responsibility and the wish to foster inclusion and curiosity. The aim to promote physical activity for all, including people with ID, was seen as a central task for sport clubs. With their longtime experience in organizing physical activities for young and older people, sport clubs see themselves as an ideal player to enlarge this to people with ID.Another big issue was seen in promoting contact between children with and without disabilities as a central mission of inclusion. All these aspects were affirmed by the representatives, but this general attitude is not new of course. The concrete implementation and the ability to act as an inclusive club are considered desirable but the “know how” is missing. One interview partner admitted it like this: “I am very happy that [the author] asked us to take part in this project. I am thinking about including children with disabilities in our cubs for a long time. For me, this is a very important task. All areas of life should be open for everyone. But I have to be honest: I don’t really know, how this should work. I hope, we find ways in this project to open up our groups and our minds”.The clubs all had some experience with people with disabilities in their clubs, but mostly this concentrated on family members who join with their non-disabled parents or siblings more or less regularly. A special or adapted program did not exist, nor any inclusive groups with qualified coaches. So, not much was said about former experiences, but a lot of aspects were articulated when it came to expected barriers of the participation of the children with ID. In summary, there were two main concerns. One was the expectation that the coaches were not ready for leading inclusive groups. Some may have had a general fear or a negative attitude against people with ID, but this was seen as a minor problem, because the clubs are looking for personnel who are more open minded and positive.However, being open minded is not sufficient. The coaches need to know how to design activities that serve all participants. This is challenging, and becomes even more challenging if the group is very diverse. Being adequately trained and motivated is indispensable to offer a good program. All coaches work on a voluntary basis, so it is hard to put some pressure on them to qualify more and more. In addition, there is the problem that qualification programs are quite rare. The clubs do not really know about such programs, even if they do exist. However, they are mostly offered by the Disabled Sports Association, which is, at least in Germany, not so well connected to the general sports system. There is insufficient mutual exchange between the two systems.All clubs see these problems, but they all have positive expectations as well. They see the benefit of offering possibilities for social contact, physical activity, competition, and fun. Further, not to forget, there is a financial aspect as well. The acquisition of new members is an important factor, as the following statement shows: “Honestly, we have the same problems like everyone. Our members get older, and we have difficulties to recruit younger persons. Becoming a member in a sports club is not as attractive for the kids any more as it was 20 years ago. We have to look for new groups, we have to become more attractive, especially for young people. For me, inclusive groups are a big chance to increase the number of members. We excluded people with disabilities much too long, it’s time to change it. Not only for getting new members of course, but this is an important aspect as well. We can’t offer such a variety of programs without an adequate number of members”.Thirteen out of fifteen families stayed in the program for eight weeks. The children with ID took part in several activities, mostly finding one favorable sport program each. The parents’ satisfaction with the program was on a very high level. In the second focus group, the parents discussed the initial challenges and the solutions found by the program. Two main aspects were especially mentioned. The improvement in the motoric and psychological abilities of the children was the most important topic for them. A mother said: “I was skeptical at the beginning, I have to say. I was not sure if he [her 13-year-old son] would manage it. I was afraid that it could be too exhausting to train for a whole hour every week. But that was no problem at all. He improved so much in everything. Mostly his motivation to be active is much bigger now, that is great”.The second main aspect was the assistance of the students. They served as facilitators for both the families and the clubs. In the perception of the parents, this was the decisive point for the success of the whole program. On the one hand, this speaks for the program, but on the other hand, it shows which problems still occur, even in this structured setting. The clubs alone, with their existing structures and coaches, were not seen as qualified enough for meeting the demands of the children and the families. A father’s opinion shows this: “We as a family are very happy with the program. Our daughter was happy with her gymnastic group, all kids were very kind, the activity was well adapted and the coach was very affectionate. But it would have not worked without K [a student]. She was our fixed point. If there were any questions, she was there for our daughter and for us. She was the link between us and the club. She was there when we came to the club, she was there when we pick our daughter up after sport and gave us the feeling of being welcomed. For our daughter it is very important to have a permanent contact person. The coach can’t do this for all kids, her duty is in offering a good program, and she did. But all the little things around are so important as well”.Some parents argued that they would like to have some more feedback from the coaches on the development of their kids in the group. A potential improvement for the future was seen in a kind of parents’ education. Questions arose about how to transfer an active life in to the whole family and make physical activity a permanent part of their child’s life. Only four families signed membership forms to stay in the clubs for a longer time. The reasons were different, but two aspects were central. One was due to the program structure, the other more a logistic challenge. The present program was embedded in a university study, and this was noticed by the parents, of course, like the following statement shows: “I mean, it was a very good experience for our son and us. But it is a kind of artificial situation? All the supporting students and structures are fantastic. This won’t be there in the future, so we decided not to become new members in the club for now. He needs the support of this kind of facilitation. If they [the clubs] manage this, we will be back again”.The logistic aspect deals with a widely known problem. Getting to the clubs was not very easy for all families. The clubs are located around the city, but for some families, this meant long commutes. As the children are not able to use public transport on their own, the parents have to act as support persons. This was not manageable for some families. During the 8-week program, assistance was given by the facilitators, but as long as there are no persons responsible for this, this problem will be present.The children mostly focused on positive experiences during the program. The possibility to act in their favorable sports was very well appreciated. Eight of thirteen spoke about the fun they had in doing sports, and more than half of them reported that they found friends without disabilities in the groups. Only two children said that they had met these new friends outside the training.When asked about the most important aspect of the program, answers like “the variety of sports” , “contact with normal kids” , “chance to train my body” , and “the students”  were given. Negative aspects were mentioned more seldomly and concentrated on transport issues (comparable to the parents’ view) and, in two cases, on feelings of not being welcomed. A 9-year-old girl said: “Mostly I liked it. But in my group was another girl, who was mean to me. She didn’t want to play with me and said bad words. But the other kids and the coach were nice and told her to stop it”. Most of the children did not think about the time after the program. They did not care about membership or something similar. The short duration of the program was not clear for them, nor was the need to become a full member of the club to continue the sports program.The feedback of the clubs was a central, and new, aspect of the whole study, as not much is known about their experiences. All clubs were not familiar with this kind of inclusive settings but all saw the need and the responsibility to offer such groups. The eight-week program was basically judged very positively. All club representatives reported about positive feedback from most of their members and the coaches. The inclusion of the children with ID worked quite well in most of the cases, which was surprising for the clubs. A female club president said: “At the beginning, I was not sure if this will work. But I am surprised how well it worked. I think, the kids with ID had lots of fun, as well as our previous members. The atmosphere in the groups was very nice, and you could see what is so unique about doing sports: people with different abilities perform together on the same subject. Some are more capable than others, but that’s ok for all. In my opinion the team spirit was great”.However, there were some critical aspects as well, as can be seen from the following quote from a male general secretary of another club: “All in all I am happy, that we took part in the program. We just weren’t aware of this population I have to admit. It’s an absolute win for all, for the kids and for us as clubs as well. I really hope, this will work in the future. But there are still some aspects that I am concerned about. Some of the kids really need a lot of assistance. That worked well with the students, but without them? I can’t imagine, how the coaches or the other members of the group can handle this”. Again, the special role of the facilitators emerges. Without proper assistance, the inclusive groups will face several barriers, beginning with issues in the locker room and continuing with practical help during the physical activity. The given structure with one coach per group is not sufficient to meet the demands of the kids with ID nor the ones without in inclusive groups.The coaches gave their feedback to the club representatives in a similar manner. In their opinion, inclusive groups could only work when at least two prerequisites were fulfilled. First of all, the coaches asked for more qualification concerning disability and inclusion-orientated topics. The curriculum of the existing training of coaches does not cover this at all. Second, there have to be at least two persons in each group, preferably at least one with experience in people with special needs.The last big theme, which appeared from the thematic analysis, was the perception of the children without disability who trained together with the children with ID. At the beginning, the clubs were afraid that the previous members would have concerns about the inclusive group. Luckily, this was not the case. The sense of cohesion was quite high in all the groups, even if there was some mocking from time to time. It seems like the contact in the groups was perceived as a mutual favorable interaction, which is indispensable as is long known from contact theory . Doing sAll four club representatives want to continue to open their groups for all. Officially they already are, but practically, only a few persons with disability found their way into the clubs. Through participating in this program, the clubs were reinforced in investing more effort in member recruitment and promotion for this group. “We have to do more, the potential is huge. Maybe we should build cooperation with special services or special schools” was the idea of one of the interviewees.Our findings replicate the results of several earlier studies ,33. PareThat was different for the children. All were very excited and full of hope that participation in the program would work well. However, one has to take into account that half of the kids were not really informed about the content of the program, which again shows the dependency on the parents. Their experiences from previous mainstream sport activities were mixed with a focus on negative memories. Social interaction in team sports seemed to be especially critical, which confirms studies which have shown that inclusion is easier to reach in individual sports ,37. NoneThe clubs’ points of view provided insights on a little explored topic. Mainstream clubs play an important role in offering activities for all. In Germany, sport clubs are committed to offer equal participation for all people and break down barriers that prevent participation. They stand for an inclusive sports community that excludes no one. For this, they receive public financial support and are obliged to transform their programs into an inclusive direction. Up to now, this is mostly not fulfilled. Inclusive groups are still rare, and the distinction between a disabled and a non-disabled sports system is historically grown and still current . HoweverOverall, all stakeholders were very pleased to have participated. The majority of the children had great fun, parents were pleased with the improvements of and the care for the children, and the clubs gained worthful experiences for their future development. However, a more in-depth analysis of the statements also revealed critical aspects. The children for instance reported about the new friends they found in the groups. This positive aspect was somewhat diminished by the fact that these friendships were exclusively related to the time spent in the sports groups. This finding is in line with recent studies, which showed that the transition of positive interactivity into daily life is only rarely observable ,41. On tBesides all positive aspects, parents focused on one central aspect, which was, in their perception, the core element that has made the program successful. They felt the student facilitators did a great job, as they were troubleshooters, caretakers, coach-assistants, and much more. The parents were overwhelmed by the effort the students put in. This is how an inclusive offer can work, maybe must work. The participating children had special needs, some more, some less. Coaches alone are not able to fulfill these needs. Again, this has a positive and a negative side concerning the evaluation. The presence of the students was highly valued and the conditions were almost optimal. This could be a way sport (and other activities) should be organized to improve inclusive interactions which lead to positive experiences for all. The negative side is that this is not easily achieved. In a time-limited, university study, it can be manageable, but to the best of our knowledge, there are no studies dealing with a real-life scenario in mainstream sport. There are some studies in Physical Education (PE), which advocate co-teaching or the use of paraeducators, who work together with the PE teachers . AlthougThis leads to one of the critical aspects that the clubs mentioned. The training needs of the coaches and other professional staff in the clubs has to be improved. As the coaches are mostly working on a voluntarily basis, it is difficult to force them to get more qualifications. However, maybe that is not really the problem, as most of the coaches are willing to continue their education. But there are few possibilities to do so. Training for coaches is still very concentrated on sport-specific aspects and topics. Inclusion, heterogeneity, and disability are often not mentioned, or only as an additional not mandatory offer, at least in the German Olympic Sports Confederation, which is responsible for most of the training for sport coaches. A cooperation with sport organizations from the disability sector, like Special Olympics, and their experience with inclusive sport is only at the beginning at present. A further deepening of the cooperation would be desirable.Surprisingly for the club representatives, the attitude of the non-disabled members was no problem at all. At t1, concerns were made about the acceptance of the children with ID by the members and there was some fear of losing old members because of this. This did not happen. We did not ask the members, so we can only speculate about the reasons. Maybe kids at this age are really more open than older people, as has been proposed in several studies ,47,48. MFuture studies could address some limitations of the project. We considered all meanings, thoughts, and wishes from all stakeholders through our very open research approach. The result was a wide array of topics, which were structured through thematic analysis. Nevertheless, some aspects might have been under- or overestimated and repeating the study with other clubs and participants would be valuable. It was not our intention to examine a pre-post-design in a statistical way. The use of questionnaires and scales to measure satisfaction with the program in a more structured way could add some more information. In the present study, the focus was on understanding the processes and the stakeholder’s common experiences of inclusion. Specific outcomes or intra-group comparisons were not the focus of interest. However, this could and should be a topic for future research.Answering the question if the program was a success or not is difficult. Relying on the hard facts, may be disappointing. Only four new permanent members were recruited through the project. The parents still did not believe that mainstream clubs can satisfy the needs of their kids, or they did not feel comfortable with the current arrangements in the clubs: for instance, the qualification of coaches, accessibility of facilities, and transport problems. The implementation itself, on the other hand, was judged very good. It was very well appreciated by parents and the children that sport clubs offer caretaking as well as respect among all the participants with a strong reliance on the assistance for the facilitators and setting up of this special program.The clubs’ points of view are differentiated as well. They are aware of the things that have to be improved and that they are not as far forward as they wish to be. Inclusive sports require a lot of preparation and attention to create good programs, and the needs of all participants must be considered, which is a task for the club management. However, the experience of participating in this study has been an eye-opener for participating clubs. It remains to be hoped that they will transfer these experiences in future actions.This study, again, adds evidence that some form of co-teaching is essential. One coach on its own will only be successful with very much effort, which cannot be expected from persons who do this job on a voluntary basis. Professional staff, who are paid properly, would be a good possibility, even if this is more a wish than reality.


People with severe psychiatric disorders (SPD) who experience housing vulnerability have to negotiate discontinuous mental health care pathways including poor access to common rights services and an increased risk of incarceration. To reduce morbidity and improve social integration of these people, Médecins du Monde (NGO), in association with the Ministry of Justice and APHM, is piloting the experimentation of an alternative to prison through assertive community treatment (ACT) and independent housing for people with SPS without housing who are referred to the court for immediate appearance.The main objective is to evaluate the effectiveness of the innovative program (AILSI) compared to usual services by assessing the duration of re-incarceration at 18 months of follow up.The AILSI project has been certified as a Social Impact Bond, in which private investors support the program, with the guarantee that the French government will reimburse the investments if social impact outcomes are met. To measure the effectiveness and efficiency of the program, a randomized controlled study was designed: 100 patients will be included in the AILSI group (intervention) and 120 in the TAU group . Four social impact outcomes are identified: inclusion rate, signed leases rate, total length of re-incarceration and total resource use. It is a mixed quali-quanti research, which integrates a matching to administrative health and judicial databases.Inclusions are ongoing.The AILSI program and the research methods used are described herein. In addition, detailed information on the limitations and strengths of the SIB system are also discussed.No significant relationships.


Nannotrigona perilampoides and Frieseomelitta nigra. The results showed that some insecticides have a significant negative impact on the survival of stingless bees under laboratory conditions. These results suggest that stingless bees may be negatively affected when foraging flowers of crops that have been treated with insecticides.In the neotropics, stingless bees co-exist with plant pests in agroecosystems. The use of chemical insecticides used to control sap-sucking insects may pose a risk to the communities of stingless bees. To gain insight into the potential risk of insecticides commonly used for farmers in horticultural crops, we evaluated under laboratory conditions the effects of oral exposure to five insecticides on the survival of two species of stingless bees, Nannotrigona perilampoides and Frieseomelitta nigra. At field recommended doses, dinotefuran, imidacloprid, and flupyradifurone caused the highest mortality in both bee species. These insecticides also caused the largest decrease in the survival rate when exposed to a 10-fold dilution of the field recommended doses. Notably, dinotefuran exerted a high effect even at 100-fold dilution . In contrast, cyantraniliprole had a low effect and spirotetramat was virtually nontoxic. These results suggest that some insecticides used to control sap-sucking insects may have a significant negative impact on the communities of stingless bees.Insecticides used in agricultural pest management pose survival risks to the stingless bees that forage on crops in tropical and subtropical regions. In the present study, we evaluated, under laboratory conditions, the acute oral toxicity of five selected insecticides  to two species of neotropical stingless bees:  Nannotrigona perilampoides and Frieseomelitta nigra are efficient pollinators of peppers, tomatoes, and avocado [achiote” (Bixa orellana) and Jatropha curcas, used for the production of biofuel [Melipona beecheii pollinate achiote [Scaptotrigona pectoralis, and Trigona fulviventris pollinate chili peppers (Capsicum chinense) [Stingless bees (Hymenoptera: Meliponini) are important pollinators to wild and cultivated plants . In some avocado ,3,4, and biofuel ,6. Furthhinense) , which sIn the last couple of decades, a reduction in the richness and abundance of native stingless bees has been experienced, which has been associated with various factors, such as the anthropogenic disturbance and high dominance of the Africanized honeybee , the losIn intensively managed agroecosystems, stingless bees are exposed to a variety of chemical insecticides when foraging flowers ,13. In tNannotrigona perilampoides and Frieseomelitta nigra.To gain insight into the potential risks of insecticide use in horticultural crops, we evaluated under laboratory conditions the effects of oral exposure to dinotefuran, imidacloprid, flupyradifurone, spirotetramat, and cyantraniliprole to the survival of two species of stingless bees, N. perilampoides and F. nigra were maintained in wooden hives in the field (five hives per bee species) and allowed to forage naturally. The vegetation surrounding the hives included Piscidia piscipula, Leucaena leucocephala, Tithonia diversifolia, and Parthenium hysterophorus. In the feeding zone of the stingless bees, the absence of agricultural crops under the application of agrochemicals was verified. Additionally, twice a week, 10 mL of a 50% sucrose solution (1 g of sucrose: 1 mL of distilled water) was provided to each hive as a diet source.The research was carried out at the Tecnológico Nacional de México, Campus Conkal, at Conkal, Yucatán, Mexico. The colonies of Bemisia tabaci). From these field recommended doses, 10-fold and 100-fold dilutions were prepared for the experiment of survival analysis.The commercial formulations of the insecticides were purchased from local agrochemical suppliers. All the insecticides evaluated  are reco2 section of organza mesh was fixed to the side of the bottle to facilitate the air exchange. In the middle part of the bottle (the organza mesh section) we placed a microtube (1.5 mL) for food supply, which consisted of sucrose solution (sucrose/water 1:1) ad libitum. To minimize the stress caused by confinement, prior to the bioassays the bees remained in adaptation for approximately 12 h (one night and part of the next morning) at room conditions, 25 °C and 70% R.H. Groups of 10 foragers were collected from the entrance of the hives of the stingless bees. Each group, obtained from a different hive, was placed in a plastic bottle (500 mL) with filter paper on the bottom and a 20 cmThe oral acute toxicity test was conducted in adult foragers as described by Botina et al. . Prior tp < 0.05. The normality and homoscedasticity of the data were confirmed prior to their analysis. Survival curves were obtained with the Kaplan–Meier estimators, which were generated from the percentage of mortality of bees over 2, 4, and 24 h evaluation periods with 10-fold and 100-fold dilution of the insecticides. The estimated survival functions were compared with a nonparametric Log-Rank test (Holm–Sidak method). All the statistical analyses were performed using the SigmaPlot 11.0 software .Analysis of variance (ANOVA) was used to compare the mortality caused by the field recommended doses of the insecticides over 24 h. Comparison of means was carried out with Tukey post hoc test at N. perilampoides  and F. nigra . In both bee species, dinotefuran, imidacloprid, and flupyradifurone were the most toxic. Bee mortality ranged from 90–100% when exposed to dinotefuran and imidacloprid, and from 75–90% when exposed to flupyradifurone , flupyradifurone and dinotefuran caused significant decreases in the survival rates: the highest effect was produced by dinotefuran , while cyantraniliprole, spirotetramat, and imidacloprid had no effect  dinotefuran produced a complete depletion of the survival rate . The other insecticides  had no effect , which may indicate that this insecticide would be even more toxic to stingless bees, given their high susceptibility to insecticides [Here, we observed that at field recommended doses, dinotefuran, imidacloprid, and flupyradifurone (nAChR-acting insecticides) exerted the strongest lethal effects in both bee species. For dinotefuran and imidacloprid, a dramatic decrease in the survival rate  was observed as quickly as 4 h after exposure to the 10-fold dilution of the field recommended doses. Moreover, we observed that even at 100-fold dilution, dinotefuran was able to dramatically deplete the bee survival rate . In this sense, previous studies have shown that nAChR-acting insecticides are highly toxic to various species of bees ,24,25, acticides ,28. −1), another anthranilic diamide compound, affects the flight activity of Partamona helleri and Scaptotrigona xanthotrica. In Apis mellifera, compounds from this group of insecticides have moderate effects when applied topically [The anthranilic diamide, cyantraniliprole, showed low to moderate toxicity to both species of bees at the 10-fold dilution, but had no effect at all at the 100-fold dilution. To our knowledge, this insecticide has not been previously evaluated on stingless bees. However, Tomé et al.  found thopically . In agriopically ,31,32,33opically , but witopically ,36. Thisopically . It is rA. mellifera [Apis cerana, Apis florea, and Trigona iridipennis [The cyclic keto-enol, spirotetramat, had no acute oral effects on both species of stingless bees. Spirotetramat has been recommended to control both immature and adult stages of phytophagous mites ,39, and ellifera ,44, and N. perilampoides and F. nigra to the nAChR-acting insecticides dinotefuran, imidacloprid, and flupyradifurone, negatively impacted their survival rate. Even at a low concentration (100-fold of the recommended application rate), dinotefuran produced a dramatic impact on bee survival, whereas insecticides that act on ryanodine receptors (cyantraniliprole) or inhibit lipid biosynthesis (spirotetramat) caused moderate and nontoxic acute effects, respectively. The results show that the intensive use of the nAChR-acting insecticides  to control sap-sucking insects in horticultural crops poses a threat to the communities of neotropical stingless bees that forage in the area. It is important to evaluate the impact of these insecticides on the expression of genes involved in metabolic pathways as well as to evaluate the epigenetic changes after long term exposure, in order to gain insight on the effects of these insecticides at physiological and molecular levels in stingless bees. The acute oral exposure of