To describe changes in physical performance and patient-reported outcomes in cancer survivors who participated in an exercise program as part of usual-care multidisciplinary rehabilitation and the influence of training adaptations during the coronavirus-19 (COVID-19) pandemic.2peak), peak work rate during a steep ramp test (SRT-WRpeak), 6-min walking distance, muscle strength) and patient-reported outcomes  were assessed between the start and the end of the exercise program. Linear regression analysis, adjusting for baseline levels of outcomes, was used to investigate differences in changes in outcomes between participants who underwent the original and the adapted program.In an observational cohort study, cancer survivors underwent usual-care multidisciplinary rehabilitation including a 10-week exercise program. During the COVID-19 pandemic, the exercise program was adapted with reduced training time and frequency. Mean changes and 95% confidence intervals in physical performance  and upper body muscle strength (− 10.8%) after participation in the adapted compared to the original program. No significant between-group differences were observed for other outcomes.All outcomes statistically significantly improved over time, regardless of adaptations in the exercise program. VOPhysical performance and patient-reported outcomes statistically and clinically significantly improved in cancer survivors who participated in an exercise program as part of usual-care multidisciplinary rehabilitation. Improvements of performance outcomes were smaller since the training adaptations, though only significant for SRT-WRpeak and upper body strength. Over the last decades, aging and improved diagnostics and treatment modalities have led to an increased number of cancer survivors. In 2018, approximately 50 million people worldwide were living with or beyond cancer .Research in the field of cancer survivorship care expanded in the past decades, and growing evidence emerged for the positive effects of exercise on the aforementioned side effects –10. For While most studies focus on exercise interventions alone, multidisciplinary rehabilitation programs may better address the complex needs of patients with cancer . Dutch cIn recent exercise guidelines, the majority of available evidence on the efficacy of oncology rehabilitation is derived from randomized controlled trials (RCTs). RCTs have strengthened the body of proof for the efficacy of exercise in cancer rehabilitation, but have been reported to lack generalizability to the clinical setting , 16. PatIn this observational study, we present data about physical performance and patient-reported outcomes in cancer survivors who participated in an exercise program as part of multidisciplinary rehabilitation between February 2019 and March 2021. Due to the coronavirus 2019 (COVID-19) pandemic, social distance policies and disruption of outpatient clinic care led to changes in the content of the training and a reduction in the training time and frequency. Therefore, this study had the following objectives:The primary objective of this study was to describe changes in aerobic capacity, muscle strength, HRQoL, fatigue, and anxiety and depression in cancer survivors who participated in a 10-week exercise program as part of usual-care multidisciplinary rehabilitation.The secondary objective was to compare changes in outcomes between the group of participants that followed the original program and the group of participants that followed an adapted exercise program, due to COVID-19 measures.Participants were recruited from the multidisciplinary rehabilitation program at the Department of Physical Therapy of the Maastricht University Medical Centre (MUMC +) between February 2019 and March 2021. Patients participating in the program were asked for consent to use their exercise rehabilitation data. Patients who signed informed consent were included in the study. Participants were excluded if they were unable to follow the training program as intended. Patients were eligible for the program when they were ≥ 18 years, completed active medical treatment  and were suffering from physical, and/or psychosocial complaints and/or chronic fatigue. Contraindications for participation in the rehabilitation program were the inability to perform basic activities of daily living and the presence of disabling comorbidities that seriously hamper physical exercise.This study was a prospective, longitudinal observational cohort study and all data were collected during usual-care multidisciplinary oncology rehabilitation at the MUMC + . Study procedures complied with the Declaration of Helsinki and were approved by the Medical Ethics Committee of the Maastricht UMC + with registration number 2018–0648.Participants completed a 10-week supervised, group-based exercise program. The exercise program consisted of two training sessions weekly, both starting with 1 h of combined resistance and endurance training, followed by a 30-min break and, subsequently, 30 min of varying sports activities in the gym or swimming pool. In addition, participants took part in at least one of the following interventions: a psychoeducational intervention  guided by the psychologist or the social worker; fatigue management courses  guided by the occupational therapist; return-to-work counselling  guided by the occupational therapist; and dietary counselling  delivered by the dietician. These additional programs were provided (partly) in parallel with the exercise program. Participants completed exercise tests and questionnaires before the start of the exercise program (T = 0) and in the week after completing the exercise program (T = 1). Of note is that some of the other interventions were not finished yet at T = 1.A cardiopulmonary exercise test (CPET) was performed as part of usual-care, to screen for cardiopulmonary contraindications to exercise and to determine aerobic capacity. The CPET was conducted on a cycle ergometer  as described previously . After a2) and the respiratory exchange rate at WRpeak  were averaged over 30 s. An improvement in VO2peak of 1.0 mL/min/kg was found to be associated with a 9% risk reduction in all-cause mortality and was therefore considered a clinically relevant improvement [2 at the ventilatory anaerobic threshold (VO2VAT) was determined using the “V-slope” method [2 at the respiratory compensation point (VO2RCP) was determined using the ventilatory equivalents method and the minute ventilation/carbon dioxide production (VE/VCO2) slope [2VAT and VO2RCP was determined previously, when two researchers at Maastricht UMC + both analyzed 48 tests (partly from the current study) independently. This resulted in an intraclass correlation coefficient (ICC) of 0.95  0.90–0.97) for determination of the VO2VAT and an ICC of 0.99 (95% CI 0.98–0.99) for determination of the VO2RCP, which indicates an excellent interrater reliability. The oxygen uptake efficiency slope (OUES) was derived from the relation between VO2 and minute ventilation, using the following formula: VO2 = (a × Log VE) + b, where a is the OUES [CPET results were analyzed by a trained researcher who was blinded for the moment of testing (T = 0 or T = 1), using a standardized protocol. Values of  oxygen uptake (VOrovement . Submaxi” method  and the ” method . The VO22) slope . The intIn addition, patients performed a 6-min walk test (6MWT) and a steep ramp test (SRT). These tests also gave an indication of aerobic capacity and were performed as part of the usual-care rehabilitation program, to determine baseline training intensity. During the 6MWT, participants were instructed to walk as many meters as possible, on a marked 44-m course, within 6 min. Based on the minimal clinically important difference (MCID) of the 6MWT in adults with pathology, a change in the maximal walking distance of 30.5 m was considered clinically relevant . The SRTLower and upper body muscle strength was measured during submaximal repetition maximum (RM) tests on the leg press and chest press machine, respectively. The 5-RM was estimated for both exercises and the participant was asked to perform the maximum achievable number of repetitions up to five repetitions with this weight. When five repetitions were reached, the weight was increased and participants repeated the exercise after a 1-min pause until they no longer reached 5 repetitions. True 1-RM values were calculated afterwards using the Brzycki equation . In MarcHRQoL was measured using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 (EORTC QLQ-C30). Each of the 30 item has to be rated on a scale from 1 to 4 and for two items from 1 to 7. This questionnaire distinguishes 15 subscales. The functioning scales , the global QoL scale, and a functioning sum score  were calculated. Sub-scores as well as sum scores were linearly transformed on a 100-point scale, with higher scores indicating higher levels of HRQoL , 27. A cFatigue was assessed using the Multidimensional Fatigue Inventory-20 (MFI-20), which is a 20-item questionnaire with a five-dimensional structure . Each item is scored on a 5-point Likert scale. The sub-scores range from 4 to 20, with lower scores indicating lower levels of fatigue. The sum score was calculated by adding up the sub-scores . ChangesAnxiety and depression were assessed using the 14-item Hospital Anxiety and Depression Scale (HADS). Items are scored on a 4-point scale and sub-scores for anxiety and for depression range from 0 to 21, with lower scores indicating lower levels of anxiety and depression. The sum score was calculated by adding up the sub-scores . A changAge, cancer type, presence of metastasis and comorbidities, treatment type, and time since treatment at T = 0 were extracted from medical records. Height and weight were measured at T = 0 and T = 1, after which body mass index (BMI) was calculated. The training compliance (%) was calculated by dividing the number of training sessions that participants attended, by the number of planned training sessions, multiplied by 100. Indication for other interventions in the rehabilitation program and completion rates of these therapies at T = 1 were reported as well.Participants performed four strengthening exercises each session, targeting large muscle groups of the upper and lower body, and core. Resistance training consisted of three sets of 8–12 repetitions and training intensity was set at 60% of the participant’s initial 1-RM. Endurance training in the first training session of the week consisted of 20-min walking on a treadmill, with a walking speed of 80% of their mean speed in the baseline 6-MWT. In the other training session, participants performed two sets of 10 min of interval training on a cycle ergometer, one set before and one after the resistance training program. Intervals were performed for 30 and 60 s at 65% and 30% of the participant’s SRT-WRpeak, respectively . The traThe rehabilitation program was interrupted between March 2020 and July 2020, because all outpatient activities were cancelled in that time frame, due to COVID-19 measures. Rehabilitation data of participants who were enrolled in the exercise program prior to this period and did not finish yet were excluded from this study because measurements at T = 1 were cancelled or postponed. In July 2020, national guidelines permitted resumption of the rehabilitation program. Because of the social distancing policies, exercise training took place in smaller groups of four instead of eight patients. In order to avoid a long waiting list, the training frequency was reduced to once weekly. Because there was only one training session weekly, endurance training was changed to 10-min walking and 10-min cycling in one session. Intensity of the endurance training remained the same. Contact sports and swimming were not allowed, so patients could only perform the endurance and resistance training program. For participants who were recruited from July 2020 onwards, the frequency, time, and type of exercise training changed. However, we encouraged all participants to be physically active on other weekdays and to perform body weight strengthening exercises at home once to twice weekly. Online instructions for a home-based program with strengthening exercises were offered to all participants. Other interventions of the rehabilitation program took place in smaller groups as well, or via phone calls.n) and percentages (%). Performance- and patient-reported outcomes are reported for the group of participants that completed the original exercise program and the participants who completed the adapted program since COVID-19. Outcomes are reported for measurements at T = 0 and at T = 1. Mean changes between T = 0 and T = 1 in outcome variables within individuals are reported with 95% CI. Mean differences (and 95% CI) in change scores between participants who underwent the original program and the adapted program were estimated using linear regression analysis, with the change scores as outcome, a group variable  as dependent variable, and additional adjustment for the absolute values of the outcomes at T = 0. Differences between changes in muscle strength were reported as percentages as well, to account for possible differences in baseline values due to the change of the exercise machine during the study. If the confidence intervals did not include zero, the mean change or difference in change was considered statistically significant. MCIDs are reported when they were available in literature. Changes were considered clinically relevant when they exceeded MCIDs. Statistical analyses were performed using SPSS version 25.0 .Continuous variables were checked for normality using histograms and Q-Q plots and are presented as mean ± SD or median and interquartile ranges, as appropriate. Categorical variables are presented as frequencies . This resulted in a final sample size of 185 subjects. Seventy-four and 62 participants completed the original exercise program and the adapted program since the COVID-19 pandemic, respectively. Twelve (11.0%) and 14 (18.4%) participants were unable to complete the original and the adapted exercise program due to medical or other reasons, respectively. Twenty-three out of 109 (21.1%) participants were lost to follow-up due to COVID-19 . Subjects started with the exercise program on average 4.7 ± 4.4 months after completing active medical treatment. Patient characteristics were not significantly different between groups  were women. Mean age was 55.7 ± 11.5 years and mean BMI was 27.9 ± 5.3 kg/mThe training compliance rate was 93.7 ± 7.7% and 91.37 ± 11.8% in participants who completed the original and the adapted program, respectively. The percentage of indication for other interventions and their completion rates at T = 1 did not differ notably between the groups, but the other interventions were often not completed yet at T = 1 Table .Table 2P2peak was observed after participation in the original and the adapted program, respectively  and 1.4 mL/kg/min (7.2%) in VOly Table . PatientFor nearly all performance outcomes, changes over time were more pronounced before the adaptations in the program, albeit only statistically significantly different for SRT-WRpeak and upper body strength. Mean upper body strength improved with 48.5% in participants who took part in the original program and with 21.5% in participants who took part in the adapted program. Mean improvement in SRT-WRpeak improved with 0.36 W/kg (CI 0.28–0.44) or 11.5% in participants in the original program and 0.23 (CI 0.14–0.32) W/kg or 7.6% in participants in the adapted program since COVID-19  in mean VO2peak was observed [2peak found in the current study might be explained by a lower training frequency. Moreover, the moderate- to high-intensity training prescribed in the current study was potentially not always reached due to limited adherence of training intensity. Finally, the training intensity in the current study was based on baseline performance tests and perceived exertion. Training frequency, type, and time were equal for all participants and could be more personalized in the future.The results of this study showed significant improvements in aerobic capacity, muscle strength, HRQoL, fatigue, anxiety, and depression in cancer survivors following a 10-week exercise program as part of usual-care multidisciplinary oncology rehabilitation. Changes were clinically relevant for nearly all outcomes; MCIDs were not available in literature for 1-RM leg press, submaximal outcomes of CPET, and for the sum score of the HADS. For SRT-WRpeak, only the minimal detectable change was available, which was therefore used to compare our study results with. A significant and clinically relevant improvement in VOobserved . The low2peak, which was attributed to issues with exercise prescriptions, which are often not well-reported in trials [Another plausible explanation for this inconsistency is the fact that Scott et al. only included RCTs in the meta analyses, which might have resulted in a fitter population , 16. Besn trials . In bothIn our study, a significant improvement in HRQoL was seen after participation in the original program (sum score EORTC-QLQ-C30 + 12.48) and the adapted program (sum score EORTC-QLQ-C30 + 16.00). Comparable improvements were seen in a study on the effectiveness of a 12-week, multidisciplinary rehabilitation program in breast cancer patients (sum score EORTC-QLQ-C30 + 11.67) . HoweverIn this study, we also compared changes in outcomes between participants who exercised twice weekly in the original program and participants who exercised once weekly due to changes in the program since the COVID-19 pandemic. Significant between-group differences were observed for SRT-WRpeak and upper body muscle strength, with larger improvements for the group that participated in the original program. This is not surprising, because participants in this group attended the exercise training twice weekly. When looking at changes in the other performance outcomes, non-significant differences were seen between groups, with larger improvements for the group in the original program. Attention for habitual physical activity guidelines may have increased when training frequency and time were diminished since COVID-19. Consequently, participants may have been more active outside the training program since the training adaptations, which could have reduced the expected difference in training improvements. No significant between-group differences were seen for patient-reported outcomes. Unexpectedly, improvements in HRQoL did not decrease under the circumstances of the COVID-19 pandemic . This could have been due to a “response shift”, referring to changes in internal standards and values during a crisis . This st2peak of 0.2 mL/kg/min was seen in patients with cancer who received no exercise intervention. The fact that participants took part in interventions other than the exercise training during this study could be seen as a limitation as well. Although patient-reported outcomes may have been influenced by other interventions than the exercise interventions alone , these interventions were less likely to have influenced performance outcomes since they did not contain exercise elements. Further of note is that this study was aimed at investigating cancer patients with both physical and psychosocial complaints and/or chronic fatigue. Therefore, the findings of the current study cannot be generalized to all cancer survivors.A strength of this study was the observational design and the fact that data was collected during daily practice. The results might give a more realistic reflection of the physical and psychosocial changes after an oncology rehabilitation program, when compared to RCTs with strict inclusion criteria, in an experimental setting , 16. AnoThe results of this study indicate that cancer survivors with both physical and psychosocial complaints significantly improve in aerobic capacity, muscle strength, HRQoL, fatigue, anxiety, and depression during a 10-week supervised, group-based exercise program as part of usual-care multidisciplinary oncology rehabilitation. Reductions in frequency, time, and type of training during the COVID-19 pandemic still resulted in significant improvements of all outcomes. However, improvements of most performance outcomes appeared to be smaller since the training adaptations, though only significant for SRT-WRpeak and upper body strength.


OPEN is a structured intervention program for patients who present with untreated psychosis at an early stage, under the guidance of a case manager and a periodic evaluation performed by a multidisciplinary team.The aim of the OPEN program is to create an individual care plan, promoting recovery, functionality, quality of life and prevent relapses. One year after implementation of the program, we present the first results.We performed a retrospective review of the patients’ clinical profiles included in the OPEN program.th month assessment, 4 in 5 patients showed an improvement in social functioning , and a decrease in symptom severity in all . Due to COVID-19 pandemics, group interventions were suspended, and some visits were performed by teleconsultation. No patients lost follow-up.Nine patients were included in the program. The most frequent diagnosis was schizophrenia (n=5). By the time of inclusion in the program, 5 patients used cannabis frequently; one patient kept substance use. At the 6We observed an overall positive result of the first months of this program, regarding both functionality and clinical outcomes. The main obstacle so far is the impossibility of performing group interventions since the start of the contingency measures regarding COVID-19 pandemics. We expect further results of the OPEN program with the inclusion of more patients.


The authors aimed to determine if Project Extension for Community Healthcare Outcomes (ECHO), a health-education model utilising teleconferencing technology, improves the capacity of clinicians in assessing and managing complex psychiatric patients.Three pilot Project ECHO programs were evaluated as a prospective waitlist-controlled trial, focusing on Adult Eating Disorders, Adult Intellectual Disability Mental Health, and General Mental Health. Each program comprised 9–10 weekly teleconferencing group sessions. Participants and waitlist-controls completed pre- and post-program surveys. The primary outcomes were self-reported knowledge and confidence in assessing and managing complex patients relevant to each group. Linear mixed models were used to assess the group-by-time interaction, or change over time, as appropriate.n = 21), there were statistically significant improvements in self-reported knowledge and confidence for all topics amongst participants of the Adult Eating Disorders program (n = 44). In the Adult Intellectual Disability Mental Health program, there were significant improvements in self-reported knowledge and confidence amongst participants (n = 67) for most topics compared to controls (n = 21). There were no waitlist-controls for the General Mental Health program, but within-group analysis (n = 28) showed significant improvements in participants’ knowledge and confidence following program completion, compared to baseline.Between July 2020 and June 2021, three series of the Adult Intellectual Disability Mental Health program, two series of the Adult Eating Disorders program, and two series of the General Mental Health program were delivered. Compared to waitlist-controls (Project ECHO is a feasible and effective model to develop workforce capacity in managing complex psychiatric conditions. The mental health needs of adults with complex disorders are frequently under-recognised and undertreated, including those with an eating disorder  and thosEating disorders are serious and complex mental disorders associated with a high level of morbidity and mortality as well as significant socio-economic costs . AccordiSimilarly, adults living with an intellectual disability have substantial unmet mental health needs. Close to half a million people in Australia are living with an intellectual disability, and it is estimated that more than half of this population have a comorbid psychiatric disorder . DespiteAccording to the 2007 National Survey of Mental Health and Wellbeing, 45% of adult Australians had experienced a mental disorder at some point in their lives, including 20% (3.2 million) who had experienced a mental disorder in the last 12 months [Project Extension for Community Healthcare Outcomes (ECHO) is an internationally recognised program developed by the University of New Mexico . It is aProject ECHO has been trialled in at least 59 countries in various settings . ResearcSydney Local Health District (SLHD) launched three pilot programs for Project ECHO in the latter half of 2020 with two programs run by state-wide expert mental health teams specialising in Adult Eating Disorders and Adult Intellectual Disability Mental Health, as well as a General Mental Health program targeted at clinicians in primary care with an emphasis on cardiometabolic health. The use of the Project ECHO model is relatively new in the Australian context, thus evaluating the efficacy of these programs is an important contribution to the local evidence base. Furthermore, no other Australian ECHO program at present focuses on upskilling clinicians in the management of adults with complex mental health conditions. The current global pandemic and associated increase in the use of teleconferencing technology for clinician education also contributes to the timeliness of programs such as this. We aimed to evaluate whether these ECHO programs increased clinician knowledge of the speciality area and enhanced their confidence in providing specialist care directly to patients in their own practice.The three ECHO teams developed the curricula by identifying key learning needs of potential participants through needs assessment surveys. Each needs assessment survey included 20 potential topics that were developed by the team of specialist clinicians for each Hub and were distributed through relevant networks to reach the anticipated participants of each program. Survey respondents were asked for basic demographic information (profession and service setting), and then asked to rate their interest and confidence for each proposed topic based on a 5-point Likert scale — from ‘not at all interested’ to ‘very interested’, and from ‘not at all confident’ to ‘very confident’. The final didactic lecture topics thus reflected the learning needs of health care providers and health needs of their patients based on the topics that participants rated most frequently of high interest and low confidence, as reviewed and finalised by expert consensus amongst the Hub team members. The final didactic lecture topics for each ECHO program are available from the corresponding author on reasonable request. There were some minor changes between series, particularly for the Adult Intellectual Disability Mental Health program, to reflect evolving feedback.The Project ECHO Adult Eating Disorders program was run by the New South Wales (NSW) Eating Disorders Outreach Service, which provides clinical consultation and support, and education and training to government- or state-employed clinicians managing adults with eating disorders across NSW. The program was designed to increase the specialist knowledge and expertise in managing adults with eating disorders. The primary audience were government- or state-employed clinicians across NSW. The program was also open to primary health care providers who provide care to adults with eating disorders. In 2020, the program ran two series .The Project ECHO Adult Intellectual Disability Mental Health program was run by the Statewide Intellectual Disability Mental Health Outreach Service, which aims to support the provision of quality mental health care to adults with an intellectual disability and build clinician capacity throughout NSW. This program provided training opportunities to government- or state-employed clinicians, primary care, and the National Disability Insurance Scheme provider sector across NSW. The program ran two series in 2020 and one series in 2021 .The Project ECHO General Mental Health program was run by the SLHD Mental Health Service. The program aims to support primary health care providers to build capacity in the treatment and management of people with severe and enduring mental illness. There is a focus on cardiometabolic risk and complex psychopharmacology. This program targeted primary health care providers across NSW, but especially providers in inner Sydney who support people with mental health conditions. The program was particularly intended for general practitioners, practice nurses, and allied health clinicians from the primary care sector. The program ran one series in 2020 and one series in 2021 .We implemented a prospective waitlist-controlled evaluation of the three Project ECHO programs. All participants provided informed consent. This study was approved by the SLHD Human Research Ethics Committee – Concord Repatriation General Hospital (2020/ETH00629).Clinicians who registered to participate in a Project ECHO SLHD program during the period July 2020–June 2021 were invited to participate in the evaluation. To be eligible to participate in a program, a clinician must be a health professional who provides care to adults with an eating disorder, intellectual disability, or other complex mental health issues. This included government- or state-employed medical, nursing, and allied health staff; clinicians working in private practice including general practitioners; or clinicians working for other non-government organisations.The first series of the Adult Eating Disorders and Adult Intellectual Disability Mental Health programs aimed to have ~20 participants in attendance at each session as a pilot. Given the demand for the programs, the target was thereafter increased to ~50 participants for subsequent series across all three programs. Waitlisted clinicians included those who had registered their interest for a program but were unable to participate due to group limits being reached or their personal unavailability. These waitlisted individuals were invited to form the waitlist control group. At the end of the waitlist period, they were offered to enrol in the next series of their preferred ECHO program. The potential size of the waitlist control group was thus dependent on the number of clinicians who registered their interest above the group limit for each series or who were unavailable to participate in the current series. The waitlisted clinicians were included in this evaluation as a control group to allow comparison between groups in real time. If the group limit was not reached, the intervention group was optimised and there was no control group. In this case, the analyses were limited to within-group pre- and post-intervention comparisons.The surveys were based on Moore’s widely accepted conceptual framework to evaluate continuing medical education, which has been used to evaluate Project ECHO programs internationally . Moore’sSurveys were administered to all ECHO participants and waitlist controls within the week prior to the commencement of a program (pre-survey) and re-administered for completion within 2 weeks of the program completion (post-survey). Surveys were developed by expert consensus for the respective Hubs and administered to participants online via REDCap . The prep-value of < 0.05 was considered statistically significant.The data were analysed using Microsoft Excel 2016 , SPSS Statistics version 26 , and RStudio 1.4.1717 . Data on participation, participant satisfaction, and self-reported knowledge and confidence were pooled into one group for the two Adult Eating Disorders series, another group for the three Adult Intellectual Disability Mental Health series, and a third group for the two General Mental Health series, respectively, to optimise the sample size for the analyses for each program. The data are presented as frequencies with percentage (participant demographic and satisfaction variables) and means with standard deviation (knowledge and confidence variables). Comparisons were made for self-reported knowledge and confidence for each topic assessed in the surveys, as well as the mean of all topics. Linear mixed models (LMMs) were used to assess the group (ECHO participants vs. waitlist controls) by time interaction for the Adult Eating Disorders and Adult Intellectual Disability Mental Health programs. For the General Mental Health program, there were no waitlist controls so LMMs were used to assess the change scores amongst participants only. LMM accounts for the expected correlation between pre- and post-scores within subjects while also providing improved statistical power by using all data (including participants and controls who only completed one of the two surveys) . A sub-aDuring the evaluation period (July 2020–June 2021), a total of 243 people registered for one of the Project ECHO SLHD programs. Of these, 40 people (16%) did not attend any sessions and 10 people (4%) withdrew during the program. The other 193 people (79%) were considered active participants for the duration of the program. There was a mean attendance rate of 71% per session. Table Amongst the 193 participants, 109 participants (56%) were government or state employees and 84 participants (44%) worked in general practices, private practices, non-government services, and the National Disability Insurance Scheme sector. There was strong penetration throughout NSW, with 118 participants working in metropolitan areas, 74 participants working in rural and regional NSW, and one participant working in a state-wide role.The professions represented in each program Table  reflect For the Adult Eating Disorders program and the Adult Intellectual Disability Mental Health program, there were no statistically significant differences in age, profession, primary practice location, or previous relevant training between the ECHO participants and the respective waitlist controls (detailed results are available from the corresponding author on reasonable request). There were no waitlist controls for the General Mental Health program.n = 21), participants of the Adult Eating Disorders program reported a statistically significant improvement in knowledge and confidence for all seven topics assessed  responded to the pre-program evaluation survey and 24 (43%) responded to the post-program evaluation, with a total of 44 participants included in the LMM. Compared to waitlist controls (n = 21), participants reported statistically significant improvements in nine of twelve topics for knowledge and in eight of twelve topics for confidence  responded to the pre-program survey and 40 (40%) responded to the post-program survey, with a total of 67 participants included in the LMM. Compared to waitlist controls (ce Table . Those wn = 26) with post-program responses (n = 16)  Table . Statistn = 80). Of these, 94% agreed that the didactic lectures increased their knowledge and that the case presentations were a helpful learning experience. Seventy-seven participants (96%) thought that the community of practice provided by the ECHO groups was helpful, and 88% agreed that participation in an ECHO program improved their access to specialist clinicians. Additionally, 94% of respondents agreed that they would recommend the program to other clinicians. Full details of participant satisfaction ratings for each program are in Table Across the three programs, there was a high level of satisfaction amongst the participants who responded to our post-program surveys (The current study demonstrates the feasibility and utility of Project ECHO programs for clinicians working with adults with complex psychiatric comorbidities. Participants of diverse professional backgrounds reported significantly increased knowledge and confidence in working with their respective cohorts; these findings were replicated in participants working with clinically distinct patients and made in comparison to waitlist-control groups where available. A range of professions and service settings were represented. The ECHO programs were overall well received, with a high level of satisfaction recorded.The results of the pilot Adult Eating Disorders program support the utility of the ECHO model in the delivery of the NSW Eating Disorders Outreach Service. To date, there has only been one other publication reporting on the use of the ECHO model in upskilling clinicians in the assessment and management of patients with eating disorders . SimilarLikewise, the results of the pilot Adult Intellectual Disability Mental Health program support the utility of the ECHO model in addressing some of the gaps in the health inequity experienced by adults with an intellectual disability , 11, incThere were no waitlist controls for the two series of the General Mental Health program, and the pre-post comparisons were limited by the low number of responses to the post-program survey and as such, limit the applicability of these findings. Previous publications of ECHO programs targeted at primary care clinicians in India , 32 and There are several limitations to the current evaluation which should be considered. Firstly, it should be stated from the outset that the sample size for each group is relatively small and so results should be interpreted with caution. This is reflective of a particularly low response rate to the post-program surveys, although completers and non-completers did not significantly differ, and sub-analyses were performed which largely supported the primary results. This degree of attrition is in keeping with what could be expected with respect to longitudinal studies . MoreoveSecondly, the pre- and post-program evaluation surveys used to evaluate the efficacy of these pilot programs have not been validated. Given the absence of existing standardised tools in the literature that were adaptable, the surveys were developed by expert consensus specific to the curriculum content and our study aims. Though statistically significant improvements were observed in participants’ self-reported knowledge and confidence compared to waitlist controls, as rated on a 5-point Likert scale, the magnitude of the clinical significance of these changes requires further evaluation. Thirdly, the evaluation of these pilot ECHO programs was limited to the first four levels of Moore’s framework, that is, participation, satisfaction, knowledge, and confidence/competence . FurtherFuture evaluations of Project ECHO programs should focus on objective assessment of knowledge and confidence, as well as the higher levels of Moore’s framework, including behaviour change amongst clinician participants, patient-level outcomes, and system- or community-level outcomes . GloballNonetheless, the success of these pilot programs supports the Project ECHO model as a potential tool for increasing the capacity of the workforce to care for people with complex mental health needs in community-based settings, reducing the number of people being undertreated and/or alleviating the potential bottleneck of referrals to specialist services. Identifying effective methods such as these to improve care will strengthen the response to the increasing demands for mental health care in Australia and beyond. Overall, the findings are in keeping with the success of Project ECHO programs internationally , 17. TheIn conclusion, these pilot programs demonstrate the feasibility for Project ECHO implementation in managing complex psychiatric conditions. Based on these promising results, it would be reasonable to consider that the Project ECHO implementation could be transferable to a broad range of psychiatric conditions, with the aim of providing education and training to clinicians in the management of adults with complex mental disorders. This may be particularly relevant now during a global pandemic and beyond, as health education is having to fast adapt to online mediums. Our findings suggest that Project ECHO is implementable and a model conducive to capacity building even in this challenging context.


An atypical BCR::ABL1 fusion gene transcript in chronic myeloid leukemia (CML) patients, even those with variant Philadelphia (Ph) chromosome translocation, is very rare. In the present study, we report a case of CML  with extreme thrombocytosis at onset, with the variant Ph chromosome and rare e14a3 (b3a3) BCR::ABL1 transcript. The patient was prescribed imatinib as a first-line therapy and subsequently achieved complete hematologic remission within 2 months and major molecular response (MMR) within 3 months, and the transcript was undetectable within half a year. During up to nine years of follow-up, the quantification of this rare fusion gene was consistently negative with no BCR::ABL1 kinase domain mutations. Furthermore, we collected previously reported CML cases with the e14a3 (b3a3) transcript that indicated that the e14a3 (b3a3) transcripts appeared to have a larger number of thrombocytosis and variant Ph translocations than CML in general. This subgroup of CML might have better responses and outcomes to imatinib than patients with common transcripts.  As is well known, its signature feature is the formation of the Philadelphia (Ph) chromosome, a result of a reciprocal translocation, t 9; 22) q34; q11), leading to genetic fusion between the breakpoint cluster region (BCR) on 22q11 and Abelson 1 (ABL1) on 9q34 [1, leadin2 q34; q1iagnosis . In geneiagnosis ,7. In teiagnosis . Howeveriagnosis .To date, studies focused on the classical Ph chromosome or common BCR::ABL1 transcripts in CML have been comprehensive and thorough. Nevertheless, the diagnosis, treatment and prognosis of cases with atypical BCR::ABL1 transcripts, including those with an additional variant translocation, have received relatively little attention. In the present study, we report a case of a CML patient with extreme thrombocytosis, a variant Ph chromosome and a rare e14a3 (b3a3) BCR::ABL1 transcript who achieved long-term remission at the molecular level after imatinib (Glivec) treatment during up to nine years of follow-up.9/L and a slightly increased leukocyte count of 12.12 × 109/L, which was confirmed by a second CBC . Therefore, she was referred to our inpatient ward for further examination and treatment.A 41-year-old female patient with no dizziness, fatigue, abdominal distension, bruising or thrombus presented to the Department of Hematology after being noted to have thrombocytosis in June 2013. One year prior, this patient was found to have mildly elevated platelets during a routine physical examination, but no treatment was given because she had no symptoms. She had no previous medical or surgical history or any relevant hematological family history. However, a complete blood count (CBC) analysis performed a few days before admission displayed an extremely elevated platelet count of 1742 × 10−5) [A physical examination performed in our hospital revealed no abnormalities. In particular, no hepatomegaly or splenomegaly was detected either by palpation or ultrasound. Her clinical characteristics and blood tests from a sample drawn at the time of admission are described in −5) ,10. HencAt the time of the initial diagnosis, the patient was subjected to interferon α-2b, hydroxyurea and aspirin for nearly half a month and plateletpheresis twice to decrease the platelet count and produce antithrombosis. However, the effect of decreasing the platelet count appeared to be unsatisfactory. When the diagnosis was verified, imatinib  was prescribed as a targeted therapy for CML accompanied by aspirin (100 mg daily). Blood routine examination, the quantification of the e14a3 (b3a3) BCR::ABL1 transcript and BCR::ABL1 kinase domain mutations were regularly performed in the outpatient department, and the molecular response was evaluated every 3 months until major molecular response (MMR) was achieved and then evaluated every 3, 6 or 12 months. During treatment, the patient did experience neutropenia related to the therapy and had to reduce the dose of imatinib. This patient achieved complete hematologic remission within 2 months and MMR within 3 months, and the transcript was undetectable within half a year. To date, during up to nine years of follow-up, the quantification of this rare fusion gene was consistently negative with no BCR::ABL1 kinase domain mutations.9/L, and the degree of increase has no significant correlation with the leukocyte count. We are supposed to differentiate CML from other MPNs on the basis of the Ph chromosome or BCR::ABL1 fusion gene, especially ET, although concomitant clonal abnormalities rarely exist in CML and other MPNs [9/L is one of the diagnostic criteria for accelerated-phase CML, which is rare in chronic-phase CML [As mentioned above, approximately fifty percent of CML cases have thrombocytosis at initial diagnosis. The platelet count of a few patients can even exceed 1000 × 10her MPNs ,12. A pehase CML . In our hase CML ,14. The hase CML ,16, and hase CML ,17. Othehase CML . These pOne or more additional chromosomes are added to the Ph chromosome, called a variant Ph translocation, which is found in approximately five percent of newly diagnosed CML patients . It can 9/L and 546.5 × 109/L . Approximately 78%  of the patients had thrombocytosis, defined as a platelet count >300 × 109/L, which was higher than the 50% in general CML patients [Moreover, the BCR::ABL1 transcripts in a very few CML patients are not among the three common subtypes , thus forming atypical BCR::ABL1 transcripts. Among these, the breakpoints of the BCR gene can be located outside the three well-defined regions and even exit the inserted sequence, while the breakpoints of the ABL1 gene arise in introns downstream of ABL1 exon 3. More than ten atypical BCR::ABL1 transcripts have been detected in CML patients, such as e13a3 (b2a3), e14a3 (b3a3), e13e14a3, e1a3, e4a2, e6a2, e8a2, e12a2, e16a2 and e18a2 , and thepatients . Of the patients ,30.In conclusion, e14a3 (b3a3) BCR::ABL1 transcripts, even with additional variant translocation, are rare in CML. We can confirm the possible translocation pattern of the variant Ph chromosome by means of FISH. The e14a3 (b3a3) transcripts appear to have a larger number of thrombocytosis and variant Ph translocations than CML in general, and these patients might have better responses and outcomes to imatinib than patients with common transcripts. Further studies of a larger number of CML patients with e14a3 (b3a3) transcripts should be implemented to verify these findings.


Gender-based violence is a human rights and public health issue, disproportionately affecting women. The Motivating Action Through Empowerment (MATE) bystander program aims to address violence against women by shifting focus from perpetrators and victims of violence to community responsibility for not accepting attitudes and behaviors that support or allow the violence to occur. Traditionally bystander programs have been delivered through institutions, most notably college campuses in the United States. The translation of bystander programs to community settings is not widely reported. This research aimed to understand whether a violence prevention program could be effectively delivered in a faith community setting; specifically, it focuses on the implementation of MATE in a Christian church network in the Gold Coast region of Queensland, Australia. Semi-structured interviews were conducted with ten church-based trainers in the MATE pilot program. Theoretically informed analysis using the COM-B behavior model identified that environmental factors had a large bearing on opportunities to deliver MATE workshops. This research identified six key lessons for MATE and other programs wishing to leverage faith communities: (1) Provide religious context; (2) Accommodate diversity; (3) Build faith leader capacity; (4) Employ social marketing; (5) Undertake co-design; (6) Actively administer, measure and monitor. Gender-based violence is a global human rights and public health issue that disproportionately affects women. In Australia, 1 in 5 women have experienced sexual violence from age 15, compared to 1 in 20 men; 1 in 6 women, aged 15 and over, have experienced stalking, compared to 1 in 15 men; and women are twice as likely as men to have been sexually harassed since the age of 15  were coming from and just getting all the stats, I suppose, of what has been happening out there in the public.(T06)That was very useful to be able to go OK, how to deal with the different types of people that you’ll come up against, whether it be positive or negative.(T06)The training manual provided to each trainer at the conclusion of the workshop was also valued by the church-based trainers. They were generally confident that with this resource, which included both course content and guidance on how to deliver it, they would be able to run their own MATE workshops. However, perspectives varied as to how strictly the manual needed to be followed.I think the booklet that we went away with was the most useful, practically, to then go and deliver, you know, kind of be able to facilitate something for your community.(T09)[I]f you do the MATE train-the-trainer course … we don’t get to pick and choose the topics that are delivered to us… you have to look at every single part of that wheel. Whereas when you’re delivering it and you can deliver it how you want, when you want, for whatever, there are some things that just get mixed up, like missed out.(T04)Trainers were given access to two online support communities: a community of practice hosted on Microsoft Teams for all accredited MATE trainers  and a private Facebook group just for the pilot cohort. None of the interviewed trainers had participated in the all-trainer community, and those that used the private Facebook group has mixed experiences. There was also some confusion over the purpose of the different online communities. In general, however, trainers felt that support from MATE and the NFP partner was available to them should they need it.I think there have been posts and meetings and stuff that could, you know, we could have attended […] but we haven’t been able to access the content of that.(T05)[O]ne thing I was disappointed with was we had a Facebook page that started up from the training, like for our group […] But there’s really been very little interaction on that.(T07)So, we do have like the MATE alumni group and stuff. And for me, I’m not entirely sure what the crossover or lack thereof is between [the NFP partner] and the MATE stuff I’m connected with online. I’ve seen it more as like a story sharing space rather than a support space in terms of like, I probably wouldn’t go there and be like, hey, I’m really struggling with this aspect of it all.(T03)A common area of concern identified by trainers was the lack of religious or biblical perspective presented with the MATE content. Given the Christian context of this pilot, offering a religious perspective was considered an important component of the MATE program. This perspective was necessary to both endorse the MATE program and to counter ‘faith-based’ opposition to the ideas and issues raised in the program. Trainers expressed some frustration that this perspective was not fully addressed in the MATE train-the-trainer program.[O]ne thing that was… hadn’t been formulated at that point was the biblical perspectives or, you know, aligning, I guess, of those worlds. And that was definitely something that we were waiting on prior to starting any of our training. Because we knew that the church world, Christians, were going to want to have that perspective in there.(T05)At the time of interview, four of the 10 trainers reported that they had delivered two MATE workshops, four had delivered one workshop and two had not delivered a workshop. All trainers indicated their intention to deliver MATE workshops in the future.Church leadership and staff was a priority audience in three of the seven participating churches, and of the 10 MATE workshops that had been delivered at the time of interview, half had been delivered to staff . ReasonsTwenty-seven influences contributing to trainers’ delivery of the MATE program were identified in the interviews and categorized into 12 themes. These themes were aligned to the trainers’ capability, opportunity or motivation to deliver the MATE program following the COM-B behavior model  Table 4Table 4.The MATE train-the-trainer workshop was successful in opening trainers’ eyes to the extent of violence and extending their understanding of the drivers of violence against women. Knowledge about the bystander intervention framework, the MATE program’s guide for taking prosocial bystander action in the face of violence against women, was only mentioned by one trainer, and that person could not recall the framework in its entirety. All trainers acknowledged the large volume of content in the program; however, they felt that they could rely on the resources they had been provided with to assist their own program delivery. Trainers had a range of facilitation experience, and many expressed that they were at ease with having to get up in front of people to present. However, one trainer (with facilitation experience) believed that more practice in this area was required to develop the requisite skills.I really had no background knowledge on the whole gender side of things and how that influences, you know, the process.(T06)I was thinking abuse, so I was thinking physical, yeah… and I wasn’t thinking everything else, you know, that we were taught and discussed.(T10)[Y]ou know, distraction, protocol, intervention or… I can’t remember the fourth one right now.(T05)[T]he booklet I think was amazing because it had all the topics, you know, and then just detail around how you could facilitate that.(T09)[M]y concern is around how then do people take what they’ve covered in training, in a two-day period, and do that then well with their communities.(T09)Church environment: Church leadership emerged as a critical element of the church environment, as the leadership ultimately makes the decisions about implementing and maintaining the MATE program within their ministry. Churches with strong leadership support have a clearer vision of how MATE will fit into their ministry, and in many instances have taken steps to make that happen. In churches where leadership support is not as clear, MATE has remained on the periphery.Well at this stage I would say that we are kind of on the fringe… we haven’t actually got it as being sort of accepted as a formal ministry yet… I think [the church leadership are] supportive of doing the, or the idea of having [MATE] happen. I think they, certainly some of them, feel they’re not sure how it’s gonna fit. And for some of them, they kind of go, well, it’s probably, you know, they have that kind of denial—well, is this something that we actually have in our church?(T02)In general, the trainers expressed a strong sense of the difficulty of the MATE content for a faith setting, with many suggesting omissions and modifications that would be made. The topic of gang rape, in particular, was perceived by trainers as being confronting and/or less relevant to the church audience. Others, however, acknowledged the difficult content as something that needed to be faced by the congregation. One trainer voiced their belief that Christians would not come across some of the behaviors covered in the MATE program, suggesting limits to acknowledgement of violence against women and precursory behaviors in the church.You know, like delivering [the gang rape topic] in the church context is just, you know, like that just, that will just blow people’s brains, you know. That’s just not something that most people following a Christian way of life would even encounter.(T07)[W]e’ve kind of had to be selective in what subjects you kind of choose… I think some content would be more shocking than others.(T05)Scheduling is a big issue for getting MATE into church ministry, both in terms of fitting it into already full calendars and with regard to the time the delivery team has available to deliver a MATE program. Some churches have decided to leverage these existing ministry activities events, such as men’s program meetings and youth groups, and use them as opportunities to deliver MATE content instead of scheduling standalone MATE workshops.[I]t’s been fully supported. We think, yeah, we think it’s awesome…it’s just a timing thing now. Just to, trying to get it into the schedule.(T08)[W]e realized that we need to start somewhere, and the men are willing to do it, and they’re already meeting once a fortnight anyway, so we’re just going to infiltrate a couple of their nights.(T08)Resourcing and logistics: COVID-related issues had an impact on the delivery of MATE in this pilot. Apart from lockdowns, which prevented people travelling and meeting, COVID affected the availability of resources for churches to offer the MATE program. These issues are on top of difficulties due to other time commitments that the trainers have, often stemming from work inside and outside of church. There was a hope that expanding the MATE delivery team in their church would address this. Despite the personal toll of the time required to deliver the program, some trainers were keen to take MATE beyond their church community, acknowledging that not everyone in the broader community attends church. As such, some trainers felt limited by the licensing conditions for the pilot program, which do not permit delivery of MATE beyond the church ministry.My biggest problem is I’ve moved into a pretty seriously time draining job at the moment.(T02)That was the challenge for us, just recognizing that it’s not our, it’s not part of our job description to be teaching it… it’s taking us away from our, from what we actually have to do in our job.(T10)I think for me, like, if we had a bigger team at church and we had again just more people that were officially on board with it and not just on board, but officially a pilot team on board working towards it, I think that’d be a huge asset moving forward.(T03)Is it enough just to be in the churches? No, it needs to, we need to develop this so it can be out there in the general community… but it’s then how we get it out into the general public. Because there’s still a lot of people that don’t go to church.(T06)Christian context: Trainers have a strong Christian identity based on being more Christ-like and using guidance from the Bible to achieve that. Related to this, trainers expressed a clear sense of the Christian community being distinct from the non-Christian community. This is due to the central, elevated and explicit role of biblical teaching and guidance in a Christian context compared with non-Christian contexts. Even though they generally thought that the MATE program successfully found common ground, there was a strong belief that the program needed to be shaped differently for Christian and non-Christian contexts. Trainers identified a need for guidance on how to offer biblical insights that support MATE themes and counter contrary Bible interpretations. This guidance was generally viewed as needing to come from members of the Christian community rather than the MATE program itself. The diversity of views and opinions within the Christian environment and within each church community was acknowledged by the trainers, as was the complexity that this could bring to the reception of MATE content.[I]n a church environment, we’re there because we believe in the gospel… the story of the gospel, it changes us and it and it calls us to be better people and to make a difference in our community and to become more like Christ.(T10)[W]e were obviously doing this from, you know, as the Gold Coast churches kind of coming into it, so it was it was good to have, like, [the MATE facilitators] that were doing it, that weren’t coming from that church environment, so they were able to, you know, present it, but also for both of our sides, I suppose to be able to come together and be able to understand.(T07)I think I was fully prepared to [deliver MATE] in a non-Christian environment. I… it fell short for the Christian environment.(T04)Gender and power dynamics: While the churches support the idea of gender equality, it does not always get applied in practice. This is particularly apparent among church leadership, where a number of trainers remarked on the underrepresentation of women. Conservative views and bible interpretations are challenging for trainers, as they are counter to MATE content. Church hierarchy and power structures also have an impact on MATE delivery as they interfere with participants’ comfort to express views and thoughts freely.I would say that we, our church, probably has, like a lot of churches, probably majority women, probably at least 55/45 women to men. And yet a lot of the leaders are probably men.(T02)But there’s been processes that have happened within our church, and I believe it happens in all workplaces, where that inequity comes from. So, and that’s been a little icy to have that conversation because we have ended up with mostly male leaders in our church.(T07)Well, when they talk about gender roles… they just flat out won’t go outside that. This is what the Bible says a man is and this is what the Bible says a woman is. So, as a result, they wouldn’t include LGBTI community, like because that falls outside the realm of what they believe the Bible says.(T04)And then sometimes in those environments you’re just not going to go against your leadership. Whether or not it’s a male or female, you know, like there’s just a whole different dynamic there. I guess it’s like going to a course with your boss and then trying to tell the facilitator that your boss is just flat out wrong, it’s just not going to happen. So that dynamic is there.(T04)Support and encouragement: The trainers felt support from MATE and the NFP partner was available should they need it; however, few have actively sought support. Trainers identified peers from the MATE program and members of church communities as additional sources of support, even though many had not accessed these supports. One trainer who did reach out for support was disappointed with the outcome. They were keen to connect with the peer community, prepare some MATE-related materials, and get some practical advice about delivering to a youth audience. Their expectations of the online community of peer support and practical support from the MATE program were largely unmet.[O]ne of the things that I had said when we did our first delivery is we’d like to create a little booklet… [MATE] said, oh, that was a great idea, that was a great idea. Let us work with you. And then, like, I was, like, hey, I’m ready. But yeah, nothing ever, sort of came of that.(T07)[I] definitely would love to get some more support around, yeah, how we can, some ideas around how we deliver this to, like to youth... rather than, you know, I don’t want to be reinventing the wheel.(T07)A major motivator for the trainers stems from their identity as Christians and their belief that they should model their lives on Jesus Christ or do what God wants them to do. There is also a strong sense of responsibility and leadership, both with regard to the role the church should be playing in addressing violence against women and the personal responsibility of the trainers. The trainers were also motivated by the sense of being able to take action and make change happen. They felt very empowered to facilitate positive change through the MATE program, with many echoing the idea that the program showed how everyone’s contribution could lead to greater social change. Trainers also expressed their ‘passion’ about doing something to address violence against women, suggesting that MATE gave them an avenue to follow this passion.[W]hen I think about Christ and who he was, and I read about him, he actually shows some amazing points and amazing behavior that I can model after, try and model from as a male in my community, my family.(T01)[A]s a follower of Christ I believe that one of the greatest things that he did was that he interacted with people where they are at… And so, from my point of view, that’s kind of where I’m at, is that I need to find ways to connect with people. … I’ve gotta be able to find a way to be able to be in their shoes or understand the space they’re in, or be able to, you know, be comfortable in that space so they don’t think that I’m just there to try and fix them up. But I’m actually there to be, you know, like them and to be supportive.(T02)I feel like this is something that God has really called me to do.(T07)I feel like it’s just something that, as the church, we’ve got to step up and really make a change and a difference here.(T07)They actually made me feel like, empowered me to be like, you can actually make a difference, no matter how small or big.(T01)Like just, [the train-the-trainer workshop] just sparked the passion that I have like inside of me, even more.(T07)A number of areas for improvement emerged in the trainer interviews that cut across program implementation, workshop delivery and influences on workshop delivery. Insights gained from this evaluation can guide how the MATE program is delivered and implemented in faith communities, and inform other programs wishing to leverage faith communities.Sociocultural relevance of a program to its target community is a recognized success factor in the delivery of community public health and prevention programs ,28, and While all churches in the pilot have the same core Christian values, there are variations—even within the small sample in this study—in how those values translate to practice, as well as congregational cultural diversity, and differences in staff numbers, resources and congregation sizes. All of these factors make each church—and its requirements from the MATE program—unique. Intra-denominational differences in how churches and church community members practice their faith are complexities to be considered in health promotion efforts in faith communities . The difWhile MATE presently offers a great deal of flexibility in how the program is delivered, this may be at the cost of losing core content or intentions when modifications are left up to each individual trainer. There is opportunity for MATE to facilitate adaptation of the program to ensure an appropriate fit with each church community and their needs while maintaining program fidelity. This could be achieved in a number of ways, such developing clearer guidelines for how the MATE program can be customized; preparing more ministry-ready MATE guidelines, materials and agendas that can be easily slipped into existing activities; and providing guidance and support on how to embed MATE messages into other ministry activities, such as youth and men’s groups, and in sermons and other regular church activities. As well as addressing barriers of scheduling and resources, this could be a way that churches are able to lead by example and both model MATE in their communities and normalize MATE messaging.A number of influences on MATE training delivery stem from the structure and operation of each church. These include patriarchal traditions, hierarchies within the church, conservative views, being seen to take prosocial action as a church and leadership support. With the central role they play in operational, attitudinal and behavioral elements of their church communities, faith leaders are in a position to act on all of these influences in a way to facilitate MATE delivery. Faith leaders are influential figures in faith settings and warrant particular attention with regard to implementation of public health and prevention programs ,33. ThisThe current MATE implementation views MATE as a standalone activity. Trainers are expected to deliver MATE workshops using agendas provided in the training manual, but outside of MATE workshops, there is no support for additional MATE messaging. Taking a more holistic view of MATE, its delivery and potential impacts in a church setting offers opportunities to overcome the identified barriers. For example, social marketing campaigns have been used to successfully encourage prosocial bystander behavior ,36 and mSuccessful implementation of a new intervention in an organization—in this case, including the MATE workshop in individual church ministries—requires an understanding of the behaviors and practices that need to change, the systems that are needed to support the implementation of the intervention, and the resources that are needed to facilitate this . GainingWhile the NFP partner coordinates church involvement in the MATE program, and MATE delivers the train-the-trainer workshop and provides ongoing engagement through the online communities, there is no central point actively administering the faith community program. Similarly, there is no mechanism for monitoring and evaluating what is delivered in each church, and so no way of implementing a system of continuous improvement in the program. Ongoing feedback about fidelity can help maintain community delivered programs that are closer to intended guidelines , so MATEThis research demonstrated that to realize the full potential of a model of MATE delivered through faith communities, there is a need for a program coordinator role with responsibility for the management of the pilot and ongoing support and engagement with the trainers and their churches.Only 10 of the 31 trainers (29%) in the pilot were willing to participate in this study, so the experience and delivery of MATE for more than two-thirds of the church-based trainers in the pilot remains unknown. Additionally, volunteer bias may factor in this study, as trainers who participated may have been more engaged in the pilot, and so may hold different perspectives and have had different program experiences when compared to those of the unsampled trainers.A thorough theory-based evaluation to examine how the program mechanisms identified in this study work in a faith context would provide valuable insight into the delivery of MATE in a faith setting and inform the scaling of this program to more churches and faith communities. Such an evaluation would require more active program administration to collect the necessary process information and more engagement from church-based trainers. Perspectives of MATE facilitators who deliver the program in secular and church settings would be valuable additions to this work.In a climate where violence against women continues to be a significant social and public health problem, and where resources to fund prevention initiatives are scant, delivery of MATE through church communities offers a very practical opportunity. They possess resources, networks and knowledge that are essential for developing and delivering relevant and engaging public health interventions. Lessons learned in this pilot on the Gold Coast have highlighted that to capitalize further on this opportunity there will need to be some initial investment in tailoring the program for faith communities and building social campaign resources around MATE, as well as ongoing resourcing for a coordinator who can encourage and support church communities to implement MATE in ways that are meaningful, measurable and sustainable. These lessons can also inform other programs wishing to leverage faith communities, particularly regarding the importance of co-design in developing successful, sustainable interventions.


While platial representations are being developed for sedentary entities, a parallel and useful endeavor would be to consider time in so-called “platio-temporal” representations that would also expand notions of mobility in GIScience, that are solely dependent on Euclidean space and time. Besides enhancing such aspects of place and mobility via spatio-temporal, we also include human aspects of these representations via considerations of the sociological notions of mobility via the mobilities paradigm that can systematically introduce representation of both platial information along with mobilities associated with ‘moving places.’ We condense these aspects into ‘platial mobility,’ a novel conceptual framework, as an integration in GIScience and the mobilities paradigm in sociology, that denotes movement of places in our platio-temporal and sociology-based representations. As illustrative cases for further study using platial mobility as a framework, we explore its benefits and methodological aspects toward developing better understanding for disaster management, disaster risk reduction and pandemics. We then discuss some of the illustrative use cases to clarify the concept of platial mobility and its application prospects in the areas of disaster management, disaster risk reduction and pandemics. These use cases, which include flood events and the ongoing COVID-19 pandemic, have led to displaced and restricted communities having to change practices and places, which would be particularly amenable to the conceptual framework developed in our work. The relevance and importance of ‘place’ is becoming increasingly important in Geographic Information Science (GIScience) and related disciplines. Goodchild  raised kIn this work, we aim to present a formalism for platial representations that is time dependent and does not consider ‘space’ and ‘place’ to be necessarily separated. Moreover, in the consideration of time and movement, we introduce the idea of ‘platial mobility’ that draws upon the mobilities paradigm  relationships that are valuable in performing platial analysis. The hierarchies are defined along spatial and semantic dimensions thus enabling the level of detail-based representation of places. However, it is not necessary that the two hierarchies match, as the hierarchies in the semantic dimension capture the hierarchical cognitive sense of place that may differ based on an individual or group-based experiences. This makes modeling semantic hierarchies for places quite a challenging task. However, several ontological  Paris and Vienna? One option is to consider the cities as the collection of places. In this case, the contextual distribution patterns of places can be analyzed and turned into a similarity measure. Other possibilities are taking into account any contextual theme, e.g., functional diversity and/or availability of places, mobility dynamics, air quality, transportation, disaster resilience, etc. Similarly, two restaurants can be compared based on personal experiences like quality of food, service quality, environment, cleanliness, etc.Several approaches  model by Papadakis et al. , 2019 prSupports the platial hierarchical representations at multiple levels of detail.Supports platial and platio-temporal operations.Utilizes the underlying spatial data model for spatial part of place.Considers space, time and meaning  as compositional dimensions of place.In order to fulfill the aforementioned requirements, our platial modeling approach defines place as a function dependent on four dimensions.n dimensions as key value pairs).Many spatial data representation modeling techniques already exist that provide reasonable approximations for the digital representation and manipulation of objects using formal approaches having mathematical foundations. In the absence of such models for the digital representation of places , there is a dire need to design formal platial models that have sound theoretical foundations for platial data representation at multiple levels of detail and support platial operations. Thus, a practical platial model should fulfill following requirements: The most distinguishing feature or component of platial definition is the “meaning” aspect as the other components can be handled using existing spatial models. Thus, platial meaning itself is a multidimensional structure that is intentionally segregated though could be treated as normal set of attributes of the platial definition. However, keeping the meaning separate would be useful for performing semantic platial queries that would mostly be relying on qualitative data that are captured in the meaning. The qualitative meaning dimensions can be converted to quantitative dimensions using many of the existing conversion techniques. The converted multidimensional data sets then can be analyzed using well-known multidimensional data analysis techniques, specially from the spatial data mining domain  social science basis/ontologies. McKenzie  has alsoA space at a specific time instance or time interval may refer to a different place or places for different persons as shown in Fig. As a consequence to the above definitions, we can further denote related observables Various platial constructions are based on possible combination of space time variations. In order to understand the variations, two possibilities for each space and time dimensions are taken into account. For any place under consideration, the space defining the place remains the same or may change over time. Combination of space time instances is shown in Table By definition, platial representations rely on human based notions, hence sociological considerations are important. To further enhance our notion of “platial mobility” with sociology that includes notions of place which do not have explicit spatio-temporal dependencies, we therefore connect to the mobilities paradigm, a contemporary and rich theoretical and methodological approach in the social sciences.The mobilities paradigm, based in the social sciences, is a contemporary framework which studies the movement of people, ideas and things, as well as the broader societal consequences of these flows. Urry , 2016 caplace, and treats as abnormal distance, change, and placelessness. Sedentarism is often derived loosely from Heidegger  and their valuable assets and stock from their usual settlement to safe areas, in order to survive or avoid disasters. For the sake of this study, we differentiate between the terms relocation and displacement in the context of disaster risk, considering relocation as a planned and government-assisted process, with a rather voluntary character, while displacement is the abrupt and forced movement of groups of people. Relocation is a temporary or permanent Ferris  passive Mapping platial mobility in the context of disaster management is a complex and intrinsically multidimensional task as displacements cause severe multidimensional distress, manifested at the physiological, psychological, and sociocultural levels , 1954 (8.800 m3/s), 2002 , 2013  , shape  in 2D or 3D, and topology. The scale dimension represents the platial hierarchies, also defined as a level of detail or abstraction. In the case of disaster displacements, scale can be represented by social units, i.e., household, community, business, etc.  or time intervals within a timeline of the resettlement. Time can be modeled as a single or multiple timelines , temporal (time) and meaning (semantics) dimensions. We discuss three important aspects of platial classification, platial construction and platial comparisons. We provide a classification of places and their salient characteristics and places can be temporary or permanent, movable or immovable, and instantaneous or planned.Places may be constructed hierarchically, in that case an additional dimension of level of detail is considered. Places may have hierarchical (place/sub-place) relationships that are valuable in performing platial analysis. The hierarchies are defined along spatial and semantic dimensions thus enabling the level of detail based representation of places. Since places are semantically constructed spaces by individuals or groups, that may have sense in three different scales arranged hierarchically from local to global levels. Places may have crisp or fuzzy and imprecise boundaries defined by the spatial dimension. Although approaches exist for handling the fuzziness issue in the spatial component, fuzziness may also exist along meaning dimensions that makes the platial modeling task even more challenging. Places can be compared for similarity using some distance measure along spatial, temporal and meaning dimensions. Platial semantic similarity is the similarity along meaning dimensions and can have different contexts based on the application domain.We list four requirements that a platial model should fulfill in order to be practical. In view of these requirements, our formalism approach defines place as a function dependent on the key dimensions of space, time, meaning and an optional dimension of the level of detail. Meaning is the most distinguishing component of our platial definition and is multidimensional carrying the subjective semantic information associated with the place. We then differentiate the spatial and platial models along level of detail, time, space (geometry and topology) and the meaning dimensions. We define the variability of place as the divergence of two places in meaning that can then be formulated in terms of their spatial and temporal dimensions. In this context, we introduce various possible platial constructions based on space time variations.With these considerations, we introduce the idea of ‘platial mobility’ that draws upon the mobilities paradigm that is a contemporary framework in social sciences and studies the movement of people, ideas, things/objects and societal consequences of these flows. We therefore expand existing sedentary notions of place-based GIS and also extend mobility in GIS using the mobilities paradigm in our framework. We consider this to have a paradigm shift level impact as GISs will incorporate new types of data and change in the basis of state of science incorporating multi-dimensional data to addressing common to highly complex problems.To highlight some areas in which “platial mobility” can contribute significantly, we have presented two cases involving improvement of disaster management and how disaster risk reduction can benefit from our platio-temporal representations. We also address the present and future epidemics and pandemics, and rapidly evolving COVID-19 pandemic, which can be studied and understood via our framework. These use cases highlight both the potential and relevance of our framework, especially in the context of ongoing and future climate change impacts and pandemics.For our aforementioned use cases, we intend to apply and test our framework empirically, with upcoming research studies. Based on their context, we aim to use case studies and mixed-methods based approaches as our methodological basis. Overall, our aim is to improve capabilities of GISs toward meeting demands and enhancing capacity of users, for the widespread benefit to communities of disciplinary practices to beneficiaries, including vulnerable communities and general public.