Walking has been emphasized as an important solution for preventing isolation among older adults, especially given the coronavirus disease 2019 (COVID-19) pandemic, and various methods are being proposed to promote walking in this population. In this study, a walking exercise program for the elderly was developed using various latest technologies, and the effectiveness and influencing factors of the program were evaluated.The walking program for older adults was designed using mHealth devices, social media application, and gamified elements to prevent isolation. Twelve participants were recruited via an online community of retired individuals. This one-year study involved a one-group repeated measures experimental design; an online questionnaire was conducted four times along with a focus group interview.The results showed that the e-health literacy of the 12 participants increased, while Wearable Device App Literacy/Usability, digital health self-efficacy, and walking program evaluation showed a decline. In the focus group interview, participants expressed their appreciation for this program, ways to overcome its limitations, and expectations for the next program.This study confirmed the positive effect of the online walking program for retired older adults, indicating that an online-offline convergence program suitable for the “COVID-19 era” will be necessary in the future. The world is in great chaos due to the ongoing coronavirus disease 2019 (COVID-19) pandemic .Social distancing has emerged as a necessity  to preveExercise has been suggested as an important measure to prevent depression caused by social isolation and to boost immunity during the COVID-19 pandemic. Several studies have highlighted the positive effects of exercise during a pandemic . Unlike As a means to solve these problems, digital medicine has recently come in the spotlight. Digital health includes mHealth; this includes mHealth apps , mHealth devices , and personalized medicines . In partPrevious studies have verified the effectiveness of community-centered walking exercise programs, but none have considered using wearable devices with older adults and online communities such as social media. In addition, it was difficult to find studies focusing on the difficulties of older adults in using devices or on their level of digital literacy.Thus, the aim of this study was to evaluate a walking exercise program for older adults using wearable devices and social media, and to identify factors affecting the program satisfaction.This study was conducted from October 7, 2020 to October 26, 2021. Participants were recruited by sending emails about the program to an online community. Participants were selected based on the following criteria: (1) adults over 60 years old who use smartphones in their daily life; (2) physical ability to participate in a walking program; (3) a personal belief that they are sufficiently capable of participating in the walking program. Those who did not meet the study’s criteria were excluded.Data were collected after deliberation and approval by the Institutional Bioethics Review Committee for ethical protection of study participants . The data collection period was from October 7, 2020 to October 26, 2021, and the purpose of the study, program contents, and methods were explained when conducting the preliminary survey. Consent was taken before participation.mHealth devices and Social media apps using Gamified walking program), was designed to enable socializing in conjunction with mHealth apps and devices to operate an online walking program for retired older adults during COVID-19 as shown in Fig. Gamified technology for older adults benefits them physically, cognitively, socially, and emotionally ; the mot• Space: Participants were allowed to walk anywhere they wanted. The degree of freedom of MSG walking program was high since time and place restrictions were not placed on the participants.• Task: The BAND app , which is the most commonly used social media application by people over 50 years old living in Korea , was use• Equipment: Wearable devices that can count steps  and the IoT Scale  were utilized. The user’s measurement data collected by both devices can be viewed on the Mi Fit  app. Accordingly, participants were provided with instructions on how to use the Mi Fit app.• People: The KakaoTalk app  was used among Messaging Apps for group chatting where all participants communicated with and encouraged each other. Unlike the BAND app, the KakaoTalk app was used to deliver announcements or for real time communication between participants. KakaoTalk is the most popular mobile messaging app in Korea, used by about 97.5% of smartphone users in 2020 , 30. It The detailed composition of the MSG walking program based on the STEP model is as follows.In this study, various digital health factors and devices such as wearable devices and smart phones were used to enhance participation in the program. To evaluate the change of knowledge and beliefs of the participants related to the effectiveness of this program and device use, an online survey was conducted at four timepoints: Pre, Mid 1 (1.4 month), Mid 2 (5.1 month), and Post (10.3 month).The composition of the questionnaire is shown in Table It consisted of 17 items on the socioeconomic and health status of the participants.In order to measure the participants' ability of and interest in using the Internet for health information, multiple-choice questions on frequency of contact with health information, search methods, and Internet usage time and purpose were constructed.For cognitive age, a tool measuring the four dimensions  of Barak & Schiffman (1981) was used with one item for each dimension. Each age group was measured as a categorical variable . CognitiE-health literacy refers to the ability to find, understand, and evaluate health information on the Internet, or to apply and transmit the acquired knowledge to solve health problems . In thisIn order to know how well participants understand and use the app that displays measured information in conjunction with the wearable device, an existing health application literacy tool was utilized, composed of nine quiz questions related to the application , 36. TheAn existing tool consisting of 20 items was used to evaluate the usability of the applications used in the study. It consists of items on effect, perceived ease, perceived usefulness, and user control. Usability is calculated as the average of those variables. In this study, questionnaire was partially modified to measure the usability of the MI Band app. In a previous study, the Cronbach’s alpha values of the detailed items of the tool ranged from 0.85–0.92 .To measure smartphone self-efficacy, a tool created by Kim (2017) by supplementing the concept of digital media literacy was modified to fit this study and used to measure digital health self-efficacy , 39.This scale measures body fat and weight and transmits the measurement results to the Mi app via Bluetooth. The scale served as a reward for participating in the study till the end without failing. It consists of four newly written, brief questions for this study, about the usefulness and difficulty of using the IoT scale provided as a reward for participation.In order to measure the overall satisfaction of this walking exercise program, 9 items were newly composed to be rated on a 5-point Likert scale.The Questions were about the appropriateness of the program, the needs of the community, the need for wearable devices, and the intention to continue using it.Focus group interview (FGI) was performed two months after the post-intervention evaluation and 12 months after the start of the program. Due to COVID-19, an online interview was conducted through Zoom. The FGI was conducted as a semi-structured interview inquiring about online questionnaire items, the impact of social network use on the program, and the program composition.The MSG walking program was conducted as shown in Fig. Participants were educated through an online meeting on how to use the mHealth app and other devices to participate in the walking program; a pre-intervention evaluation was also conducted. Participants set their own walking course and walked 6,000 steps every day and disclosed the results to the participant community through the social media app. To prove the number of steps, participants captured the screen of the Mi fit app and uploaded it to the BAND app every day.The results of the participants' social media activities were scored and the rankings were announced every month; a mini-award was provided as a compliment to the participants with the seven highest scores. The score was calculated by summarizing each user's level of participation, based on the number of posts that achieved the goal and the number of comments or likes on other users' posts.At the end of the program, an IoT scale was provided as a reward to the participants who participated until the end.The monthly mini-award was conducted as shown in Fig. For data collection, as described previously in Fig. The effects of usability, e-health literacy, and exercise programs, excluding app literacy, were measured on a Likert scale ranging from 1 to 5. App literacy comprising nine quiz questions with responses on a scale of 0 to 9 was also converted to a five-point scale for easy comparison.The significance of the differences in measured values before and after the start of the MSG program was tested through Wilcoxon signed rank test.Initially, 15 individuals consented to participate in the study. One person left owing to health reasons before the start of the study and data for two participants with a high non-response rate were excluded during analysis. Data from 12 participants were finally used for analysis. Participant characteristics are shown in Table All of the participants, except for one, were living with their family or spouse, and all the participant’s self-conceived health status was average or higher. Also, they all had a bachelor's degree or higher, and about half had a diagnosis of hypertension and diabetes.The questionnaire was administered, and each item was converted to a five-point scale. Wearable device app literacy, which was measured on a scale of 9, was changed to a full scale of 5 using a proportional formula.The results of the questionnaire are shown in Table To check the changes in trends in the study variables, the Wearable Device App Literacy results were converted to scores ranging from 1–5. It was downscaled by multiplying five-ninth .The usability of the Mi Fit app measured using the Wearable Device App Usability scale had an initial average score of 3.39 0.64) out of 5 as shown in Fig.  out of 5It was observed that the weight of the participants did not change significantly from a mean of 66.13 (7.35) kg to 66.08 (7.04) kg.In contrast to the score of the app literacy quiz for evaluating the appropriate use of the application, which reduced from 3.92 (1.20) to 3.42 (1.69), the score for e-health literacy increased from 3.59 (0.61) to 3.84 (0.53).p = 0.009) and the perceived usefulness (p = 0.018) dimension of app usability.A significant difference was found in smartphone self-efficacy , which was 9.27 years lower than the participants' actual mean age, 68.44 years (5.08). Although the effect of factors other than intervention cannot be excluded, the difference between the actual age and the cognitive age was observed to be lower than the actual age of all participants from 3 years old to the largest 20 years old.The results of the FGI performed 2 months after the intervention were as follows. When asked about the decrease in satisfaction with the program over time, the participants expressed overall satisfaction. They said that this program made them move and feel social connection during COVID-19, however over time, the novelty of the program started diminishing. They reported feeling a sense of monotony in simply measuring the number of steps and answering a series of difficult questions, and a decrease in competitive spirit due to the decrease in participants over time.When asked about the effect of community activities using social networks on walking exercise programs, participants reported the experience of Hawthorne effect. The Hawthorne effect is a type of reactivity in which individuals modify an aspect of their behavior in response to their awareness of being observed. The participants also stated that the walking course shared by them had a positive effect on walking exercise motivation. Some said that with the new “COVID-19 era” they expected to see the next level of MSG walking program that converges online and offline participation.Lastly, when asked about their regrets during the walking exercise program and improvements they would want in the future, many participants stated about the inconvenience of the step count verification process. They mentioned that the process of capturing and uploading application screenshots had to be performed manually every day, hence, it would be helpful if it was automatically linked. Additionally, the program was reset at midnight and the records were deleted, which was inconvenient. Participants also complained about the disadvantages of the program with limited face-to-face activities and the need for incentives according to the degree of participation and achievement.Most existing studies on walking exercise programs for older adults reported changes in their physical and mental functions as a result of the program. However, unlike previous studies, this study applied an exercise program to retired older adults using wearable devices and social media (MSG program) to identify program-related factors that affect program participation.As the program progressed, the digital literacy of the participants tended to increase. Conversely, the usability evaluation showed a decline over the course of the study.The questionnaire results showed that the participants’ weight and health status did not change significantly, similar to the results of existing health management studies on adults using wearable devices –42.There were some interesting findings related to usability. The score of the overall evaluation of usability decreased overtime. The pre-intervention evaluations of usability were high due to novelty such as anticipation of a new device that had not been used before. Subsequent evaluations saw a decline because of a change in opinion about the device after actually using it. This is consistent with the results of previous studies .This suggests that the results of long-term use of new devices are more meaningful than the results of initial or one-time use and how the evaluation of new devices can be relatively positive due to the novelty effect.In the case of the user control dimension of usability evaluation, the results increased from 2.75 (0.68) points in the pre-intervention evaluation to 2.75 (0.68) and 2.97 (0.82) points in the Mid 1 (3 months) and Mid 2-evaluations (5 month), respectively. However, in the post-intervention evaluation the average was at its lowest at 2.61 (0.61) points.This was expected because at the first evaluation the user is not familiar with the device, and the understanding increases with the increasing usage period. This might also be the result of higher standards of evaluation as knowledge in the relevant field increases.As a result of indirect confirmation through user control, there was no significant difference between the pre and post results. However, the 'User Control' value rises up to 5 months and then falls, as shown in Fig. In the case of e-health literacy, a gradual increase was observed. We believe the long-term use of this application can lead to the overall increase in literacy in the field.App literacy showed a sharp decline in post-intervention evaluation. Instead of reflecting an actual decrease in participants' app literacy, this is speculated to be a result of the increase in fatigue due to the repeated quiz-type evaluation and decrease in the fidelity of evaluation at a time point 5 months after the last evaluation. Participants may have been annoyed about being exposed to questions about simple app usage that were repeated every day for five months. It might also be the result of insincere participation in the quiz and overconfidence.Contrary to the researchers’ expectations, participants rated “course sharing” as a useful feature. Initially, the researchers had not thought about course sharing. However, the participants started sharing their own trails by taking pictures and posting them.Social media was organized in the program as a device to encourage effective program execution and continued use intention of the participant in the Corona situation. However, the participants showed a tendency to enjoy social media activity itself considerably. Clearly, there were previous studies that social media had a positive effect on the health and vitality of the elderly, unlike the dysfunction of social media in relatively young adults and adolescents , 47. HowIn case of the first pre-intervention evaluation, most participants faced difficulties as they had no experience using a mobile questionnaire. The process became easier for the participants from the second questionnaire, which was conducted three months later. This made it possible to indirectly confirm that the ability to navigate the online questionnaire increased while participating in the program. In the evaluations conducted in the 3rd and 5th months, the missing values that were judged to have been a result of participants' inexperience in using the questionnaire were found to be completed. Through this, it was observed that the digital literacy of users increased indirectly. This can be interpreted because participation in programs using information and communication technology, such as this program, increased related competency and digital literacy of older adults .Considering these contents, active use of wearable devices should be considered in the overall health care of the elderly.In addition, this study was completely conducted online due to COVID-19, but surprisingly, high-quality research and smooth progress were possible. In a situation where social communication was restricted due to social distancing, travel restrictions were applied, and people were mostly staying indoors, this program involving people of similar age and experiences (retirement), getting to share their outdoor activity  experience, was positively evaluated by participants.If similar studies are conducted after the pandemic, it will be possible to indirectly measure the effect of social distancing and restrictions caused by the pandemic on online activities.Although this study has important implications, the statistical results are not normally distributed due to the small sample size. There was no control group to compare the quantitative results of intervention and it was difficult to accurately measure the individual cognitive differences with data collected by self-report. Due to these limitations, the results are difficult to generalize to other older adults. Generalizability is also limited by the fact that the participants of this study were retired older adults from a university in Korea and most participants were highly educated. Also, the cognitive age before the experiment was not measured, so there is a limitation in the absolute evaluation.However, despite these limitations, the study has significance in that it provided comprehensive analysis by exploring the research from various angles and at various levels using not only quantitative data, but also qualitative data such as observation of program progress and the participant interview and analysis of social network activity.Using the experience of this study, a follow-up study is needed to collect data in a time series with a control group in a large sample group and to characterize the variables affecting the persistence factor through RM-ANOVA analysis.This study analyzed the experiences of retired older adults participating in a walking program using wearable devices and social networks. This autonomous walking exercise program might have had a positive effect on the activities and health level of participants.Moreover, in the interview, participants emphasized the application of interpersonal strategies and the importance of creating supportive interventions at a social level to promote walking in specific groups.Although the results of this study cannot be generalized, they can help in identifying appropriate strategies and considerations when planning various exercise or physical activity programs for older adults.


Supported accommodation intends to address challenges arising following release from prison; however, impact of services, and of specific service components, is unclear. We describe key characteristics of supported accommodation, including program components and outcomes/impact; and distil best-evidence components.We conducted a systematic review, searching relevant databases in November 2022. Data were synthesised via effect direction plots according to the Synthesis Without Meta-analysis guidelines. We assessed study quality using the McGill Mixed Methods Appraisal Tool, and certainty in evidence using the GRADE framework.Twenty-eight studies were included; predominantly cross-sectional. Program components which address life skills, vocational training, AOD use, and mental health appear to positively impact criminal justice outcomes. Criminal justice outcomes were the most commonly reported, and while we identified a reduction in parole revocations and reincarceration, outcomes were otherwise mixed. Variable design, often lacking rigour, and inconsistent outcome reporting limited assessment of these outcomes, and subsequently certainty in findings was low.Post-release supported accommodation may reduce parole revocations and reincarceration. Despite limitations in the literature, the findings presented herein represent current best evidence. Future studies should clearly define program components and measure their impact; use analyses which reflect the high risk of adverse outcomes, such as time-to-event analyses; and consider outcomes which reflect the range of challenges faced by people leaving prison.Registration: PROSPERO registration CRD42020189821.The online version contains supplementary material available at 10.1186/s12954-023-00832-8. The global prison population exceeds 11 million, with the rate of growth exceeding that of the general population , or are The challenges for people after release from prison have been well documented –8, incluEvidence from cohort studies suggests interventions targeting post-release challenges can have a positive impact on social, health, and criminal justice trajectories –20. AssiPost-release housing instability is particularly challenging because it increases the difficulty of meeting community corrections requirements and, therefore, the likelihood of parole breaches and revocations , 22. ComA 2018 scoping review sought to identify the effectiveness of post-release supported accommodation in improving criminal justice and health outcomes, including physical health, mental health, and substance use issues, and sought to identify the program components associated with positive outcomes for people released from prison . The revThe risk-needs-responsivity model for assessment and treatment for people who experience incarceration, includes three core principles: to match the level of service to a person’s risk of reoffending (risk), assess criminogenic needs and target them in treatment (needs), and tailoring interventions to the learning style, motivations, abilities, and strengths of clients  on 5th May 2020, with updated searches completed on 22nd September 2021 and 9th November 2022. We used a comprehensive set of search terms pertaining to people in or leaving custody; release from custody; and supported housing, developed in consultation with a research librarian , and reporting is in line with the PRISMA guidelines .We created a Zotero (version 6) library to catalogue studies and remove duplicates, and uploaded the remaining references to the Covidence platform  to complInitial title and abstract screening was conducted by one reviewer (DG) due to resource constraints. Subsequently, full texts were independently screened for eligibility by two reviewers . Discrepancies were resolved through discussion and referral to a third reviewer as needed.For the purpose of this review, “prison” refers to all types of adult correctional institutions . Supported accommodation refers to a temporary, transitional residence for adults recently released from prison, coupled with a therapeutic component . Studies were included if they were conducted among adults aged 18 years or older who had been released from prison (no specific time frame since release was applied) and who received any form of supported accommodation. Included studies had to provide a sufficiently detailed description of the supported accommodation program components, such as details of the accommodation type, as well as the type and extent of support provided, factors targeted by services, and structure or restrictions of the program as assessed by the reviewers. We included any study design, including but not limited to evaluations of supported accommodation services and/or their program components, as well as protocols where supported accommodation and therapy was described but no outcome data were reported.Studies were excluded if they were conducted in child and youth services or where the mean client age was < 18 years at intake, or if the service’s primary focus was on an area other than supported accommodation . Services that did not exclusively focus on these areas, but offered counselling or other support for substance use disorders or mental health problems as part of their program, were included.Given the substantial variation in study and service type and outcomes measured, a meta-analysis was deemed a priori to not be appropriate, and a narrative synthesis was planned. We used the Synthesis Without Meta-analysis (SwiM) guidelines  to synthData for each study were extracted and summarised into spreadsheets developed specifically for this review. All studies were extracted by the lead author, with 25% of studies extracted by a second person to ensure accuracy. Any discrepancies were resolved through discussion.The characteristics of supported accommodation services are presented in Additional file Data were extracted regarding nine pre-determined characteristics relating to supported accommodation: (1) year of publication; (2) country of study; (3) study type; (4) gender of clients; (5) supported accommodation type; (6) supported accommodation description ; (7) program components; (8) outcomes/impact of program (including outcome measures used); and (9) summary of the outcomes/impact of the clients.The methodological quality of studies was appraised using the McGill Mixed Methods Appraisal Tool (MMAT); , 31, whiTo assess our certainty of the synthesis findings, relevant components of the GRADE Framework incarcerated, including sociodemographic and health factors such as housing , substanIn the context of such a broad range of known challenges experienced by people released from prison, which contribute to the risk of reoffending, and the wide range of factors targeted by supported accommodation services, detailed risk assessment which incorporates identification of client needs is important to ensure appropriate service delivery. While some of the included studies described program eligibility criteria which included risk assessments , 59, 61,Further to the already described challenges related to scalability and replicability, the lack of clear program component definitions or evidence of standardisation in the academic literature creates challenges in understanding how program components can be delivered in a responsive manner. This includes targeting and dosing appropriate program components according to client risk and needs, as well as their strengths and motivations. Embedding data collection processes in service delivery may increase the opportunity to identify client risk level and needs, as well as identifying dose information. This could also contribute to measurements of the impact of certain program component on specific outcomes.Only 12 of the 28 included studies met all methodological quality criteria  resulting in mixed effect directions. Program evaluations need to be undertaken to a higher standard to allow for better understanding of effectiveness. As a result, we are limited to the information that was reported by the authors in the included literature regarding program components of these services, and work remains to identify the impact of specific components on specific outcomes. While randomized control trials of supported accommodation for people released from prison may not be feasible due to ethical considerations regarding assigning individuals to substandard housing conditions when at risk of homelessness, novel approaches to evaluation design may be employed to improve the quality of this evidence. Future research could usefully integrate multiple data sources including linked administrative data with expertise of service providers and clients to identify program components and their impact on client outcomes.Many studies evaluated outcomes across multiple facilities, without clarification around the consistency of intervention delivery. This, coupled with varied detail provided describing supported accommodation services and their program components, and varied study types created challenges when analysing data in this review. Further, we were limited in our scope to compare the effectiveness of interventions because of the above-mentioned inconsistent definitions as well as the variation in how these program components were combined in service delivery.Finally, most studies identified in our review were drawn from the United States (Additional file Given the fragmented nature of the literature, we were unable to draw unambiguous conclusions regarding the effectiveness of supported accommodation services following release from prison on either legal or health outcomes. Relatedly, we were unable to identify specific program components consistently linked with better client outcomes. Both these limitations could be addressed through primary research studies that adopt rigorous methods, clearly document program components, and explore important health as well as legal outcomes. Finally, having only one reviewer screening articles at the title and abstract stage may have had consequences for screening consistency and increasing possible selection bias.People who are released from prison experience social, financial, and health challenges; supported accommodation aims to help improve outcomes during the post-release period. This review represents the current best available evidence regarding the key characteristics of these services, however we identified considerable variability in how supported accommodation services operate and are evaluated. We found a positive effect of supported accommodation on reincarceration and parole revocation outcomes, although other outcomes had mixed direction of effect. Vocational training and employment skills and life skills program components may have a positive effect on parole revocations and reincarceration outcomes, however these findings should be interpreted with caution. We recommend that future research evaluates the impact of specific program components on client outcomes, and that studies consider outcomes which reflect to the range of challenges experienced following release from prison, including housing, mental and physical health.Additional file 1. Table 1: Key characteristics of identified services, and their effectiveness.Additional file 2. Supported accommodation: A systematic review: Appendices.


In response to the COVID-19 pandemic, we launched the Penn Medicine Coping First Aid program to provide psychosocial supports to our health system community. Our approach leveraged lay health worker volunteers trained in principles of Psychological First Aid to deliver coaching services through a centralized virtual platform.n = 408) first year housestaff  with an invitation to schedule a session with a resilience coach. We compared the mental health concerns, symptoms, and Psychological First Aid techniques recorded in (n = 67) first year housestaff sessions with (n = 91) sessions of other employees in the health system.We emailed all (Between June and November 2020, forty-six first year housestaff attended at least one resilience coaching session. First year housestaff most commonly presented with feelings of anxiety and sadness and shared concerns related to the availability of social support. Resilience coaches most frequently provided practical assistance and ensured safety and comfort to first year housestaff. First year housestaff reported fewer physical or mental health symptoms and held shorter sessions with resilience coaches than non-housestaff.This work offers insights on how to address psychosocial functioning through low-intensity interventions delivered by lay personnel. More research is needed to understand the efficacy of this program and how best to engage housestaff in wellness and resilience programs throughout training, both during and beyond COVID-19. The COVID-19 pandemic has exacerbated negative mental health outcomes among first responders, medical students, and frontline healthcare staff across the globe . PhysiciIn the last decade, many healthcare organizations have implemented wellness interventions to reduce occupational burnout, a chronic form of work-related stress . A revieThe CFA program was informed by Psychological First Aid (PFA) techniques, which include the provision of non-intrusive support, a thorough needs evaluation, and linkages to further care. Although psychosocial interventions modeled on PFA have been employed in a range of disaster contexts and populations (Bisson and Lewis 2009), including frontline healthcare workers , evidence for its general effectiveness is not yet established . DespitePreliminary results show that those who engaged with the CFA program were highly satisfied and found the services they received beneficial . In the In the present intervention, volunteer Penn Medicine employees were trained in therapeutic micro-skills based on PFA  and readIn June 2020, 408 first year housestaff were introduced to the CFA program during orientation and sent an electronic letter with information about the program and a link to confirm an appointment. In an effort to increase engagement, housestaff were automatically scheduled appointments with resilience coaches and had to opt-out. CFA sessions were scheduled and administered via a secure telemedicine platform which automatically recorded audio, session length, and session type (i.e. new or follow-up). The length of telehealth visits has been used as a proxy for service engagement and included in exploratory analyses in other contexts , 22. We We describe session length, number of follow-up sessions, endorsed concerns and symptoms, techniques utilized by coaches in sessions, and referral destinations for housestaff and non-housestaff sessions. We use two-way ANOVA and a series of chi-square analyses to compare session characteristics across client types. Given the number of these exploratory analyses, we apply a conservative α level of 0.001.F = 26.93, 34.25 vs. 47.33 min, p < 0.001). In addition, the group of non-housestaff were composed of more follow-up patients relative to the first year housestaff group .Of the 408 first year housestaff contacted in June 2020, 46 (11.27%) made an appointment with a resilience coach and attended 67 sessions for an average of 34.44 min. The duration of first year housestaff sessions were significantly shorter than non-housestaff sessions . A portion of first year housestaff expressed concerns about finances 6.41%), history of prior trauma and loss (6.41%) and past or preexisting trauma . There were no significant differences in presenting concerns between the first year housestaff and other personnel  and sleep difficulties  during sessions (see Table First year housestaff reported feelings of anxiety 16.67%) and sadness (6.41%) during their resilience coach sessions. A number of first year housestaff reported sleep difficulties (5.13%) and fatigue or exhaustion (3.85%). Relative to non-housestaff, first year housestaff had fewer reports of anxiety and fearfulness , helping to identify their immediate needs (60.26%) and helping to clarify their needs (56.41%). First-year housestaff were also commonly asked about their immediate needs (48.72%), encouraged to have social engagement (41.03%) and had steps taken to ensure their physical safety (26.92%). There were no significant differences in techniques used by resilience coaches in sessions with first year housestaff and non-housestaff  of first year housestaff were connected with other services. Among those referred, resilience coaches most commonly (77.77%) connected them to internal resources  and external professional mental health services (33.33%). We did not find any significant differences in the rate of referral or where individuals were referred between first year housestaff and non-housestaff.The Penn Medicine CFA program was developed and implemented in a large urban health system within 90 days of the COVID-19 outbreak in the U.S., providing free, timely psychosocial support to all Penn Medicine employees. We find that most of the cohort of first year housestaff that we solicited did not engage with the program: only one in ten made an appointment with a resilience coach. We find that housestaff who attended a resilience coach session presented with only slight differences in emotional symptoms from the comparison group of non-housestaff. This finding suggests that universal wellness initiatives in healthcare systems may be appropriate, and that perhaps only minimal tailoring is needed to target housestaff. Resilience coaches recorded fewer physical or mental health symptoms and held shorter sessions with first year housestaff compared to non-housestaff. It is unclear whether first year housestaff experienced fewer symptoms prior to beginning training despite COVID-19 or if they felt uncomfortable reporting symptomology in an employer-provided program, despite assurances of confidentiality. To account for these possibilities, resilience coaches were given explicit guides to facilitate sessions with individuals that did not present with specific concerns in the following year’s cohort. This refinement shifted the emphasis to proactive tactics, such as a guided exploration of the wellness services in the organization and sharing psychoeducational resources.The Penn CFA program is among a number of supportive initiatives that sought to improve the wellbeing of healthcare workers at the onset of the COVID-19 pandemic , 24. ManThis study is limited by the lack of systematic information on the composition of the non-housestaff group. Session notes reveal that this group may be composed of administrators, human resources staff, clinical nurse managers, intake specialists, second-year residents, and medical students, however due to confidentiality protocols, most individuals did not disclose their position within the organization. Unlike the first year housestaff, individuals in the non-housestaff group were not directly solicited and instead encountered the CFA program passively through internal messaging, potentially leading to sample bias. The results suggest that the non-housestaff group was composed of individuals in more severe distress than the group of first year housestaff given their higher incidence of symptoms, longer session length, and higher follow-up rate. In addition, we did not collect information from housestaff who opted out of their resilience coach session, so reasons for declining to participate are unknown. The rate of reported symptoms and concerns is that among housestaff who participated in the program, not from the cohort as a whole. Future research on the CFA program should measure psychological wellbeing before and after the intervention period and employ follow-up surveys to track subsequent service utilization in the entire cohort. Of note, the CFA program was and continues to be staffed by volunteers. Consequently, it is unclear how such a program would scale in other settings as implementation support of new interventions can vary across organizational cultures and communities , 29. SubAlthough we are unable to gauge the program’s effectiveness, the data described in this study informed ongoing resilience coach training and better equipped coaches to support subsequent cohorts of residents. In line with guidelines described elsewhere , we recoThis study is one of the first to document the physical and psychological well-being of a cohort of first year housestaff and the implementation of a low-intensity interventions delivered by lay personnel in the early months of the COVID-19 pandemic in the United States. Although future research will need to evaluate the outcomes of this program, Penn Coping First Aid shows promise as a flexible model for delivering psychosocial support to healthcare workers during times of crisis.


A conceptual working alliance model of blended  cognitive-behavioral therapy (b-CBT) for depression has been developed in the UK. However, little is known about how this important therapeutic process, namely the working alliance (WA), is developed and maintained in Internet-delivered cognitive-behavioral therapy without face-to-face consultation (i-CBT). The aim of this study was to evaluate the validity of the WA model of b-CBT in Spanish patients with depression receiving i-CBT.Psychotherapies delivered n = 9), and low-intensity support (n = 10). Three group interviews were also conducted with patients who either did not start the program (n = 8) or did not complete it (n = 6), and with patients who did complete it (n = 8).Forty-one patients suffering from mild-moderate depression were interviewed to assess their experiences of an i-CBT program. Interviews were conducted with participants who received a self-guided application (Qualitative thematic content analysis was performed using the constant comparative method, which revealed four main themes: “bond,” “goals,” “task,” and “usability heuristics,” all consistent with the existing literature. However, a new subcategory emerged, called “anonymity,” which may highlight the social stigma that mental illness still has in the Spanish context.Results suggest that the development and maintenance of the WA through i-CBT could offer a better experience of the therapeutic process and improve the clinical impact.Clinicaltrials.gov, identifier: NCT01611818. For decades, the impact of the client-therapist relationship on clinical outcomes has been one of the main topics of study in the field of psychotherapy , as well as interventions that are fully self-taught by the patient  for the purpose of comparing the effectiveness of a low-intensity therapist-guided i-CBT or a completely self-guided i-CBT, with treatment as usual-care for depression, were invited to take part in a qualitative study. Participants in the trial were recruited from PC community health centers during routine clinical practice in three regions of Spain . This project was part of a mixed-method research approach that included a multicenter RCT with depressive patients. It was approved by the Research Ethics Committee of the regional health authority of the Autonomous Community of Aragon, Spain (ref: PI10/039), which covered all the other participating autonomous communities .PC professionals identified patients who could benefit from the intervention during routine clinical practice at PC centers. For example, doctors who detected a patient with symptoms of depression in their offices could proceed to explain to them the research study and its characteristics if they considered it pertinent. People who were interested in taking part in the study were required to meet the inclusion criteria, which included meeting the ICD-10 diagnostic criteria for Major Depressive Disorder, being diagnosed with the MINI Neuropsychiatric Interview in Spanish , and scon = 10) and the self-guided group (n = 9). Three group interviews, with patients from the two intervention groups, were conducted representing the three levels of completion outlined, thus consisting of patients who: (a) did not start the program (n = 8), (b) started but dropped out of the program (n = 6), and (c) completed the intervention as intended (n = 8). No patients refused to participate in the individual interviews. However, some of them did not attend the group interviews, each of which originally included 12 participants. Considering potential absences, we expected that between 6 and 12 participants would finally participate in each group and, therefore, produce enough interactions so as to be productive in terms of discourse. The total number of participants was finally considered adequate, as data saturation was obtained  to participate in individual or group interviews, while maintaining the necessary homogeneity, but also potential discursive heterogeneity, of the original study sample. Discursive heterogeneity was also linked to different levels of participation  and receiving different treatment formats  were proposed to complement each other, with the individual interviews exploring the topic list to generate tentative hypotheses, and the group interviews favoring greater productivity of results and detail in terms of the different discursive positions. The participant sociodemographic characteristics are presented in via ICTs , and included key issues that had been identified in previous research, such as training in new technologies and opinions regarding the use of mental health interventions via ICTs  that comprised 10 modules and had a duration of 12 weeks . The pro program .2.4.Initially, a thematic content analysis  of the in = 2), who were not directly involved in the data acquisition but proposed tentative hypotheses; and the researchers (n = 2), who conducted the individual/group interviews and refined the search for information from the initial topic list toward the evaluation of tentative hypotheses; and finally participants (n = 5), who provided their agreement with the interpretations once data saturation was reached ].The concept of “genuineness” was related to the perceived efforts and involvement of professionals in the creation of an adequate WA. Participants suggested that it was a key element that influenced the process of establishing a relationship with the therapist, and that held important implications for actual clinical improvement:“… This way you’re finding out things that otherwise would never come out. I mean, he can ask you, ‘What is there? What can you see here?’ And I tell him, ‘Well, I don't see anything.’ And he tells you, ‘Well, you will see something.’  ‘No, no, I don't see anything. Let’s see, you’re asking me this because it’s a test, or because of this or that, and… and my answer is, Nothing!’ And it's there, and even if you ask me again, well, eh, in person. Well, this man, he turns it around and comes to you from a different angle and asks you again. And in the end, it turns out that where you didn't see anything, you say, ‘My God! well, yeah… there was something!’ He helps you to find that … that something.” .The “partnership” theme refers to the establishment of a working relationship comparable to a friendship between the patient and the therapist and/or computer program. Participants stated that both warmth and perceived trust about the program were important, regardless of receiving support from a professional or not:"I thought it showed quite a lot of warmth for a computer program… But, of course, that depends on the person [referring to the individual characteristics of each person who uses the program], on each person’s attitude.” .“No, I did not find the computer program to be at all suspicious; I trusted it completely.” .However, one participant in the self-guided group also described a feeling of loneliness and of being “more by yourself.” This might indicate that guidance could be an important aspect for the establishment of a working relationship:“Logically, the whole thing about using a computer was always going to be much colder, right? You’re going to feel more… lonely, or more by yourself.” .The last subcategory integrated into the bond theme, and one that emerged as a new topic in the Spanish sample was “anonymity.” This concept was consistently raised by participants. They appeared to value the anonymity of a digital intervention program in light of existing prejudice and stigmatization of mental illness and the use of mental health services by society, and the shame that participants feel because of this:“For me, anonymity is an essential part of this… Because I’m actually very ashamed to say that I have depression, so, mmm, because it’s something I don’t talk about, it’s a burden that I carry; I mean, if I would have had to give my name, I wouldn't have done it.” .“I’ve never had a problem with saying that I go to the psychiatrist, because I think that the head is a part of the body. And that there are professionals for everything; in other words, there’s a professional to treat your head, to treat your leg, for everything, so never a problem… I don’t say it all the time, but whenever I have to say it, I do. But, of course, it’s always convenient, with some issues, to have a bit of anonymity, because people don’t really understand the idea of going to a psychiatrist, because they mistake it for insanity, for people who are in a pretty hopeless situation, with… then in that case, anonymity is good…” .“Interviewer: So, do you think that the anonymity offered by online therapy is a bonus?Patient: Yes, one hundred percent. They don’t know who you are, they don’t know what, what you look like. As far as I’m concerned, totally, one hundred percent.” .3.2.The “goals” theme was also identified as an element of major significance. Participants reported that activities focused on setting goals were important for the maintaining and expanding the initially established therapeutic bond, for motivating participants to achieve symptomatic improvement. Goal-setting was also identified as helpful for promoting greater awareness of the progress made on their treatment journey:“Interviewer: Which module do you think has been the most useful for you?Patient: I think that the one that most… uh… the ones that have been most helpful were the ones where you start… uh… to set your goals; I think it’s super important because it’s the moment you begin to realize where you are and where you want to go, and without doing this, well… you also realize what’s stopping you, what’s been stopping you from doing it, the feelings that have been such a burden for you.” .3.3.The third main theme identified was the so-called “task.” This element is divided into the following two subcategories: “activity-based task” and “responsive support,” which were endorsed by their respective subthemes.3.3.1.via the Internet, which are experienced by the participant as coherent and continuous.“Activity-based task” comprises the “personalization” of tasks in relation to patients’ needs; the “usefulness” of the tasks in terms of encouraging learning and reflection while motivating patients to change their life; and the “complementary” nature of traditional therapy tasks performed face-to-face and those delivered With regard to “personalization,” patients stressed the importance of feeling motivated to complete a therapeutic program that includes content that is specific to their concerns, as opposed to a generic program. Participants also stated their preference to have access to more material that addressed their specific difficulties as they benefited less from being exposed to a wide variety of topics:“There are things that may interest you more than others. There are sections where you say, well… this here, well, it’s not my problem, I might have to skip it. But then you come across a section, a problem, where it can be of help to you. So, there are topics that have nothing to do with you, or maybe only a little… And there are other topics that could really help you, and you tell yourself that a little more information, or reading more, or… more examples wouldn’t be a bad thing… Do you follow me?” .In terms of the “usefulness” of the intervention, participants reported that some aspects of the online program that they regarded positively increased their engagement with the intervention. They included aspects that facilitated openness and mental flexibility, and those providing tools that would allow them to put the theoretical contents into practice, to apply what they had learned:“It has been useful to me, it has opened me up, because it changes the way you think and opens your mind; it gives you new ideas, ideas that, you know, that… putting them into practice can be very, very useful, very useful. It opens up your way of thinking; it makes it more flexible, and you say, ‘Let's see, let's see, let's see.’ You stop, and you remember things, that… that you can use and that… the habits you have, the ones that aren’t good or appropriate for you, well, well, and you change them. Yes. In fact, I think it has been a good experience" .In relation to the “complementary” category, all patients who had access to the digital platform said that, despite perceiving it as a useful and even necessary tool, the digital intervention program could not totally replace the healthcare professional. This was particularly the case for those who identified themselves as suffering from a deep depression that prevented them from starting with the program:“I think this type of program is a tool for support, but it could never ever replace a professional.” .It depends on the stage of depression you’re at … If you’re at a stage where you’re able to log into the program, and it helps you … In other words, when what you’re reading helps yourself to improve, then fantastic … we are achieving the goal. Now, if you’re in a very deep depression … maybe … even if you know what you are reading,. you won’t be able to put it into practice in your everyday life”. .“3.3.2.The second subdivision of “task” is called “responsive support” and includes three subcategories. The first is “accountability,” which refers to the presence of a human facilitator that provides positive feedback to help patients engage with the therapeutic tasks. The second is “guidance,” a reference to the therapist’s availability during the intervention process to provide patients with suggestions that otherwise might not arise without their involvement. The third subcategory is “expression of feelings,” through which participants express their need to share their internal experiences, including the possibility of writing comments to advance in the therapeutic process. However, participants suggested that it was important for a safe space to be created in therapy to facilitate this.Participants admitted that the presence of a person to supervise their progress on the program and their performance of the tasks set by the different modules produced a greater feeling of “accountability” over the therapeutic process, facilitating commitment to achieve clinical improvement:“When it comes to the computer, when you want to do it, you do, but if you haven’t in two or three days, even if you turn on the computer, you might feel a little guilty, and you tell yourself, ‘Oh! It’s already been two days!’ But, if you’re dealing with a person, you can’t do that. It involves a big commitment and you must be there; you can’t let them down. At least that’s how I see it.” .Similarly, patients indicated that being able to count on a person who could “guide” them through the program and could solve any doubts that might arise gave them peace of mind and security to continue moving forward with a greater sense of control regarding the therapeutic process:“Of course, it shows when you don’t have a person by your side to guide you a little or… resolve doubts… It's more about the therapy, not me; when it comes to seeing the psychologist, for example––I’ve never been to one––but I imagine that a psychologist can guide you better … They can guide you more, or they can… more than, more than on a course.” .This aspect is important enough to raise feelings of isolation and entail a risk of the participant dropping out of the program if it is not fulfilled:“Well, it would be good if … if there’s a follow-up. If the psychologist or psychiatrist who treats you follows up your case, of course. If the professional is watching the day-to-day process of how you’re getting on, your state of anxiety, your, your situation. Yes, if someone does a follow-up on that… [Doing it online] gives me the impression that… well, that it’s you alone with the machine and that nobody is following up, nobody is concerned, because, in my case, I was getting worse…” .Finally, the data show the value of having a person to whom patients can tell their problems. This is related to patients’ need to be able to “express their feelings” to another person who will listen and understand without judging:“Talking to someone helps; maybe it just helps to talk and being able to demonstrate, externalize  and so on. So maybe a machine won't give it to you.” .With regard to this need to express, the program’s relative lack of responsiveness was highlighted, particularly in the self-guided application group:“Very limited means of expression because all you had to do was to fill in a few items… it was a grid. I mean, there was nowhere for you to put, mmm… For example, it would have been nice for each module to have a space where you could leave a personal comment…” .“The answers were a bit limited… Those given by the computer I think were a bit limited because sometimes, hmm … I would have given another answer, but I had to limit myself … I think the program should have left a blank space so that you could have said something else.” .3.3.3.The fourth and last main theme of the WA model for b-CBT  that was“Accessibility” appeared to refer to ease of access to the online intervention in accordance with participants’ needs and preferences, which facilitated their involvement in the therapeutic process. Within this subcategory, a new element was detected that had not been identified in the original model. This was a reference to the specific duration of the program and to the time in which patients continue to have access to the materials after completing the intervention. Depending on this time, participants would have more opportunities to understand and apply what was learned during the intervention, as illustrated by the following point:“Doing it at any time of the day has many advantages. I usually did it in the morning, which is when I’m most awake. That’s a very big advantage, and another advantage it also has is that you can review it, you can see it again. That’s also very important because there are some videos where I didn’t manage to capture everything the first time, what with my attention problem, and so now I’ve seen them more than once, you know. I know it’s a bonus.” .“You really have to do this over and over; you really have to cram… because, you know, you’re doing it… and then you start to forget. I mean, at least for me… I’m doing it okay … and then it’s like ‘Wow! Anybody can do this!’ But later, if you’re feeling a bit down, for whatever reason, whatever, well then you actually have to … I think that in those cases, you’d need maybe a whole year, at least it should last longer, or you should have the chance to repeat it, I don't know! Or maybe keep it there a little longer, like saved, you know?” .In our study, the “interactivity” theme was defined as the ability of the program to react and produce comments and reflections from the information provided by users. In this respect, participants indicated that the digital intervention program was insufficient; they reported being left in doubts about theoretical aspects of the intervention, or with concerns that they could not express:“While I was doing the program, there would be times when I also needed an answer right away, you know. Or depending on how I felt, or how I saw certain things, mmm… Of course, the computer doesn’t answer your questions. So, you continue with the program, and you see that everything is very good and very clear. Until things come up that make you say, ‘What about this?’ Well, you leave them as they are because you can’t comment on them. So, contact is sometimes a good thing, don’t you think?" .The “ease of use” subcategory was defined in the present study as having access to an intuitive digital interface. Participants suggested that the greater the feeling of control they are led to feel they have, the greater their motivation for completing the tasks of the program. Our data revealed a nuance to the theme that did not appear in the original model with regard to the importance of adapting the language to facilitate understanding of the information included in the program:“No difficulties; it was so easy to use. At least it was easy for me. Because, otherwise, it’s fine, very easy to do. It’s not complicated, well, maybe for someone who isn’t very familiar with computers. But I didn’t find it complicated at all" .The specific nuance that was added to the model was:“Yes. It isn’t complicated. They don’t use weird words that you can’t understand. That’s what I was worried about at the beginning. I thought: ‘Huh, seeing that the stuff here is just like what doctors say, I’ll just answer the same as always: I don't know!’ But no, no, it’s okay… you can understand it perfectly.” .The “aesthetic appeal” subcategory referred to how attractive the digital psychotherapy program appeared to patients, to the extent that it influenced how useful they perceived the intervention to be:“In other words, it would have been a mistake to just have pages and pages to read; yes, I would have considered that to be a mistake. But the way they had it set up, I think they get to … get to the key issue of every point, and, I tell you, the accompanying videos and the like make it very enjoyable… and very easy, so you don’t mind repeating it, and watching it and going over it several times.” .The final subcategory, “self-directed,” was described as enabling in terms of developing a feeling of responsibility toward the therapeutic process, as well as a level of independence that empowers patients to engage with their own process. While self-directed treatment was perceived positively, there was an acknowledgement that strong willpower was required for any benefit to be possible:“The good thing about it is that you have to look at it yourself, and I also believe that where these things are concerned, you have to take responsibility for yourself. I think you have to give it your… a great deal of willpower" .“Your will to succeed gets you through it. When it comes to getting things done, it’s because you want to be cured or to improve.” .4.This study is the first of its kind conducted in the PC setting in Spain that delves into the construct of the WA using an i-CBT intervention with patients allocated to receive low-intensity support or self-guided application for the treatment of mild to moderate depression. In line with Bordin’s theory , and theThe “bond” category emerged as one of the main factors for establishing the WA, in comparison with previous models . Despite“Goals” appeared to be an independent component, in line with Bordin’s model . HoweverThe “task” category was also identified as one of the main elements necessary for the establishment of the WA. Furthermore, as observed in the United Kingdom study, the central task category was subdivided into two complementary subcategories . On the Finally, a last category, called “usability heuristics,” which is also part of the WA model for b-CBT observed by The present study has several strengths. First, our study builds on Bordin’s WA model, which is widely accepted in the scientific and clinical community, as well as the recently development for b-CBT proposed by via the Internet, maintaining the association regardless of the specific symptoms, frequency, or mode of contact with the therapist  group (B17_20R) and the Network for Prevention and Health Promotion in Primary Care (RD16/0007/0005) grant from the Instituto de Salud Carlos III of the Spanish Ministry of Economy and Competitiveness, cofinanced with European Union ERDF funds. JM-M has a Miguel Servet contract from the Instituto de Salud Carlos III . This study was supported by Institute for Health Research Aragon (IIS Aragón) and Chair of Contemplative Sciences and Master of Mindfulness of the University of Zaragoza, Spain. The funders did not have any influence on the results.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Tutoría entre Iguales, hereinafter TEI ) is Spain’s most important coexistence program for the prevention of violence and bullying in secondary schools and one of the first worldwide. So that we may better appreciate the effectiveness and benefits of this program, a comparative study has been developed between four schools that are presently following this preventive strategy (TEI centres) and four other schools that do not carry out the TEI program (non-TEI centres). Controlling the other sociodemographic variables, students’ perception of coexistence, bullying and cyberbullying has been evaluated. In total, 1015 secondary school students belonging to eight schools from four autonomous communities in Spain participated. The results reveal that the students of TEI centres have a more favourable perception of educational coexistence and indicate lower rates of bullying and cyberbullying than those studying at non-TEI centres. These results highlight the benefits of the TEI program and the need to continue promoting and expanding these preventing bullying strategies in schools.The TEI peer tutoring program (in Spanish,  In recent decades, school coexistence has been the cause of growing concern in the educational world, mainly due to the rise in conflicting situations such as bullying and cyberbullying. These unfortunate events have generated in teachers, families and professionals a special awareness and concern. As a consequence, specific programs have been implemented in schools with subsequent detailed analyses looking into the various variables of the causes and consequences of this phenomenon ,2,3.The first relevant studies emerged during the 1990s, with the publication of the Delors Report, proposed by UNESCO, which establishes as one of the four fundamental pillars of education, “Learning to live together, learning to live with others”  (p. 6). However, there is currently no single definition of the concept of coexistence, resulting in confusion in the absence of a clear approach to help guide research. In English, the term “coexistence” refers to the positive and proactive interaction between the different educational agents in schools . Carbajal  includesIn line with UNESCO’s recommendations, Hirmas and Carranza  underlinFor their part, Fierro-Evans and Carbajal-Padilla  propose On the contrary, a dysfunctional coexistence in schools can give rise to psychosocial problems in students, worse school performance, increased relational problems between family and school and loss of student self-esteem ,13. TherA highly relevant factor that negatively affects school coexistence is the emergence of violence . This phThe term bullying was first defined by Olweus  as a typAt present, the great advance of technologies has made it easier for students to access new forms of communication that are much more immediate and effective. Despite the many benefits that these advances bring, the misuse of electronic devices can lead to the emergence of other forms of violence . Recent Some manifestations of cyberbullying can be the publication of private images, the creation of false profiles, impersonation, spreading defamations of the victim, stalking, password theft, persecution on social networks, violation of privacy, exclusion and provocation. At present, these actions have legal consequences under criminal law, both for cyberbullying perpetrators and witnesses .With the emergence of the COVID-19 pandemic, numerous studies have revealed an exponential growth in cyberbullying cases and, as children increasingly access electronic devices earlier, a marked increase in younger students being involved ,22.In relation to the roles that comprise a situation of bullying or cyberbullying, we can distinguish the roles of victim and aggressor, although there are also witnesses or spectators who can be neutral or be in favour of the aggressors or the victims . All of There are numerous prevention and intervention programs and projects against this type of violence, focused on different areas which are implemented in schools ,27. HoweThe TEI program stands out as being the most implemented in Spain, although it has also been implemented in other countries, with a large amount of subsequent scientific research to measure its effects . It is aAs described by the author of the program , the TEIFor the development of the TEI program in educational centres, students are assigned a tutor who is two years above them at the same school. In the case of secondary education, 3rd-grade students are 1st-grade tutors, and 4th-grade students are 2nd-grade tutors. The tutors always take part voluntarily and are offered training in awareness, empathy, empowerment and individual and group commitment to promote the prevention of bullying in the school and help the younger students seeking help suffering from cases of violence . This prThe TEI program uses, as a practical basis for conflict resolution, a double triangle of intervention, in which the victim of bullying informs their tutor, and together, they seek a solution through dialogue. When the student-tutor fails to resolve the conflict, the victim’s tutor talks to the tutor of the student who has caused the violent situation, seeking a solution to the problem together. In cases where a solution cannot be found, the tutors ask the program coordinator (teacher) to help resolve the situation .Regarding the sequencing of the implementation process, the program consists of six distinct phases: sensitization, approval, training, development, evaluation, and improvement proposals. First, the educational centre is contacted in order to raise awareness of the importance of the program. Subsequently, the educational project is approved by the school´s management team. Thirdly, teachers, students and families receive training on bullying and its consequences, are presented with the project, and are encouraged to actively take part. Students who voluntarily wish to become tutors receive more specific training on the approaches and actions to be developed, with an accreditation card being issued upon completion of the training sessions. In the fourth phase, the tutors are assigned to the younger students and activities are carried out to foster a link between them and ensure the good use of formal and informal tutorials. In the fifth phase, at the end of each term, the teaching staff and students evaluate the effectiveness of the program. Finally, in the sixth phase, an annual final report is made, and proposals for improvement are evaluated ,36. Previous studies have shown that 95% of the schools that have implemented the TEI program have experienced an improvement in coexistence and school climate. In addition, class expulsions are reduced by 40%, school absenteeism by 26%, and some variables, such as performance and students’ self-esteem, improve ,46. AnotHowever, the scientific evidence of the TEI program has, to date, only been analysed in schools that have implemented the program and in very specific regions. Therefore, we consider it necessary to carry out a comparative study that allows for the observation of the differences in coexistence, bullying and cyberbullying between the centres in which the TEI program is implemented and those where the prevention program is not carried out in order to answer the following question: Are there significant differences in coexistence, bullying and cyberbullying between centres that have the TEI program and centres that have not implemented the TEI program?Based on the demonstrated benefits of the program and the results of previous research, it is hypothesized that the educational centres that follow the TEI program enjoy better coexistence and lower rates of bullying and cyberbullying. -To observe the existing and emerging relations between the different factors involved in educational coexistence.-To compare the coexistence relationships among students in educational centres that are implementing the TEI program to those that do not.-To verify the relationships that are established between the main roles involved in bullying and cyberbullying (victims and bullies).-To compare the incidence of bullying and cyberbullying between TEI centres and non-TEI centres.With the interest of deepening knowledge on the effectiveness of the TEI program for improving the coexistence of schools and their ability to reduce bullying and cyberbullying, the aim of this research is to achieve the following specific objectives:In order to achieve the aforementioned objectives, transversal, extensive, retrospective, descriptive research has been carried out with an ex post facto approach by means of quantitative methodology. A comparative study was carried out between centres that have applied the TEI program  and centres that have not (non-TEI centres–control group).In order for the TEI program to involve all students in the school and to be able to observe the benefits, a minimum of two years must have elapsed since its implementation. For this reason, the selected TEI centres have been implementing the program for at least two years.Regarding the variables of the research, those that are the object of study, and therefore constitute the dependent variables, are coexistence, bullying and cyberbullying. The independent variable of the study is the implementation of the TEI program, differentiating TEI centres  and non-TEI centres (control group).In this research, 1015 secondary students in Spanish schools from four autonomous communities  participated. In each of these regions, a TEI centre and a non-TEI centre took part, belonging to the same locality and with similar sociodemographic characteristics. In total, 510 students who belong to centres in which the TEI program is developed and 505 students from centres that do not have the TEI program were the subject of our study. Regarding the distribution of participants in the autonomous community, 293 are from the Valencian Community, 354 from Extremadura, 169 from Castile and Leon and 199 from Galicia. Regarding gender and academic year, the sample is quite evenly distributed, with the participation of 524 boys and 491 girls. With regard to the educational level, 292 belong to 1st of ESO , 253 to 2nd of ESO  and 229 to 4th of ESO (15-year-olds). The sampling used to select the sample was intentional and non-probabilistic, choosing the most representative centres and those that have similar sociodemographic characteristics. For the selection of the centres, it was required that they had at least two years’ experience with the program, as it is the minimum time necessary for the entire educational community to be involved.For data collection, participants were given a questionnaire that included a series of previously validated questions and scales. First, they were asked about different sociodemographic variables . This allowed us to know the characteristics of the sample and compare the participants’ responses. To analyse the variables under study, instruments and scales were used that were previously validated for other research projects.-The Positive Interpersonal Management Factor (α = 0.83) evaluates the interpersonal relationships that exist between teachers, families and students, reflecting the school climate through the communication that is established between these three educational agents.-The victimization factor (α = 0.90) evaluates the exposure of students to negative and violent actions carried out by other students.-The Disruption Factor (α = 0.90) refers to the negative actions carried out by students that interrupt the teaching–learning process.-The Social Network of Peers factor (α = 0.78) analyses the degree of support that exists between peers and the good relationships that are established between them.-The Aggression factor (α = 0.89) evaluates the presence of hostile behaviours that are carried out by students toward their peers.-The Normative Adjustment factor (α = 0.88) analyses the degree of involvement and adherence of students to the norms of the educational centre.-The Indiscipline factor (α = 86) evaluates the actions or behaviours of the students that are contrary to the rules of coexistence of the classroom and centre.-The Teacher Apathy factor (α = 0.92) evaluates the lack of interest, injustice or incoherence of teachers in the management of interpersonal relationships.The coexistence and climate of the centre were evaluated with the School Coexistence Scale (ECE) developed and validated by Del Rey et al. . This scEach of these factors was evaluated based on the perceived frequency or actual frequency based on the facts to which it refers, with a Likert scale of 5 points from 1 = never to 5 = always .The European Bullying Intervention Project Questionnaire (EBIP-Q), developed by Brighi et al., was used to evaluate bullying. [ullying. . This scullying. . ActionsIn relation to cyberbullying, the Spanish version of the European Cyberbullying Intervention Project Questionnaire (ECIP-Q) ,51 was aFor the development of the research, an online questionnaire using the Jot-form application was sent to each student by means of a personal link. Prior to their participation, the objectives and purpose of the project were explained to the participants, guaranteeing at all times their anonymity and the confidentiality of their responses. In all cases, informed consent was then obtained. The online questionnaire was carried out within the schools during school hours in the presence of the teacher responsible for the class group as well as a member of the research team, who was available to answer all the participants’ questions.In order to facilitate analysis and interpretation of the results, the data obtained in all scales and dimensions, both in coexistence as well as in bullying and cyberbullying, were transformed to a hundredfold scale, adapting the values to a range of 0–100.For the analysis of the results, parametric tests were applied, given the high sample size, taking as a representative statistic of the average score of each group (student t and Pearson correlation). For the estimation of the effect size, Cohen’s d statistic was used. The program used to perform the data analysis was the IBM SPSS STATISTICS version 29, and for the elaboration of the graphs, the Excel program.The impact of the TEI program in educational centres was analysed through the evaluation of educational coexistence and the incidence of bullying and cyberbullying in TEI centres and non-TEI centres.Coexistence was evaluated by considering eight factors  that reflect the coexistence perceived by students in educational centres .First, the relationship between the different factors that constitute the Educational Coexistence Scale (ECE) was studied. By means of the Pearson correlation test, it was observed that there is a significant relationship between all factors. In the results shown in In the second group are the factors that are detrimental to educational coexistence . These four factors positively and significantly correlate with each other. However, they show negative and significant correlations with the factors that represent a benefit for educational coexistence, showing inverse relationships.The differences that exist in the different factors of educational coexistence between the centres that are following the TEI program and those that are not were analysed.t-test for independent samples (p < 0.001).The results of  samples , it was t-test for independent samples, it has been observed that these differences are also statistically significant in the five factors (p < 0.001).However, in the factors that have a negative implication for school coexistence , non-TEI centres obtained a higher average score than TEI centres. After applying the student For the calculation of bullying and cyberbullying rates, EBIP-Q and ECIP-Q scales were used, respectively. With both scales, the levels of aggression (bully) and victimization (bullied) were analysed, both in the school environment and in the virtual environment.p < 0.001) between them all. To observe the relationship between the main protagonists of bullying (victim and bully) and cyberbullying (cybervictim and cyberbully), Pearson’s correlation test was applied. The results  show thap < 0.001), which indicates that on the Internet, people who are victims often act as aggressors as well. In addition, the correlation between bully and cyberbully is also quite high , indicating that there is a tendency for students who are bullies in the physical educational environment to also be bullies in the virtual environment.These results indicate that there is a tendency for students involved in bullying to assume all roles at the same time, being victims and bullies, both in the physical school environment and in the virtual one. The highest correlation is observed between the roles of cybervictim and cyberbully . In the virtual environment, TEI students  also show lower levels of cybervictimization than students in schools that do not follow the TEI program . These differences are statistically significant, as indicated by the student t-test for independent samples (t(1012.998) = −3.950; p < 0.001; d = −0.235).In schools where the TEI program is implemented, students identified themselves to a lesser extent as harassed, reporting lower levels of victimization  than in non-TEI centres . Applying the student  samples , we obset-test for independent samples, we observed that these differences in identification as aggressors are statistically significant, both in the physical world (t(1001.306) = −3.794; p < 0.001; d = −0.230) and in the virtual one (t(957.888) = −5.046; p < 0.001; d = −0.289).Focusing on the role of the bully, it becomes clear that participants of TEI centres  have reported to a lesser extent that they enact aggressive behaviours directed toward peers than students of non-TEI centres . This same phenomenon is extrapolated to the virtual environment, where students of TEI centres  ensure that they carry out fewer cyberaggression acts than students of non-TEI centres . After applying the student In educational centres, in addition to training on academic and curricular content, it is necessary to contribute to the personal and social development of students by promoting the values necessary to live in society and favouring a civic coexistence free of violence.It has been shown that bullying is more frequent in schools and environments with very rigid or arbitrary rules, excessive competitiveness, a lack of support from teachers, or in environments in which there is insufficient awareness of the importance of good coexistence for learning . On the Therefore, in schools, it is important to develop specific programs such as the TEI program, which seeks to improve the climate and culture of schools, involving the entire educational community while paying special attention to students.With this need in mind, this research has shown that the TEI program promotes better coexistence in schools and generates lower levels of bullying and cyberbullying when compared to schools where this program is not being undertaken. Thus, the initial hypothesis of our study is confirmed, which is also supported by previous research that has demonstrated scientific evidence which supports the TEI program ,37.Focusing on the first research objective, the evaluation of coexistence in schools through the ECE scale , has shoComparing educational coexistence between TEI and non-TEI schools, according to the second research objective, it has been revealed that the students of the TEI centres also have a more positive perception of this aspect than students of the non-TEI centres. Higher average values have been obtained in those factors favourable for coexistence  in TEI centres. Conversely, higher average values in the factors that negatively affect coexistence  are found in non-TEI sites. Thus, students have a more favourable perception of coexistence in the centres where the TEI program is implemented than in those centres in which the prevention program of school bullying has not. These results indicate that the TEI program represents an improvement in coexistence in schools, as has already been reported in other previous studies ,37.Regarding the variables of bullying and cyberbullying, and addressing our third research objective, the roles of victim and aggressor have been analysed, both in traditional bullying and cyberbullying. The results suggest that there is a high and significant relationship between the four roles . These results reveal that those students who are victims also act as aggressors, this phenomenon occurring both in traditional harassment and cyberbullying. Thus, it is confirmed that there exists a relationship between the primary roles in school bullying, victims and bullies. These findings had also been demonstrated in previous studies where continuity and overlap between victim and aggressor roles were found, especially in the virtual context . In addiFocusing on the fourth and final research objective, the incidence of bullying and cyberbullying has been compared between TEI and non-TEI schools. It has been shown that TEI centres report fewer aggressors and victims, both in traditional harassment and in cyberbullying. These results show that the TEI program contributes favourably to reducing bullying and cyberbullying, as other studies have previously affirmed ,37. TherPrevious studies ,53 have The presence of bullying and cyberbullying causes innumerable negative consequences for all those involved, which affects the students’ mental and emotional health. There exists scientific evidence that mental disorders are increasing among adolescents, with symptoms such as anxiety, depression, isolation, obsessive routines, concentration span problems, sleep disorders, autolytic disorders and even suicidal tendencies or symptoms of post-traumatic stress. These are all often the result of bullying and cyberbullying . In addiAs can be seen, bullying not only has negative consequences for the student who suffers or carries it out but for the entire educational community that witnesses it, be it directly or indirectly. It is, therefore, essential to design educational programs or strategies that help prevent bullying and promote coexistence and the creation of a healthy school climate. The TEI program is aimed especially at developing emotional skills and promoting values such as empathy, cooperation, empowerment and commitment in students as preventive and deterrent elements of violent behaviour. These strategies promote psychological well-being, and reduce the appearance and development of mental disorders, which are sadly rife among adolescents in recent times.It is important to note that this study is based on the collection of data through self-report instruments, which implies certain inherent limitations. The data obtained rely on responses provided by participants, which may be subject to cognitive biases, lack of precision, or even the possibility of socially desirable responses. Additionally, self-assessment can be influenced by personal and subjective factors, which could affect the objectivity of the results. Despite these limitations, measures have been taken to ensure the confidentiality and sincerity of responses, and appropriate statistical techniques have been used to minimize the impact of potential biases. However, it is essential to recognise that the use of self-report instruments represents a methodological constraint that should be taken into account when interpreting the findings of this study.Another significant limitation of this research has been the sample selection. The number of schools that participated was limited in comparison to the total number of study participants. This limitation implies that the results and conclusions should be interpreted with caution and may not be applicable to a broader population of educational institutions. For future research, it is recommended to consider a more diverse and larger sample of schools to improve the generalizability of the findings. Despite this limitation, this study provides a solid foundation for future research in the field of coexistence and the prevention of school bullying.Thanks to this research, we have made progress in understanding the effectiveness of the TEI Program in improving educational coexistence and reducing levels of school bullying and cyberbullying, laying the groundwork for future investigations in this field. One possible direction for future research could be the development of longitudinal studies that allow us to track changes in students from the beginning of the TEI program’s implementation and follow the participants’ progress over time. Additionally, comparing our findings with similar research in different geographical or cultural contexts could further enrich our understanding of the program’s effectiveness.In the future, it is necessary to continue researching the comorbidity that exists between school bullying and mental health while also examining the benefits that may arise from the TEI program for promoting psychological well-being and reducing emotional problems in students. Certainly, it would also be interesting to continue researching the effects of bullying in more advanced academic stages, such as university studies , as wellIn this research, the TEI Program has emerged as one of the primary, highly effective strategies for promoting positive school coexistence and preventing school bullying and cyberbullying. It has been demonstrated that the advantages of the TEI Program are significant, with students in schools implementing the TEI Program experiencing better educational coexistence and a lower incidence of school bullying and cyberbullying compared to those in schools where the program is not implemented. Furthermore, the TEI Program promotes active student participation by involving older students as mentors for their younger peers. This peer mentoring dynamic contributes to creating a more inclusive and safe school environment where students feel supported and engaged, fostering values such as empathy, respect, and solidarity among peers. Moreover, empowering students as active agents in bullying prevention makes them feel like an essential part of the process, encouraging their involvement in the early identification of conflict situations and peaceful conflict resolution, and thus reducing levels of school bullying and cyberbullying.In conclusion, the results of this study support the effectiveness of the TEI Program as a valuable tool in the educational realm, as it promotes a collaborative learning environment and mutual support. These findings underscore the importance of considering the implementation of the TEI Program as an effective tool for promoting the improvement of educational coexistence and reducing cases of school bullying and cyberbullying through active student participation in the process.