Its effects on adolescents' resilience and mental wellbeing will be examined.Many stress-related mental health problems, like depression and anxiety, emerge during adolescence, with some recent studies suggesting numbers are increasing. One possible way to reduce adolescents' vulnerability to stress-related mental health problems is to increase their resilience by training them in recalling specific positive memories and anticipating specific positive future events. Therefore, an innovative A cluster randomized controlled trial with a 2 (condition) × 3 (time-point) factorial design was conducted. Classes of adolescents were randomized to either a PET program (intervention) or a CREAtive writing Training (CREAT) program (active control). Both trainings consisted of four sessions of 50 min  and were delivered in schools. Before , immediately after , and 2 months after the training , participants completed a series of self-report questionnaires. Primary outcomes are resilience and mental wellbeing. Secondary outcomes are positive affect, positive affect regulation and anhedonia. CONSORT criteria for conducting and reporting RCTs will be used.ClinicalTrials.gov . We plan to develop a free, online, web-based self-directed PET protocol for teachers if the study provides evidence for the effectiveness of the PET program in increasing adolescents' resilience and mental wellbeing, so teachers can deliver the program to future students without the need of professional external trainers.Ethical approval was obtained from the Social and Societal Ethics Committee (SMEC) and the study has been preregistered on Open Science Framework (OSF) and  Many stress-related mental health problems emerge during adolescence and represent the largest cause of the burden of disease among young people . FurtherOne important way to reduce the burden of disease due to stress-related mental disorders is to shift the focus from addressing deficits to strengthening protective factors. This fits with the call to complement a treatment approach with a preventative approach . Our stuRecent basic research indicates that recalling specific positive memories is one such resilience-enhancing factor, both in adults and adolescents. Studies show that recalling specific positive memories is associated with reduced vulnerability to emotional problems in the face of stress , activelIn a similar vein, research suggests that anticipating specific future positive events holds promise as a potential focus for resilience and mental wellbeing promoting interventions. Basic research in young adults shows, for example, that anticipating positive events leads to improved coping and recovery following stress . Such fior future events, while it has become clear that both have unique, yet complimentary benefits. Whereas (positive) memory specificity has been linked to less negative thinking , focusing on the enhancement of the specificity of both past and future positive events in adolescents. Studies showed that there is considerable overlap in the brain structures that are involved in thinking of past and future events. A recent meta-analysis showed that both processes of past and future thinking have cerebral bases that involve the medial temporal lobe (including the hippocampus), as well as frontal, temporal, and parietal areas  the present moment experience of positive emotions, (ii) the regulation of positive emotions when they are experienced, and (iii) the basic capacity to experience pleasure .So besides looking at the experience of positive emotions as such, we will also explore the impact of the PET program on how adolescents regulate such positive emotions. This is an important focus, as research shows that regulation of positive emotions is also a prominent factor in the development or prevention of emotional problems. For example, youngsters who typically dampen or downplay positive emotions (by using thoughts such as “These good feelings won't last”) are more likely to suffer mental ill-health , 31. On In the context of positive emotion and its regulation, we will also examine the impact of the PET program on anhedonia. In contrast to dampening or savoring, anhedonia refers to a lack of capacity to experience interest or pleasure in activities that might otherwise be thought to be rewarding . In addiA cluster randomized controlled trial with a 2  × 3  factorial design was conducted. Classes of adolescents were asked to complete measures of the study outcomes at all three time points (see procedure).N = 65 for each condition) provides 80% statistical power to investigate the effectiveness of the PET program, with an alpha of 0.05 and estimated medium effect sizes of 0.25 (d = 0.82 (for increased specificity) to d = 1.78 (for anticipated pleasure)  , 14, thiMage = 13.2, SDage = 1.00) and 93 in the CREAT program . Gender distribution was approximately the same in both groups .Participants were recruited via secondary schools in Flanders, Belgium. Years 1 to 4 (1st and 2nd grade) of general secondary education were invited to participate, referring to ages 12 – 16. Five different schools (spread across three provinces) participated in the study. Each school selected one pair of parallel classes, which resulted in five pairs of classes . In total, 188 adolescents participated in the study. Of all the adolescents, 95 were in the PET program . One booklet was addressed to the adolescent and the other to their parent(s). Adolescents and their parents were invited to sign their versions of the informed consent in duplicate. In consultation with the school, a deadline was agreed on for the adolescents to hand in the two signed versions of the informed consent. Direct access to the school communication platform was asked for as contact information of participants and their parents is integrated in this platform, which was needed to provide participants with their unique participation code.Subsequently, participants completed the baseline assessment online, which consisted of a series of self-report questionnaires. It is only after completion of this first assessment that the researcher who was coordinating the study in the schools and who delivered the trainings was informed about the result of the random allocation (conducted by an independent statistician) of classes to one of the two conditions. The training programs started 1 week after the first assessment, and, in every school, classes received training sessions on the same days. Furthermore, training sessions were delivered by a researcher without a teacher being present. In that way, contextual variation across sessions and classes was kept to a minimum . In addition, efforts were made to ensure that both trainings closely resembled in terms of format, structure, intensity, interaction between adolescents, invitations to practice with the skills taught during the in-class sessions. In this way, we aimed to prevent that adolescents would start to speculate about study hypotheses.After completion of the trainings, adolescents of both groups took part in two final assessments. That is, a similar series of self-report questionnaires were presented 1 week (post-training) and, again, 2 months after the final training session (follow-up). Assessments in parallel classes  were administered at the same day to minimize potential confounding effects by contextual factors. Per assessment, completing the self-report questionnaires took approximately 60–90 min. Self-report questionnaires were administered via Qualtrics (GDPR-proof online survey platform) on the laptop/tablet of the participants at school, with the intention to minimize errors due to manually entering data and missing values . One of the involved researchers was present during the assessments, so participants could ask questions if necessary.Bol.com  as an incentive. In addition, participants and participating schools will be debriefed via email about our specific hypotheses and they will have the possibility to contact the researchers for additional information. Participating schools will automatically be informed about the general results.At the end of the study, participants will receive a €25-voucher for The PET program is a group-based training program combining Memory Specificity Training  and FutThe control training or CREAtive writing training (CREAT) follows the exact same format and length as the PET program . Following brief psychoeducation on the rationale behind the PET program, participants completed a series of creative writing exercises – which are not self-referential – using funny and thought-provoking writing prompts. They were explicitly instructed not to write about themselves as the main character in their stories, to mitigate against the risk of partially triggering expected working mechanisms of the PET program. Concerning the rationale, participants were told that creative writing has been found to be beneficial for mental wellbeing, as they cultivate creativity and stimulate imagination skills. A similar CREAT program has been successfully used before in an online version as a control training for a memory specificity training .Primary outcomes are resilience and mental wellbeing. Secondary outcomes are positive affect, positive affect regulation and anhedonia.In the self-report questionnaires below adolescents were instructed to consider and rate their experiences of the past 2 weeks. All scales have proven psychometric quality (see below) and have been used successfully in adolescents before , 40–43. not at all) to 5 (very often), with higher scores indicating higher resilience . The CD-RISC shows good construct validity, convergent and divergent validity, test-retest reliability, and good internal consistency with a Cronbach's alpha value of 0.85 in young adults  to 5 . Higher scores reflect higher mental wellbeing . There is evidence for good convergent, construct and discriminant validity and for high internal consistency (α = 0.88) in an adolescent sample  was measured using the Short Warwick-Edinburgh Mental Wellbeing Scale (SWEMWBS) , 49. Thet sample , 50, 51.very slightly or not at all) to 5 (extremely), with higher scores reflecting higher positive affect . The scale has good convergent and discriminant validity and good internal consistency  in a sample of adolescents  was administered to assess positive affect (secondary outcome) , 53. Thelescents –54.not at all) to 4 (very often). The minimum total score a participant can get on the RPA-C is 17, the maximum is 68. There is evidence for good convergent and incremental validity and internal consistency for each scale is sufficient to good  in both children and (young) adults  –57 was u) adults –57.completely untrue) to 5 (completely true) with higher scores reflecting higher levels of anhedonia . The total scale of the LASS has good internal consistency with a Cronbach's alpha value of 0.81 (Symptoms of anhedonia (secondary outcome) were measured using the Leuven Anhedonia Self-report Scale  . All 12  of 0.81  and ther of 0.81 .never) to 3 , with 0 as a minimum total score, and 63 as a maximum total score. There is evidence for good construct and concurrent validity and good internal consistency of the subscales of the DASS-21 in both adolescent and adult samples, with Cronbach's alpha ranging from 0.79 to 0.94   was used to 0.94 , 61.only potential positive future events regardless of the cue word valence.The Episodic Future Thinking Test (EFT-T) , 62 was The Autobiographical Memory Test (AMT)  measuredThe AMT and EFT-test were complemented by a series of single-item ratings , 39 follalmost never) to 5 , with 13 as a minimum total score, and 65 as a maximum total score.The Leuven Exeter Dampening Scale-General  is a newly developed self-report scale, aimed at covering a larger variety of dampening appraisal styles compared to traditionally used scales. The LEDS-G consists of 13 items  that are rated on a 5-point scale going from 1  to 7 , with higher scores reflecting higher levels of savoring .A Dutch  version of the 10-item-version of Abridged Ways of Savoring Checklist for Adolescents   was usedAs part of the second assessment point, adolescents were asked about the extent to which they actively engaged in the training and actually completed the homework exercises. Additionally, some questions about their personal experiences with the training were presented. As part of the final assessment, adolescents were asked to which extent and how they continued practicing the skills they learned during the training. Finally, they were asked a few questions about the perceived impact of the training.The EFT-test and AMT are not expected to have possible disadvantages for participants, as they do not directly assess (expressions of) mental health or wellbeing. Instead, they explicitly focus on positive generated future thoughts and memories. Some of the self-report questionnaires do tap into aspects of mental health  though, which may result in some adolescents becoming aware of their engagement in suboptimal ways of regulating positive emotions, low levels of positive emotions, etc. However, such gained insights in one's own mental wellbeing and ways of regulating emotions should not necessarily be considered problematic. It may rather encourage participants to pay (more) attention to their mental wellbeing and ways to enhance it.www.awel.be, tel. 102; www.tele-onthaal.be; jongerenadviescentra). This information was referred to again at the three assessment phases.Irrespective of the experienced impact – if any – of the baseline assessment, the intervention group was offered the PET program immediately afterwards. The PET program aims to stimulate resilience and mental wellbeing, increase levels of positive emotions, and create a shift toward more adaptive ways of positive emotion regulation. In addition to participants of the intervention group, participants of the control group may benefit from their active control training (CREAT). We do not rule out the possibility that participants in the CREAT program would also experience (some) positive effects from that training by focusing on positive emotions  and non-training-related factors of the training. Furthermore, as part of the informed consent, participants were provided with a list of relevant contact points if they experience the need for counseling , who has a background in clinical psychology (master degree). Additionally, regular supervision was organized by FR  and the back-up trainer (LB), both closely involved in the developmental process of the PET and CREAT programs. Ultimately, no emerging safety issues or adverse events occurred. Nevertheless, if this had been the case, this would have been discussed immediately with the PI (FR) and documented via the available adverse event form for emerging safety issues.However, no inconveniences are expected to be caused by the PET program. Previous research, cited above, has already demonstrated the beneficial impact of both components (MEST and FEST) on several outcomes , and the PET program is explicitly focused on the elaboration of positive personal experiences. As mentioned above, also for the CREAT program no indications for negative consequences were found in a previous study . FinallyAge and demographic data  were recorded. Participants were asked to fill in a unique participant code , so their name cannot be directly linked to the data collected in this study . As soon as data collection is finished (including linking of data of the three assessment points), the file in which names of participants are linked with the unique codes, will be deleted.The school communication platform was used to send participants their unique codes and practical information about the study. As part of both trainings, participants were handed over a printed version of the exercise sheets (during sessions) and worksheets (homework). If needed, a digital version of the worksheets was sent via email. All contact information will be deleted as soon as data collection is finished. As part of the informed consent, participants could fill in their email address if they want to be informed about the general study findings. After communication of the findings, this list with contact information will be deleted.Qualtrics, the platform that was used for the assessments, is GDPR compliant and all surveys were created on a KU Leuven licensed (protected) Qualtrics-account. As data of a personal and sensitive nature require to be transferred, stored, and handled with optimal guarantee for security and in accordance with EU privacy regulations, the data from the self-report questionnaires will be analyzed based on unique participant codes.All analyses will be completed in accordance with CONSORT standards. Intent-to-treat analysis will be used. Our primary and secondary outcomes will be analyzed using analysis of variance (mixed ANOVA) with time  as a within-subjects factor, and condition  as a between-subjects factor. Any baseline differences will be covaried in analyses.t-tests will be calculated to examine group differences at post-training and follow-up time points. To correct for the inflated risk of a Type I error from multiple comparisons, Benjamini and Hochberg's , random effects for the dummy variables representing time clustered within individuals, and an interaction between time and group will be run to detect changes between groups for the primary and secondary outcomes. Follow-up independent samples chberg's  false dihttps://admin.kuleuven.be/raden/en/smec). Subsequent modifications to the protocol were submitted to SMEC. Moreover, this study has been preregistered on Open Science Framework  and ClinicalTrials.gov (NCT05757180).Ethical approval for this study was obtained from the Social and Societal Ethics Committee  took place in January 2023, the second assessment (post-training) in March 2023, and the third and last assessment (follow-up) in May 2023 . The codcombi-training (PET program) that focuses on the enhancement of the specificity of both past and future positive events in adolescents. Working with both past and future positive events is expected to allow people to integrate past, present, and future experiences. This is important for creating a sense of meaning, purpose, and direction in one's life. Finally, in addition to the post-training assessment, the RASPERA-study includes a follow-up assessment to examine the impact of the PET program on the study outcomes 2 months after the training.The RASPERA-study uses a cluster randomized controlled trial design to investigate the effect of the PET program on adolescents' resilience and their mental wellbeing as primary outcomes, compared to a control training. Furthermore, the RASPERA-study examines potential underlying mechanisms of the impact of the PET program on resilience and mental wellbeing, with a particular focus on positive emotions and related emotion regulation styles. In addition, the RASPERA-study is the first study to investigate the effect of a One limitation of the study design is that, due to the primary focus on resilience and mental wellbeing, data collection solely relies on self-report measures. Furthermore, generalizability of the results might be somewhat limited, because for this initial examination of the effectiveness of the PET program only secondary schools in Flanders (Belgium) participated in the study. However, this initial test is crucial to find support for the effectiveness of the PET program on the study outcomes. In a next step, future studies should further investigate the applicability of the PET program in other contexts.We plan to share consolidated findings in an article, which will be submitted for publication in a peer-reviewed journal. Furthermore, we plan to develop a free, online, web-based self-directed PET protocol for teachers if the study provides evidence that the PET program is effective in increasing adolescents' resilience and mental wellbeing, so teachers can deliver the program to future students without the need of professional external trainers.The studies involving humans were approved by the Social and Societal Ethics Committee (SMEC). The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation in this study was provided by the participants' legal guardians/next of kin.LB, FR, DH, and AD were involved in conception and study design. EL and LB were responsible for drafting the article and collected the data and they will analyze them. EL was responsible for recruitment of the participants. All authors were involved in critical revision of the article, approved the final version of the article, and agreed to be accountable for all aspects of the work.


We obtained a total of four categories and eighteen subcategories: structure , participants , assessment , other components . The perspectives of the professional experts and of the adolescents that we obtained from this study contributed to the design of a proposal for a program to promote adolescents’ PMeHL.Over the last years, there have been several studies that have shown insufficient levels of adolescents’ mental health literacy (MHL). Knowledge about intervention programs that promote positive mental health literacy (PMeHL) among adolescents is still very scarce. In this sense, we defined as objectives to identify and describe the necessary components to design a program proposal that promotes adolescents’ PMeHL. We conducted an exploratory, descriptive, qualitative study using two focus groups in July and September 2022 with an intentional non-probability sample of eleven participants . Data were analyzed using content analysis, using NVivo The mental health of adolescents has been a subject of interest in recent years, not always for the best of reasons. The high prevalence of mental disorders is a reality ,2, but aWe are aware that adolescence is a turbulent transitional period in the life of a human being, because it is full of marked and rapid changes in biological terms, which are also reflected in mental, psychological and emotional terms, and where brain neuroplasticity is high ,6. This These concepts of health literacy (HL) and MHL have been gaining more expression and interest in the last decades, not only by health and education professionals, but also by researchers. According to the integrated model proposed by Sørensen et al. , HL refeThe concept of positive mental health (PMH) has also clearly emerged in recent years in the health field, due to its salutogenic dimension, and although it does not have a universal definition, it is related to an individual’s ability to understand themself and their environment in order to optimize daily functioning in relation to themself and others . AssociaRecently, Carvalho et al.  publisheSchool has been recognized by several researchers as a privileged context for the promotion of HL and MHL in children and adolescents ,18,19,20Therefore, we must invest in interventions that promote adolescents’ PMeHL, so that they acquire competencies that allow them to deal with and experience all of the normal changes in this stage of human development in a healthy way, thus making a huge contribution to the future of having mentally healthy and resilient adults ,6,22. ThIn this sense, and continuing our research to date in this area, we gathered a group of experts and sought to explore their perspectives on a PMeHL program for adolescents, using the focus group technique in order to obtain information to design an intervention proposal.core elements: (1) “considering context”, which in our case is the school context, and (2) “engaging stakeholders”, such that in the focus groups, besides health and education professionals, who are the potential facilitators of the intervention, we also included adolescents, who are the target group.In order to identify and describe the components necessary to design a program proposal to promote adolescents’ PMeHL, we used the new framework for developing and evaluating complex interventions  from theThe research question that guided the present study was the following: What are the necessary components for designing a program to promote PMeHL among adolescents?Consolidated criteria for reporting qualitative research (COREQ) checklist , such as citizenship. (P4_Teach_F1)Should ideally be a transversal intervention, not in a particular discipline; it could be included in the content of several disciplines. (P6_ChildPsy_F1)Format. It was considered by the participants that the program should have a modular format , organized by sessions , and they highlighted the importance of being based on the adolescents’ needs :It can be more modular. (P1_SpNurs1_F1)I think that being organized by sessions is perfect; there has to be a logical following. (P7_SpNurs3_F2)It doesn’t make sense to me to do a comprehensive promotion or prevention program for everyone, maybe more targeted and more individualized to the needs of each one. (P7_SpNurs3_F1)Contents. There was consensus among the participants that the contents should be based on the factors of the Multifactor Model of Positive Mental Health, i.e., personal satisfaction, pro-social attitude, self-control, autonomy, problem-solving and self-actualization, and interpersonal relationship skills , and should have as background the health literacy matrix, especially the dimension of ‘apply’ :If we intend to have an intervention, a literacy program and to focus on positive mental health, then it is important that we base our content on the foundations of positive mental health. (P8_SpNurs4_F1)The issue of ‘access’, ‘understand’ and ‘apply’ is important for literacy, and [it should be] very focused on ‘apply’. (P1_SpNurs1_F1)The participants also emphasized the importance of addressing emotions in order to clarify them for adolescents and to differentiate them from diagnoses of mental disorders . They recommended that special emphasis be placed on positive emotions and praise , as well as on coping/resilience strategies :There is a confusion between emotions and diagnoses. (P3_SpNurs2_F1)maybe we won’t talk about all of them [emotions],; we talk about the primary emotions eventually for the level of development they [adolescents] are at, [and] we talk about the most primary emotions. (P1_SpNurs1_F2)(…) to praise strength, (...) working on positive emotions. (P5_Res_F1)(…) Also in this subcategory, participants pointed out that the content should be based on the adolescents’ needs :According to the needs of the target audience itself. (P2_Psy_F2)In addition, it was suggested by some of the participants that the Delphi technique should be used to validate the content of each module and session :to validate this [session content], is to look at it thoroughly, maybe with a Delphi technique; I think it’s the simplest way to do it. (P8_SpNurs4_F2)(…) Length and frequency. It was suggested by participants that the program must have a well-defined start and end date for implementation (P7_SpNurs3_F1) and that it should have a regular frequency during implementation to ensure a certain continuity. Every two weeks or monthly implementation was suggested , with concern that the frequency of implementation needs to be adapted to the school context :An intervention program at the literacy level has to be tight; it has to have a beginning and an end. (P7_SpNurs3_F1)Frequency every 2 weeks or monthly. (P9_SpNurs5_F1)In relation to frequency, I think it can be variable; it differs from school to school, [and] it depends on each school’s citizenship project. (P7_SpNurs3_F2)Regarding the length of each session, participants proposed 45 min, which corresponds to one class period , but pointed out that the length may vary depending on the content to be covered and the dynamics to be carried out, and that in some cases two class periods may be required, i.e., 90 min :Maximum duration of 45 min. (P9_SpNurs5_F1)I think that the duration is very relative, because it is very much associated with the content. (P10_Ad1_F1)the time I think has to be between 45 and 90 min; if we can negotiate, 90 min is much easier. (P1_SpNurs1_F2)(…) Pedagogical methods. Participants recommended giving priority to the use of active/dynamic pedagogical methods , with a concern to be appropriate to the goal of each session . In addition, they suggested using methods/models that have already demonstrated effectiveness (P6_ChildPsy_F1):in a more dynamic way and not exactly being closed in a room and listening to what someone tells us. (P10_Ad1_F1)(…) If we have people who still do not have a basic knowledge of what we are going to explain, maybe it is important to start with a more expository issue, then move on to the most active strategies, so we already have a higher level of knowledge that is likely required for the application. (P8_SpNurs4_F1)trying to look for positive models that have already demonstrated success and try to reproduce them. (P6_ChildPsy_F1)(…) Pedagogical techniques. Several pedagogical techniques were listed by participants that they most recommend to be used during program implementation, such as role-play/theater , games , group dynamics , discussion and reflection , group work , online information searches (P9_SpNurs5_F1) and movies/videos (P1_SpNurs1_F2).The importance of having a diversity of pedagogical techniques in each session and throughout the program was also underlined :I think that a 50-min class has to have 4 or 5 different activities to be dynamic and to [encourage] interaction between the students and the facilitators of the program. (P4_Teach_F1)Resources. During the discussion, some participants suggested including technology as a resource to be used in the program implementation , because it is very suitable to the adolescents’ preferences, although they warned about a careful use of these technologies  due to the obstacles/problems they may imply, pointing out that there are also other resources that can be used during the program :Adolescents like means of application; for example, any intervention must have digital means. They are the Z generation, they are already the Alpha generation, they were born in the digital environment, and this must be present.(P5_Res_F1)Technology is good, and it’s appealing, but it’s also distracting; there has to be a balance between these two ideas of technology, yes, but with some caution because we can have a lot of obstacles later in our program. (P8_SpNurs4_F1)Schools sometimes don’t have internet and that doesn’t make it easy; however (…), they [internet and apps] are not the only thing we can work with. (P4_Teach_F1)Denomination. Although some suggestions for possible denomination of the program were made, participants suggested that it would be more interesting if the name of the program was chosen based on suggestions from the adolescents themselves, for example through a competition or voting , keeping in mind that the denomination needs to be short :the name (…) do a competition, for example, to choose, or a student vote. (P11_Ad2_F1)[To determine] The name, (...) it has to be something small to stay in memory, that is easier for diction. (P7_SpNurs3_F2)Target group. According to the participants, the program we are designing should start being implemented from the fifth grade and then continue in the following school years , i.e., start covering adolescents from 10 years old on. Furthermore, they proposed keeping classes together , dividing them into small groups during the sessions . The following context units demonstrate the achieved findings:Mental health literacy has to be worked on as early as possible, it has to start in the 5th grade (…); however, it has to be worked on throughout life. (P4_Teach_F1)I think it’s important to keep the class, because we know our colleagues better. (P11_Ad2_F1)groups have to be smaller. (P5_Res_F1)(…) Program facilitators. Participants considered that the program facilitator team should consist of health professionals and school professionals  to enrich the program:always as a team: School Health, teachers, everyone, always a team. (P1_SpNurs1_F1)(…) I feel that we all have to be there because that’s the only way to bring even more benefits because our views and our visions of everyone are important, (...) I speak (...) of nursing, I also speak of the school psychologist, I speak of the professionals that we have available. (P1_SpNurs1_F2)Furthermore, two very important aspects were highlighted in the program design; on the one hand, the team should be composed of at least two facilitators , and on the other hand, the facilitating team should be maintained until the end of the program implementation (P7_SpNurs3_F1), to guarantee continuity:We need at least two program facilitators to implement the intervention/session plus the class director, who is assisting, and a psychologist from the school. (P3_SpNurs2_F1)The reference person who starts the program stays until the end (…) in order to give continuity. (P7_SpNurs3_F1)Timing. Participants considered that evaluations should occur before the application of the program and at the end , as well as during the follow-up . At these moments, the adolescents would be subject to self-evaluation by filling out instruments that will allow us to verify the existence or not of improvement in the results. The following context units illustrate the results achieved:It is important that we have a pre and post assessment here to see if there is effectively a gain. (P8_SpNurs4_F1)Always! At least after 3 months. (P9_SpNurs5_F1)[Follow-up] Adolescent assessment was also recommended in each session , through a hetero-evaluation performed by the program facilitators, to understand if the adolescents are able to apply the themes addressed in the sessions, and to get answers to the program process indicators:It is important to have an assessment of the process (…) in each session. It even gives us feedback on the improvement of the sessions because we can always improve the program. (P1_SpNurs1_F1)“can you apply this information of positive psychology and positive health literacy to your everyday life, even just one thing? If you did, what did you apply it to?” This is what enriches the competences of these adolescents. (P5_Res_F2)[Ask the adolescents] Evaluation instruments. Participants suggested the use of instruments that already exist and are validated for the assessment of positive mental health and mental health literacy . However, they stated that in order to be able to make a more specific evaluation of the results regarding positive mental health literacy, the most correct thing to do would be to create an instrument to evaluate the results of the application of this program, as well as observation grids for the process evaluation in each session . The following context units demonstrate the results we obtained:there is Claudia’s instrument, then there is Bjørsen’s own study. (P1_SpNurs1_F1)(…) throughout the sessions we have observation grids. (P1_SpNurs1_F1)(…) To have a questionnaire that gives you an answer, a test that gives an answer to your program, you will probably have to build an instrument. (P8_SpNurs4_F1)In addition, they recommended that the instruments should allow for the assessment of acquired competencies and not just knowledge :The instruments of evaluation cannot only be effectively instruments of knowledge; there must also be competencies here. (P1_SpNurs1_F2)a scale of (…) perceived competence or self-efficacy; it’s always easier for us to see a difference here. (P8_SpNurs4_F2)(…) Planning, articulation and adaptation. Participants mentioned that the program should focus on practical things , should be adapted to the adolescents’ and context’s needs , that facilitators should be careful with the language used  to make sure the message is delivered correctly, and emphasized that, above all, good planning and articulation with the school is required :It is better to focus on simple and practical things and bring awareness and give tools. (P3_SpNurs2_F1)It is good to have this flexibility and this possibility of being able to adjust the program to the needs of the context, the needs of the adolescents and the capacity of the school. (P1_SpNurs1_F1)must be planned at the beginning of the school year so that we are successful in the implementation. (P3_SpNurs2_F1)[The program] Involvement. According to the participants, it is important that in the implementation of the program, the adolescents themselves who are going to be targeted by the program are involved , as well as the parents/legal representatives  and the school :Adolescents should have a voice and should be listened to in their needs. (P3_SpNurs2_F1)I think it shouldn’t be something addressed just to us, but also to parents. (P10_Ad1_F1)with the involvement of the school. (P2_Psy_F1)(…) Training. It was mentioned by the participants that it is essential to have prior training for all facilitators about the program and its implementation :So, I think it was important for us to talk about this, that in order to be applied, it is necessary to provide training to those who are going to apply it, whether they are citizenship teachers, which seems fine to me, or whether they are Class Directors. (P7_SpNurs3_F2)Special situations. The participants warned that there may be adolescents with special educational and health needs, but they should not be excluded from the application of the program . They also advised that special care should be taken with immigrant adolescents (P7_SpNurs3_F1) and with adolescents with mental health concerns (P2_Psy_F2). The following context units illustrate the findings obtained:I think that no one from the class should be removed because they have some of these criteria. I think that (…) someone who has a special need can continue to participate; it may not have the best result we expected, but it is important that he/she continue in the session anyway. (P8_SpNurs4_F1)If we have foreign students, at least have care taken in the translation and in explaining the terms. (P7_SpNurs3_F1)Adolescents who already have some level of suffering associated, [should not be] excluded, but perhaps the approach with these [students] will have to be different. (P2_Psy_F1)Partnerships. It was mentioned by the participants that it would be interesting to establish partnerships, for example, with institutions of higher education, for data analysis (P3_SpNurs2_F1):partnerships (...) to do the work of research data, because in clinical practice, I cannot do research and clinical practice. (P3_SpNurs2_F1)(…) Referral. Finally, participants recommended procedures that should be in place if facilitators identify adolescents who need specialized support (P1_SpNurs1_F2):because when we have to refer a situation that we have identified, we will have to refer it “outside ourselves”. (P1_SpNurs1_F2)(…) Through the visualization of the word cloud generated during the content analysis, illustrated in This study explored the perspectives of a group composed of professional experts and adolescents on the design of a proposal for a program to promote positive mental health literacy among adolescents. As result, we were able to identify and describe the components necessary to design the proposal of the mentioned program, and these components were grouped into four categories: structure, participants, assessment and other components.structure, the participants suggested that the program should be offered to adolescents at school, mostly in citizenship classes, since schools are considered by several authors to be a privileged context for the promotion of mental health, HL and MHL [apply’ [Regarding the category  and MHL ,18,19,20 and MHL , Morgado and MHL , Laranje and MHL , Choi et and MHL  and Cost and MHL . The con and MHL  in the s and MHL  indicate and MHL ,11, emph [apply’ . It was  [apply’ , which iparticipants’, it was consensual that the program should have as its target group adolescents from the fifth grade on, and it was advised that the class to which the adolescents belong should not be broken up, but the class should be divided into small groups during the sessions [In the category ‘sessions ,32,33,36sessions ,8,18,36.assessment’, participants advocated for evaluation before and after program implementation and also during the follow-up [In relation to the category ‘ollow-up ,37,38, wollow-up ,30.other components’, there are several extra suggestions that may contribute to a greater effectiveness and success of the program, which emerged from the participants’ responses throughout the focus group. In particular: (1) the need for good coordination with the school in terms of short- and medium-term planning; (2) the importance of involving the adolescents themselves in the planning and implementation of the program, giving priority to their expressed needs, their opinions and active participation in decision-making, as well as the involvement of the school and parents/legal representatives; (3) the requirement for the facilitating team to undergo training prior to the implementation of the program; (4) the need to adopt inclusive and more protective measures in case there are adolescents with special health and educational needs, or non-native speaking adolescents or adolescents with mental health concerns; (5) the extreme importance of having a previously defined referral circuit for specialized care for the adolescents that the facilitators identify during the implementation of the program; and (6) the establishment of partnerships with some entities, for example, for the analysis of the data resulting from the evaluation instruments, but which may also be important in the context of the aforementioned specialized care for adolescents. These suggestions are consistent with several published works [Finally, in the category ‘lanning;  the impoed works ,9,33,36.It is noteworthy that in several subcategories (throughout the two focus groups) the participants emphasized that it was extremely important that the program be adapted to the adolescents’ needs and also to the needs and characteristics of the school context, which is in line with what the new framework for developing and evaluating complex interventions  advocateDespite the methodological rigor and the relevance of the achieved findings, this study has some limitations. First, the results cannot be generalized, since we used a non-probabilistic sample. Second, the small number of adolescents that participated in the focus groups and their limited diversity in terms of characteristics may have limited the diversity of the perspectives obtained. Third, the unbalanced group of experts may have conditioned the representativity of the various professional groups. Lastly, both focus groups included the same participants.In conclusion, the participants of this study expressed their ideas about the components that a program to promote adolescents’ PMeHL should contain, thus contributing to the design of the program proposal. They considered that it should be a program implemented at school by a team of facilitators composed of health and education professionals. This program should be aimed at adolescents from the fifth grade on, with a focus on citizenship classes, composed of several modules, with each module organized into sessions, each 45–90 min long, with a quarterly or monthly application frequency. Active teaching methods and techniques must be used. The contents should be based on the factors of the Multifactor Model of PMH and based on the dimensions of access, understanding and application of HL. This program should also include the application of adolescent outcome assessment instruments before and after implementation and at follow-up, as well as adolescent process assessment instruments at each session. To increase the program success, participants recommended: good coordination with schools; the involvement of adolescents, parents/legal representatives and the schools themselves; the adoption of inclusive and protective measures for the most vulnerable adolescents, which should include a referral circuit for specialized care; and the establishment of partnerships with other entities.In terms of implications for clinical practice, we believe that in the future, this program will make an outstanding contribution to the promotion of adolescents’ mental health and well-being by supporting professionals in clinical practice  and educational professionals  in their care of this group of the educational community.It will be necessary to develop further research studies to obtain a program properly validated and adaptable to adolescents and their context, while having a standard base structure. This means that it is important to conduct Delphi studies for the validation of the contents of each session, to perform a pilot study, and after that to develop experimental or quasi-experimental studies.In future studies, the participants in the focus groups should be more balanced, regarding their number and their characteristics of experts and adolescents, to provide a higher strength of the findings. In addition, separate focus groups should also be organized, i.e., one with experts and then one with adolescents, to enhance the expressivity of adolescents’ perspectives and to contribute to their help to researchers in the applicability of the proposals made by the experts. If possible, it would also be interesting to conduct focus groups with different groups of experts and with different groups of adolescents, to ensure an even higher degree of data saturation.


A qualitative case study approach with in-depth, semi-structured interviews of key school staff, and student feedback was used to assess a school kitchen and garden program in the regional area of North-West Tasmania, Australia. A detailed program description was produced to conduct a realist evaluation with a Context-Mechanism-Outcome configuration, followed by a program theory evaluation through the construction of a retrospective program logic model. Dedicated kitchen and garden spaces, knowledgeable teachers committed to the program, provision of sufficient materials and consumables, and support from the school and community were found to be the basic requirements to establish a program. Additionally, it is essential to integrate both the kitchen and garden teaching components into the school curriculum. The positive outcomes  of the program were dependent on the underlying factors, including dedicated support of school leadership, teaching staff, and the parent body for effective student engagement in the teaching spaces and for wider engagement from families and the community. The students’ feedback provided supporting evidence of increased food literacy with improvements in their understanding, abilities, and attitudes towards gardening, producing healthy food, and preparing food. This may further lead to enhanced food security for students’ families and the broader community. Communities in rural and/or regional areas often have poorer health outcomes than their metropolitan counterparts, being challenged by geographic location and associated socio-economic determinants . ConsequThe resulting adverse diet-related health and well-being consequences may develop across all stages of life , and thiFood literacy is a set of inter-related knowledge, skills, and behaviors to meet food needs, including planning, selection, preparation and eating, which empower individuals, households, and communities to maintain and strengthen healthy diets . ImproviSchools play a significant role in promoting food literacy among children , althougThe positive effects on children’s health and wellbeing are generally context specific, contingent on a combination of underlying mechanisms working mutually . School The aim of this study was to use a case study approach to evaluate a primary school kitchen and garden program in North-West Tasmania and answer the research question: “Do school-based gardening programs have potential to enhance food literacy and food security in rural and/or regional communities?”.This case study is centered on the Kitchen & Garden program in a primary school. This program is part of a suite of support programs designed to supplement core learning areas . The schThe Burnie Local Area Government Area is situated in rural/regional North-West Tasmania, Australia, with an estimated population of 19,918 in 2021 . The popThis study was part of the CAPITOL  Project, managed by the School of Health Sciences, College of Health and Medicine, University of Tasmania, with research team members having extensive expertise in exercise and nutrition science, public health, and education. For the development of the case study, a qualitative research methodology was utilized, which involved three stages—data collection, data analysis, and verification and reporting . Data coThe study was approved by The University of Tasmania Human Research Ethics Committee (application number H0018654). A purposive sampling approach was used to recruit a small number of key individuals and, as we utilized a constructivist paradigm, this was sufficient to attain in-depth and information-rich data . AccordiAn interview guide was produced to explore key foci associated with the program . The intThe TIDier itemized checklist reporting methodology was used to analyze the data generated from the interviews, and together with review of the additional provided material, was used to produce a thorough depiction of the program. Additionally, surveys completed by students were appraised and summarized. Realist evaluation was then employed to establish a Context-Mechanism-Outcome configuration prior to the construction of a retrospective program logic model, enabling elucidation of the “theory of change”. To ensure accuracy, the analysis process involved triangulation for consensus, with three researchers independently reviewing program details, materials, appraisals, and evaluations.The rationale for the above approach was based on the fact that many community-based health promotion initiatives, such as those in school settings, develop organically with clear local ownership and purported positive health and well-being outcomes, but without formal evaluation to substantiate the work . InherenTo ensure the interpretation of data was correctly representative of the program, the program description and evaluation results were verified and confirmed with the participants  prior to finalizing the report.The development of a program description revealed that the rationale for the Kitchen & Garden initiative was to enhance student’s food literacy by improving knowledge and understanding of healthy eating, food cultivation, and scientific principles . The proThe summary of the student’s feedback (n = 9) to the survey conducted by the school provides supporting evidence on the students’ enjoyment, engagement, development of skills, access to experiential learning, in addition to sustainability of the Kitchen & Garden (KG) program. This student feedback was also considered for the realist evaluation and program theory evaluation. Below are selected comments:Enjoyment: “I enjoy participating in the KG program!”; “I love it so much”; “I do enjoy doing all of the gardening”,Engagement: “I enjoy planting thing(s)/feeding the chickens. I like cooking it’s pretty fun in my opinion”; “I enjoy it because I’m engaging in KG program and I like getting my hands dirty”; “Because it teaches us ways to take care of the enviro(n)ment and take care of animals”,Skill development and experiential learning: “Learning more about making things out of clay & getting better with painting”; “I get to learn more about plants and animals. Learning about the plants are helpful because I have a garden at home”; “I’m learning how to garden and cook when I get to a(n) adult I’ll know how”.Sustainability: “It’s important for kids to have fun at school sometimes so they want to come to school”; “Because KG can help a lot in the future and if you have a garden at home KG can help a lot”; “All schools should have the KG program (be)cause they learn life skills”.The contextual elements identified encompassed a wide range, including recognizing the need for the program, emphasizing the significance of having centrally located and inter-connected kitchen and garden spaces, and providing a committed teacher and learning assistant . The mecThe theory of change for this program was exemplified by constructing a retrospective logic model . This moWe adopted a case study methodology to explore the potential of a primary school kitchen and garden program in enhancing food literacy and food security among students and families in a rural/regional community. The realist evaluation approach revealed that acknowledging the contextual factors is fundamental for the program’s success. This includes providing exclusive kitchen and garden spaces, having knowledgeable and dedicated teaching staff, procuring materials and consumables through support from the school and community, and complementing the core learning by incorporating the program into the curriculum and facilitating cross-curricula connections. Furthermore, the key underlying elements essential to outcomes ranged from dedicated support from the school leadership team, teaching staff, and parent body to effectively engaging students in the kitchen and garden spaces, and to garnering strong engagement and participation from families and the wider community.After the construction of a retrospective program logic model, the theory of change inherent to the Kitchen & Garden program became evident, with available resources and strategies influencing outputs and outcomes, while simultaneously acknowledging the underlying assumptions necessary for change. The evaluation results demonstrate the program’s potential for enhancing food literacy, and consequently, promoting food security for children, their families, and the broader local community. Moreover, as rural communities may be disproportionately affected by food insecurity , the proThe attainment of improved food literacy was evidenced by linking curriculum teaching to experiential learning activities. For example, students engaged and participated in various activities such as planting vegetables and fruits from seed, harvesting, and consuming the produce, all while developing a fundamental theoretical understanding of the processes involved. Additionally, students had opportunities to care for animals, including chickens, which facilitated their understanding of animal husbandry practices, while also fostering a deeper connection to the origins and utilization of food. Further, the project work involved constructing “bee hotels” to attract bees to the garden for plant pollination, which supported student’s comprehension of plant and animal life cycles. The efficacy of experiential teaching in enhancing food literacy was supported by student survey responses, demonstrating improved knowledge, skills, and attitudes towards gardening, animal care, and cooking. The benefits of linking nutrition education with experiential approaches in school-based gardens has been shown to positively influence dietary habits in students, with increased fruit and vegetable knowledge and behavioral change . SimilarThe school places great emphasis on fostering strong relationships with students, teachers, parents, and the wider community. This aligns with its mission to empower individuals and is reflected in various programs. Because students recognized the practical value of the initiative and acknowledged the benefits of gardening knowledge for home-based gardens, this could lead to improved food security for families. Studies exploring the role of school gardens in other rural areas have similarly found that children do have the ability to gain food-related knowledge, skills, and values, which supports sustained food security in the community . School To expand school-based programs in rural or regional areas, and improve food literacy and food security, exploring public–private partnerships would be crucial. Following this study, the primary school partnered with 24 Carrot Gardens, a local not-for-profit organization that works with schools and the wider community, together with local volunteer architects, to co-design bespoke school gardens . In ruraAlthough this study has provided supportive evidence for enhanced food literacy, as well as potential for enhanced food security, the findings may not be transferable in all contexts. For example, schools may have limited resources to facilitate dedicated kitchen and garden spaces, teachers, expertise, and time, to develop and maintain effective programs. Similarly, assumptions that the school leadership team, the school, and broader community will be fully engaged with such programs may not hold true in all circumstances. Ideally, program logic models should be developed early in planning and subsequently used to inform monitoring and evaluation. However, we adopted a retrospective approach, which may be viewed as unorthodox, but nevertheless provided critical insight into program components and the theory of change. Additionally, the retrospective development of logic model has previously been conducted in childhood obesity research . FurtherIn summary, this paper presents a case study of a primary school kitchen and garden program, demonstrating enhanced food literacy, and in turn, the potential for enhanced food security in children, families, and, by extension, the community. Given that many schools in rural and regional areas have opportunities to incorporate school-based gardens, a capacity exists for similar programs to have positive community impact. As there is an urgent need across public health domains for early intervention to prevent childhood malnutrition including obesity and the expanding chronic disease burden in rural and regional areas, well-designed evidence-based school-based gardening interventions provide viable options to help address these major problems.


Cochlear implants are a neural prosthesis used to restore the perception of hearing in individuals with severe-to-profound hearing loss by stimulating the auditory nerve with electrical current through a surgically implanted electrode array. The integrity of the interface between the implanted electrode array and the auditory nerve contributes to the variability in outcomes experienced by cochlear implant users. Strategies to identify and eliminate poorly encoding electrodes have been found to be effective in improving outcomes with the device, but application is limited in a clinical setting.The purpose of this study was to evaluate a clinical method used to identify and selectively deactivate cochlear implants (CI) electrodes related to poor electrode-neural interface.Thirteen adult CI users participated in a pitch ranking task to identify indiscriminate electrode pairs. Electrodes associated with indiscriminate pairs were selectively deactivated, creating an individualized experimental program. Speech perception was evaluated in the baseline condition and with the experimental program before and after an acclimation period. Participant preference responses were recorded at each visit.p = 0.006) and sentences in noise (p = 0.020). Additionally, ten participants preferred the experimental program prior to the acclimation period and eleven preferred the experimental program following the acclimation period.Statistically significant improvements using the experimental program were found in at least one measure of speech perception at the individual level in four out of 13 participants when tested before acclimation. Following an acclimation period, ten out of 13 participants demonstrated statistically significant improvements in at least one measure of speech perception. Statistically significant improvements were found with the experimental program at the group level for both monosyllabic words (Results from this study suggest that electrode deactivation may yield improvement in speech perception following an acclimation period. A majority of CI users in our study reported a preference for the experimental program. This method proved to be a suitable clinical strategy for identifying and deactivating poorly encoding electrodes in adult CI users. Cochlear implants (CI) are surgically implanted neuroprosthetic devices which allow for open-set speech perception in individuals who obtain limited benefit from conventional amplification. While CIs provide an improvement in auditory ability to virtually all individuals who qualify and properly use the device, speech perception outcomes remain highly variable among this population .Cochlear implants systems work by filtering incoming auditory signals into frequency bands and delivering electrical pulses through contacts placed along the cochlea in a tonotopic organization mimicking a healthy cochlea. Ideally, each contact will stimulate a distinct neural population that will yield independent channels of stimulation with a high degree of spectral independence from adjacent electrodes, thus resulting in distinctive pitch percepts along the basilar membrane. In reality, a high degree of individual variability is related to a suboptimal electrode-neural interface. The primary peripheral factors that contribute to variability in the electrode-neural interface include spiral ganglion survival patterns e.g.,  and intrA range of behavioral and objective techniques have been developed to identify poorly encoding electrodes. The most common behavioral measures include electrode discrimination e.g., , pitch sWhile evidence of the benefits of electrode deactivation in some CI users have been established for decades, this practice is not widely adopted by clinical audiologists . ClinicaThe purpose of this study was to evaluate the benefit of deactivating poorly encoding electrodes using a pitch ranking task. In this study, we exclusively used clinical tools available in the United States to identify and deactivate indiscriminate electrodes. Participants were tested in a baseline and experimental program immediately following the creation of the experimental program, and again following a 3–6 week acclimation period. It was hypothesized that the experimental program would result in significant benefit for adult CI users, measured by speech perception performance and user preference.This study was conducted as a prospective within-subject repeated measures design. Participants were recruited to complete an electrode pitch ranking task to identify the presence of indiscriminate electrode pairs. Following the pitch ranking task, an experimental program was created where one or more electrodes related to indiscriminate pairs were selectively deactivated. Participants performed speech perception testing in their baseline condition , with the experimental program prior to an acclimation period, and with the experimental program following a 3–6 week acclimation period. Participants also completed a preference-ranking task at each visit. Participants were blinded to the program conditions for all evaluations.Twenty-four adult CI participants were initially recruited for this study. Two participants were excluded as they could not reliably report pitch-ranking, and 8 participants discontinued participation as they did not report any indiscriminate electrode pairs . One participant reported indiscriminate pairs, but discontinued participation in the study due to reasons unrelated to the study protocol. Participants who completed the experimental design included thirteen adult CI users , ranging in age from 20 to 81 years (mean = 54 years). Participant inclusion can be visualized in Participants were compensated with a $25 gift card per appointment. This study was conducted in accordance with all applicable government regulations and University of Arkansas for Medical Sciences (UAMS) research policies and procedures. This protocol was approved by the UAMS Institutional Review Board (IRB) to conduct the study (IRB Protocol #205194).Prior to pitch ranking measurements, the participants’ personal sound processor was connected to the most recent programming software available at the time of evaluation . The device parameters of the sound processing algorithm (referred to as “program”) that the participant preferred to use in daily life  served as an initial program for all programs used in this study. Any deactivated electrodes in the clinical program remained deactivated, and the reason for deactivation was recorded from clinical records see . TelemetAn experimental program was created from the participants’ baseline program. Testing of pitch ranking consisted of a two-alternative forced choice task comparing the participant’s perceived pitch of adjacent electrodes. The participant was asked to identify which electrode was higher in pitch. Stimulation was presented using pulse trains with an interstimulus interval of 0.5 s. Participants were trained using 2–4 trial runs comparing the most apical and basal active electrodes. Participants who did not demonstrate accurate pitch ranking in the training condition were dismissed at this time. Electrode pairs were compared in both the apical and basal direction, with a minimum of two stimulus sweeps in each direction. A pair was considered indiscriminate if the user reported the same pitch or a pitch-reversal on a majority of the comparisons (3 out of 4 confusions). In the case of an equal number of incorrect and correct responses (2 out of 4 incorrect responses), a tie-breaker comparison in each direction was presented. If there was still a tie, the electrode pair was not considered indiscriminate.Once an electrode pair was determined to be indiscriminate, a decision was made regarding which electrode to deactivate. To make this decision, two programs were created wherein each electrode of the pair was deactivated. That is, for program A the apical electrode was deactivated, and for program B the basal electrode was deactivated. Each participant listened to a spoken passage using each program and was asked to select a preferred program. The preferred program was used as the experimental program. If the user had no preference, the most apical electrode was selected to be deactivated with the exception of the most basal two electrodes, in which the most basal electrode was deactivated. For participants who reported one or more indiscriminate electrode pairs, this process was systematically repeated with one pair investigated at a time, beginning with apical indiscriminate pairs, and moving basally. In cases where several indiscriminate electrodes were grouped together, a decision was made to leave the maximum number of electrodes activated.After an electrode was deactivated, the program was presented to the user to confirm acceptability before considering additional indiscriminate electrode pairs, if any. Changes to the participants’ baseline program were kept to a minimum with the exception of the experimental change , which prompted the programming software to automatically reallocate the frequency bands of active electrodes and adjust the pulse width to keep the overall stimulation rate similar to that of the baseline program. The changes in pulse duration and rate were considered minimal. For CN users, the number of spectral maxima remained the same. For AB users, consideration was given to current-steering strategy utilized in their sound coding strategy. Each electrode had at least one adjacent electrode making it available to pair with another electrode. Slight adjustments in gain were applied for users who requested a volume comfort adjustment. This was typically implemented on electrodes adjacent to the deactivated electrode(s). The program which contained the deactivated electrodes is referred to as the “experimental program.” The experimental and baseline programs were compared, and slight adjustments were made to global loudness levels until both programs were reported to be perceived as equally loud.n = 12 for that condition.Speech perception ability was measured using the participant’s baseline program and experimental program immediately following the establishment of the experimental program. Testing involved the administration of recorded materials including consonant-nucleus-consonant (CNC) test  in quietTo assess perceived benefit of the baseline and experimental program, participants were asked to rank subjective preference between the two programs using a visual 5-point Likert scale which ranged from “strongly prefer program A” to “strongly prefer program B,” with “no preference” being the center option. The preference assessment was administered within 1 h of the creation of the experimental program. For the preference assessment, the participants were blinded to the programs which were presented in random order. The user listened to a passage spoken by the tester, their own voice, and the voice of a companion if available. After several opportunities to hear each program, the participant was asked to fill out the comparison form.Participants returned for follow-up testing after a 3–6 week acclimation period where the participant only had access to the experimental program. Data logging confirmed full-time use of the experimental program with each participant. Speech perception assessments were readministered using the same conditions described above. Participants again completed the blinded preference assessment. Following all testing, participants were also allowed to subjectively describe their experiences in freeform.p = 0.05). Post hoc analysis was determined using Wilcoxon sign-ranked testing with a Bonferroni correction applied. Participant preferences are reported descriptively.Statistically significant benefit in speech perception scores at the individual level was defined by critical difference values determined in n = 13 participants, a significant criterion of α = 0.05, and a power = 0.8. These criteria yield an effect size of 0.85, which is a large effect size as interpreted by Cohen’s d .Based on the number of CI users available to the researchers at the time of this study, it was estimated that the sample size would range between 20 and 30 participants. Twenty-four participants were initially recruited, but ten participants did not qualify for the experimental protocol and one participant opted to discontinue involvement. A total of 13 participants were included in group analysis. An analysis to determine effect size was conducted using G*Power version 3.1.9.7  using thohen’s d . For then = 13 for speech in quiet testing and n = 12 for speech in noise testing). Friedman’s test indicated group differences for CNC words (p = 0.006). A Bonferroni post-hoc test indicated an improvement in group performance with experimental program compared to baseline both prior to the acclimation period (p = 0.023) and following the acclimation period (p = 0.004). There were no group differences in group performance measured by AzBio Sentences in quiet (p > 0.05). Group differences were also indicated in the evaluation of AzBio Sentences in noise (p = 0.020). A Bonferroni post-hoc test indicated group improvements with the experimental program following the acclimation period compared to baseline (p = 0.003). Additionally, further improvement with the experimental program was found when comparing performance with the experimental program after the acclimation period compared to performance with the experimental program before the acclimation period (p = 0.010). Group differences can be found in Group differences were compared using non-parametric repeated measures statistics due to small sample size , measurable improvement in speech perception was found less frequently with the experimental program among CN users. Only two out of the five CN device users demonstrated statistically significant improvement on any of the measures . The findings with CN users are consistent with results of Only one participant in our study utilized a ME device, therefore the data should be considered with caution. Interestingly, this participant had only one electrode deactivated  and demonstrated significant improvement on all measures of speech perception before and after acclimation. These device-specific findings may guide more research in manufacturer-specific guidelines for identifying and deactivating indiscriminate electrodes.Participants responded favorably to the experimental program. All participants found the experimental program to be tolerable through the acclimation period as evidenced by full time use of their device in the acclimation period. Most participants slightly preferred the experimental program prior to the acclimation period and shifted to a stronger preference following the acclimation period. Notably, the three participants who had no statistical improvement in speech perception preferred the experimental program both prior to and following the acclimation period, suggesting there may be benefits in sound quality in which speech perception testing is not sensitive. Research suggests that CI users have a bias toward a program in which they have the most experience , therefoOur study adds to the literature indicating that adult CI users have the potential to experience benefit by selectively deactivating electrodes associated with indiscriminate electrode pairs. Of clinical importance, 22 of the 24 recruited participants (91.7%) could reliably complete the pitch discrimination task which indicates good feasibility in adult populations. Of these 22 participants, 14 participants (63.7%) reported at least one indiscriminate electrode pair. This indicates that a moderately high rate of cochlear implant users with indiscriminate electrodes which can be identified using a clinical task. Despite the moderately high prevalence of poorly encoding electrodes and potential for individual improvement following deactivation, clinical audiologists do not commonly practice electrode deactivation . This isOur study found speech perception performance and participant preference to increase over time with the experimental program. The number of individuals with statistically significant improvements in speech perception increased from 4 to 10 (out of 13) following the acclimation period of 3–6 weeks. This should signal to clinicians that validation of their changes may not be immediately apparent and require follow-up evaluation at a subsequent visit to confirm benefit.Finally, this research has implications for future development of programming practices among audiologists who program cochlear implants. Participants in our study did not have corresponding post-operative imaging to compare to perceptual reports of pitch, however, the relationship between pitch discrimination and known electrode location as verified through CT scan is an interesting area for exploration. Additionally, this task could be considered in the application of programming auditory brainstem implants, as the arrangement of the channel-to-electrode relationship is challenging due to the less distinct tonotopic organization of the cochlear nucleus as compared to the cochlea.A strength of this study is it is the first of its kind to use clinically available equipment to deactivate electrodes based on a pitch ranking task, thus demonstrating the clinical feasibility of implementing this practice. An additional strength is that we used a prospective within-subject study design, with a follow-up after a 3–6 week acclimation period where the CI user exclusively utilized the experimental program.Limitations of this study include a small sample size, which is consistent with CI research. We also did not have a control condition where participants had electrodes deactivated randomly, therefore we cannot entirely rule out the improvement being simply related to fewer channels instead of tonotopic-specific deactivations. Additionally, participants were not retested in their baseline condition after the acclimation period, which would have strengthened our results. In our participant population, there was a lack of equal distribution among CI device manufacturers which could not be balanced due to our available participant population. Additionally, while every effort was made to blind participants to testing conditions, participants were often aware of the conditions due to their familiarity with their baseline program. Blindness to program condition during the acclimation period could not be guaranteed for the same reason. While we acknowledge the bias of potential awareness of the new program, prior research suggests a bias for the program which the user has the most experience with , thus, wThe present study provides additional evidence to support electrode deactivation based on discrimination in an effort to improve speech perception. A majority of CI users had improved speech perception performance with the experimental program, and only one participant performed significantly worse on one measure. Additionally, a majority of CI users preferred the experimental program. This study supports the practice of pitch ranking and deactivation approaches in an effort to improve patient performance and satisfaction.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the UAMS IRB. The patients/participants provided their written informed consent to participate in this study.SW was involved in protocol design, execution, coordination, and analysis of the study. SA was involved in protocol design of the study. Both authors contributed to manuscript revision, read, and approved the submitted version.


PurposeRemediation is a daunting process for both residency leadership and trainees due to several factors including limited time and resources, variable processes, and negative stigma. Our objective was to transform the remediation process by creating a transparent institution-wide program that collates tools/resources, interdepartmental faculty mentors, and positive rebranding.MethodsEducation leadership across seven specialties created a process for trainees with professionalism and interpersonal-communication skills deficiencies. Formalized departmental program-based improvement plan (PIP) and an institutional house staff performance enhancement plan (HPEP) were developed by consensus of triggers/behaviors. Utilizing published literature, a toolkit was created and implemented. Trainees were enrolled in HPEP if PIP was unsuccessful or exhibited ≥1 major trigger. Wellness evaluations were incorporated into the process to screen for external contributing factors. Surveys were sent to the program director (PD), faculty mentor, and trainee one month and six months after participation.ResultsBetween 2018 and 2021, 12 trainees were enrolled. Overall feedback from PDs and the trainees was positive. The main challenge was finding mutual time for the faculty mentor and trainee to meet. Six-month surveys reported no relapses in unprofessionalism. One-year follow-up of the trainees was limited.ConclusionsUtilizing an institution-wide standardized process of performance improvement with the removal of negative stereotyping is a unique approach to remediation. Initial feedback is promising, and future outcome data are necessary to assess the utility. The HPEP may be adopted by other academic institutions and may shift the attitudes about remediation and allow trainees to see the process as an opportunity for professional growth. Remediation in medical education has been defined as “the act of facilitating a correction for trainees who started on the journey toward becoming a physician but have moved off course .” AlthouRemediation is a challenging endeavor for both residency leadership and trainees. There is variation not only in the practices of remediation among specialties but also in the terminology used to approach struggling trainees ,9. AlthoTo our knowledge, there are few institutions that have created a uniform process for all trainees utilizing faculty and resources across multiple specialties. Although the milestones for patient care and medical knowledge vary among specialties, professionalism (Prof), interpersonal and communication skills (ICS), systems-based practice (SBP), and practice-based learning and improvement (PBLI) are shared values and commonalities that allow for pooling of resources and interdisciplinary mentorship. One other institution-wide remediation program implemented at the University of Colorado School of Medicine was established in 2006 and is focused on the remediation of a spectrum of learners ranging from medical students to faculty across all core competencies . In a peWe sought to change the landscape of remediation with two objectives in mind: (1) Create an institution-wide standardized process for remediation of trainees utilizing institutional resources; and (2) positively rebrand the process by eliminating the term “remediation” and provide institution-wide transparency.Creation of the Housestaff Performance Enhancement Program Subcommittee (HPEPSC)This program was developed and implemented at an academic university-based institution. A group of education leaders across seven specialties  in our institution formed a graduate medical education subcommittee (HPEPSC). The HPEPSC sought to achieve its goals by investigating current best practices for remediation and creating a program for the competencies that are shared among all specialties: Prof, ICS, SBP, and PBLI. The committee agreed to address Prof and ICS in Phase 1 of the project, with SBP and PBLI to be addressed in the forthcoming Phase 2. We decided to eliminate the term “remediation” to facilitate a more positive perception of the program. The creation of the process, toolkits, and triggers was an iterative expert consensus of the committee and content expert based on our literature search.Creation of the toolkit and the triggersWorking off the toolkit published by Regan et al. , professTriggers for each of the categories were created by consensus of the HPEPSC. Triggers were defined as behaviors or actions that were non-compliant with the established standards of professionalism and ICS for our institution, common milestones, and the medical field. Triggers were identified based on prior behaviors by trainees and were classified as minor, moderate, or major based on the severity of the action/behavior. Mild triggers were actions/behaviors that were present in an isolated or infrequent evaluation and warranted a conversation between the PD and the trainee. Moderate triggers were actions/behaviors that were noted in multiple evaluations or complaints, and required intervention by the residency leadership, but did not negatively impact patient care. Major triggers were actions/behaviors that were repeatedly present in multiple sources , negatively impacted patient care, or egregiously violated professional and ethical standards .” PIPs are initiated at the discretion of the individual program and are considered internal methods of improving resident performance. The HPEPSC asks programs to implement a PIP when trainees fail to meet appropriate milestone levels and/or exhibit ≤2 minor triggers despite counseling or a minor trigger in the presence of one moderate trigger. Residency leadership performs wellness/burnout evaluations to identify any external contributing factors or circumstances. All conversations pertaining to the PIP are documented and placed in the trainee’s file, and the GME office is notified for tracking purposes only. Participation in PIP is not disclosed to future employers for trainees who have no further incidents. Trainees are unsuccessful if there are repetitive unprofessional behaviors, there is a failure to correct current behaviors, new or additional triggers are exhibited, or goals for PIP are not achieved. Unsuccessful PIPs are documented in the trainee’s file, and they are referred to the institutional house staff performance enhancement program (HPEP) (see Appendix A).HPEP processHPEP is implemented when the trainee is unsuccessful in a PIP, consistently fails to meet appropriate milestone levels, is more than one level below expectation on one or more Prof or ICS milestones, exhibits more than two minor triggers repetitively despite counseling, exhibits two moderate triggers, or exhibits one or more major triggers (see Appendix A). The decision to enroll the trainee in the HPEP is made in collaboration with the trainee’s PD, Clinical Competency Committee, Department Chair, and the Designated Institutional Official (DIO). The trainee is notified in writing by the PD and the HPEPSC Chair and is required to visit the institution’s resident wellness and excellence center to screen for contributing external factors. Faculty mentors are chosen by the subcommittee chair in conjunction with the PD, and focused improvement plans are created utilizing the HPEP Prof/ICS Toolkit  by the HPEPSC for the trainees, the PDs, and the faculty mentors. Each evaluation was composed of 8-9 questions using a 5-point Likert scale (strongly agree-strongly disagree) with two questions asking for challenges or obstacles that were faced and suggestions for potential improvements to the HPEP process. These electronic evaluations were anonymous and sent to all parties one month, six months, and 12 months after the completion of the HPEP cycle. The timing of the evaluation was chosen to enable longitudinal monitoring. All evaluations were reviewed by the HPEP members and feedback was used to make improvements. Reminders to fill out evaluations were sent to all parties on a biweekly basis.For the analysis of this program, the Institutional Review Board approved this project.Our institution sponsors 48 ACGME-accredited residency and fellowship programs with 663 trainees. During the academic years from 2018 to 2021, 12 trainees entered an HPEP cycle for Prof and/or ICS. All 12 trainees completed the HPEP cycle. All trainees enrolled in the HPEP completed one 3-month cycle and 10/12 of the trainees did not exhibit any additional unprofessional behaviors or had any problematic communication issues following the completion of the HPEP cycle. One trainee graduated shortly after completion and the last trainee’s contract was not renewed at the end of the academic year that coincided with the HPEP cycle.One-month evaluationsThere were two trainees who left the institution within one month of completing the HPEP. Therefore, a total of 10 evaluations were sent to the trainees with 7/10 (70%) completed. Evaluations were sent to all 12 PDs and faculty mentors with a response rate of 9/12 (75%) for both. PDs were mostly positive in their responses  "strongly agreed" or "agreed" with statements pertaining to the ease and value of the process as well as the mentoring experience. When responding to the statement about whether participation in HPEP would not be used against the trainee by future credentialing requests, four of the seven trainees responded neutrally, while three agreed or strongly agreed.Most of the faculty mentors responded "agree" or "strongly agree" to statements regarding being paired with the mentee in a fast and efficient manner and working well together with the mentee , meeting on a regular basis with the mentee, creation of a streamlined action plan and having appropriate and specific goals and objectives, and PD availability and responsiveness . Three mentors felt that they had difficulty facilitating meetings with the mentee and three mentors felt that the HPEP process required a significant time commitment.Six-month evaluationsOf the 12 trainees, five did not receive the six-month evaluation because of non-renewal (1), completion of training (2), and within six months of completion of the HPEP (2). Of the 12 mentors and PDs, two did not receive six-month evaluations because their trainees were within six months of HPEP completion.Six out of the 10 (60%) PDs responded to the six-month survey. None of the PDs referred their trainees back to the HPEP or thought that the trainees continued to meet with their mentors following the HPEP cycle. Two out of the six PDs felt the trainee continued to use the skills and tools that they learned through the PEP while three were neutral and one disagreed. Two noticed that the trainee’s behavior was and continued to be positively impacted by the HPEP process while four were neutral. Four of the six PDs felt that the trainees continued to believe that the HPEP process contributed positively to their professional development while two remained neutral. Five PDs said that they would very likely refer other trainees to the HPEP and would recommend that other PDs use the HPEP for their trainees while one PD was undecided.One house staff responded to the six-month evaluation. Their response indicated that they did not continue to meet with the assigned faculty mentor after the HPEP. The responses to all the other statements were agree or strongly agree. Two faculty mentors responded to the six-month survey. Although only one faculty continued to meet with their mentee, both faculty agreed or strongly agreed that the trainee continued to ask for guidance after the HPEP cycle was completed and continued to use the skills and tools learned in the HPEP and their behavior continues to be positively impacted by the HPEP.Twelve-month evaluationsOf the 12 trainees, five were unable to complete the 12-month evaluation because of non-renewal (1), completion of training (2), and within six months of completion of the HPEP (2). Of the 12 mentors and PDs, two did not receive 12-month evaluations because their trainees were within six months of HPEP completion.Five of the 10 PDs responded to the 12-month evaluation. Two of the five PDs felt that the trainee continued to use the skills and tools that they learned, the behavior was and continued to be positively impacted, and that the HPEP process positively contributed to their professional development while three PDs were neutral in these domains. All the PDs said that they would use the HPEP if needed in the future for other trainees. All PDs reported that their trainees were not referred to the HPEP for continued professionalism or ICS issues.Only one trainee responded to the 12-month follow-up survey. The respondent did not meet with their mentor following the HPEP but answered agree or strongly agree to other statements pertaining to altering the way they practice medicine, recommend the program to other trainees if needed, and would volunteer to participate in other areas in need of improvement.Three of the 10 faculty mentors responded to the 12-month evaluation. One agreed that the trainee continued to meet with them and ask for guidance and feedback following the HPEP. Two positively responded that the trainees continued to use the tools and skills learned in the HPEP. Two of the mentors would recommend other faculty to serve as HPEP mentors and all three agreed or strongly agreed that they would be happy to participate as an HPEP mentor again.Our program is unique in that we created a transparent institution-wide approach to assisting our trainees who did not meet minimum expectations while we positively rebranded and changed the perception of the remediation process. We wanted our trainees and faculty to see remediation as a golden opportunity, rather than a permanent blemish on their record once the trainee has graduated from residency or fellowship. Most United States’ state medical licensing boards do not require that PDs report residents who have been on remediation . HoweverThe process, as well as the toolkit, may be helpful in institutions across all specialties to use for education in professionalism and interpersonal communication skills for trainees in their programs. Implementing a transparent process will help to create a standardized mechanism for programs to follow and perhaps allow trainees to see that the institution is committed to their learning and improvement. Jennings and Slavin  suggesteOur program incorporates a wellness screen into the process by requiring trainees who are referred to the HPEP to visit the Resident Wellness and Excellence Center (RWEC). The RWEC provides confidential counseling services to the house staff at no charge and is geared toward assisting trainees with stressors that may arise inside or outside of their program. We felt that this was an important step in the process given the significant amounts of stress, burnout, and physician suicide that are affecting the medical profession on so many levels -49. In aOverall, Phase 1 of the HPEP was well received by the trainees, mentors, and the PDs. The use of faculty mentors outside of the trainees’ specialty was implemented to allow the trainees to feel like they had a “champion” who was objective and would not be negatively influenced by interactions prior to or following the HPEP. One of the challenges that the participants of the HPEP experienced was finding time for the trainees to meet with their faculty mentors. In one case, this may have been due to the trainee’s attitude toward being in the HPEP, as they were noted by the mentor as being dismissive. However, given the demanding service schedules of both trainees and faculty, it stands to reason that the residency program should make reasonable allowances for these mentoring sessions to occur. As a few of the trainees had reading and reflective essay assignments, it is also reasonable that the training program and institution create a supportive environment to allow the participants to complete these tasks within the constructs of the functioning of the program and their scheduled work hours.Our study has several limitations. Even though the first phase of our program has been successful in achieving its goals, the evaluation of the effectiveness of our program is limited by the small number of participants. It is also difficult to track trainees once they have graduated from the program, so longitudinal follow-up is limited. We anticipate that obtaining long-term outcomes of our program may be limited by the fact that it is difficult to follow the HPEP trainees’ performance once they have graduated from their training programs and have obtained outside employment as faculty or fellows, which would require continued contact between the program and its graduates. Further, it may be possible to assess for relapses in professionalism by querying medical licensing boards to see if the graduates had any professionalism issues that required disciplinary action. In addition, there are some unprofessional behaviors  that purposefully were not addressed in the HPEP because they are routinely referred to human resources by institution policy. With respect to the toolkit, the resources that are listed were not based on published literature and have not been proven to be helpful themselves, rather they were created for use based on the published recommendations of simulation-based case discussion. Finally, due to the COVID-19 pandemic, the HPEP process was paused as our institution was in the pandemic emergency stage for two months. The interruption in the HPEP process may have led to breakdowns in communication and loss of any previous progress that was made prior to the pandemic. In addition, six- and 12-month follow-ups may have been poor secondary to the fact that communication was hindered by the patient care demands and challenges with resources during the pandemic.The HPEP is a standardized process utilizing institution-wide resources that had positive outcomes after one year of enrollment. Rebranding the remediation process by framing it in a positive way, removing the word “remediation,” and providing transparency may eventually shift the attitudes toward remediation.