BCR/ABL1 fusion and an inherited Charcot-Marie-Tooth neuropathy detected during the induction treatment.Both high hyperdiploidy (HeH) and the translocation t are recurrent abnormalities in childhood B-cell acute lymphoblastic leukemia (ALL) and both are used in current classification to define different genetic and prognostic subtypes of the disease. The coexistence of these two primary genetic aberrations within the same clone is very rare in children with ALL. Here we report a new case of a 17-year-old girl with newly diagnosed ALL and uncommon cytogenetic and clinical finding combining high hyperdiploidy and a cryptic BCR/ABL1 fusion, which was caused by the insertion of part of the ABL1 gene into the 22q11 region, was proved in HeH clone by FISH, RT-PCR and CGH-SNP array. In addition, an abnormal FISH pattern previously described as the deletion of the 3′BCR region in some BCR/ABL1 positive cases was not proved in our patient.High hyperdiploid karyotype 51,XX,+X,+4,+14,+17,+21 without apparent structural aberrations was detected by conventional cytogenetic analysis and multicolor FISH. A cryptic BCR/ABL1 fusion, is presented and to the best of our knowledge described for the first time. The insertion of ABL1 into the BCR region in malignant cells is supposed. Clearly, further studies are needed to determine the genetic consequences and prognostic implications of these unusual cases.A novel case of extremely rare childhood ALL, characterized by HeH and a cryptic  Pediatric B-cell precursor acute lymphoblastic leukemia (BCP-ALL) is a heterogeneous disease on both the cytogenetic and genetic levels . A numbeBCR/ABL1 fusion gene, is a rare finding in children with ALL, accounting for ~3% of cases, and is traditionally associated with a poor outcome /46,XX[3]. However, FISH with the BCR/ABL Extra Signal and BCR/ABL Dual Fusion Probes detected the BCR/ABL1 fusion with an abnormal FISH signal pattern (1F2O1G), consistent with a breakpoint within m-BCR and the loss of the 3′BCR signal from der(9) in ten out of eleven metaphases and ~70% of the interphase nuclei  was not detected by array CGH and BAC probes and only other chromosomal abnormalities were found, including trisomies of chromosomes X, 4, 14, 17, and 21, cryptic deletion of the short arm of chromosome 20 [del (20) (p12.1p12.1)] and submicroscopic amplification of the 22q11.22 region  no classical or variant Ph translocation was detected by conventional cytogenetic/mFISH; (2) loss of the 3′BCR region, although expected from interphase FISH signal pattern, was not confirmed by array CGH or by FISH with BAC probes for this region, i.e. entire BCR signal remained on chromosome 22 and was not translocated on chromosome 9; and (3) only the BCR/ABL1 fusion was proved at the RNA as well as DNA level, while the reciprocal ABL1/BCR fusion was not found by any of these approaches.Based on the cytogenetic and genetic results, it is clear that the BCR/ABL1 fusion on der(22). The current inclusion of array techniques into routine practice could lead us to reevaluate the real occurrence of deletions of either the 3′BCR or 5′ABL1 region in BCR/ABL1-positive cases  previously described by FISH analyses.Our results show that only parallel cytogenetic, molecular cytogenetic, and molecular genetic analyses can provide detailed information about cryptic and prognostically significant aberrations that could not have been achieved with any of these techniques used independently. The metaphase FISH results were important for the correct interpretation of the interphase FISH findings, because only this analysis could identify the location of the BCR region into ABL1 at 9q34 or rarely of ABL1 into BCR at 22q11 [Several patients with CML, or less frequently with ALL, have been reported with cryptic insertions of part of the at 22q11 ,14. Howeat 22q11 ,16, and There is no difference in the gain of specific chromosomes  between patients with high-hyperdiploid ALL and commonly encountered ALL aberrations, and those with high-hyperdiploid ALL. The only exception is the trisomy of chromosome 2, which was previously described as a quite frequent chromosome gain in patients with translocation t . HoweverFrom a clinical perspective, patients with HeH and well-known translocations are considered to represent a biologically distinct subgroup, which may have independent prognostic implications . From prBCR/ABL1 fusion, is presented and described for the first time and the insertion of ABL1 into the BCR region in malignant cells is supposed. Although several cases of childhood ALL with HeH and general ALL-specific aberrations have been published, the exact pathogenetic mechanisms of the disease in these patients have not been clarified. Clearly, further studies of these uncommon cases are necessary to determine the genetic consequences and real prognostic implications of these phenomena.In conclusion, a novel case of extremely rare childhood ALL, characterized by HeH and a cryptic Written informed consent was obtained from the patient’s parents for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Introduction: The October 2005, Kashmir earthquake main event was triggered along the Balakot-Bagh Fault which runs from Bagh to Balakot, and caused more damages in and around these areas. Major landslides were activated during and after the earthquake inflicting large damages in the area, both in terms of infrastructure and casualties. These landslides were mainly attributed to the minimum threshold of the earthquake, geology of the area, climatologic and geomorphologic conditions, mudflows, widening of the roads without stability assessment, and heavy rainfall after the earthquake. These landslides were mainly rock and debris falls. Hattian Bala rock avalanche was largest landslide associated with the earthquake which completely destroyed a village and blocked the valley creating a lake.Discussion: The present study shows that the fault rupture and fault geometry have direct influence on the distribution of landslides and that along the rupture zone a high frequency band of landslides was triggered. There was an increase in number of landslides due to 2005 earthquake and its aftershocks and that most of earthquakes have occurred along faults, rivers and roads. It is observed that the stability of landslide mass is greatly influenced by amplitude, frequency and duration of earthquake induced ground motion. Most of the slope failures along the roads resulted from the alteration of these slopes during widening of the roads, and seepages during the rainy season immediately after the earthquake.Conclusion: Landslides occurred mostly along weakly cemented and indurated rocks, colluvial sand and cemented soils. It is also worth noting that fissures and ground crack which were induced by main and after shock are still present and they pose a major potential threat for future landslides in case of another earthquake activity or under extreme weather conditions. The epicenter of the earthquake  was 19 km from Muzaffarabad and 105 km from Islamabad . The earthquake occurred along the Balakot-Bagh Fault which is a reverse fault that runs along the right bank of Jhelum River from Muzaffarabad to Naushara and crosses the Jhelum River to the west bank. The Kashmir earthquake represents the most devastating earthquake in South Asia in recorded history.th October 2005, highest numbers of aftershocks (122) were recorded and by the end of 2005, a total of 1,778 aftershocks were recorded.The Kashmir Earthquake .o.Jhelum River and its tributaries (Neelum & Kunhar) drain the region. The rapid flow of these rivers have resulted in intense fluvial incision, thus producing steep lower valley slopes that have a gradient of > 50Landslides can be triggered by an earthquake, either by an increase in shear stress or due to decrease in soil strength. Significance of landslides depends upon location and magnitude of earthquakes but local conditions can also be of much importance. Earthquake triggered landslides have caused significant loss of life throughout history (Table 1).2. Hazara-Kashmir syntaxis dominates the area and is enclosed by Main Boundary Thrust (MBT). The footwall of MBT is composed of Murree Formation.Geological Map of the Area: Ghazanfar et al., 2010).The Kashmir earthquake triggered mass movements and these mass movements directly or indirectly caused approximately 26000 fatalities. The landslides that were triggered by the earthquake have an area of >7500 kmLandslides in Murree Formation occurred alongside lower valley slopes. Landslides in Hazara Formation occurred in the fluvially incised slopes. Rockslides were extensive on the mid slope regions. Muzaffarabad Formation showed extensive fissuring.2 in area) and were mostly in the form of shallow rock and debris falls from the top few meters of weathered bed rock and soil. Rock falls (<100 m2) and rock slides were common on ridge and spur crusts throughout the whole region. Slopes which have a gradient of < 20o and which were present on foot wall rocks of the MBT showed little evidence of landsliding. Landslides in Murree formation occurred along lower valley slopes which have a gradient >50o. The study also showed that the Precambrian Dolomites and siliciclastic rocks of Muzaffarabad formation were extensively fissured. Previous studies on the effects of large earthquakes in Himalayan region were carried out by Owen et al., (1995)Owen et al., (2008)Landslides that were triggered by the earthquake were concentrated in specific areas that were associated with geomorphology, lithology and human factors. More than half of landslides were in some way associated with road construction and human activity (Table 2).The number and extent of landslides in case of Kashmir earthquake exceeds that of 1991 Garhwal earthquakesMonsoonal climate persists in Muzaffarabad with annual precipitation of ~1500 mm. Snow falls at altitudes of >1500 mm during winter. The fissuring that was caused by Kashmir earthquake resulted in more landsliding in 2006 during monsoon period. The debris produced as a result of landslides was re-deposited by floods resulting in landscape modification.o. It was also noticed that most of the landslides occurred on the hanging wall of the fault. < 30% of the earthquakes occurred on or within 1 km from the fault. Approximately 50% of landslides occurred within 2-3 km of the fault. The highest density (3.2 landslides / km2) of landslides was found near Balakot in Precambrian metamorphic and sedimentary rocks whereas the second highest density (2.9 landslides / km2) was recorded near Muzaffarabad in Eocene and Paleocene limestone.o), whereas at much greater distance of 20 km, large landslides also occurred on gentler slopes. Half of the landslides occurred in Miocene sandstones and siltstones.Sato et al., (2007)Geological Map of the Area showing landslide distribution: Kamp et al., 2008)o– 35o. It was observed that the most important parameter that controls landslides is lithology. 152 Landslides occurred in Igneous Rocks formations covering a total area of 224 km2 whereas 1941 landslides occurred in sedimentary rock formations covering a total area of 2292 km2.The land-cover classification using ASTER satellite imagery was carried out by Kamp et al., (2008)Areas that are underlain by Muzaffarabad, Murree and Panjal formations show highest landslide susceptibility to future failures. Formations that are in proximity to faults are also prone to future landsliding.It is highly likely that the sites of earlier landslides may be activated and new landslides can occur along fissures especially after heavy rainfall. The ASTER 2005 Land Cover classification that was carried out by Kamp et al., (2008)According to Kamp et al. (2010)According to Sato et al., (2007)Large extent of slopes were cracked within 5 km of the fault. In the years that followed, the amount of landsliding in Kashmir increased due to increase in precipitation. The rise in groundwater caused many slope failures.According to Ghazanfar et al., (2010)According to Kausar et al., 2010)10, the eAccording to Dellow et al., (2007)The first type of landslides were formed over/adjacent to the fault ruptureThe second type of landslides which extend about 10-20 km from fault trace were formed on hanging wall side of the fault3. The third type of landslides were formed on the footwall side of the fault and were rare except within 2-3 km of fault traceStudies by Saba et al. (2010)View of the source of the Hattian Bala rock avalanche (Dana Hill): Dunning et al., 2007.).The Hattian area is located in Jhelum Valley. The Kashmir earthquake reactivated a landslide south of Hattian. The slide has its origin from Dana Hill in the form of huge rock avalanche. The slide blocked the tributaries of Jhelum River (Karli and Tung tributaries) creating a natural dam (The landslide has a total volume of approximately 85×106 m3; whereas, the affected area is about 1.8 km2. Falls and slides are a significant problem after an earthquake and they risk a population and infrastructure in lesser part of valleys.Danna Hill lies on hanging wall of Muzaffarabad fault. The movement was favored by structurally controlled southeast plunging syncline.,,,o-35o.,,,The earthquake caused thousands of landslides and made many slopes unstable. Almost 26000 people lost their lives due to landslides only. The landslides were triggered by the main shock and later by aftershocks. Slope failure as a result of earthquake can only occur when a critical magnitude and peak ground acceleration is achieved as in case of Kashmir Earthquake. Muzaffarabad was the worst area affected by the earthquake. The earthquake resulted in deep seated cut slope failures and rock falls. The distribution of landslides was concentrated along precise areas related with geology and human impacts. Almost 90% of landslides were small and were in the form of rock and debris fall.Slope instability will increase as more forests are being converted to agricultural land and this instability during the event of an earthquake can cause landsliding. Ground shaking and structural failure were main reasons for triggering of Hattian Bala Rock avalanche. Most of landslides were small and only one the Hattian Bala landslide was major. The nature and accumulation of debris on eastern side shows that the debris moved at very high velocities.A powerful 7.8 Mw earthquake occurred in Nepal on 25th April, 2015 and it was followed by a powerful 7.3 Mw earthquake on 12th May. Tens of thousands of landslides were triggered as a result of these two earthquakes. The landslides were triggered as far as Everest region. Many villages were affected by these landslides and hundreds of people lost their lives because of these landslides. Many more landslides can be triggered as a result of more aftershocks, gravitational failure and precipitation. Almost all of landslides were falls and slides of rock and soil. The landslides will pose serious hazard during ongoing 2015 monsoon season and 2016 monsoon season. These landslides are consistent with 2005 Kashmir earthquake landslides.Kashmir earthquake caused thousands of landslides and made many slopes unstable. The Kashmir area is highly prone to landslide hazards due to its geology and structures. Mass movements can easily be triggered by slight tremors in the region. Shaking from any major future earthquake will cause liquefaction of soil, hence causing the slope to lose cohesion. Older landslides can also be activated from earthquake induced landslides. Undercutting of slopes by river erosion and human activities are the main reasons for secondary failures. More than 50% of landslides were caused by human impacts like conversion of forest land, occupancy on exposed slopes and construction of roads. The landslides patterns are quantifiably related to ground motions. Co-seismic landslides occurred at regions with steep slopes and high roughness under the influence of strong ground motion. The study show that co-seismic landslides increases in regions close to epicenter and with increasing earthquake intensity. It is also worth noting that fissures and ground crack which were induced by main shock are still present and pose a potential threat for future landslides in case of another earthquake activity or under extreme weather conditions. The debris produced as a result of landslides was re-deposited by floods resulting in major landscape modification. The landslides patterns are quantifiably related to ground motions. Co-seismic landslides occurred at regions with steep slopes and high roughness under the influence of strong ground motion. The study show that co-seismic landslides increases in regions close to epicenter and with increasing earthquake intensity. Proper identification of various types of these movements is very essential for proposing their mitigation and preventing future loss of life and property. People may be warned not to construct in the vicinity of the rupture and avoid living at the foot of the mountains. If landslides hazards are not adequately mapped and mitigated with increasing commercialization and urbanization, the problems of landslides will greatly affect life and economy.The authors have declared that no competing interests exist.


The stigma of schizophrenia constitutes a major barrier to early detection and treatment of this illness. Anti-stigma education has been welcomed to reduce stigma among the general public. This study examined the factors associated with the effectiveness of a web-based educational program designed to reduce the stigma associated with schizophrenia.Using Link’s Devaluation-Discrimination Scale to measure stigma, the effect of the program was measured by the difference in pre- and post-program tests. In the present study, we focused on program participants whose stigma towards schizophrenia had considerably improved (a reduction of three points or more between pre- and post-program tests) or considerably worsened (an increase of three points or more). The study participants were 1,058 parents of middle or high school students across Japan, including 508 whose stigma had significantly decreased after the program and 550 whose stigma had significantly increased. We used multiple logistic regression analysis to predict a considerable reduction in stigma (by three or more points) using independent variables measured before exposure to the program. In these models, we assessed the effects of demographic characteristics of the participants and four measures of knowledge and views on schizophrenia .Participants’ employment status, occupation, basic knowledge of schizophrenia, pre-program Link’s Devaluation-Discrimination Scale score, and social distance were significant factors associated with a considerable decrease in the stigma attached to schizophrenia following the educational program. Specifically, full-time and part-time employees were more likely to experience reduced stigma than parents who were self-employed, unemployed, or had other employment status. Considerable decreases in stigma were more likely among parents working in transportation and communication or as homemakers than among other occupational groups. In addition, parents with higher pre-program levels of stigma, lower basic knowledge, or lower social distance were more likely to have reduced levels of stigma.Based on the regression analysis results presented here, several possible methods of reducing stigma were suggested, including increasing personal contact with people with schizophrenia and the improvement of law and insurance systems in primary and secondary industries. The first episode or prodromal symptoms of schizophrenia typically occur in adolescence ,2. HowevIn recent decades, various educational programs have been developed aimed at reducing the stigma associated with schizophrenia. For example, a video about schizophrenia was played for 571 students from eight high schools across Canada . In anotThe internet-based survey was conducted by a Japanese survey company. The sampling frame for this study was a total of 44,000 people listed in a database administered by this company as the parents of middle and high school students in Japan. From this group, a sub-sample of 5,000 parents was drawn using stratified random sampling (stratified by gender and place of residence). Of these parents, the 2,690 who agreed to participate in the survey answered a questionnaire about their geographical characteristics and living environment and then completed additional questionnaires about their knowledge of and views on schizophrenia, including Link’s Devaluation-Discrimination Scale for measuring stigma, both before and after watching an educational program. We refer to the tests about stigma administered before and after the program as the “pre-program test” and the “post-program test”. The interval between pre- and post-program tests was 1 week, and 2,465 parents completed the post-program test. All participants used a web-based questionnaire-answering system provided by the company conducting the survey. The present study design is a one-group pre-test and post-test design. Changes in stigma score ranging from −2 to 2 points were considered not to be significantly affected by the educational program, so the characteristics of parents with that level of change could not be used effectively to explore causal factors of educational effect. The final participants included in this study were therefore limited to the 1,058 parents whose absolute differences between pre- and post-program stigma scores were 3 points or more. Written informed consent for participation in the study was obtained from all participants. This study was approved by the Medical Ethics Committee of Niigata University.The demographic factors and the corresponding categories used in this study are shown in Table Link’s Devaluation-Discrimination Scale modified for schizophrenia was used for measuring the stigma attached to schizophrenia among parents of middle and high school students  Means (± standard deviations) were used to characterize the distributions of continuous variables. The Shapiro-Wilk test was used to assess the normality of the distribution. The Mann–Whitney Table Average scores on Link’s Devaluation-Discrimination Scale for each participant were calculated by taking the mean of scores on the 12 scale items. Based on this average stigma score, participants were divided among four stigma level categories. To describe an individual participant’s stigma level, participants were labeled as having a “minimal” , “low” (≥ 2 but < 2.5), “moderate” (≥ 2.5 but < 3), or “high” (≥ 3) stigma level ,18. ThosTo assess overall stigma changes, the means ± standard deviation of Link’s Devaluation-Discrimination Scale in pre- and post-programs for the whole sample  were 32.8 ± 4.4 and 32.8 ± 4.4, respectively. In terms of the difference between pre- and post-program scores on this scale, the mean ± standard deviation was −0.06 ± 3.71. The Wilcoxon signed-rank test was used to compare the paired distributions of pre- and post-program scores on Link’s Devaluation-Discrimination Scale. The P-value of the test was 0.176, suggesting that the distributions of pre- and post-program stigma were not significantly different. What is more, of the 2,465 parents who completed both pre- and post-program tests, 994 (40.3%) had a decreased stigma score.U test; P < 0.001).The results of univariate analyses for clarifying the characteristics of stigma-increased and stigma-decreased groups are also shown in Table Multiple logistic regression analysis was used to explore the characteristics associated with changes in total stigma scores following the educational program Table . First, We then estimated a logistic regression model predicting a considerable reduction in stigma score including demographic factors and the four measures investigated in the pre-program test as candidate independent variables  Table –2. Theseet al. (32.86 ± 6.22) [In this study, demographic and social factors were used to characterize the changes in levels of stigma towards schizophrenia, which were measured by Link’s Devaluation-Discrimination Scale before and after watching an internet-based educational program. Among parents of Japanese middle and high school students, mean stigma scores before and after watching the educational program on schizophrenia were identical (32.8 ± 4.4), and our analysis comparing the distributions indicated that the pre- and post- program distributions were not significantly different . The scores of pre- and post-program stigma found in the present study were similar to the stigma score reported by Berge  ± 6.22) , suggestThe design of the present study, in terms of both the delineation of the working sample and the choice of the dependent variable, facilitated the detection of new findings. Besides the parents with considerably-changed stigma scores, there were also some whose stigma scores changed slightly. These slight changes could be caused by either the educational program or random error. Consequently, if all these heterogeneous participants were studied simultaneously, it would be difficult to test the true educational effect of the program . We therIn the logistic regression analysis that included only demographic and social factors as independent variables, employment status and occupation were selected as significant factors associated with considerable changes in levels of stigma (comparing the odds of considerable decreases to the odds of considerable increases). To the best of our knowledge, this is the first time that the effect of employment status has been shown on stigma towards schizophrenia. The employment status described as “other” includes those who are self-employed, working in family-owned businesses, and unemployed. The overwhelming majority of this group was unemployed . Compared with those with “other” employment status, levels of stigma were significantly more likely to decrease among both full- and part-time employees. The degrees of freedom of social contact are relatively high among full- and part-time employees compared with the “other” group. In particular, unemployed and self-employed people have fewer opportunities to be in contact with different kinds of people and ideas. In contrast, full- and part-time employees, such as doctors, salesmen, lawyers, and civil servants, come into contact with a wide range of people in their professional lives. This result for employment status and occupation, then, could be seen as meaning that people with wider social and interpersonal relationships were more likely to be affected by the program in terms of reducing levels of stigma towards schizophrenia. A previous study on social contact and stigma indicated that people may become broader-minded and more accepting of difference through intergroup contact, with differences going beyond age and affinity orientation. It was also reported that requiring greater interpersonal disclosure may help to reduce stigma .The result on occupation type could be interpreted as a “stigma reduction” effect and a “degree of reduction difficulty” in different sectors. According to statistics of the Japanese Ministry of Health, Labour and Welfare , the empApart from demographic and social characteristics, other factors surveyed before watching the program were also used as independent variables in the logistic regression analysis. These factors included the pre-program scores on Link’s Devaluation-Discrimination Scale, basic knowledge about schizophrenia, social distance, and the ability to distinguish schizophrenia from other disorders. These measurements of schizophrenia-associated stigma obtained before the educational program were incorporated in a second model to predict the stigma changes caused by the program. Knowledge, pre-program score on Link’s Devaluation-Discrimination Scale, and social distance were included in the final logistical regression model as potentially-significant independent variables. This study demonstrated that the pre-program level of stigma was a significant explanatory variable. According to a previous study on anti-stigma education, lower levels of understanding and a more negative attitude towards mental illness allowed more potential for improvement following the program . It can et al. reported that the more information people were given about schizophrenia, the more negatively they viewed the illness [In this study, some parents did not change their attitudes towards schizophrenia. There are two possible causes of stigma not changing. One is the increase of stigma synchronized with the improvement of knowledge about schizophrenia. In this study, increases in levels of stigma tended to occur among parents who had more knowledge before watching the program. This is consistent with some previous studies that have indicated that stigma towards mental illness increases with increased knowledge -32. For  illness . The rea illness -33, and  illness ,35. SpecThe above perspectives confirm that simple knowledge-imparting programs are not always effective in decreasing stigma. Similar results were also found in Hong Kong and the United States ,36. AlteThere are several possible methods of reducing levels of stigma. In line with the above discussion about the association between employment status and stigma changes and the importance of supplementing knowledge communication with contact for parents of middle and high school students, two types of anti-stigma interventions could be conducted in the future. One involves increasing contact in daily life with people with schizophrenia. Most laypeople lack opportunities to absorb knowledge and make personal contact with people suffering from schizophrenia, especially if their contact opportunities are limited by their employment status. Suitable ways of encouraging this kind of contact might be lectures by psychiatrists and people with or recovered from schizophrenia in community centers or parents’ meetings at school. The second type of anti-stigma intervention involves incorporating contact with people with schizophrenia within the educational program itself. It is possible to include interview videos of people who suffered from schizophrenia as adolescents and their parents, who could talk about the experiences of their actual daily lives and effective treatment methods. These positive examples could make parents hopeful regarding the treatment of schizophrenia and aware of the importance of early detection and treatment. Furthermore, improving the law and insurance systems in primary and secondary industries could make people more willing and relaxed regarding the possibility of working with people with schizophrenia, thus reducing the stigma among this population -40.This study also has several limitations, and some of the conclusions drawn here will lead to further debate. First, because the invitation to take part in the survey and the viewing of the educational program were conducted over the internet, parents who frequently used the internet were more likely to be included in the sample. Therefore, the sample in this study may not be representative of the wider population because of the nature of internet-based surveys, which makes the occurrence of non-response inevitable. Of the 5,000 candidates for participation in this study, 2,310 parents did not respond. For these parents, we were unable to obtain agreement to participate or any data regarding their characteristics, and it is possible there are some differences between respondents and non-respondents in terms of characteristics and attitudes. Second, regional cultural and psychological factors were not considered as explanatory variables of the effects. These would be a valuable consideration future studies. Third, the result of this study, with almost equal numbers of participants in the stigma-increased (n = 550) and stigma-decreased (n = 508) groups, underlines the fact that the theory of how educational efforts can affect stigma changes is in need of further development. However, the primary objective of this study was to explore the factors related to the characterization of considerably decreasing or increasing stigma using appropriate statistical analyses, and the results suggest that our educational program resulted in considerable decreases in stigma for participants with specific characteristics. This finding has encouraged us to conduct further studies. Concretely, we need to evaluate the reproducibility of the findings on the stigma-decreasing effect of our educational program for the Japanese parents of adolescents with certain characteristics. Additionally, it is necessary for us to investigate the cause of increasing stigma for the other parents in detail and to consider whether there are alternative strategies to prevent the considerable increases in stigma observed among some parents in this study. In particular, it is essential that future research give more deliberate consideration to strategies for anti-stigma education for parents with a variety of characteristics.The results of this study suggest that participants’ employment status, occupation, basic knowledge of schizophrenia, initial Link’s Devaluation-Discrimination Scale score, and social distance were significant factors associated with the likelihood of a considerable decrease in stigma towards schizophrenia as a result of the educational program. The results of the analysis presented in this article have several implications in terms of promising methods for future anti-stigma education efforts. For example, contact with people with schizophrenia in daily life would likely be effective for parents whose interpersonal contacts are limited, video contact with adolescents with schizophrenia and their parents might encourage hopefulness and awareness regarding schizophrenia among parents, and the improvement of the law and insurance systems would intensify the sense of security of parents working in primary and secondary industries, consequently decreasing the fear and stigma associated with schizophrenia.The authors declare that they have no competing interests.YL was the principal investigator and was responsible for the study concept and design, was involved in the data management, carried out the statistical analyses, and drafted the manuscript. MW was involved in drafting the manuscript. HY conducted the data collection and was involved in the data management. KA supervised the first author and was involved in interpreting the data and drafting the manuscript. All authors revised the text critically for important intellectual content and read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/14/258/prepubThe Link Devaluation–Discrimination Scale (modified for schizophrenia) .Click here for file


Wolbachia-infected, transmission-compromised, mosquitoes to reduce dengue transmission. Previous introductions of genetically-modified strategies for dengue vector control have generated controversy internationally by inadequately engaging host communities. Community Engagement (CE) was a key component of the ED Program’s initial open release trials in Queensland Australia. Their approach to CE was perceived as effective by the ED team’s senior leadership, members of its CE team, and by its funders, but if and why this was the case was unclear. We conducted a qualitative case study of the ED Program’s approach to CE to identify and critically examine its components, and to explain whether and how these efforts contributed to the support received by stakeholders.Worldwide, more than 40% of the population is at risk from dengue and recent estimates suggest that up to 390 million dengue infections are acquired every year. The Eliminate Dengue (ED) Program is investigating the use of In-depth semi-structured interviews were conducted with 24 participants with a range of experiences and perspectives related to the ED Program’s CE activities. Our analytic approach combined techniques of grounded theory and qualitative description. The ED Program’s approach to CE reflected four foundational features: 1) enabling conditions; 2) leadership; 3) core commitments and guiding values; and 4) formative social science research. These foundations informed five key operational practices: 1) building the CE team; 2) integrating CE into management practices; 3) discerning the community of stakeholders; 4) establishing and maintaining a presence in the community; and 5) socializing the technology and research strategy. We also demonstrate how these practices contributed to stakeholders’ willingness to support the trials.Our case study has identified, and explained the functional relationships among, the critical features of the ED Program’s approach to CE. It has also illuminated how these features were meaningful to stakeholders and contributed to garnering support within the host communities for the open-release trials. Our findings reveal how translating ethical intentions into effective action is more socially complex than is currently reflected in the CE literature. Because our case study delineates the critical features of the ED Program’s approach to CE, it can serve as a framework for other programs to follow when designing their own strategies. And because the findings outline a theory of change for CE, it can also serve as a starting point for developing an evaluation framework for CE. Community Engagement (CE) is gaining increasing recognition as an important dimension of biomedical, public health and global health research, including neglected tropical disease research. Yet, there has been little agreement about the specific goals of CE and about the best ways to design, conduct, and evaluate it. CE was an integral component of the ED Program’s initial open release trials in Queensland, Australia and our retrospective case study of their approach to CE in that setting helps explain why the ED program was well accepted in the host communities of the initial field trials. Our analysis has generated an empirically grounded framework for CE that explains the linkages between the foundational ethical and practical commitments made by the ED program and its funders and the specific operational practices adopted by the ED program, through which these commitments were realized. Our case study also identified how these practices were meaningful to stakeholders and contributed to their willingness to support the ED program, in general, and the open-release trials in particular. This framework provides research funders, investigators, implementation partners, policy makers, research ethics committees and host communities an example to follow when designing their CE strategies and assessing whether CE is being conducted to high ethical standards. The WHO has described dengue as “the most important mosquito-borne viral disease in the world” . WorldwiWolbachia, a bacterium that naturally infects a wide range of insect species, could stably infect Aedes aegypti mosquitoes—the main vector of dengue transmission , “well this has got to be bigger than that. We really do need to look at this as an all hazards risk assessment and we need to work out what all those hazards are and categorize them.” We just had this huge brainstorming exercise that delivered well over 100 potential hazards. … There were political issues. There were social issues. There were economic issues and there were regulatory issues. And so, we thought well okay, we need a way of tackling this. And again, there’s no blueprint. Nobody has done this in Australia as far as Australian legislation was concerned. The championing of CE by the ED Program’s senior leadership team, including its Principal Investigator, established CE as a high priority and sent a strong signal to the ED team that CE was to be taken very seriously.But I think amongst some of the scientists involved there was a view that what science does is so self-evidently a public good that you really don’t need to pay much attention to these issues. . . Equally, and I think this is really important, there were signs of a very different attitude …I don’t think there’s any doubt that [the PI], who was the leading light in this, or a leading light. It was very obvious to me early on that he certainly was well aware of the need to genuinely consider the social aspects. Not simply as a PR exercise. Leadership on CE was manifested in three key program decisions: (1) CE would be an integral component of the ED Program; (2) sufficient human and financial resources would be invested in CE; and (3) sufficient time would be dedicated to CE before, during, and after the planned open-release trials. These decisions set the stage for the success of the ED Program’s approach to CE. CE had to be "meaningful" to stakeholders themselves and not simply useful to the investigators. That CE had to be meaningful to stakeholders was embodied and manifested in nine core commitments and guiding values that: (1) served as the ethical foundation for shaping the ED team’s approach to CE; (2) informed how the ED team would interact with stakeholders; and (3) provided practical guidance in terms of designing and conducting specific CE activities and practices. Our analysis of interviews with internal and external stakeholders identified a clear set of core commitments and guiding values. Although these were never formalized by the ED program, they were explicitly and implicitly evident in the ED Program’s approach to CE, and in the experiences of both internal and external stakeholders. The central idea anchoring the ED Program’s approach was that throughout the entire duration of the project—including the planning and conduct of any open-release trials—Wolbachia technology; (2) to understand stakeholders’ perspectives on the history of biological control in the region, and the current sociopolitical context; (3) to gain an understanding of stakeholders’ knowledge of dengue-transmitting mosquitoes and their behaviour; and (4) to identify what these stakeholders wanted to learn more about, and believed others would want to learn more about, and how they wanted to be engaged—including opportunities for becoming involved in the project  to find out how people wanted to be engaged. What was the methodology that they were most comfortable with? How would they want us to interact with them? What level of engagement were they most comfortable with? Do they really want to participate, or do they just want to be informed? Wolbachia  group could certainly provide some assistance to them, and I was so enthusiastic about the project that I was able to talk my team into helping them out pretty easily. Wolbachia technology, but had to be concerned with, and attentive to, the meaning of CE as well as the meaning of the technology and the way in which it was being introduced, to a wide range of stakeholders in the host communities.Our case study has identified the critical features of the ED Program’s approach to CE and illuminated how these features were meaningful to stakeholders and contributed to garnering their support for the open-release trials, although it is likely that other less obvious factors also contributed to this support. From the outset, the ED leadership recognized that CE could not simply be a set of practices to facilitate the introduction of the The implications of these findings are important in the current climate of increased attention to CE in the field of health research , 30, 31 Another salient finding was the importance of explicit requirements for CE and sustained material support for CE by the funding agencies. Research funding programs have had an important impact on CE over the years. For example, the U.S. National Institute of Allergy and Infectious Diseases (NIAID) of the National Institutes of Health (NIH) has required Community Advisory Boards (CABs) as a condition of funding for HIV clinical trials for more than 20 years , and othThe ED Program’s approach to CE also involved several important ethical dimensions, expressed through their core commitments and guiding values, and realized through the operational practices of discerning the research community, establishing and maintaining a presence, and socializing the technology and research process. These dimensions align well with some of our own recent work to articulate the ethical goals of CE, in particular, to demonstrate respect for stakeholders as people, first and foremost, and not simply as a means through which investigators can achieve their scientific goals. The ED PWolbachia technology to have a major impact on dengue globally. Further, the ED Program’s explicit commitment not to foist the project on the community is unusual and commendable in a field that continues to wrestle with what it means to obtain the support of the host community and to establish the role of research subjects and citizens in determining whether vector control research should proceed [The ED Program’s attention to ethical dimensions of CE is significant, given the lack of guidance about CE available to the ED team at the time these trials were initiated. The ED team’s commitment to being “straight-up and honest” in all of their interactions with stakeholders contrasts sharply with the secrecy that surrounded the Cayman trials  and refl proceed , 13, 14.all of the ED team’s interactions with stakeholders were effective, or successful, or were perceived as such by stakeholders. But we did not find any examples of serious concerns by any stakeholders that went unaddressed by the ED team. Given the detail of the insights offered by interviewees and the extensive social networks represented by our individual participants, we view this as a salient finding.All of the stakeholders we interviewed seemed to have a clear sense that the ED team members were not simply “going through the motions”, but were reflecting genuine beliefs about the way stakeholders should be treated. This suggests that specific forms of interaction with stakeholders without the same underlying ethical commitments could be perceived as empty by stakeholders and might jeopardize the process of securing support. As a cautionary note, our findings do not imply that The empirically grounded CE framework we have delineated here also offers opportunities for paying greater attention to the relationship between CE operations and important ethical and practical outcomes associated with CE. Our case study provides some promising insights into the inter-personal and social underpinnings of “support” or “acceptance” for community-level interventions. Funders should appreciate the importance of these insights and should undertake efforts to improve their ability to characterize and cost CE activities so that they might be better integrated as a legitimate element of their funding portfolios.Our study has three significant limitations. First, because of its retrospective nature, participants’ accounts were vulnerable to normal limits of recall. Second, the fact that the open-release trials were conducted with no detected adverse outcomes for the community might have limited deeper consideration by some stakeholders and resulted in insufficiently critical positive attitudes towards the ED Program and the CE approach. And, third, we had to rely on the ED team to help us identify participants, since there were no natural sampling frames outside the ED program to identify external stakeholders. As a result, our sampling strategy was constrained and vulnerable to some selection bias. In particular, it was very easy to identify external stakeholders who held positive views, and reported positive experiences about the ED program, but it was more challenging to find “tolerators” or individuals who opposed the project throughout its duration. We attempted to minimize this bias by: (1) purposively sampling external stakeholders who had been skeptical of the technology at some point in the research process; (2) probing ED team members about any specific external stakeholder concerns and about the nature and range of external stakeholder attitudes they had encountered; and (3) with all participants, delving more deeply into any concerns expressed about the technology and/or the engagement process. These approaches kept us cognizant of the potential for positive framing effects and elicited important insights about external stakeholder concerns and opposition, which helped to minimize its impact. However, it is likely that additional interviews, particularly with more “tolerators” would have revealed important details that are not adequately represented in our findings.The framework we delineate in our results provides an explanatory account of how and why the ED Program’s approach to CE worked in the Queensland trials. Given that it delineates both the foundational and operational dimensions of CE that contribute to a coherent and ethical CE strategy, the framework outlined here has several potential applications. In the immediate term, it can serve as an example for other teams to follow when designing and planning their own CE strategies, whether engaging in their own open release trials or introducing other biotechnologies, or in any complex stakeholder engagement. This is not to suggest that ‘one-size-fits-all’, as each setting and intervention will have its own unique characteristics and challenges, and some settings will necessitate more or less intense CE strategies than the one reported here. It also provides funders, partner institutions, regulators, research ethics committees, civil society organizations, and the general public with a means to begin to assess whether CE is being conducted to high ethical standards. In the longer-term, the ED CE architecture might serve as a useful starting point for developing a robust evaluation framework that could be applied prospectively to guide the planning and implementation of CE strategies, and retrospectively to evaluate their associated processes and outcomes , 36.


Although obesity among immigrants remains an important area of study given the increasing migrant population in Australia and other developed countries, research on factors amenable to intervention is sparse. The aim of the study was to develop a culturally-competent obesity prevention program for sub-Saharan African (SSA) families with children aged 12–17 years using a community-partnered participatory approach.A community-partnered participatory approach that allowed the intervention to be developed in collaborative partnership with communities was used. Three pilot studies were carried out in 2008 and 2009 which included focus groups, interviews, and workshops with SSA parents, teenagers and health professionals, and emerging themes were used to inform the intervention content. A cultural competence framework containing 10 strategies was developed to inform the development of the program. Using findings from our scoping research, together with community consultations through the African Review Panel, a draft program outline (skeleton) was developed and presented in two separate community forums with SSA community members and health professionals working with SSA communities in Melbourne.The ‘Healthy Migrant Families Initiative (HMFI): Challenges and Choices’ program was developed and designed to assist African families in their transition to life in a new country. The program consists of nine sessions, each approximately 1 1/2 hours in length, which are divided into two modules based on the topic. The first module ‘Healthy lifestyles in a new culture’ (5 sessions) focuses on healthy eating, active living and healthy body weight. The second module ‘Healthy families in a new culture’ (4 sessions) focuses on parenting, communication and problem solving. The sessions are designed for a group setting (6–12 people per group), as many of the program activities are discussion-based, supported by session materials and program resources.Strong partnerships and participation by SSA migrant communities enabled the design of a culturally competent and evidence-based intervention that addresses obesity prevention through a focus on healthy lifestyles and healthy families. Program implementation and evaluation will further inform obesity prevention interventions for ethnic minorities and disadvantaged communities. The United Nations’ Food and Agriculture Organisation reported that, at 26.8%, sub-Saharan Africa has the highest prevalence of undernourishment, representing 234 million individuals who suffered from hunger in the 2010–2012 period and a growth of 64 million in the last 2 decades . NumerouAcculturation refers to the phenomenon through which migrant populations adopt the cultural patterns  of their host society whilst perhaps maintaining aspects of their own culture to varying degrees . In factAlthough obesity remains an important area of study given the increasing migrant population in Australia and other developed countries, research on factors amenable to intervention is sparse. Most importantly, sub-Saharan African migrants are under-represented in obesity related research programs due to their low health literacy, poor English proficiency, and other cultural barriers. Studies seeking to determine socio-cultural factors to be included in obesity prevention programs targeting marginalised migrant communities are urgently needed. Therefore, the aim of this study was to develop a culturally-competent obesity prevention program for sub-Saharan African families with children aged 12–17 years using a community-partnered participatory approach.The cultural competence framework was used to guide the development of the program. Cultural competence refers to “a set of congruent behaviours, attitudes and policies that come together in a system, agency or among professionals and enable that system, agency or those professions to work effectively in cross-cultural situations” . CulturaSawyer and colleagues  have ideAn interactive community-partnered participatory approach was adopted, whereby the intervention was developed in collaborative partnership with communities, and community members were recruited and trained to participate in all aspects of the project implementation ,19. EffeThe target population was families with children aged 12–17 years (see proposed mode of implementation below). Our previous research in this subpopulation shows that sub-Saharan African children and adolescents are at increased risk of obesity, but factors predisposing them to obesity are not yet well understood ,20-27. TIn the second phase, a survey was conducted among African teenagers and their parents living in Melbourne to quantify various aspects of their health . The first survey was exploratory in nature and sought to test the recruitment approaches, to evaluate the application of parenting and family functioning scales, and to identify aspects of parenting and family functioning associated with obesity . The stuFinally, the development of the program outline and program materials involved a number of steps. Informed by findings from Phases 1 and 2, literature reviews, and community consultations through the African Review Panel, a draft program outline was developed and presented in two separate community forums with African community members and health professionals working with African communities in Melbourne. The first forum was conducted at a community event in December 2011 to celebrate the African Review Panel’s contribution to the project, disseminate findings from Phases 1 and 2 and gather feedback on the draft program outline. The second forum, in March 2012, provided other African community members with an opportunity to hear the program results to date and provide feedback on the draft program plan with the assistance of bilingual workers. Both forums were effective in obtaining useful feedback that informed additional community consultation and finalisation of the final program, ‘The Healthy Migrant Families Initiative: Challenges and Choices’ (HMFI).Education materials to accompany the program were developed and informed by academic and grey literature, consultations with parenting experts, the research team, nutrition, and health professionals working with African families, the African Review Panel, and health providers to the African communities in Melbourne.Ethical approvals for all phases of the project were obtained from Deakin University Human Research Ethics Committee and/or Monash University Human Research Ethics Committee.The Healthy Migrant Families Initiative: Challenges and Choices program was designed to assist African families in their transition to life in a new country, by providing them with culturally sensitive and relevant training about healthy eating, active living, and communication and problem solving within the family unit. The goal of the intervention was to promote healthy eating and physical activity levels among children by strengthening family cohesion, enhancing family resilience, and promoting whole family lifestyle change. The program content consists of nine sessions, each approximately 1½ hours in length, which are divided into two modules based on their topic. The first module ‘Healthy lifestyles in a new culture’ (5 sessions) focuses mainly upon healthy eating, but also touches on active living and healthy body weight. The second module ‘Healthy families in a new culture’ (4 sessions) focuses on parenting, communication and problem solving. The session titles, purposes and key messages, and activities belonging to each module are presented in Table The sessions are designed to run in a group setting, as many of the program activities are discussion-based. Ideally, a group would have a minimum of six participants and up to 12 participants, to allow greater diversity in the group discussions. Though the session materials and program resources  are comprehensive, consistent with the cultural competence framework, the sessions should ideally be run by qualified bilingual health professionals such as dieticians or nurses, family support workers, and family counsellors who have experience working with African migrant families (or from the target communities for tailoring purpose). For instance, the ‘lifestyles’ module should be run by an Accredited Practising Dietician or nutritionist and the ‘families’ module should be run by a qualified social worker or parenting educator. Facilitators would be expected to become familiar with the program and program resources. If the facilitator is not multilingual in the languages of the program participants, a bilingual interpreter will be required at the sessions.Several key resources have been developed to ensure that the HMFI is run consistently across differing groups and settings, and by different facilitators. The resources cover the following materials:Session PowerPoint Slides’ – one set of slides per session; to be projected onto a wall or screen whilst running the sessions to serve as a visual aid‘‘Activity materials’ – various materials to assist the participants in their learning, including:Picture cards of food, ingredients and relevant nutritional information – cards to facilitate discussion about the healthfulness of different foods and mealsSession summaries – summary sheet of each session for the participants to take home and share with their familiesOther educational aids – healthy food pyramids adapted to include common traditional African foods for each participant to keep at home, and wallet-sized laminated food choice decision aids for use at the supermarket‘Instruction Manual’ – a resource comprising an overview of the program and the relevant resources for running the program and a reference point for program implementation‘Facilitators Manual’ – the ‘go-to-guide’ for facilitators about how to conduct the HMFI program. It outlines the role and responsibilities of the facilitator, summarises each session, and provides instructions and guidance for facilitating the sessions and optimising discussion e.g. communication types, how to optimise discussion, how to avoid barriers to communication, how to use active listening, adult education principles, safety and ethical considerations ession Guide’ – provides useful information for facilitators about how to run each session including discussion suggestions, activities, time for each session and activity, and background information regarding the facilitation materials.‘SThis is the first study to develop a culturally competent obesity prevention program for sub-Saharan African migrant families in Australia. The developed program addresses two main components: healthy lifestyles and healthy families. The intervention is designed to be delivered to parents for three reasons: 1) to address the intergenerational acculturation gap, 2) to maximise the effect of parental involvement; and 3) to develop cultural competence strategies that maximise community ownership of the program.Various studies have observed a dyadic acculturative stress resulting from differing pace of acculturation between migrant parents and their offspring, with children acculturating faster than their parents. The acculturation gap-distress hypothesis stipulates that when immigrant parents and children acculturate at different pace , the main outcomes include migrant parents and their children holding different values and preferences which often clash, family conflict as well as youth maladjustment ,30. It hThe intervention was developed in partnership with the community, and culturally competent strategies to sustain their participation and maximise their ownership of the program have been provided. Culturally tailored interventions should respect cultural practices, encourage retention of healthy traditional food practices, and work with people to identify ways by which they can modify their traditional foods to make manageable healthy changes. They should also identify and enlist influential family members, in particular those who shop for and prepare the food . Both ofThere are some limitations worth outlining. The paper provides a description of a best practice approach to developing interventions that would be culturally relevant and acceptable to immigrant and other ethnic minority groups. The described process adopted a culturally competence framework and would be well-suited to immigrant or other ethnic minority groups when researchers and practitioners are interested in developing culturally competent programs. Nevertheless, the paper is not about the evaluation of the program as we do not yet have data on the program implementation, tailoring process, and program efficacy. A randomised controlled trial is planned in the near future to evaluate the intervention’s impact on primary outcome (child body mass index) and secondary outcomes . The evaluation will also shed light on the steps required to tailor the intervention to other culturally and linguistically diverse populations .The Healthy Migrant Families Initiative developed in this project is evidence-based and grounded in cultural engagement principles. Implementation and evaluation using the same cultural engagement principles will further add to interventions to promote culturally competent obesity prevention strategies for African and other communities settling in Australia.


The purpose of this study was to undertake a process evaluation to examine the reach, adoption and implementation of a school-community linked physical activity (PA) program for girls aged 12 – 15 years (School Years 7 – 9) using the RE-AIM framework.Various approaches were used to assess 'reach’, 'adoption’ and implementation: (a) a school environment survey of intervention schools (n = 6); (b) teacher feedback regarding the professional development component (91.1% response rate) and lesson implementation (60.8% response rate); and (c) post-intervention focus group interviews with physical education (PE) teachers (n = 29), students (n = 125), coaches (n = 13) and instructors (n = 8) regarding program experiences.Reach and Adoption: Seven schools , five tennis clubs, eight football clubs and five leisure centres participated in the program during 2011. Implementation: Program design and professional development opportunities  supported implementation and student engagement in PA. However, there was a lack of individual and organisational readiness to adopt program principles. For some deliverers there were deeply embedded ideologies that were not aligned with the Game Sense teaching approach upon which the program was based. Further, cognitive components of the program such as self-management were not widely adopted as other components of the program tended to be prioritised.The program design and resources supported the success of the program, however, some aspects were not implemented as intended, which may have affected the likelihood of achieving further positive outcomes. Barriers to program implementation were identified and should be considered when designing school-community linked interventions. In particular, future programs should seek to assess and adjust for organizational readiness within the study design. For example, shared commitment and abilities of program deliverers to implement the program needs to be determined to support program implementation.ACTRN12614000446662. April 30th 2014. The decline in physical activity (PA) levels and the possible associated health problems of young people continue to be of growing concern internationally . The decSchools are considered a key health setting to promote PA since young people attend and spend a considerable amount of time in school . The conMost PA promotion interventions have been conducted in the United States and United Kingdom and have tended to focus on children aged 6–12) rather than adolescents aged 13 – 19) , you are a long way behind those that do play so lots of the rally type things, hitting into this box or some of the kids had no hope of even getting it in that direction, if at all over the net… Teachers provided feedback  on the extent to which the lesson plans contained within the teaching manual were implemented. Teachers reported that the lesson was implemented in line with the lesson plan 'almost all’  or 'most’  of the time. However, focus group discussions with teachers and coaches revealed that the understanding of, and commitment to, the intention of a Game Sense approach varied and subsequently influenced the consistency of program implementation. Firstly, there were varying degrees to which teachers and coaches subscribed to the intentions of a Game Sense approach . Specifi“I try to do it, I don’t know how well I do it, but I try” PE Teacher, Intervention School E). Another explained that they were from the “older methods” of teaching and despite some professional development on Game Sense, found it difficult to “take the next step to actually put it into your life, I think you need to revisit it again and again and again before you actually get that change happening….” . Similarly, some coaches were more experienced than others with Game Sense pedagogy, as some commonly applied it to their coaching practices, whilst others had not. Experienced coaches commented that Game Sense was ideal for girls who had limited fundamental motor skills, enjoyed the social nature of participation and who did not want to focus on competition or technical aspects of the sport. These comments from teachers and coaches highlight the need for ongoing dialogue with the research team during implementation to help overcome the challenges associated with implementing alternative teaching pedagogies.In addition, some teachers had little or no experience with Game Sense; they discussed the approach as being quite new, reflecting that they were unsure on their execution of the approach (e.g. “human resource and organisation was non-existent and their [the school’s] compliance to the details and structures that were set out were non-existent” (Tennis Coach). It was felt that the school’s lack of commitment hindered the coach’s ability to deliver the program successfully. Another coach reported that classes were often late to program sessions. In addition, the length of PE classes ranged from 60 to 100 minutes across the seven schools, and as such coaches commented that 60 minutes was often not enough time to deliver the content and 100 minutes was too long to keep students engaged. However, leisure centre instructors felt that even 60 minutes was too long, particularly since their community-based programs such as group fitness classes are structured around 45-minute sessions.There were also some communication breakdowns between the schools, coaches and instructors, which resulted in a small number of school sessions being rescheduled or cancelled. For example, one tennis coach commented that one school’s “jumped over pillows” when they designed a fitness circuit at home or “started walking the dog” to fit physical activity into their lives outside of school .The intervention incorporated several elements to promote PA outside of school including the self-management journal activities to encourage girls to be independently active and also formally linked PE classes with existing community sport and recreation providers. In terms of the extent that the self-management journal activities were implemented, teachers reported, that the majority were not implemented at all , although a third of teachers set the journal activities as homework . The main reason that journal activities were not implemented was that teachers prioritised the PA component of the program over the cognitive component during class time. As a result, very few students reported that self-management journal activities were completed; indeed the majority were unaware of these activities. There were, however two cases in which groups of students discussed the journal activities that their teacher had set and they had commented that they With the football coach there was no talk of come down, … it was driven by me and I thought here is your opportunity mate to get kids to be excited and come down to your club and build your numbers and that didn’t come through at all. PE teachers, coaches and instructors attempted to encourage students to attend outside-of-school programs by using strategies such as flyers, notices in school newsletters and 'spruiking’ during PE classes. Students who had completed the baseline surveys also received SMS messages generated from the research team. There were a few instances, however, where community programs were not discussed appropriately or in a timely manner with students by the coaches or instructors. In these instances, students were provided only with vague details about the programs, due to a lack of communication between the coach/instructor within the school and the local club program facilitator. For example, a teacher reflected: Another factor impacting upon the uptake of the community programs was that while it was envisaged that students would be taken to visit the community clubs and leisure centre facility at least once during each unit, not all participating PE classes did so. In one case the facility was fully booked for public programmed classes and in another three cases there was poor communication between the coach and the community club. As a consequence, some students were not exposed to the clubs/facilities as intended, which is likely to have impacted on the likelihood of attending the subsequent community program.Student response to the lessons was reported by teachers as positive or very positive , although Year 9 students were reported to respond less positively for both football and tennis lessons. Teachers also reported that students responded positively or very positively to the coaches’ methods/approach/style .“even the most inactive girl was out there having a go” in the PE classes . Teachers noted that participation improved since the emphasis of the program was on games rather than skills and drills, included recreational activities via the leisure centre program, and had opportunities for single-sex classes. Teacher commented they enjoyed it because: They weren’t drills. Kids hate drills. Absolutely hate them. My kids are like, do we have to do drills but with the game-sense model I found it worked way better” .“They get lost in the moment of doing a body attack, doing a pump class and they could just go for it” .The qualitative focus groups further explored participants’ satisfaction with the program and the associated factors that influenced program satisfaction. Primarily, teachers were satisfied with the program because they perceived that PA behaviour among the girls improved where Some teachers also reported that students’ confidence in activities increased and were surprised at the level of skill developed during the school component, although some teachers also commented that the level of skill development was probably not enough for students to confidently transfer their participation to organised sport outside of school. Teachers attributed the increase in confidence and skill development to the inclusion of activities that focused on making small skill progressions and more specifically, enhancing cognitive understanding of the tactics and strategies that underpin game participation, which was a fundamental principle of the Game Sense approach.[I learnt] a lot seeing as how I don’t really play any sports so it was quite nice to actually be able to play a sport and not completely suck at it .Yeah, like it [the teaching/coaching] shows you how to do it. You’re not just playing and going, what do I do….and you don’t just kick the ball…..we learned skills and then he [the coach] said that we have to do that sometime in the game, and you get a point that you do that. So it showed us how to do it [the skill in a game-based situation]. Students also reported enjoying the activities and teaching approach adopted in the design of the program. They commented that they learnt new sports skills, such as learning how to serve and rally in tennis, and dribble and score goals in football. In particular, students who perceived themselves as “not sporty” reported feelings of success in performing sports activities and as such reported the development of new skills. For example students commented: I liked the change in what we were doing [with leisure centre activities] because when you do sports at school, it’s always just these games you have to learn how to play when you didn’t want to, but there you learned something different than usual; [it] was actually good to learn and could always help you later in life. .Students also reported learning about the availability of different types of sports and physical activities in the community. In particular they commented that they enjoyed the recreational activities organised by the leisure centres, which were commented on positively for their ability to offer something 'different’ from the usual PE lesson that in our participants’ experience tended to privilege team sports and games. For instance, a student reflected on her experience with some of the leisure centre activities which included Zumba and fitness circuits: “a more even chance” of playing and being active in the PE class; especially because boys were not dominating the activity, teasing, or being too competitive. One student reflected that the girls-only classes were important “…because most of the girls that do PE with boys, they just don’t do it. They don’t bring their uniforms and then they don’t do it.” . This comment was reiterated by a student at another school who commented “…and girls weren’t embarrassed at all. Like the girls who sit out they were happy to join in and they had a lot of fun” .The inclusion of single-sex classes was a topic hotly debated by girls. A number of girls who perceived themselves to be either 'sporty’ or 'non-sporty’ and either active or non-active reported that they enjoyed single-sex classes because they had “Most of the girls were harder to make friends with, and like be social with, like they all have their own groups of friends; whereas the guys just blend in and then you can blend in too. Girls just seem to stick to their own little groups.”. Co-educational PE classes were also preferred by some sporty or active girls, as boys provided the opportunity to have “someone to compete against” , whereas less sporty or active girls were more likely to minimise their participation.On the other hand, co-educational classes were preferred by some girls who had experienced negative peer interactions with other girls – “boys just upset the class totally....when the girls were by themselves, absolutely fantastic.” (Tennis coach). It seems that coaches found the delivery of single-sex classes easier to implement as they did not need to spend as much time managing students in single-sex classes.There was also a lack of agreement among teachers, coaches and instructors about the perceived benefits of single-sex classes. Some teachers reported that their students enjoyed the opportunity for single-sex classes; however others reported that single-sex classes did not work and suggested that cohesion and inclusiveness of the students within the class was more important than the gender mix. Tennis and football coaches, however, consistently reported that single-sex PE classes worked better than co-educational classes. They commented Professional development opportunities and resources were provided to teachers, coaches and instructors to support program implementation. A total of 45 teachers from the seven schools participated in professional development workshops conducted at each school by research staff. The aim of the workshop was to 1) present to teachers a range of activities that model a Game Sense approach to teaching tennis and football; 2) to present fitness activity ideas and discuss these activities in terms of technique, safety, progressions and other relevant considerations; and 3) build partnerships between teachers the community sport and recreation providers. Workshop feedback was received from 41 teachers (91.1%) and was generally very positive. Teachers mostly agreed or strongly agreed that the content was interesting and relevant , that the time and duration of the workshop was appropriate , and that participants had an opportunity to contribute to discussion , and to ask questions or clarify issues . Participants also agreed or strongly agreed that as a result of participating in the workshop they felt more aware of the key issues for girls regarding participation in PE, community-based sport and PA .They also reported that the workshop confirmed some of their own perceptions about the issues girls face in terms of PA participation . As part of the workshop, activities were conducted with teachers to identify how each school could create more meaningful and relevant learning experiences for girls in PE and to plan how the program could be implemented within the existing school structure. Teachers agreed or strongly agreed that both of these activities were useful . Overall teachers rated the workshop as good  or very good .Loved the questioning, loved the variety of activities and I suppose the flexibility of it…. If it wasn’t working, then you use your own knowledge, your own assessment of the kids to modify from there and if one activity didn’t work you could hopefully go on to a different one….You did have some substance in activity and questioning and resources behind it and I think that was valuable. The focus group discussions further supported the notion that teachers were satisfied with many of the resources provided; particularly the lesson plans which they reported challenged students to participate in activities because it focused on games rather than drills and higher order thinking through questioning. It also provided teachers with flexibility to respond to the needs of the students. For example a teacher commented: Unfortunately I don’t think our school or our administration values the PE or the sport or health very highly…..but then they’re telling [the sports coordinator] that the culture needs to change in sport …[or]…they won’t be spending any more money…[but]…they don’t listen – that to change [the sport] culture you need to change it in PE first. You’ve got to change it there for kids who want to go further and do more stuff… At the moment we don’t even have two basketball rings working properly. One’s broken and they’ve just tied it up so now we can’t play basketball in the gym. A number of teachers, however, indicated that there were school timetable constraints on implementing the program to its full potential, and felt that PE was often marginalised within the broader school curriculum. Teachers commented that it was difficult to provide positive experiences in PE for students when PE was marginalised in the school curriculum. For example, a group of teachers commented: “I was there for one class and these kids were working hard, really hard, she was like 'you’re not working hard enough! Come on kids!’ I was like 'ease up!’” . Second, some leisure centre facilities did not have the staffing capacity to implement a wide range of recreational activities; therefore students only received a somewhat limited scope of activities in their leisure centre-based lessons, which tended to be focused on fitness circuits rather than incorporating other activities that leisure centres have available. Third, the group fitness room at one leisure centre facility had clear windows and doors and therefore participants were visible to the public, which made students self-conscious about people watching and resulted in students disengaging from the activity.Coaches and instructors also reported being mostly satisfied with the resources such as the lesson plans provided to implement the program. However there was a lack of capacity among some providers to implement activities in PE classes; particularly among leisure centre providers. First, there was a lack of experience or capacity among some leisure centre instructors to implement recreational/leisure activities for secondary school students whose motivation, interest, and fitness levels varied. For example, some leisure centre instructors were reported by teachers to be unable to cater to the students’ fitness levels and create a supportive class room environment on which to build student learning and interest in recreational activities. One teacher described an instructor as very militant, using a command style and explained The implementation of the program aimed to make positive changes to rural and regional-living adolescent girls’ health-related quality of life (HRQoL), PA levels and mediators of PA. The program was implemented in a real world setting, with PE teachers engaging in professional development opportunities that sought to introduce them to the principles underpinning the design of lesson plans and facilitate links to community-based sport and recreation providers. There were a number of significant positive results in terms of program effectiveness , which wHowever, notwithstanding some positive outcomes, the degree of success of the intervention was limited by a range of factors. This study provides critical discussion around the barriers to implementation of a school-community linked program to inform practitioners and future intervention-based research in schools.The socio-ecological model was a useful framework to consider and address the wide range of factors that influence PA behaviour and as such the program was underpinned by several elements reported to be most effective in promoting PA among girls , 6. ThesThe likelihood of such a program achieving the intended health outcomes, such as changes in HRQoL, PA or mediators of PA is highly dependent on its implementation. Schools are undoubtedly a complex and challenging setting in which to implement change and are often constrained by barriers such as organizational factors, policy constraints, lack of resources and a crowded curriculum . More spIndividual and organisational readiness to implement the program varied. For instance, self-management strategies were not well implemented by teachers because they tended to implement cognitive components of the intervention in a selective manner. Furthermore, there were deeply embedded ideologies based upon performance discourses that reinforce the acquisition of skills through demonstration, explanation and practice teaching approaches , which wTeaching pedagogies such as Game Sense often incite resistance from practitioners because they challenge the traditional and enduring belief that fundamental movement skills are prerequisite to game play . The impOrganizational readiness for change varies as a function of how much organizational members value the change…When organizational readiness for change is high, organizational members are more likely to initiate change, exert greater effort, exhibit greater persistence, and display more cooperative behavior. The result is more effective implementation.Fundamentally, despite the use of a range of capacity building strategies, the implementation of the program required organizational changes in order to maximise individual changes at the student level. Weiner  conceptuOrganizational readiness for change has been identified as an under-recognised area in health promotion practice  and therSingle-sex classes were a contentious issue in this study. Since the mid 1980’s there has been a shift in Australia to the implementation of co-educational classes for PE; although there is continuing controversy on co-educational and single-sex PE , 56. As Some limitations to this study need to be acknowledged. Direct observation of program implementation may have strengthened the assessment of process evaluation; although this too is not without measurement issues. Direct observation was not practical for this large study due to the high cost associated per observation . In addiReach, adoption and implementation were high due to the provision of professional development opportunities and resources to deliver the program and satisfaction with the design of the program by teachers, coaches/instructors and students. It was evident, however, that some aspects of the program were not fully implemented as intended, which affected the likelihood of the program “quantitatively” achieving other intended public health outcomes, such as improvements in PA levels. This study provides useful information for future school-community linked interventions to address barriers to implementation; in particular the need to assess and control for organizational readiness within study designs.


Dorcus titanus platymelus (Oder: Coleoptera). The wing unfolding process of Dorcus titanus platymelus was examined using high speed camera sequences (400 frames/s), and the hydraulic pressure in the veins was measured with a biological pressure sensor and dynamic signal acquisition and analysis (DSA) during the expansion process. We found that the total time for the release of hydraulic pressure during wing folding is longer than the time required for unfolding. The pressure is proportional to the length of the wings and the body mass of the beetle. A retinal camera was used to investigate the fluid direction. We found that the peak pressures correspond to two main cross-folding joint expansions in the hind wing. These observations strongly suggest that blood pressure facilitates the extension of hind wings during unfolding.In most beetles, the hind wings are thin and fragile; when at rest, they are held over the back of the beetle. When the hind wing unfolds, it provides the necessary aerodynamic forces for flight. In this paper, we investigate the hydraulic mechanism of the unfolding process of the hind wings in  BecauEnergy is required to unfold and/or fold the hind wing and to prevent wear at critical locations in the wing . This enDorcus titanus platymelus (Oder: Coleoptera). This work provides insight into the flight behavior of insects. The folding/unfolding mechanisms of the beetle hind wing may provide design inspiration for portable micro air vehicles (MAVs) with morphing wings and bioinspired deployable systems.In this paper we investigate the hydraulic mechanism of the unfolding of hind wings in 2.Dorcus titanus platymelus. The series of unfolding movements of the hind wings of four beetles are shown in The pressure measurements obtained in the beetle hind wings . We can A retinal camera was used to confirm which veins were involved in the hydraulic mechanism of the unfolding of hind wings. The experimental live beetle was injected in the abdomen with a fluorescent agent. Four seconds later, fluorescence was observed in the costa and media posterior . The fluThe costa is hollow, as shown in This work provides insight into the flight behavior of insects; the folding/unfolding mechanisms of the beetle hind wing may provide design inspiration for portable MAVs with morphing wings . By actu3.Dorcus titanus platymelus is a type of phytophagous, aggressive beetle, with strong flight capability. The hind wings are folded beneath the elytra when not in use, and these beetles are capable of reducing the length of wings by up to 55%. Beetles were captured in the wild, in Shanghai, China. The microstructures of cross sections of veins were captured using an inverted fluorescence microscope . After the hind wings were dehydrated, the hind wings were prepared for analysis by embedding, sectioning and staining (hematoxylin-eosin). Flying beetles were photographed with a high-speed camera .11m · Hz1/2/W, sound velocity of 2000 m/s, relative dielectric constant (ɛ/ɛ0) of 9.5 ± 1.0 (1 KHz), and electro-mechanical coupling factor (K33) of 10%–14%. The sensor was installed on the costa vein by double sides-sided adhesive tape, and the elytron on the testing side was removed but preserved on the opposite side. The beetle was kept alive and allowed to move freely. When the sensor and measurement system were completely installed, the experimenter used a stick to simulate the beetle’s abdomen. This resulted in the beetle expanding its hind wings at which point the data were collected. These tests were repeated four times. General piezoelectric materials are sensitive to pressure, when you stretch or bending a piece of PVDF piezoelectricity thin-film, the film between the upper and lower electrode surface can produce an electrical signal (charge or voltage), and is proportional to the strain of stretch or bending. In order to improve the signal-to-noise ratio of the analog input signal, the signal filter was used to attenuate the noise  were designed as a control system to investigate variation of fluid pressure in the veins of the hind wings . The senTo confirm which veins of the hind wings were involved in the hydraulic mechanism during unfolding, a retinal camera  was used. Retinal camera testing was performed with a fluorescent agent to color the walls of the veins. One milliliter of green fluorescent indicator (FITC) was injected in beetle abdomen at time 0 . The mea4.The folding/unfolding characteristics of hind wings are special features of beetles. Folding may sometimes occur along flexion lines. In general, extension of beetle hind wings most likely results from the hydraulic pressure of blood.In the current study, we demonstrated fluctuations of hydraulic pressure, appearing as two peaks during unfolding of wings; the first maximum peak corresponded to the initiation of unfolding, and the second peak corresponded to the unfolding of the tip of the wing. The maximum value of the peak in pressure varied between 6.07 and 9.29 Pa. The time interval between the two peaks ranged from 0.68 to 1.59 s, and the total time of expansion ranged from 5.80 to 6.73 s. Pressure is proportional to the length of wings and the body mass. The total time for the release of hydraulic pressure during folding of wings is longer than the time required for unfolding. In addition, we found that blood flows only through the costa vein, ending at the marginal joint which then turns towards the humeral cross-vein, and the media posterior veins, ending at a transverse fold. Our results demonstrate that blood pressure facilitates the extension of hind wings during the unfolding process. We anticipate our work to be the basis of further sophisticated research on the folding and unfolding mechanisms of beetle hind wings as these mechanisms may provide design insights for portable MAVs with morphing wings and give inspiration to the development bioinspired deployable systems.