Increasing physical activity (PA) brings many health benefits, but engaging people in higher levels of PA after their 60s is not straightforward. The Functional Fitness MOT (FFMOT) is a new approach which aims to raise awareness about the importance of components of fitness , highlight benefits of PA, engages older people in health behavior change discussions, and directs them to local activity resources. This battery of tests combined with a brief motivational interview has not been tested in terms of feasibility or effectiveness.To assess whether the FFMOT, provided in a health care setting, is appealing to older patients of a community physiotherapy service and to understand the views and perceptions of the older people undergoing the FFMOT regarding the intervention, as well as the views of the physiotherapy staff delivering the intervention. Secondary aims are to assess the feasibility of carrying out a phase 2 pilot randomized controlled trial of the FFMOT, in the context of a community physiotherapy service, by establishing whether enough patients can be recruited and retained in the study, and enough outcome data can be generated.A mixed-methods feasibility study will be conducted in two physiotherapy outpatient clinics in the United Kingdom. A total of 30 physically inactive, medically stable older adults over the age of 60 will be provided with an individual FFMOT, comprising a set of six standardized, validated, age-appropriate tests aimed at raising awareness of the different components of fitness. The results of these tests will be used to provide the participants with feedback on performance in comparison to sex and age-referenced norms. This will be followed by tailored advice on how to become more active and improve fitness, including advice on local opportunities to be more active. Subsequently, participants will be invited to attend a focus group to discuss barriers and motivators to being more active, health behavior change, and the scope for individuals to improve their PA levels. To inform the design of a future trial, descriptive , quantitative , and qualitative data  will be collected.Recruitment and enrolment for the trial started in September 2015. Follow-up will be completed in June 2016. Results are expected to be available at the end of 2016.Allied health professionals play a key role in encouraging older adults to increase their PA, but with little evidence on how best to do this within their clinical practice. The purpose of this feasibility study is to examine the introduction of a new service: The FFMOT. The views and perceptions of the older people undergoing the FFMOT and relating to its delivery in clinical practice will be explored. Data, which will inform the feasibility of a randomized controlled trial of effectiveness of the FFMOT in promoting improved PA, will be reported.International Standard Randomized Controlled Trial Number (ISRCTN): ISRCTN38950042; http://www.isrctn.com/ISRCTN38950042 Increasing physical activity (PA) brings many health benefits, improved health care outcomes, and reduced health care costs . PA recoThe Scottish Government has recommended that allied health professionals play a central role in encouraging people to be more active . PhysiotRikli and Jones  previousacceptability, demand, implementation, and practicality for the participants, that is, to assess whether the FFMOT, provided in a health care setting, is appealing to older patients of a community physiotherapy service, and to understand their views and perceptions undergoing the FFMOT regarding the intervention, and (2) acceptability, demand, implementation, practicality, and integration for the staff delivering the FFMOT, that is, to assess their views on delivering the intervention to the target participants and within the setting of a community physiotherapy clinic. Secondary aims are to assess limited efficacy, that is, the feasibility of carrying out a phase 2 pilot randomized controlled trial of the FFMOT, in the context of a community physiotherapy service, by establishing whether enough patients can be recruited and retained in the study, and relevant outcome data can be generated.Due to the lack of in-depth research and existing data about the FFMOT in a clinical setting, a feasibility study is indicated . TherefoThis is a mixed-method phase I feasibility study with a pre-post design.A convenience sample will be identified and recruited from one UK health board area, from among the current caseloads of community physiotherapists working in two physiotherapy clinics for musculoskeletal (MSK) conditions. Participants are eligible for participation if they are (1) aged 60 years or above, (2) not physically active for at least 30 minutes in 5 days or more, or for at least 150 minutes (2½ h) in total in the past week, as indicated by the questions on the Scottish Physical Activity Screening Question , and (3)Where patients are deemed eligible, the screening physiotherapist will introduce the nature of the study verbally to them. The screening physiotherapist will then ask potential participants if they wish to receive a study information pack and, if so, they will be given the pack during the appointment. Participants who are interested will then complete a contact details form and post it to the main researcher, who will subsequently telephone them in order to explain the consent procedures, and make an appointment for them to attend an FFMOT session. All participants will continue to receive standard physiotherapy assessment and intervention as deemed appropriate by the screening physiotherapist, irrespective of their involvement in the study.This study is a feasibility study so no formal power calculation has been carried out. However, rates of participant retention at 3-month follow-up in feasibility studies of exercise interventions for adults range between 71-100% -18. AdopAll physiotherapists working at the two participating physiotherapy clinics, who assess and treat MSK outpatients, will be eligible to screen patients as potential participants.There are 3 physiotherapists involved in coordinating the study within the service. They will also supervise the 2 trained technical instructors (TIs) who will deliver the FFMOT. The TIs will receive training in both the delivery of the FFMOT  and in mEach recruited participant will be provided with an individual FFMOT session, which lasts for 45-60 minutes. The FFMOT in this study comprises 6 of the 7 standardized, validated, age-appropriate tests aimed at raising awareness of the different components of fitness:1) 30 Second Chair Stand ,22, as a2) Chair Sit and Reach ,23,24, a3) Back Scratch , as an i4) 8 Foot Up and Go ,25, as a5) Handgrip Strength , as an i6) Single Leg Stance ,28, as aThe 6-minute walk test, for endurance, will not be used within this FFMOT battery due to space constraints within the clinic.The results of these tests will be used to discuss the different components of fitness, to highlight the individual’s strengths and weaknesses in these components, and to provide the participants with personal feedback on performance in comparison to sex and age-referenced norms. This then allows discussion around the person’s activity history, needs, and preferences so that information about local opportunities to engage in PA can be introduced and encouraged. Specific goal setting (short and longer term) is discussed and each participant is provided with information about appropriate local activity opportunities and home exercises, based on their FFMOT results. This information will be provided in the form of written booklets/leaflets and links to websites of some of the opportunities available. For those who wish to exercise at home, home exercise booklets will be provided .The following information from every patient screened during the recruitment phase will be collected: (1) the clinic at which the patient was assessed/treated, (2) sex, (3) age, (4) postcode, (5) patient responses to the 3 questions in the Scottish Physical Activity Screening Question, (6) eligibility criteria, (7) whether the study was introduced verbally to the patient, and (8) whether the patient accepted the study information pack. Recruitment and retention rates at the key stages of the study  will also be monitored and recorded.The Community Healthy Activities Model Program for Seniors (CHAMPS) Activities Questionnaire for Older Adults  will be Between 2-4 weeks after participants have attended the FFMOT session, they will be invited to attend a 60-90 minute focus group. Each group will consist of a maximum of 12 participants. The focus groups will be moderated by the first author (LDdJ) according to a bespoke, predesigned discussion guide. The discussion guide contains a set of semi-structured, open-ended questions. The interview process during the focus group comprises a 4-step approach to ask the participants the following:1. Their reason(s) for taking part in the study.2. Their PA awareness .3. The FFMOT and its appeal  recommending it to others, suggestions for improvement to make it more appealing, and views on timing and location of provision of the service).4. Their experiences of the study procedures .Four semi-structured individual interviews, of up to 60 minutes, with the supervising physiotherapists and the 2 TIs will be held no more than 2 weeks after all FFMOT sessions have been provided. The interview process for these interviews comprise a 3-step approach to ask the staff about the following:1. Previous experiences in working with older people, therapy, fitness testing, exercise, research, and background knowledge of fitness tests/testing.2. Perceptions of the FFMOT .3. The FFMOT in the context of a community physiotherapy service .All focus group discussions and staff interviews will be audio recorded onto an encrypted digital recorder.As this is a feasibility study, the analyses will be primarily descriptive. Reasons for exclusion, participant recruitment and retention rates, number of completed questionnaires returned, and incidence of missing questionnaire item responses will be explored. Additional analyses will be conducted of any demographic differences  will be anonymized, will not affect their confidentiality in any way, and that it will not be possible to identify information about them when the results of the study are published.A favorable ethical opinion of this study was granted by the NHS South East Scotland Research Ethics Committee 01, Scotland UK (Reference 15/SS/0118). Approval was also granted by the NHS Lothian Research & Development Office (Reference 2015/0283). The study is sponsored by Glasgow Caledonian University (Reference RIE13-127).Recruitment and enrolment for the trial started in September 2015. Follow-up will be completed in June 2016. Results are expected to be available at the end of 2016.Allied health professionals are tasked with playing a key role in encouraging older adults to increase their PA. Older adults need unique consideration in how they are recommended to become more physically active, in particular doing activities that improve strength and balance, but there is little evidence for allied health professionals on how best to do this within their clinical practice. The FFMOT is a new approach that aims to raise awareness among the over-60s of the importance of components of fitness such as strength, balance and flexibility, highlight the benefits of PA, engage older people in health behavior change discussions, and direct them to appropriate local activity resources. However, there is no existing data about whether the FFMOT could work in this setting, and therefore performing a feasibility study is indicated. The purpose of this mixed-method phase I feasibility study with a pre-post design is to examine the introduction of the FFMOT for older adults, within two community physiotherapy MSK clinics in the United Kingdom. Specifically, the views and perceptions of a convenience sample of older people undergoing the FFMOT relating to the delivery of the FFMOT in clinical practice will be explored. Patient recruitment/retention rates, and the extent to which outcome data can be collected, will be evaluated with a view of planning a future randomized controlled trial of the FFMOT compared with the usual treatment provided (recommendations for increased activity). Participants included in this study will be provided with single, 45-60 minute consultation, including age-appropriate functional tests, which could potentially increase their motivation to become more physically active. Increased PA could help them improve their gait, balance, mobility, and general health in the longer term. If this feasibility study suggests the FFMOT can work in the clinical setting, then a definitive RCT will be proposed in order to look at whether the FFMOT is efficacious and effective at increasing PA in older adults.


Older African Americans carry a disproportionate share of chronic diseases. The purpose of this study was to identify the characteristics of urban-dwelling African Americans with chronic disease participating in Chronic Disease Self-Management Education (CDSME) programs and to examine factors related to successful program completion .Data were analyzed from 11,895 African Americans who attended a CDSME program at one of the five leading delivery sites . Logistic regression analyses were used to assess the associations of demographic, delivery site, and neighborhood characteristics with CDSME program successful completion.Approximately, half of the African American participants were aged 65–79 years, 83% were female, and 92% lived alone. Approximately, 44% of participants had three or more chronic conditions and 35% resided in an impoverished area . Successful completion of the CDSME program was associated with being between the ages of 50–64 and 65–79 years, being female, living alone, living in an impoverished community, and attending a CDSME program at a residential facility or community center.Findings highlight the unique patterns of attendance and delivery within the context of self-management interventions among this unique and traditionally underserved target population. Understanding such patterns can inform policy and practice efforts to engage more organizations in urban areas to increase CDSME program adoption. Particularly, employing strategies to implement CDSME programs across all delivery site types may increase reach to African American participants. Currently, over 43 million US residents are 65+ years of age with that number projected to increase to approximately 80 million by the year 2040 . Along wThe drastic increase in the number of older adults, particularly those from diverse racial/ethnic groups, is associated with burgeoning rates of chronic disease. Approximately, 50% of aging adults report two or more chronic conditions, and data show that the prevalence of having two or more comorbidities is higher among aging African Americans than other racial/ethnic groups  . MoreoveConsiderable efforts have been made nationally to address issues surrounding the management of chronic illnesses among underserved and disadvantaged individuals –13. In fAs a result, a national study of the CDSMP was conducted resulting in greater racial/ethnic diversity among participants than had been seen in previous research focused on self-management , 11, 13.While much has been written about national dissemination and implementation of the CDSME programs –12 as weIn addition to African Americans facing unique challenges  that may influence health behaviors, health status, and utilization of health care –6, AfricThe aforementioned findings suggest the importance of extending CDSME research in an effort to understand the patterns of chronic disease management among urban-dwelling aging African Americans. Studying African Americans specifically in this context is a unique contribution to the literature in that African Americans embody cultural similarities but also intragroup differences. It is important for researchers, health care providers, and policy makers to recognize the vast array of characteristics that may be represented in aging African Americans in order to provide services that are appealing, feasible, and that lead to successful completion of effective behavioral health programs.Therefore, the objective of this study is to (1) determine the characteristics of urban-dwelling African Americans with at least one chronic condition who participated in a CDSME program, and (2) determine factors associated with successfully completing the program.Communities Putting Prevention to Work: Chronic Disease Self-Management Program initiative  itiative . This inLiving a Healthy Life with Chronic Conditions, Fourth Edition  were included.Participants were asked to self-report age , sex , and living arrangement . In addition, residential ZIP Codes provided by participants were used to determine percentage of residents within the ZIP Code that fell below a 200% federal poverty level, and the percent of African American residents residing within the participants’ ZIP Code.Health status was determined using the participants’ self-reported chronic conditions. Participants were presented with a list of chronic conditions  and asked to indicate whether or not they had been diagnosed with each condition by a health care provider. The number of self-reported chronic conditions were summed to create one count variable, and the prevalence of each individual disease was calculated based on participants’ self-report.Delivery site information was collected through administrative procedures. For the purposes of this study, analyses focused on the five leading delivery sites . Participants attending CDSME programs at any other delivery site types  were omitted because of inadequate case sizes. Reports of participants attending the CDSME program at any delivery sites or delivery sites labeled as “other” were omitted from analyses due to the complexities of interpretation.Completion of the CDSME program was the dependent variable of interest in this study. Attending at least four of the six classes was considered successful completion of the program. This criterion is consistent with criterion used in previous work focused on the CDSMP , 12, 20.t-test, one-way ANOVA, and chi-square analyses were conducted to examine differences in sample characteristics by number of chronic conditions  and by CDSME programs completion status . Specifically, independent samples t-test analyses and one-way ANOVA were used for continuous variables and chi-square analyses were used for categorical variables. Subsequently, a multiple logistic regression model was employed to determine the association between the independent variables  and successful completion of CDSME programs.First, frequencies were examined to assess demographics, health status, and utilization by delivery site type among the total sample of urban-dwelling African Americans with chronic disease. Next, independent samples N = 11,895) are displayed in Table Descriptive statistics for the sample of urban-dwelling African Americans N = 1,895 areWhen examining differences in characteristics across number of chronic conditions , a statistically significant difference was found among the three groups on age, sex, living situation, disease prevalence, poverty level, and delivery site type. Notably, larger proportions of participants reporting three or more chronic conditions were ages 65–79 years (53%), female (86%), and living with someone (98%). As expected, larger proportions of participants who reported having any of the chronic conditions ultimately had more comorbidities. A larger proportion of participants who attended workshops at senior centers and faith-based organizations  reported only one chronic condition. Conversely, a larger proportion of participants who attended a workshop at a health care organization or community center  reported two chronic conditions. Lastly, a larger proportion of participants who attended the CDSME program at a residential facility (28%) reported three or more chronic conditions.p < 0.001), female (p < 0.001), report living alone (p < 0.001), and report fewer chronic conditions (p < 0.001). A significantly smaller proportion of successful completers reported arthritis (p = 0.05), depression (p < 0.001), lung disease (p < 0.001), whereas a larger proportion of successful completers reported having diabetes (p < 0.001). There were no significant differences found in cancer, heart disease, hypertension, stroke, and osteoporosis disease prevalence between successful and non-successful completers. Lastly, significant differences were found across delivery sites between those who successfully completed CDSME programs and those who did not. A larger proportion of participants who successfully completed CDSME programs attended senior centers, whereas a smaller proportion of successful completers attended CDSME programs at other delivery sites  (p < 0.001).Table p = 0.001 and OR = 0.85, p = 0.025; respectively). However, the odds of successfully completing the program increased for females  and those that live alone . Number of chronic conditions was not significantly associated with successful completion. Compared to senior centers, attending the CDSME program at a residential facility or a community center decreased the odds of successfully completing the program . In addition, living in an impoverished neighborhood reduced the odds of successfully completing the CDSME program .Table An initial research objective was to identify the characteristics of African American participants and the program delivery infrastructure that served them. In many regards, the urban-dwelling African American participants with chronic disease had profiles similar to participants seen in earlier CDSMP studies , 26, 27.Although the participants in our study were demographically similar in many ways to those in previous research describing populations and delivery characteristics, this study clearly demonstrates unique characteristics that are worthy of highlighting, and important to consider in policy, practice, and future research. Particularly, the burden of chronic disease among urban-dwelling African Americans cannot be ignored. While the ranking of chronic condition prevalence rates for specific disease type was similar to CDSME program participants in other studies , the actIn addition to examining differences across chronic conditions, our study also closely examined differences in characteristics for successful completers and non-completers of the program as well as identified factors that were associated with successful completion. Results indicated that successful completers of the program were older than those who did not complete the program. However, the regression analyses showed that compared to participants below the age of 50 years, being between the ages of 50–64 and 65–69 years decreased the odds of successfully completing CDSME programs.Considering that African Americans are diagnosed with chronic conditions much earlier in life in comparison to other groups , it may Due to the limited number of African American male participants and the findings highlighting gender differences in completion status, it is important to note the implications for the health of African American males. Unfortunately, the health of African American males has been likened to that of individuals living in developing countries . AfricanWhen examining health status in this study, individuals who completed the CDSME program had fewer total number of chronic conditions and reported lower prevalence rates of arthritis, depression, and lung disease. Interestingly, successful completers in comparison to non-completers reported higher rates of diabetes and no significant differences for the other conditions. Moreover, the total number of chronic conditions was not associated with successful completion. Erdem and Korda  reportedWhile there were no significant differences in successful completers and non-completers based on neighborhood level poverty, living in an impoverished community was associated with a lower likelihood of successfully completing the program. Research has consistently documented the association between socioeconomic factors and health, particularly highlighting the vulnerabilities of living in poverty . It is pTo our knowledge, no research has closely examined the association of living in an impoverished community with completing the CDSME program among urban-dwelling African Americans. Findings not only suggest the need for future research in this area but also provide preliminary results that should be considered when implementing and disseminating the CDSME program in certain communities. Providing additional support that would foster increased completion rates of the CDSME program to residents of this community could lead to positive health outcomes for a population that is at risk for continued health and health care disparities.Finally, our analyses indicated that delivery site type is an important factor for urban-dwelling African Americans when considering program completion. Senior centers had the largest proportion of completers whereas faith-based organizations and community centers had the smallest proportion of completers. However, it is important to note among African Americans only that faith-based organizations and community centers had the smallest proportion of program participants. When examining the association between delivery sites and successful completion, findings indicated that the odds of successfully completing the program were significantly decreased if one attended the CDSME program at a residential facility or community center compared to attending the program at a senior center. Interestingly, there was no significant relationship between successful completion and faith-based organizations or health care organizations. This is in contrast to another study including participants from multiple racial/ethnic groups that found that completion rates for the CDSME program are lowest at residential facilities but highest at faith-based organizations . Other sTherefore, one promising strategy for increasing the reach of CDSME programs may be to work more closely with faith-based organizations and health care organizations in urban African American communities. Embedding the program in existing infrastructures  may yield greater participation and completion of the program. Findings indicating that the odds of successfully completing the program are lowered for those participating at a residential facility or at a community center may be a result of a number of barriers. For example, residential facility participants may have a number of health complications resulting in the inability to successfully complete the program. Individuals participating in CDSME programs at a local community center may have other family responsibilities or transportation issues that could serve as a barrier to participating in a program for six consecutive weeks.Given that many of the measures were collected using self-reports, it is possible that participants may over- or underreport health status variables. However, self-report of chronic conditions is used as a valid measure in studies examining health in aging individuals . In addiAmerican Recovery and Reinvestment Act Communities Putting Prevention to Work: Chronic Disease Self-Management Program  panel of Review Editors. Because this Research Topic represents work closely associated with a nationwide evidence-based movement in the US, many of the authors and/or Review Editors may have worked together previously in some fashion. Review Editors were purposively selected based on their expertise with evaluation and/or evidence-based programming for older adults. Review Editors were independent of named authors on any given article published in this volume.


The U.S. correctional population is disproportionately burdened with chronic health conditions, particularly mental health and substance use disorders. Though inmates receive health care, linkages to care upon release are often poor or nonexistent. Further, the magnitude of the justice-involved population strains state and Federal finances. The annual cost per offender awaiting trial in Rhode Island is approximately $40,000. A diversion program  with linkages to health care has the potential to reduce costs by addressing the underlying physical, mental, and behavioral health issues keeping individuals in the justice system.We describe a diversion pilot program and our observations thus far. In partnership with Brown University and The Center for Prisoner Health and Human Rights, Justice Assistance, a nonprofit organization in Cranston, Rhode Island, received support from the Rhode Island General Assembly to develop a program to reduce the Rhode Island awaiting population by linking participants to community-based health care. The pilot program developed, Office of Community Alternatives (OCA), tests an intensive case management model. MAPIT  is an Internet-based motivational interviewing program piloted as a component of the OCA program.To determine OCA feasibility at the superior court level, we explore: whether clients engage in treatment; levels of support from courts, the offices of the public defender and attorney general; whether clients return to prison; how much time case managers spend with clients; and client satisfaction with MAPIT.As of October 1, 2014, 25 individuals were enrolled in the OCA. Twenty-five clients completed a substance use assessment; 13 completed a mental health assessment; 10 completed a physical health assessment; 24 were prescribed treatment, and 24 began treatment. Nine individuals were terminated from the OCA due to noncompliance. Eight of those terminated returned to the adult correctional institute with new charges, while one is out with a bench warrant. Three clients completed the OCA program. None of those who have completed the program have recidivated.Given the unprecedented collaborations in support of this program, there has been a high level of scrutiny over the referral process. This has significantly slowed enrollment. Recent discussions make us hopeful that in the future we can establish strict eligibility criteria.We hope to conduct qualitative interviews with clients and stakeholders, and begin evaluating impacts of OCA and MAPIT.


Although adolescents are often referred to residential treatment centres because of severe externalizing behaviours, a vast majority demonstrated comorbid symptoms of depression and anxiety. Covert internalizing symptoms in these adolescents might be easily unrecognized and therefore untreated. Adolescents with mild intellectual disability (MID) are overrepresented among youth with both externalizing and internalizing problems. There are yet few treatment programs available for adolescents with both externalizing and internalizing problems.The CBT-based resiliency program, Op Volle Kracht (OVK), which is based on the US Penn Resiliency Program (PRP), was adapted to suit the needs of adolescents with both externalizing and internalizing problems, either with or without MID, in Dutch residential treatment centres. The effectiveness of this group intervention program of eight sessions will be tested in a randomised controlled trial (RCT) with N = 182 adolescents aged 12–16, allocated to either the target intervention plus treatment as usual (OVK + TAU) or treatment as usual only (TAU). The main outcome variables include depressive symptoms (primary), anxiety, behavioural problems, and group therapeutic climate. Cognitive styles and coping styles will be included as possible mediators. Assessments take place at baseline (T1), one week before the start of the program (T2), immediately after the program (T3), and at three months follow-up (T4).The program assets include its wide implementation possibilities due to low costs, the short duration of the program and the delivery by group care workers, and its suitability for adolescents with MID. Further strengths of the present study design include its robust method (RCT), the ecological validity, and the inclusion of possible mediators of treatment effect. The program emphasizes individual risk factors for depression rather than social and family factors. Implications for practice and future research are discussed.NTR4836Dutch Trial Register  In the Netherlands, approximately 25,000 children and adolescents receive residential treatment in the youth welfare system 11,000), youth mental health care 9300) and care for youth with intellectual disabilities each year (5700) [1,000, yo00 and caYouth receiving residential treatment are often referred to treatment for severe externalizing behavioural problems  . ResearcAdolescents with comorbid internalizing problems are more severely impaired and have more academic problems, more severe somatic complaints, more problems related to substance use, and poorer overall functioning than adolescents with externalizing problems alone –12. MoreThe high rates of comorbid internalizing and externalizing problem behaviour stress the need for a systematic approach to reduce internalizing problems among youth in residential treatment settings, instead of focusing mainly on externalizing problems. Recent meta-analyses suggest that cognitive-behavioural interventions targeted at emotional resilience for adolescents can significantly reduce internalizing symptoms and decrease the risk for future internalizing symptoms compared to control groups –19.However, most cognitive behavioural interventions are targeted at youth without comorbidities and are insufficiently adapted to youth with complex problems that often are too disorganized in terms of coping with daily life stress, family problems, school problems, etc., to benefit from formal CBT programs. Moreover, to date there are no Dutch CBT programs targeted at youth with MID. This is surprising, given the high rates of youth with MID in residential youth care >20 %)  and the  %  and tIn response to these problems, the existing evidence-based Penn Resiliency Program (PRP) was strongly adapted to (1) suit the needs of the target group, both for adolescents with and without mild intellectual disabilities, and (2) to maximize accessibility by keeping implementation costs low. PRP is a theory-based universal school-based depression prevention program designed for early adolescents (ages 10–14 years) that teaches cognitive-behavioural and coping skills and is one of the most successful programs to increase emotional resilience and to prevent depressive developmental outcomes. Positive results from this program are found in an evaluation of 17 controlled studies evaluating PRP with 2498 participants in total  and adolThe aim of the present study is threefold: (1) to test the effectiveness of OVK within the usual treatment program (OVK + TAU) in reducing symptoms of depression (primary outcome) compared to treatment as usual alone (TAU), (2) to identify mechanisms that can explain program effects , and (3) to test the effects of OVK on secondary outcomes . It is hypothesized that OVK + TAU will be more effective in reducing symptoms of depression in youth than TAU alone, immediately after the program and at three months follow-up. Regarding the explanatory mechanisms, it is hypothesized that OVK + TAU will decrease negative cognitive biases and increase the adequate coping styles. Both of these constructs are expected to mediate the hypothesized effect of OVK on symptoms of depression. Concerning the secondary outcomes, the OVK program is expected to decrease anxiety, since the program contains cognitive and behavioural strategies that are hypothesized to be effective not only for depression, but also for anxiety . A posiThe study design will be reported in accordance with the CONSORT 2010 statement for reporting parallel group randomised trials. The medical ethics committee CMO Region Arnhem-Nijmegen, The Netherlands, has approved the study: NL-49211.091.14.This study is an open cluster randomised controlled trial with two conditions: the OVK condition incorporated into the usual treatment (OVK+TAU) versus treatment as usual alone (TAU) see Fig. . There iRandomization will be conducted by an independent statistician of the Radboud University Nijmegen and will take place on the level of the naturally existing treatment groups rather than on the level of individuals (clustered randomization). In the Netherlands, residential treatment groups usually comprise 8–10 adolescents that follow the same treatment program, live in the same building, and are usually taken care of by a permanent staff of nurses and social workers. The benefits of randomisation of natural groups are as follows: (1) it minimizes contamination among adolescents and staff; (2) it best reflects the natural situation in residential treatment settings, increasing the ecological validity of the study; (3) adolescents who will receive the intervention program know each other already and are used to undertake therapeutic activities together; and (4) staff members who will conduct the program already have a therapeutic relationship with the adolescents. Stratification on the cognitive level (MID versus non-MID) will be needed in order to ensure that the cognitive level is evenly distributed across the control and intervention conditions.To test the effectiveness of the intervention, all adolescents and their parents will complete self-report questionnaires approximately one month before the start of the program and before adolescents know to which condition they are assigned , approximately one week before the start of the program (T2), immediately after the program (T3), and three months after the end of the program (T4). Adolescents in the control condition will complete the questionnaires at exactly the same time points. To make sure that all adolescents (MID and non-MID) understand the questionnaires, adolescents will be assisted in filling out the questionnaires by a trained research assistant that is blind to condition.NTR4836. The time frame for the data collection will be from October 2014 until March 2015.The OVK program will be added to the existing treatment program at the participating groups. The 8-week program will be delivered every week by the permanent staff members at the treatment group who has received training specifically for this purpose. By incorporating the program in the standard treatment program at the groups, we maximize the likelihood that all adolescents can attend sessions, and we minimize stigmatization or social exclusion. To minimize attrition rates, adolescents who are dismissed before the end of the program will be given the opportunity to continue the program at the treatment group. The trial is registered at the Dutch Trial Register: An a priori power analysis revealed that a sample of N = 182 would be necessary to obtain a power of .8. Three large institutes for residential treatment, including Pluryn De Hoenderloo Groep (youth care), Pluryn Jan Pieter Heije , and Karakter child and adolescent psychiatry  will participate in this study. All treatment groups with adolescents between 12 and 16 years old, boys and girls, with a full-scale IQ of 50 or higher will be invited to participate. There are 20 treatment groups with 8–10 adolescents each that meet these criteria, of which are 8 youth care groups (Pluryn De Hoenderloo Groep), 8 groups for youth with MID (Pluryn Jan Pieter Heije), 2 mental health care groups, and 2 mental health care groups for youth with MID (Karakter child and youth psychiatry). Five groups (40–50 adolescents) include only boys, three groups (24–30 adolescents) include only girls, and twelve groups (96–120 adolescents) include both boys and girls. If the participants in the groups agree to participate, they will receive more information about the program and training, and the CDI-2 will be administered as a baseline assessment for depression (T1). Subsequently, groups will be randomly allocated to either one of both conditions. From the treatment groups selected, none of the adolescents will be excluded in order to avoid stigmatization and social exclusion. All parents will receive a letter with information regarding the goals and content of the study and will be asked permission for their child’s participation by passive informed consent. Since not all parents may understand written Dutch, given the expected social and ethnic characteristics of the sample, group care workers will ask the parents if they have understood the letter and if they have any questions. Parents and adolescents are free to withdraw themselves from the study at any time. Next, 2–3 permanent staff members of groups allocated to the intervention condition will receive a three-day training conducted by two experienced and licensed psychologists with broad expertise in cognitive behavioural therapy. Subsequently, T2 will be administered, and the training program will start.The program OVK is based on the principles of cognitive behavioural therapy . CognitiTreatment duration: Given the relatively short treatment periods in residential care, the program was shortened from 16 to 8 sessions of 45 min, including only the CBT component of the original program.Integration in existing treatment plans: The program was incorporated in the existing treatment plans by formulating goals for the training that matched treatment plans. To integrate the taught techniques in the therapeutic living environment, adolescents will make an individual implementation plan together with the group care workers .Fit with the target group: To make the program suitable for a target group of youth with complex problems, the current program contains less verbal and more practical and visual elements , the text and layout of treatment materials were simplified, and efforts were made to optimize generalizability to daily life . For youth with MID, a parallel version of the program was created, following the suggestions of the expert group and Didden : (1) theThe original OVK program  wasto recognize and describe feelings and thoughtsto detect inaccurate thoughtsto evaluate the accuracy of inaccurate thoughtsto challenge inaccurate thoughts by considering alternative interpretationsto use behavioural techniques to regulate emotions .In the final program, adolescents are trained in the following cognitive-behavioural skills:The sessions included group talks, individual and group exercises, and video fragments. After each session, the adolescents are assigned a homework task that takes approximately 15 min. The program will be delivered by permanent staff members at each location that will receive a 3-day training session covering the theoretical principles of CBT, practical training in CBT skills and therapeutic techniques, and an in-depth covering of the intervention protocol. The training will be delivered by experienced and licensed psychologists with broad expertise in CBT. All staff members will receive a detailed manual of the intervention program, and they are offered the opportunity to contact the research team for additional support during program delivery.For all participants, demographics , information on treatment setting , IQ-scores, DSM-IV diagnoses, pharmacological information (medication use and dose) and juridical status (whether and when a child protection measure was imposed) will be retrieved from their treatment charts.The primary outcome will be depressive symptoms as measured by the Dutch version of the Children’s Depression Inventory 2 (CDI-2) . The CDIPossible mediators include negative cognitive styles and coping styles.will be measured with the Children’s Negative Cognitive Errors Questionnaire – Revised (CNCEQ-R) , which iwill be measured with the Children’s Response Style Questionnaire (CRSQ). This 25-item self-report questionnaire categorizes adolescents’ responses to negative emotions in three subscales: ruminative response, distracting response, and problem solving. Each item describes a possible response and is rated on a 4-point scale, ranging from ‘almost never’ to ‘almost always’. The CRSQ demonstrates moderate levels of internal consistency .according to adolescents will be measured with the Dutch translation of the Spence Children’s Anxiety Scale (SCAS) . The SCAwill be assessed using the Strengths and Difficulties Questionnaire (SDQ)  for bothwill be assessed using the subscale responsiveness of the Dutch translation of the Prison Group Climate Inventory (PGCI). The subscale consists of 12 items rated on 5-point scales, ranging from 1 = ‘I do not agree’ to 5 = ‘I totally agree’. The overall PGCI-scale with 63 items demonstrates good validity and reliability .t-test with a one-sided significance level of 0.05 and equal sample sizes, revealed that a sample size of 102 (51 for each group) is required to obtain a power of .8. To accommodate for the clustering effect, we inflated the sample size with a factor of 1.49 following the suggestions of Campbell et al. [The expected effect size for this trial was Cohen’s d = .50. Although in a Dutch study on the effectiveness of OVK among youth with subclinical levels of depression (CDI score >15), the effect size of Cohen’s d = .7 was found , we chosl et al. . ExpectiAll data will be analyzed in accordance with the intent-to-treat (ITT) principle but will also be analyzed separately for the completers only. For the ITT analysis, missing values due to loss of respondents or missing item scores will be handled through multiple imputation using the Markov Chain Monte Carlo method in the statistical package Mplus6 . MissingThe hypotheses will be tested with mixed effects linear regression analyses in Mplus6. Because adolescents are nested within groups and groups are nested within locations, a three-level analysis is most appropriate to account for the non-independence of the data. However, this technique requires relatively large numbers of clusters (~25) and members in clusters (~25) . With 3 To explore the mediating role of adolescents’ cognitive styles, coping styles, and therapeutic climate, mediation analyses will be performed using Mplus. The significance of indirect paths will be tested via bootstrap sampling. Moderating effects of age, gender, and treatment setting on the relation between depression and anxiety will be explored by entering the moderating variables as predictors for depression/anxiety. The moderation and mediation analyses will be done for the OVK and TAU conditions separately. Reporting of the results of the study will be in accordance with the CONSORT statement .This study protocol presents a randomised controlled trial testing the effectiveness of an adapted version of the newly developed intervention program OVK on depressive symptoms. The program is based on the PRP-program  and is sAn asset of the proposed study is that it is one of the first studies examining a program to increase emotional resilience in a residential setting and is also the only Dutch CBT program specifically adapted to adolescents with MID. There is a strong need for interventions addressing internalizing problems in this complex target group, given that youth in residential settings often display elevated levels of internalizing problems, but problems are often unrecognized and residential treatment is not sufficiently effective in reducing internalizing symptoms. Other than most RCTs, the present study not only examines effectiveness but also takes into account the possible mediators of change. Moreover, the study has a robust design, with a relatively large sample and assessments including multiple informants, and it takes place in a natural setting to optimize ecological validity and generalizability into real-life settings. Another strength is that the program will be group administered, thus enabling all adolescents in treatment groups to participate and minimizing stigmatization. This also optimizes opportunities for adolescents to implement the skills taught in OVK to their daily lives. Finally, the OVK program contains only eight sessions and takes place at treatment groups where adolescents live, therefore a minimal drop-out rate is expected.A limitation of this study is the open rather than blind design; as participants and other informants included in the assessments (parents and/or caregivers) are aware of the condition they are in, self-reports may be biased. Nevertheless, research assistants administering the questionnaires are blind to condition. Moreover, participants will be told that the program aims to ‘help them to better deal with difficult situations’, without mentioning the specific effects expected on the outcome variables, thereby minimizing expectation effects. Finally, the last planned follow-up assessment is three months. A longer follow-up period would have offered better chances to map longer-term effects of the intervention; however, then a large drop-out rate would be expected, since the follow-up period would extend the relatively short (6–12 months) period during which adolescents are in residential treatment.With regard to the program content, a limitation is that mainly individual risk factors associated with depression will be addressed  as opposed to contextual risk factors like family characteristics, friends, and school situations. However, the program contains elements to teach adolescents how to implement the new skills across different contexts. For example, adolescents will make an implementation plan, with actions and helpful thoughts they can use across different situations to influence their mood. Moreover, the group care workers are strongly engaged in the program and are key persons to maintain contact with parents, family, schools, and leaders of leisure activities.If the adapted OVK program is effective among youth within residential care in improving emotional resilience and in reducing (future) depressive symptoms, this may lead to better general outcomes of residential treatment on general functioning. Comorbid internalizing and externalizing problems are longitudinally associated with a higher prevalence of suicidal attempts and suicidal ideation, poorer academic performance, higher service use rates, and higher criminality rates as compared to youth with externalizing problems alone –15. MoreFinally, this study will contribute to our knowledge about depression and anxiety in this complex target group and about factors that mediate intervention effects , which could serve as a starting point for further improvement of residential treatment programs and programs targeted at emotional resilience.Internalizing problems are common among youth within residential treatment centres with and without MID, but are often overshadowed by the more visible and disruptive externalizing problems and therefore pose challenges in treatment and diagnostics. As a result, internalizing problems are often undertreated. This protocol describes a study examining the effectiveness of an adapted version of the Dutch CBT-based program OVK on depressive symptoms of adolescents with and without MID in residential treatment settings. This is the first Dutch study evaluating a group-administered CBT-program that is especially adapted to adolescents with MID. Mediators of the effect are taken into account.


Iran is one of the countries located on the “thalassemia belt” and a thalassemia prevention program was approved in our country in 1995. Many different researchers have studied the success of this program with no unanimous findings.A comprehensive literature search was performed using PubMed, Web of Science, and Google Scholar databases in Farsi and English languages for relevant articles published up to March 2015. A total of 46 articles regarding thalassemia prevention were identified. After screening the titles and abstracts, 27 articles were excluded because they were the same articles, review articles, and case reports. Finally, 16 articles about the success of the Iranian thalassemia prevention program were selected for the evaluation.The findings show that the program has been significantly successful in the reduction of the new thalassemia births, though not in a few provinces like Sistan and Baluchestan. The role of the network of genetic labs has been also indispensable in the reduction of the new births. However, there is ambiguity over the impact of the program on the attitude and awareness of people across the country about the prevention of inherited diseases. However, with the success of the Iran thalassemia prevention program, it needs to be modified to be more compatible with the relevant social textures of different provinces. The second effort to evaluate the thalassemia prevention program in Iran was made by Abolghasemi et al. who considered two different phases in their study: the first phase during which the screening of marriage candidates was the only strategy to reduce the rate of thalassemia and the second phase in which the abortion in special medical cases received religious approval which made the use of prenatal diagnosis (PND (possible in prevention of thalassemia. They concluded that the former phase was not that successful and the latter phase on the contrary was success (Thalassemia major is an inherited disease most prevalent in the region called thalassemia belt . Iran is success . However success . In yet  success . Miri et success . But the success . In the Search StrategyA comprehensive literature search was performed using PubMed and Google scholar database for relevant articles published with the following key words “thalasemia,’’ ‘‘Iran,’’ “Hemolytic disorder’’, “Beta globin deficiency’’. All eligible studies were published before March 30, 2014. In addition, studies were identified by a manual search of the reference lists of reviews and retrieved studies. We included all the case–control studies and cohort studies that investigated the thalassemia prevention program. All eligible studies were retrieved and their bibliographies were checked for other relevant publications. When the same sample was used in several publications, only the most complete study was included following careful examination.Inclusion criteriaAll studies were included if they met the following criteria:  cohort a2. The primary study on the efficacy of the program and its high success rate in shrinking the thalassemia new birth cases was conducted by Samavat and Modell in 2004; they calculated the number of the new births to be 78 in 2002 that showed 937 decreases from the estimated expectation (The thalassemia prevention program started in 1995 and prevailed in the whole country two years later . Miri etectation ; thus, HMiri et al. while asserting the program success have estimated the new birth rate of thalassemia to have decreased from 864 in 1996 to 239 in 2009; this indicates of the success in prevention of the expected birth rate of 82.3% in 2009 ,6. The fThe research observations show the program success in the other high-rate thalassemia provinces like Fars and Mazandaran. Joulaei et al. have provided evidence for the significant decrease in the new thalassemia births in Fars province during 1997 – 2011 . Ghanaeinew thalassemia births in Isfahan was also approved by Zeinalian et al.  whose fiThe other aspects of the program including its success in the attitude and behavior change of citizens should be also taken into account. Kosarian et al. considers this aspect of the program successful in Mazandaran province  with whiAll studies indicate the success of the thalassemia prevention program in Iran though with no consistency in all the provinces. Therefore, the program strongly requires to be made more native and compatible with the norms of the provinces especially in Sistan & Baluchestan where we are witness to many new thalassemia cases on an annual basis. Regarding the PND lab network, all findings unanimously show the increasing efficacy in the prevention of thalassemia; however, all the researchers recommend that the decision makers be more persistent for further and easier access of the carrier couples to PND. As far as the attitude and behavior changes are concerned, the program has been of little avail in the provinces different in their social context and norms. More importantly, except for the medical practitioners directly involved in the program, other medical specialty groups should be more informed on the program and the importance of thalassemia prevention. Since the Iran thalassemia prevention program is represented as a distinct model among the developing and Muslim countries, the success of the program can promote the value of the thalassemia prevention in the attributed countries located on the thalassemia belt. To increase the success, it is imperative to make the program more compatible with the native parameters of the provinces and perform regular evaluations over the program. Making efforts to clarify the importance of the thalassemia prevention for the young girls and boys before the marriage age and for all medical specialties can lead to stronger public incentive for voluntary participation in thalassemia prevention. The Authors have no conflict of interest.


Early detection and treatment of eating disorders is instrumental in positive health outcomes for this serious public health concern. As such, workforce development in screening, diagnosis and early treatment of eating disorders is needed. Research has demonstrated both high rates of failure to accurately diagnose and treat cases early and low levels of perceived access to training in eating disorders by health professionals–representing an urgent need for clinician training in this area. However, significant barriers to the access of evidence-based training programs exist, including availability, cost and time, particularly when large geographic distances are involved. Online learning presents a solution to workforce challenges, as it can be delivered anywhere, at a fraction of the cost of traditional training, timing is user controlled, and a growing body of research is demonstrating it as effective as face-to-face training. The Centre for Eating and Dieting Disorders in Australia has developed an Online Training Program In Eating Disorders, to educate health professionals in the nature, identification, assessment and management of eating disorders. The aim of the current study was to evaluate the ability of this online learning course to improve clinician levels of knowledge, skill and confidence to treat eating disorders. As well as its effect on stigmatised beliefs about eating disorders known to effect treatment delivery.One-hundred-eighty-seven health professionals participated in the program. A pre training questionnaire and a post training evaluation examined participants’ levels of knowledge, skill and confidence to treat eating disorders, as well attitudes and beliefs about people with eating disorders.Significant improvements in knowledge, skill, and confidence to treat eating disorders was found between pre and post program assessment in health professionals who completed the course, along with a significant decrease in stigmatised beliefs about eating disorders.The results of this study demonstrated that the online training program was an effective tool in increasing health professionals’ level of knowledge, skill and confidence to treat people with eating disorders. The results also demonstrated that online training reduced health professionals’ personal bias towards people with eating disorders. Limitations of this study include the use of self-report measures rather than observation of the health professional in clinical practice. As a result, it is not possible to make determinations regarding the translation of these results to clinical settings.The findings of this study suggest that online training programs may present an innovative solution to the considerable workforce development challenges faced by clinicians needing training in eating disorders. Eating disorders (EDs) are biologically based serious mental illnesses  which muEarly diagnosis and treatment are essential to a good outcome, but barriers presently exist across the health system. Even though the spectrum of health professionals dealing with EDs has increased in recent years, specific training in or experience with ED patients is still lacking . In theiLack of empathy combined with negative stereotypical images of patients with eating disorders and their families are not uncommon . StigmatIn Australia, and elsewhere in the world, workforce education poses a particular set of problems. Australia has a generalist mental health model, so that care for EDs is delivered for the most part by clinicians in general practice, community clinics, general medicine, emergency departments and psychiatric wards. Funding for specialist services is limited, which means that training of health professionals at all places where contact with individuals with EDs arise becomes a priority if adequate evidence-based care is to be provided. Further, there is a tyranny of distance with communities being spread across large geographic areas, with relatively few metropolitan hubs of expertise. Like many countries, most health infrastructure in Australia is located in large urban centres, leaving rural and regional areas under-serviced. This means that many health care professionals working in regional and rural locations, and the clients with eating disorders that present to them, are disadvantaged in terms of access high quality care and training.Online training presents a potential solution as it can be delivered anywhere, at any time, and at a fraction of the costs of traditional training methods. There is growing body of research , 23 suggWhile several internet-based programs targeting self-help and support in eating disorders –33, exisRecently Fairburn and Wilson  have argTo address the issues of workforce competencies and skill to detect, diagnose and manage eating disorders in the Australian health workforce, The Centre for Eating and Dieting Disorders (CEDD) has developed an online learning program for health professionals in the nature, identification, assessment and management of eating disorders. This comprehensive, interactive core competencies based training is the first of its kind internationally, the result of a collaborative project spanning a number of care settings and institutions, and draws on the extensive clinical and research experience of internationally renowned specialists in the field. This interactive program provides comprehensive training in diagnosis along with the medical, psychological and dietetic management of these mental illnesses.The current study examined the impact of the above program on the knowledge, skills, willingness, confidence and stigma levels of health professionals treating eating disorders within the Australian health workforce.The study was reviewed and approved by the Royal Prince Alfred Hospital. The program was advertised globally via online advertisements on mental health related institute websites and the CEDD website and email list serve. Health professionals from Australia and other countries  provided informed consent to participate in the study and had 6 months to complete the online training program. Health professionals registered progressively from July 2012 to October 2013. During this 6-month period, 187 health professionals completed the program.Training modules and topics were designed and written by both expert and novice panels of health professionals inclusive of nurses, dietitians, psychologists, psychiatrists and general practitioners (GPs), and curriculum development was based on literature reviews and expert consensus building. The program comprises five modules–understanding eating disorders, diagnosis, preparation for treatment, treatment and management–each 3.5 h in length, and combines text-based psycho-education, role-plays, interactive exercises and quizzes, as well as video footage of sufferers and their families. Each of the five learning modules contains a core curriculum, required to pass the quiz, an ‘in practice’ section with additional clinical tools and role-plays, and a resources section with key readings and resources.Program participants were required to complete a pre training questionnaire prior and a post training evaluation upon completion of the program. Pre and post training self-report questionnaires were developed by the authors and are available over the Internet for the purpose of evaluating the effectiveness of the online training program. Participants were asked 10 questions rating their current level of knowledge (e.g. the risk factors associated with the development of an ED), and 9 questions rating their skill level for assessment and treatment of EDs (e.g. ability to conduct ED screening) on a 5-point Likert scale . Participants were asked 6 questions regarding their personal attitudes and beliefs about people with an ED to assess stigma (e.g. they are to blame for their condition) and asked to rate on a 5-point Likert scale . Participants rated their willingness and confidence in treating each of the eating disorder subtypes on a 5-point Likert scale ranging from 1  to 5 . Additional items assessing demographic data including gender, age, primary professional discipline, work setting, length of time in practice and prior experience treating EDs were included at baseline. Participants also rated their experience of the online training program.Data were analysed using SPSS Version 20.0. Wilcoxon signed ranked test was used to investigate changes between pre and post training evaluation scores for items and subscales  as appropriate for nonparametric data.The mean age bracket of the 187 participants was 31 to 40 years and the vast majority were females (91.4 %). All of these participants completed the program in its entirety, and all of the questionnaires at pre and post. Half of the participants (49.2 %) reported having been in practice for less than 5 years. Of those who completed the online learning program, 34.6 % were psychologists, 22.7 % nurses, 19.5 % dietitians and 9.2 % social workers. The majority of respondents indicated they worked in a community health or mental health centre (40.2 %). More than half of the respondents (62.2 %) indicated their employment setting as being within the metropolitan area and the other 36.8 % worked in a rural/regional employment setting.Almost half (46.0 %) of the respondents reported they don’t have the skills to treat ED patients. In addition, 34.0 % of respondents indicated that there were not enough resources available to help them adequately treat these patients with only 2.7 % indicated they did not like treating this patient group or that it was too time consuming.p < 0.001), and their clinical skills assessing and treating eating disorders   , BN , BED  and EDNOS .Health professionals reported a significant increase in their confidence to treat each EDs after completing the online training program, across all ED subtypes, AN  and EDNOS  increased significantly after completing the online training program. There was no difference between pre and post training evaluations in health professionals’ willingness to treat anorexia nervosa , and bulimia nervosa .Participant’s willingness to treat BED (z = 2.58, The acceptability of the program Overall the program received overwhelmingly positive self-report reviews. 96.2 % of respondents indicated that their current clinical practice had improved as a result of completing the online learning program. 98.4 % of respondents indicated that their expectations of the online learning program were met. 99.5 % of respondents indicated that the program was relevant or highly relevant to their practice. 95.8 % of respondents indicated that the program met their needs. One hundred percent of respondents stated that they would recommend the online learning program to other health professionals.The purpose of the current study was to evaluate the effectiveness of an online training program specifically developed to disseminate evidence-based knowledge to health professionals working in the area of EDs. Online training programs offer a significant advantage over face-to-face training, particularly when considered within the context of rural and remote geographic locations, such as those within Australia, where training programs may not be easily accessed.The results of this study demonstrated that the online training program was an effective tool in increasing health professionals’ level of knowledge, skill and confidence to treat people with EDs. The results also demonstrated that online training reduced health professionals’ personal bias towards people with EDs.The lack of significant change on some measures of the willingness to treat item was likely result of a ceiling effect–in that pre willingness to treat was in this cohort very high.Limitations of this study include the use of self-report measures rather than observation of the health professional in clinical practice. As a result, it is not possible to make determinations regarding the translation of these results to clinical settings. Another limitation included the absence of a wait list or manual control condition in order to compare different training methodologies.The importance of this study lies firstly in the uniqueness of its subject, which targeted a broad range of health professionals, participants including psychologists, nurses, dietitians and social workers. The comprehensive format allowed access to best practice strategies from experts in the ED field covering a wide range of medical, dietetic and psychological management practices. Despite the diverse backgrounds of the participants the results were positive in all areas of assessment.We note that no GPs were involved in the evaluation of this program and hence we are unable to report on the effect of the program for this important health discipline. This is believed to be a result of advertising and promotion of the program being more effective within the public hospital and clinic system, and GPs being a difficult sub-population to engage in learning both due to access to them, and considerable professional time constraints. Future research needs to evaluate the effectiveness of the program for GPs.To our knowledge this online training program is the first of its kind internationally. The results of the study suggest that it may be an effective tool for the dissemination of knowledge, skill and confidence to general health clinicians in the diagnosis, treatment and ongoing management of eating disorders.This study demonstrates support for a novel avenue of training in the area of EDs. Based on the results of this study, it is possible to conclude that this online training program offers the potential to make a substantial contribution to the development of the ED workforce. The online program has the capacity to reach large numbers of health care professionals and the ability to overcome barriers to access including time, cost and distance. Despite improvements in treatments for EDs, it is apparent that there are unmet needs for treatment and barriers to treatment-seeking amongst individuals with EDs, and a lack of workforce training is one of the factors contributing to this. These barriers included stigmatising attitudes and a lack of ED specific skills amongst health professionals. This online training program was able to increase knowledge, skill and confidence in health care professionals and also reduced personal bias towards sufferers.


To evaluate the immediate and sustained effectiveness of the first Jamie's Ministry of Food Program in Australia on individuals' cooking confidence and positive cooking/eating behaviours.A quasi- experimental repeated measures design was used incorporating a wait-list control group. A questionnaire was developed and administered at baseline (T1), immediately post program (T2) and 6 months post completion (T3) for participants allocated to the intervention group, while wait -list controls completed it 10 weeks prior to program commencement (T1) and just before program commencement (T2). The questionnaire measured: participants' confidence to cook, the frequency of cooking from basic ingredients, and consumption of vegetables, vegetables with the main meal, fruit, ready-made meals and takeaway. Analysis used a linear mixed model approach for repeated measures using all available data to determine mean differences within and between groups over time.All adult participants (≥18 years) who registered and subsequently participated in the program in Ipswich, Queensland, between late November 2011- December 2013, were invited to participate.In the intervention group: 694 completed T1, 383 completed T1 and T2 and 214 completed T1, T2 and T3 assessments. In the wait-list group: 237 completed T1 and 149 completed T1 and T2 assessments. Statistically significant increases within the intervention group (P<0.001) and significant group*time interaction effects (P<0.001) were found in all cooking confidence measures between T1 and T2 as well as cooking from basic ingredients, frequency of eating vegetables with the main meal and daily vegetable intake (0.52 serves/day increase). Statistically significant increases at T2 were sustained at 6 months post program in the intervention group.Jamie's Ministry of Food Program, Australia improved individuals' cooking confidence and cooking/eating behaviours contributing to a healthier diet and is a promising community-based strategy to influence diet quality. Healthy food choices and eating patterns are essential for promoting good health and well-being and preventing a wide range of chronic diseases One concerning trend is the increasing consumption of energy dense foods of lower nutritional value prepared outside of the home This evidence underpins the proliferation of community-based cooking skills education programs which are being used as a strategy, both by government and non -government organisations, to promote cooking skills and cooking confidence as a vehicle to healthy eating. For example, the recent World Cancer Research Fund's (WCRF) “NOURISHING” food policy framework specifically identifies cooking skills education within its nutrition education policy area, which is one of the ten key policy areas of action to foster healthy eating and prevent obesity This study aims to evaluate the immediate impacts and longer term outcomes of Jamie's Ministry of Food program, in Ipswich, Australia using a quasi-experimental, repeated measures design. This paper reports the impacts of the program in terms of cooking confidence and cooking and eating behaviours. This quantitative component is embedded within a larger mixed methods evaluation Jamie's Ministry of Food programs have been running since 2008 in the UK funded by a mixture of private and public sources. In 2010, Jamie's Ministry of Food was brought to Australia by The Good Foundation (TGF), a not-for-profit, health promotion organisation funded by The Good Guys, a major Australian electrical goods retailer, in partnership with Jamie Oliver. In April 2011, the first Australian Jamie's Ministry of Food Centre opened in Ipswich, Queensland (QLD). The Ipswich Centre is predominantly funded by philanthropist Mr Andrew Muir (owner of The Good Guys) and QLD State Government, as well as local partners. Whilst the program is all inclusive and not targeted towards a specific demographic group, Ipswich was deliberately chosen as the location due to its population's lower socioeconomic status Jamie Oliver's manifesto is to inspire individuals to cook simple basic meals from scratch both for themselves and their families To provide a basis for evaluation enquiry, a program logic model was developed to determine the potential pathways to behaviour change The evaluation used a quasi-experimental design with a wait-list control group. All program participants aged 18 years and over were invited to participate in the evaluation. Participants who signed up to the program >10 weeks before their course start date, due to the length of the wait-list at the time, were allocated to the control group whilst participants who signed up to the program <10 weeks before their course start date, were allocated to the intervention group. Intervention participants were surveyed at three time points (before the program start (T1), on program completion (T2) and six months after program completion (T3), whilst control participants were surveyed 10 weeks before program start date (T1) and just prior to beginning their first class (T2). An online questionnaire was used followed by a postal version sent to all non-respondents or to anyone who did not have access to a computer or the internet. Data collection ran from December 2011 to December 2013. Six month follow up data were not collected from controls; instead, data from Queensland State-wide monitoring of vegetable intake A self -administered quantitative measurement tool was developed Secondary outcomes included changes in self-reported cooking and eating measures including: (i) frequency of cooking the main meal from basic ingredients; (ii) frequency of eating ready-made meals at home; (ii) frequency of eating vegetables with the main meal, all measured on a scale from 0 =  never to 7 =  daily; (iv)serves of fruit per day measured as per daily vegetable intake and (v) frequency of eating takeaway per week measured from 0 =  never to 5 = 5 or more times per week.Sample size calculations were based on the primary outcome of a change in self-reported vegetable intake. The study was powered to detect a mean change in self-reported vegetable intake of 0.5 serves per day, at 80% power (0.05 significance) starting from a baseline measure of 2.5 serves a day All continuous outcomes were analysed using linear mixed models for repeated measures to determine mean differences between groups over time. This type of analysis copes with unbalanced groups, missing (at random) follow up data and enables all available data to be utilised to determine the estimated changes in mean outcomes. Predicted means from the mixed model analyses are reported in all tables in the results section. Each analysis was also subsequently run with separate adjustments for gender, age (dichotomised at below 50 or 50 years and above) and categories of employment status then with all three covariates together, to account for the potential effect of baseline differences  to “extremely confident” (5) were regarded as a continuous variable in the primary analysis - an acceptable technique for larger data sets To explore the sustainability of the intervention group effect over time, a repeated measures analysis was performed using the intervention group data collected at all three time points. For the primary outcome measure of self-reported vegetable intake, a two-sample t-test comparison between the 6-month post-program intervention group mean and the reported state-wide mean was performed.All analyses were performed using STATA software (version 12.0). Results were deemed significant at the P<0.05 level.Over the two-year data collection period, approximately 1960 participants registered for the program and were invited to participate in the evaluation; 1526 were allocated to the intervention group and 434 to the control group. Some 45% of intervention and 55% of control participants invited to participate in the evaluation completed the baseline assessment (T1). Of those participants who completed baseline, 55% of intervention and 63% of control participants completed the T2 assessment. In the intervention group, 31% of those participants who completed baseline, also completed both T2 and T3 assessments.At baseline , the majIn the intervention group but not the control group, there was a statistically significant increase between T1 and T2 in all cooking confidence measures (P<0.001) both individually and when combined into a cooking confidence score . StatistWhen analysis was restricted to the intervention group only to test the sustained effect of the program (i.e. to T3), statistically significant increases in all cooking confidence measures (P<0.001) were reported for pairwise comparisons between T1 and T2 (P<0.001) and T1 and T3 (6 months post intervention) (P<0.001) but not between T2 and T3 . StatistSelf-reported daily vegetable intake increased significantly between T1 and T2 in the intervention group by just over a half serve  but not in the control group . A statistically significant group by time interaction (P<0.001) was found . All adjFor the intervention group only, daily vegetable consumption increased significantly from T1  to T2  and T3 , although the change between T2 and T3 was not significant (P = 0.273). The change between T1 and T3 was significant  as was the overall effect of change over time (P<0.001) .Results of the t-test comparison between the self-reported mean vegetable intake at T3 for the intervention group  and state-wide monitoring data from the 2012 Queensland Self-Reported Health Status Survey  Cooking the main meal from basic ingredients increased significantly from T1 to T2 in the intervention group  and the overall group by time interaction effect was statistically significant (P<0.001) . Both thAnalysis of data from the intervention group only  showed aThis is the first published quantitative evaluation of Jamie's Ministry of Food Program providing evidence of the program's impact on participants' cooking and eating behaviours. While evaluation recruitment was relatively modest at baseline (∼47% response rate), the retention rates were similar to other recent studies in this area These findings are encouraging and align with evaluation of other cooking skills programs that have found positive results with respect to improved cooking confidence Additionally, the apparent agreement between results around daily vegetable intake, consumption of vegetables with the main meal, cooking confidence and cooking from basic ingredients, all of which reported statistically significant increases, suggests that the program influences many aspects of cooking and eating behaviours simultaneously and the parallel increases in these variables are consistent with the causal logic model proposed for the program Furthermore, acknowledging that self-reported daily fruit intake did not result in a statistically significant difference between groups at T2 (P = 0.06), a 0.40 serves per day increase was still found between T1 and T3 in the intervention group only analysis (P<0.001). Nevertheless the statistically significant results between groups for self-reported vegetable intake and not for self-reported fruit intake possibly reflect the emphasis within the Jamie's Ministry of Food program to promote and teach inclusion of vegetables or salad with the main meal.The results of this study offer the strongest quantitative evidence at this point in time to specifically support the premise that Jamie's Ministry Food program improves cooking confidence and leads to healthier cooking and eating behaviours. The evaluation also adds to the literature more generally around the effectiveness of cooking skills programs per se, particularly given the relatively large sample size, use of a control group and six month follow up measures, all design elements which have been lacking in many other studies of community cooking skills interventions Jamie's Ministry of Food Program in Australia, has succeeded in recruiting large numbers in the communities in which it is operating and has attracted both private and public investment even when it precedes evidence of program effectiveness. This may speak to the influence of Jamie Oliver himself as program ambassador and his capacity to mobilise various players within communities. Whether or not this celebrity endorsement augments program effectiveness and what role such programs should play in the promotion of public health nutrition, remain questions for future research as does determination of the efficiency of the program measured against known alternatives through cost-effectiveness analysis. However the results suggest that the Jamie's Ministry of Food Program holds promise as a community-based strategy and should certainly be considered as part of a comprehensive approach to improving diet quality.This evaluation has, for the first time, demonstrated that the Jamie's Ministry of Food Program has positive personal, dietary and likely health impacts for participants through improvements in cooking confidence, cooking and eating behaviours towards a healthier diet. These benefits were sustained at 6 months post program suggesting the program does have an enduring effect on program participants and should be considered as a component in any suite of interventions targeting healthy eating.S1 TableCooking confidence measures at baseline and follow up adjusted by age, gender and levels of employment independently and all together.(DOCX)Click here for additional data file.S2 TableCooking and eating measures at baseline and follow up adjusted by age gender and levels of employment independently and all together.(DOCX)Click here for additional data file.S3 TableResults of ordinal logistic regression for confidence to cook questions.(DOCX)Click here for additional data file.S4 TableResults of the logistic models for dichotomised confidence questions (“not confident” and “confident”).(DOCX)Click here for additional data file.