Expanding the use of evidence-based behavioral interventions in community settings has met with limited success in various health outcomes as fidelity and dose of clinical interventions are often diluted when translated to communities. We conducted a pilot implementation study to examine adoption of the rigorously evaluated Healthier Families Program by Parks and Recreation centers in 3 cities across the country  with diverse socio-cultural environments.Using the RE-AIM framework, we evaluated the program both quantitatively  and qualitatively (interviews with Parks and Recreation staff and participants following the program).REACH: Among the 24 participants who completed pre/post surveys, 62.5% were 25–34 years old, and average child age was 3.6 (SD 0.7) years. The distribution of self-reported race/ethnicity was 54% non-Hispanic White, 38% non-Hispanic Black, and 8% Latino. EFFECTIVENESS: Qualitative interviews with participants demonstrated increased use of the built environment for physical activity and continued use of key strategies for health behavior change. ADOPTION: Three of five (60%) collaborating sites proceeded with implementation of the program. IMPLEMENTATION: The average attendance for the 12-week program was 7.6 (SD 3.9) sessions, with 71% attending > 50% of sessions. Average fidelity for the 12 weekly sessions was 25.2 . MAINTENANCE: All 3 partner sites continued offering the program after grant funding was complete.The 3 partner sites recruited a total of 26 parent-child pairs. This pilot is among the first attempts to scale-out an evidence-based childhood obesity intervention in community Parks and Recreation centers. While this pilot was not intended to confirm the efficacy of the original trial on Body Mass Index (BMI) reduction, the effective and sustained behavior change among a geographically and ethnically diverse population with high attendance and fidelity demonstrates an effective approach on which to base future large-scale implementation efforts to reduce childhood obesity in community settings.The online version of this article (10.1186/s12889-018-5403-z) contains supplementary material, which is available to authorized users. Implementation of evidence-based childhood obesity interventions is an important component of combating obesity and its long-term health consequences. Over the last two decades there have been over 300 randomized controlled trials to prevent or treat childhood obesity . While sCommunity-based implementation research is an emerging field that focuses on how efficacious interventions should be modified so that similar results can be achieved in different settings with more diverse populations . In theiDespite the identification of these contextual factors required for successful community-based implementation, programs like the DPP have met with more limited success when translated into community settings among traditionally under-represented populations . Very feSalud con la Familia) was developed in 2009, and a randomized controlled trial (RCT) demonstrated efficacy at reducing child BMI among a sample of 106 Latino parent-child (ages 3–6) pairs , 2218, 2icipants . We do nA quantitative assessment of organizational readiness to adopt the Healthier Families Program was conducted using a modified version of an instrument developed by Helfrich et al. , which cParticipant surveys were conducted before and immediately after the 12-week program and were used as indicators of effectiveness for this pilot. This survey consisted of 76 items and measured how frequently participants used behavior change techniques , how frequently participants used specific strategies for healthy behaviors , and how frequently children engaged in specific healthy behaviors . These items were either coded dichotomously (yes/no) or as the number of times per day or week. A research assistant from the study team conducted semi-structured interviews via telephone with families immediately following the program’s implementation and then 3 months after the program implementation. The research team developed an interview guide that asked questions about the following domains, including probing questions  were used to summarize responses to the survey items. While each site received anonymous and individualized reports regarding the responses to survey items at their center, we present them in aggregate here to preserve confidentiality. The survey was administered electronically and data were stored in a secure REDCap database. All data were analyzed using STATA version 14.2 .The interviews were audio recorded and the recordings were transcribed by a professional transcription service. Our systematic approach to content analysis involved three stages . First, The quantitative and qualitative data used to evaluate the Healthier Families Program are organized using the RE-AIM framework, and key themes identified through the qualitative analysis are presented in Table n = 8, 7 and 9 . The final enrollment at each site was A comparison between the sociodemographics of participants who enrolled in the program with the US Census data for their zip code is shown in Table p < 0.05) of families met physical activity goals, and 58.3% met healthy diet goals (p < 0.05). Parents also reported using strategies for healthy behaviors that were taught during the intervention, including the plate method (p < 0.05), using food labels to evaluate sugar content (p < 0.05) and fiber content (p < 0.05). Parents also reported that their children were engaging in healthier patterns of diet, media use, and physical activity, though not reaching statistical significance.The efficacy of the Healthier Families Program has been previously reported . BecauseQualitative data obtained from 24 participants immediately following the intervention were used to describe changes in important health-related behaviors. For example, families expressed that they had increased knowledge about a variety of topics as a result of participating in the program. Most of the new knowledge that families reported acquiring was related to topics such as healthy sleep, parenting, and media use. Many participants shared that they already knew about healthy foods and physical activity. The program, however, served to encourage and equip families to actually make changes to their physical activity and eating behaviors by providing strategies for engaging their entire family in the change process. When asked about the impact of participating in the program, one participant responded, “I was just telling my husband earlier today, I looked in the mirror and I can already tell I’ve slimmed down. We have eaten less fast food. We were sharing at our last meeting, how people are eating out less, spending more time together. It’s made me more mindful. Things where I was thinking about before, there was no accountability behind it, has made me more mindful.” While another said, “It’s made me more conscious, and making little choices here and there that add up over time. I think that’s when it’s been most beneficial to me, that it’s put it in the forefront of my mind instead of not even thinking about it at all…”.In general, parents identified the family-engagement aspect of the program as critical to its efficacy. One parent said, “I think it was good for my kids to get that specific instruction because they just seemed more interested. We went to healthy foods class, these are healthy foods, they had some buy-in. It wasn’t just my class, it was theirs too.” Another parent said, “You start the program at the beginning you’re with your kids then your kids leave and you get this great, adult interaction while your kids get to go hang out with friends, and I loved the way it’s set up. It’s set up to be family time, it’s an adult time and then family time again. Something about that was really special.” In response to a question about what made it difficult to meet weekly health behavior goals, one participant said, “All the obstacles like time to plan, illness, holidays, things that just disrupt the pattern of life in general.”Parents enjoyed having the opportunity to hear ideas about parenting and healthy living from other parents. They seemed to appreciate the opportunity to share ideas and similar life experiences with other parents. One parent said, “I really liked that you got together with other parents. Especially they’re kind of in the same boat you are and just wanting to do good for their families and they’re able to connect and see exactly what they’re doing and see if there’s ways that what they’re doing will help you.” Another mom said, “…the social aspect of it, being around other people that are in a similar stage of life and bouncing ideas off of each other that way where you know that there’s other women going through the same thing.”When asked specifically about use of their built environment for physical activity, participants indicated increased use of the Parks and Recreation centers as a result of the program. One participant said, “Yes, it did make me want to look more into the activities that are available there so I can sign up the kids. It did interest me, yes.” Some respondents indicated that participating in the program opened their eyes to the availability of the Parks and Recreation centers and the opportunities therein. One participant said, “Actually, it got me interested in looking at the Parks and Rec as an option for going to work out. Before, I had a membership at [local fitness center] and when I realized that they offer some of the same things and some of these classes are free. If it’s not cheaper it’s free. I’m definitely looking at going to a rec center versus paying a membership for a gym. That was one thing that was an eye-opener, like, okay, I didn’t know they had all of these different classes. They also allow you to bring your kids…” There was also a sense that some people were motivated to continue to participate in the activities at the rec centers because other families from the program might be there as well. One participant said, “I didn’t realize there was so much available… then knowing some of the other families were going to do certain things so that we’d all be together again, that is kind of cool too.”A full description of the determinants of organizational adoption has been reported elsewhere . At the Prior to piloting the program, key informant interviews from community members and organizational leaders demonstrated an eagerness to participate, recognizing close alignment between community priorities and the objectives of the Healthier Families Program. A local recreation center patron shared that the Healthier Families Program, “seems like a very good program to offer in this community. Everyone is very concerned about health and we want to eat right and we want to do right.” Similarly, recreation center staff reported that their team was “really focused on health and wellness and trying to provide that for people in the community.” Another staff member emphasized that this focus was, “not just while [community members] are here with us, but we also consider how do we get them to take that then beyond, and make that part of their lifestyle.”Following the implementation, Parks and Recreation staff were asked the following questions with a response option of 1–5 (5 = strongly agree): How ready is your center to continue offering the Healthier Families Program? How engaged is leadership in continuing to offer the Healthier Families Program? How much of a priority is the Healthier Families Program in your center? Ratings ranged from 3 to 5 and the means were from 4.3 to 4.7. This shows substantial agreement that the centers felt ready to implement the program, that the leadership was engaged, that the program was a priority, and that it was easy to implement.Furthermore, participant interviews following the three-month program showed successful adoption. When asked how well-trained their facilitator was, respondents in general seemed to think the facilitators were adequately trained. Several commented that their facilitator was very positive, enthusiastic, and welcoming. Facilitators did not seem to be leaning too heavily on the printed material/reading from a facilitator’s guide. Participants felt they were fairly knowledgeable about the material. Multiple people indicated that they really liked it when their facilitator brought up examples or applications from their own life/own experiences. Several commented on the children’s program facilitators and how much their children enjoyed interacting with these individuals on a weekly basis. Several respondents remarked that while they liked the program, they were not sure what they would be willing to pay to attend a similar class in the future. Many indicated that the fact that the class was free was a major incentive for their participation and/or they would only be willing to pay a nominal fee in the future.Prior to implementation, key adaptations were instituted to contextualize the intervention for each community. These adaptations were made with input from the local recreation center staff in conjunction with the study team, and did not alter the core content of the intervention. Primary adaptations included reducing session time from 90 to 60 min, re-branding for each local site, developing enhanced training modules for new facilitators (emphasizing facilitation and behavior change techniques), implementing a web-based facilitator training program, and providing a snack instead of a meal at the end of each session. Each site made small customizations for printed materials, communication strategies (email) and engagement of children depending on their age and developmental stage.The average attendance for the 12-week program across all three sites was 7.6 (SD 3.91) sessions, with 43% attending at least 80% of the sessions and 71% attending at least 50% of the sessions. Both families and Parks and Recreation leaders identified time constraints as the biggest barrier to program participation. Families indicated that other activities such as errands, taking children to and from school, travel, and holiday activities, in some cases, prevented them from attending all of the class sessions. No one identified money or finances as barriers to their participation in the Healthier Families Program probably because this pilot program was offered at no-cost to the participants.Fidelity was assessed by using a checklist to score video recordings of each session submitted by the sites and scored by two independent raters. Average fidelity for the 12 weekly sessions was 25.2 . There were no significant differences in attendance or fidelity across the three sites (data not shown).When interviewed about implementation following the program, Parks and Recreation leaders reported that implementation was dependent on having the right staff, training them in how to facilitate the program, and allowing them to do their jobs. There were only very minor difficulties with staffing, with most of these comments reflecting upon specific staffing activities or general praise for how well staff did in implementing the program. One respondent said, “I can’t think of anything really specific that didn’t go well. I think we were surprised with how much training was required, but I think, in the end, [staff] and I both realized why that was necessary in making sure that we were doing it the way it needs to be done and fidelity and all of that. Not that it didn’t go well, it was just kind of an interesting journey. Whereas, other programs, we just kind of jump in. Just the commitment, I think, was surprising, but I think well worth it.”On the other hand, staff were not used to leading sessions in which both parents and young children were present. Staff expressed appreciation of how the Healthier Families Program was able to get adults and children to engage with each other. They saw a number of ways that families could benefit from the parent-child interactions, and from interacting within the structure of the program. In addition, staff reflected on some of the challenges they faced in engaging the families. Several noted that it was a learning process, and the skills involved in engaging families in the process of making change is quite different from the skills involved in classroom teaching. They shared that they got better at doing this over time. One Parks and Recreation leader said, “An ability to connect with families and both kids and adults. That can be really tricky, because they’re two quite different ... To be able to engage both the kids and the grown ups is tricky. I would say being able to lead a discussion I guess more by asking questions, so guiding the discussion rather than leading the discussion. It’s not as much about teaching as it is asking the right questions so people discover it for themselves. That can be really hard if you’re coming at it as a typical teacher or class instructor. It’s not just about giving the information. It’s about helping people find it for themselves.”While time-intensive for training, working with the Healthier Families Program was perceived as personally beneficial by the Parks and Recreation staff and administrators we interviewed. Staff participants identified a number of ways that participating in the Healthier Families Program allowed their own personal skills to improve. Some felt more confident afterwards, especially in their ability to facilitate group interactions. They felt that specific skills such as listening and getting families to participate also improved. Even the administrators saw a benefit from working with the program as a way to improve skills.Additionally, Parks and Recreation staff noted some logistical barriers to implementation such as slow internet speeds when uploading video recordings, language issues, dealing with families that brought other children, and finding the ideal time of day to accommodate everyone’s schedule and needs. They also noted that families faced obstacles to participation such as competing activities, scheduling difficulties, family problems, poverty, transportation issues, and staying motivated to attend weekly sessions.Three months following the intervention, participants completed key-informant interviews, which demonstrated sustained behavior change as a result of the intervention. When asked about any changes made in behaviors as a result of the program, one participant responded that her family was “Exercising more, which we didn’t used to do.” Another responded, “Mainly with the prepping, so we eat healthier now and essentially joined the gym. We work out more. We got more active and involved just because of the accountability of it and just thinking about it, because from the classes, you think about it more.” Another parent responded, “My kids help a lot more with preparing foods now. I think when they get a chance to prepare, they like eating healthier because they worked hard at making it. I think it’s a little bit easier for them to eat things that they wouldn’t normally try just because they made it.” When asked about the most important impact of the program, one participant responded “I think it’s mostly made me be more aware of all of the aspects of having a healthy family. I think before I was really focused on the eating habits, and I guess just helping me realize that there’s more to just eating healthy.” And another responded, “We’ve been exercising a lot more, five times a week now, every week. It’s been like three months now. We’ve been doing that since we ended the program. It’s been pretty good.” One participant commented, “I liked the SMART goals because it just ... You know, it made me realize that it’s not a whole huge change that has to take place at once, but just working on little things day by day, to just be a little bit more conscientious of what you’re doing with food and exercise, and everything between.”In key informant interviews with Parks and Recreation staff following the program implementation, the issue of sustaining the program was viewed as a matter of finding funding or partnerships to help underwrite the various costs of the program, with secondary concerns about identifying the right facilitator and finding enough families to fill the program each time it’s offered. One respondent said, “Definitely resources because we all have to meet our revenue for the year, so this program being so long, we have to try to get some grants and things like that. I know that we’re hoping to run it for a long time and see if there’s interest in it. I won’t really know until after the first one starting in January, if we even have interest in that program.”Following the initial 12-week implementation, each of the study sites elected to continue offering the program, identifying it as an important program for their community. Due to price structuring within the local Parks and Recreation system, one site is required to charge for the class. They are seeking funding from local partners to eliminate charging participants and consider this a potential barrier to enrollment. Another site recommended shortening the program to 8 weeks, given the typical seasonal programming and schedules they coordinate. The study team continues to assess their implementation using the fidelity checklist for video-recorded sessions, but we no longer provide on-going feedback. We also developed a self-assessment of fidelity to be completed by facilitators, and compare those self-ratings to the study team’s assessment using the gold standard of video-taped sessions. After adapting the fidelity checklist tool to have a range of 1–2 , the study team rated videos for all three sites that have fully implemented the program without additional research support. This revealed agreement between self-assessment and the study team’s assessment resulting in high fidelity program implementation.Community-based implementation scale-out research evaluates how efficacious interventions should be modified so that similar results can be achieved in different settings with more diverse populations. We report on the successful pilot implementation of an effective behavioral intervention designed to prevent and treat childhood obesity for preschool age children in community Parks and Recreation center settings. Using the RE-AIM framework to evaluate the public health impact of this pilot we identified successes and next-steps to guide the field of community-based implementation science and to inform broader implementation of the Healthier Families Program. At the organizational level, the evaluation revealed the need for close alignment between the goals of the Healthier Families program with local community priorities and community member’s interests. This alignment led to successful uptake of the program with high fidelity and attendance. Most notably, each of the Parks and Recreation centers that participated made the decision to sustain these efforts after grant funding ceased. When assessing the program for changes that affected individuals, it was evident we were able to adapt the program to reach participants from a range of socioeconomic communities. While the current study was not powered to test for changes in BMI, we demonstrated changes in the use of behavior change techniques, the use of strategies for implementing healthy behaviors and trends toward healthier nutrition, physical activity, and media use. Finally, qualitative data generated from interviews with both local Parks and Recreation staff, and program participants reiterated the successful uptake of the program in the community as well as sustained behavior change and use of the built environment.Parks and Recreation centers around the country are prime candidates for this type of translational research, and future efforts should focus on expanding the reach of behavioral obesity interventions in environments that young children and families frequent. Fidelity monitoring, one of the most important aspects of effective replication, required multi-modal training that included ongoing feedback in response to real-time evaluation. Challenges included clearly delineating the difference between an adaptation necessary for effective contextualization in each community and how that could alter the fidelity of the program to the original evidence-based approach. An additional challenge included Parks and Recreation staff having the time to engage in training modules and to have support staff during the intervention to effectively engage both parents and children.During the preliminary phases of this scale-out pilot, we initially engaged five community Parks and Recreation centers. Throughout the pre-assessment phases, only three elected to continue. The main reasons that sites decided not to move forward with the implementation phase were not having the necessary physical resources and not having close alignment with community participants’ priorities. Consequently, we would suggest that any attempt to replicate a community-based behavioral intervention would first conduct a careful assessment of alignment with community priorities and resources to avoid investing in a program that will have a low likelihood of success.In this pilot scale-out implementation project, geographically diverse communities had high interest in delivering the Healthier Families program, as well as interest from families in program participation.. The pilot outcomes of healthy behavior change in parents with young children indicated similar changes over three months regardless of the community, suggesting that core skills such as setting and meeting family goals in nutrition and physical activity can be strengthened in diverse populations.community-based implementation research, especially among behavioral interventions for childhood obesity. Conceptual models, like the Consolidated Framework for Implementation Research (CFIR) provide a strong theoretical foundation [This is one of the first attempts to conduct undation . The CFIundation . Along wThis study had several limitations. First, as this was designed as a pilot study, we engaged three Parks and Recreation centers and 26 families. Consequently, we cannot make generalizations about the effectiveness of the intervention, or say with certainty that these implementation methods will be applicable in other contexts. Furthermore, the study sites and participants who engaged in the program were early adopters, enrolling without use of targeted recruitment methods, and were likely to be more highly engaged than the general population. Our assessment approach for health behaviors was limited to pre-post surveys, which may be subject to either recall or social desirability bias given behaviors were not recorded in real time. Finally, the RE-AIM framework defines maintenance as six months following an intervention, however, we were only able to collect data 3 months after intervention completion due to the feasibility of maintaining follow-up in each community.To generate sustainable solutions to the childhood obesity epidemic, identifying tested strategies that are ripe for dissemination and implementation will be necessary. Yet, this is only the first step in the process. This must be followed by a systematic approach to adapt and contextualize these strategies to ensure effective spread. While our pilot program had a small sample size, our results demonstrate promise and highlight the importance of contextualizing the intervention for effective scaling-out while providing a rigorous approach to ensure high fidelity. Future research in community-based implementation science should focus on developing robust training platforms that can reproducibly train interventionists from a wide range of backgrounds to deliver health behavior interventions with high fidelity. Ensuring both practical implementation in a variety of context and maintenance of the original program’s essential components requires systematic strategies that can be utilized for effective implementation of programs that have promise to improve the public’s health.Additional file 1:Example of an ADAPT Fidelity Report: Module- Healthy Snacks & Drinks. (DOCX 22 kb)


To understand the implementation quality of the Tier 1 Program of the Project P.A.T.H.S., 25 schools and three school social service units were randomly selected to participate in telephone interviews regarding the quality of the implementation process of the Tier 1 Program of the P.A.T.H.S. Project. In the telephone interviews, the participants described the responses of the students and the workers to the program, the perceived benefits of the program, their assessment of the positive and negative features of the program, as well as difficulties involved in the implementation process. Results showed that most workers perceived that the students had positive responses to the program and half of the workers had positive experiences about the program, although negative comments on the program design and difficulties in the implementation were also recorded. Nearly all workers (97.1%) regarded the program to be beneficial to the students and most of them (78.6%) had positive global evaluation of the project. In short, while the program implementers expressed concerns about the program design and the implementation process, they generally regarded the program as helpful to the students and they had positive global evaluation of the program.


Kyrgyzstan, where HIV is concentrated in prisons and driven by injection drug use, provides a prison-based methadone maintenance therapy program as well as abstinence-oriented therapeutic community based on the 12-step model called the “Clean Zone.” We aimed to qualitatively assess how prisoners navigate between these treatment options to understand the persistence of the Clean Zone despite a lack of evidence to support its effectiveness in treating opioid use disorders.We conducted an analysis of policy documents and over 60 h of participant observation in February 2016, which included focus groups with a convenience sample of 20 therapeutic community staff members, 110 prisoners across three male and one female prisons, and qualitative interviews with two former Clean Zone participants. Field notes containing verbatim quotes from participants were analyzed through iterative reading and discussion to understand how participants generally perceive the program, barriers to entry and retention, and implications for future treatment within prisons.Our analyses discerned three themes: pride in the mission of the Clean Zone, idealism regarding addiction treatment outcomes against all odds, and the demonization of methadone.Despite low enrollment and lack of an evidence base, the therapeutic community is buttressed by the strong support of the prison administration and its clients as an “ordered” alternative to what is seen as chaotic life outside of the Clean Zone. The lack of services for Clean Zone patients after release likely contributes to high rates of relapse to drug use. The Clean Zone would benefit from integration of stabilized methadone patients combined with a post-release program. Throughout the world, and specifically within Eastern Europe and Central Asia (EECA), incarceration, substance use disorders (SUDs), and HIV are inextricably linked . The regp < 0.001) to have remained free from opioids within 12 months as compared to those who received voluntary methadone maintenance treatment [There are few evidence-based treatments available in prisons worldwide, where care often falls below community standards , 5. Unlireatment .Despite the absence of data supporting the use of rehabilitation facilities based on the 12-step model, doctors, employers, and judges regularly refer patients with SUDs to these treatment programs. Why the model has popularity among providers and clients and how they perceive it to work even in the presence of suboptimal results remain to be explored. Kyrgyzstan provides a valuable case study as the only post-Soviet country to have such an abstinence-only treatment facility integrated into the criminal justice system. This independent unit embedded within a prison and known as the “Clean Zone” has provided a 12-step treatment model over the past 10 years but has not previously been independently assessed. Moreover, an understanding of its cultural significance may help shed light on the persistence of such programs despite the lack of corresponding evidence attesting to its effective treatment of SUDs. Such an assessment can help ensure a culturally appropriate solution to the future of 12-step models in EECA prisons, especially considering that Kyrgyzstan serves as a regional leader on HIV/AIDS prevention and treatment policies . Given rFocus groups with therapeutic community clients and individual interviews with staff members were conducted in February 2016. These were complemented by a review of secondary data sources and policy documents on the implementation of the 12-step program and the “Clean Zone” prison in Kyrgyzstan.In Kyrgyzstan, where the prison population is 7683 , 30.4% oWhat are the barriers and facilitators to entry and retention in the Clean Zone program?What information is available on the effects of this program on the treatment of SUDs among clients within prison and after release?Is the program being conducted with an efficient use of resources?How is the “Clean Zone” program viewed by both prisoners and staff and how does this compare to attitudes regarding OAT in treating opioid use disorders?How can the program be improved to better meet the health needs of prisoners with SUDs?The aim of the study was to conduct a qualitative and independent assessment of the functioning of the “Clean Zone” and provide recommendations to prison administrators and funders. In doing this, we combined principles of inductive and deductive reasoning . ThroughN = 20) of the therapeutic community. The choice of the Atlantis sites, made by the prison administration, was motivated by their proximity to the capital city of Bishkek. Of the three Atlantis centers visited, one was cordoned off from the rest of the prison, creating an isolated environment similar to the Clean Zone. The Clean Zone is an independent unit located on the territory of Prison 31. Eligible study participants included prisoners (participants of the Atlantis and Clean Zone programs), staff (Atlantis and Clean zone), prison administrators, and released Clean Zone participants (NGOs).Three researchers  visited four sites, including the Clean Zone and three Atlantis programs over one week in February 2016 and spent over 60 h conducting participant observation as well as focus groups with a convenience sample of participants  and staff members . Focus groups and interviews were advertised to a group of potential participants. It was made clear that participation would not affect their stay in the prison, all questions would be voluntary, and all responses would be anonymous.A topic guide was used for each focus group and individual interview, which was developed iteratively through a combination of lines of questioning from emerging findings and pre-conceived markers of program evaluation literature . The guiUpon consultation with the prisons department, focus groups were not audio-recorded to ensure participants’ comfort and openness of the discussion of sensitive topics as well as the expression of diverse opinions within the group. This was also relevant as one of the authors did not speak Russian and thus interactions between the researchers and the participants were mediated by interpretation provided by the other two researchers. All focus groups lasted about 90 min and interviews lasted 30–45 min. Instead of audio-recording, extensive field notes were taken by three of the authors during the focus groups and participant observation. Field notes included verbatim quotes of particular salience from participants. These interviews were supplemented by informal conversations we had with our colleagues in Kyrgyzstan and in Ukraine—such as the staff of the non-governmental organization AIDS Foundation East-West, the NGO “Ranat” in Bishkek, and the Ukrainian Institute for Public Health Policy. These meetings gave us a sense of the public profile that the Clean Zone and Atlantis have.First, we assessed the effectiveness of the program based on analysis of policy documents and interviews with study participants (study questions 1–3). Based on scant evidence attesting to the long-term effectiveness of therapeutic communities in treating SUDs , 22 and Extensive field notes were analyzed to draw conclusions from unstructured observations . ImmediaThroughout our fieldwork and analyses, we discussed how our professional and academic backgrounds shaped our reflective “gaze” when encountering participants . ThroughPrisoner participants were predominantly male  whereas staff participants were predominantly female (67%).With regard to the study questions, we found the following:How effective is the Clean Zone and the Atlantis program at treating SUDs?What are barriers and facilitators to entry and retention in the program?2.What information is available on the effects of this program on the treatment of SUDs among clients within prison and after release?Nearly all individuals within the Atlantis program did not advance to the Clean Zone for various reasons: (1) insufficient time left on their sentence; (2) individual preferences not to participate, primarily due to an understanding of the Clean Zone being a space with restricted movement and stringent rules; (3) not deemed eligible by Clean Zone staff who assess whether they would be optimal candidates or not; (4) many do not complete the Atlantis program and therefore are not eligible; and (5) stigma of being associated as “loyal” to the prison administration rather than to other prisoners.3.Is the program being conducted with an efficient use of resources?This conclusion is verified and supported by the presence of prisoners in the colonies  who have completed the Clean Zone previously and described their relapse trajectory in which they are released from prison to the community, but in the absence of employment, housing, and social support, nearly all participants relapse and this relapse occurs almost immediately after release. Furthermore, the data collected by the Clean Zone staff also suggest many patients  drop out of the program either by refusing therapy or breaking the rules of the program.There are currently a maximum of 12 to 24 available slots in each Atlantis program at eight prisons, yet in almost all instances, they were not full. Thus, the 100-person capacity of the Clean Zone program, with 19-funded clinical and custodial staff, remains considerably underutilized, with the maximum number of participants in the program at any one time being 45. Staff reported marked difficulties in being able to recruit a sufficient number of participants from the Atlantis program into the Clean Zone. Why does support for the Clean Zone persist despite the lack of evidence base?4.How is the “Clean Zone” program viewed by both prisoners and staff and how does this compare to attitudes regarding OAT?Three themes emerged that provide insight into the cultural significance of the Clean Zone program.The staff of the Clean Zone and Atlantis, as well as the Clean Zone clients, presented with an omnipresent sense of pride toward the goals of the work they were set to accomplish. The staff seemed to be sincere enthusiasts who deeply enjoy their work with opioid-dependent prisoners; they were knowledgeable about and experienced with the 12-step program and had also undergone various training programs and seminars  to extend their appreciation and understanding of how the 12-step program works.rebiata, i.e., boys, which, in the Russian language, has affectionate and slightly patronizing undertones used when a senior person makes a reference to a junior person under their wing. Furthermore, the director of the Clean Zone performed the functions of the matron by advocating for her charges toward various organizations like NGOs, trying to raise funds to cover the expenses of keeping the facilities tidy, well-stocked with food supplies, warm, and in a good state of repair in winter. A former colonel of the Kyrgyz police told us a story of how the director of the Clean Zone went to great lengths to have a heating unit replaced in the facilities in the late fall a year ago to ensure the clients have comfortable living conditions. It is our impression that, to the clients, many of whom had no close family, the director of the Clean Zone serves as a parental figure, providing ongoing care and a sense of support. Also, she performed the parental role of providing a strict moral code of conduct, and her ardent belief in the values she was bringing forward  enhanced the legitimacy of these values in the minds of the clients.The director of the Clean Zone seemed to exude a matron-like concern for the well-being of the clients and the performance of her duties. When she referred to her clients, she used the word Professional pride on the part of the staff was matched by the prisoners’ enthusiasm toward the goals of sobriety and social recovery. There was a particularly exuberant contingent among the clients who stated that they appreciated feeling a part of a community and having support of the other clients who were responsible for each other. They stated that they also had a responsibility to report on others who were using drugs or not behaving “adequately.” The Clean Zone director later confirmed this, saying that surprise drug testing is carried out in the facility. The social support found in this program was given a lot of value, since many of the participants lacked this sort of support in the community.A strong idealism was reflected in the strict adherence to order and the goals of sobriety in the face of a lack of evidence for the continued effect of this program after release. Given the challenges of post-release life and a lack of support after release, changes for sustained sobriety were bleak. Yet, staff and prisoners alike set their aim at sobriety which was understood as complete abstinence from any substance use, including legally prescribed medications like methadone, for the rest of their lives. Idealism was also visible through the prisoners’ ardent insistence on stating their own exceptionality and on how they felt being different, stronger, and more mature—both in comparison to the rest of their peers and in comparison to themselves prior to entering the Clean Zone. Each of them wanted to feel as though they were the exception, not the rule; if the rule was that a substance use disorder was a chronic and relapsing condition, each prisoner in the Clean Zone wished to assert themselves as being an exception to this process where relapse would not happen to somebody like themselves. To support this vision of their new, improved selves, during the focus group discussions, they shared stories how other, sicker, and/or older prisoners had given them a kind of a blessing to pursue sobriety and a decent life and how these other prisoners expressed trust in their abilities and will to accomplish this goal. Yet this idealism meant that Clean Zone clients segregated themselves from the rest of their extended primary peer group of other prisoners with a SUD not only spatially (by living in a separate facility) but also culturally, and cultivated a sense of moral superiority.Simultaneously, they appreciated that the level of social support that was accessible to them through Atlantis programs and/or Clean Zone was unattainable upon release: many prisoners had no families and no home to return to and many worried about jobs and income. Only three former clients of the Clean Zone had jobs in NGOs and six had volunteer positions, with the others’ employment situation being uncertain. Only 67 released Clean Zone clients maintained contact with the Clean Zone and were known to be abstaining from using substances. In the face of such unlikely prospects for success, clients however persisted in their wish to be the exception and not the rule. While the staff and the prisoners appreciated that the lack of services upon release may present a challenge, they felt that the prisoners’ willpower would be the principal tool to keep them sober. When we spoke to the two graduates of the Clean Zone program, however, they recognized the need for a transitional program after release, saying “being confronted with reality on the other side, you’re faced with social problems, you continue using” and “if there’s no continuation of the Clean Zone, all the effort put into them here is useless.” They estimated that about 80% of inmates have no passports and no ability to get a passport, so that after release, they often return to illegal activities since a passport is necessary to find legal employment.The staff and the prisoners demonstrated a strong suspicion toward methadone which they did not view as a treatment, but, rather, demonized and feared it. This exposed a process of “othering” and seeing “us”  versus “them” . Also, we detected a certain moral superiority in the prisoners’ discourse: for example, one prisoner in the Clean Zone during the focus group recounted a story of how an older prisoner who had taken him under his wing had instilled in him a fear of methadone as something he had taken but that is best avoided. The prisoner felt that “all eyes were on him” as he was going to try and accomplish the goals of sobriety that his (older and more senior) fellow prisoners had not been able to achieve. Prisoners who had chosen the Clean Zone were viewed and felt themselves as more advanced on the way to recovery than methadone patients. The idea that methadone patients could potentially share Clean Zone or Atlantis resources (as the resources in the Clean Zone were underutilized since it was functioning well below its capacity) was rejected vehemently by prisoners and by the staff. Those on methadone were not considered sober or “clean” by participants or staff and methadone patients were not seen as being on the path to recovery. This perspective points to the understanding of methadone as not being a viable treatment and therefore irreconcilable with the goals of the Clean Zone.This study is the first to evaluate and describe an abstinence-only program in a criminal justice setting of EECA. It is particularly important to understand the persistence of the “Clean Zone” program in Kyrgyzstan, where opioid-dependent prisoners choose between internationally recommended HIV prevention services—NSP and methadone maintenance treatment (MMT)—and an abstinence-only 12-step treatment. Our fieldwork explored patient and provider perspectives about the program as well as analyzed the performance of the Clean Zone. In light of a worldwide literature attesting to the limited efficacy of 12-step programs in treating opioid dependence as well as the poor resource allocation of the Clean Zone, the program is buttressed by both the prison administration and its participants. We argue that negative attitudes among OAT participants undermine the path to recovery for opioid addiction, relegating addiction treatment with OAT to an inferior position in comparison to abstinence-only programs, despite the international literature supporting it to be the most effective treatment for opioid addiction. Here, we explore the cultural value attributed to the Clean Zone program, particularly in relation to social standing within the prisoner subculture, which must be understood in order to proceed with the effective implementation of drug treatment in the Kyrgyz as well as other EECA criminal justice systems.While no systematic research assessment of the Clean Zone’s effectiveness has been conducted to date, our interviews with staff and participants, as well as the data collected and shared with us by the Clean Zone staff, suggest that relapse to alcohol and drug use is high among the Clean Zone’s former patients. This is consistent with the overwhelming majority of evidence, which shows that 12-step programs have only a 5 to 15% success rate at abstinence from long-term opioid dependent persons, which is hardly better than no treatment at all , 28. TheOur analysis revealed that the Clean Zone program’s resources and capacity are highly underutilized. The Atlantis program—the only feeder pathway to the Clean Zone—acts as a bottleneck to the Clean Zone which is operating significantly under capacity. The perception among other prisoners that those who enter the Clean Zone are “traitors”—fleeing prisoner life to hide in the secluded Clean Zone for their offenses against the prisoner subculture—emerged as an especially strong driving force against entering the program. This lends weight to the argument that it is not the lack of effectiveness but, rather, the social standing among peers that plays a greater role in disincentivizing the Clean Zone. Further qualitative research should explore prisoner subculture in shaping decisions for the treatment of opioid dependence.Despite the lack of evidence for recovery and the strong opposition to the program among the prisoner population in general, a strongly minded minority decides to take part in the Clean Zone. This idealism, as noted in research elsewhere within EECA , is commOur recommendations for the Clean Zone program are to:Establish a transitional program for soon-to-be-released Clean Zone clients that continues 6 to 18 months after release, including shelter, social rehabilitation, linkages to employment, and preparation of legal documents. This can be accomplished at no additional costs by cost-shifting from the 100 bed prison unit to aftercare activities post-release.Create similar rehabilitation opportunities for methadone patients who are not using illegal substances. A Clean Zone for stable methadone patients would be equally beneficial to them, provide opportunities for transitional care, and address the negative and undermining attitudes of Clean Zone participants toward OAT. Such a strategy of integrating methadone patients into the underutilized Clean Zone should proceed in order to align goals for recovery for all patients who are not using illegal substances. Remove the barriers to entering the Clean Zone in order to fill to capacity, which would minimally include stable methadone patients that have as their goal to remain off of illegal substances.The data are limited by its cross-sectional assessment and non-representative nature. Using qualitative data can be useful for program development, however, especially as a quantitative assessment would not be reasonable here given the lack of worldwide literature to support abstinence-only programs. In this case, a qualitative study can better address the stakes that are involved in participants making choices for or against therapeutic community treatment or methadone maintenance for their opioid dependence.The low level of interest in the Clean Zone by prisoners themselves and high staff-to-client ratio suggest that, if the Clean Zone were to be continued, it would benefit from integration of stabilized methadone patients combined with a post-release aftercare program. The extraordinarily hostile and negative attitudes toward methadone maintenance treatment, however, persist among patients in the Atlantis program and the Clean Zone. This perception may, in part, have evolved from methadone being originally introduced as a harm reduction strategy alongside PNSPs, rather than as an evidence-based treatment for opioid use disorders. As such, methadone was viewed as a means to prevent HIV transmission, but not as an effective treatment for opioid addiction. The Clean Zone, based on within-prison therapeutic communities, harbors negative attitudes toward OAT, stating that individuals with addiction problems cannot be in recovery from their addiction as long as they take any form of psychoactive substance, including medications prescribed by a physician. Indeed, programs such as the Clean Zone run contrary to the 2013 understanding of substance use disorders that are chronic, recurring conditions. These conditions, while never cured, may be in early (3–12 months) or sustained (>12 months) remission or effectively treated using maintenance therapy with OAT. Moreover, SUDs may be qualified as “not treated” when someone is in a controlled setting like an inpatient addiction treatment unit, hospitalized, or within a criminal justice setting . The hos


Hemimelia as a congenital anomaly is a failure of development of extremities formation in embryonic period. This anomaly is defined as complete absence of the part of extremities and different forms were explained for hemimelia. Adactyly is an alternative name for transverse hemimelia and is a rare disorder in the most of animal species. A two months old male lamb with normal vital signs was referred to clinic due to both hind limbs shortness and absence of hooves from the birth day. Clinical and radiological examinations were performed and partial hemimelia was confirmed radiographically in both hind limbs. In left hind limb, total absence of the toe indicated presence of adactyly in this limb. No other congenital deformities were diagnosed in skeletal system based on clinical and radiological examinations. According to our knowledge, this is the first report of such rare conditions in a lamb. Clinical findings and radiological signs of this rare anomaly in a lamb were described in this report. The most common sites for these anomalies are distal limbs.4-6 Congenital absence of a portion of extremity is defined as hemimelia that includes several forms. Complete absence of distal portion of the limb is called transverse hemimelia or congenital amputation.7 Adactyly is an alternative name represented by total absence of the toe.3 It is defined as a congenital anomaly that all or part of digits and their structures such as hooves do not develop.6,8 Although adactyly has been reported in human and animals, but it is a rare condition.9Congenital anomalies are defects in anatomical structures or functions present at birth.10,11 and different animal species.9,12-19 In farm animals, it has been reported in shorthorn calf 12 and two cases of the Czech cattle population13 as well as Southdown lamb.14 In carnivores, this anomaly has been shown in cat15,16 and dog.9 Adactyly has also been described in Welsh foal,17 camel18 and donkey.19 Information of the only report of adactyly in lamb was not available in detail. Clinical findings and radiological signs of this rare anomaly in a lamb were described in this report.Adactyly as an uncommon anomaly has been reported in human A healthy two months old male lamb with congenital anomaly of both hind limbs was referred to the Veterinary Teaching Hospital of Ferdowsi University of Mashhad, Iran. Based on the owner’s information, the lamb was born with abnormal hind limbs. Clinical examinations were performed and the lamb was referred to the radiology department for further evaluations of the affected limbs. Mediolateral and dorsoplantar radiographies  of the both hind limbs were performed.On physical examinations, the lamb was alert and its vital signs were within normal limit. The lamb was standing in oblique manner craniocaudally because of both hind limbs shortness due to absences of distal end of hind limbs. Distal part of the left hind limb was defective at the level of the fetlock joint. In right hind limb, tarsal joint was formed but its distal part was not formed completely. The distal ends of both hind limbs were covered by skin with small amount of keratinized tissue in some regions without skin damage. In spite of the absence of hooves and distal extremities in both hind limbs, the lamb walked normally. No congenital abnormalities were seen in skeletal system in external examinations except of above-mentioned anomalies. Radiography revealed that distal extremities of metatarsal bone III and IV were covered by soft tissue opacity but phalanges were not formed in left hind limb . In righ20 Congenital limb anomalies occur due to mutation in genes called HOX genes which are important components responsible for interpretation of limbs developmental patterns. Limbs anomalies can be manifested in three different categories including dysplasia, reduction and duplication defects.8 Genetic defects, chemotherapeutics , drugs such as thalidomide and corticosteroids (in chick embryos), malnutrition (lack of riboflavin), transplacental viral infections and X-ray were considered as causes of congenital anomalies.21 This study described adactyly as an uncommon congenital anomaly in a lamb. In the embryonic stages, hoof originates from modification of epidermal cells situated in skin covering the limbs and finally forms a hard keratinized organ. The hooves have a real structure at the birth and play an important role in protection of the inner tissues.20 So that, lack of skin replacement with this specialized cornfield tissue can result in many complications such as skin wounds and injuries in underlying tissues. This article reported this defect in a male lamb, although the etiology of adactyly in this case was not obviously clarified.Adactyly is marked by absence of fingers and their related structures such as hoof. In ungulates, this defect prevents progress of hoof formation; therefore, presence of skin tissue in distal end of limbs instead of hoof is obvious. Presence of keratin in the hoof structure converts this structure to the suitable surface for bearing the animal weight and protection against surface injuries.


Alcohol media literacy programs seek to mitigate the potentially harmful effects of alcohol advertising on children’s drinking intentions and behaviours through equipping them with skills to challenge media messages. In order for such programs to be effective, the teaching and learning experiences must be tailored to their specific cultural context. Media in the Spotlight is an alcohol media literacy program aimed at 9 to 12 year old Australian children. This study evaluates the process and implementation of the program, outlining the factors that facilitated and inhibited implementation. From this evaluation, a pedagogical framework has been developed for health professionals implementing culturally responsive programs in school settings.n = 11 interviews), program evaluation questionnaires completed by children (n = 166), lesson observations completed by teachers (n = 35 observations), and reflective journal entries completed by the researcher (n = 44 entries). A thematic analysis approach was used to analyse all of the data sets using NVivo. Inductive coding was used, whereby the findings were derived from the research objectives and multiple readings and interpretations of the data.Process measures included: semi-structured interviews with teachers before and after the program was implemented (Five key pedagogical considerations were identified that facilitated implementation. These were: connecting to the students’ life worlds to achieve cultural significance; empowering students with real-world skills to ensure relevance; ensuring programs are well structured with strong connections to the school curriculum; creating developmentally appropriate activities while providing a range of assessment opportunities; and including hands-on and interactive activities to promote student engagement. Three potential inhibitors to implementing the alcohol media literacy program in upper-elementary school classrooms were identified. These included topic sensitivities, classroom management challenges, and fitting new programs into already busy school schedules.Overall, the program content and individual lessons were well received by the teachers and students. The lessons learned from the development, implementation and evaluation of this program can provide health professionals with key pedagogical strategies for designing culturally responsive educational programs. Culturally responsive programs are critical for ensuring interventions are effective for their specific context. There are significant physical, mental and social consequences that can result from underage drinking, such as impaired memory and brain functioning, accidents, injuries, violence, risky sexual behaviour and self-harm –3. ChildMedia literacy education, which involves students accessing, analysing, evaluating, and creating media in a variety of forms , 16, is While AML programs have made a valuable contribution to the alcohol prevention field –25, the The Australian advertising scene is replete with depictions of Australian cultural stereotypes such as the ‘larrikin’ male sharing a beer with mates at the beach or over a BBQ , 32. ForExisting AML programs have also focused solely or primarily on print advertisements, rather than teaching students skills in analysing the broad range of multimodal alcohol advertisements to which they are exposed in Australia and elsewhere . MultimoGiven these gaps in the evidence base, Media in the Spotlight, an AML program for Australian children, was developed. While there are cultural differences within the Australian ‘context’, this study sought, as a preliminary step, to tailor the program to the broader Australian context. The program was contextually tailored through inclusion, analysis and critique of Australian alcohol advertisements, Australia media clips, and the values promoted through these advertisements, such as associating alcohol with mateship, sport and larrikinism. Unlike US based AML programs –24, the Findings from a quasi-experimental trial of the ten-lesson interactive program demonstrated positive results on a range of measures including an increase in media deconstruction skills, decreased perception of social norms for teen drinking and decreased alcohol expectancies . These sIt is critical to understand the factors that can increase uptake of such programs in schools and strengthen their sustainability. Previous evaluation research in this area has focussed primarily on quantifying the effectiveness of programs, with limited attention given to the implementation process . ProcessThis process evaluation included semi-structured interviews with teachers before and after the program was implemented, student evaluation questionnaires, teacher lesson observations, and researcher reflective journal entries. Multiple process measures were integrated into the intervention design to obtain rich data from stakeholders including teachers, students and the program implementer; and the triangulation of data sources was employed to increase study validity .n = 83 students), or a wait-list control group (n = 82 students). The schools had relatively high indexes of community socio-educational advantage (ICSEA), with values ranging from 1040 to 1045 (1000 is the median) I liked all the videos you were showing early, the cricket where they had to count how many ads they saw. I think they enjoyed that and they were really surprised, by maybe how many, the amount of times they saw it, they thought wow, watched cricket before but hadn’t realised. They were excited to create their own ads. All of the teachers identified that the program was meaningful to the students as it connected to their life worlds. The program connected to seminal aspects of the Australian culture, through the inclusion of current and familiar advertisements across a range of advertising platforms, and references to popular sports, leisure activities, and cultural events.It is important to emphasise that the program did not increase the students’ exposure to, or identification with, the alcohol advertisements, but rather made them critically aware of the presence of these advertisements and their impact on shaping societal values and beliefs.I think they could now look at an ad and probably with their parents walking through a shopping centre and say look at that, what are they trying to do, and I think they’d be able to rattle off what the advertiser is trying to get you to think, which I was pretty impressed by, the level of understanding that they got throughout the 10 weeks and I think they could probably do that now without prompting. that you always have to look for the hidden message and the techniques used and if they’re true or not. [I learnt] The content in this lesson was great. It really got the students thinking critically and applying their knowledge. Related to the above-mentioned theme, all of the teachers noted that the program equipped students with skills to critically analyse the alcohol advertisements that they are surrounded by and was therefore relevant to their everyday lives. Again, the additional data sources confirmed the identified theme. About half of the students identified a media literacy skill as the most important component of the program.In the context of this study, the students were equipped with skills that translated to their everyday lives.In the pre-interviews, all five teachers noted that the program would be easy for a classroom teacher to implement due to its structured and detailed nature. In the post-interviews, all six teachers expressed confidence that they would be able to implement the program as is, with just a few small adjustments to suit the needs of their classes. These adjustments may include providing additional support for a student with specific learning needs to reduce the complexity of a task and aide understanding. For example, the students may be provided with a partially completed proforma for analyzing alcohol ads, where the persuasive techniques used in an advertisement are listed and the student provides examples of the techniques.It was really detailed which is really good and obviously very clear the connections that are being made with the syllabus which I think is really helpful as a teacher because as you probably know time is so precious because there’s not much of it and we struggle to fit everything in. The way that you’ve organised it, as I said before, flows, so going from one activity to the next, each following week, I think they’ll sort of gain the knowledge as they go which will be good rather than sort of jumping around. Whereas I feel we’ve actually been involved in a few other research projects and a few of them tend to do that, they jump around a little bit rather than continually building on the information, like building the field. All the lessons up until this one prepared the students for this activity. All students were able to participate and had the prior learning required to make the counter-ad. [Teacher observation of lesson 9]In the pre- and post-program interviews, the teachers also noted that the program aligned well with outcomes from both the English (Language Arts) and PDHPE syllabi. The teacher observations and researcher reflective journal affirmed that the program was structured in a way that made it manageable to teach.In the current study, strong program alignment with the school curriculum and adequate detail were considered valuable components of a school AML program.I think it was pitched definitely at the right level. I think they were able to understand all the concepts and everything pretty well. One of the best features I liked was your exit slips, I thought that was a really good idea, for them to refocus at the end of the lesson, but also for you as an evaluation tool, ‘did they get what I was hoping to achieve?’ I really like that idea. I think I might use that myself. Loved the post-it note strategy! Great assessment for learning [Teacher observation of lesson 2]In the post-program interviews, all six teachers reported that they believed the students had achieved the intended learning outcomes due to the developmental appropriateness of the activities. The researcher’s reflective journal also noted that the majority of students appeared to be grasping the intended learning outcomes for each lesson. In either the pre or post-program interviews, four out of the six teachers commented positively about the opportunities that the assessment tasks afforded to provide feedback on student learning, refine teaching practice and report on whether learning outcomes have been met.Including assessments throughout the program allowed the implementer to continually assess whether the students were grasping the key concepts and provide further scaffolding where needed.The counter-ad was fun because we could expose the truth You’ve obviously tried to use a lot of teaching strategies, not just one way of doing things. The visual literacy stuff is really relevant…and anything in terms of designing stuff the kids love. Because there was a lot of visual, there was a lot of discussion, speaking and listening, there was a lot of communicating going on…it covered all learning, some children like tactile, some children like visual, so it covers all those learning needs. The role play was a good way to engage students. [Teacher observation of lesson 3]In the pre and post-program interviews, all of the teachers noted that the students were involved in the learning experiences due to the hands-on and interactive nature of the program, providing examples from specific lessons. This was reinforced by the teacher observations and the researcher reflective journal. In the post-program interviews, five of the six teachers identified the creation of the counter-ad, where students changed aspects of an advertisement to reflect a truth about alcohol that was not shown in the original ad, as the most engaging component of the program for the students. In the student program evaluation, the majority of the students identified the hands-on activities, in particular the counter-ad creation, as the best part of the program.The counter-ad activity was particularly engaging as it involved the students in creating text that challenged the messages presented in alcohol advertisements.I suppose one challenge might be because it is talking about alcohol, you may get some kids saying some things…my brother likes to go out and drink, that sort of thing. I’ve got one boy who’ll look to be cheeky whenever he can… like the picture of the girls towards the end there I thought was tastefully appropriate, you could get definitely worse pictures than that, but I’m sure he’ll find something funny to say about it. In the pre-program interviews, four of the five teachers flagged the sensitive nature of the alcohol topic as an issue to be mindful of, particularly around student disclosures.The teacher observations and researcher reflective journal did not note any issues arising from the sensitive nature of the alcohol topic as the program was being implemented. Furthermore, alcohol topic sensitivities were not raised by any of the six teachers in the post interviews, suggesting that it was not a significant issue in the current program. The topic was approached in a way that connected to the students’ lifeworlds, using the advertisements that they are surrounded by as a springboard for exploring problematic alcohol usage. While the topic is sensitive, it is mandated in the school curriculum. The schools and teachers were therefore in agreement that the topic needed to be taught to the children. The advertisements included in the program were carefully selected and only those which students would have already been exposed to were included. For example, it was decided to not include alcohol brand pages on Facebook given that the students are below the legal age for Facebook usage.No [major challenges]. Probably the challenges I saw were more from the point of view of the kids not being used to your teaching style and you not knowing them as well. There were a few that might have had a bit of difficulty…they struggle to pay more attention…but that’s more them, not so much the content you were teaching, because I know what their behaviour is normally like… The students seemed engaged throughout the whole lesson. They were a little fidgety towards the end, maybe an “out of seats” activity could have helped engagement. In the pre and post-program interviews, none of the teachers foresaw any significant challenges in implementing the program, although they flagged the usual everyday classroom management challenges, and the challenge of the implementer not knowing the children. The teacher observations and researcher reflective journal also noted everyday classroom management challenges.Classroom management issues will always be present to an extent, however they can be minimised through implementing the aforementioned pedagogical considerations. As highlighted by one of the teachers, some classroom management issues may be alleviated by the regular classroom teacher implementing the program as they have a thorough knowledge of individual student needs and capabilities.Time. Just time, like everything else. It’s one of those things that things happen, days happen…that just take away from your time and just to get through every single thing, may or may not be an issue depending upon what else is going on in the school. I think being in fourth term, there’s so much going on. In a way in Year 5 it is good because they’re a bit more mature, Year 6 maybe earlier, maybe third term heading towards high school. In the post-program interviews, two of the six teachers identified lack of time as a potential barrier to implementation due to the competing demands present in elementary school.For the current program, each lesson addressed outcomes from two curriculum areas. This integration of subject matter also afforded more time and flexibility for teaching the program.This study evaluated the process and implementation of Media in the Spotlight, an interactive AML program created for a specific cultural context. The study aimed to provide a pedagogical framework for health professionals implementing culturally responsive programs in school settings. In a time of significant curriculum change and competing demands for elementary school teachers , it is vOverall, the program was well received by the teachers and feedback suggested that they were open to a cross disciplinary approach to alcohol prevention in schools. The teachers did not report any significant inhibitors to implementation apart from classroom management issues and the time constraints imposed by an overcrowded curriculum. The issue of time constraints in an “overcrowded curriculum” is commonly cited as a problem for teachers , 48. HowThe teachers also expressed confidence in being able to implement the program themselves due to the program’s structured and comprehensive nature. A well-structured program that is achievable, interactive and relevant for students will also keep students engaged and reduce the likelihood of classroom management issues , 50. GivThe qualitative data sources indicated that the program was enjoyable and acceptable to the students, with the hands-on activities identified as a key strength of the program. This finding is supported by education learning theories such as constructivism which posits that students learn through constructing knowledge and meaning from their experiences . FurtherUsing culturally bound advertisements as an entry point to learning about alcohol proved powerful, as it connected to the students’ life worlds  through There are several limitations that should be considered when interpreting the results of this study. The teacher process evaluation data was collected from six teachers in four schools and therefore may not be representative of the wider teaching population, although opinions do represent a range of teaching experiences from early career to highly experienced teachers. Additionally, there may have been a bias against negative disclosure as the interviewer was also the intervention creator and deliverer. However this may have also helped disclosure as the interviewer had developed a rapport with the teachers. Cultural considerations may need to be more narrowly defined to specific regions within a country. Media in the Spotlight was developed, implemented and evaluated in an area with a high percentage of white Anglo-Saxon Australians. In other areas of Australia with more diverse ethnicities, the cultural considerations may differ. Nonetheless, the principles from the pedagogical framework can be applied to other contexts.There are significant benefits in early prevention , where i