The adulteration of the illicit drug supply with fentanyl and its analogues is driving the ongoing overdose crisis in North America. While various harm reduction interventions address overdose-related risks, there is growing interest in safer supply programs, including the MySafe Project which utilizes a biometric dispensing machine that provides pharmaceutical opioid alternatives to the toxic drug supply. However, the experiences and perspectives of professional community partners on program implementation remain unexplored. This study aims to examine professional community partner perspectives on the feasibility, as well as barriers and facilitators to the implementation of the MySafe program.Semi-structured qualitative interviews were conducted with 17 professional community partners involved in program implementation across four pilot locations in Canada. Thematic analysis of interviews focused on perspectives on safer supply, barriers and facilitators faced during program implementation, and recommendations to inform future scale-up of low-barrier safer supply models across Canada.Participants identified a variety of barriers, including the dependence on clinician buy-in, coupled with regulatory and logistical constraints. In addition, some participants perceived hydromorphone to be an inadequate substitute to the increasingly toxic street opioid supply. Lastly, technical difficulties were described as barriers to service uptake and delivery. Conversely, having political and community buy-in, availability of wrap-around services, and collaborative communication from the MySafe team served as facilitators to program implementation. Though community partners preferred establishing MySafe machines into existing community organizations, they also discussed benefits of housing-based MySafe programs. The potential role of this program in mid-sized to rural cities was also emphasized.To address the overdose crisis, there is an urgent need to implement and evaluate novel solutions that address supply drivers of crisis. Community partner-informed research plays an integral role in ensuring program acceptability and proper implementation. Our findings identify current gaps and facilitators underlying the efficacy of one such model, together with future directions for improvement. Participant recommendations included a diversification of medications offered and types of locations for MySafe programs, a streamlined national approach to prescribing guidelines coupled with more robust training for healthcare professionals, and an emphasis on service delivery within an integrated services model. Our findings underscore a potential gap between the goals of healthcare providers in ensuring comprehensive care and the necessity for low-barrier models such as MySafe that can function both within and outside of integrated service models. Canada is grappling with an ongoing overdose crisis driven by an illicit drug supply of both increasing potency and variance, greatly exacerbating drug use-related risks and harms to people who use drugs (PWUD) , 2. A raFollowing the promising outcomes of randomized controlled trials demonstrating the effectiveness of injectable diacetylmorphine and hydromorphone in Canada , 13, injExisting safer supply literature primarily accounts for the perspectives of PWUD enrolled in safer supply programs in Canada, which is integral for ensuring relevancy and acceptability of public health measures. While there has been a recent study capturing professional community partner perspectives on safer supply in the context of COVID-19 pandemic , no studIn December 2021, the MySafe program was piloted across Canada as a means of providing a low-barrier, regulated, and safer supply of opioids as a response to the increasingly adulterated and inconsistent illicit drug supply. The first of its kind, this biometric machine dispenses tablet hydromorphone on a pre-determined schedule, with machines currently located within either housing-based or community organization-based settings  . The usen = 17) involved in the design, proposal, and implementation of the program. Professional community partners included clinicians  (n = 7), program managers and executive directors (n = 7), and political and health authority representatives (n = 3). Interviews focused on perspectives on safe supply, barriers and facilitators faced during program implementation, as well as recommendations to inform the future scale-up of the MySafe Program specifically and low-barrier safer supply models more generally across Canada. At the time of data collection, only one of the four pilot locations was operational, while the others were in early implementation stages.This study employed a qualitative approach and was conducted as part of a larger evaluation of the MySafe program. Our study draws on semi-structured interviews with key professional community partners (n = 6) and Victoria (n = 4), British Columbia; London, Ontario (n = 2); and Dartmouth, Nova Scotia (n = 5). AFM and GB outlined study objectives and eligibility criteria via an enrollment script sent to the MySafe program staff, who then forwarded this email to a list of relevant parties that played key roles within program implementation based on their expertise and degree of involvement across all the aforementioned sites. The list included community partners that were directly involved in day-to-day operations  as well those who were positioned to enact systems-level change in the larger context within which such safer supply models exist . Participants self-enrolled in the study by contacting the study team directly. Participation in this evaluation was voluntary, and a research team member was available to answer any queries prior to study enrolment. Participation in this evaluation was voluntary, and a research team member was available to answer any queries prior to study enrolment. All participants provided written, informed consent prior to the commencement of each interview, and their data were anonymized upon collection. In addition, due to the small sample size of this study, participant locations are not specified for any quotes included within this publication in an effort to maintain confidentiality.Recruitment was purposive and done primarily through MySafe program staff members at each of the initial implementation sites: Given the broader policy context of a lack of a streamlined national approach to the application of prescribing guidelines within Canada, the implementation of the MySafe program was driven largely by professional community partner buy-in and their sustained engagement, especially that of clinicians. There was a broad consensus among study participants that continued reliance on clinician support for program uptake presented a significant barrier to its implementation. Participants identified several concerns with the overreliance on clinicians. Firstly, as prescribing guidelines are left open to interpretation by the regulatory Colleges, program access hinges on individual prescribers’ attitudes toward safer supply and harm reduction. Conservative understandings of the guidelines restricted equitable access of safer supply medications to PWUD in certain jurisdictions. According to one program manager:not [being] set up to be as good financially for the pharmacies” (S9—program lead). It was also reported that prescribers wanted to avoid reproachment from their respective regulatory Colleges that may impact their licensing ability if they engaged with the program. This led to hesitation among clinicians and pushback from the association of pharmacies in some jurisdictions as this program was perceived as diminishing their reach, as illustrated in the following quote:I think the pharmacies are interested in the technology but they’re battling with the fact that they don’t want to be sanctioned by the Colleges either and the Colleges don’t want these machines there. The other pushback from the association of pharmacies is they have a lot of concerns that these machines will replace the pharmacist and things, so that’s kind of an existential threat that MySafe obviously doesn’t, MySafe isn’t going to do that (S9—program lead)Secondly, some participants who were onboarding pharmacies for the provision of safer supply medications for MySafe machines were met with reluctance and fear of collaborating with a safer supply program. Some participants noted that this was due to the MySafe program “Some of the challenges I think are that it disconnects the access to that medication or product from the rest of the person… a lot of people are on various medications, daily [dispensed] or otherwise… so, it becomes sort of less clear, …what the advantage is to separating that… from going to the pharmacy because there would be concern that people would maybe, “Oh, I’ll just go to that machine and just get my Dilaudids  and I’ll ignore my other medications that are at the pharmacy,” or vice versa Lastly, some health authority participants felt that the MySafe model disconnects program participants from holistic and integrated healthcare approaches. Given that many PWUD live with co-morbidities, several professional community partners preferred the pharmacy or community-based health services model because there was concern that program participants may begin prioritizing their safer supply medications over those for other illnesses if the machines were placed in non-clinic-based settings. By isolating the machines in such settings, there was concern that it would disrupt existing connections with care providers and silo program participants away from other available health and social supports. One participant explained:As a result, many participants who were health authorities felt that the machines should be integrated into well-established community-based pharmacies or harm reduction organizations for maximal benefit.There’s regulatory challenges with it [MySafe implementation] because the College of Pharmacies is really particular around dispensing and holding of medication, as they should be, but it’s created some challenges…We worked with Dispension  for a few months, worked with our partners at [the pharmacy], made it really clear that we couldn’t, we don’t have the policies or the proper structures in place to house narcotics… So then we found ourselves with a barrier. (S15—program lead)Varying levels of policy challenges were encountered by a number of participating sites, who at the time of data collection, had yet to successfully implement the MySafe program. In one location, regulatory restrictions around the dispensing and storage of controlled substances in non-pharmacy-based settings impeded program roll-out:But as soon as it came to the actual owner of the hotel, it was immediately shot down. They don’t want to promote drug use in the sites. Just pure ignorance. (S12—clinician)Furthermore, having regulatory, political and clinician support was at times insufficient if there were on-site logistical constrains such as reluctance on part of property owners or management to house the machines. Private property owners that were not acquainted with harm reduction approaches perceived these machines as normalizing and promoting substance use and thus pushed back against such initiatives. These structural barriers limited the reach of MySafe programs in residential settings:very forward-thinking” (S5—program lead) by professional community partners from smaller cities when comparing their respective local contexts. Participants felt that implementation of MySafe was not going to be effective if done in the same manner in all locations without accounting for the unique local and provincial contexts. For example:Barrier is lack of understanding for the context, right? Like just thinking that because it works one way in B.C., that it’s going to work that way everywhere else. And I mean, it just isn’t… I feel like every meeting I have, I have to explain the provincial context, and explain why it’s the best position here. And so, I feel like I’m constantly having the same conversation, time after time after time (S5—program lead)Several participants also felt that while the current model may apply well in certain settings , it failed to account for the unique needs and constraints of others . Large urban cities such as Vancouver were perceived to be “Instead, tailored implementation specific to each community’s needs was seen as essential for feasible and successful roll-out of the program.“very loose” eligibility criteria (S9—MySafe lead/clinician), access to the program was limited by differences in enrollment criteria between sites. In one location, there was reportedly pushback in enrolling those with certain comorbidities such as liver or kidney conditions whereas this exclusion criteria did not apply for other forms of opioid agonist therapy . Participants from another location reported that PWUD who were already accessing OAT were ineligible for MySafe program enrolment, as illustrated by the following excerpt:This is what we encountered when safer supply first started and the Colleges were telling people … [that] because they’re already on OAT so why would they need Dilaudid for safe supply? But again, …take your therapeutic hat off, put your harm reduction hat on. He’s already using off the street. We already have heroin testing positive in his urine so OAT is not working well enough for him or her. So why would we say to them “No, keep on using dirty street drugs.” It doesn’t make any sense. This is a person who’s already engaging in care with you… saying “Hey, I want to try and get off my stuff but I’m having a hard time”… We should be saying “Do you need this in addition to your OAT?” (S11—clinician)While the MySafe program is intended as a low-barrier program with “what’s in it should be dictated by what is being requested” (S8—program manager). Another participant explained further:If this was 2015 and just at the beginning of the emergence of fentanyl in the drug supply, the MySafe machine would probably have been this amazing tool that we could use. And now, however, we’re 6 years later and people’s tolerances are so high that they’re not really being met by tablet safer supply and there isn’t going to be a doctor in the world that’s going to prescribe injectable solutions via a vending machine. (S16—clinician)In addition, hydromorphone was considered by some to be an inadequate substitute to the increasingly toxic unregulated drug supply. As noted by a study participant: As a result, numerous participants called for a diversification of medication offerings in the MySafe program to ensure relevancy and perceived it as a facilitator to program engagement.ranging from software updates that never happened to mechanical jamming of the medication cartridges in the vending machine” (S16—clinician) were identified by many participants as a critical challenge. Professional community partners from an operational MySafe site reported frustration among program participants due to persistent technical problems to the point that some opted to re-enroll in pharmacy-based programs. Technical support was provided by the dispensing machine company; however, support tended to be limited by differences in time zones. For example:There was one day where a dose got stuck in the machine. And nobody on site had a key to open it. I think they had to contact the pharmacy and the pharmacy was busy so they had to contact the nurse who did the deliveries and she was on outreach… you don’t want to have everybody being able to open the machine up but you need to have access for things like that… I mean there have been a number of software glitches, with difficulties registering, difficulties with affecting the biometrics… (S12—clinician)During initial implementation, frequent technical difficulties “Participants pointed to the shortcomings of having medication dispensation that was mediated by technology as opposed to staff relied heavily on the software working reliably each time as a barrier.community willingness to work outside the box” (S13—program manager) to incorporate novel and innovative mechanisms for healthcare delivery was considered an essential prerequisite at different stages of program roll-out. In this regard, larger urban centers experienced a smoother and easier process integrating MySafe programs as there was a greater understanding of harm reduction and a higher willingness and ability to fund such initiatives. For example:Several pharmacies [were] very willing and very helpful… partly because they were already involved. Like they already were working with one or two other programs around doing this type of work, so I think… it was easier in a bigger city where there’s pharmacists who are already doing addictions type work and are pretty familiar with the substances. (S1—program lead)To ensure smooth implementation of the MySafe program, it was reported that having political and community buy-in alongside adequate funding was instrumental especially during the initial phases of setting up the program. Having “It’s very controversial, right? Like a lot of people, like the Health Authority… they just had this idea that people just walk up to the machine and put their hand out… there was no involvement of a physician… because that’s the way it was like highlighted in the media… But that’s not what it is… I’ve had to explain I don’t know how many times, like this is still a medical model… people still have to be assessed by a doctor. They’re still going to have to do a certain amount of urine drug screening. You know, they’re still going to have to have contact with people… so that has been a downside of it, is because especially in a province that doesn’t have safer supply, to then come out with this big hoopla machine (S5—program lead)Conversely, relatively smaller urban settings tended to have scarcer resources, fewer prescribers, and more conservative approaches to substance use. As a result, professional community partners from these areas highlighted the varying levels of structural barriers encountered when trying to introduce MySafe programming into their existing continuum of care. According to this participant from a smaller city:The political will to fund safer supply initiatives coupled with support from local prescribers and property management to house MySafe machines played a key role in determining program roll-out.As far as I understand the proposed kind of model of care might look a little different in each city but would generally involve the peer support workers and nursing support and then prescribers and case manager and that kind of thing (S7—clinician)Participants identified access to additional wrap-around services as a key facilitator to implementation and felt that it bolstered program uptake and efficacy. Embedding MySafe machines in established community organizations such as SCS, community clinics, or other harm reduction services would provide program participants with further linkages to support along the continuum of care. Many professional community partners felt that the availability of such supports in close proximity of the machine would have a positive cascading impact on other key determinants of health such as housing and employment, as well as direct impacts on drug use-related risks. As one participant explained:We didn’t ever expect the [funding] to come through, so I think having that has been awesome… So I think when we [were] talking it up with neighbours and the city and stuff, like it was really like, “Hey, like this is providing this service but it’s not alone.” I think most people’s fear was we just got a vending machine… and be isolated but I think we’re pointing out, hey, like we got a lot of staff time associated with this and actually give staff more time to do the work that they ought to be doing, which is having the conversations and all that. So, I think that that tie-in is massive (S1—program lead)Furthermore, there was broad sentiment that having program participants frequent MySafe sites with wrap-around services available daily would allow for greater rapport between staff and program participants promoting more positive health outcomes. For example:Having MySafe machines nested within existing community organizations with pre-established wrap-around services would enable professional community partners to secure funding and support from physicians and regulatory bodies as it alleviated concerns around the MySafe model deviating from holistic healthcare approaches.The operations manual and like all of the instruction like the support that has come from MySafe Society has been great… when we sent the manual to our physician initially who agreed to prescribe, like it was all very straightforward to him and he didn’t have any concerns about it… I think because there were resources available to them, like here’s the instruction manual and… here’s a pharmacist you can call in Vancouver who can talk to you about their experience with it. (S14—program manager)Several professional community partners from operational sites highlighted a high degree of responsiveness to troubleshooting requests, resource sharing, and access to technical support resources that allowed for a seamless collaboration between site staff and the MySafe Society. As discussed previously, frequent technical difficulties were reported with the machines at an operational site; however, these challenges were mitigated with responsive communication with the MySafe team. It was noted by participants that the MySafe Society conducted frequent check-ins, including site visits, and provided opportunities for information sharing between staff at different MySafe locations. Their support resources were also considered concise and relevant which allowed for community partners such as prescribers and site staff to understand and incorporate the program into their practices with ease. These streamlined efforts contributed to a conducive environment for program implementation and were considered a key strength of the MySafe model. According to one participant:These resources and efforts served to mitigate some of the technical difficulties encountered as well as to help secure the buy-in of clinicians—a necessary prerequisite for program enrollment.Aside from describing implementation barriers and facilitators, participants also discussed their perspectives on what types of settings would benefit from a program like MySafe. For example, they highlighted that having not one but several machines across a variety of settings would be a salient determinant of program uptake. In order to ensure acceptability across different contexts, study participants emphasized that program locations should be determined on an individual basis with site-specific professional community partners. However, there was a general preference to embed MySafe machines into trusted services that already exist in communities , both as a means of securing political and community buy-in as well as providing wrap-around services to promote holistic approaches to the healthcare of PWUD who often live with comorbidities. This would also help bypass policy barriers faced by housing providers regarding onsite program implementation.…if you have it in the pharmacy then you might as well just write the order as daily dispense and then the pharmacist can talk to the patient and have that conversation and build that rapport…The only advantage that I can see [of] having it in a pharmacy is that we already have pretty significant security because of what we store…Most pharmacies aren’t open 24 hours. And again, we’re dealing with clients who might be out all night partying and doing stuff and then they sleep during the day and they don’t get up until 5:00 at night so how is that gonna be helpful if you’re putting into a pharmacy? Even if they say close at 9:00 pm which is pretty late in my mind. That might be pretty early for my patients. (S11—clinician)Both SCS and pharmacy-based settings had similar benefits in that they had existing managerial staff and security, and established ties with the target community. However, both these settings lacked the ability to offer 24-h access to medications and were not accessible to those with transportation or geographical constraints, which were identified as critical barriers to access for PWUD. In addition, professional community partners reported that pharmacy-based settings may potentially negate the low-barrier aspect of the MySafe model due to stigma attached with medicalized settings. According to one participant:“allows one doctor to support 40 or 50 people” (S8—program manager), thereby allowing for areas with low prescriber availability or buy-in to have avenues for safer supply access. However, geographical restrictions may hamper proper implementation in rural settings due to the dispersed distribution of PWUD across vast distances  highest fatal overdose rates are, which is like Timmins and Porcupine, Thunder Bay, Sudbury, people are spread out at a very wide area. So one machine, which is typically, I think, what most agencies could hope to afford at this time, is just not going to do it. (S17—clinician)Housing-based settings addressed some of these challenges, namely the provision of unrestricted 24-h access, safe storage within residence, and involved no travel for the people that lived there. However, the transient nature of people staying in supportive housing-based settings raised concerns about what access would look like in the event of an eviction or a move-out. Additionally, some participants argued that such a model disconnected program participants from other supports and medications that could be accessed from clinical settings. Lastly, many community partners considered the potential of this program in small to mid-sized cities as especially impactful due to the ability to scale up cost-effectively in places with limited resources and support. Having even one machine istances . As one While the program holds potential for scale-up in mid-sized to rural cities, funding challenges and political was reported as a potential barrier within these settings.This qualitative study examined the perspectives of professional community partners on the feasibility of, and barriers and facilitators to, the implementation of the MySafe program across four initial pilot locations in Canada. Our findings highlighted several barriers to program roll-out: the continued reliance on clinician buy-in for program uptake, provincial and regional restrictions resulting in inequitable program access, and the perceived inadequacy of hydromorphone to meet the needs of PWUD coupled with technical difficulties with the machine. Conversely, professional community partners identified several key facilitators, including: the provision of wrap-around services alongside a MySafe machine, securing political and community support of the program, and having a collaborative and communicative working partnership between local community partners and the MySafe Society. In light of these identified barriers, participants shared several recommendations for improvement, emphasizing consultation with local community partners to promote program relevancy to their individual contexts. Moreover, embedding machines within trusted community organizations and diversifying medication offerings and program locations to include housing-based settings were proposed as possible improvements to service delivery.Our study findings speak to the importance of community partner involvement in program design and implementation given that plans for two of the four pilot sites included in this study did not materialize. As of August 2022, implementation went forward in Vancouver and Victoria, British Columbia, whereas the program never became operational in London, Ontario and Dartmouth, Nova Scotia, reiterating participant narratives around greater ease of implementation in large, urban cities compared to smaller urban settings. Past implementation science research has supported the role of context in determining program impact, advocating against a one-size-fits all approach in the development of public health interventions –40. The Study participants showed a strong preference for the MySafe machines to be embedded within other community supports as a way to connect hard-to-reach populations to a continuum of care . The existing literature attests to the benefits of integrated service models in engaging PWUD in overall health-promoting behavior and securing community support , 58. ForIn a qualitative study investigating attitudes of PWUD toward embedding buprenorphine treatment at a syringe service program, there were reportedly mixed feelings about the enmeshing of the two related but distinct services . For exaMoreover, access to the MySafe program would vary considerably depending on each jurisdiction’s existing regulations and clinician buy-in. Participants considered this a significant barrier that manifested into a range of challenges for program uptake such as an inconsistent eligibility criteria and low clinician willingness to onboard participants onto the MySafe program at some sites. Due to Canada’s decentralized healthcare system characterized by the autonomy of provincial governments in allocating funds and delivering healthcare services, a pervasive lack of standardization of drug policy and prescription guidelines has contributed to inequitable access to available supports. This points to the need for a coordinated roll-out of future guidelines across all Colleges paired with robust training of clinicians involved in the delivery of substance use care. Furthermore, provincial mechanisms such as health orders could be enacted to provide security and assurance to clinicians providing access to safer supply in order to safeguard them against repercussions from their respective Colleges. Given the concerns around the inadequacy of hydromorphone, existing and future safer supply programs need to adapt their medication offerings in congruence with the needs of the local context that should include access to diacetylmorphine, including inhalable options , as wellOur study has several limitations. Firstly, participant views represent a snapshot of the perceived barriers and facilitators primarily at pre-implementation or early implementation stages of the MySafe pilot program. Since some of the pilot locations did not progress toward becoming operational, other influential factors may not be adequately captured by our findings. Secondly, the professional community partners that participated in the study were all involved with the MySafe program in some capacity and may therefore hold a more positive bias on safer supply programs. The views reported in this study may not be representative of professional community partners with more traditional or conservative perspectives on substance use. Future research should focus on the perspectives of a diversity professional community partners to understand potential barriers and facilitators. In addition, the perspectives of PWUD on program design are not captured within this dataset. However, these will be explored in future publications from our larger evaluation of the MySafe program.In conclusion, as the overdose crisis evolves with the continually changing unregulated drug supply, the need for additional novel and innovative responses has grown as existing avenues of overdose prevention remain limited and under-utilized. Our findings include valuable insights and recommendations from professional community partners. Community partner-informed research plays an integral role in ensuring program acceptability, implementation, and future rollout of public health interventions, including safer supply programs. Our findings identify current gaps and facilitators underlying the efficacy of one such model, together with perspectives that can be used to inform future policy and best practices in implementing the MySafe program and similar iterations of low-barrier safer supply models across Canada.


Some children of parents with mental illness need support. This study aimed to develop and test the effectiveness of an e-learning program for training elementary schoolteachers to support children of parents with mental illness.The program, which included a 30-min video-based e-learning program, aimed to help schoolteachers gain basic knowledge about mental illness and children of parents with mental illness, recognize children in need of support, and gain confidence in supporting them. A school-based cluster randomized controlled trial was conducted, and the schools were randomly divided into intervention and control groups. The teachers at these schools signed up for the program and participated individually. The outcome measures for the schoolteachers were evaluated at three time points: baseline (T1), post (T2), and one month later (T3). Along with the Sense of Coping Difficulty subscale (primary outcome measure), the following self-developed outcome measures were used: actual behaviors and attitude toward supporting children, knowledge, and self-assessment of program goals achievement. The Sense of Coping Difficulty subscale results at T3 were compared between the groups. Effectiveness over time was assessed for all the outcome measures. The interaction between baseline and intervention effects on the Sense of Coping Difficulty subscale was analyzed. As a part of the process evaluation, open-ended text responses were analyzed qualitatively.p = 0.007). Over time, a significant effect was observed on the Sense of Coping Difficulty subscale, actual behavior, knowledge of onset timing and probability of onset, and achievement of all program goals. Exploratory analysis was particularly effective for those who encountered a high level of difficulty in supporting children. The participants’ text responses indicated that they planned to look carefully at children's backgrounds and stay close to them in the future.Baseline responses were collected from 87 participants in the intervention group and 84 in the control group. The total score of the Sense of Coping Difficulty subscale at T3 was significantly lower in the intervention group than in the control group (The program was effective for schoolteachers in supporting children of parents with mental illness.UMIN000045483; 14/09/2021. Mental illness is an important public health issue affecting many people, with one in five Japanese individuals reportedly being affected during their lifetime . The perIn Japan, it has only been about 15 years since the existence of children raised by parents with mental illness became known to society . In receEven if the children themselves are caring for their parents or struggling with family matters, they are often reluctant to seek help because of stigma . A similPrograms for improving schoolteachers’ mental health literacy have already been developed; many of these have induced improvements in schoolteachers’ knowledge, attitudes, and confidence in supporting the mental illness of students . Mental In Japan, 50-min video material has been developed for schoolteachers to improve their mental health literacy . SpecifiThis program aimed to help schoolteachers gain basic knowledge about mental illness and children of parents with mental illness, recognize children in need of support, and gain confidence in supporting them. In mental health literacy education aimed at schoolteachers, their knowledge regarding mental illness and confidence in supporting students in need of support often indicate a program’s effectiveness . In addiA school-based cluster randomized controlled trial (RCT) was conducted to test the effectiveness of the program. Contamination of the information provided across groups within the same school may have occurred. Therefore, the RCTs of schoolteachers could use schools as clusters . The schThe program, which was offered online on an individual basis, could only be watched by the intervention group. The outcome measures were evaluated using a self-administered web survey by comparing the two groups at three time points: baseline (T1), post (T2), and one month later (T3). Ethical considerations allowed the control group to participate in the same program after the final T3 response. No major changes were made to the methods after trial commencement. The trial findings were reported in a subsequent publication in accordance with the Consolidated Standards of Reporting Trials (CONSORT).Requests for research participation were sent to 322 public elementary schools in three Japanese prefectures. Only schools that were willing to cooperate were included in the study.A maximum of 10 schoolteachers participated from each school. The inclusion criterion was full-time schoolteachers, and the exclusion criteria were difficulty in understanding Japanese and being unable to conduct web surveys or operate video watching. The sample size was determined with reference to 50-min video programs for improving schoolteachers’ mental health literacy in Japan , 25. TheThe program was called the WATASHI-KOKO (“We are here” in Japanese) PROGRAM. It involved a 30-min video-based e-learning program for elementary schoolteachers, which was designed to help them support children of parents with mental illness. It aimed to help schoolteachers gain basic knowledge about mental illness and children of parents with mental illness (Purpose 1), recognize children in need of support (Purpose 2), and gain confidence in supporting them (Purpose 3).The program was created with the support of “KODOMO-PEER” (“children’s companions” in Japanese), which is the largest self-help group for adult children of parents with mental illness in Japan. The program content was created based on a childhood needs survey that received responses from adult children of parents with mental illness . First, To gain basic knowledge about mental illness Purpose 1), the program content was created with reference to previous research on a mental health literacy education program for schoolteachers , 27. The, the proTo gain basic knowledge about children of parents with mental illness Purpose 1), the program content was created based on a survey that received responses from adult children of parents with mental illness . The sur, the proTo help schoolteachers recognize children in need of support (Purpose 2), the program content was developed based on the survey that received responses from adult children of parents with mental illness . In the To help schoolteachers gain confidence in supporting children in need of support (Purpose 3), the program content was developed based on the survey . In an oTheoretically, the program content was also based on a four-tiered approach for delivering professional development programs related to parental mental disorders . In thisIn accordance with the learning process, the content structure of the program was based on the Transtheoretical Model (TTM) of health behavior change by Prochaska et al.  and GagnGagné’s instruction is an effective process when teaching others . The leaThe specifics of the program are shown in Table The outcomes were measured at the individual level. The questionnaire was developed by multidisciplinary experts who were research members of this project. The pre-test was conducted among 18 elementary schoolteachers. After watching the video of the program, they were asked to answer the questionnaire and also asked to indicate any points where they had found it difficult to understand sentences or words. Consequently, a few points were raised by the schoolteachers, and some of the wording was corrected.The Sense of Coping Difficulty subscale was used to assess confidence in supporting children (Purpose 3 of the program). The Sense of Coping Difficulty/Possibility Scale refers to analogous concepts of self-efficacy, which is the expectation that professionals can deal with difficult situations , 33. TheThree self-developed questions were used at T1 and T3 in order to assess the effects of program Purposes 2 and 3 on behaviors and attitudes. The program introduced the life situations of children in need of support and highlighted certain signs to look out for when identifying such children. The first question asked schoolteachers whether, over the past month, they had looked at children with the perspective that they could be children in need of support. The second question asked schoolteachers whether, over the past month, they had recognized the presence of a child(ren) in need of support. The program recommended that schoolteachers who had recognized a child in need of support first consult with other teachers in the school instead of worrying about the situation by themselves. The third question asked schoolteachers whether, over the past month, they had consulted other schoolteachers within the school about a child(ren) in need of support. The schoolteachers responded to these questions using “yes” or “no” options.Knowledge questions, with responses that could be correct or incorrect, were administered to the schoolteachers; they were developed in order to assess program Purpose 1 . The five items related to parental mental illness were lifetime prevalence of mental illness, types of mental illness, age of onset of mental illness, difficulties of living with people with mental illness, and mental health and welfare life support services. The five questions related to children were about the percentage of children with parents having mental illness, children's own awareness, counseling, impact on health, and the common roles of young carers. Some of the items were based on previous research on mental health literacy education , 27, 34,The degree to which the participants had achieved the eight items representing the program goals was measured using a seven-point scale ranging from “not at all” (1 point) to “very well” (7 points). The following goals were set as an assessment for achieving program Purpose 1: 1) be able to describe the impact of parental mental illness on children’s lives, 2) be able to describe children’s feelings, and 3) be able to describe the significance of school for children. The following goals were set as an assessment for achieving program Purpose 2: 4) be able to recognize children in need of support. The following goals were set as an assessment for achieving program Purpose 3: 5) be able to describe how to support children, 6) be able to act appropriately toward children, and 7) be able to act appropriately in school. Professionals’ negative attitudes regarding parenting with mental illness can hamper support provision . TherefoThe process and feasibility evaluation measures were as follows: program satisfaction ; whether the participants would recommend the program to other schoolteachers ; length of the program ; what the participants learned was new (yes/no); if yes, what was impressive (open-ended text response); whether their way of thinking had changed (changed/not changed); if so, how it had changed (open-ended text response); and how they planned to act (open-ended text response).The basic characteristics included age, gender, years of experience, job title, experience in special needs teaching, experience of supporting parents with mental illness, experience of supporting students with mental illness, experience of learning about mental illness, and the history of someone close, who has, or is suspected of having, a mental illness.When school-based applications were received by the research office, a random number table was prepared by a person who was unrelated to the implementation process, and independent allocations were made to either the intervention or control group in the order of arrival of the applications. After the school applications were received, the same research descriptions, which were designed for individuals, were sent to both the intervention and control groups. Because of ethical considerations and the need to ensure that the participants understood the purpose of the study, we simply stated, in the research description, that the children of parents with mental illness might face challenges. After the allocation of the schools, data managers were no longer blind.The next time any schoolteacher’s individual application form arrived at the research office, the schoolteacher was assigned to the group to which the school was assigned. The participants were guided to their allocation group after the application, and they were no longer blinded. The web surveys and the video were sent at pre-set times, using a computer research electronic data capture accumulation and management system. The quantitative data analyses were blinded to the analysis.As the primary population, the full analysis set (FAS), excluding the scores of those who did not respond to T1 from all randomized participants, was used in all analyses, except process and feasibility evaluation. The per-protocol set (PPS), which excluded participants who did not respond on time, those who did not complete watching video on time in the intervention group, and those who withdrew from the study, was also defined for sensitivity analysis of the primary outcome.Baseline characteristics are summarized as mean and standard deviation for continuous variables and frequency and proportion for categorical variables. Student’s t-test, chi-square test, and Fisher’s exact test were performed for comparisons between the intervention and control groups.The difference in the Sense of Coping Difficulty subscale at T3 between groups was evaluated by a t-test on cluster-specific means. As a sub-analysis, a multilevel analysis with a mixed model was performed, with group as fixed effects, and school as random effects, adjusting for some baseline characteristics. We fitted a mixed model for repeated measures (MMRM), with group, time points  and their interactions as fixed effects, and schools and study participants as random effects.The three actual behavioral and attitude items were compared between the groups using chi-square analysis. A multilevel analysis was then conducted using a mixed-effects logistic model.For the 10 knowledge items, the percentage of correct answers for each item was compared between the groups using chi-square analysis or Fisher's exact test. The total number of correct answers was compared using a Wilcoxon rank-sum test. Mixed-effect logistic models were also fitted.For program goal achievement, the medians and interquartile ranges of the scores and the total scores for each item were calculated and compared, using the Wilcoxon rank-sum test. MMRM were also fitted.In an exploratory manner, we examined the interaction between the baseline score and intervention effects on the Sense of Coping Difficulty subscale.The open-ended text response was analyzed qualitatively as part of a process evaluation. We created classification axes based on similarity and separated them into the smallest units whose meanings could be understood . First, The missing data were not imputed. A p-value of 0.05 or less was considered significant. All analyses were performed using SAS9.4 .This study was approved by the Ethics Committee for the Intervention Study of Osaka University Hospital . Written informed consent was obtained from all the participants. This study was conducted in accordance with the principles of the Declaration of Helsinki. This project has been registered in the Clinical Trial Registry . No adverse events were reported.While filming one individual in the video, we asked her to decide whether she would like to have her face and name included in the video. She chose to show her face but not disclose her name. We notified the person in writing and obtained her consent for the study participants to watch the video.This study was conducted between October 2021 and May 2022. The flow of study participants is shown in Fig. Eighty-six participants in the intervention group and 82 in the control group completed T3. Of the 86 participants in the intervention group, 73 became PPS, excluding 8, who responded after the deadline, and 6, who watched after the deadline . Of the 82 participants in the control group, 73 had PPS, excluding nine who responded after the due date.The number of participants did not reach the originally expected number. This result was attributable to the schools’ response to COVID-19. The number of people infected with COVID-19 was declining in Japan in the fall of 2021. However, when this study began, schools reopened after the summer break; although students were able to attend school, schoolteachers were busy due to government orders to strengthen infection control measures in schools . From JaThe demographics of the study participants in the intervention and control groups are shown in Table p = 0.007) and PPS , as well as multilevel analysis using a mixed model with covariates. The effect size (Cohen’s d) of the total score was –0.90 (FAS) and –0.86 (PPS), indicating large enough.The analysis results for the Sense of Coping Difficulty subscale at T3 in the FAS and PPS are shown in Table p < 0.001). The least squares means estimated using the mixed model are shown in Fig. As shown in Table p = 0.002), whereas the other two behaviors were not significantly different at T3 in the chi-square test. The same was true for the mixed-effects logistic model results (not shown).Of the three actual behaviors and attitude, only “looked at children from the perspective of a child in need of support,” was significantly different at T3 ), “half of those affected by mental illness develop the illness by their mid-teens” (no. 6) ), and the total number of correct answers (p = 0.009). The same was true for the mixed-effects logistic model results (not shown).Of the 10 knowledge items, those effective up to T3 were “mental illness affects 1 in 5 people in their lifetime” (no. 1) : for those with lower scores (lower difficulty), there was no significant difference between groups (p = 0.812); for those with higher scores (higher difficulty), the intervention group had a significantly greater effect than the control group (p = 0.001) as shown in Table In an exploratory manner, an analysis of the interaction between baseline and intervention effects on the Sense of Coping Difficulty subscale found a significant interaction , "just right" (60 participants), and "short" (0 participants).In terms of “what you learned was new in the program,” 82 answered “yes” and 4 answered “no.” Among those who agreed, Table Regarding “whether your way of thinking has changed,” 60 felt that it had, while 26 felt that it had “not changed.” Of those who got “changed,” in order of preference, 19 "want to stay involved with the children," and 16 wrote, "view of the children's background.”Regarding “how you plan to act,” the most common responses were, in descending order, "look carefully at the children's background," written by 22 participants, "continue to stay close to the children," by 20, and, "try to be aware of children in need of support,” written by 19. Related to the school's organizational response, some responded, "entire school responds, not just individuals," "share with the entire school, not just individuals," "create a safe environment at school," and "share with other schoolteachers.”The intervention and control groups had approximately the same number of clusters and schoolteachers, with no significant baseline differences. The mean age of the study participants was 43.6 years (intervention group) and 41.1 years (control group), similar to the mean age of public elementary schoolteachers in Japan, 42.6 years .Additionally, 55.2% (intervention group) and 58.3% (control group) of the study participants were female, slightly less than the 62.4% of all public schoolteachers . This maThe experience of working with parents with mental illness was common to more than half of the participants, but only about 30% had learned about mental illness. Among elementary schoolteachers who resigned because of illness, 69.1% resigned because of mental illness , thus inThe program was effective in reducing schoolteachers’ difficulty in supporting children of parents with mental illness. The effect sizes were as large as –0.90 (FAS) and –0.86 (PPS). Goal attainment was also effective for over one month. Few studies on mental health interventions for schoolteachers have been conducted using RCTs . To dateAlthough exploratory in nature, this program was found to be particularly effective for those with higher scores (higher difficulty in support) on the Sense of Coping Difficulty subscale. The program included what children appreciated about their schoolteachers, such as staying close to them and listening to them. In the analysis of the open-ended text response, many schoolteachers planned to continue to stay close to the children. Staying close to children does not require schoolteachers to develop any specialized skills in dealing with mental illness. This may have given schoolteachers the confidence to provide support.Knowledge was effective up to the T3; the correct response rate of “mental illness affects 1 in 5 people in their lifetime (no. 1),” and “half of those affected by mental illness develop the illness by their mid-teens (no. 6).” These items were objective measures of the onset timing and probability of onset. However, no significant effects were found for items not expressed numerically . Many previous programs on schoolteachers’ mental health literacy have also been effective in increasing knowledge . HoweverFor actual behaviors and attitude, only “looked at children from the perspective of a child in need of support” had a significant effect in the past month, whereas “recognized the presence of a child(ren) in need of support” and “consulted within the school about a child(ren) in need of support” had no significant effect. There were significant effects on goal attainment related to confidence at the behavioral level (nos. 4–7). In the analysis of the open-ended text response, “the importance of staying close to children” was the most common impression (21 participants), and “continue to stay close to children” was also the second most common action plan (20 participants). The “view of the children's background” also changed their outlook (16 participants), and they were willing to “look carefully at the children's background” (22 participants). Therefore, it is thought that, although they were able to look at the children from the viewpoint of children in need of support, this was not reflected in changes in their behavior . One possible reason is that the child(ren) in need of support could not be detected in a month. Therefore, a long-term evaluation may help schoolteachers recognize such a child(ren). Another possible reason could be that children are wary of their surroundings because they do not want their parents to be known. A total of 55% of adult children of parents with mental illness reported that they did not show signs that those around them could recognize when they were in elementary school , and theAll program goal achievement scores remained effective up to one month later. We believe that the effect took hold for one month, not only due to the program content but also because of how it was structured. While developing this program, we considered the current lack of social awareness regarding the existence of children with parents having mental illness. Referring to the TTM, the program included self-re-evaluation, and we asked the following questions before providing new knowledge, “Have you ever met a child like this?” Baseline participants’ information indicated that more than half of them had experience working with parents having mental illness. Therefore, it is assumed that the participants recalled children they had met in the past and reflected on their own responses at that time. Furthermore, after watching the independent adult in the video, they may have thought about the aftermath of their own support. It is believed that they could become more confident in their support and more willing to provide support with hope. Though this program involved a short 30-min video, we believe that the structure of this program was also effective in that its effect lasted for one month.Although Japanese schoolteachers are very busy, 168 of the 171 baseline participants remained in the study until the end. This may have been due to the short duration of the program (30 min) and the easy participation in the e-learning format, which was not restricted to any location and allowed them to choose their own locations. The length of the program was “long” (26 participants), “just right” (60 participants), and “short” (none). Therefore, although a shorter length would have been more desirable, the current one was considered acceptable. Thirty minutes would be sufficient to set up a training session with additional group work after watching the video. As mentioned in the open-ended text response section, it is sometimes difficult to solve problems unless they are shared and handled by the entire school. The need for an approach that involves the entire school has been pointed out in a previous study . In a naThis study had several limitations. First, the program assessed the understanding and behaviors of individual schoolteachers but not the organizational response of the school as a whole. There were opinions that in order to identify and support children, not only the efforts of individual schoolteachers, but also the whole school approach is needed. Therefore, in the future, this program should be shared with the entire school and evaluated from an organizational perspective as well. Second, it was assumed that the study participants had some interest in the issue, and those who had no interest in the issue at all would not have participated in this study. Therefore, we do not know whether this program is effective for those who have no interest in the issue. Third, mental health conditions involve a wide spectrum of conditions. This program does not cover all mental illnesses.We developed a 30-min video-based e-learning program to help elementary schoolteachers support children of parents with mental illness and evaluated its effectiveness using a school-based cluster randomized controlled trial. It was observed that it was significantly effective, over one month, in reducing difficulties in supporting children.


The goal of the present study was to investigate factors associated with sustainment of two evidence-based programs for nutrition promotion in early care and education (ECE) settings – Food Friends (FF) and Together, We Inspire Smart Eating (WISE).N = 55) from centers that had previously been trained in WISE or FF completed a survey. Program-specific measures included Steckler's Perception of Innovations, the Program Sustainability Assessment Tool (PSAT), and the Organizational Readiness for Change Assessment (ORCA). For our primary outcomes, two measures of sustainment were examined: Nutrition Continued Practice  and Program Fidelity . Multiple regression was used to determine the association of these outcomes with program, years since last implementation, and overall scores on predictors. Follow-up correlation analyses were used to investigate outcome relationships with context submeasures due to high intercorrelations between predictor submeasures.In a cross-sectional study design, ECE directors (p = 0.03). All subscales of the PSAT  were significantly correlated with Nutrition Continued Practice . Program Fidelity was significantly predicted by PSAT and Steckler Perception of Innovation scores. All subscales of the PSAT were strongly positively correlated with Program Fidelity ; relative advantage  and level of institutionalization  were positively correlated with Program Fidelity.Nutrition Continued Practice was significantly predicted by program and overall PSAT score. WISE programs had significantly higher Nutrition Continued Practice scores than FF program (This study suggests that factors associated with the continued practice of program principles are partially distinct from those that are associated with the sustainment of specific practices driving program fidelity. Results suggest capacity building strategies may be important for both continued attention to nutrition and physical activity as well as sustaining fidelity to specific evidence-based practices. Healthy eating –3, regulSustainability is the endurance of a program after a defined program period and after the ending of external implementation support, which is characterized by (a) the integration of the program in an existing institutional or community system , 21 (b) Reflecting the growing emphasis on sustainability in implementation, there are several theories, models, and frameworks dedicated to understanding this topic . One of Across these reviews, only two studies were identified that examined sustainment of obesity prevention or nutrition promotion programs in ECE. Whether the general pattern of key factors for sustaining programs holds in the ECE setting is unknown. Ward and colleagues used a mixed methods approach to assess factors related to sustainment of the Healthy Start-Départ Santé intervention program after 2 years of the initial training in 140 ECEs in Canada . Qualita® (FF), which includes Fun with New Foods and Get Movin' with Mighty Moves and (2) Together, We Inspire Smart Eating (WISE)®. Both programs have a focus on nutrition; FF also has a PA component. Specifically, the purpose of the present study was to understand sustainment factors associated with continued use of FF and WISE over time, as well as any factors that might be unique to the sustainment of each program. To that end, directors of centers that had or were currently implementing FF and WISE completed a survey that assessed (a) continued attention to nutrition and physical activity support at their center and (b) current FF and WISE fidelity, (c) internal and external contextual factors related to sustainment and program-specific components .The current study addresses this research gap by identifying barriers and facilitators of the sustainability of two intervention programs in ECEs in the United States: (1) Food FriendsFood Friends is a preschool program implemented mainly in Colorado, U.S. that was designed to address healthful eating behaviors and PA patterns in preschoolers . FF includes offering new foods and taste tests over 18 weeks; teachers are trained to role model trying the new foods. There are 8 FFs mascots that introduce children to each food group. FF has a companion program, Mighty Moves, focused on supporting development of motor skills through structured activities, music, and classroom enhancements . It was implemented successfully for over 20 years and has been shown to both increase children's willingness to try and consume novel foods (food preference) and improve gross motor performance in the short-term , 37 and WISE was similarly designed to increase healthy eating habits in early childhood in children aged three to eight years old across a 9-month school year, although it does not include a physical activity component. WISE includes weekly food experiences and supporting activities that align with ECE educational standards and has been shown to create positive changes in both child and family eating behaviors. These include incorporation of more fruit and vegetables into the diet after experiencing WISE and decreased intake of nutrient-poor foods  compared to children not exposed to WISE , 41. WISvia email invitation first; these invitations were followed with phone invitations if the email did not receive a response. Our target sample size was 112 (nWISE = 49 and nFF = 63) to provide 80% power to detect medium sized effects and reflect the imbalance of trained centers in each state to date  and a section that assessed specific use of either FF or WISE . Participants had the option to continue to the FF and WISE specific portion of the survey. Only participants who completed the second portion of the survey were included in the following analysis.The survey was divided into 5 sections: (1) Your Role at the Center (2) Nutrition and Physical Activity at the Center, (3) FF/WISE Programming at the Center, (4) Factors Influencing the Use of FF/WISE at the Center, and (5) What It Is Like at the Center. These sections reflected adaptations of three key measures: Steckler's Perception of Innovations , the OrgIn this section, items assessed characteristics of the center and the person completing the survey including: (1) level of involvement in decisions about nutrition and physical activity at the center, (2) years of experience in ECE and at the center, (3) role at the center and years in the role, (4) other roles at the center, (5) whether the program was a Head Start, (6) the center's total capacity and hours of operation, (7) tax status of the center, and (8) school district (if applicable). These items were used to describe survey participants and to screen for eligibility for completing the survey. Individuals with no role in making decisions about nutrition and physical activity at the center were asked to provide an alternate email for the person involved in those decision. At the end of this section, respondents were asked if they wanted to continue the survey.per se . Continued Attention items were self-developed based on salient aspects of the training and evidence-base of FF and WISE . Items on Concern about Nutrition/PA were adapted from the Steckler and colleagues measure of Awareness Concern about Prevention scale , even if specific programs/interventions are not sustained on scale . NutritiAt the end of this section, participants indicated if they had used FF and WISE in the prior 7 years. Survey items also branched to ask for the number of years the program was used, the most recent year of use of each program, and their role with the program. We also include an open-ended response on reason for discontinuing use. Based on participants' response to the question about use of FF/WISE, the remainder of the survey was specific to their experience with either FF and WISE . If the program indicated no use of FF and WISE in the past 7 years, the survey ended.In this section, participants provided responses to items about Program Fidelity, as well as Level of Use, Level of Success, Relative Advantage, and Level of Institutionalization which were adapted items from the Steckler Perception of Innovations Measure . ProgramThis section included items adapted from the Program Sustainability Assessment Tool (PSAT) . SpecifiThe final section of the survey included items from the Organizational Readiness for Change Assessment (ORCA) including items on Staff Culture, Opinion Leaders, and General Resources . These qThe research team conducted 5 cognitive interviews to refine and adapt survey items, three with prior participants in the FF program and two prior participants in the WISE program. For the interviews, one study Principal Investigator (PI) and one research assistant held a video conference with each participant. The participant opened the survey on their personal computer and shared their screen as they completed the survey. The research team invited the participants to talk aloud as the completed the survey, explain the rational for their responses, ask questions about the items and/or instructions, and note any aspects that were confusing or unclear. The researchers documented the items on which participants had comments and questions and asked the participants to suggest improved wording. In addition, the researchers prompted the participants at the end of each page to give feedback about the format, item response options, and instructions. The researchers also monitored for signs of confusion  to prompt participants to explain their thought processes. Finally, the researchers asked participants to review the initial survey instructions both before and after completing the survey to improve clarity about the survey's purpose and contents. Improvements were made to the survey iteratively to test changes in wording with subsequent interview participants. The PSAT Partnership and Program Evaluation sub-scales were excluded from the full survey because of confusion and poor performance during cognitive interviews.p-values were generated identifying participants whose response sets were multivariate outliers. Long-string analysis looks for consistent identical responding within surveys , and acceptable cut-off values are determined based on survey design. An even-odd consistency correlation can assess the extent to which participants chose similar answers to even and odd questions within a given survey, with inconsistent responses indicated by low correlation scores  and Program Fidelity . Continued Practice was calculated by summing up scores from four measures, described in the Nutrition and Physical Activity at the Center portion of the survey, that capture the extent to which program elements were being used at centers. These included a measure of continued attention to nutrition and PA at the center , concern about nutrition and physical activity at the center , the use of nutrition program components ”), and nutrition and PA training . From these items, composite scores for Nutrition Continued Practice and Physical Activity Continued Practice were calculated separately. FF consisted of two programs that were targeted at changing nutrition and physical activity practices in ECE contexts, whereas WISE is only targeting nutrition in ECE. Therefore, central comparisons of continued practice are made on the continued practice of nutrition, and physical activity continued practice is a secondary variable/outcome measured only for FF.Program Fidelity was calculated by a set of seven items that measure the extent to which each center was following key components of FF or WISE. Participants indicated the extent to which their centers were using key elements of FF or WISE in the last year each program was implemented . Responses to the seven items are summed to create the Program Fidelity score.N = 55, regression analysis with the initial number of predictors  were no longer adequately powered. Additionally, both the adapted PSAT (α = 0.97) and Steckler Perception of Innovation (α = 0.89) measures had high internal consistency across items regardless of subscale. When correlations between subscales were investigated, the intercorrelations among subscales within these scales caused substantial multicollinearity issues  differences in PSAT, Steckler Perceptions of Innovations, and ORCA subscales were also assessed using MANOVAs in order to determine if there were program-specific differences in these variables. All analyses were conducted in SPSS 27 .n = 51 WISE participants, n = 54 FF participants) began the survey. Of the 105 individuals that began the survey, 82 (78%) completed the first portion of the study, 58 (55%) proceeded to the end, and three were later removed from the sample due to careless responding. Thus, there were a total of 55 participants  whose responses about their centers were included in the final analysis. Most participants were female , White  and non-Hispanic . The average participant age was 49.3 years  = 32 years, maximum (max) = 65 plus years; missing = 19). Participants had worked an average of 21.0 years in ECE  and had worked at their current center for an average of 14.0 years . Most participants had been in their current role for 0-5 years . Most of the participating centers were not Head Starts n = 40 (72.7%); served fewer than 100 children; were open 4 or 5 days a week; and were mainly metropolitan  and micropolitan , as determined by U.S. Department of Agriculture Rural-Urban Community Area codes . For FF centers, the mean number of years since last implementation was 3.3 years . The mean difference in lag between FF and WISE was significant (t(53)= 3.51, p < 0.001). Chi-square tests did not indicate that center demographics or director demographics were significantly associated with survey completion.Lag was determined as the number of years since FF or WISE has been implemented at a center. For WISE centers, the mean number of years it had been since implementation was 1.4 years  = 2.05, p = 0.087, F = 1.33, p = 0.285, F = 0.195, p = 0.899, Two-way MANOVAs were used to investigate if PSAT, Steckler Perceptions of Innovations, and ORCA subscale measures differed by program type (FF/WISE) after controlling for lag. There were no differences in PSAT scores by program  = 4.13, p = 0.004, R2 = 0.24; see t = −2.28, p = 0.028). WISE programs reported higher Nutrition Continued Practice  compared to FF programs . Overall PSAT score was also a significant predictor of Nutrition Continued Practice . Because of issues with multicollinearity among PSAT subscales, follow-up analyses looking at the relationship between PSAT subscales and Nutrition Continued Practice were performed with simple bivariate correlations. Nutrition Continued Practice was significantly positively correlated with all PSAT subscales: communications , funding stability , strategic planning , organizational capacity , environmental support , and program adaptation . The regression model with program, lag, and overall ORCA, Steckler Perception of Innovation, and PSAT scores did not predict a significant portion of variance in FF-only Physical Activity Continued Practice scores  = 0.28, p = 0.89, R2 = 0.05).The regression model with program, lag, overall ORCA, Steckler Perception of Innovation, and PSAT scores accounted for a significant proportion of variance in Nutrition Continued Practice scores  = 13.31, p < 0.001, R2 = 0.55). Both the overall PSAT score  and overall Steckler Perception of Innovation  were significant, positive predictors of Program Fidelity scores. Program Fidelity scores were significantly and positively correlated with all PSAT subscales: organizational capacity , program adaptation , communications , strategic planning , environmental support , and funding stability . Program Fidelity was significantly correlated with only two of the four Steckler Perceptions of Innovation measures: level of institutionalization  and relative advantage .The regression model predicting Program Fidelity indicated that program, lag, and overall ORCA, Steckler Perception of Innovation, and PSAT scores accounted for a significant amount of variance in Program Fidelity scores , providing evidence that program-specific attitudes influence program-specific outcomes. The Steckler constructs of Institutionalization and Relative Advantage were most highly associated with sustained Program Fidelity. That is, perceiving FF/WISE as better than alternative program options and integrating FF/WISE into center schedules, routines, and norms was correlated with programs' continued use of specific program elements . This finding is consistent with a recent review finding perceived benefits and program integration as key factors for sustained implementation of health behavior programs in schools and ECEs . It is aWe also examined program differences in outcomes to further examine the association of Intervention characteristics with sustainment outcomes. Only one difference between FF/WISE programs was observed; Nutrition Continued Practice was significantly higher for WISE compared to FF after controlling for lag and other predictors. This may be because of the singular focus of WISE on nutrition compared to the dual focus of FF on nutrition and PA. For example, Ward and colleagues found that ECE centers were more likely to maintain healthy eating than physical activity components of their intervention, stating that focusing on both may be a challenge for centers . OverallBeyond the DSF construct of Intervention, some findings support the association of the Practice Setting and Ecological System with sustainment outcomes. In fact, the overall PSAT score was the most important predictor in the presence of other predictors for both outcomes. Specifically, both Nutrition Continued Practice and Program Fidelity were significantly predicted by overall PSAT scores with high correlations will all PSAT sub-scores. Indicators of the importance of the Practice Setting included moderate to strong correlations between sustainment outcomes and communication, strategic planning, the center's adaptation of programs, and organizational capacity. While communications and planning are potentially malleable targets for supporting sustainment, organizational capacity may be less so. Consistent with a 2020 review by Herlitz et al. of sustainment of public health programming in schools , our stuThe importance of the Ecological System was supported with a strong correlation between PSAT Environmental Support and Program Fidelity, a moderate association between PSAT Environmental Support and Nutrition Continued Practice, and moderate associations between PSAT Funding Stability and Program Fidelity and Nutrition Continued Practice. Our findings on the importance of funding are consistent with a review of studies on sustainment of obesity prevention programs in community settings, which identified resources as the most frequently identified factor for sustainment . Shoesmivia institutional revenue and monetary resources. We were not able to test interactions as expected because of challenges with measuring factors related to sustainment.Taken together, these results support the importance of all levels of the DSF in understanding sustainment. Specifically, intervention characteristics , practice setting traits , and the ecological system  were important predictors in our study. Although not tested in our study, elements identified by the DSF may be interlinked in complex manners. For example, evidence-based practice integration and continued training over time have been identified as important predictors of sustainment , 33, butr = 0.52, contributing to high variance inflation factors in the proposed analyses and a need for a revised analysis approach. This was a somewhat unexpected finding because original confirmatory factor analyses of the PSAT in over 250 public health programs  supported a factor structure with 8 distinct domains . We did not reach these numbers, and many programs that started the survey did not complete it in its entirety (45%). Thus, our study was slightly under-powered compared to our original design. Several strengths offset these limitations. First, we were able to collect information about two distinct programs across two U.S. locations. This increases the generalizability of our findings about the key factors associated with sustaining nutrition/PA programs in ECE. We were also able to model wide variation in lag since implementation, despite surprising null findings regarding its predictive power. Finally, our study was able to simultaneously examine multiple domains theorized by the DSF to be associated with sustainment outcomes in an ECE setting. This approach revealed that, for the present sample, contextual and systems characteristics were the most predictive of continued attention to nutrition/PA and specific program practices.The study has additional limitations and strengths. A key limitation is that study recruitment and data collection was conducted during the COVID-19 pandemic. Programs that were able to be reached and participate during this time may differ in systematic ways from programs that were non-responsive. Specifically, it is possible that only more resourced and/or engaged centers were able to respond, which may have truncated the range of variables in our study. This concern is somewhat attenuated by the findings on program capacity's influence on sustainment outcomes, which indicates useful variability was present in the sample. A related limitation is that our sample size did not reach desired numbers for the previously proposed moderation analysis. Based on initial recruitment predictions, it was estimated that approximately 40% of the potential recruitment pool would respond to the director survey . TS was also supported by the National Institute of General Medical Sciences of the National Institutes of Health under Award Number 5P20GM109096. TS and GC have salary support from NIH UL1 TR003107. TS, GC, DZ, VM, SJ, and JS have salary support from R37CA252113.Authors LW-M and TS have a financial interest in the technology (WISE) discussed in this presentation/publication. These financial interests have been reviewed and approved in accordance with the UAMS conflict of interest policies. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding agencies.