Thus, the workplace violence prevention program was effective for nursing students.The study aimed to develop and evaluate a violence prevention program for nursing students to improve communication self-efficacy, problem-focused coping style, emotion-focused coping style, and the ability to cope with violence. Using an eight-session violence prevention program, the study was designed as quasi experimental, with a pretest, posttest, and follow-up assessment with a nonequivalent control group. Nursing students from the fourth year of a university were selected as participants; 22 students were assigned to the experimental group and 23 to the control group. Data analysis included Chi-square, Fisher’s exact test, Levene’s Test, Mann–Whitney U-test, and repeated measures ANOVA. Results showed that the experimental group showed significantly higher posttest scores for the problem-focused coping style (F = 20.77,  Many types of workplace violence occur in the healthcare field ,2,3, incIn the USA, surveys of 3765 registered nurses highlighted the prevalence of workplace violence among nurses, that 21% registered nurses and nursing students reported being physically assaulted in a 12-month period, and that more than half of the nurses and nursing students were verbally insulted ,14.The majority of nursing students at clinical training sites experienced diverse types of violence, including from patients, caregivers, nurses, doctors, and hospital employees. They experienced violence in emergency rooms, general wards, psychiatric wards, and intensive care units; as many as 40% to 98.2% of study respondents experienced violence ,16,17,18Coping is defined as a process and method of controlling stress with cognitive behavior, by attempting to actively regulate internal and external demands. A coping style is defined as the specific process and method of dealing with stress and emotions. Problem-focused coping includes coping styles such as collecting information about the problem and making a behavioral plan to directly address or alter the stressful event; emotion-focused coping includes coping styles such as maintaining distance, self-condemnation, and imagination to relieve negative emotional distress related to a stressful situation .Research has shown that nursing students are faced with serious problems caused by violence during clinical training in hospitals, and this adversely affects their roles and work performance. It is, therefore, necessary to develop a violence prevention program to provide knowledge and promote self-confidence so that nursing students can cope with and manage any inappropriate, threatening, or violent event during clinical training and develop a situational intervention ,26. As aLimited domestic and international studies have applied violence prevention programs to nursing students that addressed coping with and managing violence, prevention training ,42,43,44Violence prevention programs should address how to improve self-confidence in communication during a violent situation ,41 and sResearch has shown that a teaching method involving a real-life violent situation and simulation where the participants were asked to prevent and cope with violence was very effective in developing nursing students’ coping abilities with violent situations during clinical training . CommuniAccordingly, this study aimed to develop and evaluate a violence prevention program for nursing students in clinical training that incorporated communication skills and the art of self-defense; to do so, a conceptual model was developed based on the programmed conceptual model of Kim , as applThis study aimed to develop and apply a violence prevention program for nursing students in clinical training and evaluate its effects.Hypotheses 1 (H1).The experimental group participating in a violence prevention program has a higher level of communication self-efficacy than the control group.Hypotheses 2 (H2).The experimental group participating in a violence prevention program has a higher level of problem-focused coping style than the control group.Hypotheses 3 (H3).The experimental group participating in a violence prevention program has a lower level of emotion-focused coping style than the control group.Hypotheses 4 (H4).The experimental group participating in a violence prevention program scores higher in observational evaluation of the ability to cope with violence than the control group.Based on the model by Kim , which iIn this study, Step 1 was planning, Step 2 composition, Step 3 implementation, and Step 4 evaluation. Step 1 involved setting a program goal and conducting a literature review and needs analysis. Step 2 involved developing program intervention techniques, setting length and timing of sessions, grouping, composing program contents, and conducting preliminary research. During Step 3, the violence prevention program was implemented. Step 4—evaluation—involved measuring communication self-efficacy and problem- and emotion-focused coping styles, simulating violent situations in emergency rooms, and rating the ability to cope with violence through observational evaluation.This is quasi-experimental research using a nonequivalent control group pretest-posttest design to develop and evaluate a violence prevention program for effectiveness.n = 22) and the control group (n = 23), according to the training cycle. All the participants were female and in their early 20s. The mean age of the experimental group was 22.4 years and that of the control group was 24 years. To determine the sample size, G*Power 3.1.2 [The researchers recruited nursing students who were seniors in the Nursing Department at K University in North Gyeongsang Province in South Korea. Eligible participants were students who had completed at least one year of clinical training and who had experienced verbal abuse, physical threats, physical violence, or sexual violence from patients, caregivers, nurses, doctors, or other staff members at clinical training centers at least once during the clinical training period. To ensure that informed consent was obtained, students were informed of the purpose of this study, and then they provided written consent. Students selected as participants were randomly assigned to the experimental group (er 3.1.2  was usedThe Counseling Self-Estimate (COSE) Inventory, which was developed by Larson , translaBased on the theory of Lazarus and Folkman , Bae 5959 createTen items related to violence risk and safety management, communication, and attitude from the sub-items of the instrument developed by Seo  were useThis study was approved by the Institutional Review Board (IRB NO. 40525-201711-HR-78-05) of K University. Before beginning the research, the researcher personally clarified the purpose, contents, and methods of the research with the dean of the faculty for the Nursing Department at K University and obtained permission to conduct the research. Participants’ general characteristics, communication self-efficacy, and problem-focused and emotion-focused coping styles were measured in both the experimental and control groups. Posttest was performed in both groups after the end of the eight-session program, and three professors performed an observational assessment of the participants’ ability to cope with violence while running the simulation. To minimize inter-rater measurement errors, protocols regarding data collection methods, procedures, and tools were created to train the assistants.Three observers performed an observational assessment of the participants’ ability to cope while running the simulation. As for internal consistency among the three observers, Cronbach’s α was estimated at ≥0.9. Participants in the experimental group were paid 20,000 won for participation in each session of the program and 5000 won for a meal; participants in the control group were paid 15,000 won for participation in the research. Refreshments were also provided during the simulation.The principal researcher and two research assistants participated in the study. The first researcher is a professor of psychiatric nursing and has 17 years of clinical experience and 10 years of educational experience. She has extensive experience in communication training programs for nursing students. The second researcher is also a professor of psychiatric nursing and has more than 30 years of educational experience. The first research assistant is a professor of adult nursing and has been running a program for simulation of adult nursing for students for 3 years. The second research assistant is a professor of adult nursing and has 3 years of experience in basic nursing simulation and adult nursing simulation teaching for nursing students. In the simulation, three professional actors were employed as research assistants. The first researcher explained the purpose of the violence prevention program to two professional lecturers before the program. The key concepts, activities, and contents were also explained and shared to proceed with the program To develop a violence prevention program, intervention program techniques, length, timing of sessions, grouping, and theoretical frameworks were analyzed through a literature review based on the program development model suggested by Kim . The feaBefore designing the program, a literature review was performed to select the theme and goal of each session. To develop the program’s content, previous studies regarding violence experienced by nursing students, violence at hospitals, and violence prevention programs for nursing students and nurses at the national and international levels were reviewed.Two researchers and a special lecturer who served as an assistant conducted the sessions, and three professional performers were employed to act as patients in the simulation. For two days, the preliminary program was run as an intensive. The students suggested the need for a full explanation of the definition and contents of violence at the introduction stage. They also indicated that their personal participation would be less boring and attract greater attention than a lecture-based program. Their opinions were incorporated by adding discussion, interview skills training based on self-examination of communication, role play, and the art of self-defense in a 1:1 real-life situation to the program. The violent situation simulation involved verbal abuse and physical violence by an acute pancreatitis patient who visited an emergency room with upper abdominal pain complaints; the patient then became mad when a nurse requested reception. The simulation was revised and complemented by an expert. The finally confirmed program is shown in The violence prevention program was conducted for the students in the experimental group in a total of eight sessions—120 min per session, two sessions per week—for four weeks from 1 May to 5 June 2019. The students in the control group were given a 120-min lecture in the first session.Session 1 involved an introduction to the program introduction, explanation of group rules, videos on hospital violence, development of solutions, and presentation of suggestions. Session 2 involved writing a scenario and role play presentation after watching videos as well as discussing therapeutic and non-therapeutic communication. Session 3 involved listening and good speech training. Session 4 involved 1:1 interview training for participants to examine their own communication, detect their own problems, engage in introspection, and incorporate changes to their therapeutic communication. Session 5 involved watching YouTube videos related to verbal abuse, followed by composing verbal abuse cases, writing a scenario, and a role play, as an attempt to prevent and cope with verbal abuse. Session 6 involved watching YouTube videos related to physical violence, followed by writing a scenario, and a role play using therapeutic and non-therapeutic communications. Session 7 involved watching YouTube videos related to physical violence, followed by composing physical violence cases, writing a scenario, and a role play, as an attempt to prevent and cope with physical violence; and Session 8 involved consolidating violence prevention and coping methods, issuing a certificate of completion, completing a posttest, and evaluating educational satisfaction to understand the effectiveness of the program. Three months after completion of the program, the simulation was conducted for the observational assessment to determine the persistence of the effectiveness. Watching YouTube videos, writing a scenario, role play presentation, listening training, good speech training, assertiveness training, and the art of self-defense were used to promote the goal of each stage in the conceptual model of the violence prevention program. The program assessment involved pretest, posttest, and follow-up assessment.x2 test and Fisher’s exact test were performed to determine homogeneity. Repeated measures ANOVA was performed to analyze the variables of communication self-efficacy and problem-focused and emotion-focused coping styles for inter-group differences, degree of intra-group changes, and interaction effects. The non-parametric method of the Mann–Whitney U-test was used to compare mean differences in the ability to cope with violence between the experimental and control groups.The collected data were processed by using SPSS/WIN 25.0 to perform frequency analysis and multiple-answer analysis for the participants’ general characteristics and experiences with violence; x2 test and Fisher’s exact test found no significant inter-group differences between the experimental and control groups, which indicated homogeneity in the general characteristics.The participants’ general characteristics are presented in Homogeneity tests were performed for dependent variables such as communication self-efficacy, problem-focused and emotion-focused coping styles, and the ability to cope with violence between the experimental and control groups prior to the program. Communication self-efficacy and problem-focused and emotion-focused coping styles were homogeneous, whereas the ability to cope with violence was not homogeneous .p > 0.05)  .Analysis of the normal distribution of the measured variables with the Kolmogorov–Smirnov test in the experimental group and the control group revealed that the ability to cope with violence was not normally distributed and was analyzed with the Mann–Whitney U-test.The sphericity assumption indicates the equivariance condition in which the correlation between each pair of data measured repeatedly is the same, and that the variances in each process are the same for each process. If the sphericity assumption is satisfied, univariate analysis is used .p > 0.05), so univariate analysis was used.Based on the result of Mauchly’s sphericity test, communication self-efficacy, problem-centered coping style, and emotion-centered coping style satisfied the assumption (p = 0.845), time points , or period-group interaction . Thus, Hypothesis 1 was rejected , time points , and period-group interaction . Thus, Hypothesis 2 was supported  but statistically significant changes in time points  and period-group interaction . Thus, Hypothesis 3 was partially supported . Thus, Hypothesis 4 was supported  led to a statistically insignificant improvement in communication self-efficacy through a communication training program due to clinical knowledge of cases and the lack of self-confidence among nursing students who were sophomores . In addiThe experimental group experienced more statistically significant effects in terms of the problem-focused coping style in the posttest, and follow-up assessment, than the control group. This result is similar to the finding of Park, Kim  that nurSimilarly, the experimental group showed more statistically significant effects in terms of emotion-focused coping styles in the follow-up assessment than the control group. This result is supported by another study’s finding that a psychological education program led to a reduction in coping based on avoidance . In thisThe observational assessment for the ability to cope with violence was performed through a simulation at the evaluation stage. This study is differentiated from the previous research of Choi and Lee , and ChoThe limitation of this study is that students who apply for the program in the 4th grade are unable to see the long-term effects and changes in coping with workplace violence incidents by employing students as a nurse.This study developed and applied a violence prevention program for nursing students and confirmed that the program was an effective intervention for improving the problem-focused coping style, improving the ability to cope with violence, and reducing the emotion-focused coping style. The investigation of the behavioral changes after program intervention revealed that the scores of coping with violence were higher in the experimental group than in the control group. The violence prevention program for nursing college students in Korea is not implemented currently, but if the program developed in this study would be standardized and applied as a regular education before the clinical practicum, it would be helpful to prevent the nursing students from violence during the clinical practicum. Thus, it is recommended that nursing students be provided with systematic education in nursing schools and training centers in the form of a violence prevention program prior to participating in clinical training.


Benign biliary strictures can be difficult to manage. Untreated biliary strictures can lead to complications, such as chronic cholestasis, jaundice, recurrent sepsis, and secondary biliary cirrhosis, which can have severe ramifications. The management landscape is constantly evolving, with the development of modifiable self-expandable metal stents and biodegradable stents. This review critically appraises current endoscopic treatment strategies, in particular focusing on the shortfalls, such as stent migration and stricture recurrence. It also proposes a treatment algorithm based on aetiologias and the location of the strictures. Benign biliary strictures (BBSs) are challenging to manage. Most benign strictures are related to surgical procedures, following bile duct injury after liver transplantation and laparoscopic cholecystectomy, with reported incidences varying from 3% to 13% ,3, respeNot all BBSs are the same and they can have varying features depending on the etiology. For example, in CP, BBSs are long and involve the intrapancreatic portion of the common bile duct (CBD). In liver transplantation, BBSs are generally short and narrow. In post-cholecystectomy biliary strictures, BBSs are usually near the main hilar confluence. The approach to the management of BBSs is diverse and includes endoscopic, surgical, and interventional radiological options, all of which can be associated with complications, which can be life threatening in nature, including sepsis, pancreatitis, hemorrhage, and perforation. Endoscopic therapy is considered as first-line management secondary to its superior safety profile, efficacy, and less-invasive nature in contrast to surgical or percutaneous techniques. However, there is a possibility of stricture recurrence, and with stent insertion, there is a risk of stent occlusion and migration. The endoscopic technique for BBSs is continuously advancing and we have previously proposed an endoscopic classification to assist with treatment therapies dependent on the location and etiology of biliary stricture .Plastic stents have been the mainstay of treatment in conjunction with endoscopic biliary dilatation. However, this approach can be time and labor intensive, demanding multiple interventional procedures to upsize and exchange stents. This also increases the chance for complications, such as cholangitis and bleeding, and places large demands on healthcare resources. There has therefore been interest in exploring the use of self-expandable metal stents (SEMSs). This technique requires reduced procedures and may also provide faster stricture resolution. However, limitations include a higher risk of migration. The European Society of Gastroenterology Endoscopy (ESGE) guidelines reinforce that multiple plastic stents (MPSs) and SEMSs are the standard of care currently for the treatment of BBSs  . Newer fIt is important to note that many studies are retrospective with high variability, and as such, many recommendations made by ESGE are based on low- or moderate-quality evidence, particularly those pertaining to SEMSs, as well as the duration of stenting. The original standard of care was to place size 10 French plastic stents across strictures. The stents were then slowly upsized and exchanged every 3 months accompanied by dilatation for up to one year . It is iSEMSs address some of the limitations of plastic stents; they have a larger diameter as well as a greater expansion force. SEMSs have wider diameters  when compared to plastic stents and also have technical advantages as they are easier to insert and less time arduous than placing MPS . The greThe SEMSs used in BBS are all fully covered to prevent tissue ingrowth and stent epithelization into the duct wall, making removal possible. Most are made from a polytetrafluoroethylene layer and have drawstrings situated at the top margin of the stent to facilitate subsequent removal. The stents described from here on are all fully covered SEMSs. In general, stricture resolution and remodeling of the bile ducts appears to be quicker with SEMS compared to MPS, requiring less than the total 12 months of stent exchange duration required with plastic stents. This shortened period is thought to reduce the rate of stent-related complications in particular with stent removal without compromising stricture resolution.It is imperative to select the right stent for the right indication and location. The major determining features are based on the stricture length, location, and etiology. SEMSs are best suited to CP-related strictures and some cases post surgery. The use of SEMSs in strictures at the hilar confluence is not recommended due to the risk of impaction as well as occlusion of the intrahepatic branches from the opposite lobe, which can lead to sepsis . If the Unlike plastic stents, there are less vigorous studies of the dilatation protocols for SEMS in BBS. Furthermore, the optimal SEMS indwelling duration is unknown. Current practice with SEMSs placed for anastomotic strictures employ a 3-month placement; however, longer treatment times may be more effective for stricture resolution, as seen in instances for CP where stents are placed for up to a year . There are concerns that an extended SEMS indwelling time may raise the risk of cholangitis from stent occlusion or migration. There are also risks with stent embedment from the mucosal hyperplasia occurring at the tips of the stent . One lar2 being quoted from 57% [Several meta-analyses have demonstrated that SEMSs were similar to MPS for BBS resolution whilst requiring fewer ERCP procedures ,16. In ofrom 57%  to 96% [from 57%  without Developing a gold standard endoscopic therapy for BBS is limited by the fact that there is no accepted classification for BBS. Whilst the Bismuth classification for malignant biliary strictures can assist with clinical decisions, the equivalent classification for BBS has limited applicability to endoscopic interventions . We refeType 1 strictures are located at the distal CBD and occur in conditions, such as in CP. Here, biliary strictures are due to extrinsic compression from fibrotic pancreatic tissue on the bile ducts. It is important that cancer is ruled out before placing stents for 10–12 months at a time. SEMSs have been studied extensively; a systematic review found CP-related BBS attained increased resolution at one year than MPSs  . Long-teOverall, outcomes are less positive for CP than for anastomotic strictures after liver transplantation. This is related to the fact that BBSss in CP are generally longer and more complex. Furthermore, there is fibrosis and calcification of the pancreatic parenchyma related to chronic inflammatory changes. ESGE guidelines recommend temporary insertion of MPSs or of an SEMS for treatment of BBS related to CP  .Type 2 strictures occur in the upper CBD or common hepatic duct, such as a liver transplant anastomotic stricture or post-cholecystectomy strictures. Placement of an incremental number of plastic stents exchanged every 3 months over one year is the standard of care for these strictures . Post-cholecystectomy BBSs are generally short and occur frequently at the upper third of the common hepatic duct or hilar confluence. As a result, SEMSs are less attractive because of the risk of impaction of the upper edge into the hilar roof as well as the risk of stent migration secondary to unstable positioning of the deployed stent. Furthermore, they have not been well studied and are under-represented in multi-center trials ,14. ESGEPost-liver transplant, strictures can be anastomotic biliary strictures (ABSs) or non-anastomotic biliary strictures. For anastomotic biliary strictures, MPS is the gold standard . Meta-anNon-anastomotic biliary strictures are strictures that occur more than 5 mm proximally to the anastomosis. These are characterized by multiple extrahepatic and/or intrahepatic ABS with recurrent sludge or stone formation. They are more refractory to endoscopic therapy than ABS, requiring greater numbers of stricture dilatation, longer periods of stenting, and have greater rates of stricture recurrence. The issues with stent migration and the possibility of stent-induced biliary strictures is ever present, particularly if the diameter of the stent is not adapted to the caliber of the CBD. Various strategies have been used address migration issues. These include the insertion of a double-pigtail plastic stent within an SEMS as an anchor . This reResults for newer intraductal SEMSs, stents that are located completely within the bile duct , have beNewer endoscopic techniques, such as stenting above the papilla, “inside stent”, have been studied to prolong stent patency, especially in patients post-stent patency. This works as a core stent to prevent kinking of the bile duct at the end of the SEMS as well as preventing duodenobiliary reflux . Type 3 strictures are intrahepatic, including the hilum, such as in primary sclerosing cholangitis (PSC). Like in CP, it is important to exclude malignancy where appropriate prior to endoscopic therapy. In the first randomized trial of patients with PSC and a dominant stricture, short-term stents were not superior to balloon dilatation and in fact may be harmful. The study was terminated early due to a significantly higher occurrence of treatment-related significant adverse events for short term stenting, including cholangitis, post-ERCP pancreatitis, and cholecystitis. As a result, balloon dilatation should be the initial treatment of choice for dominant strictures in patients with PSC as it can result in a decrease in cholestasis in the majority of patients at 3 months . FollowiType 4 are surgical anastomoses, such as hepaticojejunostomy, which can be challenging for management due to an altered anatomy. The approach has traditionally been via percutaneous transhepatic biliary drainage (PTBD), but if a center has expertise and availability, then double balloon enteroscopy (DBE)-assisted ERCP is an attractive option. A retrospective cohort (102 patients) with repeated DBE-assisted ERCP and balloon dilatation and insertion of a plastic stent if required demonstrated a high stricture resolution rate (77%). This was a vigorous and time-intensive protocol necessitating monthly visits. There was also a high stricture recurrence in 42%, with a median time to recurrence of 3.4 months, and cholangitis in 10% of cases . A meta-Current evidence for all described interventions shows a high stricture resolution rate. However, the main limiting factor is stricture recurrence. There is ongoing research into strategies best to manage SEMS migration, which would allow for stents to remain longer in situ. We have discussed the properties of newer stents with antimigration strategies. There is also interest regarding biodegradable stents; stent removal is not required due to spontaneous stent disintegration. These items can be custom-made in the desired size and length depending on the BBS. However, there is concern regarding the gradual reduction in expansive radial force as the stent degrades as well as initiating a potential inflammatory foreign body reaction. In a multicenter study, 107 patients with refractory BBS  and biodThe current endoscopic management algorithm of BBS has evolved in the last 20 years. There is constant research and innovation to reflect the unique etiologies and site of strictures. Endoscopic techniques, protocols, and materials are constantly changing. Currently, the stenting protocol with multiple plastic stents is the standard of care for post-surgery BBS. SEMSs are an excellent alternative in many situations, such as chronic pancreatitis. The evolution of biodegradable stents could provide logistical benefits. More studies are required for stronger recommendations to be made by guidelines.


Mobility is important to sustain for older adults to live independently. The purpose of this project was to evaluate teach back and ask me 3 interventions with a health education program that included Otago strength and balance exercise and a walking program The pilot program, Mobility Matters, was completed with 16 older adults , 69% African American, 94% female. Older adults with moderate fall risk were recruited from community centers and participated in a 3-month program where they were paired with physical therapy students for pre- and post-intervention assessment. Participants were randomly assigned to a health literacy intervention group (HLG) (n=9) and received teach back and ask me 3 intervention twice a month for three months. The control group (n=7) received the same program of balance exercises/ walking program and after 3 months was given the health literacy intervention. Groups were not significantly different on age, gender and REALM scores. Assessment measures included: timed up and go, 30 second chair rise, 4 stage step test, 6 minute walk test, and activity balance confidence scale (ABC). Paired t-test analysis revealed mean significant differences on the measures of four stage balance test (p =.008), six-minute walk test (p=.026) and approached significance on ABC (p=.054). No significant differences were found for the non-health literacy group on all measures. The results suggest that health literacy intervention may improve outcomes for health education interventions with balance and aerobic exercise.


Accidents and the resulting injuries are among the world’s biggest health care issues, often causing long-term effects on psychological and physical health. With regard to psychological consequences, accidents can cause a wide range of burdens including adjustment problems. Although adjustment problems are among the most frequent mental health problems, there are few specific interventions available. The newly developed program SelFIT  aims to remedy this situation by offering a low-threshold, web-based self-help intervention for psychological distress after an accident.The overall aim is to evaluate the efficacy and cost-effectiveness of the SelFIT program plus care as usual (CAU) compared to only CAU. Furthermore, the program’s user-friendliness, acceptance, and adherence are assessed. We expect that the use of SelFIT will be associated with a greater reduction in psychological distress, greater improvement in mental and physical well-being, and greater cost-effectiveness compared to CAU.Adults (n=240) experiencing adjustment problems due to an accident they had between 2 weeks and 2 years before entering the study will be randomized into either the intervention or control group. Participants in the intervention group receive direct access to SelFIT. The control group receives access to the program after 12 weeks. There are 6 measurement points for both groups . The main outcome is a reduction in anxiety, depression, and stress symptoms that indicate adjustment problems. Secondary outcomes include well-being, optimism, embitterment, self-esteem, self-efficacy, emotion regulation, pain, costs of health care consumption, and productivity loss, as well as the program’s adherence, acceptance, and user-friendliness.Recruitment began in December 2019 and will continue at least until January 2021, with the option to extend this for another 6 months until July 2021. As of July 2020, 324 people have shown interest in participating, and 48 people have given their informed consent.To the best of our knowledge, this is the first study examining a web-based self-help program designed to treat adjustment problems resulting from an accident. If effective, the program could complement the still limited offerings for secondary and tertiary prevention of psychological distress after an accident.ClinicalTrials.gov NCT03785912; https://clinicaltrials.gov/ct2/show/NCT03785912DERR1-10.2196/21200 The World Health Organization reports tens of millions of accidents annually, with about 5 million people dying from the consequences of their injuries ,2. Accidadjustment problems are especially common and frequent among accident victims [disorder. A longitudinal study on adjustment disorder after trauma exposure and major injury conducted in Australia found that participants with adjustment disorder 3 months after the trauma were more likely to meet the criteria for a further psychiatric disorder 12 months post-injury [Not everybody who suffers an accident develops psychological problems. Nonetheless, when taking into account possible short-term implications such as fear, pain, or helplessness, as well as potential long-term consequences like permanent physical damage or financial challenges, the development of psychological problems after an accident is easily understandable . Therefo victims ,9. By ad victims . Adjustm victims . If perst-injury . Thus, tt-injury ,13.One possibility to implement early interventions for the treatment of psychological distress due to an accident is the development of web-based interventions. Numerous studies have shown that web-based interventions are an effective treatment option for various psychological problems and demographic groups ,15. TherIn this respect, studies on another form of guidance, namely guidance on demand, are of particular interest. With the guidance on demand approach, contact with a professional is only established at a participant’s request but is not scheduled or planned per se.The findings on the effectiveness of guidance on demand are mixed. In a study on the treatment of tinnitus via the internet, Rheker et al  reportedThese findings suggest that the guidance on demand approach lies between guided and unguided programs in terms of effectiveness. The approach thus offers a middle way and has the potential to combine some of the most prominent advantages of both guided and unguided treatments: Participants are given the security of knowing that they can turn to a specialist for help and are therefore not completely on their own. However, since no regular contact is scheduled, fewer staff are needed. Thus, programs with on-demand guidance generate lower costs and are less limited to the time and resources of a project’s employees than guided programs. This allows for flexible use at a self-determined pace. Due to the voluntary nature of the contact with a specialist, the participants’ social exposure in a program with guidance on demand can be as low as in an unguided program. Programs with guidance on demand also have other advantages of web-based interventions such as easy availability and scalability .In recent years, various web-based treatment options for adjustment problems and disorders have been developed. One of them is Trastornos Adaptivos Online ,24. The A further web-based intervention for the treatment of adjustment disorders is the Brief Adjustment Disorder Intervention ,26. ThisAnother unguided web-based program for adjustment problems is ZIEL  . The ZIEAgainst the background that accidents can have various long-term psychological consequences such as adjustment problems, which are often not or insufficiently treated, we have developed SelFIT. The program was realized as a web-based program in order to provide an easily accessible psychological treatment option to accident victims. Considering the results and conclusions from previous research on web-based self-help interventions for adjustment problems described above, SelFIT was not created as a treatment for adjustment problems in general, but specifically for the treatment of psychological distress and adjustment problems after an accident. This focus allows for more specific thematic tailoring to the needs of the target population. Additionally, the guidance on demand approach was chosen in order to take advantage of as many benefits of guided and unguided programs as possible without generating excessive additional costs.The aim of this study is to conduct a randomized controlled trial to evaluate the new SelFIT program developed for people who experience adjustment problems after an accident. Specifically, the objectives are to evaluate the efficacy and cost-effectiveness of SelFIT used in addition to care as usual (CAU) compared to only CAU; to analyze the acceptance and user-friendliness of the SelFIT program and draw conclusions for further development of the program and the type of guidance applied in the program ; and to explore and analyze moderators , mediators , and predictors  for the efficacy of the program.This study is a prospective longitudinal RCT. The study population are German-speaking adults (≥18 years) who suffer from adjustment problems after experiencing an accident between 2 weeks and 2 years before entering the study.The lower time limit was set in order to reach injured persons as soon as possible after the accident and thereby prevent the development or worsening of psychological distress such as adjustment problems. The upper time limit was set in accordance with the time criterion of a chronic adjustment disorder according to the current version of the International Classification of Diseases (ICD-10 ).After receipt of the informed consent and the initial screening, participants are randomized equally (1:1 ratio) into the treatment or the control group. Randomization is stratified by the point value that participants score on the questionnaire used as the primary outcome measure (12-16 points vs ≥17 points) in order to make the two groups comparable regarding their symptom expression on this measure. This is done with a computerized random number generator and randomly permuted block sizes using Randomization.com . RandomiRecruitment takes place via advertising on social media, websites, and internet forums, and with different organizations and self-help groups, as well as through referrals from rehabilitation clinics, psychotherapeutic practices and clinics, physiotherapists, medical doctors, and hospitals. People interested in participating can leave their contact details on the study home page and will then be sent the participant information either by email or by post, according to their choice. After the signed informed consent form is sent to the study team, potential participants are asked to complete the first online questionnaire to check that they do not meet any of the exclusion criteria and meet all the inclusion criteria described below.According to the inclusion criteria of this study, all participants must have experienced and be able to specify an accident during the period from 2 weeks to 2 years prior to participation in this study; exceed the cutoff value for at least a mild psychological burden on the 21-item Depression, Anxiety and Stress Scale ; be at lPersons who show severe depressive symptoms (Beck Depression Inventory II score>29) , show suThe SelFIT program takes 12 weeks in total. It consists of an introduction, 8 thematic modules, and a conclusion. The thematic modules are described in Participants are encouraged to work on one module per week and to repeat and deepen the various exercises during the last 4 weeks of the program in order to facilitate the transfer to their own everyday life. However, participants are free to choose both the order and speed of processing of the modules themselves. All modules consist of a video, various texts, exercises, and weekly tasks. In addition, participants are asked to indicate which of a list of feelings, moods, and physical conditions they currently experience. This allows them to observe how their well-being changes over the course of the program.Since the study employs a guidance on demand approach, participants can contact the study team if needed or desired. For this purpose, they can either write an email or use the chat function within the program. In the settings, there is also the option to choose whether participants want to receive a reminder email after a certain period of inactivity. Other than this, contact with the study team, a therapist, or a counsellor is not planned by default.Module 1: Accidents and their consequencesInformation about psychological and physical consequences of accidents as well as the symptoms of adjustment problemsSurvey of the participant's current situation and well-beingModule 2: Changing perspectivesInformation on automatic and irrational assumptions, chains of thoughts, and the influence of thoughts and assumptions on one's state of mindExercises with the aim of cognitive restructuringModule 3: Understanding different reactions to accidentsInformation about frequent psychological reactions to accidentsExercise to identify physical symptoms of anxietyModule 4: ActivationBehavioral activation with suggestions for different types of activationDevelopment of a personal activity planInformation about the importance of physical activityModule 5: Self-careInformation about post-traumatic growthExercises to promote acceptance, gratitude for positive aspects of life and personal resourcesModule 6: Finding calmInformation about sleep and sleep hygieneExercises to promote mental and physical relaxationModule 7: Addressing painful feelingsInformation about typical reasoning errorsInformation about and exercises for dealing with painful feelings such as guilt, shame, anger, and resentment after an accidentModule 8: Self-efficacyInformation about attribution styles, self-fulfilling prophecies and self-instructionsIdentification and activation of personal resourcesExercise to promote self-confidenceAll instruments used over the course of the study are self-report questionnaires that are completed online. The primary outcome measure is the short version of the Depression, Anxiety and Stress Scale with 21 items . Each ofAdjustment problems are also assessed using the Adjustment Disorder–New Module 20 . The queDepressive symptoms are additionally assessed using the Beck Depression Inventory II . This quRegarding the accident, we ask for a short description of the event, the time that has passed since, and its subjectively perceived severity.Pain due to the accident is assessed by the Brief Pain Inventory , which cTwo questionnaires, each with a different emphasis, are used to assess the cost-effectiveness of the SelFIT program. The costs of health care consumption and productivity loss are assessed using the Treatment Inventory of Costs in Psychiatric Patients , a self-We also assess embitterment and optimism. The Bern Embitterment Inventory , an 18-iGeneral well-being and the ability to cope in everyday life are assessed by the Short Form 12 Health Survey . The queFurthermore, we assess self-esteem, self-efficacy and emotion regulation skills. Self-esteem is measured using the Rosenberg Self-esteem Scale . This scThe General Self-Efficacy Scale  serves aThe program-related factors we survey include user satisfaction and program usability. This is assessed using the Client Satisfaction Questionnaire ,51, an 8A further program-related factor is adherence, measured by the frequency and duration of use. Those parameters are gathered within the program by means of, for example, the number of log-ins or the percentage of pages and segments that have been accessed and browsed through at least once.Demographic variables obtained from the first online questionnaire include gender, age, family status, and level of income and education. Additionally, participants are asked to indicate whether they have received or currently receive any treatment for mental health issues or physical rehabilitation.All data is assessed online, either within the program platform or via online questionnaires programmed in Qualtrics . Data ind=0.2 and d=0.35 as well as a correlation between the groups of r=0.4. Those estimates are based on the results of previous web-based interventions for adjustment problems [In order to specify the sample size needed for the planned analyses, we conducted a power analysis based on a probability level of .05 and a power of 0.80 using G*Power (Heinrich-Heine-Universität Düsseldorf) . To testproblems .d=0.35) to 238 (for d=0.2) participants in total for this analysis. Since the program does not include weekly guidance but rather guidance on demand, we expect slightly smaller effect sizes. Based on these calculations and assumptions we decided to target a sample size of N=240 participants.The a priori power analyses yielded a necessary sample size of 80 . Missing values will be substituted using multiple imputations. Sensitivity analyses will be conducted for both the data sets with and without the imputed data.We will use linear mixed models to analyze all continuous outcomes as a change from baseline to compare effects between the two groups and over the different measurement points. In case of a missing at random mechanism, we will conduct multilevel regression analyses, which are less sensitive to missing data. Multiple regression analyses allow us to include several predictors such as time of measurement or group allocation .Furthermore, exploratory analyses will be conducted. One of these will examine the association between adherence and outcome, since a higher adherence has been shown to have a positive effect on outcome ,57.All analyses will be conducted using SPSS (IBM Corporation) and R .The study is conducted according to the principles of the World Medical Assembly Declaration of Helsinki , the SwiRecruitment, screening, inclusion, and randomization of participants is scheduled to take place between December 2019 and January 2021. Due to the COVID-19 pandemic, recruitment was slowed down. For this reason, the recruitment phase may be extended by 6 months if we are unable to recruit enough participants by the end of January 2021.As of July 2020, 324 people have shown interest in participating, and 49 people have given their informed consent. We are confident that we will be able to recruit enough people for three reasons. First, a recruitment cooperation with one of the largest rehabilitation clinics for injured persons in Switzerland will start in August. This means a steady influx of participants. Second, all persons who have expressed interest in participating but have not registered are contacted again and asked if they would like to participate in the study. This has proven to be an effective strategy so far. Third, we can extend the recruitment phase if necessary. The project’s recruitment schedule is shown in Accidents and their consequences often affect not only a person's physical well-being but also their mental health and their professional, personal, and social environment. Thus, accidents often mean a significant change and new challenges for those affected. Adjusting to those changed circumstances can be difficult. This also applies to adjustment efforts when returning to everyday life after rehabilitation is over, for example. A lack of support during this time may lead to the development or worsening of psychological distress such as adjustment problems. Easily accessible treatment options such as the SelFIT program could remedy this situation. For this reason, SelFIT was implemented as a web-based self-help intervention, which allows a high degree of flexibility in terms of time and location and can be used with comparatively little effort. Based on the findings of previous studies on adjustment problems and web-based interventions, SelFIT comprises a guidance on demand approach. This enables users to obtain support when needed with minimal personnel costs. Unlike previous web-based programs on adjustment problems, SelFIT does not address adjustment problems in general. Instead, the focus is specifically on the treatment of psychological distress and adjustment problems after an accident. This allows the content of the program to be matched more specifically to the needs of the participants.To the best of our knowledge, this combination of web-based delivery, guidance on demand, and focus on the psychological support of injured persons has not yet been done.Due to this novel approach, SelFIT could also contribute to expanding the scope of therapy options and offers of clinics, practices, or hospitals. Here, the program could serve as a supplement to face-to-face therapy. In addition, SelFIT can also offer extended psychological support, for example after the end of a rehabilitation program in the transition to everyday life at home or as a transitional offer after the end of psychotherapy.The results of this study will provide insight into the efficacy and cost-effectiveness of the SelFIT program. The analysis of the program’s user-friendliness and adherence may provide information for further adaptations to different user needs.Possible limitations of this study include typical challenges of web-based interventions such as the self-selection of participants. This is addressed by recruiting through various channels, such as program referrals from a rehabilitation clinic for injured people, recruitment via social media, and recommendations by physiotherapists. Another potential limitation is participants’ physical restrictions due to the accident, which may make it difficult to use a computer or other technical devices. In such a case, access to the program might be limited.The narrow focus of participants to be included in the study can have disadvantages. Although this allows for more specific tailoring, it makes the target population significantly smaller and recruitment more difficult.


Boarding schools can provide quality secondary education for Aboriginal students from remote Aboriginal Australian communities. However, transition into boarding school is commonly challenging for Aboriginal students as they need to negotiate unfamiliar cultural, social and learning environments whilst being separated from family and community support. Accordingly, it is critical for boarding schools to provide programs that enhance the social and emotional skills needed to meet the challenges. This study evaluated a 10-session social and emotional learning (SEL) program for Aboriginal boarders and identified contextual factors influencing its effectiveness. The study combined a pre-post quantitative evaluation using diverse social and emotional wellbeing measures with 28 students between 13–15 years  and qualitative post focus groups with 10 students and episodic interviews with four staff delivering the program. Students’ social and emotional skills significantly improved. The qualitative findings revealed improvements in students seeking and giving help, working in groups, managing conflict, being assertive and discussing cultural issues. The focus groups and interviews also identified program elements that worked best and that need improvement. Secure relationships with staff delivering the program and participation in single sex groups stood out as critical enablers. The findings lend evidence to the critical importance of collaborative design, provision and evaluation of SEL programs with Aboriginal peoples.  Schools are increasingly urged to play an active role in promoting the social and emotional wellbeing of their students and to pay particular attention to those most vulnerable to negative health and learning outcomes . The secThis education passage for Aboriginal boarders is, however, doubly fraught, because they are separated from the social and cultural support of their family and community, while at the same time having to adapt to a new cultural, social and learning environment and increased academic demands . ConsequIn addition, the wellbeing of young Aboriginal Australians is substantially worse than their non-Aboriginal peers. To address this situation, the Australian Government  declaredThe Western Australian Aboriginal Child Health Survey (WAACHS) found that almost a quarter of Aboriginal children in Western Australia, aged 4–17 years, were at high risk of experiencing clinically significant emotional or behavioral difficulties—a proportion that was substantially higher than the state’s general child population . SimilarThis range of evidence as to the burden of social and emotional difficulties affecting Australian Aboriginal young people highlights an urgent need for effective, preventive efforts to reduce this disproportionate level of distress, increase educational success and improve life trajectories. Here, social and emotional learning (SEL) programs provide a promising pathway. SEL programs have been effective in increasing resilience to adversity, improving mental health and reducing suicidal ideation ,15,16,17The benefit of schools formally teaching social and emotional skills is supported by an extensive literature. The OECD  publisheIn their meta-analysis of programs that sought to enhance students’ social and emotional learning, Durlak and colleagues  identifiSEL programs have now been researched in developed and developing countries across a range of socioeconomic contexts and cultures, using both quantitative and qualitataive methods. The quantitative studies have included meta-analyses and randomized controlled trials that have investigated short-, medium- and long-term impacts of SEL ,22. ThesDespite this large body of research, consideration of cultural responsiveness in the design of SEL programs is a relatively new area, with debate emerging about how social and emotional skills are defined, valued and expressed in different cultural and familial contexts. These contexts are important because cultural traditions shape norms of expression in relation to gender, age and context and also influence how emotions are expressed and interpreted ,23,24. LDobia and Roffey  have, thWithin this collectivist understanding of identity, connectedness is more than the individualized sense of belonging to school and family, which has been identified as a protective factor for young people living in Western contexts . Gee et Although boarding schools have long been a part of the Australian education system, there has been little research into the use of SEL programs as support structures for boarding students generally, and even less for Aboriginal boarding students in particular ,34. MoreFew studies have specifically considered SEL programs for Aboriginal boarding students. Redman-Maclaren and colleagues  reportedMander  investigThis review of research indicates the need for a SEL program designed to suit Aboriginal Australian boarding students. Wellbeing education strategies are more likely to be effective when they are responsive to the social and cultural world students live in, address the specific challenges they experience and integrate students’ perspectives on what is needed to address these challenges . ResearcA SEL program that was substantially designed to attune to the cultural and social context of Aboriginal boarding students from remote communities was evaluated using an explorative mixed-methods pilot study. Based on the philosophy of pragmatism, mixed methods research is a synthesis of quantitative and qualitative research. Pragmatism is a powerful third paradigm choice that delivers research results containing more detail and greater balance . The quaThe ‘Making Connections’ SEL program that this study evaluated is a 10-session program that drew on some elements of the Resilience, Rights and Respectful Relationships (RRRR) SEL program ,44. ThisThe program was substantially re-designed to attune to the context and needs of Aboriginal boarding students. The revised program drew upon the holistic Aboriginal conceptualization of wellbeing as suggested by Gee et al. , which eFurthermore, the program provided scenarios informed by Mander’s research , which rThe boarding staff and teachers delivering the program participated in two days of preparatory professional development in the ‘Making Connections’ Program. This training incorporated a summary of the evidence-base informing the program and active sampling of each of the session activities in the program. Emphasis was given to modelling and explicit coaching in use of the games and collaborative learning strategies. The training emphasized the importance of positive ‘holding’ relationships on the part of teaching and boarding staff, and the essential contribution of a positive relational climate within the learning group ,32.All boarding students from Years 7–9 (average ages 13–15 years) in one Australian Northern Territory school were recruited to participate in the study. Of the 28 students recruited , 21 completed both pre and post surveys. All participating students came from remote Aboriginal communities. All students had actively consented to participate in the program, with accompanying permission from their parents or guardians/adults acting in loco parentis.The student survey was adapted from the instrument used in the earlier classroom based SEL intervention in the same school . The lanThe survey incorporated the Kessler 5 (K5) . The K5 An abbreviated version of the Resilience and Youth Development Module (RYDM) from the California Healthy Kids Survey was incorporated in the survey instrument to measure students’ internal and external resilience factors that have been linked to positive developmental outcomes . This inStudents were asked to rate statements on ‘Internal Assets’  and ‘School Resources’ . Response options ranged from 1  to 4 (very much true) on an unbalanced, 4-point Likert scale. Additional statements on ‘Boarding Group Connectedness’ (5 items) and ‘Social and Emotional Skills’ (5 items) were included in the survey on the basis that they measured specific issues taught in the SEL curriculum. These original items in the study’s survey are listed in t-tests were used to assess whether there was a significant change in any of the measures between baseline and post-intervention.As treated analyses of the K5 and the four internal and external resilience measures were conducted using SPSS v24 . Paired The qualitative component utilized symbolic interactionism as the theoretical framework ,54 and gThe two student focus groups asked students what they learned from participating in the SEL program, what aspects they enjoyed and what aspects they disliked. The students were also asked to suggest how the program could be improved. The focus group with teachers and boarding staff asked about their experiences delivering the program. In particular, they were asked to identify the program elements that worked well and those that did not, and how the program could be better tailored to the needs of Aboriginal students from remote communities. The focus groups were conducted by two interviewers, for support, elaboration in questioning the respondents and to ensure a more complete record of responses. Written notes were taken in all focus groups, as prior discussion with school staff indicated recording of the interviews would be inappropriate. The notes taken by each researcher were typed and compared for consistency immediately after the focus groups.In line with theoretical sampling, insights from focus groups were used to inform additional sampling to gather in-depth information from teachers and boarding staff using individual episodic interviews. These interviews averaged an hour in length and were conducted by one researcher to gather data on the psychological and contextual factors influencing program implementation and how they interact over time. Notes were immediately typed after each interview then returned to the interviewee for checking. All teachers and boarding staff elected to engage in the checking process  and retuThe data was analyzed using grounded theory analysis strategies . Analysit-test values, degrees of freedom and p statistics. ‘School Resources’ was analyzed as two separate scales because some items used a 5-point Likert scale, while others used a 4-point scale.The mean pre and post K5 and the four internal and external resilience measures are presented in The mean K5 score indicated the boarding students were experiencing high/very high levels of psychological distress at pre and post-intervention. After receiving the program, there was no significant improvement in student scores. Similarly, there was no significant change on the RYDM Internal Assets, RYDM School Resources , RYDM School Resources  and Boarding Group Connectedness measures. However, there was a significant change in the Social and Emotional Skills measure, with average item scores increasing from 2.99 at baseline (just under pretty much true) to 3.28 post-intervention (between pretty much true and very much true).Data collected from students and teachers/boarding staff about the SEL program were analyzed based on four major themes: (1) what was liked about the program, (2) what was disliked about the program, (3) social and emotional skills/outcomes of the program, and (4) suggestions for improvement. The key findings for each theme are presented below starting with the student focus group findings, followed by the teachers/boarding staff findings.The students liked the practical nature of the program activities, preferred activities that were student led, and enjoyed participating in the participatory games. The students preferred it when the boarding staff rather than the teachers facilitated the program as they already had a more personal relationship with them. This pre-existing, more holistic relationship meant that engaging in program activities did not feel similar to schoolwork. Both male and female students preferred the gender-segregated sessions, as they felt less pressure to conform to role expectations, and were more relaxed and natural in their participation.The preference for boarding staff over teachers as facilitators stemmed from not knowing the teachers as well and feeling they were expected to behave as students in a classroom, which inhibited their participation in activities. They did not like it when didactic teaching methods were used because it devalued their perspectives on the issues being considered. They did not like the program being delivered instead of their one-hour evening homework period, as by this time they were tired, hungry and often arrived late because of sporting commitments. They reported that some topics were boring because the material covered issues that they felt they already understood. They also said that the activities used too many words they did not understand, and involved too much reading and writing. The students felt more confident about participating when the activities were more talk based.Overall, students thought it was a good program for discussing the social and emotional issues they faced, and for providing them with the opportunity to build practical skills in this area. They said they developed greater self-confidence, which made them more comfortable expressing their opinion and helping others experiencing difficulties. The students believed they developed better skills for managing conflict and working with others in group situations. They also indicated the program improved their ability to concentrate when in class.In terms of improving the program, the students suggested the sessions be delivered several times during the week rather than just once, as it would be easier for them to remember and build on what had been learned previously. They suggested the same boarding staff, who they knew, deliver the program as they already had a relationship with them and were more comfortable talking about emotional issues with them. The students wanted the program to focus more on helping them develop emotional skills, including developing personal skills that would make it easier to get a job when they left school. Finally, the students suggested the program provide more opportunities for cultural sharing as they missed that when they were away from home.The analysis of the teacher and boarding staff focus groups and individual episodic interviews shows that the teachers and boarding staff valued the training they received to implement the program. They considered the activities practical, well-structured and with a good explanation as to relevance for students. They also valued being provided with the theory that underpinned the program activities and the research evidence that supported their effectiveness. Both groups agreed that the students responded better when boarding staff took the lead in facilitating activities because of the more relaxed nature of the relationship, which confirms the perspectives of the students. Also like the students, the teachers and boarding staff found that the gender-segregated sessions were better managed by the students and more productive in terms of topic focus.The teachers and boarding staff indicated that the interactive and animated nature of the program coupled with the variety of activities was engaging for the students. The use of games was mentioned specifically as setting the right tone for the sessions, which was further enhanced if a non-classroom setting was used as the workshop space. The teachers also mentioned that their prior involvement in delivering the SEL program to all Year 7 and 8 students in the school was a considerable advantage in terms of enhancing their confidence using student centered interactive techniques.One teacher made the point that it was hard for the students to relate to teachers as anything other than as authority figures who expected them to behave well and focus on their study. This situation tended to make teacher-facilitated sessions default to the instructive pattern of a classroom lesson, even though that was not the intention or design of the program. Didactic delivery also tended to occur when teachers prioritized ‘covering the material’ in the allocated time. Both groups indicated that the co-gendered sessions were problematic because the students were distracted and found it hard to focus on the topic. Delivery of the program in the evenings was not considered ideal because the students were running out of energy.There was also general agreement that the program sessions should be grouped closer together to aid memory and continuity as the weekly interval between sessions meant time had to be spent reviewing what had been covered in the previous week. Another issue mentioned by the teachers and boarding staff was that some students, particularly boys, could not see the point of the non-competitive nature of the collective games played because there were no winners. Finally, both student and facilitators made the point that the literacy requirements of the program could be better tailored to the students and should contain more culturally relevant material.The teachers and boarding staff agreed that throughout the program there was a noticeable improvement in student social and emotional skills. They particularly identified improvements in the students’ ability to speak in public situations, to seek help from adults and to work co-operatively with other students. They also commented on the personal growth they observed in the students over the course of the program. For their part, students said they were more confident about sharing their cultural background and showed greater cross-cultural understanding.There was range of suggestions from teachers and boarding staff for improving the program. As a general approach, seeking ideas from senior boarding students was seen as giving greater relevance and substance to the program because of the challenges they had experienced and the skills they had developed to overcome them. In terms of program content, the suggestions stressed less reliance on literacy skills; greater emphasis on identifying and reinforcing existing strengths; acknowledging and rewarding task completion; and maintaining a focus on emotional regulation, conflict resolution, relationship skills and strategies for maintaining a sense of wellbeing. In terms of program delivery, the suggestions emphasized that the pedagogy should be informal, interactive, affirming and enjoyable; games should be included, but with a purpose understood by students; the sessions should be delivered during the day, rather than in the evening and should be grouped close together. Small, gender-specific groups are preferable; and there should be activities that facilitate cultural sharing. In terms of program facilitation, there was strong support for the program being delivered by boarding staff who were familiar to the students and with whom students had pre-existing relationships. An additional suggestion was to have a respected Aboriginal facilitator where possible.The primary aim of this study was to evaluate the relevance and effectiveness of a pilot SEL program that had been designed for use in the Aboriginal boarding context. The quantitative evaluation produced mixed results. The social and emotional skills of the students did improve significantly from pre to post intervention, but there was no significant change on the K5 Psychological Distress, ‘Internal Assets’, ‘School Resources’ and ‘Boarding Group Connectedness’ measures. The qualitative data about program relevance and contribution was more affirming. The analysis of the three focus groups  and the individual episodic interviews with staff indicated that both students and staff consistently and independently reported an increase in student social and emotional skills such as seeking help from and giving help to others, working in groups, managing conflict and asserting themselves. In addition, the students themselves experienced, and staff observed, the following associated outcomes: increased self-confidence, better ability to focus on school-work, and personal growth in general. Interestingly, and importantly, the teacher/boarding staff identified greater student confidence in discussing cultural issues. The qualitative findings also provided insights into what worked, what did not work and how the program could be improved.These mixed results are encouraging in the context of what can be realistically achieved in the short term by a pilot SEL program in its early phase of development and testing. The qualitative results are consistent with the considerable research on the benefits of SEL programs ,19,62 anWhile the changes associated with the program are encouraging, the results from the K5 measure of psychological distress are a cause for concern as they indicate that the boarding students were experiencing high/very high levels of psychological distress at both times of measurement. These results are congruent with research evidence of high psychological distress and heightened mental health risk among Aboriginal young people ,11,12,13Two strong themes emerged from the focus group data that relate to the secondary aim of this study, namely identifying the contextual factors that influenced the impact of the program. The first key theme is connection or relatedness. The relationship between the boarding students and boarding staff emerged as critical for facilitating students in engaging in the program. Insights into the importance of a positive relational climate are also provided by LaGuardia and Ryan  and ReevHowever, students reported that they prefer to engage in SEL with boarding staff rather than teachers because the relationship with boarding staff is more personal and open, and occurring in an informal setting that is being less constrained by authority and didactic teaching. In such relationships there is a sense of safety that provide a secure base from which to learn. The importance of the teacher student relationship, specifically in the Aboriginal context, was also outlined Dobia and Roffey  in theirThe boarding staff interacting at a personal level with the students, outside of the formal education context, enables them to better able to balance authority with acceptance and nurturance in ways to which young Aboriginal people can relate. When Aboriginal students come to boarding school, they face a loss of the emotional security that comes from living with their family, having an extended network of kinship support and understanding their Aboriginal cultural environment. At the same time, they need to adapt to considerable changes in their education process and cultural setting, while experiencing the challenges of adolescence. Experiencing trusting and nurturing relationships with boarding staff would seem to be central to improving SEWB in the boarding setting. Hence, creating a secure relational base within the boarding school environment is an important contextual factor influencing the contribution of a SEL program.The second contextual factor was quality and consistency of program delivery, which when compromised was disruptive and negatively affected engagement and security of the students. There were three key inconsistencies reported that affected the quality of program delivery. Firstly, the program was not consistently led by the same facilitator(s) due to staff rostering. This inconsistency was reported by the students as making it more difficult to create trusting relationships and a safe learning environment. This factor was heightened due to the disparity in the more formal facilitation style used by the teachers and the more relaxed style of the boarding staff. A second factor disrupting the relational process was the presence of observers in a number of sessions. These observers were visiting educators not known to the students who attended to witness the program in operation as it was a novel initiative within the school. These interruptions inhibited student participation and interrupted the natural flow of the sessions.A third inconsistency in program delivery occurred in relation to group membership. On some occasions the sessions were delivered to mixed gender groups, while in other instances the sessions were conducted in single gender groups. The group membership depended on the topic being presented as some topics were gender sensitive and it would have been culturally inappropriate to include both genders. There was also trialing of the type of group that worked best in terms of student engagement. Feedback from all focus groups indicated that the single gender groups worked best overall and exploration of this issue will usefully inform future SEL programs with Aboriginal boarders. However, in the context of this study the discovery process introduced inconsistencies that were disruptive.This study is limited by the small number of participating students from one school and by the absence of a control group. However, the study was designed as a pilot for the purpose of exploring the relevance and contribution of a SEL program in its first phase of piloting with Aboriginal boarding students. Desired outcomes of the pilot included suitability of the study design, evidence of program effect, and student and facilitator advice for program development. Consequently, the design limitations have to be balanced against the benefit that can come from a small pilot. The scope of the focus groups with students was also limited by the scale of the study. Only one focus group was conducted with each gender and the students were invited based on their ability to comfortably express themselves in English. Accordingly, the views expressed came predominantly from older students who were more confident in using English as a language to express their views, meaning that the perspectives of younger students and those with more limited English were not included.This study has demonstrated that an evidence-informed, culturally responsive SEL program designed for Aboriginal middle school students (Years 7–9) can be effectively delivered by boarding staff in the boarding school setting, can achieve student endorsement, and can lead to significant improvement in student social and emotional skills. Particularly important findings for the context and delivery that underpinned engagement with the program was the need for secure relationships with those delivering the program, the importance of cultural sensitivity as an enabler of effective engagement, and the importance of adhering to participatory rather than didactic modes of program delivery. Secure relationships with facilitators hold students in a safe and nurturing space, and these secure relationships made it easier for students to explore cultural, social and emotional issues together. Accordingly, future SEL programs for Aboriginal boarders need to consider not just program content and delivery, but additionally the choice of facilitators to ensure program provision occurs in the context of secure, authoritative and nurturing relationships. The finding that complex and changing contextual factors, especially cultural factors, affect the relevance and impact of the program lends further evidence to the importance of co-designing, co-evaluating, co-facilitating and co-revising programs together with Aboriginal peoples . As stud