Introduction: Sudden impact disasters often result in the displacement of large numbers of people. These movements can occur prior to events, due to early warning messages, or take place post-event due to damages to shelters and livelihoods as well as a result of long-term reconstruction efforts. Displaced populations are especially vulnerable and often in need of support. However, timely and accurate data on the numbers and destinations of displaced populations are extremely challenging to collect across temporal and spatial scales, especially in the aftermath of disasters. Mobile phone call detail records were shown to be a valid data source for estimates of population movements after the 2010 Haiti earthquake, but their potential to provide near real-time ongoing measurements of population displacements immediately after a natural disaster has not been demonstrated.Methods: A computational architecture and analytical capacity were rapidly deployed within nine days of the Nepal earthquake of 25th April 2015, to provide spatiotemporally detailed estimates of population displacements from call detail records based on movements of 12 million de-identified mobile phones users.Results: Analysis shows the evolution of population mobility patterns after the earthquake and the patterns of return to affected areas, at a high level of detail. Particularly notable is the movement of an estimated 390,000 people above normal from the Kathmandu valley after the earthquake, with most people moving to surrounding areas and the highly-populated areas in the central southern area of Nepal.Discussion: This analysis provides an unprecedented level of information about human movement after a natural disaster, provided within a very short timeframe after the earthquake occurred. The patterns revealed using this method are almost impossible to find through other methods, and are of great interest to humanitarian agencies. Operationally they were used in the aftermath of the Haiti 2010 earthquake to quantify population mobility and displacement patterns, in the Haiti 2010 cholera outbreak outputs to inform the early response activities,,,,,,,,,De-identified mobile phone call detail records (CDRs) contain the time and associated cell tower of text messages and calls and thus can be used to study human behaviour and mobility patternsHere, we report on ongoing work following the 2015 Nepal earthquake, where estimates of national level population movements based on de-identified data from 12 million mobile phones were released to all parties within nine days of the earthquake. The work was made possible by the establishment of a collaboration with the operator before the earthquake. Details of the analysis technical framework, population movement patterns after the earthquake and areas for future research will be discussed.The Gorkha earthquake, named from the district in which it originated, struck on the 25th April 2015 at 11.56 am local time. The quake had an intensity of 7.8Mw with an epicentre at 28°14'24''N, 84°45'0''E,As of 1st June 2015, the Nepali Government estimated the earthquake to have caused 8,673 deaths and 22,309 injuriesThe destruction of villages and towns in the most severely-affected regions further contributed to population displacement, compounded by severe damages to transport infrastructure Mobile phone use in NepalNepal has 26 million mobile phone subscriptionsSetupThe Flowminder Foundation develops methods for estimating mobility patterns and population displacement. It has established collaborations with mobile phone operators in countries where analyses of de-identified mobile operator data can support preparedness and response to humanitarian disasters. An agreement between Flowminder and Ncell in Nepal was signed 6 months before the earthquake. The first technical planning meeting between the parties took place in Kathmandu one week prior to the earthquake. Although the technical set-up had not been completed at the time of the earthquake, Ncell were able to provide access to de-identified data for Flowminder analyses within six days of the earthquake.CDR analysis was undertaken in compliance with the GSMA privacy guidelines developed in the context of the Ebola outbreak,,The analysis framework was developed in the Python programming language, and consisted of a series of preprocessing steps automatically run for each new day’s CDR data, followed by separate analyses designed to investigate particular aspects of mobility after the earthquake. Analysis was performed using custom-written code, which used the standard scientific Python stackPreprocessingEach day’s CDRs were provided by 1am on the following day and historical data back to January 2015 were also provided. The preprocessing steps were designed to reduce this raw CDR data (which was provided as approximately 12GB of CSV files per day) to a more manageable size, which consequently lowers the time and memory usage of the subsequent analyses significantly. The preprocessing involved:location ID, thus reducing the data to around 2.5GB per day.Shrinking the raw data by removing unused information, and assigning each separate tower location a Calculating a ‘daily location’ for each user . This was designed to be a single tower location which represents the location of the user for that day. As the aim was to investigate displacement, the overnight location of a user determined their daily location. Investigations were made into how best to estimate this location from the location of all calls a user made that day, including subsetting by time, or spatially grouping calls. However, in Nepal, the most appropriate definition was judged to be simply the location of the last call the user made that day.,,Assigning daily locations on administrative boundary level based on the tower level location. In this work administrative boundaries at level 3 (District) and level 4  were used, digitised from Nepali governmental maps by the UN Organisation for the Coordination of Humanitarian AffairsEstimating population flowstransition matrix containing the flow of users between each possible pair of locations,Conceptually, flows can be estimated by simply recording a location for each user at two different times, and then counting the number of users who moved from one location to another. This produces a post-earthquake flows) were normalised using pre-earthquake mobility estimates . Normal flows were calculated as the changes in location from a benchmark period  to a comparison period just before the earthquake . Post-earthquake flows were calculated between the benchmark period and the focal period, which is the period of interest, the most recent week of data  moving between each pair of locations. This can be summarised to produce two metrics for each region: the total above-normal inflows , and the total above-normal outflows .The flows calculation produced a Scaling population flowsHumanitarian agencies require information about total population flows, rather than the subset represented by subscribers. Assuming SIM card movements to be representative of population movements, absolute flows were estimated by scaling SIM cards counts based on local Ncell user penetration rates. The number of active SIM cards in an area, for example an administrative unit, was calculated from CDRs. Pre-earthquake census-based population data is however not available per tower area or for small administrative areas. Data from WorldPop, which provides gridded population estimates per 100x100 meter grid square for the entire country, was used to estimate finer level population countsFor each District (administrative level 3), WorldPop population counts for 2015, adjusted to match UN estimates at the national level, were summed to produce administrative-level population estimates. Scaling factors, used to estimate absolute population flows were then calculated at District level. It was assumed that the ratio of the flow of SIM cards resulting in the following scaling factor used in the analyses:This was validated for the context of Nepal by comparing the scaled estimates of total inflows (including static users) for each area during the pre-earthquake baseline period with the census population data for that area, which showed a close match.To understand how flows were changing in the weeks following the earthquake, anomalous flows were calculated for each week of interest, with the focal period gradually moving forward in time.Analyses of returning residentsAn additional question of importance to relief work is identifying regions to which people have not returned, as this may indicate regions in which recovery has not yet reached sufficient levels. One way to assess this is to identify users who have left their home location due to the earthquake, and continue to reside in another location.This can be done by determining the home location of users over a long benchmark period prior to the earthquake (1st January until 7th April 2015 in this case), using the same method as for the flows calculation above. A user was counted as displaced if they had spent at least seven consecutive days away from their pre-earthquake home location in a two week period after the earthquake. Iterating through the remaining data the percentage of displaced users who remained away (i.e. at a location different to the pre-earthquake home location) was calculated.Plotting the percentage of users who had not returned over time gives an indication of the rate at which users are returning to a given location. As this is a percentage it does not suffer from the uncertainties that scaling may introduce in the analyses above. Over time, a portion of users disappear from the data set. This may be because they have left Nepal or their SIM card has become inactive. We assumed that the same percentage of missing users remained away from home as those who were present in the data set.Using this data, trends in the ‘return rate’ for each region can be derived as well as snapshots of the most recent data. In the latter case regions are coloured based on the mean and standard deviation of the dataset, marking regions with a high  as well as to the highly-populated areas in the central southern region of Nepal . OverallLooking at the flows into each region over time, from just after the earthquake until mid-July  shows shThe other regions can be categorised into three groups: those which experienced little changes in flows due to the earthquake , those which experienced very large inflows immediately after the earthquake  and the remaining regions, which experienced a moderate increase in flows  immediately after the earthquake. Flows in all regions  seem to have stabilised since late June.The trends in return rates over time  show a sExamining this spatially, at VDC-level , shows wWe showed that an estimated 390,000 people above normal left the Kathmandu Valley soon after the earthquake. Many of these moved to the surrounding areas, and the highly-populated areas in the central southern area of Nepal. People who left their home area after the earthquake have gradually returned, with the return rate varying between regions. By late July, all Districts had less than 15% of people still away from their original home location, with some as low as 5%.The analyses presented above have provided an unprecedented level of information about human displacement after the Nepal earthquake. This data has never been available before in such a short time after a natural disaster has occurred, which was made possible by having a data access agreement in place as well as the operator providing rapid access to the data very soon after the earthquake. The analyses reveal national level population mobility patterns and return rates which are extremely difficult or impossible to acquire using other methods. These are of great relevance to humanitarian agencies, as mobility patterns can help identify where aid should be directed, and low return rates can identify areas where recovery and reconstruction work may not be progressing well.Reports containing these results, along with interpretation, were distributed to relevant humanitarian agencies working on the ground in Nepal, and are available online at the WorldPop website . Key results of analyses were included in reports by the UN Resident Coordinator,,The analyses have several limitations, some of which were due to the speed with which the analyses needed to be delivered and several of which are possible to address in future studies. Phone ownership is skewed towards certain population groups: potential biases include higher ownership of phones among males than females as well as among higher income groups and certain age groupsFurthermore, analyses estimate the number of people moving after the earthquake but not the reasons for doing so. While estimation of population flows above and below normal levels aims to address this issue, a higher precision in displacement estimates would have been possible if analyses had been combined with population surveys. Such surveys are now being planned as well as comparison between CDR-derived displacement estimates and survey-based data collected by third parties.CDRs only provide location updates for individuals when a call is made. In this dataset calling frequencies were relatively low, with around 50% of people calling at least every other day. Detailed movements among users with infrequently updated locations are therefore missing from the data A small proportion of SIM cards become inactive over time. New SIMs tend to enter the dataset at roughly the same rate but there is no way of linking the old and new SIMs to a particular user. Most analyses can be corrected to account for this effect, but this may cause bias if the data is analysed over very long time frames.In these analyses we assumed that towers belong to the administrative area in which they are placed, as tower functionality and replacements took place repeatedly during the period. Coverage areas do however often extend over more than one administrative area, which may have contributed to bias. This can potentially be improved by dynamically accounting for changing tower coverage areas in the analyses. For many VDC areas little or no data is available. The principle reason for this is that the mobile network did not have sufficient coverage in these regions to make statistically significant inferences. However, while these areas geographically make up a large proportion of the area of Nepal, they are mostly concentrated in the sparsely populated mountainous areas with small population densities. We were not able to take into account seasonal drivers of population movements. Ideally, one or several years of historical data would be used to adjust for seasonality in these mobility patterns.Avouac et al. (2015)The value of CDRs when integrated with more traditional data sources within modelling frameworks has been shown across multiple disease, development and disaster application examples. The field of CDR analytics in the humanitarian space is therefore moving beyond pilot studies and towards a more mature and operationally valuable platform. Here we have shown how this can be achieved in a disaster response situation through the partnership of scientists, mobile network operators and response agencies. The work described is not a single study, but the initiation of an ongoing dynamic and near-real time monitoring system, providing data support to a country with high levels of poverty, and populations that are highly vulnerable to the effects of natural disasters and disease outbreaks.The authors have declared that no competing interests exist.


Community-based obesity treatment programs have become an important response to address child obesity; however the majority of these programs are small, efficacy trials, few are translated into real-world situations . Here we report the short-term impact of a scaled-up, community-based obesity treatment program on children’s weight and weight-related behaviours disseminated under real world conditions.Children age 6–15 years with a body mass index (BMI) ≥85th percentile with no co-morbidities, and their parents/carers participated in a twice weekly, 10-week after-school child obesity treatment program between 2009 and 2012. Outcome information included measures of weight and weight-related behaviours. Analyses were adjusted for clustering and socio-demographic variables.age 10.1 (2.0) years; Mattaendance 12.9 (5.9) sessions). Beneficial changes among all children included BMI (−0.65 kg/m2), BMI-z-score (−0.11), waist circumference (−1.8 cm), and WtHtr (−0.02); self-esteem (+2.7units), physical activity (+1.2 days/week), screen time (−4.8 h/week), and unhealthy foods index (−2.4units) . Children who completed ≥75 % of the program were more likely to have beneficial changes in BMI, self-esteem and diet  compared with children completing <75 % of the program.Overall, 2,812 children participated (54.2 % girls; MThis is one of the few studies to report outcomes of a government-funded, program at scale in a real-world setting, and shows that investment in a community-based child obesity treatment program holds potential to produce short-term changes in weight and weight-related behaviours. The findings support government investment in this health priority area, and demonstrate that community-based models of child obesity treatment are a promising adjunctive intervention to health service provision at all levels of care. One in four Australian children aged 5–14 years are overweight or obese . The eviIn public health, once interventions have demonstrated efficacy through randomised controlled trial designs , the next steps are to translate the research through replication and to scale-up and disseminate the interventions to a much larger population in the ‘real-world’ setting . RCTs arMEND is a UK community-based child obesity treatment intervention –11 desigA pre-post non-controlled design was used to report the outcomes of the Go4Fun program implemented between 2009 and 2012. In total, 293 programs were delivered by 15 Local Health Districts (LHD) across NSW. Government funding for the program is based on the proportion of overweight/obese children and geographical spread of each LHD. Written consent by a parent was a requirement for participation. The study was approved by the University of Sydney Human Research Ethics Committee.n = 70 and 14.0-14.8 years n = 19). Children had to be overweight or obese (body mass index [BMI] ≥85th percentile based on the CDC growth references) [Participants were either self-referrals  or referred by health professionals, relevant organisations and community members. Whilst the Ministry of Health centrally manages the program, each LHD undertakes recruitment within their area  and participates in local partnerships and promotions to target communities at social disadvantage. Children were eligible for the program if they were aged 7–13 years, however a small number of children whose birthdays were close to the age criteria were included in the program and the analysis , based on the Australian Bureau of Statistics’ Socio-Economic Indexes for Areas (SEIFA) . SES was2) was calculated and BMI z-scores determined from CDC reference data [One trained facilitator at each LHD collected outcome measures at the first and last session of the program. Measures included the child’s height (m), weight (kg) and waist circumference (cm). BMI , daily serves of fruit and vegetables (open ended), consumption of sugar-sweetened beverages, potato chips, lollies/chocolate, and takeaway foods . For the analysis, the responses were dichotomised as ‘not frequent’ (rarely once a week) and ‘frequent’ . An unhealthy food score was also derived as an index of the frequency of eating unhealthy foods , with higher scores indicating a higher frequency of eating unhealthy foods. Parents also reported on their comprehension of nutrition labels, how often they cooked “fresh food from scratch at home”, and how often the family ate meals together at the table. Children completed the adapted Rosenberg Self-Esteem Scale, which comprises 10 items on a four-point Likert scale, with higher values (score range: 0–30) indicating higher levels of self-esteem .Data analysis was undertaken using SAS software . The purpose of this study was to report change in real-world, uncontrolled circumstances so missing values were not imputed. However we did assess imputation of baseline values and the direction and order of magnitude of coefficients were similar in those estimated using complete case data. Additionally, to provide policy-makers with evidence based on real world compliance where the threat of not achieving 100 % participation in community-based programs must be considered we made a pragmatic decision which would be considered useful for policy decisions and defined ‘completers’ as children who attended ≥75 % of intended program sessions and non-completers as children who attended <75 % of the program.For continuous variables mixed models were used to estimate the mean values and 95 % confidence intervals (CIs) at each time point (before and after the program) controlling for age, sex, season, area level of socio-economic disadvantage , area level of remoteness (ARIA+), and the number of sessions attended. Participant was modelled as a random factor to account for the paired before and after values on the same participant. Programme ID was also modelled as a random factor to account for the cluster design of the study. The mean change in outcome between before program attendance and after the program was assessed using a linear mixed model with change as the dependent variable and controlling for baseline as well as the factors above but with only Programme ID as a random factor. Effect sizes were determined using Cohen's d  and calcFor categorical dietary variables, generalized linear mixed models were used to calculate the prevalence of being in the frequent consumption group before the program and after the program. Again the model was controlled for the relevant fixed and random effects. The prevalences were compared using odds ratios and their 95 % confidence intervals to compare the odds of being in the frequent consumption group after the program as compared with before.Further modeling was done to compare the outcomes of completers and non-completers. The models were analogous to those previously described but instead of number of sessions included as in independent variable in the model, a binary variable of completers versus non completers was included. In the continuous case, change from baseline scores were modeled as the dependent variable and the mean change in each group of completers and non-completers was calculated and then compared. In the binary outcome case, the probability of being in a high consumption group was modeled as the dependent variable through a logit transformation. A completer versus time interaction was added to the models to calculate both the odds ratios for the odds of being in the high consumption group after the program compared with before for the completers and non-completers groups separately. The overall odds ratios comparing completers and non-completers over both time points were also calculated. The linear mixed models were implemented in SAS v9.3 using proc mixed for the continuous outcomes and PROC GLIMMIX for the binary outcomes. Model parameters were estimated using residual maximum likelihood and residual pseudo-likelihood methods respectively.n = 851) attending ≥ 90 % of sessions. Completers were more likely to be girls (p = .008), non-Aboriginal (p = .001), and to live in less socially disadvantaged areas (p < .001)  were recruited in 293 programs in 15 LHD’s. Of these children, 336 (10.7 %) did not attend any sessions 2,812 attended one or more sessions . Of the 2,812 children who attended the program, 1,520 completed ≥ 75 % of sessions (‘completers’) with 56.0 % . Overall, the mean changes in program outcomes were statistically significant and in the desired direction , with the exception of understanding nutrition labels, which showed a 77 % reduction in ‘always’ understanding nutrition labels after attending the program . Medium effects sizes (d = .20-.38) were observed for change before and after the program in self-esteem, screen time, physical activity, daily vegetable intake, and a large effect size for change in unhealthy food index (d = .41). Tables p < .001).Table dex d = .1. TablesThe purpose of this study was to report the outcomes of a known, effective child obesity treatment program (MEND) that was government-funded, scaled-up and implemented across communities in NSW, Australia. The findings indicate that in the short-term significant, albeit clinically small, improvements are achievable in children’s adiposity, weight-related behaviours. While there are no similar studies to compare with our findings, they are commensurate with those reported by the UK MEND at 6-months under an RCT design . The impn = 116) while Go4Fun® has been scaled-up and disseminated into a real-world setting. Further, only obese children were enrolled in the UK program and the intervention was longer  [Differences in the magnitude of change and a higher retention rate in the original UK efficacy trial  may be dChildren who participated in Go4Fun did improve their screen-time, physical activity and, dietary habits; key weight-related behaviours which must precede change in adiposity. Importantly, improvements in children’s self-esteem suggest that attending the program had no negative effects on the children. An unexpected finding was the decline in parents understanding of nutrition labels on completion of the program. This may reflect the current confusing status in Australia of different nutrition labelling formats   on food We examined outcome differences between completers and non-completers to inform policy decisions on the program’s delivery. Greater beneficial changes in BMI and diet behaviours were observed among children who completed the program compared with children who did not complete the program. Although children who completed the program did not consistently demonstrate better outcomes on all weight-related behaviours, the fact that children who completed the program had a significantly higher probability of decreasing their intake of ‘extra’ foods’  is highly relevant given the evidence shows that Australian children over-consume such foods , 22. OthInformation on how scaled-up programs such as Go4Fun® perform in the real-world outside of controlled circumstances is limited and, yet for policy makers this information is critical for program funding and delivery decisions. Process evaluation of the program  showed tThere are a number of limitations to consider in the interpretation of our findings. The high rate of missing data has the potential to introduce bias which may impact on the effect sizes reported here. Parents were asked to complete a questionnaire on behalf of their child at the first and last session, with the Go4Fun facilitators, yet for unknown reasons, many questions were not completed suggesting our data were missing at random. Both the questionnaire and software were developed by MEND Australia, however, there were issues with data entry  and the high rate of missing data suggests better facilitator training is required to ensure program fidelity in real-world situations. Similarly the reliability the anthropometric measurements was not assessed so the level of measurement error is unknown. Children’s pubertal status was not measured because of the invasiveness of such tests in a community-based program and may have confounded our results given maturation has a large independent impact on adiposity, fitness and cardio-metabolic risk.The lack of long term follow-up is an obvious and significant limitation as these data would provide valuable information on the sustainability of positive change in weight-related behaviours, which would further inform program planning. There is no definition of completion for community based interventions so defining completion as ≥75 % attendance could be considered contentious, however 100 % attendance is an unrealistic expectation when shifting from controlled to real-world implementation. Attrition rates from paediatric weight-loss programs are not known, but among adults attrition rates vary from 10 to 80 % with the most predictive correlates for dropping out being high treatment expectations and low self-efficacy . For polThe finding that improvements in weight and weight-related outcomes remained significant after controlling for potential confounders suggests that the program helped facilitate positive lifestyle changes in the children. Furthermore, almost three-in-five children completed the program which suggests that government-funded, community-based child obesity treatment programs do resonate with most participants, can be scaled-up and provide improvements in weight and behavioural outcomes . Longer-Go4Fun® programs demonstrated small but beneficial changes in overweight and obese children’s weight and weight-related behaviours in the short-term. Completing the program was associated with greater improvements in diet, but not other weight-related behaviours. An important policy decision which will influence funding is to examine the current program format to determine the optimal number of sessions required to achieve desired outcomes. The outcomes provide promise that community-based child obesity treatment programs are an adjunctive intervention to tertiary obesity health service, but long term follow up is necessary. Go4Fun is a service delivery program, however strategies to minimise missing data would assist the ongoing evaluation process.


Introduction: The execution of composed educational programs for general practitioners is one of the most common methods of continuing medical education. This research project aims to evaluate one of these programs.Methods: For this purpose, a pre- and post-test design was developed. The subjects consisted of 45 participants. They were tested in two stages: before and after the program. A questionnaire was also used to gather the participants’ views on four variables including teachers' behavior, the degree of achieving the objective of the program, objective of the learner, and satisfaction with the program.Results: Based on the results of this study, the mean scores of the participants’ knowledge increased from 10.05 (pre test) to 12.61 (post test), (p<0.0001). In addition, the results showed that the teachers’ behavior and satisfaction with the program were rated by participants as the highest and least, respectively.Conclusion: The results of this research are indicative of the effectiveness of the composed educational program in continuing medical education. Nevertheless, such programs are recommended to be further evaluated with more rigorous design. Medical sciences change rapidly with new scientific information and technology ; therefoOn the other hand, the quality control and establishment of effective continuing medical education programs have been under consideration from long ago and the need for their evaluation has repeatedly been cited -6. NeverComprehensive evaluation of CME programs needs sufficient time, energy and resource for planning and organizing evaluation. That's why the evaluation methods mostly focus on opinion evaluation. Although the effect of CME on behavior change has been investigated , there aIn an investigation of the status of CME of the Iranian Medical Society, it was concluded that in most CME programs complaints, violations and problems with medical documentation and the society’s culture are not considered. The main objection of the participants in the program was lack of harmony among the professional needs of the participants and clinical problems of the physicians with the subjects raised in the continuing educational programs . In anotPresently, CME is presented in most of the main universities and service providing centers of the country. This has been immensely expensive. Evidence suggests that in most cases, the evaluation of these programs is only conducted using the opinions of the participants which indeed cannot be illustrative of different aspects of evaluation . ConsideIn this pre-test post-test evaluative design study, 45 general practitioners who attended a training program participated. Five variables including “level of knowledge”, "meeting the program and participants' objectives", "teachers' behaviors", and "satisfaction with the program" were investigated using a knowledge test and a valid and reliable 19-item instrument for evaluation of continuing education program. The knowledge test was developed by the professors of Shiraz University of Medical Sciences. They were asked to develop relevant higher order multiple-choice questions in accordance with the objectives of their speech and present them to one of the researchers. The questions then were modified by an expert panel to ensure its validity. Also, the reliability of the test was measured using the result of the same program executed previously. KR20 of the test revealed a high reliability for the test (0.88). The same knowledge test was used in both pre-test and post-test.To measure other variables, Henker and Hinshaw’s questionnaire was used. This questionnaire was developed based on Steven’s theoretical framework for measurement of the above-mentioned variable . The ori At the beginning of the program, a brief description of the method in which the research was conducted was brought to the attention of the physicians. To make their identities confidential, researchers prepared numbered cards enclosing them in envelopes.  Each physician, then, selected an envelope (containing the card) and considered its number as his/her identity number. They were requested to write this card/number on their examination sheets and evaluation forms. The knowledge test was taken at the beginning of the first day and the end of the last day (the 4th day). The questionnaire for evaluation of other variables was distributed among the subjects at the end of the program. Every attempt was made to secure a good administration of the test, an appropriate environment, space and timing. Nevertheless, with respect to the inclusion of the codified number on the sheets , the participants did not feel nervous or anxious at all.To analyze the data, the paired t-test was used. For other data, multiple range test and ANOVA were used. Spss 14  was used and p<0.05 was considered as significant level Ethical considerationsInstitutional Review Board (IRB) approval for the study was obtained from the Ethics Committee of the University (ECSUMS). Verbal consent was obtained from each physician. The purpose of study, voluntary participation, confidentiality and freedom to take the test and provide feedback on evaluation forms were reviewed. 45 physicians participated in this study  with a mean age of 32.5 ranging from 26 to 44. The participants' level of knowledge before and after the educational program as compared in the two administered test shows that the mean±standard deviation of the scores increased from 10.05±1.48 to 12.61±1.61, which is a significant difference (p<0.0001).The mean scores of the items included in the opinion questionnaire showed that the mean scores given to the 19 existing items ranged from 3.91 to 5.27 (out of 6). Teachers' behaviors obtained the highest scores . The low“Responsiveness of the program to actual problems encountered while working”“Appropriateness of the program organization,”“Ability of the program to fulfill expectations”“Comprehensiveness of the program”The result obtained from this evaluation indicates that participation in the continuing educational program is effective in enhancing the knowledge level of the physicians. Comparison of the mean rating obtained from the participants’ views on four other variables showed that the highest and lowest mean ranking belonged to the teachers' behavior and satisfaction with the program, respectively .Although knowledge scores of the physicians were unfavorable at the pretest, they increased as the result of attendance in the composed CME program. In other studies, enhancing the knowledge level of physicians has been considered as evidence of the effectiveness of CME programs , 15-17. Extensive content and didactic teaching strategies usually applied in our CME programs are not appropriate for producing a change in behavior. It appears that the change in behavior would rather be expected after CME programs focusing on more specific contents. In such specific courses, medical records may be used as a tool for performance evaluation . Also diTherefore, complexities of the factors associated with the change in behavior make it difficult to attribute any change in behavior to a single CME program. Furthermore, comprehensive evaluation of CME programs is not feasible in all situations. Methodological and organizational barriers in conducting such evaluation programs have been highlighted as the reason for the scarcity of articles measuring the effect of continuing education programs on patients . ConsideIn the current study, we did not measure competence or performance of the physicians. However, considering the existing correlation between the scores of written tests and performance based tests  and the The results of this research showed that items related to participants' expectations were rated at a moderately low level. This finding may be attributed to the lack of harmony between educational content and learners’ real needs, and/or program objectives. Lack of harmony between social needs and the time allotted to these needs during continuing education program in Iran was identified in previous research . This fiA comparison of the mean rating of the participants’ views showed that teachers' behavior obtained the maximum mean rating. This result was not unexpected as very experienced teachers took charge of continuing education programs. This is not always the case. CME delivered through community-based educationally influential physicians is identified as an effective way to change the physicians’ behavior in small communities with no prior ongoing educational programs .Although the mean ratings of the physicians' views were all in acceptable ranges, that for satisfaction with the program was lesser than the means of other variables. Satisfaction with the program, however, is subjective to subjectivity and might be affected by many individual factors such as motivation and interests. Also based on the findings of this evaluation, the following low rated items by our participants may explain the slightly lower rating of satisfaction with the program . These iThe evaluation of the CME program meets the criteria of the Accreditation Council for Continuing Medical Education (ACCME) which required the CME providers to measure the effectiveness of the CME activity in meeting the identified educational needs in terms of satisfaction, knowledge, or skills .In summary, this evaluation showed that participation in the form of CME program results in an increase in the knowledge level of physicians. Participants also rated the teachers' behavior as the highest rank. They achieved the program’s objectives and learning objectives and were moderately satisfied with the program. However, further evaluation using more rigorous design is suggested to delineate a better image of the effectiveness of CME programs.


Some antibullying interventions have shown positive outcomes with regard to reducing violence. The aim of the study was to experimentally assess the effects on school violence and aggressiveness of a program to prevent and reduce cyberbullying. The sample was comprised of a randomly selected sample of 176 adolescents , aged 13–15 years. The study used a repeated measures pre-posttest design with a control group. Before and after the program, two assessment instruments were administered: the “Cuestionario de Violencia Escolar-Revisado” (CUVE-R [School Violence Questionnaire – Revised];  The prevalence of school bullying is verified worldwide, with no notable differences due to geographical, cultural, or educational context. Aside from the debate about the possible importance of numbers, actually, in all schools, some people are suffering their peers’ bullying, and other people are acquiring antisocial behaviors. The highly negative consequences for all of the victims and aggressors involved oftentimes endure for the rest of their lives. The problems that arise of bullying and cyberbullying  entail long-lasting and extensive effects that must be faced.Reviews of studies on the consequences of bullying and cyberbullying  have shoVictims of cyberbullying suffer the same or even greater psychological harm than victims of face-to-face bullying: the damaging information is available to everyone 24 h a day, the bullies are often anonymous, the victimization process is continuous and unavoidable, and most of the time, it is very difficult to eliminate the published material, which is usually publicly accessible for long periods of time. Adolescents tend to be reluctant to talk to adults about the abuse they are suffering due to the emotional trauma, their fear that adults will think they are to blame, fear of possible “revenge,” or concern that their use of the Internet or mobile phone will be restricted .There are many studies showing that the victims have depressive symptoms . KowalskThis study was motivated by the concern for peer violence expressed by parents, teachers, and society in general. Other forms of bullying are currently emerging, such as cyberbullying, which consists of using ICT, mainly the Internet  and mobile phones, to perpetrate peer bullying. Cyberbullying consists of aggressive and intentional behavior repeated over time against a victim who cannot easily defend him- or herself. Various means are used for bullying: SMS, telephone bullying , recordings of acts of physical aggression or humiliation disseminated by mobile phone or the Internet, bullying by means of photographs and videos distributed by mobile phone or uploaded to YouTube, e-mails, instant messages, social networks, websites, etc. .Reviews of studies analyzing the prevalence of cyberbullying showed that violence through ICT has recently become a relevant problem in all developed countries. The rapid development and growth of this new form of harassment has generated the urgent need for prevention and intervention. Empirical evidence suggests the need for active prevention and intervention strategies in educational, family, and clinical-therapeutic settings.Some antibullying interventions have shown positive outcomes in reducing violence . In receIn addition, diverse antibullying programs have decreased aggressive behavior outside of the classroom, disruptive behaviors in the classroom , the perBrief Internet Cyberbullying Prevention Program  and control  students. The participants were fourth- to ninth-grade students in Finland. Results revealed a significant intervention effect on the frequency of cybervictimization (KiVa students reported lower frequencies of cybervictimization at posttest than students in a control condition). Program  intervenMedia Heroes Cyberbullying Prevention Program . The program promotes cognitive restructuring of the roles involved in bullying/cyberbullying situations. Specifically, it stimulates the modification of cognitions, which in turn fosters changes at the behavioral level; that is, victims learn to defend themselves and observers intervene in favor of the victims.Some anti-cyberbullying programs  have pro2 = 0.26, p > 0.05. Twenty-five percent were 13 years old, 48.9% were 14, and 26.1% were 15.This study sample included 176 adolescents, aged between 13 and 15 years, who studied Secondary Education (grade 8); 77 (43.8%) males and 99 (56.3%) females. Of the initial 178 adolescents, two moved to another school before completing the program. Of the total sample, 93 (52.8%) were randomly assigned to the experimental condition, and 83 (47.2%) to the control condition. No significant differences as a function of sex were found between experimental and control participants, χA random sampling technique was used, applied to the list of schools in Gipuzkoa  and the type of school (public–private). Block randomization was performed by a computer-generated random-number list of schools prepared by the Department of Education of the Basque Government. The sample was recruited from three schools. Of these students, 44.3% attended public schools, and 55.7% private centers. The sampling unit was the school class.f = 0.25), with a power of 0.90  for the univariate F tests among the dependent variables, finding a minimum sample size of 171 participants . It exceeds the average European expenditure for R&D&I/GDP in innovation and its human development index of 0.96, as calculated by the Basque Institute of Statistics with methodology from the UN, represents a very high level. With regard to the availability of ICT in Basque schools, the report of the Department of Education of the Basque Government  A letter was sent to the directors of the randomly selected schools from the list of schools in Gipuzkoa, explaining the project and requesting their collaboration; (2) Interviews were held with those directors who agreed to collaborate to present the project and distribute the informed consent forms for parents of the study participants; if the director of the selected center refused to collaborate, the procedure was repeated with the next school on the list, taking into account the type (public–private) and/or the socio-economic-cultural level of the school that declined to participate; (3) After receiving the parents’ consent, we administered the pretest to both experimental and control participants, using two assessment instruments to measure the dependent variables that the program was expected to affect; (4) Subsequently, the intervention program was applied in the five experimental groups (19 one-hour sessions), while the four control groups received the regular tutorship program of their school; and (5) After the intervention, at the posttest phase, we administered the same instruments as at pretest to both experimental and control groups.The study complied with the ethical values required for research with humans , and received the favorable report of the University Research and Teaching Ethics Committee of the University of the Basque Country (CEISH/112/2012).The program comprises activities aimed at preventing and/or intervening in bullying situations. The intervention consisted of 19 one-hour sessions carried out during the school term. The activities that make up the program have four main goals: (1) to identify and conceptualize bullying/cyberbullying, and the three roles involved in this phenomenon; (2) to analyze the consequences of bullying/cyberbullying for victims, aggressors, and observers, promoting critical capacity and the capacity for reporting these actions when they are discovered; (3) to develop coping strategies to prevent and reduce bullying/cyberbullying behaviors; and (4) other transversal goals, such as developing positive variables .Table 1).The program was designed for administration to groups of adolescents by a teacher, psychologist, or school pedagogue. The program’s 25 activities are distributed in three intervention modules or axes about bullying and cyberbullying (see This module is made up of five activities to help the group identify and discriminate the differences between bullying and cyberbullying in a specific situation. The aim of this module is for the group to acquire the necessary knowledge to be able to: (1) identify and define different types of bullying and cyberbullying, (2) analyze the differences between the two phenomena, and (3) know the main roles involved in these types of behaviors.This module is made up of five activities aimed at analyzing the direct and indirect consequences of bullying and cyberbullying. It is important to understand what is happening, what the victims are feeling, what effects it has on all the people involved…, to finally develop competencies that inhibit such behaviors.This module contains 15 activities whose aim is to analyze the performance patterns of bullying situations from the viewpoint of all three roles involved  to prevent, cope with, solve, eliminate, or minimize the effects of this type of violence. In other words, it consists of applying the knowledge acquired to seek plausible and effective solutions to situations of bullying and cyberbullying.It is important to observe that one of the key aspects of the intervention program to prevent and cope with bullying and cyberbullying is training the participants to confront and know the consequences of this type of bullying. Accordingly, it is increasingly important to develop a series of transversal competences that implicitly complement each module in the enhancement of group processes and the generation of personal and social skills to inhibit bullying and cyberbullying. These goals are transversal to all three intervention modules. Summing up, the intervention program advocates for the development of a critical capacity, providing participants with the values of active listening and respect for others, which in turn lead to common good and democratic coexistence.Each activity is described in a technical sheet that summarizes its specifications to simplify its implementation. The technical sheets of the program activities describe various parameters: (1) Goals: the specific goals of the activity; (2) Activity: the guidelines that the adult should offer the group for its development, and the implementation phases and procedure to be followed by the group; (3) Discussion: proposed questions or suggestions to promote debate or discussion; (4) Materials: resources needed to carry out the activity are described. A download link is provided when the activities involve viewing a video on YouTube, and the CD attached to the manual includes a file with all of the links to videos used when implementing Cyberprogram 2.0, in addition to dozens of links to videos about bullying, cyberbullying, social networks, sexting, grooming, Internet safety…. for use if the adult wishes to temporarily expand the implementation of this intervention; (5) Approximate duration of the activities; and (6) Group structure or how to organize the group in each activity . The manual includes the technical cards of the activities, the program’s implementation methodology and the assessment instruments.inter-session constancy, which implies performing a weekly 1-h session; (2) spatial-temporal constancy, as the program is applied on the same weekday, at the same time, and in the same physical space ; (3) constancy of the adult who directs the program, who must have psychopedagogical training; and (4) constancy of the session structure. The sessions begin with the group members sitting in a circle on the floor. The adult explains the activity, its goals, etc., and the participants carry out the action. Subsequently, there is a discussion and guided reflection phase, led by the adult. The adult promotes critical reflection through the formulation of non-judgmental questions. All sessions follow this structure, except for the first one in which the intervention program, its goals, duration, and types of activities to be implemented are presented and explained. The program uses diverse group dynamics techniques to stimulate the development of the activity and debate: role-playing, brainstorming, case study, guided discussion by means of formulating questions, and so on.The program’s group application entails the four constant variables of the intervention’s methodological framework: (1) Should aggressors be punished? Firstly, we showed the video “X Nada” [For no reason] (http://www.youtube.com/watch?v=REA80mMaCsY), which tells the story of a group of adolescents who beat up another teenager, who must be hospitalized as a result. The attack is filmed with a mobile phone and uploaded to the Internet. In this video, an adolescent suffers an attack of “happy slapping” carried out by Roy, the aggressor, and his gang of pals. After seeing the video (14 min), teams of five people are formed and they debate about whether the aggressors should be punished and what should be done to eradicate their aggressive behavior. For this purpose, each team names a secretary who records all the members’ suggestions to solve the problem. Subsequently, by turns, each team selects by consensus the most efficacious and constructive way to penalize the aggressor of bullying/cyberbullying and dramatizes the scene by representing the chosen solution.For example, Activity 14. After the representations, sitting on the floor in a circle, the entire group discusses the responses of each team, and a debate is initiated in which the pros and cons of the teams’ proposed responses are analyzed, clarifying which are more efficient and positive to inhibit aggressive behaviors in perpetrators of bullying and cyberbullying. The published program manual  presentsWe administered two assessment instruments with psychometric guarantees of reliability and validity to assess the effects of the intervention before and after the program.Cuestionario de Violencia Escolar Revisado”  to 5 . For example: “Some students film or take pictures of classmates with their mobile to make fun of them.” “The teachers punish unfairly.” “Some students hit other classmates when they’re on the school grounds.” “Some students badmouth other students.” The Cronbach alpha coefficient obtained with the original standardization test sample confirmed high internal consistency . The coefficients obtained with the study sample were higher . The exploratory and confirmatory analyses revealed a 6-factor model. The standardized regression coefficient showed statistically significant factor loadings.“Cuestionario de agresividad premeditada e impulsiva en adolescentes”  to 5 (strongly agree). For example, “I think my aggressiveness is justified.” “When I get mad, I react without thinking.” “Being aggressive has helped me gain power over others and improved my social level.” Psychometric studies confirm the reliability of the Premeditated and Impulsive Aggressiveness scales, α = 0.83 and α = 0.82, respectively. The coefficients obtained with the study sample were similar (α = 0.82). The CAPI-A correlated positively with impulsivity and with reactive/proactive aggressiveness, thereby ratifying its convergent validity. Premeditated aggressiveness presented a slightly higher correlation with proactive aggressiveness, and impulsive aggressiveness had a higher correlation with reactive aggressiveness.“To assess the program’s effect on the dependent variables, firstly, we carried out descriptive analyses (means and standard deviations) and univariate and multivariate analyses of variance (ANOVA and MANOVA) with the pretest scores obtained on the CUVE-R (school violence) and the CAPI-A (aggressiveness) by the experimental and control participants. Secondly, we carried out descriptive analyses and analyses of covariance of the pre-posttest differences  using the pretest differences between the two conditions as covariate, thereby determining the intervention’s impact. In addition, to analyze whether the change was similar in males and females, first, we performed ANOVAs with the pretest scores and, subsequently, ANCOVAs of the pre-posttest differences in the dependent variables of both sexes.F = 7.12, p < 0.001, with a small effect size . The descriptive analyses of each variable and the results of the pretest ANOVA (see Table 2) revealed statistically significant group differences in all types of school violence before implementing the program, with the experimental participants scoring higher than the control group. Except for the variables social exclusion and disruption in the classroom, which had small effect sizes, the effect sizes of the remaining variables were moderate and high.With regard to school violence, firstly, we performed a MANOVA on the pretest CUVE-R scores of the experimental and control groups. The results of this pretest MANOVA on the variables school violence  showed statistically significant group differences before the intervention, Wilks’ lambda, Λ = 0.798, F = 12.09 p < 0.001), with a medium effect size . With regard to each type of school violence, we conducted descriptive analyses and ANCOVA of the pre-posttest differences in both conditions, with the pretest scores as covariate. The results of the ANCOVAs (see Table 2) confirmed statistically significant group differences in pre-posttest change in all the variables of school violence measured, except for disruption in the classroom. The effect size was large for all variables. Examination of the change produced in the experimental and control participants (see Table 2) showed that, whereas the experimental group mean (Me) decreased significantly in almost all the variables of school violence, the control group mean (Mc) increased: teachers’ violence toward students , students’ physical violence , students’ verbal violence , social exclusion , violence through ICTs , and total violence .Secondly, to assess the program’s efficacy in diverse types of violence, we analyzed the pre-posttest change. The results of the MANCOVA of the pre-posttest difference of means for all the variables of school violence revealed statistically significant group differences in change, Wilks’ lambda, Λ = 0.664, F = 5.90, p < 0.01, showed statistically significant group differences before the intervention, with a small effect size . The descriptive analyses of each variable and the results of the pretest ANOVA comparing the two conditions (see Table 2) indicated statistically significant group differences only in premeditated aggressiveness, with higher scores in the experimental group, and a moderate effect size.Regarding aggressiveness, firstly, we conducted a MANOVA of the pretest scores of the CAPI-A. The MANOVA results for aggressiveness, Wilks’ lambda, Λ = 0.936, F = 13.99, p < 0.001, with a small effect size . Complementarily, as regards each type of aggressiveness (impulsive and premeditated), we conducted descriptive analyses and ANCOVA of the pre-posttest group differences, using the pretest scores as covariate. The results of the ANCOVA (see Table 2) confirmed statistically significant group differences in pre-posttest change both in premeditated and impulsive aggressiveness. The effect size was large. Comparison of the change produced in the two conditions (see Table 2) revealed that the experimental group decreased its mean (Me) significantly more than the control group (Mc) in premeditated  and impulsive aggressiveness .Secondly, to assess the program’s impact on aggressiveness, we analyzed the pre-posttest change. The results of the MANCOVA of the pre-posttest difference of means in aggressiveness showed significant group differences in change, Wilks’ lambda, Λ = 0.859, Table 3) revealed no statistically significant differences between males and females in all the variables of school violence assessed. Therefore, there were no sex differences before the intervention, and the change due to the effect of the program was similar in both sexes. Regarding aggressiveness, the results of the pretest and pre-posttest ANCOVAs by sex (see Table 3) also showed that there were no sex differences before the intervention, and that the pre-posttest change was similar in premeditated aggressiveness; however, females decreased impulsive aggressiveness significantly more than males.The descriptive analyses of each variable and the results of the pretest and pre-posttest ANOVAs by sex ; (b) students’ physical violence ; (c) students’ verbal violence ; (d) social exclusion ; and (e) violence through ICT or cyberbullying (violent behaviors by means of electronic instruments such as mobile phones and the Internet). Therefore, the results allow us to confirm Hypothesis 1 almost completely because the program decreased almost all types of school violence; no differences were found only in behaviors of disruption in the classroom. Secondly, the results show that the experimental group significantly decreased premeditated aggressiveness and impulsive aggressiveness. Hence, the data also confirm Hypothesis 2.The aim of the study was to assess the effects of an antibullying program on school violence and aggressiveness. Firstly, the results obtained confirm that the program had a very positive effect, as it promoted a decrease of school violence: (a) Summing up, the results show that the program significantly decreased behaviors related to the different types of school violence: physical, verbal, social, and technological violence among students and by teachers toward students. In addition, it stimulated a decrease in impulsive and premeditated aggressiveness. These results point in the same direction as other studies showing the efficacy of antibullying interventions to improve the social climate of the classroom and the school , intragrThirdly, the results have revealed that the change stimulated by the intervention program was similar in males and females for all the variables of school violence assessed and for premeditated aggressiveness. However, in impulsive aggressiveness, females decreased significantly more than males. Therefore, Hypothesis 3 is confirmed almost completely, pointing in the same direction as other studies showing that intervention programs to promote socio-emotional development and prevent violence affect both sexes similarly .The program’s activities create and structure situations of communication, cooperation, and empathy that explain the intervention’s positive effects in decreasing violent behaviors (diverse types of school violence and aggressiveness). This decrease may be explained by the emphasis of the Cyberprogram 2.0 on activities concerning the feelings of those involved, and particularly, the emotional experience of the victim. Many program activities emphasize the negative consequences of bullying for victims, perpetrators, and observers, the responsibility of observers, and critical analysis of aggressors. This is consistent with a previous evaluation  that conThe results show the therapeutic effect of this type of intervention. This role of the school as a context for development has already been pointed out by other researchers . The proFrom the viewpoint of psychological development, previous assessment studies of Cyberprogram have confirmed that the program’s experimental participants increased their capacity for communication, empathy, skills for assuming another’s perspective, confronting and resolving interpersonal conflicts constructively, self-esteem… , 2015a,bAmong the possible reasons for greater program efficiency are: (1) the time allocated to the intervention ; (2) the characteristics of the included activities ; (3) the involvement and training of the teachers who implement the program ; and (4) the parents’ participation . Therefore, educational authorities should raise awareness among the entire school community  through awareness-raising campaigns, training teachers to implement programs that inhibit violent behavior, and seeking financial support for the implementation of these proposals.As reported when describing the study’s participants and context, the students of the Basque Country have a high level of access to ICT, and previous studies e.g.,  have shoThe conclusions drawn from this study have interesting implications for educational and clinical intervention with all adolescents involved in bullying/cyberbullying situations, especially with aggressors. This work provides empirical evidence showing that an antibullying program can have a very positive impact on different types of school violence and different kinds of aggressive behavior.Altogether, the results allow us to emphasize the importance of implementing programs during childhood and adolescence to promote socio-emotional development, improve coexistence, and prevent/reduce violence. The best way to prevent violence is through the promotion of harmonious coexistence, and Cyberprogram 2.0, an evidence-based intervention program to prevent cyberbullying, is proposed within this framework. All schools should define an action protocol for cases of harassment and a plan to prevent violence and promote peaceful coexistence. All students should participate in preventive programs to inhibit all modes of violence. In addition, didactic proposals must be implemented for the family for both prevention and intervention in violence.The use of self-reports, with the inherent bias of social desirability, is a limitation of the study. For future research, we suggest using hetero-reports in which parents and teachers inform of adolescents’ attitudes and behaviors and/or observational techniques to assess and ratify the program’s effects. In addition, the research sample size is insufficient to provide results generalizable to the population. Therefore, we suggest an assessment of the program with a larger sample size and of broader origin. Future lines of research could analyze the connections of cyberbullying with personal  and family factors , that could help to identify relevant variables for prevention and intervention programs. In addition, an interesting future challenge would be to analyze the effect of the characteristics and training of the adult who directs the intervention on the changes stimulated by Cyberprogram in the adolescent participants.MG has designed research and the program. Also she has carried out the data analysis and has written the article. VM-V has designed the program and has implemented the program with adolescents.The 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.


There is increasing uptake of workplace physical activity programs to prevent chronic disease. While they are frequently evaluated for improvement in biomedical risk factors there has been little evaluation of additional benefits for psychosocial health. We aimed to evaluate whether participation in a four-month, team-based, pedometer-based workplace health program known to improve biomedical risk factors is associated with an improvement in well-being, immediately after the program and eight-months after program completion.At baseline (2008), 762 adults  employed in primarily sedentary occupations and voluntarily enrolled in a physical activity program were recruited from ten Australian worksites. Data was collected at baseline, at the completion of the four-month program and eight-months after program completion. The outcome was the WHO-Five Well-being Index (WHO-5), a self-administered five-item scale that can be dichotomised as ‘poor’ (less than 52%) or ‘positive’  well-being.At baseline, 75% of participants had positive well-being (mean: 60 ± 19 SD WHO-5 units). On average, well-being improved immediately after the health program  and was sustained eight-months later . In the 25% with poor well-being at baseline, 49.5% moved into the positive well-being category immediately after program completion, sustained eight-months later (p < 0.001).Clinically relevant immediate and sustained improvements in well-being were observed after participation in the health program. These results suggest that participation in workplace programs, such as the one evaluated here, also has the potential to improve well-being.The online version of this article (doi:10.1186/1471-2458-14-953) contains supplementary material, which is available to authorized users. The World Health Organization defines health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity". As physA series of physical activity interventions in a range of settings have found beneficial effects for improving mental health and well-being–12. One Within the context of a pedometer-based work-place health programs, several program characteristics could potentially improve well-being directly. Firstly, as described above, an increase in physical activity is likely to have a direct beneficial effect on mental health through mechanical theory. Secondly, through psychological theory participating in physical activity the participant may increase awareness of fitness capabilities and may increase self-esteem and willingness to participate in other social activities. ThirdlyFour pedometer-based workplace health program evaluations have encapsulated some of the broader aspects of health, 49, 50.This paper aimed to evaluate whether participation in a four-month, pedometer-based, workplace health program known to improve biomedical risk factors was also associated with an improvement in well-being. The secondary aim was to identify participant characteristics associated with immediate and long-term improvements in well-being. Potential benefits were assessed immediately after the program (at four-months) and in the longer-term (eight-months after program completion).This paper was undertaken as part of a larger study, titled the Global Corporate Challenge® (GCC®) Evaluation study, 51–55.The GCC® is a corporate organisation that undertakes a world-wide, annual, four-month (May to September), team-based, visible step-count pedometer, workplace health program. The target is to achieve 10,000 steps per day, which is based upon the World Health Organization’s recommendation. Teams oIn 2008, 259 of the workplaces participating in the GCC® had an office located in Melbourne and several were approached by GCC® employees regarding their interest to be study sites for an evaluation. Preference for approaching workplaces was based on early conscription to the GCC® 2008 event, a large number of employees, a variety of sedentary occupations, and the availability of a designated GCC® coordinator. Ten evaluation sites consented, providing access to 4,138 people enrolled in the GCC®. Participating workplaces sent internal emails to inform employees of the evaluation and after interest was registered, Monash University staff sent an email with an explanatory statement and consent form. Seven hundred and sixty two voluntary consenting participants, aged 18 years and above and were recruited and assessed in April/May 2008. GCC® EvData was collected at baseline, four-months and eight-months after the completion of the program. An Internet self-report questionnaire incorporated demographic information–59 –65, a seTo compare differences between those with poor versus positive well-being at baseline, baseline measures and average daily step-count throughout the four-month program were assessed. Several variables were dichotomised as meeting commonly accepted clinical guidelines: physical activity (at least 150 minutes of moderate intensity activity per week)–78, fruiBaseline demographic variables, as well as, the process variable of average daily step-count throughout the four-month program (indicating compliance with the program) were assessed as potential ‘predictors’ of well-being change in response to the program. Psychosocial measures were not considered ‘predictors’ of well-being change due to the potential for introducing bias.Unless otherwise indicated, continuous data is summarised as mean ± standard deviation (SD). Analyses were performed using Stata version 11. Robust Participants who did and did not return at four-months or eight-months after program completion were compared according to baseline variables, four-month change variables and average daily step-count data, where relevant.Change in well-being after participation in the health program was assessed by analysing the difference between baseline and four-month, and the difference between baseline and eight-month after program completion measurements using linear regression. Analyses of change were also stratified by baseline well-being status. The potential magnitude of the regression to the mean effect on the observed change in well-being was estimated using an established method. PositivThe primary analysis assessing change in well-being associated with participation in the health program included participants who completed the WHO-5 at the three data collection rounds. A secondary (sensitivity) analysis was undertaken using participants with complete data on the relevant two rounds for each analysis of temporal change.Demographic and the process measurement of average daily step count were assessed as potential predictors of immediate and long-term well-being change. Potential predictors were assessed by univariable and multivariable regression analyses with well-being change as the outcome variable.The study, project number CF08/0271-2008000125, was approved by Monash University Human Research Ethics through the standing committee on ethics in research-involving humans.Of the 734 eligible participants, 93% (n = 685) completed the WHO-5 at baseline, 64% (n = 468) completed the WHO-5 at baseline and four-month and 55% (n = 407) completed the WHO-5 at all three time-points.Those who completed the WHO-5 at all three time-points were more likely to be older , have a professional position , participate in the GCC® due to appearance reasons , not smoke tobacco , meet baseline physical activity guidelines  and undertake more steps during the health program .At baseline the distribution of well-being was left skewed, with the majority (75%) being in the positive well-being category. Participants who were older, participating in the GCC® for health reasons, met fruit and physical activity guidelines, had a higher mental quality of life and had undertaken at least 10,000 steps per day on average during the program were more likely to be in the positive well-being category at baseline, Table Immediately after the health program, in the 407 participants with complete data at all three time-points, an average improvement of 3.5 units compared to baseline (p < 0.001) was reported and this was sustained eight-months later , Table In the 407 participants with complete data at all three time-points, no evidence of immediate or long-term change was found for those with positive well-being at baseline . Significant immediate and long-term improvement was observed for those with poor well-being at baseline . Consequently half of those with poor well-being at baseline moved into the positive well-being category at four-months  and this was sustained at eight-months after program completion . The expected effect of regression to the mean in the group with positive well-being at baseline was that change would be in a negative direction , a greater decrease than observed (as described above), Additional fileWhen complete case analysis  was undertaken, the magnitude and statistical significance of the changes were similar to the primary analysis; with the attaining of statistical significance for sustained improvement in the proportion with positive well-being , Additional fileAt four-months, baseline characteristics associated with immediate improvement in well-being were tertiary education and greater number of steps during the program, Table At eight-months after program completion, baseline characteristics associated with long-term improvement in well-being were younger age and being widowed, separated or divorced, Additional fileIn this study of 407 adults employed in primarily sedentary occupations and voluntarily enrolled in a physical activity program, 75% of participants were achieving positive WHO-5 well-being scores at baseline. On average, well-being improved immediately after the health program and was sustained eight-months later. A substantial benefit was seen in those with poor well-being at baseline, with around 50% of this group having positive well-being at both four and eight-months after program completion. Achieving a greater number of steps during the program was associated with immediate well-being improvement.The overall immediate and long-term changes in well-being for the total enrolled population were not clinically significant. This isThe most prominent characteristic associated with improved well-being in the general study population and those with poor baseline well-being was undertaking more steps during the health program. While a few demographic characteristics were associated with well-being change, these were not consistent across analyses. As previously discussed, the program may be having the greatest benefit in those with the greatest opportunity to improve, those who have slightly healthier habits that may find it easier to make the small changes required for a visible outcome and those who achieved the step goal of the health program.Two reviews of workplace physical activity interventions reported insufficient evidence to assess general well-being as an outcome. Conn et. al observedAs previously discussed, four pedometer workplace health program evaluations have encapsulated broader aspects of health, 49, 50.Our results support findings from these prior evaluations focusing on health related outcomes that participation in such programs is associated with improvement in positive psychosocial health, especially in those with lower psychosocial health at baseline. In addition, a positive relationship between improvement in positive psychosocial health and physical activity level during a program has also been previously observed. Touger-Decker et. al reportedThe strengths of this evaluation study included the large sample size and the variety of sedentary occupations within the sample, 52. TheThis study is the first to assess the WHO-5 Well-being Index in a working adult population and is the first to assess general well-being, rather than psychological factors specifically related to physical health, in a pedometer-based workplace health program evaluation. At baseline we observed that three quarters of employees were achieving positive well-being scores at baseline. Clinically relevant benefits associated with participation in the health program were observed in the other quarter that had poor well-being at baseline. In addition to anthropometric and biomedical benefits that have been previously observed, psychosocial benefits also appear to be associated with participation in this four-month, pedometer-based, physical activity, workplace health program. These results suggest that a health program such as this which incorporates both physical activity and team involvement has the potential to improve well-being, especially in those who have poor well-being and actively participate in the health program.Effects of regression to the mean on changes in the WHO-Five Well-being Index by baseline well-being sub-groups.(DOC 74 KB)Additional file 1:Sensitivity analysis of immediate and long-term change in well-being: complete case data.(DOC 49 KB)Additional file 2:Linear regression analyses assessing potential predictors of improving from ‘poor’ to ‘positive’ well-being at four-months.(DOC 42 KB)Additional file 3:Linear regression analyses assessing potential predictors of improving from ‘poor’ to ‘positive’ well-being at twelve-months.(DOC 43 KB)Additional file 4:


Recently, other toxins, namely phenol-soluble modulins (PSMs) expressed by community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) strain USA300 (LAC WT) were shown to have ex vivo intracellular cytotoxic activity after S. aureus invasion of osteoblasts, but their in vivo contribution in a relatively PVL-sensitive osteomyelitis model remains poorly elucidated.In bone and joint infections (BJIs), bacterial toxins are major virulence factors: Panton—Valentine leukocidin (PVL) expression leads to severe local damage, including bone distortion and abscesses, while pvl+hla+psms+ LAC WT and its isogenic Δpsm derivatives (LAC Δpsmα and LAC Δpsmαβhld) using an inoculum of 3 × 108 CFUs. Mortality, hematogenous spread , lung and bone involvements were assessed in two groups (non-survivors of severe sepsis and survivors sacrificed on day (D) 14).We compared the outcomes of experimental rabbit osteomyelitises induced with Δpsm derivatives . Non-survivors’ bone LAC-Δpsmα  or -Δpsmαβhld  densities were significantly higher than LAC WT (6.43 log10 CFUs/g of bone). Conversely, lung Δpsmαβhld CFUs were significantly lower than LAC WT (P = .04). LAC Δpsmα, Δpsmαβhld and WT induced similar bone damage in D14 survivors, with comparable bacterial densities . Meanwhile, pulmonary histological scores of inflammation were significantly higher for LAC Δpsmα- and Δpsmαβhld-infected rabbits compared to LAC WT  but with comparable lung bacterial densities.Severe sepsis-related mortality tended to be lower for Our experimental results showed that deactivating PSM peptides significantly limited bacterial dissemination from bone during the early phase of infection, but did not affect local severity of USA300 rabbit osteomyelitis. Staphylococcus aureus (CA-MRSA) USA300 clone has been responsible for severe infections, including bone and joint infections (BJIs), especially in children [Since 1990, extensive spread in the United States of the community-associated methicillin-resistant children . The glochildren , and syschildren ,6.S. aureus BJI severity [α-hemolysin (Hla), was also shown to contribute to BJI pathogenesis [Numerous CA-MRSA virulence factors have been identified , some ofseverity . CA-MRSAogenesis . We prevogenesis .S. aureus chromosome. PSMs encoded by the first two loci have been designated PSMα and β. The third PSM locus encodes the δ-toxin; its open-reading frame is part of the RNAIII effector of the staphylococcal accessory-gene regulator (agr), a major two-component system coupled to a density-sensing cassette controlling the expression of most S. aureus virulence factors. All PSM-encoding genes are under agr control, either through the AgrA-mediated regulation pathway for psmα and β, or as a consequence of the co-transcription with RNAIII, as for hld [agr.In addition to PVL and Hla, secreted peptides called phenol-soluble modulins (PSMs) have been identified as key virulence factors that are also strongly expressed in staphylococci and CA-MRSA . PSM-enc for hld . Thus, PS. aureus osteomyelitis. PSMs are small peptides with amphipathic properties, allowing them to destabilize lipid bilayers at high concentrations. This activity has been linked to receptor-independent cytotoxicity to host cells, including neutrophils and osteoblasts, the bone-forming cells [in vivo outcome of osteomyelitis.Several PSM biological functions impact pathogenesis and, possibly, the course of ng cells ,14. Moreng cells . Finallyng cells ,17 and ing cells  and cellng cells . These cin vivo studies on PSMs using a model of skin-and-soft-tissue infection, the LAC psmα-deleted strain, but not the other psm-deleted strains, was significantly less able to cause skin lesions in mice [α and Hla contributed to the pathogenesis of USA300 skin infections in rabbits [α peptides had no impact in a PVL-negative ST72 CA-MRSA strain in a mouse model of skin infection [In previous  in mice . Also, K rabbits , whereasnfection . Moreovenfection . Furthernfection  and, thuα expression was associated with extensive bone damage inducing the death of infected human osteoblasts in an ex vivo model of intracellular infection [in vivo PSM BJIs requires using a model sufficiently close to the human situation in terms of PVL susceptibility. In particular, murine models used in previous studies of PSM involvement in CA-MRSA osteomyelitis could not account for the PVL effect, because murine immune cells respond poorly to PVL [Concerning BJIs, PSMnfection , whereasnfection . Addressy to PVL , unlike y to PVL . Hence, In this context, we sought to determine the contribution of PSMs to local and systemic osteomyelitis severity in a PVL-sensitive rabbit model of acute BJI, using the highly virulent USA300 CA-MRSA strain LAC, which expresses PSMs, Hla and PVL, and its isogenic derivatives lacking PSM expression.S. aureus Los Angeles County wild-type strain (LAC-WT), and its isogenic Δpsm derivatives , all kindly provided by Frank Deleo, as for our previous studies. The strains were created and originated in Dr. Michael Otto’s laboratory and were previously described [We used the clinical escribed .Δpsm derivatives were constructed via allelic replacement with a spectinomycin-resistance cassette of the psmα and psmβ operons, as previously described [hld gene inside RNAIII to disable δ-toxin. Technical difficulties and cost prevented us from verifying modifications/confirming plasmid transfer with a gene-recomplementation assay.The escribed , and by μm filters, and the pellets were washed and resuspended in phosphate-buffered saline (PBS). All inocula were quantified by optical density (OD), then serial dilutions were plated on tryptic soy agar .Microorganisms were stored at –80°C until use. Prior to the experiments, bacteria were cultured in casein hydrolysate and yeast extract medium (CCY) at 37°C with shaking for 18 h. After centrifugation, the supernatants were passed through 0.22-ad libitum access to food and water, in compliance with French legislation on animal experimentation and with the approval of the Animal Use Committee of Maisons-Alfort Veterinary School. Rabbits were anesthetized by intramuscular injection of 25 mg/kg each of ketamine  and 2% Xylazine . An 18-gauge needle was inserted percutaneously through the right tibial metaphysis into the medullary cavity to aspirate 0.4 mL of bone marrow. Infection was induced by direct injection of 0.1 mL of a sclerosing agent (3% sodium-tetradecyl sulfate), followed by 0.2 mL of inoculum (3 × 108 colony-forming units (CFUs)) and 0.1 mL of saline to rinse the syringe. Fentanyl-patch analgesia was given for 7 days following surgery.Norden’s method  was usedΔpsmα (n = 24) or LAC Δpsmαβhld (n = 24) to evaluate the in vivo impact of PSMs. Nineteen LAC-WT—infected rabbits served as controls.Animals were assigned to receive either LAC Animals were monitored daily for general and local signs of osteomyelitis  and were weighed on inoculum and sacrifice days. Moribund animals  were euthanized by rapid intravenous injection of pentobarbital. Otherwise, rabbits were observed until day (D)14 post-infection to assess PSM impact on the osteomyelitis time course.Before death, venous blood was drawn for culture and serum samples were stored at –20°C for later antibody-profile determination.On the day of death, lungs, right leg, spleen and kidneys were removed. Both lungs were weighed and visually examined. Left lungs were stored at –80°C until determination of bacterial densities and right lungs were embedded in paraffin for histological examination  for diffusion, edema, congestion, hemorrhages, thrombi, inflammation, megakaryocytes, infarcts, abscesses, pleural involvement and bacterial density. Spleen and kidneys were crushed and cultured on blood agar to determine their infection status. Macroscopic appearance of the right leg was noted and photographed, and the upper third of the tibia was frozen for subsequent quantitative culture, as previously described .Anti-PVL and -Hla antibodies were detected with specific enzyme-linked immunosorbent assays (ELISAs). Antibody levels are expressed as arbitrary units per mL (AU/mL), as previously described . Anti-PSt-test. Non-parametric Mann—Whitney U-tests were used to compare tibial bacterial counts and 2-way ANOVA with Tukey’s multiple comparisons tests for histological scores.Percentages of hematogenous spread , bone deformations and abscesses were compared using Student’s The Kaplan—Meier method was used to estimate survival mortality, with inoculation as time 0 and censoring at sacrifice on D14. Percentages of survivors were compared with the log-rank (Mantel—Cox) test .t-test after log10 transformation.Survivors’ antibody-titer changes between D0 and D14 were analyzed with paired Welch’s 8Δpsmα (n = 24) or Δpsmαβhld (n = 24) CFUs; the two that died immediately post-anesthesia (1 each in Δpsmα or Δpsmαβhld group) were excluded. Nineteen LAC-WT—inoculated rabbits served as controls.We inoculated 48 rabbits with 3 × 10Δpsmα-infected (P = .47) and 61% of Δpsmαβhld-infected animals (P = .72).D1 blood cultures were positive for 50% of the LAC-WT—infected rabbits tested vs. 65% of Δpsmα and seven (30%) of Δpsmαβhld groups , with respective median survival of 5 and 4 days ). The lack of significantly different mortality rates between Δpsmαβhld and WT groups, as opposed to the significantly different Δpsmα group, was likely attributable to random fluctuation and small sample size rather than to a real difference between Δpsmα and Δpsmαβhld groups. Indeed, Kaplan—Meier survival curves (Δpsmα- and Δpsmαβhld-infected rabbits (P = .06).Ten (52%) LAC-WT—infected rabbits died of severe sepsis with disseminated infection between D0 and D7 (median: 4 days) compared to five (22%) of the l curves  showed aΔpsmα vs. 100% of Δpsmαβhld and LAC WT, NS) and kidney  cultures. Macroscopic examination of all non-survivors’ lungs found red and congestive lesions, as in the LAC-WT group. Their lung histological scores confirmed the comparability of Δpsmα and Δpsmαβhld vs. LAC-WT infections. However, LAC-WT bacterial lung densities were higher (8.19 (interquartile range (IQR), 7.55–8.23) log10 CFUs/g than Δpsmαβhld  log10 CFUs/g P = .04), but comparable to Δpsmα (6.79 (IQR 5.62–7.10) log10 CFUs/g, P = .25).Most non-survivors had positive spleen  Δpsmαβhld log10 CFUs/g vs. 6.43  log10 LAC WT CFUs/g of bone   but no cortical deformation (NS).All non-survivors had infected bones, with median bacterial densities of 6.9 (IQR 6.85–6.96) logctively) . As for Survivors were sacrificed on D14 to evaluate bones and organs .Δpsmα- and Δpsmαβhld-infected survivors did not differ from LAC-WT—inoculated rabbits for hematogenous dissemination: 17%, 19% vs. 11% spleen-positive cultures (NS) and 34%, 44% vs. 11% positive kidney cultures (NS). Histological scores were comparable except for higher lung inflammation in Δpsmα (P = .04) and Δpsmαβhld (P = .01) than LAC-WT infections .D14 fections , while mΔpsmα and Δpsmαβhld vs. LAC-WT strains, respectively, induced similar bone deformities , muscle abscesses , and bone bacterial density  log10 CFUs/g and 5.91  log10 CFUs/g) vs.  log10 CFUs/g) (P = .95 and .82)  .P = 3.5 × 10−5, paired t-test of log10 values) and anti-Hla antibodies , thereby confirming a significant immune response towards the two toxins. Survivors’ and non-survivors’ D0 anti-PVL and anti-Hla antibody titers were similar  based on a larger sample size (tissue homogenate of a large piece of tissue) and (ii) assessing living but not dead cells.Our main results demonstrated that, during the early first phase of acute disseminated severe sepsis, deactivating PSMs tended to limit sepsis-attributable mortality, albeit not significantly. in vitro and ex vivo observations of PSMs’ osteoblast cytotoxicities [These findings agree with the previously described role of PSMs in facilitating bacterial dissemination from an infected catheter in a mouse model , 28, a bxicities .α) during the early phase of severe sepsis could be due to elevated production of agr-dependent toxins, including Hla and PSMs [The impact of PSMs , much more than Hla or PVL [S. aureus isolates. A double-mutant strain Δpvl–Δpsmαβhld would have helped test this hypothesis, but we were unsuccessful in constructing one.Alternatively, the absence of PSMs’ effect on bone damage in D14 survivors could be explained by two hypotheses. First, nfection . That ponfection , or by onfection . PSMs ara or PVL . Our resα significantly limited bone remodeling in mice after creation of a cortical defect in the femur and local inoculation of 1 × 106 LAC-WT or Δpsmα1–4 CFUs [Our results do not corroborate those of Cassat et al, who showed that PSM1–4 CFUs . However1–4 CFUs ,4,5,31.Δpsmα and Δpsmαβhld groups were also unexpected [Δpsmαβhld and LAC-WT groups. FPR2 is known to be expressed by several epithelial tissues including human, mouse and rat lungs. However, FPR expressed by rabbits is only 68% homologous to FPR2. Also, FPR2 can be triggered by different ligands and induce pro- or anti-inflammatory responses [Finally, because PSMs were shown to play a proinflammatory role by inducing neutrophil activation and cytokine release through the through human formyl-peptide receptor-2 (FPR2) pathway, the higher pulmonary inflammation scores for expected . Our resesponses . TherefoS. aureus. This strong dependence of staphylococcal osteomyelitis pathophysiology on host susceptibility factors and the infecting strain’s toxin-gene content are exemplary of the difficulties that must be overcome to improve our understanding of this disease. Beyond the pathogenic role of toxins, other bacterial factors related to quorum sensing and hypoxic response in poorly oxygenated bone tissue are likely equally important to establish bone infection, as recently demonstrated by comparisons of S. aureus genes essential to infection in abscess and osteomyelitis models [S. aureus lineages [S. aureus infection [In conclusion, our results showed that deactivating PSMs prevented bacterial dissemination from bone during the early stage of the infection, but did not impact the local severity of rabbit USA300 osteomyelitis during the later stage. In agreement with our earlier work on PVL and Hla involvements in CA-MRSA osteomyelitis ,10, thess models ,34. Amonlineages ; and is nfection . In thisnfection .