Chronic myeloid leukemia (CML) is a blood cancer currently well managed with drugs that inhibit the protein responsible for the disease. However, some patients are resistant to these drugs and can progress to fatal phases of CML. This review focuses explicitly on genomic mechanisms that contribute to drug resistance in CML. The ability to predict how patients will respond to treatment at the early stages of the disease is important for selecting optimal therapy and administering more potent drugs before the disease progresses. Currently, only mutations that affect drug binding are included in routine monitoring in drug-resistant patients. This review illustrates other genomic mutations and sequence rearrangements that may impact treatment response and contribute to drug resistance and disease progression. We highlight the potential future role of expanded genomic testing for managing patients with CML.BCR::ABL1 kinase domain mutations in drug resistance, which led to the development of more potent TKIs. Next-generation sequencing studies are revealing additional mutations associated with resistance. In this review, we discuss the initiating chromosomal translocation that may not always be a straightforward reciprocal event between chromosomes 9 and 22 but can sometimes be accompanied by sequence deletion, inversion, and rearrangement. These events may biologically reflect a more genomically unstable disease prone to acquire mutations. We also discuss the future role of cancer-related gene mutation analysis for risk stratification in CML.Chronic myeloid leukemia (CML) represents the disease prototype of genetically based diagnosis and management. Tyrosine kinase inhibitors (TKIs), that target the causal BCR::ABL1 fusion protein, exemplify the success of molecularly based therapy. Most patients now have long-term survival; however, TKI resistance is a persistent clinical problem. TKIs are effective in the BCR::ABL1-driven chronic phase of CML but are relatively ineffective for clinically defined advanced phases. Genomic investigation of drug resistance using next-generation sequencing for CML has lagged behind other hematological malignancies. However, emerging data show that genomic abnormalities are likely associated with suboptimal response and drug resistance. This has already been supported by the presence of  BCR::ABL1 fusion is the only event necessary to induce CML [BCR::ABL1 transcripts using qualitative or quantitative reverse transcriptase–polymerase chain reaction (qRT–PCR) or cytogenetic analysis to detect the Ph chromosome [BCR::ABL1 kinase domain mutation T315I. A number of novel BCR::ABL1 inhibitors are also in the development pipeline or under investigation in clinical trials [Chronic myeloid leukemia (CML) is a hematological malignancy that is a prototype for genetically based diagnoses in cancer. This is due to the BCR::ABL1 fusion . Molecular monitoring of peripheral blood BCR::ABL1 transcripts is the gold-standard recommended monitoring strategy, as opposed to bone marrow cytogenetics, due to its higher sensitivity and less invasive nature [Close monitoring throughout treatment is essential to determine the response. It includes blood counts to assess the hematologic response, cytogenetic assessments of bone marrow to determine the percentage of metaphases that contain the Ph chromosome, and molecular monitoring of peripheral blood e nature ,4. RapidBCR::ABL1 levels of ≤0.1% on the international reporting scale (IS), while a complete cytogenetic response is approximately equivalent to ≤1% BCR::ABL1 IS [A major molecular response is defined as :ABL1 IS ,4. While:ABL1 IS . Most pa:ABL1 IS . However:ABL1 IS . IdentifBCR::ABL1 kinase domain that interfere with drug binding. This finding resulted in the development of TKIs with increased potency that can overcome most of the known imatinib-resistant mutations. BCR::ABL1 mutation analysis is now routine for monitoring patients with treatment failure. However, these mutations are only detected in approximately 50% of resistant patients [BCR::ABL1 transcript type, derivative chromosome 9 deletions and variant Ph translocations.This review explores genomic mechanisms that may influence response to therapy and patient outcome. The detection of these genomic events at different time points, such as diagnosis, drug resistance, and blast crisis, has the potential to aid clinical risk stratification and to identify drug targets. TKI resistance is a significant issue that has been found to have a genomic cause in mutations in the patients . Advancepatients . Other gBCR::ABL1 kinase domain [BCR::ABL1 kinase domain mutations have been described thus far. Mutations conferring resistance to second-generation TKIs may also develop, although these mutations are less frequent. Therefore, BCR::ABL1 mutation analysis is recommended for patients with suspected treatment failure as defined by clinical guidelines [While imatinib therapy revolutionized the treatment of CML, reports of imatinib resistance emerged. The best known genomic mechanism contributing to resistance is a mutation within the e domain ,17,18,19e domain . Thus, ke domain . More thidelines ,4 in ordidelines ,4.ABL1 and the TKI [Kinase domain mutations are detected in about half of all patients with acquired resistance . However the TKI . Isoleuc the TKI . Mutatio the TKI ,19,30,31 the TKI . It has  the TKI . Using N the TKI . A study the TKI . Patient the TKI ,36.BCR::ABL1 kinase domain mutations could be analyzed. A study from our laboratory used mass spectrometry to detect low-level dasatinib and nilotinib-resistant mutations in patients who failed imatinib therapy [BCR::ABL1 mutations 6–9 months earlier than Sanger sequencing in patients who failed second-line TKI therapy, and found that low-level mutations can persist even when good outcomes were achieved [With the advent of more sensitive sequencing technologies, the impact of single low-level  therapy . More se therapy ,39. NGS achieved ,41. Mutaachieved . This isThere is an ongoing development of TKIs to circumvent TKI resistance and to overcome the toxicity associated with the second and third-generation TKIs. One such TKI is Specifically Targeting the ABL Myristoyl Pocket (STAMP) inhibitor asciminib, which is currently in clinical trial. Asciminib allosterically binds to BCR::ABL1 at the myristoyl-binding pocket, and as a result, the conformation of the ATP-binding domain is altered, and inhibition occurs ,42. ThusBCR::ABL1 kinase domain have developed in asciminib-treated patients, as detailed in BCR::ABL1 mutations. Studies have already found that combination treatment with other TKIs has higher efficacy than single-agent treatment [BCR::ABL1 kinase domain mutations for asciminib resistance [Nevertheless, in a phase 1 dose-escalation study, myristoyl pocket mutations overlapping the reatment ,48,49,50reatment . Mouse mreatment . Similarsistance .BCR::ABL1 mutation sensitivity profile, as outlined in clinical guidelines [To summarize, different mutations confer different degrees of resistance to specific TKIs. Therefore, TKIs must be carefully selected based on their idelines ,4. The sBCR::ABL1 fusion, genetic variation occurs in the breakpoints involved in the initiating translocation on chromosomes 9 and 22. Furthermore, additional genomic rearrangements accompanying the formation of the BCR::ABL1 gene fusion are also a source of genetic heterogeneity in CML. These can take the form of variant translocations due to the participation of one or more chromosomes in addition to 9 and 22 in the Ph chromosome, which are detectable by bone marrow cytogenetic analysis. In the 1980s, Southern Blot analysis of DNA detected sequence deletions adjacent to the translocation breakpoint that were thought to be of no clinical consequence. In the 1990s, fluorescence in situ hybridization (FISH) techniques detected large sequence deletions at the breakpoint on the derivative chromosome 9 that spanned several hundred kilobases. The deletion status was found to be an independent predictor of poor patient outcomes. With the advent of advanced sequencing technologies in the 2000s, the genomic complexity accompanying the formation of the Ph chromosome became evident with the detection of novel gene fusions and complex rearrangements that included sequence inversion and fragmentation. As technology has advanced, the resolution of the detection of complex genomic events has been enhanced. Cytogenetic and FISH analysis are still used in the management of CML, particularly at diagnosis and resistance assessment, since molecular analysis has largely replaced these techniques for long-term monitoring of treatment response. In this section, we discuss the clinical impact of additional rearrangements and how NGS has significantly expanded our understanding of the complex nature of these rearrangements.At the formation of the BCR (M-BCR) and a 140kb region between exons 1b and 2 of ABL1. This event results in a 210 kDa BCR::ABL1 protein and common BCR::ABL1 transcripts where either BCR exon 13 or 14 are fused to ABL1 exon 2. These transcripts are termed e13a2 (previously known as b2a2) and e14a2 (previously known as b3a2), and a proportion of patients express both transcripts due to alternative splicing [BCR::ABL1 transcripts occur in >98% of CML patients [The most common breakpoint in CML occurs in the 5.8kb major breakpoint region of splicing . These cpatients . The e14patients .BCR::ABL1 transcripts are rare and occur in 1.93% of patients [BCR, known as the minor breakpoint region (m-BCR) and generates a 190 kDa BCR::ABL1 protein. A third transcript type generates a p230 kDa BCR::ABL1 protein and an e19a2 BCR::ABL1 transcript. The breakpoint usually occurs within BCR intron 19 in the μ-BCR region [Atypical patients . These iR region  and are R region . Other aR region .There are conflicting findings as to whether this genetic variation in transcript type impacts treatment outcome ,56,57. SBCR::ABL1 transcript type has also been found to influence the success of treatment-free remission. Studies reported that patients with the e14a2 transcript had a higher probability of achieving sustained MR4.5 (BCR::ABL1 ≤ 0.0032% IS), which is a deep molecular response and a prerequisite for stopping therapy in an attempt to achieve treatment-free remission [BCR::ABL1 transcripts [The emission ,67. Thisemission ,69,70. Wemission . Therefonscripts ,72. Furtnscripts . Howevernscripts . The impnscripts ,74. In sBCR::ABL1 fusion is formed when the terminal sequence of the q arm of chromosome 9 is swapped with the terminal sequence of the q arm of chromosome 22. The genomic breakpoints usually occur within the BCR gene on chromosome 22 and the ABL1 gene on chromosome 9. Beginning with the initiating translocation event, genetic heterogeneity in CML is detectable cytogenetically in some patients by observing variant translocations , ETV6::RUNX1, CBFB::MYH11 and RUNX1::RUNX1T1 [RUNX1::RUNX1T1 fusion is generated by a translocation between chromosomes 8 and 21 and confers a favorable prognosis. However, the prognosis can be altered when the translocation involves complex rearrangements with additional chromosome involvement or cryptic rearrangements where the sequence is inverted [Additional rearrangements have been reported with fusion transcript generating translocations in other malignancies, and some may indicate an inferior patient outcome. In acute leukemia, rearrangements such as submicroscopic deletions and inversions have been associated with known and novel fusions, including :RUNX1T1 ,110,111.inverted . These eKMT2A rearranged acute lymphoblastic leukemia (ALL) is associated with a poor prognosis, and there are multiple different KMT2A fusion partners. More than half of the rearrangements are complex, involve three or more chromosomes, and are accompanied by large deletions or inversions adjacent to the breakpoints [KMT2A-rearranged childhood ALL for a subset of patients where the reciprocal rearrangements were detected [ABL1::BCR fusions identified in CML patients. The ALL patients that lacked the reciprocal fusion exhibited complex translocations or carried a single KMT2A rearrangement [ABL1::BCR fusion was not detected in patients with Ph-associated rearrangements [KMT2A-rearrangements lacking reciprocal fusion are also markers of a genetically more unstable disease is unknown.Childhood akpoints . These aakpoints . Interesdetected , analogoangement . We founngements . The Ph-ngements . They coEWSR1::ERG and some EWSR1::FL11 fusions in Ewing sarcoma, wherein the rearrangements involve inversions and other complex rearrangements rather than simple reciprocal translocations [Similarly, complex gene fusion generating rearrangements have been reported in solid tumors, such as ocations . These cocations ,117. NotTMPRSS2::ERG [BCR and ABL1 genes, and multiple novel gene fusions in addition to the BCR::ABL1 fusion. Some of the novel fusions involved inversions that brought genes into the same transcriptional orientation. Furthermore, the unusual positioning of the fusion partners as either the 5′ or 3′ gene, relative to their original locations on chromosome 9 or 22, indicates that sequence fragmentation and random reassembly of genes likely occurred. The incidence of complex rearrangements in multiple cancers and a noticeable impact on outcome in some cases align with our finding of a poorer outcome for CML patients with Ph-associated rearrangements with the chromoplexy-like mechanism of action.Chromoplexy was first discovered in patients with prostate cancer involving fusions such as SS2::ERG . These cSS2::ERG . Figure SS2::ERG . Whole eTo summarize, genomic events similar to Ph-associated rearrangements have been found in other hematological and solid tumor malignancies. These may adversely impact outcomes, which supports our findings in CML. Further studies focusing on the impact of the Ph-associated rearrangements on treatment outcome could potentially enhance clinical risk prediction for patients with CML and aid the selection of first-line TKI treatment.BCR::ABL1 mutations has recently improved. NGS studies have confirmed the role of mutations in cancer-related genes [RUNX1, a regulator of hematopoietic cell differentiation [RUNX1 mutations, including gene fusions, in the transformation to blast crisis [RUNX1-mutated blast crisis [BCR::ABL1 negative hematological cancers: TET2, IDH1, IDH2, and ASXL1. This study found no IDH1 or IDH2 mutations and TET2 and ASXL1 in only a few patients [ASXL1 to be the most frequently mutated gene. These findings have been validated by other studies, which found that cancer gene mutations were more frequent at diagnosis in patients who progressed to blast crisis and were therefore associated with inferior outcomes [ASXL1 was also found to be one of the most frequently mutated genes [Our understanding of the mechanisms of drug resistance and treatment failure beyond ed genes ,121,122.ntiation , was mutntiation . Studiest crisis ,126. Dowt crisis . Roche-Lpatients . A more patients . We founpatients . Furtheroutcomes ,126. ASXed genes ,120,126.ed genes .ASXL1 associated with BCR::ABL1 kinase domain mutations [CUX1, KIT, and GATA2 may play a role in TKI intolerance as these mutations were found at higher rates in intolerant patients than TKI resistant patients. The authors found that these genes were myelodysplastic syndrome-related genes and mutations affected hematopoiesis, especially in relation to cytopenias, which are associated with intolerance [ASXL1, RUNX1, IKZF1, BCORL1, KMT2D, DNMT3A, JAK2, TP53 and TET2. IDH1 and IDH2 were rare, consistent with earlier studies [A study by Wu et al. observed an increased frequency of utations . This stolerance . The mos studies .ASXL1 is the most frequently mutated gene in CML [ASXL1 occurred in 69% of patients. The poorest response and outcome to third-generation TKIs occurred for those patients with three or more cancer gene mutations. Furthermore, cancer gene mutations and additional chromosomal abnormalities were independently associated with progression-free survival. Certain additional chromosomal abnormalities acquired during therapy are currently considered a criterion for treatment failure [ASXL1 mutation status and variant allele frequency, which demonstrates the potential power of genomic testing for risk stratification. Complementary to these findings, Xue et al. [ASXL1 mutations were the most common in each disease phase. Furthermore, in vitro modelling of an ASXL1 mutation in BCR::ABL1-transformed cells found that this mutation conferred a significant degree of resistance to first and second-generation TKIs. Further studies are warranted to assess the TKI sensitivity of other common mutations reported in CML. These future findings could influence treatment decisions.Recent research by Zhang et al. and Xue et al. have confirmed that e in CML ,132. Zhae in CML . MutatedBCR::ABL1 kinase domain mutation [BCR::ABL1 mutations frequently co-occur with mutated cancer genes [BCR::ABL1 kinase domain mutations also had cancer gene mutations, including gene fusions and deletions [IKZF1 gene are among the most frequently detected in lymphoid blast crises [There are currently no clinical guidelines for diagnostic monitoring of cancer gene mutations  or guidamutation . Howeverer genes ,125. In eletions ,125,133.eletions ,121,126.t crises ,125,133.ASXL1 as mentioned above [RUNX1 and UBE2A that have been recurrently mutated in CML. Studies using Ba/F3 transfected with BCR::ABL1 and the K562 CML cell line found that UBE2A mutations contributed to the downregulation of myeloid differentiation pathways [RUNX1 mutations contributed to the downregulation of DNA repair machinery and promoted genomic instability [BCR::ABL1. Hence, cancer gene mutations could potentially assist in guiding a more personalized medicine approach to treating CML.There is a growing body of evidence indicating that the detection of cancer gene mutations has the potential to be utilized for risk stratification and could guide treatment decisions . Furthered above , as wellpathways . RUNX1 mtability . This inBCR::ABL1, CML is a genetically heterogeneous disease. Many years of research on BCR::ABL1 kinase domain mutations have demonstrated the importance of monitoring TKI resistance and the appropriate TKI selection. TKI therapy has overcome the poor risk previously associated with derivative chromosome 9 deletions and variant translocations. There remains controversy regarding the impact of specific BCR::ABL1 transcript types on treatment outcomes. The advent of large scale and sensitive sequencing technologies has revealed a more genomically complex and heterogeneous disease in select CML patients, especially those with inferior outcomes. This genetic heterogeneity may yield potential future biomarkers of treatment outcomes. The novel discovery of Ph-associated rearrangements already demonstrates a previously unknown genomic mechanism that has the potential to impact patient outcomes. Recent studies of complex rearrangements in other leukemias and solid tumors have also reported an association with poorer outcomes. The co-occurrence of BCR::ABL1 kinase domain mutations and cancer gene mutations in a high proportion of resistant patients indicates that we should not consider resistance as either BCR::ABL1-dependent or BCR::ABL1-independent. Rather, resistance mechanisms may act interdependently to drive disease progression. We predict that expanded NGS testing for rearrangements and cancer gene mutations will enhance risk prediction, more reliably classify TKI resistance, and identify novel future targets for therapy.It is abundantly evident that despite the consistent genetic signature of


The effectiveness of the program statistically depended on its complete implementation (χ2(2) = 7.62, p = 0.022). In the group of non-completers, the prevalence of victimization did not change during the observation period of 2 years (χ2(2) = 4.64, p = 0.099). In the group of the completer schools, a significant decrease in bullying between t0 and t1 was found for victims  and perpetrators . After 24 months (t2), this decrease could be retained . Furthermore, we found the following moderators of program effectiveness in the completer schools: (1) gender  and (2) school grade . The German version of the OBPP significantly reduced the bullying prevalence in the completer schools. Effective prevention needs time and resources: fulfilling the 18-months implementation period was the basis for positive results.Bullying is a common and significant risk factor for mental and physical health problems. The aim of the outlined study was to evaluate the German version of the Olweus Bullying Prevention Program (OBPP) and to investigate potential moderators of its effectiveness. 23 schools started with the implementation and all students were invited to complete the Olweus Bullying Questionnaire annually. For our analyses, the data from grades 5 to 9 were used (t0: The online version of this article (10.1007/s00787-020-01647-9) contains supplementary material, which is available to authorized users. Bullying is defined as negative actions, which occur repeatedly and over a long period of time. It is discerned from peer-conflicts by an imbalance of power. Consequently, the person who is being bullied has difficulties to defend him-/herself and the perpetrator is superior . The larBullying increases the risk for a wide and diverse range of health and psychosocial problems with long-term effects even in later adulthood , 6. FurtN = 11,052 students. The results showed a reduction in direct victimization in grades 3, 5, 6 and 7, but not for indirect victimization. Perpetrator rates decreased in grades 4, 5 and 7. Grades 11 and 12 showed an increase in bullying. According to Olweus and Limber [In a meta-analytic review, Ttofi and Farrington  investigd Limber  the progThe aim of the current study was to evaluate the implementation of the German version of the OBPP in a sample of German secondary schools. We hypothesized that the number of bullying victims and perpetrators will be reduced when schools successfully implement the OBPP. In addition, potential moderator effects of gender, class level and school-type were tested.The German OBPP project was funded by the Baden-Wuerttemberg Foundation (Baden-Wuerttemberg Stiftung) as part of their program “Youths Mental Health”; thus, participation in the OBPP was free of charge for all schools. The study was conducted at the Department of Child and Adolescent Psychiatry, University of Heidelberg and performed in compliance with the Helsinki Declaration. It was approved by the ethics committee of the Medical Faculty of the University of Heidelberg (S-341/2014) and the respective school authorities. In addition, the study was registered at a WHO trial registry .A prospective quasi-experimental design with an annual student survey  was used, and the OBPP was implemented after baseline in each participating school. All students, teachers and caregivers were informed about the OBPP implementation as well as the evaluation study by leaflet. Regarding the survey, students gave informed consent and caregivers were informed about the study and had the opportunity to object to the participation of their child (opt-out). The survey was conducted annually just before summer vacation. The data were collected from students in class-sized groups during a 45 min online survey.The recruiting process started in 2014. Only regular secondary schools  with at least 100 students, starting from grade five, were eligible. The intended design was a randomized control trial (RCT) and 30 schools from our regional catchment area were randomly selected and invited to participate. Although the schools were intensively contacted via both mail and personal phone call, all of these schools declined. Subsequently, the catchment area was expanded stepwise. It took schools between several weeks and months to settle their decisions, and we still received very little consent to participate, thwarting the project timeline and funding resources. Given that we were forced to work with a lower number of schools than originally expected, and that schools were even less willing to participate in the context of a potential allocation to a control group, we finally moved from the RCT design to a quasi-experimental evaluation study.n = 23), a total number of n = 6485 students (grades 5–9) were invited to complete the survey. The final number of students who consented to participate in the OBPP evaluation during baseline assessment was n = 5759 (88.8% response rate). We divided grades 5, 6 and 7 (age 10–13 years) and grades 8–9 (age 14–16 years) into two different grade groups.Initially, 413 secondary schools in the state of Baden-Wuerttemberg were informed about the program via e-mail, mail and phone calls, and invited to participate in the OBPP and its evaluation. 13 schools accepted our offer and started with the program in 2015 (first cohort). In a second step, we further expanded the catchment area and invited another 1102 schools (794 new schools and 308 schools who did not respond during the first cohort). 10 schools accepted our invitation and started the program in 2016 (second cohort). Supplement figure A1 provides detailed information about participants in each group following the CONSORT 2010 Flow Diagram . OverallPrior to the start of the study, all OBPP materials were translated into German in close collaboration with Olweus International Bergen and a translation company. The original teacher handbook was translated from Norwegian , the parFor every school, a keyperson, called Olweus-Coach, was selected. This person received a 7 day training carried out by Olweus International Bergen (3 blocks: (1) day1–3: before implementation started, at the beginning of the school year, (2) day 4/5: 5 months after the program had started, (3) day 6/7: at the end of the school year), as well as regular supervision during the implementation phase. The Olweus-Coach in turn was responsible for the implementation of the program components at school, for example regular study- and supervision groups for all staff members, regular class meetings and cooperation with parents. For further details of the program, see Olweus and Limber  and suppThe Olweus Bullying Questionnaire Revised (OBQ-R)  is a 57-The effect of the intervention on the rate of bullying was estimated with multilevel mixed-effect logistic regressions with being bullied (yes/no) as dependent variable and time of assessment  as fixed factor. To take into account that students within one class are more similar then students between classes and students within one school are more similar than students between schools we added random intercepts for each school and for each combination of class and assessment time nested within schools. The short-term effect (1 year) of the program is estimated by the odds ratio between the probability of being bullied at t0 and t1 and the long-term effect (2 years) by the odds ratio between t0 and t2. We also tested the possible moderator variables program completion, gender, grade-level, school-type and cohort. For each of these moderator variables the variable itself and the interaction of the variable with assessment time were added to the regression. A significant interaction would mean that the program effect is influenced by the levels of the moderator variable. Of special interest is cohort as moderator. A significant interaction between assessment time and cohort would indicate a confounding between program effect and general trends in time, limiting the interpretation of the results. To estimate the effect of the program on the number of bullying perpetrators, the same set of models were estimated with being a bullying perpetrator (yes/no) as dependent variable. We assumed an independent variance–covariance structure for all mixed models; the hypotheses were tested with Wald-tests of linear contrasts using a significance level of α = 0.05. For all calculations, the statistic program Stata 16 was used .Out of the 23 participating schools (intention-to-treat), 16 schools successfully implemented the OBPP (completer), while seven schools canceled implementation of the program within the 18-months implementation period (non-completer). Five of these seven non-completers took part in the annual student survey at all three time points and two schools completed the survey at two time points only. Table p = 0.033) but no reduction between t0 and t2 . 6.71% reported being a perpetrator, with a range of 0.0–16.39% across schools. The number of perpetrators was reduced between t0 and t1 (t1: 4.99%), which comes up to a relative reduction of 25.62% . Again, this effect was not stable at t2 .At baseline, 9.21% reported being a victim of bullying, with a range of 2.0–17.46% among the 23 schools. An intent-to-treat analysis (including both completers and non-completers) showed a significant reduction between t0 and t1  = 7.62, p = 0.022), indicating that the trajectories of the victimization rates differed between completer and non-completer schools. While the completer schools showed a significant reduction in victimization over time (χ2(2) = 15.17, p < 0.001), the non-completers showed no change in the rate of victimization during the observation period (χ2(2) = 4.64, p = 0.099). Figure χ2(2) = 0.35, p = 0.840).A significant interaction between program participation and assessment time was found in the regression of bullying victimization . This corresponds to a relative reduction of 24.87% in being bullied. Between t0 and t2, the relative reduction remained 25.26% , indicating stable program effects. These odds ratios reflect a small effect size in epidemiological studies [At baseline, 9.14% reported being a victim of bullying. After 1 year, the bullying rate dropped to 6.87% at t1 .The reduction was stable at t2 . These results reflect small effect sizes [The number of perpetrators could be reduced from 6.16% at t0 to 4.42% at t1, which corresponds to a relative reduction of 28.25%  were found. Including gender as a moderator of the program effect resulted in a significant interaction between gender and assessment time for victims (χ2(2) = 10.85; p = 0.004). Girls showed a significant decrease between t0 and t1 , as well as between t0 and t2 . This indicates that being a victim of bullying for girls reduced by half after 2 years of intervention, which is interpreted as a medium effect size in epidemiological studies [p = 0.125; t0 vs. t2: OR = 0.93; 95% CI 0.74–1.18, p = 0.570).At t0, no differences for the prevalence of victimized girls (9.75%) and boys . As opposed to victims, there was no interaction between gender and assessment time for perpetrators (χ2(2) = 0.68; p = 0.713), indicating that the program did not affect male and female perpetrators differently. Table At t0, boys were significantly more likely to be perpetrators than girls . The data showed a significant interaction between grade group and assessment time in predicting victimization (χ2(2) = 7.12; p = 0.028). Grades 5–7 showed a significant decrease between t0 and t1  and between t0 and t2 , which is a medium effect size in epidemiological studies [p = 0.009; medium effect size) but there was no change between t0 and t2 anymore .At t0, an inverse relationship between the prevalence of being bullied and grade was found, with a victimization rate of 10.00% at grades 5–7 and 8.07% at grades 8–9 . For being a perpetrator, no interaction of assessment time with grade group could be shown (χ2(2) = 1.25; p = 0.535); see Table At t0, the overall rate of perpetrators differed between the grade groups, with higher rates in grades 8–9 . There was no interaction between school-type and assessment time in predicting victimization (χ2(2) = 3.13; p = 0.209).At t0, no differences for the prevalence of victimization in A-level (7.51%) and B-level schools (9.92%) were found . Also, the interaction between school-type and assessment time was not significant in predicting perpetration (χ2(2) = 4.88; p = 0.087). Again, see Table At t0, the prevalence for being a perpetrator did not differ between A-level 5.25%) and B-level (6.60%) schools (5% and B-χ2(2) = 5.61; p = 0.061) and for perpetrators (χ2(2) = 3.69; p = 0.158), indicating that the program did not affect the two cohorts differently.There was no interaction between cohort and assessment time for victims , than for boys which might suggest that the program is more effective in reducing female victimization. However, it is also well possible that girls may tend to answer more socially desirable in respective outcome questionnaires. This was rather surprising since no previous studies working with the OBPP reported an interaction by gender in this direction. Therefore, it would be questionable to explain this effect only by program content or requirements that may favor girls. So far, authors reported that some components of anti-bullying programs worked better for girls , others for boys . It is Secondly, the victimization rate could be reduced between t0 and t1 in both grade-levels; however, after 2 years, the positive effects could only be retained for grades 5–7 but not for grades 8–9. Thus, we revealed an overall successful pattern for grades 5–7, with a medium effect size , but a dn = 119 and n = 422. Therefore, we consider the large sample size (of N = 5759) and our transparency in the reporting of the recruitment process as two major strengths, when compared with the previous studies. Our findings of low feasibility may point to the need of new programs that integrate effective whole-school approaches but require less time and costs to be implemented. However, prevention definitely needs time and resources to be effective [Despite the significant reduction of bullying in the completer schools, the study demonstrates a potential lack of feasibility of the OBPP in the current German school system. As illustrated by our difficulties in recruitment, German schools have been unlikely to participate in the OBPP even under relatively optimal conditions . In the future—outside of research studies like ours—schools would have to pay for the materials and Coach-Workshops, which may even increase barriers for the successful implementation of the program. Thus, the overall public health value of the OBPP for Germany may be questionable. In this study, we provided transparent reporting of our difficulties in recruiting schools including its implications for further dissemination. Four studies conducted in Germany during the last decade were included in a recent meta-analysis. However, none of these provided detailed reporting of recruitment rates , 30. Theffective  and it i of N = 559 and ouConsequently, our conclusion is: It is necessary to increase the feasibility of the OBPP or any other antibullying program that may include similar whole-school approaches probably alongside with political actions that may also involve the provision of respective resources. If schools work with the OBPP over a period of 18 months, they may experience considerable benefits as indicated by reduced bullying rates.For interpreting our results, it needs to be considered that these are not the results from a RCT. Although an RCT was originally planned, the study design was changed due to the low commitment of schools to participate in the study in general, and in a control condition in particular . It is not new that the realization of a RCT design in complex organizations like schools is problematic . HoweverBullying reduction can be achieved by the German OBPP in case of a successful implementation of the program over a period of 18 months. However, the extremely low participation rate outlined above as well as the high dropout rate during implementation (both at the school level), imply that some necessary adaptations might be needed to make the program more feasible for schools. Moderator analyses showed that adaptations may also be needed to make the bullying prevention more effective for boys and more stable for grades eight through nine. In their meta-analysis, Gaffney, Farrington and Ttofi  reportedSupplementary file1 (DOCX 418 kb)Below is the link to the electronic supplementary material.


Conflicting schedules and geographic access limit prospects for mutually beneficial relationships between experts and early career professionals. A formal long-distance mentorship program could address these barriers and potentially bridge the gap of traditional face-to-face mentorship. This study was done to determine the feasibility of implementing a formal long-distance mentorship program amongst public health physicians of Nigeria.A mixed-method study comprising of in-depth interviews and surveys was used to collect information from members of the Association of Public Health Physicians in Nigeria. A total of 134 survey participants were recruited consecutively during an annual scientific meeting of the association. In-depth interviewees were purposively selected to ensure diversity in expertise, experience, and social stratifiers such as age. Quantitative data were analyzed using descriptive and inferential statistics, while qualitative data were analyzed using thematic content analysis.Public health physicians of Nigeria are willing to participate in a formal Long-Distance Mentorship Program, and four elements of feasibility were highlighted as necessary for implementing the program. Namely i) capacity to coordinate LDMP, ii) technical expertise and individual competence to provide mentorship, iii) financial capacity to implement and sustain LDMP, and iv) demand for mentorship by mentees. There is a consensus that the organizational structure of the National Postgraduate Medical College of Nigeria and West African College of Physicians provide an enabling environment to initiate a LDMP for public health physicians of Nigeria. The vast human resources with various expertise and the annual National conferences can be leveraged upon to champion and administer the program. However, there is a need for an administrative structure and technical expertise to enable proper coordination. More so, the need for demand creation and the financial requirement was considered gaps that need to be filled to be able to ensure feasibility. Bivariate analysis showed a significant relationship between the dependent variable (preferred role- mentor/mentee) and independent variables , while the binary logistic regression model showed that physicians are more likely to participate as mentors with each unit increase in the number of years of practice. This further buttressed the need to commence the mentoring process as soon as trainees gain entrance into the program, as mentorship does not just prepare them for excellent public health practice, but also builds their capacity to mentor the younger and upcoming public health physicians.There are enabling structures to incorporate a formal long-distance mentorship program for public health physicians in Nigeria, and physicians are willing to participate in such a program. However, the feasibility of establishing a successful and sustainable program will require robust coordination, technical expertise, demand creation, and financial commitment at both institutional and college levels. There is an integral connection between mentorship and professional career development within the medical profession . ThroughWithin the field of public health, mentorship has recently been emphasized in many academic programs as the key driver of every successful career. Once past residency, early-career physicians have fewer mentorship opportunities, while they also will be expected to become mentors themselves. The crucial need for long-distance mentorship amongst public health physicians was further re-emphasized in a plenary session in the 2016 annual conference that was held in the Federal Capital Territory. Mentorship was portrayed as fundamental to the program, however, difficulties in finding someone local, with whom a mentee can develop a mutually beneficial relationship persists .The traditional method of mentorship involves one-on-one mentoring in a synchronous environment . One-on-With the advent of online applications for teaching and learning, long-distance mentorship has been conceptualized as the online or electronic version of mentoring . It invoPublic health training in Nigeria is expanding to include more residents in both academic and community settings. As a result, most residents find themselves training far from their envisaged, or chosen role models and desired mentors, separated by time and distance. Conflicting schedules and geographic separation make it impossible for the residents to access these important people face to face . There iLong-distance mentorship overcomes the limitations of traditional mentorship and bridges the gap of traditional face-to-face mentorship with overwhelming effectiveness . It is aThis study used a cross-sectional design, with the convergent mixed-method model to explore context-specific evidence for the feasibility of establishing a formal long-distant mentorship program for public health physicians in Nigeria. Qualitative and quantitative data were collected concurrently, and data integrated by merging of findings. The convergent mixed method of data collection was used to enable data triangulation and more robust synthesis of findings. In-depth interviews were used to explore i) stakeholder’s perception of a formal LDMP, ii) feasibility of jumpstarting such program, iii) available resources and gaps, iv) enabling and constraining factors for implementing and sustaining a successful long-distance mentorship program. The qualitative survey was used to elicit information on respondent’s perception of mentoring, willingness to participate, preferred role (mentor/mentee), and willingness to embrace best practices for long-distance mentorship.This study was conducted in Delta State, Nigeria, amongst Public Health Physicians of Nigeria. This group of physicians is brought together under the Association of Public Health Physicians of Nigeria (APHPN), an association the draws its membership from 36 states of Nigeria and the Federal Capital Territory. The Association of Public Health Physicians of Nigeria (APHPN) comprises medical doctors who have been trained or are undergoing residency training in public health/community medicine in Nigeria. They are uniquely trained in both clinical medicine and public health to provide medical diagnosis and patient care; conduct teaching and research, and serve in various capacities in different parastatals to maintain the health of the population.Public health physicians work in healthcare settings, public health departments, and government agencies, development organizations, as well as academia. Their work is focused on the population rather than the individual; provision of essential public health services to the population. Public health physicians are present in all the states of the federation and are brought together under the national body which holds scientific meetings annually. All physicians who have some form of training in public health or who are practicing public health are eligible to be members of the association. As at the time of the study, APHPN had a membership strength of 2000.The study population for the survey comprised of public health physicians who were attending an annual national scientific conference which was hosted by the Delta State chapter of the association in 2018. This comprised of training consultants, resident doctors undergoing training in community medicine or undertaking a Master’s program in Public Health, public health practitioners in health ministries, departments, and agencies. Respondents for in-depth interviews comprised of stakeholders and members of the association who were considered knowledgeable based on their input and wealth of experience within the association.For the survey, all members of the association who were attending the annual scientific conference were invited to participate in the study, and only those who gave consent were interviewed. Conference attendees who were not members of the association were excluded from participating in the study.Respondents for the in-depth interview were purposively selected to ensure maximum variability and representation of diverse perspectives with respect to leadership contributions/experience within the association, area of expertise, and social characteristics such as age. Participants were asked to suggest additional people to be interviewed. Ten prospective respondents were contacted for the in-depth interviews , and seven of them were interviewed. Three prospective respondents were not interviewed as data saturation was reached.p < 0.05. To ascertain possible predictors of the capacity in which the respondents were willing to participate (mentor/mentee role), binary logistic regression was conducted with significant independent variables.Information sheets and consent forms were provided to all eligible participants and they were given time to read through and ask for clarifications from the researchers before documentation of consent. A self-administered structured questionnaire was used to collect respondents’ information on their demographic characteristics, perception of mentoring, willingness and readiness to participate in a formal LDMP, and the capacity in which the respondents preferred to participate (their preferred role-mentor /mentee) in the program. The dependent variable is the preferred role of the respondent (mentor /mentee), while the independent variables include i) age, ii) sex, iii) year of graduation, iv) the number of years of practice as a public health physician. Numeric variables were summarized using means and standard deviations. Categorical variables were summarized using frequencies and proportions. To identify the relationship between the sociodemographic characteristics of the respondents and the capacity in which the respondents preferred to participate (preferred mentor /mentee) in the program, cross-tabulation of the dependent variable- preferred role (mentor /mentee) and independent variables  was conducted. Statistical significance of observed associations was set at Participants were contacted either physically or via email with a brief description of the study objectives, their roles as participants in the study, and consent forms. Participants had no prior knowledge about the interviewer’s personal goal. In-depth interviews were conducted using semi-structure interview guide to elicit information on feasibility, available resources, and gaps that need to be filled to be able to implement a formal long-distance mentorship program. Five of the interviews were conducted face-to-face in the offices of the respondents, while two were conducted over the telephone. The interviews were conducted in the English language. Reflexive thinking was applied in the conduct of the interviews and reflexive insights fed into subsequent interviews to minimize subjectivity. Field notes were taken and the interviews were audio-recorded with the consent of the participants. Each interview lasted between forty-five minutes to one hour and none of the interviews were repeated.Preliminary data analysis proceeded simultaneously with data collection, and emerging findings informed deeper inquiries in subsequent interviews. Audio-recorded interviews were transcribed verbatim and transcripts anonymized with pseudonyms. Proper thematic content analysis began with the reading of two transcripts repeatedly to achieve immersion and derive codes by identifying words that capture key concepts. Initial codes were reviewed and sorted into categories based on linkages between key concepts. The themes that represented key issues with the feasibility of long-distance mentoring were developed for initial coding and inductive analysis. The codes include the perception of respondents on i) organizational capacity to coordinate LDMP; ii) availability of technical expertise/individual competence to provide mentorship; iii) financial capacity of the organization to implement and sustain LDMP, and iv) demand for mentorship by mentees.The research team includes three public health physicians who are well-grounded in health policy and systems research and qualitative methodology; a professor of public health a senior lecturer and a resident doctor, all in the department of community medicine. All members of the research team have significant prior experience in conducting qualitative research. The interview guide was developed and discussed with experts, to ensure that the guide, probes, and prompts were free of pre-conceived opinions of team members on the subject matter of interest. The study findings have been reported in line with the consolidated criteria for reporting qualitative research (COREQ) .The response rate was 75%. A total of 141 questionnaires were collected, 6 were filtered as a result of incompleteness and, 134 were analyzed. The results are presented below.Table Figure Figure Bivariate analysis showed a significant association between the preferred role (mentor/mentee) and i) age category Table , ii) yeaThe independent variables  were used to predict the preferred role of respondents (dependent variable). The result of the logistic regression analysis is presented in Table p > 0.05 (0.185)), indicating that the model is correctly specified. The -2log likelihood = 102.1, and the Nagelkerke R square = .379. Additionally, about 40% of the variance in the dependent variable is explained by the predictor variable in the model, with percentage accuracy classification, PAC =82.8%.A binary logistic regression was used to predict the capacity (preferred role) in which physicians were willing to participate in the long-distance mentorship program. The dichotomous outcome variable of interest was willing to participate either as a mentor or as a mentee. The possible predictors were i) age, ii) the number of years of practice as a public health physician, and iii) year of graduation. The Hosmer and Lame show goodness of fit was not statistically significant (p = 0.02). For every unit increase in the number of years of practice, the estimated odds ratio favored a decrease of 12%  in the likelihood to be a mentee. Therefore, as the number of years of practice increased the odds of being a mentee decreased. The independent variable “age” and “year and graduation” was not statistically significant .The binary logistic model resulted in a statistically significant finding for the independent variable , but there will be a need for coordination. This could rest on a Chief Programme coordinator, just like we have the Chief examiner. It will need strong coordination, administration, and systems to take action when progress is not being made. An advisory team which will consist of high-level people to provide strategies and guidance for running the program.” There is a need for the college to set up a committee, establish standards and expectations, kick it off, encourage it, facilitate it as much as they can. “The college already has an existing secretariat to work with. It doesn’t need a new one. All it needs to do is to set up a committee to champion it. There is a need for an administrative structure, this will not work with the usual civil service work, we need people who are able to follow things through, in a project sense.” There was consensus that the national and regional training colleges (which make up the association) have well-organized structures to support training; therefore, the colleges will be able to champion and administer a long-distance mentorship program. Respondents noted that membership of both colleges comprises categories of people at various stages in their career, and mentorship could easily be incorporated into the training program. However, they highlighted the need for the establishment of a dedicated administrative structure and a planning committee to i) set up logistics for implementation, ii) pilot the affairs of the program, iii) establish guidelines and directives, and iv) monitor and evaluate the program. Some of the respondents noted that the colleges would have to play an active role to properly coordinate all actors and activities of the LDMP. Some respondents further suggested that the existing secretariat could be used for coordinative purposes, while others opined that a new secretariat should be established for effective coordination, monitoring, and evaluation of the program.“The already existing conferences can be leveraged upon and time can be set aside, probably a day, for interaction between the mentors and mentees.” Some respondents agreed that the annual national and regional conferences present a very good opportunity to institutionalize mentorship, and should be leveraged upon for the annual face-to-face meetings between mentors and mentees. They suggested that a mentorship session should be included in the conference sessions, specifically for mentoring activities.“They can organize it, to an extent, but not absolutely. They can create awareness and establish guidelines for such mentorship arrangements. They can also enlightenment people to understand the need for it. That is the extent to which the colleges can get involved” “long-distance mentorship is the way to go, it very practical, but the college will not be able to administer and run it, they can only promote it, while individual institutions will be in a better position to administer it” Two respondents expressed reservations about the capacity of the training colleges to coordinate a formal LDMP. They felt that coordination of the program should be done at the institutional level and that the role of the college is that of demand creation and establishment of guidelines.There was a consensus that the association has highly skilled and experienced mentors, who are willing to mentor the younger colleagues; and also, willing and dedicated mentees who are eager to be mentored. However, respondents highlighted the need for a strong Information and Communications Technology (ICT) system to be set up to manage technicalities and ensure the smooth running of the program. Being a long-distant mentorship program, it will require a lot of virtual communication between participants, it will also require virtual monitoring.“We have a lot of highly skilled personnel in various fields of expertise. The college has vast human resources that are underutilized, and this is one of the requirements for such a program. However, it requires a very strong ICT system to be set up, to be able to administer and coordinate the program. Also, support staff to handle the technical issues as they arise. The existing secretariat might suffix for cost efficiency. But there is need for identification of ICT experts” (R6 College Consultant)A technical working group and a strong secretariat will be needed. It requires people who are trained to a tracking system for proper coordination and feedback. It will also need an advisory team which will consist of high-level people to provide strategies and guidance for running the program.” (R7 College Professor)Respondents further highlighted the need for a system that will enable and monitor communication, as well as provide support to ensure meaningful engagement between participants. They also noted the need for other technical equipment and facilities: software applications for audio-visual communication, reliable internet connectivity, laptops, pads, phones. They agreed that reliable and efficient internet is far-fetched in most institutions, highlighting that college members mostly depend on their private internet, even when there is institutional access. This is due to the unreliable nature of institutional internet, even when available. Respondents however noted that non-governmental organizations have more reliable internet access than most government-owned institutions. They stressed the need for the provision of efficient and reliable institutional internet access across all institutions under the colleges“There are financial gaps because it will definitely require some finance. The college needs to identify the importance of the mentorship program and the future benefit. If they can think futuristic, they should be able to create a budget line for mentorship from the money they are already getting to be able to institute such a program.” (R6 College Consultant)“Money cuts across everything and will also be needed for payment of staff and running the secretariat.” Some of the respondents highlighted that implementing a long-distance mentorship program requires a substantial financial commitment. They stressed that the colleges must be able to make meaningful commitments to start and sustain such a program. They must create a budget line for mentorship and ensure that funds are released for operational costs. There was consensus that the colleges may not be able to implement LDMP given their current financial capacities and the funding gaps that exist for other activities.“There is poor awareness and lack of willingness as a result of poor understanding of the concept and the need for mentorship. Willingness on paper is quite different from action [active participation]. There is need for awareness creation to reorient members towards the culture of mentorship” (R4 CollegePprofessor)“The biggest thing is the willingness of members to commit time to do this. There is a need for awareness creation at every level, during conferences at the national and regional level. This will help to get people involved and committed to making it work. The role of the college is to create awareness. Demand creation was a recurrent theme amongst the respondents. Respondents agreed that there is a poor understanding of the concept of mentorship and its relevance among members of the association, and this may result in poor demand for mentorship from potential mentees. Creating awareness to enable college members to understand the benefits of mentorship was recommended as a strategy that will enable participation. Some respondents stressed that the most crucial role of the college should be awareness creation, leveraging every opportunity and platform like the annual scientific conference.“The already existing conferences can be leveraged upon, and time can be set aside, probably a day, for interaction between the mentors and mentees.” To sustain the demand for mentorship, respondents opined that the annual national and regional scientific conferences held by both colleges and APHPN present a good opportunity to institutionalize mentorship. These platforms should be leveraged upon to increase uptake and sustain ofthe mentorship program. Respondents suggested that mentoring sessions should be included in the program schedules to enable face-to-face interactions between mentors and their mentees.Increasing limitations to one-on-one mentorship due to conflicting schedules and geographic separation continue to deter mentorship, a very important aspect of career progression. Long-distance mentorship bridges this gap, but this has not been explored amongst public health physicians. Evidence on the feasibility of establishing a formal long-distant mentorship program for public health physicians of Nigeria may set the implementation processes into motion. We used in-depth interviews to explore the feasibility and used a cross-sectional survey to ascertain the willingness of public health physicians to participate in a formal long-distance mentorship program.Public health physicians are willing to participate in a long-distance mentorship program. This was highly expected considering that the period of residency in public health represents a critical training phase, during which the physician is expected to acquire practical skills and expertise for sound public health practice. The field of public health is such that needs guidance and coaching for goal-oriented navigation . MentoriIn-depth interviews highlighted various elements of feasibility required to implement a LDMP program: organizational, technical, financial, and market feasibility. These elements are critical for feasibility, as they were captured by a framework proposed by Mbuagbaw et al. for setting up a long-distance mentorship program for researchers. The authors developed the framework through a comprehensive literature review and an appraisal of the first Canadian Institutes of Health Research - Canadian HIV Trials Network international postdoctoral fellowship program. They identified the components of a long-distance mentorship program, categorizing them into three classes- critical, important, and supportive components. This framework aligns with the components of feasibility identified in our findings. It captured “technical expertise” as a critical component, while it captured “coordination” and “funding” as important components for planning a long-distance mentorship program .The framework also captured the “enabling environment” as critical for setting up a long-distance mentorship program. This is a crucial requirement, as successful mentorship in academic medicine requires an enabling academic environment for effective mentorship . The colStakeholders acquiesced to the need for proper coordination of the program, such that will involve a mentorship committee, a technical working group, a strong ICT team, and other administrative staff for effective program implementation. However, stakeholders differed on the level of coordination; the majority proposed central coordination (at the college level), while the minority opined a decentralized coordination (at the level of various institutions under the college). Coordinating at the institutional level will limit preferred mentor-mentee pairing; a mentee may not be able to find a desirable mentor within his or her institution with respect to the desired areas of expertise and other considerations. The college has diverse experts dispersed all over member institutions; college members in a particular institution may not be aware of the human resources or potential mentors available in other institutions under the college.Therefore, the machinery of the college and the association can be leveraged to create coordinated linkages between mentoring pairs. A well-structured mentoring program that connects early-career researchers with diverse experts may stimulate new networking possibilities and lead to effective collaborations amongst investigators with different skills and expertise . FurtherWe identified enabling factors that have great potential to foster and sustain collaborations and quality mentorship amongst public health physicians- the vast wealth of highly skilled and well-experienced mentors and dedicated mentees who are willing to participate in the program; the training structure of the residency program, which creates an enabling environment for incorporating a mentorship program within the colleges; the already existing annual national and regional conferences that could also be leveraged upon for demand creation to reinforce the process. The annual conferences could also be an avenue for an initial face-to-face meeting for mentoring pairs. However, this may require an additional day to the usual conference period, for more effective and meaningful face-to-face interaction between mentoring pairs. Face-to-face interaction that precedes subsequent virtual interactions has been found to foster adequate interaction between mentoring pairs, enabling more meaningful relationships.Virtual communication is a fundamental requirement for long-distance mentorship . Our finBased on our findings, public health physicians of Nigeria should pay close attention to starting a formal LDMP that will enable upcoming physicians to receive good mentorship, and also build their capacity to become good mentors as well. This is critical for quality training and sustaining institutional excellence. It is not surprising that the number of years that a physician has practiced public health can predict the capacity in which the respondent will participate in the mentorship program (either as a mentor or as a mentee). The likelihood of becoming a mentor increased with every unit rise in the number of years of practice, further buttressing the need for the mentoring process to commence as soon as trainees gain entrance into the program. This is crucial because the mentoring process does not only prepare trainees for excellent public health practice but also prepares them to become a mentor to younger and upcoming physicians. This form of continuity will inculcate the culture of mentorship in the association, and foster excellence and successful career progression amongst public health physicians of Nigeria.The convergent model of mixed-method enabled triangulation and integration of findings for more robust syntheses. In-depth interviews also enabled deeper exploration of stakeholders’ perspectives on the various components of feasibility, and gaps that must be filled to be able to implement a long-distance mentorship program amongst public health physicians of Nigeria. However, in-depth interviews did not ensure maximum variability and representation across the length of years of practice, as residents were not captured in the interviews. Also, the quantitative survey was limited to only members of APHPN who attended a particular scientific conference. Therefore, generalization of findings may not be made with certainty for members who did not attend the conference.Public health physicians in Nigeria are willing to participate in a formal long-distance mentorship program. There is a great opportunity to leverage the organizational structure of the training colleges for program implementation. The existing vast human resources, training structure of the college, enabling academic environment, and annual conferences that assemble members annually are factors that will enable the process. However, there are identified gaps that must be put in place for a successful program- robust coordination at the college level, a good financial plan, and strong Information and Communications Technology (ICT) system are needed to ensure the smooth running of the program. Significant program uptake will require personal commitment and intense demand creation, both institutional and college level. Given the relevance of mentorship for successful career progression and the limitations of the traditional face-to-face method of mentoring, instituting a formal mentorship program should be considered for the public health physicians of Nigeria. It is, therefore, crucial to explore contextual strategies and considerations for initiating and implementing formal long-distance mentorship program, with peculiarities to public health physicians of Nigeria.


The study aimed to investigate the psychological and physiological effects of forest therapy programs on adolescents under probation. Fifty probationary teenagers from the Ministry of Gyeonggi Justice Compliance Support Center participated in the study. The study explored the effectiveness of a nonrandomized control group pretest–posttest design forest therapy program. The forest therapy program was conducted for two days and one night for the experimental groups (N = 33), who participated in the forest therapy program, and the control group (N = 17), who received two days of attendance center orders program in the lecture room of the Ministry of Gyeonggi Justice Compliance Support Center. As a result, adolescents under probation who participated in forest therapy programs had a beneficial effect on psychological well-being (K-WBMMS) and HRV’s HF (high frequency) and LF/HF (A ratio of Low Frequency to High Frequency) compared to those who received the general attendance center orders program. These results support that forest therapy programs play a positive role in the psychological and physiological effects of probationary adolescents and can affect the diversity of rehabilitation programs for probationary adolescents. Delinquency, which was previously limited to unsupervised wandering, has emerged as a serious social problem as the proportion of violent crimes such as theft, school violence, group sexual assault, and murder has increased daily. Since 1989, South Korea has implemented a probation system that improves criminality in accordance with volunteer activities and attendance center orders, while living a normal life at home, school, and the workplace, and without imprisoning teenagers who commit crimes .Youth crime rates continue to decline due to the efforts of programs for adolescents under probation. In 2018, the number of probationary teenagers stood at 35,626, 4.2% less than that in the previous year. Also, the proportion of teenagers who received their first probation in the past decade accounted for 48.3% in 2018, compared to 66.1% in 2009 [Adolescence is the stage of life in which people experience the most risks, opportunities, frustrations, and achievements . AccordiHowever, compared to adolescents who come from stable environments, juvenile offenders usually hail from vulnerable environments, where their psychological, familial, peer group and social resources are insufficient for healthy growth and development. Difficulties in emotional support due to specific family structures such as single parents, divorce, or remarriage ,14,15, iThe influence of stress may vary depending on how stress coping resources control stress . High leHowever, the current attendance center orders require a professional program that deals with emotional and physical stability as much as retraining to prevent re-offending and help young probationers develop healthy growth in the form of group therapy such as mental development training, human relationships, sex education, and substance abuse education . To thisAccording to a report by Lee et al , subjectInterest in forest activity intervention is increasing day by day to help teenagers participate in effective attendance center order programs. Forest activities are known to play a positive role as a space for psychological and physical recovery. It has been reported that forest activities relieve negative emotions, such as depression and anger ,41,42 anForest therapy programs use physical activities and psychotherapy to help improve the health of adolescents. Forest activities can give physical energy to teenagers. Through various activities using natural objects, teenagers experience a sense of achievement, fun, and immersion, and improve their concentration. Through this, teenagers’ confidence and personal capabilities can be increased, and their interpersonal capabilities can be enhanced through cooperation and intimacy with the members who worked together . AccordiStudies of juvenile offenders with forest experience also showed potential psychological healing ,58,59,60These previous studies show that forest therapy helps develop prosocial connections and bonds and introduces positive psychological and physiological stimuli for juvenile offenders. However, there is still a lack of underlying research to help young people with psychological and physical stability through forest therapy programs, and more evidence on health benefits is needed. Therefore, this study aimed to investigate whether forest therapy developed by referring to the characteristics of probationary adolescents affected their psychological and physical conditions.Hypothesis 1.Adolescents under probation who have experienced forest therapy programs will see a greater positive change in their psychological well-being in comparison to those who have attendance center orders.Hypothesis 2.Adolescents under probation who have experienced forest therapy programs will show a greater positive change in HRV than those who have attendance center orders.The program was conducted with 50 juvenile probationers from the Gyeonggi Justice Compliance Support Center. This study was conducted with the approval of the IRB (CBNU-201809-SB-711-01) of Chungbuk National University Industry–Academic Cooperation Foundation. The researcher made a recruitment announcement to a Justice Compliance Support Center in Korea to conduct a forest therapy program for probationary youth. After a meeting with a Justice Compliance Support Center that expressed its willingness to participate in the program and the overall progress of the program, the probationary youth were notified of the recruitment. Participants were selected from those who completed a voluntary participation agreement after explaining the purpose and content of the study. The forest therapy program was conducted in different groups of participants, and in the case of the experimental group, the two-day, one-night program was divided into 8 people in the first, 9 people in the second, and 13 people in the third. The control group had 17 participants in two days.N = 8, control group N = 6) and 36 high school students . An overview of the demographic data is shown in Most of the juvenile probationers who participated in the study identified as “male” (92.5%). The age range was 15 to 20 years old. The average age of the experimental group was 16.4 years, and of the control group was 15.8 years. Participants included 14 middle school students , larch (larix kaempferi (Lamb.) Carrière), and ash (fraxinus rhynchophylla), among others. The natural environment is excellent. The altitude of Saneum Healing Forest varies from about 200 to 1000 m, making it suitable for forest therapy programs using climate and exercise therapy. The valley, which has abundant water resources, is located around the Health Promotion Center. By generating anions, Healing Forest Road is known to make people feel increased immune health, mental stability, and freshness. The Saneum Healing Forest is a suitable destination for forest therapy based in sensory programs , who participated in the forest therapy program, and the control group (N = 17), who received two days of an attendance center orders program. A pretest measurement was conducted before the forest therapy program began. On the first day, participants arrived at the Healing Forest Center to understand the questionnaire, fill out the psychological well-being questionnaire, and measure their HRV. After the pretest, the schedule for the next two days and one night was introduced, with precautions for safety. Participants placed their luggage in their accommodations, finished their lunches, took a break, and began the forest therapy program. After the first day of the program, they stayed overnight at the Saneum Recreation Forest and proceeded with the program the next morning. After sharing their impressions, the program ended. The questionnaires were filled in and HRV was measured. After these were completed, the participants returned home with a probation officer.The program consisted of three themes, and its purpose was to observe positive psychological and physical changes through activities in the forest. The first theme, “Go to the Forest” , was designed to raise interest in forests, form intimacy between participants, and prepare participants to adapt to the new environment. The second theme, “Do in the Forest”  aimed at relaxing the mind and body through walking in the forest and meditating in the forest environment through five senses. Moreover, they were encouraged to reflect on the past and think about the future. The final theme, “With the Forest and Well” , was designed to provide an opportunity to define dreams and visions for the future see .The forest therapy program was conducted by two forest therapy instructors. Two probation officers participated in the program to encourage lagging participants. They participated in the play to increase the participants’ immersion and to safeguard the participants. Each program’s progress time and unit program were adjusted according to the participant’s immersion or condition. Detailed forest therapy program activities were scheduled as shown in To measure the psychological well-being of adolescents, Park and Choi  translatThe HRV test is a method of measuring the reaction of the autonomic nervous system. The sympathetic nervous system is activated during experiences of tension and stress, and the parasympathetic nervous system activates during relaxation. The activities of the autonomic nervous system and the sympathetic nervous system are measured by analyzing the power spectrum for the change in the interval. HF (high frequency) indicates the activity of the parasympathetic nervous system, and LF/HF (a ratio of Low Frequency to High Frequency) indicates the balance between the sympathetic and parasympathetic nervous systems. In this study, participants were measured in comfortable sitting positions for three minutes using uBioMacpa instruments.p < 0.05.All statistical analyses were performed using SPSS 21.00 . A response paired sample t-test was performed to identify changes in psychological well-being and HRV between the pre- and post-test. ANCOVA was conducted to compare differences between groups . The pretest results were used as covariates (baseline data) to eliminate the effects of different levels of individual psychological well-being and HRV. All statistical tests were performed at a significance level of t = −5.64, p = 0.000). Among the subfactors of psychological well-being, self-esteem , mental balance , social involvement , sociability , control of self and events , and happiness  showed improvement in the mean value improved and showed significant results. Conversely, the control group did not show effects on the psychological well-being of juvenile probationers. Control group did not change significantly, not only in psychological well-being, but also in subfactors such as self-esteem, mental balance, social involvement, sociability, control of self and events, and happiness.The results of paired t-tests between pre- and post-tests, which verified how affected the psychological well-being for each group presented in p = 0.000). In the verification of the subfactors of psychological well-being, the experimental group that attended the two-day/one-night forest therapy program showed a positive change in self-esteem , mental balance , social involvement , sociality , control of self and events , and happiness .To examine the effects on juvenile probationers’ psychological well-being, a covariance analysis (ANCOVA) was conducted to compare the different values before and after the program experience for each group see . It was t = −3.77, p = 0.001) and LF/HF . The juvenile probationers’ activity in the forest was physiologically stable and positively affected. Conversely, the control group did not show effects on the HF or LF/HF of juvenile probationers.The results of paired t-tests between pre- and posttests, which verified how affected the HRV for each group presented in p = 0.026) was observed in adolescents who received forest therapy. In the experimental group, LF/HF also showed a positive effect   see . The forThis study was conducted to promote the psychological and physical stability of probationary youth by participating in a camp-type forest therapy program, which was organized to reflect their characteristics, for two days and one night. The results of this study showed that the forest therapy program influenced the psychological well-being and physical health of probationary adolescents. Empirical studies show that forest therapy programs, as well as simple activities in the forest, affect the health of participants. However, few studies have reported the psychological and physical effects of forest therapy programs for adolescents under probation. Therefore, this study suggests that these programs can help improve the psychological and physical health of probationary adolescents.The results of the effectiveness of forest therapy programs for adolescents under probation are as follows: First, the experimental group that received the forest therapy program experienced a significant improvement in psychological well-being after the program. Self-esteem, mental balance, social involvement, sociability, control of self and events, and happiness, which are components of psychological well-being and have greatly improved. However, there were no significant changes in the control group. These results are consistent with prior studies that show that activities in forests have a positive effect on the psychological well-being ,64,65. KSecond, the experimental group that received the forest therapy program experienced significant improvement in HRV’s HF and LF/HF physiological stability after the forest therapy program. However, there was no significant change in the control group. This was consistent with the findings of prior studies that forest activities provide physiological stability through the activation of parasympathetic nerves ,49,67,68Third, there was a clear difference between the forest therapy group and the control group. The forest experience not only positively affected the development of social emotions, such as emotional acceptance and improved emotional control of teenagers, but also provided physiological stability. Forest therapy played a role in reducing stress from everyday life. The program intervention, which combines the healing elements of nature to help subjects improve their activities in the forest, is likely to have promoted physical stability changes, increasing their resilience in the natural environment.The forest therapy experience for probationary youth affected not only their emotional stability, but also their mental and physical resilience. Forest therapy played a role in reducing stress from everyday life. These programs may improve adolescents’ positive thinking toward the future along with an increased sensitivity or sense of cooperation with others. All these factors contribute to character development and personal growth. Such programs can play an active role in improving mental health and for reaching target goals for probationary youth. Forest therapy programs are not passive activities. Instead, participants experience the forest through meditation, physical activity, mental and physical relaxation, and ecological education. This mental health service provided to adolescents has a significant impact on delinquency behaviors and reducing recidivism ,72. ThusSeveral limitations exist in this study. First, it is difficult to identify and present a suitable period for the effectiveness of participants in the detailed program with a program that lasted for one night and two days. Further research is needed to clarify the effects of the participation period and the continued effectiveness of the program after returning to daily life. Second, the sample size was small, and there are limitations to generalizing the results. Therefore, further research is needed for a variety of participants, depending on the type and motivation, characteristics of the individual offenses. In the case of juvenile delinquents, there are various factors that affect crime. Therefore, different types of interventions are needed. Third, participants’ experience, satisfaction, and preferences in the forest can affect the results. Due to the participants’ satisfaction with the forest, it can be difficult to see it as an effect of the forest therapy program alone. Fourth, there was minimal control over the daily activities of the control group. The types of activities other than program activity hours in the control group  may have varied, which may have affected the outcome comparison. Fifth, a deeper approach is needed to discuss new possibilities for the psychological and physical well-being of probationary adolescents. Additional research using qualitative analysis is needed to understand the process of changes in an individual’s emotions and cognition through forest therapy programs. In addition, longitudinal studies on the changes in participants will also be needed. These limitations should be considered for future research.Nevertheless, this study is significant in that it verified the applicability and effectiveness of forest therapy programs with special groups of youth guardians. Future studies should organize various forms of forest therapy programs tailored to the individual needs and goals of probationary youth. It is reported that the forest therapy program will contribute to the social and emotional development of probationary youth, which is the purpose of the probation system.The results of this study show that forest therapy can help improve the psychological and physiological symptoms of emotionally unstable juvenile probationers, who are establishing themselves in various experiences at this stage of life. Therefore, forest therapy can contribute to emotional stability and health promotion if it is used to manage psychological stability.