National strategies are needed to continue to promote the broader benefits of participating in sport and organised physical activity to reduce physical inactivity and related disease burden. This paper employs the RE-AIM framework to evaluate the impact of the federally funded $150 million Move it AUS program in engaging inactive people in sport and physical activity through the Participation  and Better Ageing (over 65 years) funding streams. A pragmatic, mixed-methods evaluation was conducted to understand the impact of the grant on both the participants, and the funded organisations. This included participant surveys, case studies, and qualitative interviews with funded program leaders. A total of 75% of participants in the Participation stream, and 65% in the Better Ageing stream, were classified as inactive. The largest changes in overall physical activity behaviour were seen among socioeconomically disadvantaged participants and culturally and linguistically diverse participants. Seven key insights were gained from the qualitative interviews: Clarity of who, Partnerships, Communication, Program delivery, Environmental impacts, Governance, and that Physical inactivity must be a priority. The Move It AUS program successfully engaged physically inactive participants. Additional work is needed to better engage inactive people that identify as culturally and linguistically diverse, Aboriginal and/or Torres Strait Islander and those that live in disadvantaged communities in sport and physical activities. Tangible actions from the seven key insights should be adopted into workforce capability planning for the sport sector to effectively engage physically inactive communities. Physical inactivity is a major public health and economic concern to global communities . DespiteEffectively evaluating the impact of population-level physical activity programs is complex and challenging. A lack of integrated evaluations and weak intervention designs are common, and few evaluations are transparent in their protocol reporting and many fail to assess program reach, omitting key process information required to make a judgement of value and translation ,10. The In 2019, Sport Australia announced a $56 million investment into two funding streams, the Participation  and Better Ageing  streams. Funding focused on engaging inactive target groups in organised sport and PA, including people living with a disability, Aboriginal and Torres Strait Islanders, women and girls, disadvantaged communities, individuals with (or at risk of) long-term conditions, and culturally and linguistically diverse (CALD) and older people.The ‘Theory of Change’ guided the evaluation methods to inform how the program impacted both the capacity of the sport and PA sector (funded organisations) . A logicA quasi-experimental mixed method design used a pre-post survey, alongside qualitative data collection with funded program operational leaders. Participant characteristics and program designs for the two streams (Participation and BA) differ and have been analysed and reported separately.The University of Sydney ethics committee granted ethics approval for this evaluation (2019/533 and 2020/250). Where required, written informed consent was attained prior to data collection. Surveys were expected to be distributed by the funded organisations to all registered participants before and after their participation in the funded program, or at 6 months post initial registration. Socio-demographic data were collected from participants including postcode, which was used to classify both socioeconomic status using the Socio-Economic Indexes for Areas (SEIFA) , and remThe primary outcome of the survey data was meeting PA guidelines status, assessed using the validated single item measures for children 5–17  and adulAll Move It AUS grant funded organisations were invited to participate in a 30–45 min qualitative interview . A purpoParticipants’ demographic characteristics were calculated using descriptive statistics, including frequencies and proportions. Logistic regression models were used to determine whether the pre/post timepoint was associated with meeting physical activity guidelines and sport participation (at least twice per week). Model 1 is unadjusted and model 2 adjusts for age, sex, language, remoteness, and socioeconomic status. All analyses were performed in SAS Enterprise Guide 9.4 . All audio recordings of the qualitative interviews were transcribed verbatim for analysis by a professional transcription company (Way With Words). Framework Analysis was deemed an appropriate approach to analyse qualitative data due to the systematic nature of the semi-structured interviews . Intervin = 62), or July 2019 to July 2020 . Due to the impact of the COVID-19 pandemic, 32 of the funded programs were provided an extension beyond the planned completion date in June 2020. The 62 organisations in the Participation stream engaged 495,528 people, with 43,638 participants participating across 26 BA funded programs. A small proportion of participants responded to the pre/post survey, with 3483 (0.8%) and 6687 (15.3%) of Participation and BA stream participants responding to the survey, respectively. The results for each funding stream are presented separately herein, using the RE-AIM framework. In total, 88 diverse organisations were funded to deliver activities from July 2019 to July 2020  more likely to meet guidelines at follow-up, compared to baseline  . Weekly There was a decline in the number of participants achieving PA guidelines in the BA programs, with participants 35% less likely to meet guidelines at follow-up, compared to baseline  . This waThe qualitative data also evidenced that targeted approaches to engage and deliver appropriate activities to new target groups was in engagement. Appropriate program design was also necessary to effectively retain participants to achieve PA guidelines through continued participation.A diverse range of 88 organisations were funded through the Move it AUS grant program, including 35 national sporting organisations , 7 state sporting organisations , 30 non-government organisations , 4 educational organisations , 4 clinical organisations , and 8 local city councils . The organisations were at different levels of readiness, which impacted the adoption and integration of the program within the organisations’ strategies for long term results. Our findings showed that organisations with existing internal buy-in from leaders were more likely be using the support from Sport Australia to scale-up an idea already in place, rather than scoping out a pilot to test the feasibility of a new product . The impClarity of who organisations aimed to reach was provided in the Move It AUS grant guidelines informed program design, recruitment, and delivery to overcome barriers specific to the nominated target groups.Partnerships were recognised as a mode of working synergistically to reach new audiences or provide new offerings designed to reducing physical inactivity through new target groups.Communication was redefined externally to emphasise the fun, social, and non-competitive aspects of sport participation and internally to advocate for internal buy-in for the funded activity and new target audience.Program designs included a traditional or modified sport, the provision of educational or capacity building resources, or a multifaceted approach. High quality program deliverers and program flexibility were central to the effective implementation and adoption of funded programs.COVID-19 disruptions forced funded organisations to pivot online, which impacted reach and program delivery both positively and negatively. Although this time enabled organisations to reflect on improving key aspects of delivery, it also emphasised the importance social connections in project delivery.Governance from Sport Australia allowed organisations to try new approaches in recruiting target groups and legitimised internal commitment to these new strategies.Participation strategies to reduce physical inactivity were recognised as a priority across the sport ecosystem despite competing priorities for resourcing within funded organisations.The qualitative analysis of the interviews with program leads was synthesised into seven key insights :Clarity There was a 5% increase in participants in the Participation stream that was seen in those that “don’t know” whether they will drop out of sport or PA after the program, with a reduction in the proportion of participants who had already dropped out by 8.7%. A total of 91% of participants in the BA stream reported that they were planning to continue their current sports and physical activities at the post time point. This suggests there may be an impact of retention in programs, despite the impact of COVID-19 on participation opportunities.The sustainability of programs was a common concern within funded organisations (coded under “program delivery” and “governance”) . Most inThis study aimed to evaluate how a national grant program reached and engaged inactive communities in sport and physical activity, and to understand the impact on the capability and capacity of the sport sector to meet the needs of inactive communities. This is the first time that a nationally funded grant program in Australia has specifically targeted inactive participants and results suggest that the clear focus and strategic direction of the grant program was successful in recruiting inactive people. Despite the impact of COVID-19, the programs successfully demonstrated how organised sport can reach inactive populations and investment in sport can achieve health outcomes for these populations . Seven kA major barrier to reducing physical inactivity is the initial engagement and reach to recruit key inactive groups ,20. The Program design should begin with clearly defined target groups and include co-design where possible . ChallenThere was a reduction in the proportion of participants achieving PA guidelines in the BA stream, most significantly observed in the most disadvantaged and CALD participants. Research has found that the effect of COVID-19 on population participation in PA was not equal, and further work is required to address the widening equity gap in PA, particularly in the return to sport and organised PA after COVID-19 ,25. HoweRecently released by World Health Organisation, the Fair Play advocacy brief has called for greater cross-sectoral collaboration to better engage and retain inactive target groups . Our evaFunded organisations were responsible for disseminating the surveys. Some surveys were not able to be determined at either time point but are included in the aggregate total of respondents. Some organisations modified the data collection methods during program delivery due to unforeseen practicality implications such as language barriers and available resourcing. Findings would be strengthened in future with information on maintenance and the long-term impact of the Move It AUS grants, particularly in the absence of COVID-19 implications. Participation in the qualitative surveys was voluntary, and the possibility for self-selection bias should be noted.The strong engagement of inactive people in Move It AUS funded programs demonstrates the success and acceptability of targeted interventions in engaging inactive people to reduce physical inactivity and improve health for all. The sport sector is motivated and mobilised to be part of the solution to physical inactivity, and integration of the seven key insights from this study can inform future policies and opportunities supporting sporting programs for inactive populations in the future. Utilising grant programs to broaden the population engagement throughout sport and enhance the capability of the sport sector is one strategy for increasing population levels of PA and understanding the unique contribution sport makes to our local communities.


Patients treated for chronic mental disorders and who receive atypical antipsychotics are in most cases at risk of gaining weight, the excess of which is complicated in the long term by metabolic syndrome (MS). The management of these patients is effective if it includes Therapeutic Education.Describe the therapeutic education program developed for patients on antipsychotics who have metabolic syndromeIn this work, we present the educational program that we have developed for patients undergoing psychiatric treatment with atypical antipsychotics, who have been stabilized for at least 3 months and who suffer from SM.It is a program that starts with the inclusion consultation and educational diagnosis with the first step of clinical , biological  and psychometric  assessments. Our initial program includes 6 sessions and 2 maintenance sessions at 1 month and 3 months after the 6th session. The objectives were divided between information about DM, motivation to eat a balanced diet, physical activity and improvement of quality of life. We also included stress management and positive psychology activities. Assessments are repeated at the end of the initial program and at the last maintenance session.Our program was developed according to the Geneva therapeutic education recommendations. We plan to apply it to groups of patients in our departmentNo significant relationships.


Supporting parents with severe and persistent mental illness (SPMI) requires knowledge, skills, and a positive attitude toward parenthood. We developed a Japanese e-learning program for public health nurses (PHNs) to enable them to support parents with SPMI and their family members. This study aimed to evaluate the effectiveness of the program in improving the knowledge, skills, attitudes, and self-efficacy of PHNs in supporting them.A three-hour video-based e-learning program was developed. A randomized controlled trial was conducted with 176 PHNs responsible for maternal and child health in Japan. The outcome measures included the Sense of Coping Difficulty/Possibility Scale, skills to support people with SPMI, and achievement of program goals. Outcome data were collected at three time points during the study: baseline (T1), post-intervention (T2), and one month after T2 (T3) using self-administered electronic questionnaires. Outcome measures were assessed by comparing the two groups at the endpoint (T3) using t-tests and ANOVA. Effectiveness over time was assessed using a mixed model for repeated measures, with group and time interactions as fixed effects.p<0.001). The Sense of Coping Difficulty subscale had a large effect size (Cohen’s d=1.27). The analysis of the results of a mixed model for repeated measures showed that the group and time interactions on all outcome measures were not significantly different at T1 but were significantly different at T2 and T3.The study participants were randomly allocated to two groups:89 in the intervention group, and 87 in the control group. The total score and the scores in the two subscales of the Sense of Coping Difficulty/Possibility Scale in the intervention group at T3 were significantly higher than those in the control group, as shown by the t-test and ANOVA (all The program was effective one month after its completion, particularly in reducing PHNs’ difficulties in supporting parents with SPMI.UMIN000045765, November 1, 2021. According to an international survey by the World Health Organization, the lifetime prevalence of mental illness ranges from 12% to 47% (18% in Japan) , and oneThe symptoms and cognitive impairment of parental SPMI can create difficulties in maternal-child interactions, household chores, and childcare –13. PareNurses play a crucial role in supporting parents with SPMI . In JapaAdditionally, a systematic review article dealing with parents’ experiences with SPMI regarding the care they received  revealedAs in Japan, working with parents with SPMI and their families in other countries can be perceived as difficult, complex, and challenging for nurses . Vives-EFamily-focused practices emphasize family as a unit of attention . In suppBuilding therapeutic relationships with parents and their family members requires professionals to have positive attitudes toward them . HoweverTherefore, it is important for nurses to improve the knowledge and skills necessary to support parents with SPMI  and reduE-learning is rapidly gaining popularity as a means of continuing education for nurses, and their satisfaction with such programs is high . The litDigital storytelling has also been used in nursing education . It compE-learning programs are available for professional development in the area of parental mental illness . The twoThis study aimed to evaluate the effectiveness of a Japanese e-learning program for PHNs in supporting parents with SPMI and their family members.A randomized controlled trial (RCT) was conducted to test the effectiveness of the program. The study participants were randomly divided into intervention and control groups by stratified allocation based on their years of experience. The program was offered online, and only the intervention group could view it multiple times and at their own convenience during the six-week period. The outcome measures were evaluated by using self-administered electronic questionnaires from the Research Electronic Data Capture (REDCap) to compare the two groups at three time points during the study: pre (T1), post , and one month after T2 (T3). Ethical considerations allowed the control group to participate in the same program after the final T3 response. The trial findings were reported in a subsequent publication, according to the Consolidated Standards of Reporting Trials (CONSORT).The inclusion criteria for the study were full-time PHNs in charge of maternal and child health who worked at city health centers in Japan, and had less than ten years of experience as PHNs. The exclusion criteria consisted of those on whom electronic questionnaires or video-viewing operations could not be conducted. Information about the study was mailed to all 833 cities nationwide and the applicants applied individually.The sample size was determined with reference to the effect size of a similar e-learning program for practitioners . A two-sThis scale refers to analogous concepts of self-efficacy, that is, the efficacy expectation of the feeling that professionals can deal with families in difficult situations , 44. In In this study, the following items were asked about supporting parents in raising their children. For each item, the total score was given in the format of “not at all disagree” (1), “disagree” (2), “agree” (3), or “agree very much” (4). All items on the Sense of Coping Difficulty subscale were replaced with reversed items. Higher scores indicate that they felt less challenged and more capable of coping with supporting parents in raising their children. In summary, higher scores indicate higher self-efficacy.The validity of the unidimensional variable of the four items to self-evaluate the skills in dealing with mental health issues was confirmed . In thisThe achievement level of the six program goals was assessed on a seven-point scale from “not at all” (1 point) to “very much” (7 points) in terms of how well PHNs could explain their knowledge and skills.In addition to age and gender, this study identified support experiences, which can be related to the practice of support . ConsideThe number of times each module was viewed is reported. To evaluate feasibility based on the length of the program, the participants in the intervention group were asked to choose among long, just right, or short.Following the participants’ applications, entries were made in the order in which they were confirmed to have been sent and received through e-mail. The participants were automatically divided into two groups using REDCap, a data accumulation and management system, using a stratified allocation method based on years of experience (five years or less and six years or more). Entries were closed when the number of participants reached 176. Once participants were automatically assigned to one of the groups, they and data managers were not blinded to the groups. Electronic questionnaires and intervention materials were delivered automatically at the preset time points. The analyst blindly analyzed the outcome measures.This program was named YURAIKU-PRO. The program is a three-hour video in relation to an e-learning program for professionals to support parents with SPMI and their family members. The introduction (Module 0) and Modules 1–6 were divided into basic and specialized modules. The specific times and contents are listed in Table This program was developed through discussions in five meetings , through e-mail among six parents with SPMI and seven multidisciplinary professionals who were research members of this project, including psychiatrists, public health nurses, psychiatric nurses, and mental health social workers. The six parents were core members of a self-help group called “YURAIKU” (meaning “relaxed parenting”). In addition, one spouse and two adult children of parents with SPMI who ran self-help groups participated in two meetings and provided comments. First, the author developed a draft video using the findings from previous interviews and a survey of parents with SPMI , their sThe e-learning program has five main characteristics. First, it focuses on the perspectives and support needs of parents with SPMI. Second, it is a family focused practice that supports an entire family. Third, it is a program with content for multiple professions in order to understand basic knowledge and skills. Fourth, it is based on experiences and support skills obtained through interviews and surveys of parents with SPMI and their children, spouses, and professionals to support them. Fifth, digital storytelling is used.The goals were as follows:1) be able to describe the symptoms of mental illness and the difficulties in child rearing arising from the characteristics of mental disorders; 2) be able to describe the situation and feelings of the parents, spouses, and children involved; 3) be able to describe the support needs of the parents, spouses, and children involved; 4) be able to describe how to support the entire family; 5) be able to outline the roles of maternal and child health, child welfare, mental health, and medical welfare; and 6) be able to describe how to collaborate with multiple agencies and professionals. The program goals included knowledge and skills regarding parental SPMI , family-focused practice , parent and family situations, support needs for therapeutic relationship building , and interagency collaboration .The program was developed based on a training framework to deliver professional development programs in the area of parental SPMI . The fraThe learning process in each module was composed of Gagné’s instructional events . To gainThe total study population was defined as the Intention-to-Treat (ITT) population. Two types of population analyses were performed. For the evaluation of outcomes in this trial, the full analysis set (FAS) was used, excluding the scores of those who did not respond to T1. The other type was the per-protocol analysis set (PPS), which excluded those in the FAS who did not respond on time, those who did not complete all modules before the deadline (six weeks) in the intervention group, and those who withdrew from the study.First, descriptive statistics for FAS were calculated, and group comparisons between the intervention and control groups were made. Next, the total score on the Sense of Coping Difficulty/Possibility Scale at one-month post-intervention  as a primary outcome measure was calculated for the FAS, and the difference between groups in the mean was calculated by t-test and Cohen’s d was calculated as the effect size. As a sub-analysis, an analysis of covariance (ANCOVA) was performed using the baseline score (T1) and years of experience as covariates. The same analyses were performed for PPS. The same analysis as that for the total scores was performed for the two subscales of the Sense of Coping Difficulty/Possibility Scale.To examine effectiveness over time, we fitted a mixed model for repeated measures with group, time point , group, and time interactions as fixed effects, and study participants as a random effect and analyzed the total scores and subscales. A mixed model for repeated measures, similar to the Sense of Coping Difficulty/Possibility Scale, was performed with scores on skills related to mental health issues and the sum score of achievement of program goals.Process evaluations were analyzed in an exploratory manner only in the intervention group. To examine the relationship between the number of views and outcome measures, we used a linear model with the change from baseline as the dependent variable and the mean number of views and years of experience as independent variables. Short reports submitted by participants after viewing each module were reviewed by the researchers to determine if they contained anything that needed to be improved regarding the videos.p-value of 0.05 or less was considered significant. All analyses were performed using SAS9.4 .The missing data were not supplemented. A This study was approved by the Ethics Committee for the Intervention Study of Osaka University Hospital . Written informed consent was obtained from all participants. This study was conducted in accordance with the principles of the Declaration of Helsinki. The researchers did not reveal the identity of the participants to the health centers. In addition, the data were separated from personal information and managed with an ID. This project was registered in the Clinical Trial Registry . No adverse events were reported.This study was conducted between November 2021 and March 2022. The flow of study participants is shown in Fig. The demographics of the study participants in the intervention and control groups are shown in Table Analysis results for the total score and two subscales of the Sense of Coping Difficulty/Possibility Scale at endpoint T3) in Intent to Treat Analysis (FAS) are shown in Table  in IntenAs shown in Table The number of views for each module in the intervention group is presented in Table Of the 84 participants in the intervention group who finished all modules, 17 (20.2%) answered “long,” 67 (79.8%) answered “just right,” and none answered “short” for the length of the program.In the intervention group, the total score and scores of the two subscales of the Sense of Coping Difficulty/Possibility Scale at the endpoint (T3) were significantly higher than those of the control group. Moreover, the analysis results of a mixed model for repeated measures showed that the group and time interactions on total scores of the Sense of Coping Difficulty/Possibility Scale and the subscales, skills related to mental health issues, and the sum score of the program goal achievements were not significantly different at T1, but were significantly different at T2 and T3. This result indicates that significant effects were observed over time up to one month after the intervention. The program achieved its goals and was as effective as intended.The effect size was moderate (Cohen’s d=0.65) for the Sense of Coping Possibility subscale, whereas it was large enough (Cohen’s d=1.27) for the Sense of Coping Difficulty subscale . In a suThe Sense of Coping Possibility subscale also had a moderate effect size, but the effect persisted until one month later. This measure may also reflect a change in PHNs toward positive attitudes. We believe that digital storytelling and incorporation of verbatim descriptions by parents with SPMI are effective.Skills related to mental health issues also showed a sustained effect up to one month after the intervention. This indicator is a self-assessment measure of knowledge, support skills, and support experience. It can be concluded overall that the participants gained knowledge and skills.The sum score of program goal achievement also showed a sustained effect up to one month after the intervention. Program goal achievement was based on the ability to explain their knowledge and skills in parental SPMI, family-focused practice, parent and family situations, support needs necessary for therapeutic relationship-building, and interagency collaboration. Overall goals were achieved through this program.In this study, an e-learning program was evaluated using an RCT. Many e-learning programs for continuing education for nurses are primarily used to improve nurses’ knowledge, skills, and self-efficacy , and we It has been reported that e-learning programs for professional development exist for parents and families; however, few have been evaluated for their effectiveness . Two e-lThe program also worked well as an e-learning program one month after its completion. One reason for the continued effectiveness of the program may be its learning style, which was divided into six modules. Although the modules were short, it is possible that the effect was sustained by repeated self-reflection and action planning each time using Gagné’s instruction . Of the This study has several limitations. First, the effectiveness evaluation was not available until after one month, making evaluation over a longer time period impossible. Next, as we measured self-efficacy for support, we did not know whether the study participants could successfully support them. Third, significant effects of the program were found, even after adjusting for years of experience as a PHN. This program may be effective for PHNs with more than ten years of experience, which was not the subject of this study. Fourth, owing to the data management system used in the study, it was not possible to determine if the video was actually viewed all the way through or for how long.Finally, a potential bias is that many participants may have worked in workplaces that understood the training, or were studious. Thus, a shorter program may be appropriate for those who are less interested in studying or who cannot view it during their working hours, but only during their private time. Possible research directions include shorter programs, long-term evaluation of effectiveness, inclusion of PHNs with more than ten years of experience, and data analysis, including bounce rates and viewing time for each module.The recommended method for viewing this program is not to view all modules at once but to reflect and practice daily each time one module is viewed. This repetition is believed to result in higher retention of knowledge and skills.A possible direction for future research is to develop effective training programs for professionals other than PHNs. Training programs for childcare workers and mental health professionals appropriate for their respective specialties should be developed.The e-learning program YURAIKU-PRO was found to be effective, particularly in reducing PHNs' difficulties in supporting parents with SPMI. In addition to the knowledge and skills related to parental SPMI, family-focused practices, therapeutic relationship building, and interagency collaboration are especially important when supporting parents with SPMI. The use of digital storytelling through e-learning is effective and recommended as a training style for nurses.


Recent research has underscored the immense diversity and key biogeochemical roles of large DNA viruses in the ocean. Although they are important constituents of marine ecosystems, it is sometimes difficult to detect these viruses due to their large size and complex genomes. This is true for “jumbo” bacteriophages, which have genome sizes >200 kbp and large capsids reaching up to 0.45 µm in diameter. In this study, we sought to assess the genomic diversity and distribution of these bacteriophages in the ocean by generating and analyzing jumbo phage genomes from metagenomes. We recover 85 marine jumbo phages that ranged in size from 201 to 498 kilobases, and we examine their genetic similarities and biogeography together with a reference database of marine jumbo phage genomes. By analyzing Tara Oceans metagenomic data, we show that although most jumbo phages can be detected in a range of different size fractions, 17 of our bins tend to be found in those greater than 0.22 µm, potentially due to their large size. Our network-based analysis of gene-sharing patterns reveals that jumbo bacteriophages belong to five genome clusters that are typified by diverse replication strategies, genomic repertoires, and potential host ranges. Our analysis of jumbo phage distributions in the ocean reveals that depth is a major factor shaping their biogeography, with some phage genome clusters occurring preferentially in either surface or mesopelagic waters, respectively. Taken together, our findings indicate that jumbo phages are widespread community members in the ocean with complex genomic repertoires and ecological impacts that warrant further targeted investigation. Caudovirales with genomes over 200 kilobases in length [Caudovirales used concatenated protein alignments to generate phylogenies and found that the most supported clades within the Caudovirales family do not consistently correspond to genome length [Caudovirales.Although historically noted for their small virion sizes and simple genomes , virusesn length . While an length . For exae length . Furthere length . Taken tn = 93) of complete Caudovirales genomes on NCBI’s RefSeq Viral Genome Portal  and 2.2% of the INPHARED database [Caudovirales [Although the first jumbo phages were isolated as early as the 1970s , these vdatabase . All culovirales , 16. Somovirales  or sophiovirales , 19. Regovirales , and a rovirales .Pseudomonas aeruginosa phage PhiKZ) [Despite this apparent broad environmental distribution, common methods for viral isolation and diversity surveys often bias against the inclusion of jumbo phages. Because viruses have historically been considered smaller than cells, many viral diversity surveys specifically examine only small particle sizes. For example, in plaque assays, agar concentrations are often too high for larger phage particles to diffuse through compared to smaller particles . Moreovee PhiKZ) , howevere PhiKZ) , but ofte PhiKZ) . Overalle PhiKZ) , jumbo pIn this study, we examine the diversity and prevalence of jumbo phages in the global ocean. We develop a workflow for generating and validating high-quality jumbo bacteriophage bins from metagenomic data with which we identify 85 bins of jumbo phages. We then compare the genetic content of these jumbo phages with other cultured phages of all sizes and metagenomic jumbo phages from other studies. We find that the jumbo phages of this study group into five distinct clusters that are distinguished by diverse replication machinery and infection strategies, implicating a broad range of potential jumbo phage-host interactions in the ocean. We then assess the distribution of jumbo phages belonging to these genome clusters in the ocean by using metagenomic data from Tara Oceans . Mappingn = 469) including many non-Tara metagenomes (n = 165). We focused our benchmarking and distribution analyses on Tara data [Due to the large size of jumbo bacteriophage genomes, it is likely that they are present in multiple distinct contigs in metagenomic datasets and therefore require binning to recover high-quality metagenome-assembled genomes (MAGs) . This haara data  because ara data , which gara data , VIBRANTara data , and Cheara data  , the INPHARED database [To assess global diversity patterns of jumbo bacteriophages, we combined these jumbo phage bins together with a compiled database of previously-identified jumbo phages that included all complete jumbo database , a recendatabase , the Al-database , and mardatabase   and the full set of reference jumbo phages described above. To construct the bipartite network, we compared proteins encoded in all the phage genomes to the VOG database, and each genome was linked to VOG hits that were present  marine jumbo phages, including 10 bins generated here), and included cultured phages of Group 1, which is typified by ase Fig. , implicaProchlorococcus phage P-TIM68 (NC_028955.1), which encodes components of both photosystem I and II as a mechanism to enhance cyclic electron flow during infection [The next largest phage genome cluster, PGC_C, comprised of 156 phages total (90 marine jumbo phages (57.7%); 4 bins generated from this study) and included reference jumbo phages in Group 2 31, 19.9%) which are typified by Alphaproteobacteria and Cyanobacteria phages. Likewise, the host range of other cultured phages in PGC_C support the Group 2 correspondence, either infecting Cyanobacteria (139 phages) or Proteobacteria (4 phages) Fig. . Furthernfection . This su1, 19.9% Finally, phages of PGC_D totaled at 47 phages, of which 7 were marine jumbo phages generated in this study 14.9%). This group included Group 3 jumbo phages , which is primarily distinguished by encoding a T7-type DNA polymerase but is not typified by a particular phage type or host range. Supporting this grouping, all marine jumbo phages in this study encoded a T7 DNA polymerase which belongs to family A DNA polymerases  and the marine megaphage Mar_Mega_1 (656 kb) recently recovered from the English Channel [Nodularia genus isolated from the Baltic Sea (accessions NC_048756.1 and NC_048757.1) and the Bacteroidetes bacteria Rhodothermus isolated from a hot spring in Iceland (NC_004735.1) [The largest of the phage genome clusters, PGC_A, contained 469 phages, including 135 marine jumbo phages (63 bins from this study). This genome cluster contained the largest jumbo phages, such as  Channel . Unlike To explore the distribution of the marine jumbo phages in the ocean, we first examined the size fractions in which the jumbo phages were most prevalent. To remove redundancy for the purposes of read mapping, we examined the 244 jumbo phages at the population-level  and had significantly higher relative abundances  of jumbo phages relative to the size fractions above 0.22 µm. Despite these differences in diversity and relative abundances, jumbo phage community composition did not significantly differ between the >0.22 and <0.22 µm size fractions when comparing samples based on presence/absence data , relative abundance ), and community composition between the size fractions (based on Bray–Curtis distance matrices). Collectively, samples of the size fractions below 0.22 µm were significantly more diverse  and above 0.22 µm (0.22–1.6 µm or 0.22–3 µm). The number of detected jumbo phage populations was significantly higher in samples below 0.22 µm than above 0.22 µm . Upon examining jumbo phages by group, jumbo phages from PGCs A, C, and D could be detected in all biomes, while PGB_B phages could not be detected in Westerlies samples   were detected in only one Tara station, and six (5.6%) were present in over half of the stations  ≥34 Fig. . Both th.7% were Pseudomonas aeruginosa and uniquely encoded multi-subunit RNA polymerases and tubulin, which are thought to play a role in the remarkable nucleus-like structures that these viruses employ as an anti-CRIPSR defense [Large DNA viruses are becoming increasingly recognized as critical components of the virosphere, notable for their intriguing evolutionary histories , 52, vas defense , 19. PGC defense .Caudovirales [Caudovirales.The jumbo phages we analyze are collectively widespread throughout the ocean and are typically more diverse and abundant in epipelagic waters, which reflect previous findings that surface waters usually harbor a higher per-sample alpha diversity of viral groups compared to deeper waters , 26. Larhttps://github.com/wwood/CoverM). Briefly, "even read coverage" means that the read coverage of each contig in the bin varied between one another below a variation threshold determined by reference mapping results  along with the curated jumbo phage set used in the population analysis. Proteins of jumbo bins and this reference set were predicted with Prodigal and searched against the Virus Orthologous Groups  via HMM searches . A bipartite network was made based on shared VOGs using igraph (graph.incidence) (1.2.5) [E value < 0.001; See Data Availability). Reference hits were de-replicated with CD-HIT (version 4.8.1 -c 0.9) [Because phages lack universal, high-resolution phylogenetic marker genes, gene-sharing networks have typically been used to classify phages , 62. Bip (1.2.5)  in R (ve (1.2.5)  with RSt (1.2.5) . A previ (1.2.5) , which w (1.2.5)  in R wit -c 0.9)  and filt -c 0.9) , trimmed -c 0.9)  and cons -c 0.9)  (TEST mo -c 0.9) ).p values < 0.05. Statistical tests were carried out with the ggplot2 function stat_compare_means(label="p.signif").Metagenomic reads from Tara Oceans were trimmed with trim_galore (-paired -length 50 -e 0.1 -q 50) and subsampled to an even depth of 20 million reads per sample with seqkit sample (-s 1000 -n 20000000 -2). These reads were then mapped onto the population representatives of the jumbo phage set (535 populations). For the mapping, the reference database of the representative jumbo phage sequences was created with minimap2 (minimap2 -x sr -d) , and theE value < 0.001) against the Pfam [Amino acid sequences of genes were annotated with HMM searches  , MAGs ofSupplemental MaterialSupplemental Dataset 1Supplemental Dataset 2Supplemental Dataset 3Supplemental Dataset 4


Lymphovascular invasion (LVI) is mostly used as a preoperative predictor to establish lymph node metastasis (LNM) prediction models for superficial esophageal squamous cell carcinoma (SESCC). However, LVI still needs to be confirmed by postoperative pathology. In this study, we combined LNM and LVI as a unified outcome and named it LNM/LVI, and aimed to develop an LNM/LVI prediction model in SESCC using preoperative factors.A total of 512 patients who underwent radical resection of SESCC were retrospectively collected. Logistic regression and least absolute shrinkage and selection operator (LASSO) regression were adopted to identify the predictive factors of LNM/LVI. Integrated discrimination improvement (IDI) and net reclassification improvement (NRI) were calculated to select the potential predictive factors from the results of LASSO and logistic regression. A nomogram for predicting LNM/LVI was established by incorporating these factors. The efficacy, accuracy, and clinical utility of the nomogram were, respectively, assessed with the area under the curve (AUC), calibration curve, and decision curve analysis (DCA). Finally, the random forest (RF) algorithm was used to further evaluate the impact of these factors included in the nomogram on LNM/LVI.Tumor size, tumor location, tumor invasion depth, tumor differentiation, and macroscopic type were confirmed as independent risk factors for LNM/LVI according to the results of logistic regression, LASSO regression, IDI, and NRI analyses. A nomogram including these five variables showed a good performance in LNM/LVI prediction (AUC = 0.776). The calibration curve revealed that the predictive results of this nomogram were nearly consistent with actual observations. Significant clinical utility of our nomogram was demonstrated by DCA. The RF model with the same five variables also had similar predictive efficacy with the nomogram (AUC = 0.775).The nomogram was adopted as a final tool for predicting LNM/LVI because its risk score system made it more user-friendly and clinically useful than the random forest model, which can help clinicians make optimal treatment decisions for patients with SESCC. Esophageal cancer is one of the most common malignant tumors on a global scale, with a very high mortality rate . The hisConventionally, esophagectomy is taken as the mainstay treatment for SESCC. However, substantial postoperative morbidity and mortality have been reported to be related to this treatment . RecentlLymphovascular invasion (LVI) is a histopathological condition in which tumor cells are found in the lymphatics or blood vessels . It has In this study, we aimed to explore the feasible preoperative clinical variables for LNM/LVI prediction in SESCC and to stratify LNM/LVI risk according to nomogram analysis. The development of a user-friendly clinical tool to predict which patients are at high risk of LNM/LVI will facilitate the selection of the most appropriate treatment in patients with SESCC.We retrospectively collected patients who were diagnosed with esophageal cancer (Tis and T1 stages) and underwent esophagectomy from January 2005 to May 2018. The exclusion criteria were as follows: (1) patients who had received radiotherapy or chemotherapy before surgery; (2) patients who had undergone endoscopy examination more than 1 month before surgery; (3) surgical margins did not reach R0; (4) LNM/LVI status had not been evaluated by histopathological examination; (5) patients already had undergone ESD before esophagectomy (patients received a supplementary surgery after ESD); (6) history of other malignant tumors; and (7) clinical data were incomplete. In addition, pathological findings of basaloid squamous cell carcinoma, adenocarcinoma, adenosquamous carcinoma, carcinosarcoma, mucoepidermoid carcinoma, and neuroendocrine carcinoma were also excluded. A total of 512 eligible patients with SESCC were finally enrolled in our study. The flowchart of patient selection is shown in Basic information on admissions such as age and sex was collected. Then, circumferential extension, number of lesions, tumor location, and macroscopic morphology were extracted from the endoscopic reports. Besides, the data on tumor size, depth of invasion, LNM, and LVI were obtained from the results of postoperative histopathological examination. Here, we combined the LNM and LVI as one integrated parameter which is named LNM/LVI. LNM positive and LVI negative (LNM+/LVI–), LNM negative and LVI positive (LNM–/LVI+), and LNM positive and LVI positive (LNM+/LVI+) were considered as LNM/LVI positive. LNM/LVI negative meant LNM negative and LVI negative (LNM–/LVI–).U-test. We compared categorical variables by using the χ2 test or Fisher's exact test. Variables that were significantly associated with LNM/LVI in univariate analysis or had clinical significance for LNM/LVI were incorporated into multivariate logistic regression. LASSO regression is used to reduce the dimensionality of data and screen out the most significant variables with non-zero coefficients  based on a decision tree algorithm . The ranp-value of < 0.05 was considered statistically significant. All statistical analyses were performed using SPSS version 22.0  and R version 4.0.3 .In all analyses of this study, a two-sided in situ, 245 (47.9%) were moderate differentiation, and 153 (29.9%) were poor differentiation. Circumferential extension of lesions in 406 patients (79.3%) was ≤ 1/2 and in 106 patients (20.7%) was >1/2. Among these patients, the macroscopic type of lesions in 271 patients (52.9%) was flat type and in 241 patients (47.1%) was a non-flat type. Only 35 (6.8%) patients had multiple lesions while the other 477 patients (93.2%) did not. There were 147 patients with SESCC who had positive LNM/LVI, of which 92 patients (62.6%) had LNM+/LVI–, 32 patients had LNM+/LVI+ (21.8%), and 23 patients had LNM–/LVI+ (15.6%) , including 438 men (85.5%) and 74 women (14.5%). Tumors located in the middle esophagus were found in 361 cases, followed by 133 cases with tumors located in the lower esophagus, and tumors located in the upper esophagus were only found in 18 cases. The median tumor size was 3 cm (range 3–11). A total of 142 patients (27.7%) had tumors confined to the mucosa, and 370 patients (72.3%) had tumors infiltrated into the submucosa. According to the tumor differentiation results, 114 cases (22.3%) were well-differentiated or carcinoma  (15.6%) , and theP-value of sex between LNM/LVI-positive and -negative groups was 0.051 (very close to 0.05), we then incorporated sex together with tumor size, tumor location, tumor invasion depth, tumor differentiation, macroscopic type, and multiple lesions into the multivariate logistic regression analysis, and found that tumor size, tumor invasion depth, tumor differentiation, and macroscopic type were independent predictive factors of LNM/LVI (p = 0.086); but tumors located in the upper esophagus had a lower risk of LNM/LVI compared with tumors located in the lower esophagus . Among these independent predictors, tumor invasion depth and differentiation had the greatest impact on LNM/LVI , suggesting that patients with submucosal tumors which were poorly differentiated had a higher risk for LNM/LVI. The LNM/LVI rates according to the tumor invasion depth and differentiation are summarized in The clinical characteristics between the LNM/LVI-positive and -negative groups were compared by using univariate analysis, and the results showed that tumor size, tumor location, depth of tumor invasion, tumor differentiation, macroscopic type, and multiple lesions were significantly correlated with LNM/LVI; while age, sex, and circumferential extension were not related with LNM/LVI . We also LNM/LVI . HoweverSubsequently, nine variables were incorporated into LASSO regression and five variables including tumor size, depth of invasion, tumor differentiation, tumor location, and macroscopic type were screened out to be associated with LNM/LVI . The weiFour variables  that were confirmed to be significantly associated with LNM/LVI both in multivariate regression and LASSO regression analyses were used to construct a base model (model A). However, for analyzing the predictive effect of tumor location on LNM/LVI, multivariate logistic regression and LASSO regression showed different results. So we then constructed a new model named model B by adding tumor location into model A to explore the significance of tumor location in LNM/LVI prediction. Compared with model A, the AUC of model B for LNM/LVI prediction did not significantly increase, but IDI and cNRI both showed a significant improvement after adding tumor location into model A , implyinNext, we used the five variables included in model B  to develop a nomogram that could predict the probability of LNM/LVI presence . ROC anaAccording to the cut-off value determined above, patients with SESCC were divided into LNM/LVI high-risk  and low-risk  groups. The ratio of positive LNM/LVI in the high-risk group was 48.5%, while only 12.7% of patients with SESCC presented with LNM/LVI in the low-risk group, which meant that patients with SESCC in the high-risk group had a significantly higher probability of LNM/LVI . Then, tFurthermore, all 512 samples in our study were used to construct a random forest model. The five independent risk factors identified above related to LNM/LVI in SESCC, including tumor size, tumor invasion depth, tumor differentiation, macroscopic type, and tumor location, were ranked according to the mean decreased Gini . Tumor iEndoscopic resection (ER) represented by EMR or ESD has been widely carried out to treat early esophageal cancer because it causes less trauma and improves the postoperative quality of life compared with traditional esophagectomy , 28. NevSome studies have demonstrated a strong correlation between LVI and LNM , 32, andTumor size, depth of invasion, and tumor differentiation had been confirmed as independent risk factors for LNM of SESCC in most of the previous studies , 34, 35.p = 0.086); on the contrary, in LASSO regression analysis, the location of SESCC was demonstrated to be associated with LNM/LVI  in this nomogram on LNM/LVI, we incorporated them into the random forest model and calculated the importance of each variable to LNM/LVI. The results showed that the random forest model can well-distinguish the positive LNM/LVI and negative LNM/LVI in patients with SESCC, with an AUC of 0.775 in LNM/LVI prediction. Because the established nonogram above assigned a detailed risk score to each patient, and its predictive performance (AUC was 0.776) for LNM/LVI was similar to that of the random forest model, we finally used the nomogram as a discriminant tool to predict LNM/LVI of patients with SESCC in this study.A majority of studies on clinical prediction models usually split the dataset into a training set and validation set, but our data were not analyzed in this way attributed to the limited sample size of the current study. Besides, this approach does not make full utilization of all available data to establish a prediction model, which may result in statistical inefficiency or even a waste of data . UnfortuIn summary, to our knowledge, this is the first study to combine the LNM and LVI as a unitary outcome and investigate the impact of preoperative factors on potential LNM/LVI in patients with SESCC. We demonstrated that tumor size, tumor invasion depth, tumor differentiation, tumor location, and macroscopic type were significant risk factors for the presence of LNM/LVI in patients with SESCC. Then, a nomogram and a random forest model for predicting LNM/LVI were established by incorporating these five variables. The good clinical utility of our nomogram was confirmed by DCA, and the risk score system also made the nomogram more clinically useful than the random forest model despite their similar AUC. Hence, this nomogram was adopted as a final tool for LNM/LVI prediction in patients with SESCC. According to the scoring system of our nomogram, if a patient with SESCC is classified as high risk for LNM/LVI, esophagectomy plus lymph node dissection will be prioritized to reduce potential tumor recurrence in the future. Last but not least, the nomogram established in this study is a user-friendly and practical tool to facilitate optimal treatment strategy selection for patients with SESCC by making an individualized LNM/LVI prediction.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.This retrospective study was approved by the Ethics Committee of the Zhejiang Cancer Hospital. Written informed consent for participation was not required for this study in accordance with the National Legislation and the Institutional requirements.SW and RR conceived the idea, designed the study, and revised the manuscript. JY and QS collected data. YT and SC analyzed the data and drafted the manuscript. All authors contributed to the article and approved the submitted version.This study was funded by the Medical Health Science and Technology Project of Zhejiang Province (No. 2022KY619).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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Adverse childhood experiences (ACEs) are associated with health and social problems in later life, with an early intervention highly desirable for better outcomes.The Family-Referral-Services-In-Schools (FRSIS) is an early-intervention case management program for children and families with complex unmet needs, providing access to family support, housing, mental health care, and/or drug and alcohol services. The in-school trial setting was aimed at improving service uptake which was low in its community counterpart.FRSIS was a well-regarded intervention that reduced barriers to access for vulnerable families. The school setting and non-government agency service provision led to increased acceptability and trust. The program reached 5% of the student population. Support was tailored to family need, which was often complex and involved both children and caregivers. Initially, the multi-agency partnership and governance oversight group championed the service and enabled the pilot to be established, however funding uncertainty and competing priorities saw leadership support ebb away despite operational success.The FRSIS model breaks down numerous barriers to accessing care for vulnerable families by its generalist nature and tailored approach and represents a high-trust approach to brokering appropriate care. Consistency in leadership support was a missed opportunity for program sustainability. Intervening early to address health and social issues in childhood is widely considered to have lifelong benefits. Investment in children leads to healthier adults, better able to reach their potential to positively contribute to their community 2345. Adv2346ACEs may affect subsequent generations producing cycles of disadvantage. Poor educational outcomes result in few employment opportunities, reduced income and potential poverty . Growing10In New South Wales (NSW), the policy context to support vulnerable children and young people was influenced by a 2008 inquiry into children in protective services . In resp15These health and social care reform activities, coupled with the premise that engagement in education has broader implications for the wellbeing of children and young people and into later life, led to a version of the FRS program being trialled in NSW schools – Murrumbidgee  and indeIn this case study, we describe the Central Coast Family Referral Service In Schools (FRSIS) program with details of the intervention, its implementation and evidence of the program’s impact. The key lessons derived from the study are discussed.In 2018, the author group (research team) were commissioned to conduct a formative assessment and impact evaluation of the FRSIS program by the multi-agency oversight group. By this time FRSIS had been in pilot in some schools since 2016. Ethical approval was granted in 2019 by: Hunter New England Human Research Ethics Committee (2019/ETH08686); State Education Research Applications Process (SERAP2019187); Central Coast Local Health District (Site-specific 0519-016C) and University of Newcastle (recognition H-2019-0168).Study design: A collaborative approach between the research team and the FRSIS multi-agency oversight group and stakeholder network was used to design the evaluation. This was done to represent the diverse stakeholder objectives in supporting the program, to build consensus on the evaluation approach and to identify and appraise existing supporting data sources. The stakeholders represented the organisations involved in the planning and implementation of the program , local Primary Health Network, local departments of health, social care and education, and other health and community service providers). A series of three workshops were conducted by the research team with key stakeholders, one face to face from each learning community  and a virtual workshop regarding data linkage feasibility (n = 7).Box 1.The evaluation questions to explore the program’s implementation and its outcomes are outlined in How is the Family Referral Service in Schools program operating to contribute to the objectives of the multi-agency oversight group?The primary evaluation question was: This was explored through the following sub-questions:What has been the history of implementation of FRSIS?Who uses FRSIS?Is there evidence of changes likely to be related to improved educational outcomes for students due to the implementation of FRSIS?Is there evidence of FRSIS connecting students and their families to services? What are the benefits of doing so?Is there any evidence of changes in school staff experiences due to the implementation of FRSIS?Is there evidence that FRSIS has produced other, secondary gains?Is there any evidence of negative consequences resulting from the implementation of FRSIS?A pragmatic mixed-methods approach was adopted to make best use of operational data, the views and perspectives of key stakeholders and a review of program documentation. The research team also attended seven FRSIS multi-agency oversight working group meetings over the project period (2018–2019) and sought verbal and written feedback on various stages of the evaluation including protocol design.It was determined that interviews with students and their families who used the service would not be conducted due to concerns raised by both FRSIS staff and teachers.Notably, a key ambition to link FRSIS data to other government data sources to yield in-depth insights was the subject of a workshop. There were recording procedure limitations for FRSIS data and in-depth consultation with the NSW Government Data Analytics Centre, which has responsibility and capacity for such interdepartmental linkage, revealed it would be cost-prohibitive for this project and unlikely to yield an ongoing capacity to follow up on FRSIS referral outcomes without substantial data infrastructure investments. Thus, the key indicators of program performance reported are program activity, and teacher and stakeholder reports.Qualitative data were collected by reviewing 21 program-related documents, five semi-structured telephone interviews (10% response rate) and six example case histories constructed by the commissioned NGO to provide anonymised accounts of program users’ experiences and outcomes. The purposive sample for interview and survey included school staff (n = 32) and those from affiliated organisations (n = 20), across leadership and operations roles. The interviews questioned participants’ understanding of the program and its operation. Interviews were audio-recorded and transcribed with participant permission. The low response rate and the lack of in-depth quality data within the provided documents made systematic thematic coding analysis impractical. Instead, the different qualitative sources were examined for broad insights. Quantitative data collection included a de-identified FRSIS operational dataset  and 14 surveys (27% response rate) to assess both implementation progress and perceived outcomes of the program. The survey participants were asked to indicate their level of agreement, using a 5-point Likert scale, with statements about the program’s implementation, efficiency, effectiveness, and benefits (a ‘don’t know or not applicable’ response was provided). The anonymous survey asked only for participants to indicate their current roles. Analyses of these data were limited to descriptive statistics. Microsoft Excel and R [In the case study, data from different sources are presented and discussed together. Where the source is not stated, information is from stakeholder documents or records supplied. The school-based family support workers from the commissioned NGO were referred to by various titles, ‘Family Engagement Worker’ is used here, and ‘parent’ is used to refer to anyone in a guardianship role.The Family Referral Service in Schools (FRSIS) program was designed to connect families, with a school-aged child 5 to 18 years) at risk of disengaging from education, with the health and social services they need. Between 2016 and 2018, the program was introduced into schools in three learning communities in the NSW Central Coast region. The program was part of a suite of integrated care initiatives implemented under the Central Coast Integrated Care Program (CCICP) [ years atThe program was part of the response to the area’s high proportion of vulnerable children and young people and a state-wide intention to improve family health and social services 16. In te20The Central Coast FRSIS program was an evidence-informed (literature review and integrated care expert engagement) adaptation of the FRS program into the school context to better facilitate access to the health and social care needs of vulnerable children and their families. A detailed program logic was developed for the pilot in consultation with the multi-agency oversight group.The program began in Learning Community A in 2016, with around 4,250 students . In 2018, Learning communities B  and C , with around 8,460 students in total joined. Some schools opted out of participation. Nearly all participating schools served socially disadvantaged communities as measured by the Family Occupation and Employment Index (FOEI). FOEI is used by the NSW Government for needs-based resource allocation. The commissioned NGO implemented the program with school support. FRSIS was managed by a team-leader employed by the commissioned NGO. Up to two Family Engagement Workers were employed on the Central Coast: one for Learning Community A  and the other for learning communities B and C (full-time). Schools nominated staff responsible for referring students in need of help. Students were eligible if there was evidence of educational neglect, risk of disengaging from school or family welfare concerns . However, engagement with other case management or child protection services were exclusionary criteria. With parental permission, the Family Engagement Worker assessed the whole family’s needs, the appropriate health and social services and any barriers to access. Support and strategies to link the family to services were then provided.Key staff in schools and the commissioned NGO changed throughout implementation, but frontline program operation continued. Interview data revealed that the program was supported by clear processes covering personnel changes and absences that ensured smooth transitions. Furthermore, most survey participants agreed (9/14) that systems were in place that ensured efficient transitions between Family Engagement Workers.Between August 2016 and November 2019, 392 families were referred to the service on 429 occasions . This was affirmed by the documentation and case studies. It was not uncommon for grandparents to have stepped into the parenting role. These grandparents often had complex health care needs of their own and were without support and respite care. However, interview participants reported a great deal of diversity amongst the presenting issues of students and their characteristics, although common characteristics of families were that they didn’t know how to, or were unable to, access services themselves.After the family assessment, the Family Engagement Worker made outbound referrals to appropriate services. Support was provided by initially contacting the services, educating parents and students about what was available and/or taking them to services. Depending on need, the coordination of outbound referrals was through face-to-face meetings (n = 43), telephone (n = 112), home visits (n = 152), and/or provision of information (n = 130). Non-referral information (e.g. education and support resources) was provided to families where appropriate (n = 119). When families engaged with services, most cases were closed, with the ongoing care being undertaken by the receiving services. Case histories showed that sometimes the Family Engagement Worker had multiple unsuccessful attempts to engage the family, with one example taking over six weeks.Program records showed most families were being referred to services and/or provided with information. Of the 429 occasions of service, 58.8% received an outbound referral. Service types that families were referred to are summarised in In interviews, the only circumstance under which FRSIS was said to not work was if the family refused the engagement. However, from operational data, no outbound referral was received on 41.2% of occasions of service and of those that did receive a referral, 34.3% were not known to have accessed the service. The main reasons for not providing a referral are outlined in Box 2 shows two illustrative case histories that were based on the six de-identified case histories provided. These show the complexity of family assessments to identify the need and the support required, leading to multiple referrals to health and social care to support the whole family.Whilst operational data provides a snapshot of care provision, case histories provide an opportunity to see the flexible nature of support and the difference the referral service made to families. Case History 1The school noticed Jane’s attendance had been low for the past two years. When at school, she frequently displayed aggressive outbursts and defiant behaviour. The family assessment revealed that Jane’s father John had severe depression and her two siblings had special care needs.The Family Engagement Worker arranged a referral for all the children to a paediatrician with a short waiting list, negotiated reduced fees and accessed the NGO’s brokerage funds to financially assist the family with medication not available on the Pharmaceutical Benefits Scheme (government subsidy).Jane was diagnosed with anxiety and a mild intellectual disorder. Referrals were made to the NGO’s disability team to further assess and discuss the support needs of the family, including the mental health needs, and to assist with a National Disability Insurance Scheme application. Peer support via an NGO-led community mental health program was arranged for John.Since the referral, Jane’s school attendance improved as did her behaviour at school and at home. The school attendance of her siblings was also more consistent. The family accepted all support offered and continues to work with longer-term support services. Her mother Anne reports feeling confident that they are getting the right support and that they are setting a good example for their children.Case History 2The school was concerned about Jack’s sad and withdrawn emotional state. He was increasingly unable to control his emotions, having violent outbursts. A family assessment revealed that Jack’s parents had recently separated and his older brother, Michael, also had very low attendance. Michael had been refusing to get out of bed and had run away from home in the past. Their mother Judy was struggling to manage. She was casually employed and the shared housing arrangement that she and her children were in was inadequate. There were also issues around domestic violence.Judy was reluctant to engage with health services. Moreover, Tom, the father, was highly resistant and hostile. The family’s need for ongoing support made them ineligible for a short-term general family support program. However, their support needs also did not meet the ‘Risk Of Significant Harm’ (ROSH) criteria which would have enabled support from the social services department.Nevertheless, the Family Engagement Worker collaborated with a homeless case management service to arrange more suitable housing, and Judy and her children were successfully relocated. They were able to access support from extended family and were connected with the FRS in their new location.*Amalgam of de-identified case histories provided; names are fictional.Operationally, the program was used by students from all participating schools, but with varied uptake. All interviewees regarded the program extremely positively, emphasising that this low-cost initiative provided a non-threatening approach to assist families to access much-needed services. This was echoed in the survey, with all 14 respondents agreeing or completely agreeing that, overall, the program was working well.All interviewees said the program successfully supported students and their families to access services. They reported that FRSIS enabled identification of students in need within schools, and whole family support as a consequence. This was thought important since the main support issues often lay with the parents. Most survey respondents also believed the program helped families to access services (10/14) and more families accessed services because of FRSIS engagement (10/14).In workshops, it was reflected that the Family Engagement Worker could avoid the need for families to continually retell their stories and problems by liaising with the different service providers. Interviewees said that the bridge to services provided ensured that families quickly felt that something was being done, even if there was a waiting list. Interview and case study data showed other barriers to care access were lowered through sourcing financial support for service fees and transport to appointments when necessary.Due to confidentiality concerns and the burden that de-identified data provision would place on resource-stretched schools, student attendance and behaviour records were not obtained. Hence, interview and survey data were relied on to assess whether program participation led to improved educational and behavioural outcomes. Interviewees were uncertain about whether the program had improved the educational outcomes of students. However, it was thought that school attendance had improved. Survey responses indicated a perception (10/14) that the program had improved educational engagement and attainment of students. Case histories demonstrated improvements in school attendance after appropriate support was received. Better behaviour at school and at home was also apparent. Similarly, interviewees perceived that the behaviour of students, who had behavioural problem-related referrals, had improved. Around half (8/14) of survey participants agreed that the program had resulted in improvements to students behavioural and emotional well-being, whilst two disagreed.Interviewees perceived that FRSIS relieved some of the burden on the school staff in addressing behavioural issues and supporting student well-being. School counsellors and headteachers were reassured that student welfare was being addressed. Furthermore, this work was done more effectively and efficiently because of the Family Engagement Workers’ specialist knowledge of appropriate and available services. School staff interviewees reflected greater job satisfaction. However, just under half of school staff survey respondents (4/10) agreed that FRSIS had improved their overall work and/or teaching experience; two disagreed.School interviewees believed FRSIS had fostered better relationships between themselves and parents by providing a non-threatening opportunity for having a conversation with parents in need of help. These participants believed that the program demonstrated a more holistic concern for the family’s welfare and not just a concern about educational performance. The view that the program had engendered an improved parental attitude toward the school was also expressed in the workshops. In surveys, just over half of school staff who completed the survey (6/10) agreed that their relationship with referred families had been improved by the program; two participants disagreed. Documents also suggested communication between schools and parents was improved.In workshops, it was suggested that FRSIS played a role in de-escalation of crisis incidents, avoiding the need for more punitive responses. However, school survey responses were equivocal, with the same number agreeing (4/10) as disagreeing (4/10).Interviewees emphasised that delivery by an NGO enhanced the program’s acceptability with parents. The commissioned NGO was understood to be perceived by parents as less authoritarian and punitive compared to schools and government departments . It was thought parents felt more at ease if a Family Engagement Worker was present at meetings with perceived authority figures from the social services department and the school.Interviewees reflected that the placement of the Family Engagement Worker within the schools increased the likelihood that families would be seen face-to-face  and facilitated case reopening when necessary. Meeting face-to-face was considered better for establishing rapport and building a partnership with parents.In interviews, the only circumstance under which FRSIS was said to not work was if the family refused the engagement. The reasons for parental refusal of help included a perception that FRSIS would not provide them the help they needed. Also, the community-based FRS program was available to parents not wanting school involvement. For other families, it was said they may not have been able to accept help and that this was to do with the intrinsic family capacities rather than program failure. The document review indicated that intrinsic barriers included longstanding disadvantages, mental health issues, family violence, unemployment and drug and alcohol misuse.Family refusal of FRSIS was not interpreted as a failure of the program in interviews. It was thought the Family Engagement Worker’s engagement improved family knowledge of local service availability. Furthermore, it was said that families who refused FRSIS help had sometimes later reported they had accessed the services or considered alternative educational options (e.g. home-schooling or distance education) to address the issues identified. Furthermore, another interviewee explained that refusal of help was an opportunity to consider how else the family could be supported.The main extrinsic barriers to families accessing services noted in documents and interviews were long waiting times and ‘closed books’ . It was understood that some services had so much demand that only families coming through the social service department could access them. Documents and interviews also indicated costs were a barrier to service access, especially psychological services. A lack of General Practitioners, especially those that did not charge the patient, was also considered to be an issue. Transport to services was also a barrier, but it was overcome in at least some cases by services travelling to the families or FRSIS arranging transport to appointments.The Central Coast FRSIS Working Group oversaw the implementation and governance of the program. Two learning community governance groups were developed to aid implementation. We received limited documentation related to governance, documentation related primarily to the Working Group. Since the FRSIS Manager was at the FRSIS Working Group meetings along with multi-agency representatives including the education department, when they did meet, a considerable amount of operational oversight was conducted at this level with strong communication from the frontline staff and schools. Attendance diminished over time as the program funding deadline approached and refunding concerns were not allayed.The FRSIS Working Group had at least seven staff changes during the evaluation period, including two project champions from health and education who oversaw the initial implementation. The NSW Health Integrated Care Manager role was vacant for over a year and staff worked in multiple roles or were on secondment. In addition, the loss of momentum of the Learning Community A Governance Group appeared to be linked to the lead Principal leaving.Funding was considered by most interview participants to be the most critical issue to ensure sustainability. Initial funding was provided by the health district’s integrated care demonstrator funding, with the hope of multi-agency co-commissioning or that schools would purchase the service using discretionary funding. There was uncertainty by interviewees about how the program was funded and whether the funding would be ongoing, this was also reflected in survey responses. A minority agreed the program was current funding was adequate (6/14) and that future funding would be forthcoming (4/14). It was noted in documents that because State and Commonwealth systems were not set up for joint funding that the multiagency co-commissioning of the program had been challenging. With so many partners involved this problem threatened the program’s sustainability.Operationally FRSIS functioned well with systems ensuring smooth transitions through staff changes. The number of referrals to FRSIS varied across schools, which appeared to be related to the school’s degree of program engagement and implementation maturity. The FRSIS aimed to provide support for families with children at risk of disengaging from education and connecting them to services were realised. FRSIS assisted families of students with behavioural problems, reduced school engagement and those where the welfare of the student was a concern. Indeed, FRSIS was perceived to be an effective means of helping families with complex needs, unable to access services without help, and who otherwise might fall through the net. In terms of considering integrated care access , FRSIS iMoreover, school staff experienced benefits, reporting that FRSIS fostered the belief that students’ welfare was being taken care of effectively and efficiently and relieving them of that burden. It was also apparent that the program could improve school/parent relationships. It has been documented that parental involvement with their child’s education and school leads to better educational outcomes for the child 25.The handling of student and parental problems by an outside non-government agency was also understood to improve program acceptability. However, it was valued because the service was within schools because it linked students in need to appropriate help and allowed face-to-face contact. It is difficult to conceive how families in greatest need of the kind of help that FRSIS provided would get to access the community-based version of the program.The inability to easily access cross-agency linked data related to students and families involved in the program hampered a deeper assessment of FRSIS impacts and represents current systemic limitations. Thus it was not possible to measure longer-term potential gains (or early indicators thereof) in areas such as education and health outcomes. Thus, establishing data linkage systems that enable service-user outcomes to be tracked and planning to collect all relevant data pre-implementation is vital . Even so27FRSIS did not provide all families referred to it with an outbound referral, with some engaged with other services and others only required information. A minority, however, declined help or couldn’t be contacted. Declining service was not seen as a failure because it was an opportunity for increasing the family’s knowledge and some came back to FRSIS later.Their Futures Matter lacked mechanisms to secure cross-portfolio buyin and did not have authority to drive reprioritisation of government investment’ [Where FRSIS did not perform well was in the sustained engagement of the multi-agency Working Group. Meeting attendance declined over time, as the funding contract deadline drew near, and evaluation participation was very poor. The funding uncertainty and staff changes appear to have contributed to this. This decreased engagement likely impacted the ability to champion and secure ongoing program funding. Leadership is vital to the success of integrated care initiatives 30. Recenestment’ . The sucestment’ .Other failures were outside the control of the program, including long waiting times and poor service availability, which thwarted families from receiving the needed services. These issues are common in the Australian health system and should be addressed 34.Box 3.The findings of this evaluation reinforce the prior findings  that FRS36373839404142The FRSIS program worked well as a soft entry support for children and families who often fall through the support gaps due to service fragmentation, complex support journeys and long wait times. FRSIS Program data revealed a flexible and tailored approach to supporting families to provide a referral as well as a diverse range of services and information referred to across health and social care. Program data also revealed variance in uptake in schools suggesting uneven implementation success, to be expected of a program that had yet to reach maturity.Collaborative governance a strength and a challenge – strength in inception and drive and challenging as funding uncertainty and staff changes led to de-prioritisation of FRSIS by multi-agency partners. While there were multiple early champions of the program across multiple agencies and multiple layers of leadership, this waned substantially as the funding window came to a close, despite operational success.Sustainability – this evaluation indicated clear operational success, however the time-limited program window, due to short-term funding, did not allow for implementation maturity across all schools and at the governance level. Sustained commitment from the multiagency partners was lacking (at multiple levels of leadership).Embedding evaluation at the start would have enabled data-informed program maturation and provided the evidence base early enough to justify a business case for ongoing funding. Moreover, this was particularly true given the desire to satisfy the differing goals of each stakeholder and the delays experienced in multi-agency co-design and delays in ethical approval. Even with multiple data sources and multiple ethical approvals, some data could not have been effectively drawn or linked as this capacity had not been baked into the program. This would have been an overinvestment for the pilot but highlights government data linkage and analytic limitations at the time.Collaborative and multi-agency approaches to addressing the integration of health and social care in a person-centred fashion hold great promise and policies often state this intent. However, these approaches surface inconsistent and sometimes conflicting priorities and objectives, which should be recognised and addressed at operational and strategic levels.This evaluation was hampered by three main issues. Firstly, interagency data linkage was not supported by recording procedures, eliminating the systematic capture of full client journeys and related outcomes. Secondly, the participant response rate was poor. The evaluation experienced delays in workshop scheduling and ethical approval . This led to data collection coincident with a busy time for schools and was closer to the funding deadline. Had more participants been recruited, a broader range of views may have been expressed. Whilst voluntary participation may have selected those with a positive view, the anonymity of the survey, provided an avenue for participants to express negative views safely. Thirdly, the experience of the service users was not directly gathered, following the advice from the stakeholders and consideration of the families’ welfare.FRSIS appeared to be a program based on a promising concept that was well supported by frontline staff. There was good uptake of the program addressing the engagement gap experienced by the community version of FRS, enabling early intervention for families with complex and unmet needs to receive broad-ranging support, with the hope of avoiding formal dealings with child protection agencies. The commitment of these staff ensured that the program functioned well and delivered benefits to the families and schools served. The flexibility of the program to deal with any problem and being open to any family in need within the school contributed to its success.The dominance of funding uncertainty and waning commitment from the oversight Working Group was disappointing given the operational success. The Central Coast FRSIS program showed the concept can be successfully adapted and implemented in multiple school jurisdictions, enabling consideration of wider uptake in NSW schools to effectively support children and families with complex and unmet needs in an integrated fashion.


The evidence for the positive effects of mindfulness-based interventions on psychological well-being and physical health has been convincing in recent years. As a specific form of such an intervention, the Mindful Self-Compassion (MSC) training program was developed to promote self-compassion and mindfulness. An initial study on an adapted version of the MSC training program considered it to be beneficial in psychiatric inpatient rehabilitation.The present study aims to further evaluate the link between MSC and psychological symptoms as well as quality of life.A randomized controlled trial was conducted from September 2020 to August 2021. A total of 228 patients  participated in a six-week psychiatric rehabilitation program to assess the impact of an adapted MSC training program compared to the control intervention of Progressive Muscle Relaxation training (PMR) on psychological well-being. Both training programs took place once a week for 75 minutes as part of a standardized inpatient rehabilitation program. The participants completed the Self-Compassion Scale (SCS), the Brief Symptom Inventory (BSI-18), and the Short-Form-Health-Survey-12 (SF-12) pre and post intervention.At the moment, statistical analyses are being carried out. Detailed results will be presented on the poster.The results of this study will contribute to rehabilitation research as they provide further insight into the role of MSC in the treatment of mental disorders. In addition, the clinical implications, and possible effects of changes in the rehabilitation program during the COVID-19 pandemic on the protocol and the results of this study will be discussed.No significant relationships.