PRO-Mueve Relaciones Sanas  is a gender-based violence and dating violence prevention program targeted at adolescents. The program has been designed to be implemented during three consecutive courses [from the first to third year of Spanish mandatory secondary education (ESO)] in 8 annual sessions, imparted by university students who have been previously trained and supervised by university professors. The present study evaluates the effects of the program after the first year of implementation through a quasi-experimental design  and assesses whether there are gender differences in the outcomes. The results obtained evidenced a significant reduction in benevolent sexism in the intervention group compared to the quasi-control group. Regarding hostile sexism, it was found to increase significantly in the quasi-control group, while it remained stable in the intervention group. Thus, there were significant differences between both groups after the intervention. Likewise, romantic love myths were found to decrease significantly, and knowledge about gender-based violence increased significantly in the intervention group between the two time points assessed, although there were no significant differences with the quasi-control group. No gender differences in the outcomes of the program were observed. The obtained results supported the efficacy of the program during the first year of intervention in the first course of the ESO and laid the foundation for the following phases of intervention. Gender-based violence (GBV) has significant negative consequences for those who suffer it, resulting in both physical and psychological damage, severe injuries and even death. Violence against women (VAW) has been normalized to some extent in society. This is a phenomenon that has been declared an epidemic by the World Health Organization , since oAlthough there is no clear agreement on the definition of dating violence (DV), there is consensus that it refers to dating, i.e., relations between young people and between adolescents, and that there are generally three elements which are always present: (1) the phenomenon always occurs in the context of a dating relationship; (2) an attempt to control or dominate the partner is made; and (3) there is threat of or actual violence .There are several factors that appear to be associated with DV and GBV such as: gender stereotypes, that can be defined as widespread beliefs about the characteristics and attributes that women and men have or should have and the social functions that both should or must perform ; myths rOther factors associated with DV are gender roles, understood as the part of the stereotypes prescribing what each gender should do and that condition the processes of socialization , structuOn the other hand, the consequences of GBV manifest in four areas: (1) physical problems , (2) menTo prevent violence in relationships, preventive measures focused on changing attitudes and behaviors are the most appropriate strategy in order to mitigate and palliate its effects . The effThe PRO-Mueve.In Spain, legislation  on comprPRO-Mueve Relaciones Sanas is a Spanish language primary prevention program that provides knowledge on gender-based violence and DV and promotes healthy relationships. From the perspective of the Social Learning Theory , 1977, tPreventive programs have proven to be the most effective resource in DV  and prevPRO-MUEVE was created as a structured program (step by step), with specific content for each session. It also covered the need to teach students in a practical way, as several authors have pointed out .The program was designed to run for three consecutive academic years between the 1st and 3rd years of secondary education (12–14 years) and had three general objectives: (1) To learn to distinguish between a healthy relationship and an abusive and violent relationship; (2) To become aware of the link between factors associated with violence , abusive relationships and their consequences ; and (3) To acquire skills to improve relationships .The results reported in this study therefore correspond to the first course in which the first objective and half of the second objective were covered. The specific objectives that were addressed in the first year of intervention were: (a) To learn that being treated with respect in a relationship is a legally recognized right, and that abuse is a criminal offense; (b) To know Human Rights, the Spanish Constitution and Act 1/2004 on comprehensive protection measures against GBV; (c) To distinguish situations of GBV according to the law, or other situations not present in the law – where there is a certain legal vacuum , through every day and close examples; (d) To identify the characteristics and positively assess the benefits of a healthy relationship; (e) To raise awareness about gender inequalities and their relationship with GBV; (f) To recognize sexism as a factor associated to GBV; (g) To reduce sexist beliefs; (h) To identify and reduce myths and stereotypes regarding traditional gender roles, GBV and romantic love; (i) To learn to identify and reduce the different forms of micro-sexism; and (j) To know the resources available in the community for women care and victims of GBV in the adolescent population.PRO-Mueve sessions were delivered through a collaborative learning and active participation method based on practical and dynamic exercises, and fun activities such as games, role-playing, discussion groups, video clip watching and debates. In turn, to reinforce the knowledge acquired, at the end of each session the students received a poster with the contents covered in it. In addition, they were asked to reflect upon each session over the next 3 weeks in order to be prepared to ask questions they might have before the following session.The purpose of this pilot study was to evaluate the effect of the first year of implementation on knowledge about gender-based violence and legislation, sexism attitudes, and myths of romantic love in adolescents. In addition, in response to the demand of some social organizations in our country that denounced that the programs were less effective for boys, our study also evaluates whether the program exerts a differential effect upon the girls and boys enrolled in it. This research question was prompted by the comments of some professionals and researchers in the field indicating that boys tend to be less involved in programs of this kind, and therefore benefit comparatively less than girls . HoweverTaking previous studies of prevention programs in this population as a starting point , and preM = 12.11, SD = 0.57) and 133 were girls (54.7%) and 110 were boys (45.3%).Two-hundred and seventy-one first course of High School students were eligible to participate in this study, with 207 participants belonging to the intervention group and 64 to the quasi-control group. Of these, 15 participants did not complete measures at the end of the intervention, mainly because they were not in class on the day of data collection. Six adolescents declined to participate in the study, and seven parents did not provide consent see . Thus, 22 = 0.373, df = 1, p = 0.541) or age  between the intervention and quasi-control group, which makes the two groups comparable at least in these characteristics.Previously, a power analysis had been used to determine the minimum sample size required, using the program G*Power 3.1.9.7. For a repeated measures ANOVA design (within-between interaction) with a medium effect size (f squared = 0.15), two recognized groups (intervention vs. quasi-control group), four repeated measurements (pre-test and 3 post-test), with a significance level of 0.05 and a power of 0.95, an overall sample size of 98 subjects was obtained. Respecting these conditions, with a composition of 49 persons in each group (intervention and quasi-control), the design was sufficiently well supported. Unfortunately, the pandemic and the confinement prevented us from carrying out all the post evaluations we had planned . In addition, comparisons between conditions showed that there were no differences by sex . A quasi-randomization was performed. Three classes were randomly assigned to the quasi-control condition (N = 64) and nine (N = 207) to the intervention condition. The groups remained intact with their corresponding class during the intervention or assessment sessions. The quasi-control group did not receive any intervention and it is smaller because both schools wanted their students to participate in the program.Recruitment was carried out in the city of Pinto (Madrid) at the end of the 2017–2018 academic year. Pinto is a town of just over 42,000 inhabitants located in the south of the Community of Madrid. After one meeting with the councilors of all schools of the locality (3), two of them were interested in applying the program in the 2018/2019 academic year through the entire course. Eligible participants were those who belonged to the first course of high school  completed a 1-h self-administered pre-test questionnaire. Seven months later, after the intervention group completed the program The study followed  the SpanImplementation was conducted by two leaders in each group. Every session included a research assistant. All leaders attended a 1-day accredited training course every 3 weeks before the sessions to explain the session content to the research assistants. Training was led by expert professors from the University. There were eight group leaders in total. All the group leaders were psychologists who were enrolled in the master’s degree in General Health Psychology or who were in the last course of the degree in Psychology or Criminology, or in the dual degree in Psychology and Criminology. It was decided that the program would be conducted by young people in order to ensure a lesser intergenerational distance between the instructors and adolescents, and thus facilitate greater attention and identification with the instructors. As indicated by social learning theory, adolescents learn better when they are among each other. As evidenced by drug prevention or similar programs, when the goal is to maintain desired behaviors, young people are more potent models  imitatinThe professors responsible for the program, experts in social psychology and clinical psychology, organized a DV training course (3 sessions of 4 h each) at the university in which more than 50 students participated on a voluntary basis and obtained credits. From this course onward, we asked for volunteers who wanted to participate in the implementation of the program, in exchange they were given a diploma certifying their participation and some of these students could even do their master’s degree thesis on it. With this small group of volunteers, a 2-h training session was held prior to each session with the program materials and discussions were held on the implementation of each session. Both training and implementation had no cost for the schools. The material (photocopies and stationery) was provided by the city council.A set of measures was selected from previous studies with an adolescent population. As this is a primary prevention program that starts before adolescents enter their first relationships, the selected indicators of change refer to attitudes and knowledge.Gender-based Violence Questionnaire designed by The The myths of romantic love scale developed by Complete disagreement) to 5 (Complete agreement), where the higher the score, the greater the degree of acceptance of the myth. The overall average score on the scale was used. The internal consistency presented for this study showed a Cronbach’s alpha coefficient of 0.57 for pre-assessment and 0.66 for post-assessment.Ambivalent Sexism Inventory  to 6 (Strongly agree). The overall average score on each subscale was used. The psychometric properties were found to be adequate. In this study, the internal consistency indices ranged from 0.81 to 0.86.To assess sexism, we administered the Spanish adaptation  of the Aory ASI; . This inThe levels of missing data ranged from 0 to 5% in the different items of the scales. The SPSS multiple missing value imputation procedure was used. Twenty different imputations of the missing data were calculated as recommended by Preliminary analyses were carried out. These consisted of comparing whether there were significant differences in the assessed variables in the students of the two centers (T1) and calculating the descriptive statistics of the variables of the intervention group and quasi-control group at the two assessment time points . We also calculated correlations between the same assessed variables at the two time points .To evaluate the effectiveness of the program, a multivariate analysis of variance (MANOVA) was carried out with these data. Three independent variables were used: time (pre-post measures); condition (intervention and quasi-control groups) and gender . We were interested in assessing the possible interaction between the gender program and the condition group. The dependent variables considered were basic knowledge about gender-based violence, sexism attitudes, and myths of romantic love.2) was used to estimated effect size in accordance with F value. In order to clarify the significance of the time × condition interaction effect, pairwise comparison tables and the significance level of the differences with Bonferroni adjustment were requested. For all the analyses, the statistical program version 26 of SPSS was used.To study the effect of the independent variables we selected Pillai’s criteria, as this is considered the most robust measure against violations of statistical assumptions . PartialT-tests indicated that there were no significant differences between the centers in hostile sexism, t(241) = 1.7, p = 0.076, d = 0.16; benevolent sexism, t(241) = −1.2, p = 0.203, d = 0.22; romantic love myths t(241) = 0.1, p = 0.844, d = 0.02 or in the knowledge about gender-based violence, t(241) = 0.7, p = 0.456, d = 0.08. In all cases, the Cohen’s effect size was small  or adopted a value close to this range , the is range .The descriptive statistics for the different variables in both conditions (quasi-control and intervention group) according to the two temporary measures  are summarize in Moreover, a simple bivariate correlation was computed between T1 and T2 in all the measures. F = 6.422, p < 0.001, η2 = 0.098; while time × condition × sex interaction was not statistically significant, Pillai’s trace = 0.027, associated with F = 1.662, p = 0.161, η2 = 0.027.A MANOVA of repeated measures analysis showed a significant effect of time × condition interaction, Pillai’s trace = 0.098, associated with F = 8.700, p = 0.003, η2 = 0.035; benevolent sexism, F = 14.476, p < 0.001, η2 = 0.057; myths of romantic love, F = 4.642, p = 0.032, η2 = 0.019; and knowledge about gender-based violence, F = 11.363, p = 0.001, η2 = 0.045.Considering univariate effects (of time × condition interaction), significant differences were found in the following variables: hostile sexism, In the following PRO-Mueve is a gender-based violence and dating violence prevention program targeted at adolescents. The program differs from others . These data are in line with those obtained in previous programs,  reportinBased on Cohen’s criteria (1992), the program as a whole can be considered to exhibit a low effect size. It should be noted that if we look at the overall effect size of the program (intrasubject effect of the condition) this reaches a value of 9.8%. It should also be considered that this is the effect of the first year of the intervention; the full program will require assessing the effect of the intervention in all three years.PRO-Mueve intends to be a program that implicates boys and girls equally in such a significant social issue and seeks to make boys see that they can also become victims or witness abuse in their close circles. Our findings indicate that both girls and boys benefit from the program, contrast with those of other studies which state that girls benefit more than boys . Secondly, mention must be made of the low reliability obtained in the questionnaire referred to myths of romantic love. In successive evaluations, additional measures should be used apart from self-reporting in order to allow more complete evaluation in this area. Thirdly, we did not assess whether the participants were in a relationship or have suffered from DV. Based on One of the main strengths of this study is the versatility of the intervention program, which addresses aspects as diverse as: knowledge about GBV and legislation; the resources available to adolescents in the event of witnessing or suffering violent relationships; and the enhancing of awareness regarding abusive and violent relationships, myths of romantic love, gender stereotypes, sexism and everyday micro-sexism. The program seeks to intervene in successive years on attitudes of acceptance or justification for violence in relationships and on the development of the social and emotional skills needed to ensure a dating relationship free from violence. The combination of these aspects in the intervention  is considered essential to secure true prevention of GBV and DV . AnotherThe results of the program in its first year of intervention have been positive and encourage continued implementation of the program and assessment of its effects over the next 2 years of intervention – with necessary confirmation of its long-term effects.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Clinical Research Ethics Committee from the King Juan Carlos University (code: 0404201806318). Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.LV, HT-C, and YP-R conducted the evaluation of methodology, supervisions, drafting the manuscript, and revisions for important intellectual content. YP-R performed data analysis. AA-R performed data collection, administrative, technical, and material support. All authors have read and approved the final manuscript, generated the initial research questions, developed the research protocol, and defined the inclusion and exclusion criteria.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.


Long-term care facility (LTCF) interprofessional practitioners who care for residents at high risk of emergencies due to old age, frailty, and complex diseases must be able to manage such emergencies collaboratively. A shared mental model (SMM) enhances performance toward a common goal by allowing effective collaboration through promoting the sharing of knowledge and skills among interprofessional team members. Therefore, this study developed a web-based educational program for LTCF interprofessional practitioners based on an SMM. We followed a network-based instructional system design that consists of analysis, design, development, implementation, and evaluation for developing the program. A total of 54 participants completed the educational program in four LTCFs in South Korea. A significant improvement was identified in communication knowledge, communication confidence, role recognition, transactive memory system, and team effectiveness in the experimental group. The results show that the program improved the emergency management process and reliability among interprofessional practitioners, positively impacting interprofessional collaboration and ensuring the safety of patients during emergencies in LTCFs. Interprofessional training aims to improve collaboration between the members of an interprofessional team so that emergencies such as falls, airway obstructions, and infections in long-term care facilities (LTCFs) can be managed in a successful way . CollaboA systematized process, such as the sharing of knowledge, skills, roles, and goals that helps convert individual knowledge into team knowledge, is needed to improve collaboration . To exteHowever, LTCFs struggle with limited resources and staffing ; hence, The SMM is multidimensional and consists of four domains: “equipment,” “tasks,” “team interactions,” and “team members” ,11. In eThe four multidimensional mental domains developed by Cannon-Bowers et al.  and the This study’s educational program was developed using the Network-Based Instructional System Design (NBISD) model , which iThe purpose of Step 1 was to assess the educational needs and to compose the educational content. For a learner needs analyses, this study identified the status of emergency management in four LTCFs and the knowledge and skills required for emergency management education through interviews with 32 LTCF practitioners. In addition, the scope of emergency management education for LTCFs was determined through a literature review. The educational contents consisted of organizing the existing literature on emergency management methods by focusing on frequent emergencies in LTCFs. A program developer was hired for environmental analysis, and discussions between researchers and the program developer were conducted to technically establish a web-based educational program.The purpose of Step 2 was to construct educational content and teaching methods. In this step, the educational goals, contents, methods and strategies, environment, and evaluation were specified through the Consensus-Oriented Decision-Making (CODM) process and a content validity index (CVI) with an expert group for the areas of information design, text, pictures, and video data. Next, learners were asked to interact with each other while solving a quiz to check their understanding of the content on the basis of their interactions. The program was designed to allow learners to react to and to check each other’s opinions and answers, using email and social media as channels for interacting with other learners and instructors. Strategies for motivation, such as primary education, were established, and a communication channel with researchers through social media was also designed to provide technical support if needed.Step 3 aimed to implement the learning content and system. The learning content was designed using various types of media for user interactions in learning procedures. Since the learning system focused on allowing users to study the contents at their desired times and locations, the learning content and system were developed in web-based environments. The first author (Y.R.) created a storyboard, after which the first and second authors (D.Y.) built a web browser, server, and database and conducted a pilot test to check for program operation errors.The purpose of Step 4 was to enable learners to use the developed educational program. In this step, participants were recruited, and the educational program was conducted.After developing the web-based educational program, the researchers guided the participants through telephone interviews with the head of the facility and distributed by mail the written instructions on how to use the educational program. Due to COVID-19 restrictions, visiting each LTCF proved to be difficult. Therefore, the details regarding the educational program manual were provided over the phone and through the written document. The manual for using the educational program included how to access the web program, a table of contents for the program, how to input answers, and other related information. The Korean version of “communication confidence,” “communication knowledge,” “role perception,” “transactive memory system,” and “team outcomes” were used to measure the learning outcomes. Communication confidence was measured on a scale of 0 to 10, with higher scores indicating higher confidence . CronbacThe purpose of Step 5 was to identify learning achievement. This study confirmed the results of the educational program by conducting an experiment through pre- and post-program surveys of the non-equivalence control group. The experimental group completed a web-based educational program based on the SMM, and the control group used an emergency management educational program that focused on knowledge . The surt-test, and repeated measures ANOVA were performed to confirm the differences between the before, immediately after, and two weeks after time points. Post hoc tests were performed using Bonferroni correction. All analyses were validated at a significance level of 0.05.SPSS version 25.0 was used to analyze the data. Descriptive statistics, a two-sample This study was conducted after obtaining the IRB approval of the researcher’s institution (KUIRB-2019-0174-01). After explaining to the participants the purpose of the study, the contents of the research, and that their participation was voluntary and they could withdraw from the study at any time, we obtained written consent.The web-based educational program developed consists of five chapters. Chapter 1 provides an overview of emergencies and early patient detection and includes the frequency of emergencies in LTCFs, concept of condition change, checking for condition change, professional knowledge, and the skills of interprofessional practitioners. Chapter 2 elaborates on minimizing patient injuries by providing definitions of airway obstructions, falls, and infections, while including information on patient assessment, first aid, and the role(s) of practitioners in emergencies. Chapter 3 focuses on the preparation of patient transport to the emergency department (ED) describing the patient information needed for treatment in the ED and the first aid that should be provided in the facility before transfer to an ED. Chapter 4 discusses the prevention of emergencies through identifying residents’ underlying diseases upon admission to LTCFs for determining those at high risk of experiencing emergencies, while depicting environmental management and the role of practitioners in preventing emergencies. Finally, Chapter 5 explains efficient communication between practitioners, the importance of communication, and the concept of the situation–background–assessment–recommendation (SBAR) framework and how to use it. The experimental and control groups were identified as homogenous groups in the homogeneity test for sociodemographic characteristics and dependent variables . The results of the application of the educational program are presented in p = <0.001) after education, communication knowledge , role recognition , transactive memory system , and team outcomes . A repeated ANOVA showed that, for communication confidence , communication knowledge , role recognition , transactive memory system , and team outcomes , there were significant differences between the time points before, immediately after, and after two weeks of using the educational program. As a result of the post hoc analysis of the differences between the experimental group’s scores at the three time points, communication confidence (p = <0.001), communication knowledge (p = <0.001), role recognition (p = <0.001), transactive memory system (p= 0.016), and team outcomes (p = 0.023) were shown to have improved significantly after education.Compared to the control group, the experimental group had significantly higher scores in communication confidence (t = 6.14, The emergency management capabilities of practitioners are being recognized as important because of the complex conditions of LTCF residents ,19. ThisParticipants who learned through our educational program positively evaluated the comprehensive and practical contents of emergency management, such as early detection by checking a patient’s condition changes, preparations to transfer a patient to the ED, and how to prevent daily emergencies in contrast to the existing education focused on first aid. As LTCFs must cope with a high risk of emergencies regarding their residents’ conditions, practitioners who care for residents should be provided with training to develop their first aid skills and the ability to detect condition changes early to prevent emergencies . ConditiMany residents have been transported to the ED from an LTCF. An average of more than 2 million residents in LTCFs are transferred to the ED for treatment each year in the United States , while tParticipants also stated that it was good to learn how to communicate in an emergency. Communication is one of the biggest challenges when people from different professions work together to achieve the same goal; however, standardized communication tools such as the SBAR tool can help close communication gaps among interprofessional team members . CommuniMany LTCFs have staff and resource shortages, particularly during situations that threaten residents’ safety, such as the current COVID-19 pandemic, and their limited staff is overburdened with work . Web-basThis study developed a practical education program based on the theoretical SMM. Significantly, the study supported the findings of previous research  by demonThis study shows that interprofessional practitioners can improve their collaboration ability by receiving education in role exploration and sharing and on communication for emergency management in the field. Future policy should encourage continuing education by developing and distributing programs in various subjects so that LTCF practitioners can develop emergency management collaboration skills on an ongoing basis. Moreover, future research should help develop educational programs by exploring the obstacles to web-based interprofessional education.This study has several limitations. First, physicians were excluded from this study because, as visiting doctors and not LTCF resident doctors, they were not directly involved in emergencies . Many moThis study was conducted to develop and provide a web-based emergency management educational program based on an SMM design and to identify its effectiveness. The results of adapting the SMM showed that it improved interprofessional collaborations and could be applied even in emergency situations. The program provided a systematic curriculum to improve perceptions of increasing team collaboration during emergencies. This web-based program can be used as a continuous education program for practitioners in LTCFs, where residents’ safety demands are increasing. The contents of this education program can be modified and supplemented accordingly to fit different facilities, as long as they have a similar educational goal to this program. In this study, the educational content focused on airway obstructions, falls, and infections, as these are the most frequent emergency cases in LTCFs. Further studies are required to expand the types of emergency cases included in educational programs.


This study aimed to identify facilitators and barriers to the uptake of a community-based diabetes prevention program (DPP) from the perspectives of decliners with prediabetes in a multi-ethnic Asian community.Semi-structured interviews were conducted with 29 individuals with prediabetes who declined participation in a large community-based diabetes prevention program in Singapore. Thematic analysis was undertaken to identify themes, which were subsequently mapped onto the Capacity-Opportunity-Motivation and Behavior model (COM-B).Capability) were important determinants. Family commitment had the strong potential to enable or hinder physical and social Opportunity related to participation. Many participants desired involvement of physician as part of program invitation and component. Fear of exacerbation coupled with an automatic aversion for suffering influenced Motivation for participation.We identified 16 key themes under three COM-B domains. Health status at the time of invitation, perceived ability of self-management, understanding of prediabetes condition and/or the program intention (Identifying facilitators and barriers embedded in the COM-B will assist systematic program modifications to increase participation of individuals with prediabetes. How information about modifiable risk factors is communicated by physicians at the point of diagnosis and program introduction is key to participation. Co-locating programs with family activity, development of mHealth, readiness assessment, and tailored explanation of program purpose may increase participation. These findings will be used to guide future national interventions in the community to ensure successful implementation. Prediabetes is defined as an elevation of plasma glucose above the normal range but below the diagnostic threshold for diabetes. Globally, the prevalence of prediabetes is growing. It is estimated that more than 470 million people worldwide will have prediabetes in 2030 . In a muIt is well established that prediabetes is associated with an increased risk of progression to diabetes and increased mortality even before the onset of diabetes –5. EvideThere is compelling evidence that structured and intensive lifestyle interventions and metformin are effective in reducing the onset of diabetes among people with prediabetes –11. In lnever been actively offered preventive interventions. Conclusions based upon these groups may not reflect the true motivations and behaviors of individuals who are eligible and offered to participate. In addition, currently available evidence is primarily based on studies conducted within a Western country. It is therefore important to elucidate culturally pertinent accounts of factors that may enable or hamper participation among the Asian population with prediabetes.Studies suggested that several factors hinder the successful adoption of DPPs for persons with prediabetes. They included a lack of awareness of having prediabetes, time commitment, costs of participation, poor knowledge of prevention programs, low self-efficacy, perceived health status, and limited support from social network –22. HoweTo fill these gaps, we performed a theory-informed identification of facilitators and barriers to participation in a community-based DPP from the perspectives of decliners with prediabetes in a multi-ethnic Asian community, using the Capacity, Opportunity, Motivation and Behavior model (COM-B) . To avoivia key modifications to improve feasibility and dissemination.To explore behavior-oriented accounts of factors that influenced the deliberation of non-participation, this study employed the Behavior Change Wheel as a theoretical framework. The Behavior Change Wheel is a behavioral health framework developed by Michie and colleagues deriving from 33 commonly used behavioral theories. It is underpinned by the COM-B model, which postulates that for behavior change to occur, three conditions must be met: Capability, Opportunity, and Motivation . CapabilWe used a qualitative research method to gain a systematic understanding of facilitators and barriers of non-participation in a community-based DPP in Singapore. Respondents were those who had rejected participation in the Pre-Diabetes Interventions for Continued Tracking to Ease-out Diabetes (Pre-DICTED) Program (henceforth Pre-DICTED), a large-scale government-sponsored 5-year open-label 1:1 randomized controlled trial that aims to reduce the risk of type 2 diabetes over 3 years among individuals clinically diagnosed with prediabetes. The core intervention phase of the Pre-DICTED consists of twice-weekly lifestyle classes  for 6 weeks, followed by 6 weeks of self-directed lifestyle modifications. There is an add-on metformin prescription if glucose control remains poor after 6 months of the intervention. Further details of the program can be found in the published protocol .via phone call, and the study purpose and scope of confidential and anonymous participation were explained. Upon verbal agreement of participation, an interview date, time, and venue were arranged. Informed written consent was obtained prior to the interview. Patients were selected purposively according to age, gender, and ethnicity to capture the richness of a broad range of views and experiences. A total of 38 patients were contacted, and 29 individuals agreed to participate in the interviews .rd researcher (SY). This allowed for inter-coder clarification of themes and sub-themes mapped against COM-B components, thus enhancing validity and reliability. NVivo 12 was used for data management and coding. For rigor and transparency, we anchored our methodology according to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist  and attained secondary education (76%). Approximately 58% were female and Chinese  were reported as a common factor given by respondents that impeded physical capability of participating in the program. Despite generally positive attitudes towards the Pre-DICTED, accounts of these individuals centered on the physical inability to participate. Physical weariness was cited more predominantly among older participants. Notably, a small number of respondents maintained that they had the necessary The main challenge surrounding psychological capability stemmed from respondents’ lack of understanding and knowledge of either the Pre-DICTED or the prediabetes condition. Many reported opening the invitation letter and briefly glancing through the leaflet, while others described reading the leaflet in detail. Most also remembered that they had been contacted by telephone to join “some workout, fitness program” (participant 10). However, several respondents expressed confusion over what the program was intended for. As one respondent recalled, the information contained in the invitation letter and subsequent follow-up call did not help her comprehend “what was going on” (participant 06) with the program. They decided not to participate, perceiving that they did not understand the benefits of the program.physical opportunity was the main barrier, as described in the next sub-section. For this category of respondents, there was a strong desire to prevent disease progression, and this could act as an enabler to participate in the program.Knowledge of prediabetes seems to be both a barrier and an enabler for program participation. Since prediabetes is asymptomatic, some respondents did not feel the pressing need to take action to prevent diabetes. Despite the acknowledgment of being at risk, some described their condition not as severe as people with diabetes and therefore in less need of “intervention”. Other respondents labelled themselves as “normal” rather than being overweight. On the other end of the spectrum, respondents recognized that prediabetes is a reversible condition with lifestyle changes. Having an awareness of the health consequence of prediabetes was an important step towards considering the Pre-DICTED for those whose free workout programs available in the community” and hence the Pre-DICTED was not something that is worth “forking out money  just for exercise” (participant 29). The Pre-DICTED decliners had a general tendency to have little willingness to participate if financial commitment would be required.We found that logistical aspects of the Pre-DICTED was the most commonly reported factor limiting physical opportunity to participate. For example, respondents found the location of the program inconvenient, involving long traveling time away from home. Besides physical distance, timing of sessions, which typically takes place on workdays, was reported to be a key consideration alongside other inconvenience. Some respondents described that they were working multiple jobs and hence could not physically find time to attend the program sessions. For example, younger respondents reported that it was harder to commit to a single fixed slot as their shift schedules varied week to week and rarely conformed to typical 9-6 work hours. In such cases, declination was quick with very little deliberation. The program component also emerged as something that impeded physical opportunity. For example, some respondents thought that metformin was a compulsory component and hence declined participation as their preference was for lifestyle changes alone as opposed to the combination of medication and lifestyle intervention. Another important factor that hindered participation was perceived cost. As one participant mentioned, there are “many Despite these barriers, the program had many components that seemed to be attractive to the respondents and hence would act as an enabler for participation. For example, some expressed an interest in the program’s group-based activity as they found peer support to be helpful for motivating them to continue engaging in the program. However, a minority of respondents preferred one-to-one sessions. Weight loss will be an important outcome for respondents to look forward to if they join the program as many explicitly stated that they would not consider if the focus of the program is not on weight loss. Across interviews, it became evident that clinical benefits of the program such as reversing high blood glucose, appear to be secondary to the program participation when compared with more tangible and perceivable outcomes such as weight loss.interpersonal influences that limited respondents’ opportunity to engage in the program. The commonly reported barriers to social opportunity included family and healthcare professionals. Many respondents, particularly female decliners, recounted how difficult it was to take up the program when they had to look after young children. Respondents also expressed unhappiness with the healthcare experience when providers were not forthcoming with adequate explanations on their health conditions. Some felt very strongly that besides prescribing medicines, doctors in primary public clinics rarely encouraged patients to take part in any lifestyle prevention program during the consultation. They expressed a desire for more information to be presented in layman’s term with less medical jargon.Running through the interviews was the role of At the same time, family and healthcare providers were cited as enablers for participation in the program. For example, having a good relationship with and trust in healthcare professionals played a key role in respondents’ deliberation on participation. A handful of respondents appreciated the advice given by their healthcare providers, including detailed diet and physical activity advice and explanation on progression from prediabetes to diabetes. It was commonly maintained that if family doctors had recommended a prevention program, it would certainly have considered participating in the Pre-DICTED. Importantly, there were frequent references to family responsibilities as an enabler among our respondents. Almost all respondents expressed a desire to maintain their health because they wished to continue to work and provide their family with financial support and stability. Most of the accounts seemed to reflect on respondents’ strong desire not wanting to become a burden to family if their prediabetes condition is ever worsened. Some did go on to imagine the difficult situation that could arise.reflective motivation. Respondents who reflected on their susceptibility to developing diabetes and its complications tended to have greater motivation towards making lifestyle changes and hence participation in the program. In most cases, respondents expressed a desire to maintain their independence and mobility, and this would act as an enabler. Awareness of psychological consequences of diabetes was present in many interviews, and this emerged as a powerful theme. Respondents commonly stated that having diabetes can be mentally stressful. Some often vividly portrayed the fear of falls as a result of poor wound healing, concerns about amputation, and the stress that declining work performance would lead to retrenchment.Barriers were also described as relating to Despite differing levels of capability and opportunity, respondents who reported empathy when they witnessed close family members’ suffering from diabetic complications appeared to be more receptive to participation in the program. For example, one respondent described how painful it was to observe her mother going through daily dialysis, alluding to the importance of prevention, while another respondent witnessed her aunt’s passing after amputation that encouraged him to consider participation in the program. Nonetheless, emotional reactions were not common to every participant. Some asserted that having diabetes did not affect the family member’s lifestyle, and hence diabetes may not be a serious problem. There were a couple of respondents who simply believed that prevention programs were not of interest to them.This study sought to identify factors that enable or hamper participation in community-based diabetes prevention program among decliners with prediabetes. Based on our findings, we have developed potential intervention strategies that should be considered for implementation from patient level through system level to better facilitate uptake around the six spokes of the Behavior Change Wheel   , 41–43. kplaces) . In our kplaces) . A simil of life , 45–47.  of life , 48–55. motivational factors that act as an enabler for improving participation. They included fear of exacerbation due to inaction, desire for maintaining independence, coupled with an automatic aversion for suffering as a result of observations from experiences of significant others with diabetes. Not wanting to become a burden to the family financially or with care responsibilities featured prominently in our study and was a sentiment especially pertinent in collectivist cultures (automatic motivation) and use that to tailor the conversation to foster more autonomous forms of motivation. A systematic review shows that diabetes prevention programs involving MI facilitate autonomous motivation which is then translated into improved physical activity and weight loss  to optimize the program thereby increasing participation. These findings will be used to guide future national interventions in the community to ensure successful implementation.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by SingHealth Centralised Institutional Review Board. The patients/participants provided their written informed consent to participate in this study.SY, YB, and JT conceptualized the study. SY designed the question guide. SW and DL conducted some of the interviews. DL, SW and SY performed the analysis and interpretation of data. All authors read and approved the final manuscript.The Pre-DICTED programme (The Pre-Diabetes Interventions and Continued Tracking to Ease-out Diabetes) was supported by Ministry of Health, Singapore. This work was supported by the National Medical Research Council (NMRC) through the SingHealth PULSES centre grant NMRC/CG/027/2017. The funding body had no role in the study design, collection, analysis, and interpretation of data and manuscript writing.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.


This meta-review integrates the findings of meta-analyses and systematic reviews to explore the effect of intervention programs on recidivism for juvenile offenders.The systematic literature search gathered 48 meta-analyses and systematic reviews from 53 research reports, contributing 56 independent effect sizes for analysis. These effect sizes were statistically integrated, and five moderators of theoretical and methodological importance were tested using meta-regression.rΦ = −0.09, p < 0.001) for juvenile offenders who participate in a program compared to those who do not. However, reductions in recidivism significantly vary between the levels of criminal justice system, characteristics of juvenile offenders, types of program modalities, and methodological quality.On average, intervention programs are associated with a significant reduction in recidivism (Results indicate that intervention programs can be an effective approach to reducing recidivism for juvenile offenders, especially when combined with a rehabilitative program modality.The online version contains supplementary material available at 10.1007/s11292-021-09472-z. Criminal justice policy is a topic of enduring importance for scholars, legislators, practitioners, and the public. One particular policy that has been subject to much discussion and debate regards the treatment of juvenile offenders.The “what works” question has dominated research and theory for over 40 years since Robert Martinson’s  inaugurarehabilitative model suggests that intervention programs provide the necessary tools to guide this population toward successful outcomes post-contact with the criminal justice system and provide enhanced public safety , they will correct their behavior and be deterred from future criminality by learning from the consequences of their actions  rather than exploring whether intervention effectiveness differs based on the type of offender , cognitive behavioral therapy (CBT), educational, restorative justice (RJ), specialized courts, diversion, intensive-supervision probation, wilderness treatment, and shock incarceration. Some reviews have examined the effect on recidivism across program modalities  searching electronic databases, (2) contacting researchers in the field, and (3) hand searching the reference lists of relevant texts  characteristics, program characteristics, and information about the outcome variables. The coding protocol, along with the process for its pilot testing and the rational for its response options, is provided in the Coding procedure. The lead researcher and a trained research assistant independently coded all included meta-analyses and systematic reviews. Research assistants received 15 h of training and practice coding. Any discrepancies in the extraction of the data that arose between the lead researcher and the research assistant were reconciled through discussion  using scales such as the Maryland Scale  software, version 3.0. We adopted two approaches to conducting moderator analyses. First, we tested moderators using subgroup analysis without adjusting for covariates. Second, we tested moderators using meta-regression techniques, adjusting for two covariates in the reviews: (1) methodological quality and (2) publication status. While the results of both models are reported, we interpret the meta-regression results because the inclusion of these covariates strengthens the trustworthiness of results .Calculating mean effect sizes. A weighting procedure was applied to calculate all phi coefficients for the overall and moderator analyses  was used to test total variation around the summary effect of the phi coefficients in this meta-review. A significant Qw value implies there is more variation around the summary effect than chance or error alone can explain, offering empirical justification that the moderator analysis should be conducted  between programs for juvenile offenders and recidivism differs based on factors of theoretical, practical, or methodological importance. As discussed previously, some of those factors include the type of juvenile offender, criminal justice system setting, criminal justice system exposure, type of program modality, and methodological quality of the included reviews. Heterogeneity analysis compares the observed variation in phi coefficients with the amount of variation that would be explained through sampling or estimation error alone  when conducting the meta-regression moderator analyses. A significant Qb value implies there is more variation among mean phi coefficients for the categories of the moderator than can be explained by chance alone. For example, a significant Qb value in a moderator analysis based on the type of juvenile offender signals that the mean phi coefficient differs depending on whether the youth committed a sexual, serious, nonserious, or drug offense. Pairwise comparisons were then conducted to test differences between the categories of each moderator.We used a between-groups goodness-of-fit statistic  real differences in the population  = 1.06, p = 0.901). For the second type of publication bias, we categorized effect sizes into two groups to reflect the publication status of the included reviews: peer-reviewed and non-peer-reviewed. The association between participating in a program and recidivism also did not vary significantly based on publication status (Qb(1) = 0.49, p = 0.483). Although there were no statistically significant differences, average phi coefficients were stronger for reviews that were not peer reviewed , p = 0.003, k = 5) than for those that were peer-reviewed , p < 0.001, k = 51).Publication bias. We conducted meta-regression moderator analyses on two types of publication bias: publication type and publication status. For the first type of publication bias, we categorized effect sizes into five groups to reflect the publication type of the included reviews: private reports, government reports, Campbell/Cochrane Collaboration systematic reviews, book chapters, and journal articles. The association between juvenile offenders participating in an intervention program and recidivism did not vary significantly based on publication type , p < 0.001, k = 56). Translating this summary effect into a more meaningful marker of impact  = 4371.090, p < 0.001).Overall phi coefficient with recidivism. We used summary phi coefficients from each meta-analysis or systematic review to calculate the overall relation between juvenile offenders participating in an intervention program and recidivism in this meta-review. We first averaged together reviews that included multiple summary effect sizes with overlapping samples to create one independent effect size that would contribute to the overall phi coefficient for this meta-review. A total of 56 independent phi coefficients contributed to the summary relation between juvenile offenders participating in an intervention program and recidivism in this meta-review. Overall, we found a significant mean weighted phi coefficient under the random effects model  than random error would suggest, supporting the decision to conduct moderator analyses (in addition to our substantive reasons for doing so). We thus conducted five moderator analyses to explore how variables of theoretical, practical, and methodological importance change the association between participating in an intervention program and recidivism. Table Meta-regression moderator analyses. This significant The following meta-regression results compare juvenile offenders who participate in an intervention program to those who do not, while controlling for publication status (peer-reviewed versus non peer-reviewed) and methodological quality AMSTAR-2 grade) of the included systematic reviews and meta-analyses. When conducting each moderator analysis, an average phi coefficient was calculated for each category of that moderator . These average phi coefficients reflect the strength and direction of association between participating (yes/no) in an intervention program and recidivism (yes/no). A positive phi coefficient indicates that program participation is associated with increased recidivism, while a negative phi coefficient indicates that program participation is associated with a reduction in recidivism. The regression coefficients represent pairwise comparisons, which reflect a difference in strength of the recidivism reduction between two categories of the moderator, such as two different types of offenders (see Table  grade ofQb(7) = 26.69, p < 0.001). Compared to juvenile offenders who did not participate in a program, participating in an intervention program is most strongly associated with a reduction in recidivism for sexual offenders , p < 0.001, k = 4) and serious or violent offenders , p < 0.001, k = 8). Participating in an intervention program is less strongly associated with a reduction in recidivism for non-serious or non-violent offenders , p = 0.013, k = 8) and general offenders , p = 0.013, k = 32). The weakest associations with reduced recidivism are for drug offenders , p = 0.432, k = 4).We categorized effect sizes into five types of juvenile offenders who participated in an intervention program: sexual, serious or violent, non-serious or non-violent, general, and drug. The association between participating in a program and recidivism varied significantly based on the type of offender  = 19.55, p = 0.002). Compared to juvenile offenders who do not participate in a program, participating in an intervention program is more strongly associated with a reduction in recidivism for offenders in an institutionalized setting , p < 0.001, k = 33) than for offenders in a non-institutionalized setting , p = 0.007, k = 30). A pairwise comparison revealed a statistically significant difference in recidivism between these two settings .We categorized effect sizes into two types of criminal justice settings: institutionalized and non-institutionalized. The association between participating in an intervention program and recidivism varied significantly based on the type of setting (Qb(6) = 20.74, p = 0.002]. Compared to juvenile offenders who do not participate in a program, participating in an intervention program is most strongly associated with a reduction in recidivism for correctional programs , p < 0.001, k = 14). Participating in a program is less strongly associated with a reduction in recidivism for diversion programs , p = 0.062, k = 19) and reentry/aftercare , p = 0.243, k = 8).We categorized effect sizes into three levels of criminal justice system exposure: diversion, correctional, and reentry/aftercare. The association between participating in an intervention program and recidivism varied significantly based on the level of criminal justice system exposure  as well as between correctional and reentry/aftercare programs .Pairwise comparisons (see Table Qb(13) = 59.54, p < 0.001). Compared to juvenile offenders who do not participate in a program, participating in an intervention program is most strongly associated with a reduction in recidivism for MST programs , p < 0.001, k = 4) and family treatment programs , p < 0.001, k = 5). Participating in an intervention program is less strongly associated with a reduction in recidivism for wilderness therapy , p = 0.036, k = 1) and CBT programs , p < 0.001, k = 10). Average effect sizes are relatively weaker for RJ , p = 0.001, k = 6), diversion programs , p < 0.001, k = 4), educational programs , p = 0.187, k = 3), and specialized courts , p = 0.051, k = 6). Conversely, participating in a program is associated with increased recidivism for ISP , p = 0.950, k = 2) and shock incarceration , p = 0.217, k = 2).We categorized effect sizes into ten types of program modality used to treat a juvenile offender: multisystemic therapy (MST), family-based treatment, wilderness therapy, cognitive behavioral therapy (CBT), restorative justice (RJ), diversion, educational, specialized courts, intensive supervision probation (ISP), and shock incarceration.Seventeen of the pairwise comparisons revealed significant differences in recidivism between the two groups being tested (see Table Qb(3) = 5.74, p = 0.125). Compared to juvenile offenders who do not participate in a program, participating in an intervention program is most strongly associated with a reduction in recidivism for low-quality reviews , p < 0.001, k = 11). Participating in a program is less strongly associated with a reduction in recidivism for moderate-quality reviews , p < 0.001, k = 21). The relatively weakest average association is for high-quality reviews , p < 0.001, k = 24). Pairwise comparisons .We categorized effect sizes into three levels of methodological quality for the meta-analyses and systematic reviews included in this meta-review: low, moderate, and high. The association between participating in an intervention program and recidivism did not vary significantly based on methodological quality  how intervention programs for juvenile offenders influence their return to criminality and (2) how factors of theoretical, practical, and methodological importance impact this relation with recidivism. Main findings from these analyses are discussed next.There is a significant difference (17.4%) in recidivism between juvenile offenders who do and do not participate in an intervention program. As reflected in this summary effect, programs for juvenile offenders are likely to reduce recidivism and are an important part of offender rehabilitation, reducing recidivism, and enhancing public safety. Despite this encouraging finding, more work is needed to strengthen the positive effects of programs for juvenile offenders. For example, policymakers could leverage this meta-analytic finding to help secure resources to ensure programs are available, equitable, and invested in reentry and wraparound services. Providing such programming may have higher financial costs initially, but not allocating enough resources to properly implement programs to provide consistent support across offender types and criminal justice settings may incur greater long-term societal costs.While this summary phi coefficient may appear small by conventional benchmarking  that may be attributable to lower quality studies and/or studies that have not undergone the peer-review process. Findings were remarkably consistent with our original hypotheses, with the importance of these findings for researchers, policymakers, and practitioners highlighted next.The offender type moderator analysis revealed two main findings. First, participating in an intervention program has the strongest association with a reduction in recidivism for sexual offenders and serious or violent offenders . Second, intervention programs for these two groups produce significantly stronger associations with a reduction in recidivism than for general, nonserious, and drug offenders. Taken together, these findings support that serious offenders have the most opportunity for improvement in their behavior and success upon reentry when participating in a program, suggesting that policymakers and practitioners should include those who are traditionally labeled as “high-risk,” “serious,” or “violent” in early release policies and work-release programs. However, these findings also highlight the necessity for researchers and practitioners to develop more nuanced interventions for less serious and drug offenders. These results may be a function of the best practices developed and tailored for high-risk offenders. As a result, there has been less attention paid to the development of interventions that can best support the needs of lower-risk offenders, which may be due to less research on them or lower fidelity of their implementation. Policymakers should thus consider improvements to current interventions for lower-risk offenders before continuing to swiftly adopt them.The criminal justice setting moderator analysis revealed two main findings. First, participating in an intervention is significantly associated with a reduction in recidivism in both types of criminal justice settings. Second, this effect is nearly three times greater for institutionalized juvenile offenders) than for noninstitutionalized offenders . While the effect is stronger for institutionalized juvenile offenders, it does not negate the significant reduction in recidivism in noninstitutionalized settings. Taken together, correctional researchers and practitioners should be attuned to evaluating and improving community-based correctional programs. Increasing the quality and quantity of treatment services that focus more on support rather than surveillance may provide more positive options for youth and help them avoid the behaviors and environmental factors that may have initially led them to delinquency. It may also be prudent for policymakers to focus on implementing interventions that are cost- and resource-effective that reduce the frequency of juvenile offenders cycling through the system.The criminal justice system exposure moderator revealed two main findings. First, only correctional programs had a significant association with a reduction in recidivism (25.40% difference in recidivism). Second, correctional programs are associated with a significantly stronger reduction in recidivism than for diversion and reentry/aftercare programs. Taken together, these results highlight a stark difference between correctional programming, diversion interventions, and reentry/aftercare interventions. Such a difference is likely due to the types of interventions occurring at the diversion or reentry/aftercare level, with the most support and access to programs that induce behavior change implemented for those who are incarcerated. More and better reentry/aftercare programs need to be implemented in a way that does not place youth at greater risk for re-exposure to the justice system, such as programs that help youth secure employment and strengthen connection to the community prior to release. Our findings suggest that juvenile offenders are in most need of reentry services that take a wraparound approach and focus on building relationships and connections that would ultimately provide more opportunities for successful reintegration. Relatedly, diversion programs may not truly divert juvenile offenders, but instead entrench them deeper into the system . Second, the reduction in recidivism found in low-quality reviews was significantly stronger than found in high-quality reviews. Taken together, these findings underscore the necessity for researchers to adhere to methodological best practices when conducting any review of research because findings from a low-quality review may overestimate the impact of an intervention. As a result, policymakers and practitioners may adopt interventions with inflated effects that are thus less likely to yield the desired or expected result. These possibilities should always be considered when making decisions based on reviews of research.It is important to note that all the average effect sizes were in the expected direction and in the expected relative magnitude for each moderator. However, it is also important to consider that programs with the strongest effects are not often implemented only for rehabilitative purposes. When considering the potential impact a program may have on recidivism, policymakers and practitioners should consider that the comparison is not simply a rehabilitative model versus a punitive model. While the 40-year debate on what works often emphasizes this dichotomy, program outcomes instead most often reflect a comparison between the punitive model alone and punishment plus rehabilitation. The rehabilitative model is an additive to deterrence-based and accountability strategies , which likely also contributes to the differences observed in the moderator analyses. As such, intervention programs combined with some deterrent value may signal to the youth that even though they are being held accountable for their actions, they still have an opportunity to succeed. When these two conditions  are both present in a program , juvenile offenders may experience the most behavior change as a result of participation.Indeed, many programs adopted for the most high-risk offenders in the most restrictive circumstances often follow the Risk-Needs-Responsivity (RNR) approach. This approach also helps to explain why institutionalized juvenile offenders, sexual and serious offenders, and incarcerated offenders would have the strongest reductions in recidivism if they participate in a program. Because the RNR model for evidence-based corrections proliferated programs that should target the needs of higher-risk offenders, it is likely that the programs implemented in the last two decades adhere to those best practices. As a result, the effects of more recent programs on recidivism for higher risk offenders may be stronger compared to lower-risk offenders. The programs for higher risk offenders have more research, more targeted responses that are clearly identified, and may be better equipped to induce behavior change.Moving forward, policymakers and practitioners should consider the importance of addressing more than the needs of juvenile offenders in isolation: it is also salient to preserve remnants of the contexts and lives in which the juvenile will return. Implementing effective programs for juvenile offenders can foster relationships, improve skills, and help juveniles commit to the normative aspects of society ESM 2(PDF 392 kb)ESM 3(PDF 107 kb)


Growing literature supports the use of internet- and mobile-based interventions (IMIs) targeting parenting behaviours to prevent child and adolescent mental health difficulties. However, parents of lower-socioeconomic positions (SEP) are underserved by these interventions. To avoid contributing to existing mental health inequalities, additional efforts are needed to understand the engagement needs of lower-SEP parents. This study qualitatively explored lower-SEP parents’ perspectives on how program features could facilitate their engagement in IMIs for youth mental health. We conducted semi-structured interviews with 16 lower-SEP parents of children aged 0–18 to identify important program features. Participants were mostly female (81.3%) and aged between 26 and 56 years. Transcriptions were analysed using inductive thematic analysis. Twenty-three modifiable program features important to lower-SEP parents’ engagement in IMIs were identified. These features aligned with one of three overarching themes explaining their importance to parents’ willingness to engage: (1) It will help my child; (2) I feel like I can do it; (3) It can easily fit into my life. The relative importance of program features varied based on parents’ specific social and economic challenges. These findings offer initial directions for program developers in optimising IMIs to overcome barriers to engagement for lower-SEP parents. Emotional and behavioural problems are a leading cause of disability in children and adolescents worldwide , making Growing literature supports the use of preventive interventions targeting parenting skills, parental self-efficacy and parent mental health to reduce the incidence and severity of child and adolescent mental health difficulties ,12,13,14One population uniquely underserved by parenting interventions aimed at preventing mental health difficulties are lower-SEP parents. SEP is one means of classifying people based on their relative access to social and economic resources , with inezPARENT  comments or testimonials from people. I mean when I look into doing things I always look at reviews for stuff first, especially if it costs money.”—Mother of one, 30 years oldProfessional endorsements: Parents felt they may also be persuaded that a program could benefit their child if a professional endorsed the program. Parents were most interested in health professionals’ perspectives on a program, with maternal health nurses, paediatricians, general practitioners and psychologists cited as reliable sources. One parent indicated that associations with research institutes and universities may be viewed less favourably by parents with less education due to perceived elitism among such institutions.“I feel like there are a lot of people out there, not a lot but some, that won’t have participated in any sort of further education and may not have even finished high school and are kind of put off by the “you think you are better than me because you went to university.”—Mother of one, 29 years oldEmpirical support: Five parents indicated they would be more motivated to enrol in a program if they could see it had research supporting its development and implementation. Three of these parents suggested this could be communicated through a brief summary of the literature, with relevant research cited or linked.“If I am going to invest time into something and get advice on how to parent my child … I want to know beforehand and have faith beforehand that it is something based on good evidence.”—Mother of two, 32 years oldClear benefits: The communication of program benefits was linked to perceived effectiveness. The clarity with which benefits were communicated was important to parents, with two indicating research summaries may be less meaningful, or possibly confusing. Instead, they wanted a brief list of what they could expect for their child after finishing the program or, alternatively, key words indicating what previous parents had gained from the program.“[Benefits] need to be very clear, otherwise I won’t part with my precious money … have examples of how it can help you in your day-to-day life, what you can expect to get out of it.”—Mother of one, 35 years oldProgram content: Parents sought a program that had content relevant to their needs and experiences. Participants cared that a program would address issues related to their current circumstances, with this often connected to challenges relevant to their child’s developmental stage, such as school transitions, bullying or alcohol use. The presence of specific strategies to help manage behaviours was also important. If the initial program content focussed heavily on parenting, rather than child and adolescent challenges, parents felt that the benefits may be less apparent to them.“I would want explanations behind behaviours to better understand why my children might be doing the sorts of things they might be doing and then sort of strategies to help address things.”—Mother of two, 32 years oldMultiple users: Several participants noted the benefits of allowing multiple users within a family to access the same program. They felt this would accommodate various caregiving arrangements and allow for better support for their child. Parents wanted to be able to include partners, ex-partners, grandparents, cousins, friends, siblings and children. Five parents wanted multiple parties to have access to the full program, suggesting multiple user profiles, whereas others suggested the inclusion of written summaries so that session content could be shared if needed.“I could see a lot of benefits from being able to have my husband do it, or my mum who looks after the kids, so that there is some consistency.”—Mother of two, 32 years oldLocal resources: Several parents wanted IMIs to be able to direct them to further services in their local area if they needed more information or wanted to speak to a professional. One participant suggested programs have a page where users can search their postcode and find additional community services. They felt this would enhance the sense that the program was tailored to their needs and could adequately support them regardless of their difficulties.“I feel like [people living regionally] have got less access to a lot of different resources … I find that a lot of GPs don’t really know what to do with you. So even a program that sort of helped you figure out who to turn to … or what your problem is and where to find help.”—Mother of one, 35 years oldProgram navigation: Finally, parents emphasised the importance of independent and flexible program navigation. Participants wanted to be able to exercise choice in what information or resources they had access to at any given time as this would allow them to optimise the relevance of the program and support their child better. It was suggested that this feature could include allowing users to select a subset of modules from a larger selection or allowing them to choose the order in which they complete sessions.“I know personally if I’ve got better concentration on the day I might try the more complex stuff and if I’m having an off day or a busy day where I’m trying to do everything at once I might try something that’s a bit simpler or less time consuming.”—Mother of one, 30 years oldFeatures within this theme facilitate the user’s confidence in completing the IMI. Parents reported factors such as mental health stigma, fear of judgement regarding their parenting, limited literacy and limited digital literacy as barriers to feeling capable and ready to engage with such a program. Despite these barriers, parents identified seven modifiable program features that could be used to increase their self-efficacy and subsequent willingness to engage. Language complexity: Eight parents spoke about the need for simple, easy-to-understand language, with five noting the specific importance of this for lower-SEP parents due to lower literacy and greater linguistic diversity within their communities. They advised that complex language may lead parents to doubt their ability to complete the program, reducing enrolment. To increase the approachability of the program for users with lower literacy levels, parents suggested limiting complex terms, replacing some written content with images, and providing pop-up definitions for complicated words or mental health terminology.“Well you could assume they would have less education, so nothing too complicated and nothing too scary … so that it’s, you know, welcoming, and the language is really simple.”—Mother of one, 35 years oldInclusive imagery: Parents wanted programs that used images that felt welcoming, inclusive and demonstrated the program was designed for families like them. This can be achieved by including images of families that lower-SEP parents connect with. One parent suggested using depictions of people with different skin tones, family compositions and not having any parents in suits or high-fashion clothing.“I think it would need to be a real family, and not a cookie cutter Pinterest family … really embrace that a happy family doesn’t need to be a perfect family. You know, there’s not a dad in a suit, and you know, he’s all vogue magazine and mum’s all Gucci bag.”—Mother of one, 35 years oldTranslated content: The value of having programs, or sections of programs, translated into different languages for linguistically diverse parents was conveyed by three participants. These participants recognised that a higher proportion of parents within their communities speak English as a second language. They therefore felt that having the program accessible in other languages could improve some parents’ confidence in completing such a program and increase the engagement of lower-SEP parents who speak multiple languages.“Some people can’t speak English so being able to access the information in their own language [is important] … they shouldn’t be excluded from information they may need.”—Mother of one, 26 years oldUser interface: Digital literacy was another barrier identified by parents, with several participants lacking confidence navigating websites and digital resources due to limited experience with computers. Participants suggested programs use a simple and easy-to-navigate user interface to reduce this barrier. Parents preferred a program that was bright and engaging, with navigation buttons clearly identifiable and not overly cluttered.“I think it needs to be clear and easy to see how to navigate through … If things look like text everywhere, then it doesn’t tend to look too appealing.”—Mother of two, 32 years oldAnonymous registration: Parents identified that one of the benefits of IMIs is that they offer additional anonymity compared to face-to-face programs. They felt this may be particularly beneficial for parents living in communities with greater mental health stigma or those who fear their parenting may be judged by accessing such a program. One participant suggested that programs should offer parents the option to register with minimal personal details for those who are particularly concerned about privacy.“We’ve got a few [people in our community] that are just like ‘Why would you do it [seek mental health support], why do you want other people to know your business?’”—Mother of one, 30 years oldUser-to-user support: The desire to connect with other parents and share experiences was expressed by parents. The presence of a discussion forum or an associated social media page was viewed as an opportunity to normalise some of the parenting difficulties participants were experiencing in a supportive space and share ideas based on the program content. Whilst this was seen as a means of increasing parent confidence, one participant noted that the additional time associated with such a feature could be a burden for many lower-SEP parents and, therefore, felt any peer-to-peer contact should be optional.“I think it’s good if there are parents experiencing the same thing that they can all get on together and help one another because I know some mothers that are really struggling with their kids … and not having the support themselves.”—Mother of three, 28 years oldProfessional support: Despite parents’ desire for anonymity, access to a contact person or facilitator was advocated by five parents as a means of improving the approachability of IMIs. It was noted that a personal interaction when a parent first enquires about, or registers for, a program could make the program seem less daunting. Additionally, the option to have regular check-ins or to reach out to someone appealed to many parents as this would allow them to ask questions and feel supported throughout the program, particularly if difficulties arose. Parents’ preferred means of contact with a facilitator varied, with suggestions including phone calls, emails, video-conferences and live-chat messaging.“Sometimes you can get questions or sometimes you might have a specific example from your life that is a bit outside the norm so even if … at certain points you touch base with them, but not all the way through, I don’t think.”—Mother of one, 35 years oldThis theme revolved around participants’ desire for a program that was convenient, affordable and flexible so that it would easily fit into their life. Parents described the competing demands they experience daily and the need to prioritise their limited resources, indicating that a prevention program would usually not take precedence over more immediate concerns. It was felt that by optimising the features listed in this section, barriers associated with limited time, finances and internet access could be reduced. Eight modifiable program features were identified that may facilitate parents’ sense that an IMI for youth mental health can easily fit into their life. Length of modules and number of modules: Reducing the time required to engage with an IMI was important to parents as this would allow them to more easily fit the program into their busy lives. Three parents outlined that they would like the overall program to be as short as possible, with fewer modules, whereas the remaining parents placed less importance on the overall program length and more on the length of individual sessions or modules. There was little consensus on the ideal length or number of modules, with the former ranging from 15 min to 60 min and the latter ranging from a single-session program to 20 modules. Whilst the desire for sessions to be “short” and “quick” was salient, three parents noted they did not want the quality of the content to be sacrificed for the sake of convenience. Therefore, these parents felt it was important to balance program and session length, ensuring that sufficient skill and knowledge was still attainable.“My day includes commitments that are scattered across the day with patches of dead time … so the shorter the session is, the smaller the amount of dead time you need to put it in. If you could put it in a quarter of an hour that’s, you know, while you wait for your McDonalds to be ready.”—Father of three, 48 years oldDownloadable content: Limited internet access was a barrier to engagement for four lower-SEP parents due to their homes not having reliable internet coverage or the costs associated with internet use, particularly phone data. One suggested solution for overcoming this barrier was to have content that could be downloaded. Parents indicating that they could then utilise free Wi-Fi at locations such as libraries or fast food outlets to download the necessary content and then interact with it at a more convenient time.“You’d have to work out your data before you start the program, if it’s going to be enough, or are you going to have to wait until, you know, your data’s back up to speed or something.”—Father of three, 38 years oldOngoing availability: Continuous access to the program was an important consideration to five parents’ enrolment. This feature was related to the ability to revisit content after the program was completed and also the availability of the IMI at any time through the day. Parents felt this would help them fit the modules into the most convenient moments for them, rather than having to log in at predetermined, and potentially inconvenient, times.“Children aren’t predictable so you can’t really predict when you are going to have time to do it.”—Mother of two, 31 years oldProgram platform: Over half of participants felt the platform or device through which they access the program was important to the accessibility of the program. Eight parents indicated a strong preference for a mobile- or tablet-based application, rather than a website, with two participants not owning a desktop or laptop computer. They noted that an application would allow them to download content as needed and also access the program at any time. Four parents also indicated a desire for the program to be accessible across devices so they could use a different device based on their location.“Ideally you could jump between different [devices] … You’ve got the website but you’ve also got the app and both of them access all your information.”—Mother of one, 26 years oldProgram cost: Participants described how limited financial resources had been a barrier to them accessing parenting or youth mental health services previously. This was mostly discussed in the context of secondary costs associated with completing a parenting program such as obtaining childcare, transportation costs, or in the case of IMIs, data usage. Several parents also seemed to be unaware of low-cost or free programs or services. Participants explained how despite wanting to engage in programs or services, they felt they lacked the financial flexibility to do so, with two parents expressing concerns that doing so would have resulted in difficulty meeting basic needs such as food and shelter. This financial struggle left parents feeling marginalised and isolated.“Financial constraints can be very conflicting, especially with people who are struggling to make ends meet and they need that information so they can help their children. We don’t want to feel like … bad parents.”—Mother of one, 26 years oldPayment options: Despite costs often being a significant barrier for these parents, they were hopeful that the virtual nature of IMIs could facilitate more affordable options than face-to-face programs. Options for reducing the impact of limited financial resources on enrolment included alternative payment arrangements such as concession rates, trial periods, payment plans and pay-by-module options.“I think cost would be a big factor for us in the low-income bracket … I think that is what stops people from getting services they need so just be flexible.”—Mother of two, 39 years oldContent format: A range of content formats were viewed as acceptable by parents, including videos, audio, text, graphics and cartoon sequences. Preferences often differed based on literacy levels, preferred learning styles and whether parents planned on completing the program whilst doing other tasks. As such, providing users with choice in the format of content may facilitate enrolment.“Audio would be fantastic because … in the car, driving from one place to another … That said, something that I’m clicking away on I’m probably engaging with more than something that’s pure audio so interactive would also be good to cement it in.”—Father of two, 46 years oldAcross the sample, there was variation regarding the perceived importance of program features, based on parents’ individual circumstances. These preferences were informed by a parent’s experience of factors commonly associated with socioeconomic disadvantage such as limited education or income, as well as factors such as geographic location, relationship status and gender. This heterogeneity is described below. Differences in education and income levels across the sample appeared to impact how parents viewed certain program qualities. For example, parents in the lowest income brackets reported features associated with affordability, such as program cost, payment options and downloadable content, as central to their engagement. In contrast, parents with no, or limited, post-secondary education reported that features facilitating convenience would be particularly important to their willingness to enrol in an IMI for youth mental health. Education also appeared to be associated with digital literacy, with parents with less education reporting lower confidence in using the internet. These parents subsequently reported that they would be easily deterred if a program was not simple and easily navigated. Responses also indicated that parents with less education were particularly aware of the social stigma associated with using a parenting program and consequently desired features optimising approachability. These parents also suggested that links to higher education institutes may undermine their willingness to engage, whereas parents in the sample with greater education were motivated by university-conducted research. n = 7) reported more limited access to face-to-face mental health services, and therefore sought a program which could meet a greater variety of needs, compared to those living in metropolitan areas. Consequently, regional parents were particularly interested in having regular access to a professional support person to whom they could direct questions or concerns. These parents also expressed a strong desire for programs to facilitate contact with other services if needed, for example, including lists of services and resources specific to their local area. Internet access was a barrier to engagement for several regional parents and, therefore, downloadable content or application-based programs may also support their engagement. Additionally, several regional parents reported that they were more likely to enrol if the advertising material demonstrated that the IMI was designed for, or tailored to, parents in their community, whereas this was not raised as a concern for parents living in metropolitan areas. Geographic factors also impacted parents’ reported preference. Parents who lived in regional areas (n = 9) appeared to be more focussed on the convenience of the program than their partnered peers. The desire to optimise this characteristic was driven by the sense that they had more limited available time to complete such programs. They were focussed on the importance of brief modules and accessibility on phones and tablets so that they could complete sessions whilst out of the home doing other activities. Single parents in this study  InstThe program features identified as important to lower-SEP parents’ enrolment in IMIs differ to those previously deemed relevant to other types of parenting programs, e.g., ,70,71,72Some of the features identified in the present study have not been considered important in the broader IMI literature, whereas others are already prioritised in program design. One feature not currently widely accessible in IMIs is flexibility in content format . A recent systematic review of technology-assisted parenting programs  found thThe variability in parents’ preferences across the present sample highlights an additional challenge in addressing the under-engagement of lower-SEP parents. The within-group variability documented in the present study, as well as within previous samples , suggestA strength of this study was its success in reaching a proportion of the population often not represented in parenting research. All parents in this sample had a household income below the national average , and oveA methodological limitation of this study is that some of the data obtained during the interviews was not relevant to the present study. Throughout the data collection process, efforts were made to ensure participants were accurately conceptualising IMIs for youth mental health; however, certain responses suggested that some parents lacked a clear understanding of these programs or became confused at times. For instance, one parent discussed the physical health benefits of programs for children. Where possible, parents were corrected and data unrelated to IMIs was not analysed, but some data may have been erroneously included in analyses if it was unclear that the participant was unsure. Finally, this study focussed on how programs can be optimised to facilitate the engagement of lower-SEP parents. Therefore, the research questions, interview schedule and focus of analysis fostered the identification of themes related to modifiable program features. This allowed for the development of findings that will support program developers to tailor programs based on lower-SEP parents’ preferences. However, other engagement-related factors for lower-SEP parents  would have been overlooked by our narrow focus on modifiable program features. As such, further research is needed to provide a more exhaustive understanding of the factors impacting lower-SEP parents’ engagement in web-based parenting programs for youth mental health to comprehensively address under-engagement with this population.Findings from this study offer directions for developers of parent IMIs to prioritise the inclusion and optimisation of program features that may overcome barriers to engagement for lower-SEP parents. These parents consider whether a program will benefit their child, whether they feel capable of completing it and whether it fits into their daily life. Therefore, IMI-program developers may be able to increase lower-SEP parents’ engagement in their programs by taking these themes into consideration and including associated program features . It may Findings also suggest several future research directions. First, this study highlighted the importance of qualitative research in the early stages of program development, particularly for underserved populations such as lower-SEP parents. Whilst this study focussed on program features, it would be useful for future research to further investigate the interactions among individual, environmental, program and provider factors that are important to parental engagement , as wellFinally, empirical evidence is needed to support the use of the identified program features. One necessary step is randomised controlled trials of programs that incorporate relevant features. However, to allow program developers to effectively optimise programs based on findings from this study, it would be useful to first obtain stakeholder views to determine the feasibility of identified features and then demarcate which of the identified program features have the greatest influence on the engagement rates of lower-SEP parents. One suggested method for obtaining such data from difficult-to-reach populations is discrete choice experiments . This coThis article aimed to explore the perspectives of lower-SEP parents regarding program features that may facilitate their engagement in IMIs to prevent youth mental health difficulties. Parents considered 23 modifiable program features when choosing whether or not to enrol in an IMI. These findings offer insights for program developers to tailor programs accordingly. However, preferences for program features varied across the sample, suggesting that a “one-size-fits-all” approach may not be appropriate for optimising reach within lower-SEP communities. Customisable universal prevention programs and multi-level prevention approaches therefore warrant further investigation, as well as research to determine the relative impact of identified program features on lower-SEP parents’ engagement.