This study aimed to establish a health and medical foundation for forest healing programs and provide a basis for developing an evaluation system for such programs. While the number of visitors to forests and interest in forest healing effects are increasing, few studies have examined the various indicators of the persistent changes in forest healing effects. Therefore, this study conducted pre-, post-, and follow-up experiments on 87 health and clinical indicators in a sample of 88 adolescent participants. The relationships between pre-, post-, and follow-up experiment results for each indicator were analyzed. Of the 87 indicators, 46 showed significant changes, including systolic blood pressure, diastolic blood pressure, cholesterol, serotonin, vitamin D, CD16+CD56 count, interferon-γ, resilience, and self-esteem. The findings are significant for studying diverse participants and indicators and lay the foundation for developing forest healing programs by clarifying aspects such as the indicators suitable for short-term observation versus the indicators requiring long-term observation. Based on these analyses, the results of this study are expected to be useful when conducting research to establish an evidence-based forest healing program in the future. Rapid industrialization and urbanization have led to a decline in the quality of life and happiness of urban residents, and forest healing programs are drawing attention as a means of recharging life energy and improving health . IncreasIn addition to physiological health, several studies are underway to identify the positive effects of forest healing on psychological health ,24,25,26Several prior studies have categorized forest healing effects into olfactory, visual, and environmental effects with social engagement. The olfactory effect of forest healing through green space exposure is caused by monoterpenes that radiate from forests and trees. Monoterpene is a volatile substance found in flowers and trees that functions as a sterilization agent and insecticide. α-Pinene accounts for most monoterpenes produced in forests, and several prior studies have demonstrated its anti-inflammatory, antioxidant, and anti-anxiety effects ,29,30. IThe positive physical changes achieved simply by looking at forests and trees represent the visual component of the forest healing effect. An experiment demonstrated positive psychological and physiological changes after viewing natural photographs among participants who were shown natural and urban photographs ,44,45,46Finally, regarding the environmental effects with social engagement, a study showed that the top 20% of the population in terms of the green space rate within a radius of 250 m around their home had a 12% lower mortality rate than those in the bottom 20%; the difference was most pronounced in respiratory and cancer-related mortality . In addiMost prior studies on the impact of forest healing on individual health indicators have focused on short-term evaluations, comparing pre- and post-test results on individual health indicators. However, comprehensive evaluations using diverse health and clinical indicators have not been conducted. In addition, although prior studies have analyzed the physiological and psychological effects of forest healing programs, few studies have investigated the long-term maintenance of forest healing effects through follow-up examination after the program ends. To establish a health and medical foundation for forest healing, continuous and repeated research is needed. However, at present, there is a lack of evidence to establish an evaluation system for forest healing. As the number of visitors heading to the forest for healing is rapidly growing, and there is increasing curiosity about the effectiveness of forest healing programs, it is urgent to establish a medical basis to prove the effectiveness of forest healing.This study was conducted to comprehensively evaluate the physiological and psychological effects of forest healing, based on health and clinical indicators, as a pilot attempt to lay the foundation for a forest healing program. This study aimed to verify the effectiveness of forest healing and to confirm the sustainability and change in forest healing effects through pre-, post-, and follow-up tests. In addition, the experimental period and measurements were applied on a trial basis considering the various indicators and measurement factors. Therefore, this study is meaningful in providing a basis for future research and developing an evidence-based forest healing program.The following research questions were addressed: Is there a correlation between green space exposure level and health conditions? What are the indicators of distinct changes during the study period? Which indicators are resistant to change, and which indicators are more susceptible to change? Which indicators are appropriate for short-term evaluation, and which indicators require long-term observation? To investigate the physiological and psychological effects of the forest healing program, 92 participants were recruited for the program lasting three days and two nights. Two weeks before the commencement of the forest healing program, the participants underwent a clinical assessment and responded to a self-report survey; the same assessments were conducted again shortly after the program ended. Post-treatment was measured immediately after the end of the program, but the timing of the individual participants’ measurements slightly differed due to the large number of participants. All post-treatment measurements were completed within one hour after the program. After the program, the participants were divided into three groups, and the sustainability of the changes after returning to their daily lives was assessed using the same assessment measures as pre-test and post-test after one, two, and four weeks in Groups 1, 2, and 3, respectively. A schematic diagram of the research design is presented in n = 32), Gimcheon (n = 29), and Incheon (n = 29). After excluding two participants who dropped out of the study and one who got injured during the research period, the final sample comprised 88 participants (30 from Daejeon and 29 each from Gimcheon and Incheon).Informed consent was obtained from the participants and their guardians after clearly explaining the purpose and objectives of the research. The study was conducted in accordance with the guidelines of the Declaration of Helsinki, and the protocol was approved by the Wonkwang University Institutional Review Board (protocol code WKIRB-201705-BM-027). The demographic characteristics of the participants are presented in The study was conducted with 92 adolescents aged 13–18 years, in July and August 2017, supported by the Jung Mong-gu Foundation hosted by the Korea Forest Welfare Promotion Agency. Participants were youth in residential care facilities who lived in a group in one space, and they were from the following three cities: Deajeon  of the regions, Gimcheon, Daejeon, and Incheon, was examined; the results are shown in The forest healing program was conducted at Heongseong SoopChewon, Gangwon, Korea. It is a national forest park located 840 m above sea level on Cheong-Tae Mountain . HeongseLarix kaempferi, Quercus aliena, Pinus densiflora, Abies holophylla, Betula platyphylla, Pinus Koraiensis community, and deciduous broad-leaved and mixed communities. The widest site was the Larix kaempferi community (69.37%). The percentage of forest area within walking distance of the study site was 92.24%, and the crown density was 79.20% . The aveThe three-day and two-night forest healing program was conducted in the forest. The program utilized various forest resources within Heongseong SoopChewon, such as free walking in the forest, recreation in the woods, and woodworking experience . The parThe measurement factors were divided into the following three main categories: self-report survey, clinical assessment, and qualitative assessment. As shown in p < 0.05, to identify the significant differences determined using the ANOVA.The changes in the indicators between pre-test, post-test, and follow-up were analyzed for a total of 88 participants , who were tested three times during the study period. A total of 87 variables, including 82 physiological indicators and 5 psychological indicators were examined using R 4.0.3 version and R Studio to calculate descriptive statistics and one-way repeated measures ANOVA . All valOf the 87 health-related indicators analyzed, 46 indicators showed significant differences in one-way repeated measures ANOVA, and 28 indicators showed significant differences in Tukey’s test for post hoc analysis. The results of ANOVA and post hoc tests of all indicators are presented in Cardiovascular-related indicators showed significant reductions in systolic and diastolic blood pressure and cholesterol levels in the post-test, consistent with prior studies showing significant reductions in blood pressure after forest healing programs as shown in The analysis of the heart rate variability (HRV) indicators influencing stress responses showed that LnTP and RMSSD decreased significantly over the pre-, post-, and follow-up tests, and LnLF also tended to decrease over the pre-, post-, and follow-up tests, although not significantly. LnHF decreased significantly in the post-test compared to the pre-test but increased in the follow-up test. LnLF/LnHF significantly increased during the post-test but decreased during the follow-up test. As such, the increased LnHF and the decreased LnLF/LnHF levels after the forest healing program are consistent with the results of prior studies and considering that the effect could be observed in the follow-up test, not in the post-test, it is expected that the effect takes some time to appear ,50. AlthBlood pressure and HRV levels are known to affect each other, and diastolic blood pressure is more closely related to the autonomic nervous system than systolic blood pressure ,53. PrevWhen examining immune-related indicators, both CD16+CD56 (count) and CD16+CD56 (WB), which affect the activity of NK cells, decreased in the post-test compared to the pre-test, but increased significantly in the follow-up test. This result is consistent with prior studies showing that forest healing effectively increases NK cell activity and population ,28,55. IThe indicator associated with inflammation, eNO, showed no significant difference, and the analysis of white blood cells (WBC) showed that the total number of WBC and basophils decreased in post-test compared to pre-test, but significantly increased in the follow-up test. Lymphocytes and monocytes tended to decrease over pre-, post-, and follow-up tests, in contrast to a prior study that observed significant increases in lymphocytes and monocytes ,63. The Human immune function is achieved through the balance of two types of helper T cells, Th1 (Type 1) and Th2 (Type 2). Th1 is a regulator of cell-mediated immunity, which increases inflammation in infected cells; improves macrophage function in response to viral and bacterial infections; and plays a role in innate immunity, and elimination of infectious substances. ,67,68,69The analysis of 8-OHdG and d-ROMs, indicators related to oxidative stress, showed minimal changes . AlthougNeither cortisol (CIA) nor the cortisol  related to stress hormones showed significant changes . This reAmong the health screening indicators, 25-(OH) vitamin D increased significantly over the pre-, post-, and follow-up tests, while 1,25-(OH) 3 vitamin D decreased significantly during the post-test compared to the pre-test and increased again during the follow-up test . GlucoseAmong the psychological indicators, significant results were observed for resilience, self-esteem, and vigor . ResilieThe forest healing program led to positive changes in several indicators. Of the 87 indicators, 46 showed significant changes, including systolic blood pressure, diastolic blood pressure, cholesterol, serotonin, vitamin D, CD16+CD56 count, IFN-γ, resilience, and self-esteem. IL-8 has been shown to be susceptible to interpersonal deviations, and cholesterol and BAP are considered appropriate for short-term effect observations. Long-term observation is required for indicators such as blood pressure, TNF-α, IFN-γ, and serotonin, for which effects were shown to last till the follow-up assessment, as well as for indicators such as CD16+CD56 , IL-4, vitamin D, and interpersonal competency, for which the effects were not expressed immediately after the program but were observed in the follow-up tests.Categorizing the results derived from this study according to health effects, the first health promotion effect that can be expected through forest healing programs is immunity enhancement . Among tThe second expected health-promoting effect of forest healing programs demonstrated in this study is related to stress recovery . TheorieIt is important to note that this study has several limitations. The main limitation of this study is that there is no control group that includes participants who have not participated in the forest healing program; thus, the results of this study may need to be analyzed in conjunction with the results of subsequent studies that will involve control groups. This study conducted experiments on adolescents living relatively homogeneous lives, making it difficult to generalize the health promotion effects of the forest healing program. In addition, the analysis results may not have been accurate due to the effects of the growth period, and the lack of control over other factors, such as smoking and eating habits, remains a limitation. Therefore, future studies need to investigate and account for the life patterns and drinking and smoking habits of the participants that could negatively affect the results. Further, it is believed that fear, triggered by clinical assessments, may have affected the result outcomes of the participants. While it is most desirable to measure changes in health conditions across the entire sample at five points during the study, including pre-, post-, and follow-up  tests, the study design used only three time points for assessment considering that the participants were adolescents, and because it is difficult to track down all the participants for five examinations. Therefore, the participants were divided into three groups for more efficient clinical assessment. After testing for the homogeneity of the participants, the results of all the participants were presented in pre-, post-, and follow-up tests, and the follow-up test results were sub-divided into those conducted one, two, and four weeks after the program. Data collection was attempted at the same time of the day, but voluntary participation made it difficult to control the exact time of assessment. It is considered that significant results were difficult to observe for indicators such as cortisol and those related to circadian rhythm, as difficulty in controlling the timing of sample collection and fear of testing are likely to affect biological results. In the case of saliva measurement, careful on-field examination is necessary because it was observed that there were too many missing values for analysis. On-site sampling of saliva is relatively easy and convenient, but researchers should be careful that analysis may be difficult. However, if the right measurement can be obtained at the site in the future, it will be beneficial to analyze the forest healing effects with relative ease. This study is significant, as it assessed the health indicators of the effects of the forest healing program at three time points rather than only conducting a short-term analysis through pre- and post-treatment comparisons, such as that seen in previous studies. However, the preliminary examination was conducted two weeks before the program, which may not have accurately measured indicators, the results of which change rapidly in a short period of time, such as cortisol. Therefore, subsequent studies in which pre- and post-measurements can be performed within one day of the program should be conducted to increase the accuracy of the results.In addition, this forest healing program included an indoor program; therefore, during the three-day and two-night program, the actual time spent in the forest was less than 10 h. However, based on the literature that shows that the short forest walking programs of 15–40 min had physical and psychological health promotion effects, the healing effect of the forest healing program conducted in this study is expected to be sufficient; nevertheless, increasing the proportion of forest activities in future forest healing programs is expected to have a more pronounced effect . Furthermore, as the program was conducted for healthy individuals, and not patients, most indicators showed changes within the normal range, making it difficult to observe the dramatic health promotion effect of forest healing. However, after the forest healing program, the number of outliers  was significantly reduced, and significant health promotion effects were observed in several indicators, including blood pressure. t-test showed that the significance levels were below 0.001, indicating significant changes. However, no clear evidence has been found that forest healing programs cause allergic reactions and increase inflammation levels, and it is necessary to proceed with the program in consideration of this in the future. It is expected that when conducting a forest healing program, a process of selecting the appropriate place, time, and type of program will be needed for each participant.Although forest healing had a positive impact on various health-related indicators, including the autonomic nervous system, it was also found that the nature of forest healing led to various allergic reactions in participants. Higher levels of inflammation were observed in several participants due to allergic sensitization reactions, suggesting that forest healing programs may have a negative effect on those with allergies as shown in Based on these limitations, future studies should attempt to build forest healing big data infrastructure and systems through sampling using non-invasive methods, investigating other influential factors affecting test results, and linking sensing and wearable technologies. This study is significant, as it involved a relatively large number of participants compared to small samples in the studies conducted previously, and also as it conducted a pilot study to quantify forest healing effects using various physiological indicators, such as urine and blood, as well as psychological indicators. Therefore, to establish an evidence-based forest healing program, time-series changes could be measured with varying frequency and duration, and the persistence and continuity as well as the frequency and cycle of forest healing effects could be investigated for indicators for which the effects have continued after the cessation of the forest healing program, or the appearance of effects has been relatively delayed.The study showed that the three-day and two-night forest healing program had a generally positive effect on the physiological and psychological health of the participants. Of the 87 health-related indicators, significant impacts were observed for 46 indicators, such as cardiovascular, immune function, and mental health. In this study, the effectiveness of forest healing was assessed from various perspectives by using non-universal clinical indicators. Furthermore, beyond the comparison of pre- and post-treatment, changes were observed one week, two weeks, and four weeks after the program. Therefore, this study provides a basis for selecting appropriate indicators when developing a long-term follow-up survey system in the future and is significant as a framework for evaluating forest healing effects and promoting related policies.


This study assessed the feasibility and effect of two mobile modes  in their delivery of updates and assignments to parents.Two three-armed, randomized, controlled feasibility studies were conducted. In each trial, four schools with a total of 418 students in grade 5th, mean age 10.1 years, were randomly allocated to the control arm, youth-only arm, or youth & parental component arm. Only the data of those that completed all three assessments  were analyzed: 133 in the first trial and 137 in the second.In the youth-only arm, students participated in an interactive age-tailored prevention program delivered in 10 weekly, 90-min sessions on self-care behaviors, media literacy, self-esteem, and positive body image. The control groups in both studies received three health- and nutrition-related sessions.In the parental arm, in addition to the ‘Favoring-Myself–Young’s ten sessions program, parents received updates and were requested to complete shared assignments with their children. In the first year, the assignments were sent via WhatsApp, and in the following year via “Favoring Myself” smartphone application.Facilitators were third year undergraduate students. They used a detailed semi-structured guide and received 4-weekly hours of didactic and group dynamic supervision. Mixed-methods assessments were performed using semi-structured interviews with ten parents and five school staff members each year, as well as a computerized self-report questionnaire.Feasibility of parent-adolescent shared assignments in both digital modes was lower than expected. The use of WhatsApp had higher feasibility and uptake than the use of the special application.The addition of the concurrent parental component via WhatsApp was associated with superior improvement in self-esteem and identification of advertisement strategies, compared with the youth-only program. However, adolescents in the youth-only program delivered via the smartphone application demonstrated superior improvement compared to those in the youth and parental component arm.Although the addition of the concurrent parenting component was praised by the actively participating parents, overall, under the chosen structure and population, it did not prove to add statistically significant value to the youth-only arm.NCT03216018 (12.7.2017) and NCT03540277 (26.4.2018). The school years are a period of the life-course where young people are progressively at increased risk for mental health problems and educational disengagement , 2. PrioAlthough parents acknowledge the importance of children’s physical and mental health as well as changing attitudes toward increased parent-school collaboration, few parental component implementation studies on adolescents’ prevention programs in general and positive body and self-esteem in particular, have been conducted. A systemic review of the parental component in prevention programs to promote well-being reported that most programs included a minimal or unassessed parental component . HoweverWhile involving parents appears productive in theory, it is quite different in practice. Parents’ own negative school experiences, as well as low socio-economic status and/or low technology literacy, are likely to cause an undesirable impact due to limited uptake and lesser readiness to cooperate with school. Thus, they are likely to contribute rather than mitigate health disparities –15. FurtTo address the notable disparities in access to evidence-based, cost-effective parenting interventions , and to In school-based programs, the headteacher and senior management team encourage parental involvement, but parent-teacher differences in values, beliefs and expectations about what should be done and what is helpful, and lack of mutual trust and understanding were cited as barriers to successful family-school partnership . MoreoveAs there is a lack of research on the best practices for parental engagement in shared assignments with their young-adolescents, the current feasibility studies assessed the effectiveness of implementing an evidence-based, school-based wellness program, with and without parental collaboration, through updates and shared tasks on adolescents’ self-esteem and body esteem.The study primarily aimed to assess the feasibility and acceptability of two mobile modes in terms of delivering updates and assignments to parents: WhatsApp vs. “Favoring Myself- Young,” a specially designed application. We hypothesized that using the program’s specially designed application to contact parents and deliver the shared assignments would produce better uptake and parental engagement than when delivered via WhatsApp. The second aim was to assess the impact of the additional parental component on adolescents’ perceptions and behaviors. The main hypothesis was that adding a parental element to extend adolescents’ exposure and engagement to the prevention program’s topics would result in superior self-esteem and body esteem, self-care, and media literacy.The two-year randomized clinical trial tested the feasibility, acceptability, and impact of “Favoring Myself-Young,” a manualized universal, interactive intervention program for young adolescents (5th graders) and their parents. Principals and school counselors of all fifteen elementary schools in northern Israel were contacted.The eligibility criteria for schools included: a) having at least two 5th grade classes; b) agreement to schedule the program lessons on Mondays and Thursdays, due to the availability of the students facilitating the research; c) commitment to provide an appropriate room for each of the groups; and d) commitment to the presence of a class teacher or school counselor during the sessions to ensure appropriate behavior. In both years, four schools (out of the 15 contacted) were eligible and actually participated in the study.Following the randomization protocol, eligible schools were randomly allocated by a research assistant blinded to their characteristics. Using the randomization function in Microsoft Excel, each year, schools were randomly assigned to one of the three study conditions: a) control condition, b) youth-only intervention, and c) youth with concurrent parental component condition. Schools were used as selection units to avoid contamination bias due to communication about the intervention between participants and controls within each school. Schools were blinded to condition allocation. Different schools were used for each year of the study. Differences in the baseline sample size in each arm were due to varying class sizes in each school.In the WhatsApp mode , 152 adolescents in the 5th grade were recruited for the program and 148 (97%) of them provided active consent of parents and students. However, 133 adolescents (89% of consenting participants) completed the three assessment questionnaires and were included in the final analysis. The participants’ flow is shown in the consort diagram , 266 adolescents in the 5th grade were recruited for the program, 212 (80%) provided active consent of parents and students, and 137 (65% of consenting participants) completed the three assessment questionnaires and were included in the final analysis. No differences were found in personal characteristics between those that completed all three questionnaires and those that did not. Each class was divided into two equal groups for program delivery, comprising an average of 15 participants per group. There were eight intervention groups and four control groups in the first year (6 classes divided into two groups each), and twelve intervention groups and six control groups in the second year (9 classes divided into two groups each). Research students from the project team met with parents and staff of each class to recruit schools at parent-teacher conferences. Schools were provided with study information and letters of active consent. The participants’ flowchart is shown in the consort diagram . The trial methods and analysis strategy were pre-registered. The universal trial registration numbers are NCT03216018 (12.7.2017) and NCT03540277 (26.4.2018). Parents of students at all eligible schools received information about the program and the research study and provided informed active consent. All methods were performed in accordance with the Declaration of Helsinki and Consort 2010 guidelines and regulations.The control groups in both studies received three health- and nutrition-related sessions conducted by graduate students of Nutritional Sciences. These are regular information lessons, though not usually included in the school curriculum.“Favoring Myself-Young” is an interactive program comprising 10 weekly, 90-min sessions on self-care behaviors, media literacy, self-esteem, and positive body image. It is an evidence-based intervention that was empirically supported and substantiated with research findings that demonstrate beneficial and predictable outcomes  , and follow-up (three months after program conclusion).Qualitative research aimed to better understand participants’ motives, incentives, and ideas about improving the program content, activities, or dissemination . PersonaStandardized instruments were used to measure program efficacy Table . The preThe Rosenberg Self Esteem Scale [strongly agree (3) to strongly disagree (0), while items 2, 5, 6, 8, and 9 are reverse scored. The total scores range from 0 to 30. Scores from 1 to 25 indicate a normal range; scores below 15 suggest low self-esteem, while scores above 25 indicate high self-esteem. Cronbach’s alphas in these studies were 0.79, 0.74, and 0.81 for the control, youth-only, and parental component groups, respectively.em Scale . The scaSelf-Caring Questionnaire. Developed by Prof. Moria Golan (the first author), this questionnaire includes 20 items on personal and sleep hygiene, mealtime behaviors, and personal space. Items are rated on a five-point scale from never (1) to always (5) and higher scores indicate higher self-care behaviors [N = 10) revealed a Pearson Correlation Coefficient of 0.69 for reliability and Cronbach’s alpha of 0.85 for internal validity. However, in the current studies Cronbach’s alpha was only 0.66.ehaviors . The queThe Body Esteem Scale was used to assess body perceptions. The scale consists of 23 items divided into three subscales: appearance, weight, and attribution. The mean total and subscale scores are rated on a five-point Likert scale from never (1) to always (5). Higher scores represent higher body esteem [y esteem . CronbacThe Eating Disorders Examination Questionnaire-8 adapted for children (ChEDE-Q-8) was used to assess eating disorder symptoms. The eight-item version of the original 28-item EDE-Q has excellent item characterization with high reliability. A strong correlation was found between the eight-item version and the original EDE-Q . For each statement, participants are asked to mark the frequency of occurrence in the past 28 days, and higher scores indicate a higher risk for eating disorders [isorders .The advertising scale contains one item to measure participants’ identification of media strategies—a known protective factor. It includes eight different strategies, from which participants are required to choose; identifying a higher number of strategies indicates better media literacy [literacy .The ‘Pressures by Media’ subscale of the Sociocultural Attitudes Towards Appearance Questionnaire-4 (SATAQ-4) was used to assess participants’ responses to media. Participants were instructed to rate their agreement with each item using a five-point Likert-type scale from definitely disagree (1) to definitely agree (5). A higher average score indicates higher pressures by the media to change one’s appearance [pearance .All measures were used in both studies for parents and students. The Cronbach’s alpha reliability scores ranged between 0.67–0.89.f = 0.25), 80% statistical power, and an α level of 0.05, which was relative to the improvement in the Rosenberg Self Esteem Scale [The sample size was calculated for a moderate expected effect , only those who completed the research questionnaire at two assessment times were included in the analysis. In the second trial , only those who completed the questionnaire at all three assessment times were included in the analysis, to prevent imputation bias. When data in this trial were analyzed with all participants who completed only two assessments, similar results were reached. The demographic variables between those who completed three questionnaires and those who completed less than three questionnaires were not statistically significant.Data were checked for normality using histograms, scenes, and the Kolmogorov-Smirnov test through the Box test and Levene test. Sphericity was assessed through the Mauchly test and the assumption of the equality of variance-covariance matrices. The outcome data for the first study (WhatsApp) were analyzed using multivariate analysis of variance models by calculating the deltas between measure points  and using Bonferroni post hoc analyses between study groups.In the specially designed application (second study), categorical demographic characteristics were presented as frequencies and percentages, and the association with study groups was tested using chi-square tests. Continuous demographic characteristics were presented as mean and standard deviation, and the differences between study groups were tested using the Kruskal-Wallis Test.2 for the mixed models, eta-squared for the Kruskal-Wallis Test, and Kendall’s W for the Friedman test.Most of the measures in this study  were not normally distributed and were therefore analyzed using non-parametric tests. Friedman tests were used to examine the differences between study times within each group, and Kruskal-Wallis tests were used to examine differences between the three study groups at each time point. Personal self-care hygiene and SATAQ-4 were tested using mixed model analysis. The effect size was marginal RFor the qualitative analysis, all semi-structured interviews were audio-recorded and transcribed. The interview included questions on participants’ understanding of the program aims, barriers and facilitators to engagement, satisfaction from the topics and activities, and acknowledgments of change among their children and themselves.The data were analyzed by identifying recurring key themes, which represented ways of understanding the combined meanings within the texts . We chosIn both studies, the mean age of all youth participants, both male and female, was 10.1 years SD = 0.3). Groups appeared to be well balanced regarding baseline demographic characteristics . “It is so hard to manage with four kids... the competing demands are my priority and not the suggested shared tasks…Moreover, my child is healthy; we don’t need it. Deliver it to parents with problematic children” (R.B.).Rule enforcement. School teachers perceived the engagement of parents as necessary but preferred not to confront parents who expressed silent resistance. “The contents and the activities are great and age appropriate. However, most parents choose not to cooperate, and I prefer to choose my battles. If a parent chose not to cooperate, I will not penetrate his territory. I have to respect his avoidance. Personally, I admit, I am not particularly eager to cooperate when my child’s school enrolls me in activities” (M.C.). “I did not choose this program, and it does not address my priorities in being involved in the schools’ activities.” (B.R.)Parental resistance to consent to participate in the research. Parents explained their resistance to participate due to privacy threat, fear of exposure, and law literacy regarding their and their children’s benefit from the research process. “Why should my child and I be like an experimental animal? If the program still needs research, I am not sure it is safe…” (A.R.). “I have heard from parents in the previous year that the research questionnaire is invasive. I will be honest with you; I don’t want you to wake sleeping dogs. Questions about how she feels about her body should be asked in a protective environment and not in primary school or on a research platform” (B.Y.).Preference of WhatsApp usage over unique applications due to technological barriers and privacy issues. “At the beginning, I was glad the assignments were delivered via a digital platform, but when I failed to download the application, I decided that if someone wants me to participate. I prefer if it is sent through mail” (L.A). “I am overwhelmed with all the applications on my mobile; I don’t want another one that increases the chance to hack my phone – too dangerous in our times.”High satisfaction was reported by parents and preadolescents who adhered to the shared assignments. “The topics in the program are vital for our children. The shared tasks were an excellent opportunity to talk with my child about how I handled age-related changes and how I react to stress” (B.C.). “These topics are so important, and to tell you the truth, in the classroom my child is too shy, and the shared assignment opened the door for him for intimate sharing and for me to get closer to him. Well done” (A.R).Conducted after program termination, these interviews shed light on parental and school team perceptions regarding addition of the parental component to the school-based wellness program. Five major themes emerged in the qualitative component of this study:Personal self-care hygiene was not affected by the trial condition in either digital mode. A statistically significant interaction of group X time was found  with a small effect size with superiority in the control group , there was a statistically significant group X time effect with superiority  in the concurrent parental component arm, along with all assessment times compared with the other two groups  on youths’ self-esteem in the parental component arm at post-intervention. This improvement diminished at the three-month follow-up , there was a statistically significant group effect with a small effect size , a statistically significant change in youths’ self-esteem was also found at the follow-up assessment. The improvement was larger in the control (moderate effect size) and youth-only arms , with no statistically significant change in the parental component arm Table .Table 7SIn the WhatsApp mode , there was no effect of trial conditions on either of the body-esteem subscales. In the specially designed application mode , there was a statistically significant effect of group on the body-esteem-appearance subscale, at program termination, with statistically significant superiority in the youth-only arm at post-intervention as well as at the follow-up assessment . In the weight subscale, there was no group or time effect. However, there was a statistically significant interaction of group X time with superiority in the control group at the follow-up assessment, with moderate effect size Table .Table 8SMedia literacy was assessed using the number of advertisement strategies identified and the perception of being influenced by media pressures to change one’s appearance.In the WhatsApp mode , the youth-only arm and the concurrent parental component arm demonstrated a statistically significant superiority and increase in identifying advertisement strategies over time compared with the control arm Fig.  with a l.2 = 6.44; p < 0.05), time , and time X group .In the specially designed application mode , there was no effect of trial conditions on the number of advertisement tactics identified by youth and on perceived pressure imposed by the media to change appearance (SATAQ-4). Nevertheless, when youth responses were divided into those under 1 (not affected by media) and above 1 (affected to a large extent), the analysis revealed a decrease of 29% in the control group among youth being affected (from 73.7% at baseline to 44.7 at follow-up). Moreover, a 31% reduction (from 64 to 33%) in the youth-only arm and a 14% reduction in the parental component arm (from 68% at baseline to 54% at follow-up) were found. Mixed model analysis revealed a statistically significant effect of group  integrated into “Favoring Myself-Young” a school-based interactive wellness program for 5th grade primary school students. The parental component includes weekly topic update letters to parents, with suggestions for dyad-shared assignments. A prior study has suggested this strategy to avoid parents from falling into the role of disciplinarians .The current study revealed that parents’ engagement in the shared assignments was short-term only and deteriorated during trial times. Participants’ attrition presents a significant problem for even the most well-planned and well-executed intervention projects with internal and external validity and facilitator motivation. For instance, Amaral et al. reported that 50% of intervention participants attended all four prevention program sessions and completed the posttest assessment . Morgan However, the retention rate was higher when the concurrent parental component was delivered by WhatsApp than by a specially designed application. The application was designed to create an intimate environment where parents could consult the specialist who developed the shared assignments, and ask personal questions related to the discussed topics, anonymously or openly. Moreover, this platform was intended to serve facilitators by sending memos and funny responses to generate continuity and engagement with the program topics. In contrast to our hypothesis and expectations, parents expressed resistance to downloading the specially designed application.Although parents believed in the program’s importance and shared the school’s interest in preventing risk behaviors, they did not perceive the program as being their choice or as reflecting their needs and interests. Although most parents  provided active consent, they easily withdrew their consent when it came to implementation.Barriers, such as technical difficulties, fear of exposure, concerns about privacy, and lower motivation to collaborate on shared assignments were explored retrospectively through qualitative interviews. Similar barriers were reported in studies that implemented parental components in school-based prevention programs . These bMorgan et al. (2020), who studied the long-term effect of a prevention program, reported that between baseline and 3-year follow-up, there was a non-significant reduction in adolescent cases of mental health problems relative to the control group (odds ratios (OR) 0.16–0.17), a non-significant improvement in parental support reported by adolescents with a mental health problem (OR 2.80–4.31), and a non-significant improvement in the quality of support that parents reported providing to their adolescents with a mental health problem (d = 0.38). The only maintained achievement included parents’ improved knowledge about mental health problems . Both MoFurther, it seems that WhatsApp was preferred by adults over the specially designed application. This may be attributed to the perceptions that WhatsApp is more intimate . MoreoveOverall, the study groups and the research stages showed a significant superiority in participant responsiveness to WhatsApp over the specially designed application. The concurrent parental component via WhatsApp was associated with statistically significant improvements in only two measures out of the seven outcome variables, and only one statistically significant improvement in the youth-only arm. Nevertheless, when it was delivered via the specially designed application mode a statistically significant improvement was found only in one out of the seven measures.The youth-only arm showed statistically significant improvements in three out of the seven outcome measures compared to four statistically significant improvements found in the control group, which received a shorter intervention but demonstrated higher attrition which may lead to higher false-positive outcomes in this group.The small effect size of most changes in this study may suggest that a larger sample size, more intensive exposure and new ways to create community-based participatory research are needed for future assessments..This study has several strengths. First, two active control groups were used; one youth-only group, without the parental component, and another with a shorter intervention to control expectancy effects. Second, the combination of quantitative and qualitative research methods deepens the understanding of the implementation of the parental component arm. Third, the repeated facilitation of the same prevention program and the continuity search for expansion of program exposure to students, is another strength.The current study has a few limitations. First, as mentioned before, attrition bias may increase false-positive outcome. Despite this, no effects on outcomes were found in comparing the analyses between participants who submitted the shared assignments and those who did not, as well as in the analyses between those who completed two vs. three questionnaires. Second, the findings of this study are based on self-reports, which could be subject to social desirability bias. Additionally, our results may not be representative of the preadolescent population, as this study was performed with a selective population in a small country. Thus, conclusions should be interpreted with caution. Nevertheless, the consistent non-significant effect of the experimental parental component on most measures supports the robustness of the findings, despite the limitations and the fact that the study findings contrasted with the research hypothesis.The use of the WhatsApp application had higher feasibility and uptake than the use of the specially designed application. Although parents and school team members expressed a positive stance toward shared assignments, poor uptake, dropout, and noncompliance may hinder the validity of our findings. Moreover, the relatively low rate of parental cooperation and the small effect sizes raise questions regarding the cost-effectiveness of adding a parental component to universal school-based prevention programs. Future studies should strive to overcome parental resistance as well as improve parent-school collaboration and. Moreover, a cost-benefit analysis of parenting programs is critical for scaling up prevention programs.


Neither the standard treatment nor the VE program led to improvement in standardized cognitive measures. Participants perceived both programs as enjoyable and beneficial. The refusal rate was higher in the VE program (8.6%) than in the standard treatment (0%). But in general, the VE program was well-accepted by the psychiatric patients and it required minimal involvement of the clinician due to automatic difficulty level adjustment and performance recording. However, the VE program did not prove to be effective in improving cognitive performance in the standardized measures.Standard approaches to cognitive remediation can suffer from limited skill transferability to patients’ life. Complex virtual environments (VEs) enable us to create ecologically valid remediation scenarios while preserving laboratory conditions. Nevertheless, the feasibility and efficacy of these programs in psychiatric patients are still unknown. Our aim was to compare the feasibility and efficacy of a novel rehabilitation program, designed in complex VEs, with standard paper–pencil treatment in patients with schizophrenia and major depressive disorder. We recruited 35 participants to complete a VE rehabilitation program and standard treatment in a crossover pilot study. Twenty-eight participants completed at least one program, 22 were diagnosed with schizophrenia and 6 with major depressive disorder. Participant’s performance in the representative VE training task significantly improved in terms of maximum achieved difficulty ( Schizophrenia and major depressive disorders (MDD) are neuropsychiatric conditions representing one of the leading contributing factors to the global burden of disease. Schizophrenia is a disabling and chronic condition, affecting about 1% of the population . Both coAntipsychotic medication is a standard and effective way to treat schizophrenia ,14,15 bun = 2401) conducted by Wykes et al. [Cognitive remediation (CR) represents systematic behavioral interventions focusing on generalizable and durable improvement of cognitive deficits . The ints et al. .The use of computerized systems seems very suitable for the drill practice approach applied in most clinical trials . ComputeStandard approaches to CR and neuropsychological assessment are sometimes criticized for being detached from everyday patients functioning and focusing only on the basic cognitive functions ,30. In cThis study compares the efficacy and feasibility of the VE program with standard paper-pencil treatment in a cross-over trial.To compare the effect of the VE program and standard treatment on cognitive outcome.To investigate the feasibility of the VE program.To evaluate the participants’ progress in the VE program.Goals:The study was approved by the ethics committee of the NIMH CZ Ethics Committee on the 22 March 2017 under the number 105/17. All participants signed an informed consent form containing information about the experimental procedure and exclusion criteria.n = 9), vocational school (n = 9), high school (n = 9) to university education (n = 1). The participants were recruited from the outpatients attending the Psychotherapeutic Day Center for psychotic patients in Karviná town. Participants were assessed by a psychiatrist according to ICD-11 standard symptoms  and mediDiagnosis of schizophrenia or other primary psychotic disorders or diagnosis of a depressive episode or recurrent depressive disorder according to ICD-11 .Age 18–60 yearsInclusion criteria:Severe visual impairmentNeurological disorder or comorbid psychiatric diagnosisPhysical handicap preventing the participant from participating in the VE programRefusal to give informed consentExclusion criteria:Before the beginning of the rehabilitation program, all participants completed a baseline cognitive assessment. Participants were then randomly assigned to the first rehabilitation program: VEs program or standard treatment. Equal randomization was not possible due to the insufficient number of laptops available for the VE program. After the first program completion, participants were retested with the cognitive battery and then assigned to the second program: standard treatment or VEs program. After completing the second program, the participants were once more assessed with a cognitive battery. In some cases, participants did not complete the program due to relaps-related hospitalization or due to the adverse epidemiological situation associated with the coronavirus disease, SARS-CoV-2.The virtual tasks were administered on 17.3” laptops. Participants interacted with the VEs using a keyboard and a mouse. Participants attended 12 computer sessions during 6–12 weeks. Each session lasted 30 min and consisted of a set of three VEs tasks. For the VE program, we adopted a drill–practice approach and progressively increased the tasks difficulty according to the participant’s performance. During the first session, participants were explained how to interact with the virtual environment and how to control specific tasks. During the following sessions, participants were instructed to train for approximately 5 min with the Shooting gallery and then continue for 10 min with Virtual Supermarket Shopping Task and 10 min with Objects.Shooting gallery is a variant of a standard go–nogo [ go–nogo  task in Objects is a task focusing on contextual episodic memory. Participants are asked to remember the identity, location, and sequence of objects which they collect from a virtual family house. Each trial has two phases: an acquisition phase—participants are guided towards a series of objects and tasked with remembering their order and position, and a recall phase—participants are asked to select the remembered objects from a collection of various items and then instructed to place them in their original positions and the original order.Virtual Supermarket Shopping Task (VSST) is focused primarily on memory abilities. It requires participants to remember and collect items from a shopping list in a virtual supermarket  attended a total of 12 paper–pencil sessions over a period of 6–12 weeks. Each session lasted 45 min. The session started with a warm-up game and then continued with a set of paper-pencil tasks focusing on attention, fine motor skills, recall, short-term and long-term memory, verbal fluency, visual search, cognitive flexibility, abstraction and executive functions, and numerical abilities. The tasks were adapted to each participant’s own abilities.The participants’ cognitive abilities were assessed before cognitive rehabilitation, after completing the first program, and after finishing the second program. This allowed us to precisely track their performance over long periods and evaluate the effect of each program individually.The RBANS test battery was previously standardized in schizophrenia patients  and it cAs the purpose of this study was not a clinical assessment, but a comparison of repeated performance, we have opted to use the raw scores and not the standard metrics in RBANS related analyses. We normalized the raw scores in each RBANS domain (sum of raw scores for the corresponding subtests) for each form separately. As our models control for potential score differences between different forms, we consider this approach in our scenario to be more statistically powerful. Please note, the index scores for individual RBANS domains  are presented in graphs and descriptive tables to provide representative RBANS data for clinicians.After the program, participants filled out a brief evaluation questionnaire. The questionnaire had 17 questions about participant’s enjoyment and perceived difficulty of the programs, their task preferences, willingness to participate in the program again, and their perception of achieved cognitive enhancement. The participants responded on a 5-point Likert scale .To assess the adherence to the VE program we looked at the random effects), from the investigated ones (fixed effects). The linear mixed effect models are also able to handle unequal group sizes and missing data [We chose to analyze the intervention effects on the RBANS normalized scores and the VSST improvement using the linear mixed-effects modeling approach . Linear ing data , which mp-values for the resulting models obtained using the package lmerTest [Statistical analyses were performed using R . Plots wlmerTest .From the initial number of 35 participants, seven did not finish any rehabilitation program, 28 completed at least one program and 17 completed the entire program  = −1.91, p = 0.062). Generally, the participants perceived both programs as enjoyable and beneficial.The questionnaire aimed to assess participants’ subjective perception of the program in terms of difficulty, enjoyment or subjective improvement. We found no significant differences between the standard treatment and the VE program in either category see . Needlest(156.74) = 4.04, p ≤ 0.001) (see Using linear mixed effect models we looked at how patients learned VSST as the cognitive training progressed. We defined maximum difficulty achieved as the highest difficulty level (number of items on the list) participants had reached during the session. We observed that participants were continuously able to improve and proceed to more difficult trials as the training progressed  see , althougt(1268.04) = −5.33, p ≤ 0.001) and trial times  = −9.29, p ≤ 0.001).As the trial trajectory and trial time are dependent on the participant’s performance as well as task difficulty (more items take longer to pick up), we modeled the trial time and trajectory with both session and trial difficulty as a predictor. We observed that participants improved in both of these measures as cognitive training progressed. With each new session we saw a decrease in trial trajectories  = −3.69, p ≤ 0.001), but the number of completed sessions had no effect  = 1.08, p = 0.281), suggesting that participants are not improving in their item collection precision. This lack of session effect could be explained by the relationship between item performance and the difficulty, which is also increasing across the sessions.One of the metrics we explored in our previous work and found to be indicative of cognitive performance  was the We have observed that patients suffering from schizophrenia scored lower in all RBANS domains and had significantly worse baseline performance than patients with MDDs in the language domain and RBANS total index score see . This wat(15.41) = −2.47, p = 0.026) with participant’s scoring marginally worse at the end of the study  than after the first interventions.Using linear mixed effect models we explored the effect of the intervention see  and the Although linear effects models are suited to control for individual differences and therefore participants’ diagnoses, it is possible that the participants with affective disorders could perform differently from those with schizophrenia. We modeled the cognitive performance in each RBANS standardized domain as a function of the diagnosis, session and their interaction as fixed effects and participant as a random effect. We have not found any significant interaction between the diagnosis and the session on any RBANS domain see .The primary aim of this study was to evaluate the efficacy and feasibility of a novel rehabilitation program using complex VEs for psychiatric patients. We administered the program to patients suffering from schizophrenia or MDD and compared it to standard treatment in a cross-over study. Our results show that the proposed VEs program could be, in terms of its feasibility, a suitable alternative to the standard paper-pencil approaches, which are sometimes criticized for low ecological validity  that canWe measured participants’ standard cognitive performance in the beginning and then after each program completion. The VE program did not differ from the standard treatment in terms of its cognitive outcome and we did not find any effect of either program on cognitive measures. Our results only indicate worse performance in the last assessment session in comparison with the second session in general . These findings are in contrast to the previous findings showing a positive impact of the VR program on cognitive functions in patients with schizophrenia when using immersive technology ,49,50.Although previous meta-analyses revealed significant improvement in different cognitive domains in schizophrenia after cognitive remediation ,25,26 thBoth treatments in this study used a drill–practice approach. A recent meta-analysis  emphasizFurthermore, it is possible that our sample was specific due to sociodemographic characteristics and prevalence of clinical symptoms  that can interfere with CR outcomes (for review see ). As we In this study, we focused on two main diagnostic categories—schizophrenia and other psychotic disorders and depressive disorders . Even thAnother explanation for not finding the expected beneficial effects of CR can be the low sensitivity of the RBANS battery to detect the improvement, which, especially in the memory domain, can be subtle ,24,55. ILast but not least, the significant effect of cognitive remediation reported by meta-analyses ,24,26 coThe VE program enables clinicians to automatically monitor and record participant’s performance and adjusts difficulty according to participant’s performance. This is a major advantage over the standard paper–pencil programs, where it would be time-consuming or even impossible to achieve. The data collected in the VE program allow for immediate or retroactive automated analysis and aim to achieve a more objective assessment of a patient’s day-to-day improvement or stagnation. This is not only beneficial to the clinician but can also provide useful feedback to the participant throughout the CR at no additional time cost.According to our results, the participants improved in VSST as the program progressed. We found a continuous improvement in the maximum achieved difficulty, meaning that participants were able to make fewer mistakes and memorize more shopping items in later sessions. Nevertheless, the participants did not improve in the item performance measure—a ratio of correctly picked items. This can be due to the fact that the VSST had an automatized increasing difficulty (increasing number of items on the shopping list) constantly challenging the participant and resulting in stable achievement in the item performance measure. Besides their recall performance, the participants were also able to solve the task faster and use shorter trajectories which shows increased efficiency with the task.We recruited a total of 35 participants, out of whom 28 completed at least one program and 17 finished both. Three participants out of 35 refused the VE program resulting in an 8.6% refusal rate, while no participants refused the standard treatment.This difference in refusal rate between the two training programs can be explained as follows. During the standard treatment, participant’s performance is not evaluated and no pressure is put on patients to actively participate in the training. Also, the standard treatment is administered in groups and offers more social interaction, it includes warm-up games or board games and is generally more relaxed. This could explain why some participants rejected the VE program that, in contrast, was administered individually and required the participants to actively contribute.In our sample, two participants refused the VE program after a short demonstration and claimed they did not like it, and one participant was not willing to participate because of the fear of failure. Interestingly, only participants with schizophrenia refused to attend the VE program, so the reluctance could be related to schizophrenia’s negative symptomatology, e.g., abulia and apathy ,62.t(48.38) = −1.91, p = 0.062). So, participants who completed the VE program did not dislike it, nor refused to participate again in the future. In general, participants rated both programs as enjoyable and beneficial.According to the feedback questionnaire, participants who attended the programs perceived them similarly in terms of benefit, difficulty, enjoyment and perceived cognitive enhancement. The only difference we have found was a trend towards higher willingness to repeat the standard treatment  did not allow for full randomization, and an adverse epidemiological situation led to a significant drop-out rate. The second limitation is with the RBANS battery and its forms. Although the RBANS forms are comparable in terms of difficulty ,64, our Thirdly participants filled in the feedback questionnaire after completing the entire study, which might have affected their ability to differentiate between the two programs.Moreover, the functional outcome of patients was not evaluated. In future studies, it would be beneficial to measure the quality of life or everyday functioning throughout the program, as it was proposed that complex VEs can improve the transfer of the learned abilities to real-life .The results of this study indicate that neither the standard cognitive remediation or the proposed VE program resulted in improvement in standard cognitive measures.Nevertheless, we suggest that the proposed VE program could present a suitable alternative to the standard remediation program in patients with schizophrenia and MDD in terms of its feasibility. In comparison to the standard treatment, the VE program allows easier administration with minimal effort from the clinician or therapist and automatically records the patient’s performance. This feature allowed us to evaluate the participants’ performance in the trained virtual task that improved in the course of training in terms of maximum achieved difficulty and general efficiency.Considering the adherence towards treatment, participants perceived both programs as beneficial and enjoyable but clinicians should take into account that the patients with schizophrenia can be more prone to drop out from the treatment when facing higher cognitive demands or to be more reluctant to participate in an unfamiliar treatment.


The scaling up of public health interventions has received greater attention in recent years; however, there remains paucity of systematic investigations of the scaling up processes. We aim to investigate the overall process, actors and contexts of polio immunization scaling up in Indonesia from 1988 until 2018.A mixed method study with sequential explanatory design was conducted. We carried out a quantitative survey of 323 actors involved in the polio program at national and sub-national levels, followed by Key Informant Interviews (KII)s. Document review was also carried out to construct a timeline of the polio eradication program with milestones. We carried out descriptive statistical analysis of quantitative data and thematic analysis of qualitative data.Posyandu) were key to the polio immunization implementation strategy. Challenges for scaling up during this centralized period included cold chain infrastructure and limited experience in carrying out mass campaigns. Scaling up during the decentralized era was slower due to expansion in the number of provinces and districts. Moreover, there were challenges such as the negative perception of immunization side-effects, staff turnover, and the unsmooth transition of centralization towards decentralization.The scaling up of polio immunization in Indonesia started as a vertical expansion approach led by the Ministry of Health within a centralized health system. The coverage of immunization increased dramatically from 5% in the earlier 80s to 67.5% in 1987; incremental increases followed until achieving Universal Child Immunization (UCI) in 1990 and subsequently 95% coverage in 1995. Engagement of stakeholders and funding made the scaling up of polio immunization a priority. There was also substantial multisector involvement, including institutions and communities. Local area monitoring (LAM) and integrated health posts  played an important role, yet its revitalization after the reform-decentralization era has not been optimum.Vertical scaling up of polio immunization program intervention was successful during the centralized era, with involvement of the president as a role model and the engine of multi sector actors.  Research interventions are often carried out on a small scale or within a particular context due to time and resource limitations. The results of small study projects are thus often difficult to apply in a complex health system; however, expansion efforts could potentially be executed effectively on a large scale . The pro“deliberate efforts to increase the impact of successfully tested health innovations so as to benefit more people and to foster policy and program development on a lasting basis” , the condition change, we [government] were sued and the health workers were afraid to do immunization, asking for guarantee of legal protection.” .To achieve milestone on scaling up polio program in decentralization era, the program focused more widely than just increasing polio immunization coverage through NIDs and SIA. Robust surveillance systems and lab containment were carried out to strengthen this program. Since 2002, additional staff were assigned as surveillance officers. AFP surveillance was extended to environmental surveillance in 2011. Moreover, there has also been new vaccine technology, such as the developments of non-porcine vaccine and vaccine combination. Additionally, legal protection in national immunization guidelines appeared to protect health workers from adverse events following immunization.“Then the world heard that we had LAM, and then we were invited for the presentation in 92, on how we could reach UCI by using local area monitoring tools assisted by UNICEF” .LAM is a monitoring tool to analyze immunization coverage based on target, time, and area . This toPosyandu, , is comprised of basic health activities from and for the community [Puskesmas. This activity first started by focusing on maternal and child health and family/community nutrition. In 1983, an immunization program was added.“Polio eradication will not succeed without strong immunization organization, and at the same period it was a period of public health development era through Posyandu … The aspect of community is very high” .ommunity . The serThe process of expanding the polio eradication effort in Indonesia was suitable to achieve the outcome of OPV immunization coverage status and AFP surveillance rates. Despite these indicators, other scaling up outcomes, such as cost-benefit and coverage on health system outcomes and provider outcomes, were not reported. Scaling up initiatives in other contexts usually reported patient/provider outcomes, occurred in LMICs, and were focused on infectious diseases . FurtherFindings presented in this manuscript are subject to a limitation of the used of OPV coverage only, while since 2016 polio immunization program in Indonesia rely on both OPV and IPV vaccination. Participant recruitment is also limited. There might be potential candidates who might not be interviewed due to geographical and time constrains. We also found difficulties in finding elderly participants who were involved at the beginning of program. Grey literatures data collection, especially government data and reports on the beginning of polio eradication initiatives, was also limited due to poor archiving of documents.There were two models of scaling up in the Indonesia polio immunization program, i.e., vertical scaling up in the centralization era and scaling up in the decentralized health system. Vertical scaling up emerged before polio eradication became a national priority, and became more intense in 1995. It began with advocacy for adopting the innovation within the national program . Non verIn Indonesia, early multi-sector commitment was gained through economic approaches. As mentioned by our key informant, the economic burden of vaccine-preventable diseases made multi-sector national stakeholders consider the importance of polio immunization for prevention. Although a previous study showed that centralization cannot be the only approach to stimulate community engagement, Indonesia’s previous health system demonstrated that centralization promoted Indonesia’s polio immunization program and multisector coordination with presidential support and approval .Puskesmas was assumed to have the same effect for provincial and district stakeholders. The National Statistical Bureau data shows that 9 new provinces and 233 new districts were formed after decentralization, with massive expansion of an additional 144 local governments between 2000 and 2006 [Posyandu to be able to contribute more significantly, similar to the period before decentralization.In the decentralization era, the scaling up strategy by emphasizing polio immunization through and 2006 , 27. Locand 2006 . Health Although decentralization has been promoted to accelerate the service of delivery, case studies of the polio immunization program in Indonesia show success during the era of centralization. In the era of decentralization there were health system problems such as high staff turnover, budget limitations/ reduction, and lack of resources. Previous studies mention that the better health outcomes in the decentralization era will also be followed by higher expenditures , 30.Furthermore, good program structure and program management will not be enough to ensure the program runs well. The previous success of the program occurred because of the commitment of MoH as the leading actors and the involvement of multisector organizations so it could reach the community. This commitment is based on good coordination and communication, as well as great leadership. Actors at sub-national  level conveyed good leadership from polio eradication stakeholders at the beginning of the implementation of this program, especially at early NIDs. Trust in employees, intense communication and flexibility to carry out programs make stakeholders and program managers at the sub-national level feel comfortable. Good communication within polio immunization program actors enables the activity to run well. Communication can increase the awareness of the involvement of stakeholders and communities. High awareness in the community will produce high participation as well.At the beginning of the implementation of NIDs in Indonesia, many people assumed that it was a special campaign that needed a lot of resources. However, through NIDs, the community feels affiliated to the program and wants to regularly participate in polio activities. Unfortunately, at the same time, this also raises public perceptions that activities are difficult to put on or uphold without money. Strengthening previous findings, a global initiatives when combined with community movements can be an expression of local needs and politics, rather than the facilitation of information in support of predetermined goals . Social Posyandu played an important role, yet its revitalization after the reform-decentralization era has not been optimum. The polio immunization program must be owned by local stakeholders and decision makers.Vertical scaling up polio immunization program in Indonesia works fine during the earlier stage, yet requires linkages among system levels so that a program with a specific focus can be delivered. MoH’s decision to involve the president was critical since it promoted participation of non-health sector actors in the program.


Narrative Medicine may mitigate physician burnout by increasing empathy and self-compassion, and by encouraging physicians to deeply connect with patient stories/experiences. However, Narrative Medicine has been difficult to implement on hectic inpatient teaching services that are often the most emotionally taxing for residents.To evaluate programmatic and learner outcomes of a novel narrative medicine curriculum implementation during inpatient medicine rotations for medical residents. Programmatic outcomes included implementation lessons. Learner outcomes included preliminary understanding of impact on feelings of burnout. Additionally, we developed a generalizable narrative medicine framework for program implementation across institutions.We developed and implemented a monthly 45-min Narrative Medicine workshop on Stanford’s busiest and emotionally-demanding inpatient rotation . Using the Physician Wellbeing Inventory , we anonymously assessed resident burnout during pre-implementation control year , and implementation year . We interviewed program directors and facilitators regarding curriculum implementation challenges/facilitators.n = 16; mean PBWI = 3.0, SD: 1.1) and increased by the final week . During implementation year, resident burnout was initially similar  but did not rise as much by rotation end . Implementation was underpowered to detect small effect sizes. Based on our our experience and literature review, we propose an educational competency framework potentially helpful to facilitate inpatient narrative medicine workshops, as a blueprint for other institutions.Residents highly rated the narrative medicine curriculum, and the residency program renewed the course for 3 additional years. We identified success factors for programmatic success including time neutrality, control of session, learning climate, building trust, staff partnership, and facilitators training. During control year, resident burnout was initially high (Inpatient Narrative Medicine is feasible to implement during a challenging inpatient rotation and may have important short-term effects in mitigating burnout rise, with more study needed. We share teaching tools and propose a competency framework which may be useful to support development of inpatient narrative medicine curricula across institutions.The online version contains supplementary material available at 10.1186/s12909-021-02935-x. Narrative medicine has been shown to mitigate physician burnout – emotional exhaustion, depersonalization, feelings of reduced accomplishments – by increasing personal resiliency , 2 In naNarrative medicine workshops have been difficult to implement on hectic inpatient teaching services, especially during time-intensive and emotionally demanding services, when, arguably, they are most needed –9. At ouIn 2018–2019, we implemented and evaluated a narrative medicine workshop during inpatient oncology, and assessed program and learner outcomes. We assessed the short-term effects on resident burnout, in comparison to historical controls. We share lessons learned in developing and implementing this program, identify core and advanced educator competencies, and share teaching tools including examples of systems-based and individual session challenges and approaches.This project was considered exempt by the Stanford Institutional Review Board (protocol #41690).This project was supported with funding from the Stanford Teaching and Mentoring Academy (grant #1175550–156-AABKS).Stanford medicine residents participate in the inpatient oncology rotation (Med-X) during their internship, and once during their 2nd or 3rd year. Med-X (“Med Ten”) is a four-week rotation, with average census of fifteen patients. Teams include an oncology attending, 2 residents, 2 interns and 0–3 medical students. All team members except attendings participated in workshops.Time neutrality: We worked with program leadership and substituted this workshop for a noon research conference during the last week of the Med-X rotation.Control of session: For residents to reflect, empathize, share and write, they needed protected time. We partnered with the Med-X charge nurses and unit secretaries to hold all non-essential pages.Learning Climate: To set an inviting tone, we used a comfortable private space at the cancer center’s outdoor garden proximal to the inpatient floor. Lunch was provided. Facilitators started with several quiet, meditative minutes to help residents transition from patient care. Personal/team respect and privacy were emphasized during each session.Anonymity: Participants were informed that sharing their writing was voluntary, and that no anecdotes or narratives would be shared outside the group without their permission.Adaptability: Facilitators were flexible about start times to allow for rounding or urgent clinical care.For the past 7 years, we have been conducting monthly 1.5 to 2-h narrative medicine workshops at Stanford Hospital and Palo Alto Veterans Administration Hospital during outpatient educational half-days. Residents participate three times per year as interns, and 3–6 times per year as senior residents. Residents read clinically themed prose/poetry, discussed their experiences, responded to a writing prompt for 30 min, then optionally shared their work during discussion. Three faculty alternate as facilitators. One facilitator has post-graduate training in Narrative Medicine and trained the other two faculty facilitators. The outpatient workshop has been renewed yearly, based on high resident ratings. We customized this outpatient workshop for the inpatient setting, with curriculum design following Kern’s Model  and key In July 2018, we launched the inpatient oncology narrative medicine workshop. Facilitators reviewed Narrative Medicine theory, and participants read two thematically-relevant pieces (prose or poetry) regarding the clinical oncology experience of patients and providers. Residents then wrote a narrative for 10–20 min about an experience on their current rotation. We chose more prescriptive content and prompts than typical narrative medicine workshops to directly engage team members about their current experience. Residents were encouraged, but not required, to share their work aloud, and collectively discuss their experiences, motivations, feelings and viewpoints. If residents elected not to share, faculty facilitated discussions about the writing process or general resident experiences. Residents were encouraged to continue their pieces independently after the workshop with ongoing editing and support from facilitators.During Academic Year (AY) 2017–2018  and AY2018–2019 (implementation year), we surveyed residents regarding their well-being on the initial and final weeks of the oncology rotation using the Physician Well-Being Index (PWBI), with anonymous linked identifiers. During implementation year, only 5 medical students participated joined the rotation and were not included in this analysis. The PWBI asks seven yes/no questions assessing multiple well-being domains   The Med-Since we guaranteed participant anonymity, we conducted semi-structured interviews with workshop facilitators and the Med X program director for 30–60 min with a qualitative researcher (MS) and with two internal medicine program directors via email. Facilitators answered prompts regarding development/implementation challenges, differences between inpatient/outpatient workshops, and lessons learned. Facilitators were encouraged to share specifics of what they observed or what others had shared during the process of implementation. Program directors answered prompts regarding program response to burnout, including viewpoints about narrative medicine. The interviewer took notes using the respondent’s own words and used a grounded theory approach to identify relevant themes regarding inpatient narrative medicine/implementation. The interviewer then met with facilitators to re-explore themes, identify critical challenges and success factors, including facilitator competencies needed to successfully conduct narrative medicine workshops.Over AY2018–2019, 36 medical residents completed 12 monthly inpatient oncology narrative medicine workshops, including 16 senior residents and 20 junior residents/interns. In all but one workshop, participants voluntarily shared their written narratives during discussion. Typically, two or all three residents shared their narrative work. Residents wrote about viewpoints about mortality, patient experiences of illness and death, challenging situations, and points of conflict. Two pieces are shared with permission . Significance: Initially, program leadership was skeptical that that a narrative medicine workshop could be conducted during a clinically overwhelming rotation, as writing requires some mental room to think and reflect. However, the 7-year outpatient narrative medicine curriculum built sufficient trust with program leadership to allow a trial year.Med-X floor staff partnership:“They became our champions.” (facilitator) Protecting resident’s time was paramount to successful implementation, and critical patient care issues arise frequently during the oncology rotation. Significance: A unit secretary became an internal champion, developed a strategy to triage clinical requests, hold pages, and proactively have questions addressed before the workshop began.Team leadership:“Sounds like a hard month” . Each month, a single team would come together for the workshop. Significance: Intern degree of participation and openness was largely dependent upon senior residents’ role modeling sharing behaviors.Uncovering team dynamics:“You could tell what was happening in the team, based on what they shared.” (facilitator). Significance: Teams were in various stages of burnout. Team dynamics, including support by senior resident and attending, were evident to the facilitators. Facilitators noted that these workshops could be “a canary in a cage” to help teams identify and mitigate burnout, including working with program leadership on systems changes to promote wellness.Inpatient vs outpatient narrative medicine:“This was very different than outpatient workshops … the team aspect made a difference” (facilitator). Significance: Outpatient narrative medicine workshops would bring together residents/medical students with different experiences on various rotations. The inpatient workshop was team-focused, allowing residents to share common experiences, thus deepening the nature of the discussion of personal narratives. Writing about and sharing a common experience allowed residents to additionally debrief in a way that is unique to an inpatient curriculum with an active team. This was not initially anticipated when the curriculum was created, but became a clear additional benefit to the residents.Team release valve:“This gives team members an opportunity to reflect together, and share what was hard.” (facilitator). Significance: Teams used the workshop to talk to each other personally and to process what they were experiencing – which they rarely could do during the daily press of work. Many specifically expressed gratitude for sharing their emotions/ experiences, and for ensuing peer-to-peer mentorship. Facilitators observed that some residents with “scientific mindsets,” previously skeptical of narrative medicine, seemed more receptive on their oncology rotation.Value of trained facilitators:“You need to be ready for any emotion, and to guide participants” (facilitator). More so than other rotations, inpatient oncology involves daily decisions about life, death, and sharing critical news. Significance: Facilitators discussed the need for training in moderating emotionally charged discussions, including creating a safe space for residents, holding space for strong emotions, and bringing the group to a thoughtful close after personal/emotional narratives were shared. When strong emotions or serious issues arose during the workshops, facilitators respected participant confidentiality, followed up with them personally, and provided access to residency resources for additional mental health support.Important wellness tool, amongst others: “It’s time versus intensity. And, personal resiliency is important, but so is system support.” (program director). Significance: Program directors discussed infrastructural challenges with emotionally taxing rotations, the critical role of the inpatient attending in minding the emotional health of their teams, shared other Stanford wellness resources, and considered how to implement other personal resiliency-oriented and systems-level interventions to support resident wellness while still meeting ACGME educational demands. Figure Based on positive resident feedback, the residency program has continued to renew the oncology narrative medicine workshop series for an additional 3 years. In addition to the initial developmental principles, stakeholder interviews revealed additional themes relevant to program success:n = 16) to end  of the rotation. During narrative medicine year AY2018–2019, resident wellbeing was decreased slightly less by 6% from initial weeks  to final week . Each year, 5 residents completed both pre- and post-surveys  and advanced, non-core/non-essential competencies (literary critique and writing feedback) for facilitators to conduct narrative medicine workshops Fig. . We expaWe successfully implemented a narrative medicine workshop during an intensive inpatient oncology rotation for medical residents that may mitigate short-term burnout. Implementation success hinged on program support from residency leadership, nursing, unit secretaries, and trained facilitators. During workshops, residents had the opportunity to process their emotions and to come together as a team.This educational intervention, while brief, adds to current understanding about feasibility of conducting reflective exercises during busy inpatient rotations by giving a clear roadmap and explanation of the elements of the program that made it successful. This program and study have several limitations. Burnout is a complex phenomenon with interplay between system factors and personal resilience . From a Even during the busiest and most emotionally challenging rotations, taking time to reflect and process can be a valuable experience , 19, 20.Additional file 1.Additional file 2.Additional file 3.Additional file 4.


OBJECTIVES/GOALS: Innovations with positive health impact are a high priority for NCATS and CTSAs. Program design that uses the Causal Pathway approach incorporates performance indicators that assess impact. We applied Causal Pathway thinking to an ongoing national program to enhance the evaluation of program impact. We report Lessons Learned. METHODS/STUDY POPULATION: We conducted a day-long onsite workshop to introduce the model to the project team, build capacity, and map the existing program elements to Logic Models representing program Specific Aims. A local Causal Pathway (CP) champion was identified. Alignment of the Logic Models with the CP approach (input→activities→ outputs→effects/impact) developed iteratively through biweekly, then monthly conferral among stakeholders. Key tasks included distinguishing among activities, outputs, and effects (impacts), and identification of performance indicators for each stage of the Causal Pathway. Visualization tools and an additional late stage half-day workshop were used to foster consensus. Implementation of the CP model tested the feasibility of collecting specific indicators and prompted model revisions. RESULTS/ANTICIPATED RESULTS: Program leadership and team members (n = 30) participated in the kick-off workshop. Four Specific Aims were mapped to Logic Models. Multiple Causal Pathway (CP) diagrams, one for each project in the program, were developed and mapped to Aims. Alignment of CP threads to Aims and identification of performance indicators required iteration. CP threads converged onto common final Impacts, sometimes crossing to another Aim. Performance indicators for operations were readily accessible to team members, and less so for impacts. Assumptions about program effects were subjected to specific indicators. Over time, Leadership noticed more expression of CP thinking in daily activities. New projects developed during this period incorporated the CP approach. Teams were able to streamline and simplify Logic/CP models. DISCUSSION/SIGNIFICANCE OF IMPACT: Through capacity-building and mentored exercises, an innovation team was able to infuse CP thinking into the evaluation of their ongoing program. The CP approach to design and evaluation maps progress and indicators across the life of a program from initial activities to its ultimate impact.


The STAR-VA program was an initiative out of what is now called the VA Office of Mental Health and Suicide Prevention, partnering with the national Offices of Geriatrics and Extended Care and Nursing Services. Ongoing collaboration with these national, as well as regional and medical-center-level leaders, has been critical for informing program implementation and dissemination strategies. We will discuss several key partnered strategies, including (1) linking STAR-VA to national CLC systematic quality improvement efforts; (2) engaging national inter-office program leaders in decisions about outreach to and inclusion of facilities in STAR-VA training and implementation; (3) training local STAR-VA champions on strategies for engaging local leadership support; (4) briefing leaders across the system with program updates; and (5) using national VA data to inform STAR-VA sustained implementation. Discussion will address challenges and opportunities for engaging leadership stakeholders in facilitating sustained implementation of evidence-based programs.