Background: Internalizing problems are the most prevalent mental health problems in adolescents. Transdiagnostic programs are promising manners to treat multiple problems within the same protocol, however, there is limited research regarding the efficacy of such programs delivered as universal prevention programs in school settings. Therefore, the present study aims to investigate the efficacy of a video-based transdiagnostic rational emotive behavioral therapy (REBT) universal prevention program, for internalizing problems. The second objective of the present paper will be to investigate the subsequent mechanisms of change, namely maladaptive cognitions. Methods: A two-arm parallel randomized controlled trial will be conducted, with two groups: a video-based transdiagnostic REBT universal prevention program and a wait list control. Power analysis indicated that the study will involve 338 participants. Adolescents with ages between 12 and 17 years old, from several middle schools and high schools, will be invited to participate. Assessments will be conducted at four time points: baseline (T 1 ), post-
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It is important to differentiate between selective or universal prevention programs at the beginning of program development so that the target population may be defined. One advantage of selective prevention is that it is more cost-efficient than universal prevention because it is only applied to a specific risk group instead of the general population. Second, adolescents who are currently experiencing problems may have higher motivation to take part in such a program (Jaycox et al, 1994). Moreover, it is expected that the effect sizes for a universal prevention program would not be as high as those for selective programs. This expectancy arises from the consideration that fewer adolescents in the general population have high depression scores and the average level of depression is lower than in at-risk adolescent populations. Thus, the evaluation of a universal prevention program requires a much larger sample than is necessary for a
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Universal prevention (Mrazek & Haggerty, 1994) approaches involve people who may develop a condi- tion in the future but not identiﬁably at risk currently. There has been hardly any evaluation of universal approaches to preventing depression in adulthood be- cause of cost and the very large study sizes needed (Munoz et al. 2012) although small effects in large populations can have greater societal impact (Glasgow et al. 1999). Furthermore, this has not de- terred child researchers from using this approach to randomize schools and classrooms and showing pre- vention of depression, albeit mainly in children at increased depression risk (Calear & Christensen, 2010). Particular opportunities for prevention action could exist when people face challenging life transitions that offer frequent contact with experienced health pro- fessionals. For example during pregnancy and after child birth, there is both increased actual or perceived risk and normal access to non-stigmatizing care. Stigma and the social context of childbirth mitigate against active disclosure of emotional distress (Slade et al. 2010). Encouraging evidence that a psychologi- cally focused reorganization of care, could be accept- able, feasible and effective comes from a cluster RCT of health visitor training for postnatal depression (Morrell et al. 2009). In women who at 6–8 weeks fol- lowing childbirth were termed ‘at low risk’ of depres- sion, based on a negative test on the Edinburgh Postnatal Depression Scale (EPDS; Cox & Holden, 1994), risk of depression was reduced from 11% to 8% at 6 months postnatally if their health visitor had been trained to offer additional psychological support (Brugha et al. 2011). Furthermore, the development of symptoms of depression was experimentally shown to be less likely where the health visitor had also evaluated and discussed 6–8 weeks after childbirth with the ‘at low risk’ mother her risk of depression (Brugha et al. 2011), although not providing therapy
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anxiety and depression over any given period, it has been estimated that over 30,000 participants are needed to adequately power a prevention program evaluation study . Measuring symptom reduction rather than cases can reduce this figure but still almost 1000 would be required to demonstrate a statistically significant differ- ence between conditions . However to justify invest- ment in a trial of this size, preliminary evidence, obtained in a feasibility study, is required. The aims of this study were to: (a) examine the feasibility and acceptability of using an ACT-based prevention program that targets anxiety and depressive symptoms in a non-clinical sam- ple of adolescents; and (b) to compare the impact of the ACT-based program on wellbeing and symptoms of depression and anxiety. It was expected that there would be a trend for the ACT participants to demonstrate improvements on a range of measures compared to par- ticipants in the control condition. Given the underpow- ered nature of feasibility studies, this trial sought to use effect sizes as an indication of feasibility and to provide evidence to determine whether a large-scale prevention study of this intervention would be appropriate.
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However, comparing the outcomes of single evalua- tions is difficult, among others since they were performed in different countries [18,19]. Furthermore, not all eva- luations included all relevant effects of the interventions. Comparability is importantly increased when all interven- tions are evaluated with the same model in the same set- ting. Therefore, in this paper, we translated evidence for all interventions to a single setting (that of the Dutch healthcare system) and evaluated them using the same model. This model was developed to capture all relevant health effects of the types of prevention that were evalu- ated, that is, not only effects on cardiovascular diseases, but also those on other chronic diseases that show increased risks for the risk factors targeted by the preven- tive interventions. Furthermore, effects of prevention on delaying mortality leading to diseases and costs of care in life years gained were also taken into account [20,21]. This improved the comparability of the outcomes and allowed to analyze the full trade-off between different tar- get groups for prevention.
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The PAX Good Behavior Game (PAX GBG) is a classroom-based universal preventive intervention that appears on the Substance Abuse and Mental Health Services Administration’s National Registry of Evidence-based Programs and Practices (NREPP, 2016). PAX GBG also appears in the 2009 Institute of Medicine Report on Mental, Emotional and Behavioral Disorders as one of the most effective prevention programs available (IOM, 2009). PAX GBG originated as the Good Behavior Game out of the University of Kansas in the late 1960s as a way to decrease problematic, off-task behaviors in a 4 th grade classroom. In this first iteration of the intervention, “behaving” was turned into a team competition within the classroom with rewards for the team that was able to accomplish the activity without misbehavior. The result was a classroom with dramatically reduced problematic behaviors. This led to increased student productivity and sense of safety as well as decreased teacher stress. Most importantly, it laid the groundwork for a protective intervention in which the children themselves made the changes that promoted their success (Barrish, Saunders, & Wolf, 1969).
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Psychological interventions focusing on inter- personal issues during pregnancy have also shown some promise (Spinelli & Endicott, 2003 ; Zlotnick et al. 2006). This result contrasts with two previous in- eﬀective prevention trials conducted in the same population by the present authors (T.S.B., C.J.M.) that employed external (research) therapists (Brugha et al. 2000 ; Morrell et al. 2000). Thus, individually delivered psychosocial interventions by professionals may be more eﬀective postnatally (Dennis, 2005) when in- tegrated into routine visits. For example, one other randomized trial of enhanced and personalized mid- wife-managed care in the early postnatal period also reported better EPDS outcomes at 7 weeks postnatally (Shields et al. 1997). The similarity of both sets of re- search ﬁndings runs counter to the suggestion that our result is a chance, fortuitous ﬁnding.
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This paper proposes that prevention for NEDs can be delivered via the Internet, in conjunction with an exist- ing universal prevention program for ecstasy, known as the Climate Schools: Ecstasy Module. Given the over- laps in the age of onset, risk factors and potential harms associated with both ecstasy and NED use  , it makes particular sense to deliver prevention for NEDs and ecstasy simultaneously. Furthermore, synthetic cathinones, stimulant-type NEDs, are produced to imitate the psychoactive effects of ecstasy and are also typi- cally sold in pill form   , implying that prevention messages for ecstasy and NEDs are likely to be similar and can be delivered in unison. In addition, there are clear recommendations that education for NEDs should be delivered alongside education for traditional drugs   and it is also practical and efficient for teachers to deliver education for these drugs together, as lesson time dedicated to drug education is often limited. These advantages of simultaneous delivery, coupled with the fact that there are no existing evidence-based pro- grams for NEDs, positions the Climate Schools: Ecstasy Module as an ideal basis upon which to incorporate education about NEDs. The below section describes the methods of developing the integrated Climate Schools: Ecstasy and Emerging Drugs Module.
rather than universal prevention programs . Sec- ondly, although the Climate Schools program had signifi- cant effects on reducing alcohol and cannabis use, the effect sizes were modest (<0.38) , as is expected with universal programs [12,16]. In addition, analyses of the efficacy of Climate Schools in high-risk students only (i.e., youth already using substances or youth with sub- stance using peers), found the effects to be smaller than those high-risk students experience as a result of partici- pating in ‘selective’ interventions [36,37]. This could be attributed to the fact that most universal preventive interventions address substance use through a social in- fluence perspective and do not take into account the many other risk factors involved in developing substance use disorders such as underlying vulnerabilities due to individual and genetic factors . This suggests that high-risk students may benefit from additional ‘selective’ prevention which is specifically tailored to their needs and risk factors. Selective programs offer the benefit of being able to focus on the role of other risk factors for substance use such as psychopathology and personality. Such programs have often been overlooked due to their practical limitations as not only is it difficult to ini- tially identify those individuals at greatest risk, but finding suitable, cost-effective ways to screen and deliver interventions can also be challenging . The selective personality-targeted Preventure program overcomes these obstacles.
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to reductions in symptoms rather than clinical diagnosis. The combination of self-report symptoms together with the fact participants were not blinded to the type of inter- vention they received, may have introduced some bias via the Hawthorn effect. An additional problem with the mea- sures used in many of the studies included in this review is that they combined both depression and anxiety symp- toms. Our sensitivity analysis demonstrated that the bene- ficial effects of universal prevention remained even when only studies with pure depressive symptoms measures were included, suggesting there is a true impact on de- pression. Whether there is an additional and potentially even greater impact on anxiety symptoms remains un- clear. Fourth, as workplace interventions are not often reported or published in academic material, there may be some publication bias in this area of research with publications only reporting significant results. However, the regression tests we conducted to examine the possi- bility of publication bias indicated that this was unlikely to alter our results. Finally, as we adopted a search strat- egy with only English publications, there is a possibility that there might be non-English universal prevention publications that were not identified.
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effectively with life challenges. It is feasible that such interventions are of less benefit to those who live within a protective home environment that provides strong support to assist the young person to deal with life challenges. To date, there has been relatively little research examining the moderators of universal preventive programs for depression. The few studies to date have generally examined factors such as age, gender and initial levels of depression. Generally, there is little evidence to suggest an impact of age and gender upon outcome [3,6,7]. In terms of initial levels of depression the findings are conflicting. While there is some evidence that universal prevention is more effective (at least in the short-term) for those with high baseline levels of depression , other studies have not found this effect [3,7].
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The current study will examine the effectiveness of the multimodal stepped-prevention program for suicidal behav- iors and depressive symptoms using a cluster randomized trial. This includes a combination of preventive interven- tions, such as (1) early screening and detection of suicidal behaviors with subsequent clinical referral, (2) a safety net consisting of gatekeepers at school, (3) universal prevention focusing on stigma reduction, and (4) identification of adolescents who have elevated signs of depression with sub- sequent indicated prevention. Early detection is important, as less than half of adolescents engaging in suicidal behav- iors are known at mental health care services or by other gatekeepers (i.e., family, friends, teachers and mentors at school, etc.) prior to a suicide [37, 38]. A growing body of evidence suggests that school-based screening adequately identifies students at high-risk, effectively refers these students to mental health care, and reduces the risk of suicide ideation and non-fatal suicidal behaviors [39, 40]. It is similarly important that a safety net is created at schools. Mentors should have the knowledge and skills to identify adolescents who show signs of suicidal behaviors and know how to respond to those students . Previous research has shown that a gatekeeper training based on Question, Persuade, and Refer (QPR) model can increase knowledge of suicide prevention and skills [42, 43]. Another important factor impeding identification of suicidal behaviors is the fact that help-seeking behaviors among youths is very low . Nevertheless, research has shown that help-seeking behaviors predicts better prognosis . Stigma has been identified as an important factor that impedes help-seeking among youth. Thus, it is important to develop a universal strategy aimed at reducing stigma.
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Among the three types of prevention programs, uni- versal prevention in school has several inherent advan- tages. First, a universal prevention program can access most students who are enrolled in each school district, while rarely experiencing attrition. Second, a universal approach can minimize the risk of “labeling” for stu- dents who are removed from a classroom for selective or indicated interventions. Third, a universal approach can strengthen the protective role of the school environ- ment, which might have proximal influences on chil- dren, according to the ecological model of child mental health . Fourth, because all students can participate regardless of risk or diagnostic status, implementation of a universal prevention program can support future selective and/or indicated interventions as a framework for layered or stepped preventive approaches. Universal prevention based on a cognitive-behavioral approach is designed to enhance individuals’ specific coping strate- gies for current/future adversity, and encourages applica- tion of those skills to support other students. A previous trial for adult outpatients with anxiety and depressive symptoms suggested that group cognitive-behavioral therapy (CBT) can ameliorate their emotional symptoms as well as improve their self-stigma . A group-based CBT in the classroom showed increased knowledge about mental health and decreased stigma to individuals with mental disorders. Moreover, students in the 5th and 6th grades who participated in the intervention showed significant improvement in self-efficacy, indicating that they can support friends and people around them with mental health problems . Therefore, students, as well as school personnel, can acquire mental health literacy and reduce stigma for mental disorders through teaching cognitive-behavioral skills.
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ABSTRACT Prospective universal genotyping of tuberculosis (TB) isolates is used by many laboratories to detect clusters of cases and inform contact investigations. Prior to universal genotyping, most TB prevention programs genotyped isolates on re- quest only, relying on requests from public health professionals whose knowledge of a patient’s clinical, demographic, and epidemiological characteristics suggested potential transmission. To justify the switch from on-request to universal genotyp- ing—particularly in the public health domain, with its limited resources and compet- ing priorities—it is important to demonstrate the additional beneﬁt provided by a universal genotyping program. We compared the clustering patterns revealed by ret- rospective 24-locus mycobacterial interspersed repetitive unit–variable-number tan- dem repeat genotyping of all culture-positive isolates over a 5-year period to the patterns previously established by our genotyping-on-request program in the low- incidence setting of British Columbia, Canada. We found that 23.8% of isolates were requested during the study period, and while requested isolates had increased odds of belonging to a genotype cluster (adjusted odds ratio, 2.3; 95% conﬁdence inter- val, 1.5 to 3.3), only 54.6% clustered with the requested comparator strain. Universal genotyping revealed 94 clusters ranging in size from 2 to 53 isolates (mean ⫽ 5) and involving 432 individuals. On-request genotyping missed 54 (57.4%) of these clusters and 130 (30.1%) clustered individuals. Our results underscore that TB patient networks are complex, with unrecognized linkages between patients, and a prospec- tive province-wide universal genotyping program provides an informative, bias-free tool to explore transmission to a degree not possible with on-request genotyping.
There has been a recent development in International law and politics which has influenced the legal protection of groups under the auspices of the UNO. The Universal Declaration of Human Rights 1948 and its two International Covenants of 1966 declare that ―All human beings are equal in dignity and rights‖ and prohibit all kinds of discrimination – racial, religious etc. The UN Declaration against all Forms of Religious Discrimination and Intolerance 1981 outlaws all kinds of religion-based discrimination. The UN Declaration on the Rights of Minorities 1992 enjoins the States to protect the existence and identity of minorities within their respective territories and encourage conditions for promotion of that identity; ensure that persons belonging to minorities fully and effectively exercise human rights and fundamental freedoms with full equality and without any discrimination; create favorable conditions to enable minorities to express their characteristics and develop their culture, language, religion, traditions and customs; plan and implement national policy and programmes with due regard to the legitimate interests of minorities; etc.
Pediatricians can play a key role in preventing and controlling HIV infection by promoting risk-reduction counseling and offering routine HIV testing to adolescent and young adult patients. Most sexually active youth do not feel that they are at risk of contracting HIV and have never been tested. Obtaining a sexual history and creating an atmosphere that promotes nonjudgmental risk counseling is a key component of the adolescent visit. In light of increasing numbers of people with HIV/AIDS and missed opportunities for HIV testing, the Centers for Dis- ease Control and Prevention recommends universal and routine HIV testing for all patients seen in health care settings who are 13 to 64 years of age. There are advances in diagnostics and treatment that help support this recommendation. This policy statement reviews the epidemiologic data and recommends that routine screening be offered to all adolescents at least once by 16 to 18 years of age in health care settings when the prevalence of HIV in the patient population is more than 0.1%. In areas of lower community HIV prevalence, routine HIV testing is encouraged for all sexually active adolescents and those with other risk factors for HIV. This statement addresses many of the real and perceived barriers that pediatricians face in promoting routine HIV testing for their patients. Pediatrics 2011;128:1023–1029
and a less-researched question is whether a universal program is effective for lower-risk families. To examine whether FBP also affected infant health care use for lower-risk families, we estimated the CA-ITT models separately for 4 groups: the mother had more than a high school education, the mother was married or had a partner, the household annual income was ≥ $45 000, and mothers who were not teenagers at child’s birth. We found similar statistically significant results for lower-risk children in our sample ( Table 4). Children in the lower-risk families were less likely to visit the ED in the first year and were less likely to have ≥ 9 primary care visits.
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It is conceivable that this may have attracted children with higher anxiety levels; although the original inten- tion was to conduct a universal trial, it may appear that this was an indicated prevention level project. Two groups were recruited by different methods and there was no randomization in the groups. It is necessary for programme effectiveness verification to conduct the programme sessions in regular school classes. This was impossible because of various constraints in this study and universal level execution was abandoned. In addi- tion, although the advertising method was originally applied for both groups’ recruiting, there were minimal responses for control group candidates and the snow- ball method was used for this group. It is natural that the parents of the intervention group who were recruited by advertising showed higher pre SCAS-P scores than the control group’s parents who were recruited by the snow- ball method.
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Over all, the study result shows that wealth based inequal- ities in contraceptive use still prevail in Ethiopia despite the efforts to provide them for free at all public health fa- cilities. Such existing wealth inequalities will, nonetheless, continue to pose a challenge to achieve national Health Sector Development Program targets and universal family planning coverage will not be realized. All actors in the arena have to understand that the cost of medical services is not the only reason for health disparity between the poor and the rich. Unless properly empowered to use the service, people at lower social stratum will be left behind and will be excluded from these (and other) priority ser- vices. The source of inequalities are deep rooted and multifactorial. The root causes of inequity and inequality should be systematically identified and targeted to make the services universal to all groups and achieve the na- tional Health Sector Development Program goals. Apart from deep rooted structural causes, factors at the health system level should also be carefully scrutinized as quality of the service, hospitality factors and frequent stock outs might prevent the poor from using family planning ser- vices. Further qualitative and quantitative studies should also be carried out to find out the multi-level factors that exclude poorest women from family planning services apart from financial constraints, and to continue monitor- ing success in achieving universal health service goals.
The in ﬂ uential Report Global health 2035: a world converging within a generation, pub- lished in 2013, highlighted that ‘the returns on investing in health are impressive. Reduc- tions in mortality account for about 11% of re- cent economic growth in low-income and middle-income countries as measured in their national income accounts … Between 2000 and 2011, about 24% of the growth in full in- come in low-income and middle-income coun- tries resulted from value of additional life years gained’ (Jamison et al. 2013, p. 1898). Frenk and Ferranti (2012) purport that health is an economic driver, and they are inextricably linked. They conclude that not only is it ethically right for all people to have universal health coverage, it is also a sage move econom- ically. They also state that the design of health coverage has to suit the country and be driven internally rather than by external forces. They categorically state ‘[A]id is not the answer’ (2012, p. 863). Building coverage from within a country helps that country develop its own health strategies, which align with global targets. Frenk and Ferranti (2012) further note that putting the health dollar into prevention of infectious diseases is far more ef ﬁ cient than treating the disease once an outbreak has occurred.
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