A new Irish bovine tuberculosis (bTB) eradication strategy was launched in 2021. The strategy was formulated following extensive discussions with stakeholders, formal reviews of several aspects of the existing bTB policy and relevant inputs from the latest scientific research projects. A stakeholder discussion body, the TB Forum, had been established in 2018 and this continues under the new strategy, supported by three working groups . The strategy sets out actions to address cattle-to-cattle and badger-to-cattle bTB transmission, along with actions to improve farm biosecurity and empower farmers to make their own choices to reduce bTB risk.2 covered by the vaccination programme and 6,586 badgers captured in vaccination areas in 2021. Vaccination efforts have been complemented by intensive communications campaigns, including a web enabled software application (“app”) enabling farmers to report the location of badger setts.Large scale vaccination of badgers has been rolled out under the new strategy, with over 20,000 kmCattle which test inconclusive to the tuberculin skin test have been re-tested using a gamma interferon blood test since April 2021, enabling truly infected cattle to be identified more effectively due to the higher sensitivity of this test. An enhanced oversight process has been put in place for herds experiencing extended or repeat bTB breakdowns. Whole genome sequencing is being used to investigate links between breakdowns, with the results supporting operational decision making in case management.Communications, including biosecurity advice, are co-designed with stakeholders, in order to improve their effectiveness. A programme involving veterinary practitioners providing tailored biosecurity bTB advice to their clients was established in 2021 and was rolled out nationally during 2022.A core element of the new strategy is the continual improvement of policies in response to changing bTB risks, informed by scientific research and then implemented with stakeholder consultation. Mycobacterium bovis, continues to pose a significant animal health challenge in Ireland. The objective of this paper is to describe advances within the Irish bTB eradication programme in recent years and to set out the structural relationships between scientific research, stakeholder attitudes and policy development. The paper also seeks to provide a wider historical perspective on the Irish bTB programme, putting the recent changes and strategic developments in context.Bovine tuberculosis (bTB), caused by Current bTB levels in Ireland impose significant direct and indirect costs on the public and private sectors and are a threat to Irish export market access. In 2021, national herd incidence was 4.33%, with 20,931 cattle identified as TB test reactors. Direct costs in 2021 were estimated at €105 m, with €67 m paid by the State, an estimated €35 m paid by farmers and €3 m by the EU; these figures do not include indirect costs or production losses. The costs of bTB in Ireland are not confined to financial issues; restrictions applied to infected herds can cause significant emotional distress to herdowners [An eradication programme for bTB is required under EU legislation, with the rules for countries or zones where disease is present set out in Regulation (EU) 2016/429  and Commission Delegated Regulation 689/2020 (which sets out the specific requirements for bTB). The Irish bTB programme applies these rules, as well as additional national requirements relevant to the epidemiological context in Ireland.The Irish bTB eradication commenced in 1954, with tuberculin skin testing used in all herds to identify infected cattle, which were then removed and slaughtered. At that point, it was estimated that 80% of herds and 17% of cattle (22% of cows) were infected . By 1992A major bTB research programme was established in 1991, principally involving researchers employed within the Department of Agriculture, Food and the Marine and University College Dublin School of Veterinary Medicine, with the aim of providing an evidence base for new policies and strategic decisions . ResearcA significant and ongoing research programme on the use of Bacille Calmette-Guerin (BCG) vaccination in badgers to reduce the risk of badger-mediated bTB transmission to cattle was a key element of this overall research programme ; this reThe challenge of improving diagnostics for bTB was also a focus of much research. This included work on the tuberculin test –28, the By 2016, bTB levels in Ireland had reached an all-time low, with herd incidence at 3.27%. However, the removal of milk quotas in 2015 prompted the expansion of the dairy sector in Ireland. Dairy herds, particularly the larger ones, have many risk factors for bTB, and thus have a higher disease incidence compared to other cattle enterprises. The expansion of the dairy sector was therefore associated with an increase in bTB. Consequentially, bTB levels rose each year until they peaked at 4.38% in 2020. The confluence of improved scientific understanding, the availability of new tools, increasing disease levels, and concerns about the ongoing costs and burden of bTB prompted an initiative to renew the Irish bTB strategy in 2018.www.bovinetb.ie [The TB Forum was established in 2018 to discuss bTB and make recommendations to the Minister for Agriculture, Food and the Marine on additional measures which could be implemented to reduce bTB levels and further the drive towards eradication. The Forum was composed of a range of stakeholders and submitted a report on its recommendations in 2019. This report, the policy analysis document which informed its development, and the minutes of the TB Forum meetings, can be accessed at inetb.ie . Two repinetb.ie . Followiinetb.ie .The framework for considering the range of bTB issues was for policies to be reviewed and discussed at the TB Forum and also subjected to ongoing scientific research and policy analysis. This was often an iterative process, with the results of research informing an updated policy analysis, leading to proposals which, if implemented, would then be the subject of further scientific research. These steps were not necessarily sequential but could progress in parallel, overlapping temporally. The TB Forum provided a vehicle for the frequent exchange of policy information, scientific results, and stakeholder opinions. The policies which were introduced or updated as a result of this process, and the manner of their implementation, were then the subject of ongoing discussion at the TB Forum. In this way, a network approach to policy development was employed, enabling stakeholders to participate in the co-design of policies and the consideration of challenging choices between policy alternatives.M bovis has been the subject of a considerable body of scientific research in recent decades, particularly in the UK and Ireland. Many studies investigated the potential of orally-administered BCG to generate protective immunity in badgers [The idea of using Bacille Calmette Guerin (BCG) to vaccinate badgers and thus reduce badger-to-cattle transmission of  badgers –38. DespA major field trial was carried out in Co. Kilkenny on field vaccination of badgers , 40. A sResearch on vaccination was complemented by the badger ecological research mentioned above, enabling the design of a vaccination programme which could be implemented nationally in the field. The knowledge base was further progressed by studies carried out in Northern Ireland which examined similar topics in a similar ecological situation , 43.In 2018, routine vaccination of badgers using injectable BCG was established as policy within the Irish bTB eradication programme. Initially, vaccination was carried out in areas which had been part of the field research programmes, with incremental expansion to additional areas over time. The 2019 Programme for Government included a commitment to extend the badger vaccination programme nationwide and end badger culling as soon as possible, consistent with the best scientific and veterinary advice.2 in Ireland was designated a badger vaccination area; this is more than half of the total area on which the DAFM wildlife unit operates. In these areas, vaccination is the default, although culling may still be carried out where required for epidemiological reasons. In 2021, the DAFM wildlife unit captured 6,586 badgers in vaccination areas, of which 3,958 were then vaccinated (badgers captured which are found to have been previously vaccinated are not re-vaccinated), and captured 5,868 in culling areas  and Ingenasa ),) were used on badgers prior to vaccination; badgers which tested positive were culled and sent for post-mortem examination and culture. This work is ongoing and the results are expected to be published when complete. A second innovation was the development of a mobile phone app whereby farmers could report the location of badger setts to DAFM, to improve the population penetration of the vaccination programme, a key metric for effective badger vaccination . This apThe effectiveness of the badger vaccination programme and its impact on local transmission dynamics are the subject of an ongoing research project . The interim results of this work are regularly presented to stakeholders in the context of the TB Forum, providing for a degree of stakeholder confidence in the programme and demonstrating the continued commitment to evaluating and reviewing policies, including the badger vaccination programme.Cattle which test inconclusive to the SICCT test were required to be retested 42 days later, or slaughtered and subjected to laboratory examination or a balance of herd test in line with the requirements of Directive 64/432. If the repeat test disclosed them as inconclusive again or as positive, they were deemed reactors; while if negative, they were deemed to have passed the retest. Research had confirmed that in Ireland, such cattle which pass the retest continue to pose an elevated risk of being infected , 46. BasAt the TB Forum, stakeholders raised concerns about the ongoing risk posed by such retained inconclusives; while confined to the herds of disclosure for life, they could still initiate a repeat breakdown within those herds which may spread onwards. In response to these concerns, an updated policy on inconclusives was developed and implemented, informed by the earlier research. Policy analysis revealed that approximately 3,500 cattle annually tested inconclusive, with roughly 20% of these failing the retest.The new policy required cattle which tested inconclusive to the SICCT test to be subjected to an interferon gamma blood test within three weeks. If positive, the animal was deemed a reactor and removed. If negative, the animal was still required to undergo a further SICCT test. The interval for this repeat skin retest was increased from 42 to 60 days in order to counter the desensitising effect of tuberculin injection. If the animal passed this, it would require a further interferon gamma test six months later.Other related policy changes included the mandatory removal of any previously disclosed historic inconclusives  from a herd if one or more reactors was disclosed at a test; any cattle newly testing inconclusive to be deemed reactors if one or more standard reactors were disclosed at the herd test; and where four or more cattle tested inconclusive at a herd test with no standard reactors, all four were to be deemed reactors and removed and the herd restricted. In 2021, a letter was sent to the owners of all historic inconclusives, advising them to cull these cattle if they wished to reduce the bTB risk to their herd.In the first full year of operation of the new policy, 61% of inconclusive cattle which were interferon gamma tested were positive and thus removed as reactors, with the herd restricted. Within six months of the issuing of the advice letter on historic inconclusives by DAFM referred to above, 26% of historic inconclusive cattle had been slaughtered . The number of cattle reported as tested inconclusive to the skin test was 1,497 in the first full year since the new policy was introduced, a major reduction compared to the roughly 3,500 reported annually in years prior to the new policy.The subject of herds which experience extended and/or repeated bTB breakdowns has been the focus of considerable epidemiological research in Ireland –51. The Stakeholders are aware of the differences in seriousness between breakdowns based on number of reactors and length of restriction, and the subject of how better to manage such cases was discussed at the TB Forum. Informed by the research findings cited above, case management policy was updated to emphasise the progressive removal of all sources of bTB risk from extended and/or repeat breakdown herds. For example, if such a herd is not going clear, cattle whose test result is deemed “severe inconclusive” are removed, followed by cattle with a bovine bias in the SICCT, followed by cattle considered at higher risk due to their history of exposure. The policy discussions prompted a specific research project on the relationship between the bovine tuberculin response and future risk , the resM. bovis in reactor cattle [This topic is closely linked to the broader issue of effective breakdown management, where again new research has informed policy considerations. For example, research on faecal shedding of r cattle  underpinAll cattle slaughtered in Ireland are subjected to ante- and post-mortem inspections by a veterinarian, as required under EU food hygiene legislation. This includes checks for lesions which are suspected of being caused by bTB. Such lesions, termed “suspect factory lesions” in Ireland, are sent for laboratory testing and, if positive, the infected herd is restricted. Approximately one third of breakdowns in Ireland annually are first identified through surveillance at slaughter. Given its critical role in bTB surveillance in Ireland, this area has been the subject of a number of research studies , 55, witThe primary diagnostic test for detecting bTB in Ireland is the SICCT. The characteristics of this test make it the most suited option for a mass-screening programme, given its very high specificity . HoweverThe use of the interferon gamma test was introduced as policy for serious bTB breakdowns (defined as four or more reactors) in 2015, following several years of research in Irish field conditions , 32. TheThe tuberculin used in the programme has long been recognised as a key element requiring quality control and ongoing evaluation, with research showing the importance of using tuberculin of sufficient potency in the context of an overall quality control programme on bTB testing –28.Effective communication is crucial to the success of disease eradication campaigns, and the stakeholders at the TB Forum had signalled that improving communications to herdowners should be considered a priority. This was supported by research carried out on the attitudes of Irish farmers to the bTB programme .The subject of risk communication can be particularly challenging; in 2020, each cattle herd was assigned a TB herd history risk (TBHHR) status, which described if a herd was clear (C) or infected (INF), how many full years it had been clear and the number of bTB breakdowns in the preceding 10 years. For example, a TBHHR score of C4(2) means a herd has been clear for four full years and has had two bTB breakdowns in the past ten years. Figure The conflict between the interests of the buyer in avoiding introducing potentially bTB-infected cattle into their herd versus the interests of the seller of bTB-exposed cattle in maximising the price paid has been addressed by previous reviews of bTB in Ireland, including as far back as 1991  and a 19The introduction of a biosecurity advisory module on bTB which can be delivered by veterinary practitioners to their clients, funded by DAFM through Animal Health Ireland as part of their Targeted Advisory Service on Animal Health , has enaThese actions recognise the complex challenge of engaging with stakeholders on risk communication and advocating risk-reducing behaviour, which has been identified as an important area yet one in which much work remains to be done –63.www.bovinetb.ie) and partnering with other agricultural and veterinary advisory bodies to deliver training and information.Other communications efforts established in recent years to engage with farmers include the participation of DAFM bTB team members in many public meetings across Ireland, media engagement including podcasts, radio and television, creating a series of youtube videos and leaflets on specific topics of recurring interest  of deer submitted from the other 25 counties of Ireland were positive.In response to stakeholder concerns, the policy on deer and bTB was updated such that, if herdowners in an area were concerned that deer locally may be infected with bTB and playing a role in spreading disease to cattle, they could submit deer carcases to DAFM Regional Veterinary Laboratories, which would then test those carcases for bTB free of charge and report the results locally and to the TB Forum. This work was not, therefore, a random sample of deer; rather, only deer in areas where there were thought to be significant bTB levels in cattle were submitted for testing. Between 2016 and 2020, 35 of 272 (12.8%) of deer submitted from Co. Wicklow were positive for M bovis from badgers to cattle in the area consequent to the initiation of construction.Stakeholders at the TB Forum also conveyed the concerns of some of their members that activities which could disrupt wildlife, specifically the construction of roads and the clear-felling of forestry, could lead to an increase in local bTB levels in cattle. Epidemiological research was thus carried out into these questions, with the results shared with stakeholders. Researchers reported evidence of an increased bTB risk in cattle being consequent to, not just coincident with, road construction, and hypothesised that perturbation of badger populations may have provided the mechanism for this effect . AnotherIn relation to clear-felling of forestry within a wider ecological landscape context and bTB risk, evidence was found of an increased bTB risk following clear felling of forestry , but theThe Scientific Working Group of the TB Forum considered the issue of the sources of bTB infection for cattle, including the possible role of deer; this opinion was presented to stakeholders at the TB Forum and has been published online .M bovis cultures are being analysed using WGS in Ireland, principally isolates from cattle and badgers but also from other species such as deer, pigs and alpacas. The results are used to generate a wider national perspective on the distribution of M bovis strains in Ireland, and also to inform specific operational case management decision making and to address particular epidemiological queries at local level. The use of WGS as a tool to support epidemiological investigations and case managements illustrates how technical advances, when linked to the field management of cases, can provide more evidence for the case manager to take into account, with the objective of improving decision making. A detailed analysis of the results of this initiative will be reported separately. The scientific working group of the TB Forum has considered how WGS can best be used to support improved effectiveness in the Irish bTB programme, and their guidance will inform policy development in this area.The use of whole genome sequencing (WGS) has become widespread in bTB epidemiology in recent years , 70, 71,The introduction in March 2020 of societal restrictions to protect public health in relation to Covid19 in Ireland necessitated a rapid consideration of how the Irish bTB eradication programme could be adapted such that the public health rules were complied with while protecting animal health and enabling the continuation of cattle trade, considered a vital part of the Irish food supply system.Throughout the pandemic period, there was ongoing and frequent communication between the DAFM bTB team and stakeholders, particularly those representing farmers, veterinarians, and cattle marts. As the public health restrictions changed over the course of the pandemic, so too did the changes applied to the bTB programme, following discussions on each occasion with stakeholders. This illustrates the value of setting in place structures, such as the TB Forum, for ongoing engagement between policy makers and stakeholders.M bovis. A study was rapidly carried out on the risk factors related to the likelihood of a herd with a suspect lesion in a slaughtered animal subsequently having a bTB breakdown [At the start of the pandemic, DAFM’s high containment TB laboratory became a site for Covid19 testing. Although the consequent interruption to bTB testing turned out to be brief, concerns arose at the time that there could be a prolonged interruption to bTB laboratory culture capacity, due to the use of the laboratory for Covid19 testing and due to the risk of the highly experienced laboratory staff becoming unavailable if they became infected. The question arose of how to manage herds which had cattle with suspect factory lesions, if those lesions could not be cultured and tested for reakdown . Based oGuidance was provided to herdowners and veterinarians in relation to conducting the SICCT while adhering to the public health rules. Herd tests could be postponed for up to 28 days past the due date without penalty, to allow for circumstances where one party may have suspected or confirmed Covid19 infection, or where it proved challenging to obtain help from normal sources to assist with the test on the scheduled date. Small calves are usually held by one person while the veterinarian conducted the SICCT . To allow for social distancing guidelines to be adhered to, a temporary easement was allowed whereby calves aged 42–120 days could be excluded from a herd test if either the herdowner or the veterinarian were of the opinion that they could not be tested while adhering to the Covid19 rules. This easement was removed as Covid19 restrictions and social distancing guidance were changed. A review of the epidemiological considerations and risks related to bTB in calves was carried out to support policy development during this period; this work has been published and describes the topic in more detail .Machine learning approaches to predicting bTB risk have been described . A similThe scientific working group of the TB Forum has completed a consultation on future bTB research priorities with stakeholders from farming, veterinary and research backgrounds. Following the consultation, replies were systematically evaluated and priorities for future research were identified and presented to the TB Forum. These will inform the likely direction of bTB research in Ireland over the coming years.The wider international context will also continue to inform the development of Irish bTB policy. The bTB programme in Ireland sits within the legal framework of the EU regulations on the eradication of bTB, while the attitudes of trade partners constitute a major consideration for Irish policy makers. Technical and scientific developments in relation to bTB will also influence the Irish programme, with relevant innovations considered regarding the Irish epidemiological context.The Irish bTB eradication strategy will continue to change, adapting in response to new risks and new circumstances and seeking to make use of new tools as they become available. The paradigm of developing policy based on scientific research and through engagement and discussion with stakeholders provides a responsive and flexible model for ensuring that the programme can effectively tackle bTB in Ireland, driving towards an ultimate goal of eradication.


Reading literacy is not only central to students’ academic success during their school years but also crucial to their personal development in their later life. The development of assessment instruments for reading literacy has been of interest to researchers, educators and educational administrators. The purpose of the present study was to construct and validate a comparable item bank for assessing fourth-grade students’ reading literacy.One hundred fifteen reading comprehension items were developed and administered to 2,174 Grade 4 students to construct an item bank. Using the test equating technique and balanced incomplete block design, we divided participants into 10 subgroups, and the 115 items were further assigned into 10 test forms. Item response theory software was used to estimate discrimination, items’ threshold parameters, and students’ ability parameters. The criterion-related validity was also examined in 135 Grade 4 students who completed the reading literacy test and verbal self-description questionnaire.The final item bank included 99 reading performance indicators to express high achievement. The correlation between the students’ reading literacy and the verbal self-description questionnaire was significant and demonstrated the item bank’s good criterion-related validity. The item bank developed in this study shows good psychometric characteristics and can be used to assess the reading literacy of fourth graders. Reading and learning from text are some of the most complex and uniquely human cognitive activities. Consequently, the ability to read and comprehend text is not merely an essential element of school students’ academic achievement; it also plays a critical role in an individual’s personal development both at school and in his or her later life. Therefore, reading ability, also called reading literacy, is central and crucial for students’ academic success and is necessary for overall success in modern society.Given the vital significance of reading literacy to an individual’s life, on the one hand, many researchers in psychology and linguistics e.g.,  have paiMost of these programs are firmly focused on Western populations. Although these programs have been widely used and have firmly established their explicability in Western society, they have not been entirely suitable for assessing reading literacy among the Chinese population, and there have been relatively few empirical studies that have established the generalizability of these programs across societies outside the West and even fewer addressing traditional non-Western societies such as China.The present study aimed at developing and validating a comparable item bank of reading literacy tests to evaluate fourth graders’ reading literacy performance in Chinese society. To achieve this purpose, a framework of reading literacy in Chinese society was proposed based on the assessment of reading literacy and reputable intranational or international programs of reading literacy. In particular, test items were evaluated using the modern psychometric approach and item response theory (IRT) to derive assessments from this research that are maximally reliable and valid.the Chinese Curriculum Standards for Full-time Compulsory Education. In addition, this assessment framework is used as a guide for developing and screening test questions.The purpose of this section is to propose and develop a working definition and assessment framework for reading literacy tests for Grade 4 students in China based on existing reading comprehension models and well-known reading measurement programs in conjunction with the definitions and requirements of At least three issues must be taken into consideration in our assessment framework for modeling purposes. The first fundamental issue concerns the cognitive processing of reading comprehension. The second issue concerns the characteristics of reading materials. Lastly, the third issue for modeling reading literacy is the target percentage of assessment content.Reading is the process by which readers obtain mental meaning from textual materials. The reading process involves complex cognitive processing activities, from word recognition and sentence comprehension to constructing discursive meaning. Many theoretical models of reading support that reading comprehension is a dynamic process in which readers process information explicitly stated in the text with the help of background knowledge, which causes mnemonic representations to change continuously, and these changing mental representations provide resources for the processing the next reading . The theBased on the scientific research on textual comprehension  and the Retrieval and inference are based on the surface level of text representation and the independent parts of the texts, especially the explicit information included in the text. Here, inference refers to the straightforward inference based on the context and the information explicitly stated in the reading materials. For retrieval and inference tasks, the reader needs to identify textually explicit information and make simple inferences within and across texts; for example, the reader retrieves definitions, facts, and supporting details, locating specific information in the text, figurative language, topic sentence or main idea and identifying the author’s purpose and the causal relations, character traits, sequence of events or actions included in the text.The integration and interpretation process, as in PISA’s or PIRLS’s frameworks, is based on the local and global meanings of texts. The process and the outcomes of integration and interpretation have been characterized by strong individuality. Reading tasks require the reader to make complex inferences within and across texts; for example, the reader summarizes central ideas, draws conclusions, finds evidence in support of an argument, determines unstated assumptions in an argument, infers mood or tone, integrates ideas to determine a theme, identifies or interprets a character’s motivations, and examines relations between themes and settings or characters.Evaluating and reflecting require the reader to examine and evaluate the textual content, meaning, and textual features in terms of language and structure. For example, the reader judges the author’s craft and technique, evaluates the author’s perspective on the central topic, analyzes the presentation of information, judges the coherence or logic of an argument, and evaluates the way the author selects language to influence readers.Inspired by the prevision about the categories of reading materials in the PISA survey and the NAEP Reading Assessment, two-dimensional classifications  were considered in our framework. Following these criteria, four test forms were identified and labeled as continuous literary texts, non-continuous literary texts, continuous informational texts, and non-continuous informational texts. Moreover, there was no difference between continuous and non-continuous literary texts. Consequently, only three forms could be considered and identified in our reading literacy assessment framework.The typical extensions for each text format could be categorized and described as follows: (1) literary texts include storytelling, fiction, literary nonfiction, poetry, narrative texts, and so on; (2) continuous informational texts include exposition and argumentation; (3) non-continuous informational texts include charts, graphs, tables, diagrams, forms, advertisements, and so on. The third fundamental issue for modeling reading literacy is the distribution and variety of texts that the students are asked to read for our test. Basically, this issue depends on the characteristics of the curriculum used by the fourth graders.the Chinese Curriculum Standards for Full-time Compulsory Education and in conjunction with the actual situation of language teaching in schools and expert suggestions, we propose and develop the target percentage of assessment content based on the formats of reading materials. Specifically, 50% of the texts are literary texts, 25% are continuous informational texts, and 25% are non-continuous informational texts.Based on the definitions and requirements of Without accurate assessment, efforts to understand and ameliorate the definition and framework are unlikely to succeed. The measurement of psychological processes is not direct. Reading literacy is considered a latent trait, and a model is needed to describe the relationship between that latent trait and test-taking behaviors . In geneIRT is a modern psychometric method widely applied in research in psychology, education, and linguistic. IRT has significant advantages over CTT in terms of instrumental development. The item parameters  derived from CTT are overly dependent on the sample of participants on which the test is administered, resulting in limited generalizability. As a result, the tests developed are only applicable to a target population that is similar to that in the test sample. In addition, the difficulty of an item or a test and the examinees’ ability are defined based on two unrelated metric systems; therefore, their values cannot be compared. However, when developing tests based on IRT, the item parameters of the instrument  and the examinees’ ability are estimated independently . The relDue to its psychometric properties, the IRT-based reading comprehension test may be a better measure of reading literacy than tests used in prior research. Therefore, the main purpose of this study is to develop an IRT-based comprehension test for future research. The conceptual model used in this study is as follows .For sampling purposes, the population of Chinese fourth graders was divided into six strata based on the regions of China  and the average performance level of the school at stake . A stratified cluster sample of schools was drawn according to the sampling plan. This sampling method allows the clusters within a stratum to be close in size and the differences between clusters to be small, while allowing stratified sampling to have small within-stratum differences and wide between-stratum differences, thus greatly improving the sampling effect . A totalThe instrument development process was carried out in four phases, which are described below.In this phase, the original item bank, which contained 34 texts and 206 test items, was prepared.The original item bank was designed and developed by an expert panel. The panel consisted of 26 experts and reviewers who had extensive experience working in the practice of teaching reading and educational testing.First, one group of experts, who were all Chinese teachers and Chinese teaching researchers, selected reading materials and developed test items according to our framework about reading literacy. To ensure the fitness of the reading material and the correctness of the test items, they were all analyzed by other groups of reviewers (at least 2–3 reviewers for each text and the items that accompanied it), all of whom were Chinese teachers or Chinese philologists. A number of mistakes were found and identified by the reviewers. Some of the mistakes were labeled as revisable mistakes, and some potentially incorrect test items, such as spelling or typographic errors, test items that had more than one possible correct answer, and violations of grammatical rules, were corrected and reviewed again. The reading materials or test items were removed if they were identified as incorrect or irrelevant or if the items contained any mistakes and were labeled as inadequate for revisions.Afterward, a pilot test was conducted with Grade 4 subjects recruited in Guangzhou City. Another group of experts and reviewers, who were all Chinese teachers, Chinese philologists, and psychologists, were consulted to select the key and appropriate reading materials and test items for the main study, and the psychometric qualities of test items were defined in a pilot study. At that stage, four pieces of information for each item were considered and reviewed: the exclusivity of the correct answer, the linguistic subject of the item measured, the level of difficulty, and the effectiveness or discrimination of the item. Some mistakes were identified and corrected in that phase.Finally, the original item bank retained 23 texts and 115 test items written in Chinese, and the text covered different types of literature and various topics. The mean number of Chinese characters per text was 578 (ranging in length from 95 to 922). Each text was accompanied by 4 to 6 four-option multiple-choice items.It was impossible to require all participants to answer all 115 items in the assessment. If students were required to spend several hours answering all items, on the one hand, it would negatively impact students’ participation rates. On the other hand, student performance would deteriorate due to the effect of fatigue and decreasing motivation in an extended time assessment. Therefore, in that phase, the remaining 115 items were distributed by following a balanced incomplete block design (BIBD). Ten booklets were defined, each of them containing 23 items, so that any participant could complete a booklet in less than 60 min.The BIBD booklet design is a complex variant of matrix sampling, which is widely used in large-scale educational assessments and other similar surveys . The BIBAccording to the BIBD-spiraling design, 115 items were divided into 10 blocks, which were further assigned into 10 booklets in a systematic sequence. As presented in In that phase, the reading test booklets were administered with applied paper and pencil test forms along with a packet of demographic and informational measures by grouping tests to collect the responses of participants.Participants were tested in groups during their regular class. First, all participants were given instructions about the general procedure of the investigation. Then, they were informed that they would read five texts on different topics and answer test questions for each text.Afterward, the reading comprehension test booklets, attached with an identification code for each student on the first page, were passed out. Texts and question items were presented in booklet form, with the answer sheet appearing on separate pages from the texts and items. All participants were told that the purpose of the study was to assess how well they performed on a reading comprehension test. They were asked to carefully read the concrete instructions on the booklet’s first page. For instance, they were asked to read the texts carefully, and it was not recommended that the item be omitted for statistical purposes; it was recommended that the answer be modified clearly if the need arose. The reading time was self-paced by the examinee because test anxiety and rush had a negative effect on participants’ performance and parameter estimation. The participants were told they could take as much time as needed, but it was recommended to them that they use a maximum of 1 h to complete the whole reading test. Our pilot study showed that the interval was ample enough for more than 95% of the participants to finish the test.An additional questionnaire was administered to a random sample of 135 participants from one school. After reading and comprehension testing, these participants were given a break. Then, they completed the verbal subscale of the self-description questionnaire SDQ, .In that phase, the participants’ responses were collected, cleaned, included, and analyzed based on CTT and IRT. As a result, some items were removed from the item bank; the validity of the item bank was examined; and the discrimination parameters, threshold parameters of items, and ability parameters of students were estimated.Reading tests and questionnaire sessions were conducted by administering the booklet to 10 groups of fourth graders. A total of 2,193 booklets were completed, 2,174 of which were validated by experts in educational and psychological measurements according to validation criteria. Nineteen booklets were removed. Some of these booklets were identified as including anomalous response patterns, were deemed to be unacceptable from a psychometrical perspective, and were thus discarded from the input sample. For instance, the same option was selected for all test items.The 10 reading test modules were calibrated using the two-parameter logistic item response model (2PLM) for dichotomous items. The 2PLM was written aswhere  program .After IRT analyses, the item bank’s criterion-related validity was also examined using the statistical software SPSS.IRT assumes that examinees’ responses to items are related to a single underlying latent variable; therefore, determining whether a test violates the assumption of uni-dimensionality is a fundamental precondition to IRT analysis. Strict uni-dimensionality is unrealistic with any test instrument. However, the assumption of uni-dimensionality is generally considered satisfied if a single dominant factor is present among the test items, including one test . TherefoEvidence of a single dominant factor would emerge if the size of the eigenvalues associated with the first factor were larger than those associated with the second factor and if the first factor accounted for approximately 20% or more of the variance . The resAdditionally, the scree plot test, which is a widely used test of uni-dimensionality , also sha) and item threshold parameter (b) were estimated using the 2PLM.IRT analysis was conducted for all the remaining 115 items. The item discrimination parameter , which meant that the items in the bank were generally easy.Negative a parameter values ranged from 0.14 to 1.12 . This finding indicates that the items on the comprehension test were moderate.The M = 0.13, SD = 0.81).Students’ ability levels ranged from −3.04 to 1.89 (N = 135) was 0.88. The correlation coefficient of the students’ reading literacy and SDQ verbal scores was 0.32, and the p-value was below 0.001. A moderate but statistically significant correlation demonstrated a good criterion-related validity of the item bank developed in this study.The criterion-related validity was analyzed by calculating the correlation coefficient between the reading literacy score and the verbal SDQ score. The Cronbach’s alpha of the SDQ in this sample , and these sources included literary texts , continuous informational texts , and non-continuous informational texts .the Chinese Curriculum Standards for Full-time Compulsory Education to develop an item bank to measure fourth graders’ reading literacy. This study is an attempt to place Western reading theories and assessment frameworks in the Chinese cultural context, providing evidence for the cross-cultural adaptability of reading comprehension models and international educational assessment frameworks, as well as reflecting on Chinese characteristics. This study is based on the IRT approach; the study uses a 2PLM for parameter estimation and rigorous screening of test items based on the results of parameter estimation, which provides a more objective and accurate test of students’ reading literacy and provides a theoretical approach and implementation path that can be used for the development of similar reading literacy tests in the future.The findings of the present study contribute to the literature on theoretical models and measures of reading literacy. This study combines well-known reading comprehension theories, the assessment frameworks of large-scale educational assessments and The results of this study have important practical implications for the assessment and development of reading literacy in China. The item bank developed in this study can be used for general language testing in Chinese schools and can also be provided to educational administration agencies for the assessment and monitoring of the educational quality of reading literacy. The items developed in this study present a number of advantages beyond those currently used in Chinese schools, such as the characteristics of the reading materials and the psychometric characteristics of the item. This approach can be used to measure students’ reading literacy more accurately on the one hand and to “promote teaching with testing” on the other hand, which can feed into the teaching of reading and improve the effectiveness of education, contributing to improvements in China’s compulsory education. The assessment and monitoring of compulsory educational quality is an important issue that benefits the country and the people, and accurate assessment and monitoring require scientific instruments. The test items developed in this study have suitable psychometric characteristics and can be used directly or modified to assess the quality of compulsory education. The procedures and methods used in developing the item bank in this study can also be used to inform practical work on developing assessment instruments for educational quality assessment and monitoring.Although this study has developed a valuable item bank, several limitations need to be addressed in future research. First, we could not conduct a factor analysis across the entire item bank when testing uni-dimensionality because the original item bank was divided into 10 booklets. Although the reading items were randomly assigned to test blocks and thus combined into different booklets, which can be viewed as replications, we still could not ensure that reading items from different booklets did not exhibit the prerequisite requirement of local dependence. Future research could attempt to create additional types of booklets by combining the various test blocks in different ways to better test the uni-dimensionality of the items within the entire item bank. Second, socioeconomic and technological developments have made mobile phones and computers into an integral part of our lives, and the reading of electronic texts has been integrated into every aspect of our studying, working, and living. Reading literacy is not only the key to opening up the world of traditional print texts but is also vital for electronic texts. The reading comprehension processes and reading strategies required to read print and electronic texts are both similar to and different from each other. Reading electronic texts requires readers to use a number of new reading strategies. For example, sifting through the vast amount of information on the internet to find the material needed accurately and quickly, comparative processing of multiple materials and critical thinking are particularly important. Our study did not cover electronic texts, and future research could attempt to incorporate electronic reading ability into the assessment framework and develop appropriate items to measure that ability.Overall, it is feasible to use different reading materials, such as literary texts, continuous informational texts, and non-continuous informational texts, to measure the reading ability of Grade 4 students at three levels . The item bank developed in this study contains 23 texts with 99 test items. It exhibits appropriate psychometric characteristics in terms of difficulty, discrimination and validity for the assessment of reading literacy in Grade 4 students.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Research Ethics Committee of the South China Normal University. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.QC, HZ, HF, and LM made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work. All authors contributed to the article and approved the submitted version.This research was supported by the Research Project of Philosophy and Social Science in Guangdong, China (GD22CXL01) and the Educational Science Planning Project  in Guangdong Province, China (2022GXJK176).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Background The prevalence of pain in patients with multiple sclerosis is remarkable. Fibromyalgia has been considered as one of the forms of chronic pain encompassed in multiple sclerosis, but data are restricted to studies from Europe and North America.Objective To assess the prevalence of fibromyalgia in a series of Brazilian patients with multiple sclerosis and the characteristics of this comorbidity.Methods The present cross-sectional study included 60 consecutive adult patients with multiple sclerosis. Upon consent, participants underwent a thorough evaluation for disability, fatigue, quality of life, presence of fibromyalgia, depression, and anxiety.Results The prevalence of fibromyalgia was 11.7%, a figure similar to that observed in previous studies. Patients with the comorbidity exhibited worse scores on fatigue , quality of life , anxiety , and depression  indices than patients without fibromyalgia. There was a strong positive correlation between depression and anxiety scores with fatigue . Conversely, a moderate negative correlation appeared between the Expanded Disability Status Scale (EDSS), fatigue, and depression scores with quality of life .Conclusion Fibromyalgia is a comorbidity of multiple sclerosis that can enhance fatigue and decrease quality of life, although depression, anxiety, and disability are factors that can potentiate the impact of the comorbidity. Multiple sclerosis is a common chronic demyelinating disease of the central nervous system (CNS) with rising figures of global prevalence in the last decade.The prevalence of pain in adult patients with multiple sclerosis is of ∼ 63%, with diversified characteristics, not only neuropathic.In Brazil, the prevalence rate of multiple sclerosis reaches up to 27.2/100,000 inhabitants.The present cross-sectional study was conducted in the Hospital São Vicente de Paulo (HSVP), in Passo Fundo – RS, Brazil. All adult patients with multiple sclerosis consecutively assisted by the neurological staff (Instituto de Neurologia e Neurocirurgia [INN]) from August 2021 to December 2022 were invited to participate in the study. The present survey was approved by the local ethics committee . Only one patient declined participation.Upon written consent, the participants underwent a thorough evaluation for disability, fatigue, quality of life, presence of fibromyalgia, depression, and anxiety. Disability was measured with the Expanded Disability Status Scale .ttest was used for comparing quantitative data, while the corresponding tool in case of asymmetric distribution was the Mann-Whitney U test. Correlation between quantitative data was accomplished with the Pearson correlation coefficient. Thep-value for significance was established as 0.05.The Fisher exact test was employed for the analysis of qualitative variables. The StudentOur original sample was composed by 61 multiple sclerosis patients, but due to a refusal the sample resulted in 60 participants, whose demographic and clinical characteristics are depicted inPatients with and without fibromyalgia were compared and the results are presented inWe performed the correlations between main quantitative data with special interest on fatigue index and quality of life index. These results are presented inRegarding the treatments prescribed for multiple sclerosis, a comparison  and Turkey (19.4% of 103 patients).All aforementioned studies reported a higher prevalence than the survey performed in Manitoba, Canada, in which 6.8% of patients with multiple sclerosis also had the diagnosis of fibromyalgia, instead of the 3.5% found in the general population.Misdiagnosis is one of the concerns on the theme. In a series of 110 patients diagnosed with multiple sclerosis, 15% actually had fibromyalgia.Two of the main findings or our study were the higher fatigue index and the lower quality of life index in patients with the comorbidity, compared with other patients only with multiple sclerosis. Fatigue is a common symptom of both multiple sclerosis and fibromyalgia, so it is not surprising that the association causes a higher fatigue index. Comorbidities, including fatigue, have a cumulative impact on quality of life in multiple sclerosis.Depression and anxiety are the most common psychiatric conditions in multiple sclerosis,In order to explore the relations between these factors, we performed a correlation of quantitative variables with the fatigue index and the quality of life index. Anxiety and depression scores were strongly correlated to the fatigue index , but weakly and moderately to the quality of life index, respectively, in an inverse manner . As expected by the literature,The EDSS is widely used to measure disability in demyelinating diseases of the CNS. The difference in the EDSS score between the comorbidity group and other patients with multiple sclerosis just lost significance in the statistical analysis, but this may be a limitation of our sample size. A previous survey found higher EDSS scores in the comorbidity group compared with patients with multiple sclerosis without any pain, but no significant difference among these groups with patients with multiple sclerosis who suffered from non-fibromyalgic chronic pain.Another interesting finding has emerged from the analysis: those who were diagnosed with fibromyalgia have never been prescribed interferon, despite the diagnosis of the pain syndrome having been established only later. We interpreted that the neurologists who assisted these patients with multiple sclerosis probably considered the complaint of pain as a factor for avoiding the prescription of interferons, considering the known adverse effects of these medications, including pain.The results above emphasize the importance of recognizing fibromyalgia among patients with multiple sclerosis. Fatigue, quality of life, depression, and anxiety may be worse in the presence of the comorbidity and the symptoms of recognized or unrecognized fibromyalgia may influence the choice of treatment for multiple sclerosis. In our opinion, this is enough to recommend an active search for the diagnosis of the pain syndrome also by the neuroimmune practitioner.The main limitation or our study is the sample size, as aforementioned. There is also lack of information from the pediatric population, but this is an issue shared with previous reports, because no study evaluated the comorbidity in children and adolescents.In conclusion, the present survey pointed to the existence of an important comorbidity of fibromyalgia and multiple sclerosis also in Brazil, and brought some information regarding distinctive clinical characteristics of patients with both conditions and the pertinence of recognizing this pain syndrome for a more adequate management of these patients.


Spinal canal stenosis is one of the most common vertebral column diseases, which can lead to disability. Developing a registry system can help in research on the prevention and effective treatment of it. This study designs a minimum data set (MDS) as the first step in creating a registry system for spinal canal stenosis.⍺ coefficient, which was 86%. Finally, the MDS of the spinal canal stenosis national registry system (for Iran) was confirmed through a two stage Delphi technique. Data analysis was applied through descriptive statistics via SPSS21 software.The present research is of applied‐descriptive type, performed in 2022. First, the applicable data elements about the disease were selected from a vast range of English and Farsi references, including peer reviewed articles, academic books, credible websites, and medical records of hospitalized patients. Through the extracted data, the primary MDS plan was designed as a questionnaire. The validity of the questionnaire was conducted via asking the opinion of experts . Also, its reliability was calculated via Cronbach The proposed MDS is offered in two general sets of data: administrative and clinical. For the administrative data set, 40 data elements had been proposed, as five classes. Twenty‐six of them were confirmed. In the clinical section, 95 data elements had been proposed in 14 classes; 94 of which were finally confirmed.Since there is no spinal canal stenosis MDS available, this study can be a turning point in the standardization of the data on this disease. Moreover, these precise, coherent, and standard data elements can be contributed to improving disease management and enhancing the public healthcare quality. Also, the MDS proposed in this study can help researchers and experts, design a spinal canal stenosis registry system in other countries. The main reason for stenosis is degeneration of the spinal elements including intervertebral disc and ligament flavum.The degeneration becomes more intense with aging. The disease is one of the most important reasons of spinal injuries and diminished mobility among the people above 50 years old. This may be related to Osteoarthritis, which initiates changes in the vertebral column at age of 50.Due to ageing of the world population, the incidence of degenerative spinal canal stenosis and its associated economic burden are growing.One of the most essential stages in designing a registry system related to a special disease is determining it's minimum data set (MDS).The proper selection of data elements is a major reason for the success or failure of registry systems.In recent years, extensive studies have been done on the MDS in healthcare systems. Most of these studies, especially in Iran, have dealt with presenting a model for MDS development for a disease, injury, or group of patients.This study aims to propose a national MDS for the spinal canal stenosis registry system. However, it can be applied as a model for other regions, especially for developing countries. This data set can cover all influential factors in the health of these patients such as socioeconomic status, personal and familial history, disease‐developing conditions, comorbidities, diagnostic and therapeutic interventions, and healthcare outcomes.2The applied study, was conducted descriptively and qualitatively in 2022 in Imam Reza hospital in Kermanshah, the West of Iran in four stages.2.1In the first stage, by studying the records of hospitalized patients diagnosed with spinal canal stenosis, their administrative and clinical data elements were extracted. In this regard, the list of cases was prepared from the hospital information system (HIS) based on the diagnosis code of spinal canal stenosis from ICD‐10. The records were extracted from the hospital file system based on the file number. Records were extracted by the study researcher and its data elements. The sources of the study were the files of hospitalized patients diagnosed with spinal canal stenosis (ICD‐10 code = M48.0). There were 200 cases with this diagnosis in the 2020−2021 time frame, all of which were studied.The second stage included identifying data elements for risk factors, aggravating factors and long‐term consequences of the disease. Resources for this stage include papers, MDS in other countries, websites and clinical guidelines associated with the vertebral column diseases were investigated. Based on search strategy Table , the rel2.2In the stages one and two, data were collected using data extraction form that designed based on previous studies and advice of experts from health information management and neurosurgery. The collected data were first coded, then similar cases were grouped and the duplicate ones were eliminated. Finally, the data elements were categorized as the main group, data classes, data subclass, as well as values and data elements.In the third stage, the proposed data elements are matched to the national health information systems in the Iran. The data elements were investigated considering the official health information systems such as the Iranian Health Electronic Record System (SEPAS) and Health Integrated System (SIB). The data collection instrument was a checklist, which was designed based on the findings of the first and second stages of the study. The checklist aimed to match the name and values of proposed data elements against the data elements offered in the mentioned systems, as well as to confirm the coding standard used for the data in them. The data collection was done via scrutinizing the mentioned systems and review of the available documents about their content. Based on the findings of previous stages of the study, the initial draft of the MDS of the spinal canal stenosis registry system was proposed. Next, this draft was provided to five experts including two neurosurgeons, two Health Information Management, Health Information Management, and one epidemiologist. After receiving the advices, the intended corrections were made. These corrections included changing the title of some data elements, changing the grouping of data elements, adding three new data elements, and removing two of them. Finally, based on the opinion of experts, a questionnaire was designed to determine MDS in both administrative and clinical departments. The questionnaire included administrative data elements (five classes) and clinical data elements (14 classes).2.3⍺ coefficient was used. The coefficient was calculated for the main group and entire questionnaire. The coefficient obtained for the entire questionnaire was calculated at 86%.The Delphi technique was employed for validating the developed MDS model of spinal canal stenosis national registry system. To measure the response of items, a five‐point Likert scale was used . Moreover, one open‐ended question (blank row) was set at the end of the data elements related to each class, to allow the experts to add any extra data deemed essential for the registry. For measuring the questionnaire reliability, Cronbach To acquire the opinion of experts, the questionnaires were provided to them through in‐person visits or email. The experts included faculty members with specialties in health information management, neurosurgery, physiotherapy, and medical informatics. The expert selection criteria were knowledge related to spinal canal stenosis treatment and experience related to the registry of diseases and electronic health records. The selection of experts for the Delphi technique was done through the purposive sampling method. Overall, 25 experts were chosen in this step  which are summarized in Tables 4In the present study, a MDS for spinal canal stenosis has been presented for Iran. It is divided into the administrative and clinical data groups. Most studies on the MDS have also used this classification. The examples include MDSs presented for C‐section anesthesia information management system,Given the applications mentioned in the present study, the administrative data sets for the spinal canal stenosis registry system included five classes capturing demographic data, socioeconomic data, address, healthcare identification data, and patient referral data. In the class of demographic data, eight data elements had been proposed, all being approved by the experts. The only difference between this class with other similar studies in Iran Given the study aim, which was a population registry system, one of the practical data for studying the incidence and prevalence of the disease across different regions was the patient's address. Thus, five data elements had been proposed for the address class, with three of them being approved by the experts. Two of its data including the type of residence and complete address of the patient per each country, province, and so forth had been considered for supporting the epidemiological studies of the disease across different regions. The data and classification of their values were similar to the MDS of COVID‐19 registryThe second group of data belonged to clinical aspects. A total of 94 data elements had been proposed in 14 classes, with only one remaining unapproved by the experts. The aim of the classification and proposal of data in each class was to provide important information about the disease risk factors, diagnosis, treatment, and evaluation of the treatment response process, and disease outcome. The first class of clinical data covered the disease signs and symptoms. Since pain is weighed as the most important symptom of the disease,In addition to the severity of signs and symptoms of spinal canal stenosis, the extent of disability resulting from the disease is also very important in the treatment plan and evaluation of its effectiveness. In particular, in lumbar spinal stenosis, disability evaluation becomes further important.The individual and family medical history included 22 data elements. It had been proposed first for supporting the registry of individual and family risk factor for spinal canal stenosis. The second aim was to register other underlying diseases, which can negatively affect the course or treatment of the disease. In comparison to similar registry systems such as NOR spineIn the clinical data, three classes captured para‐clinical diagnostic data elements . The medical imaging data such as MRI have great value in diagnosing spinal canal stenosis. In our study, five data elements had been proposed for medical imaging, which was similar to other studies conducted in Iran. In our study, the aim of presenting this format for diagnostic data elements such as medical imaging was to facilitate the data collection and registry in a health electronic information system (according to the action code data element). However, in the radiology form of the Spine Tango registry, numerous data elements had been considered for registering complete details of the imaging findings.For registering the treatment process data in patients with spinal canal stenosis, four data classes of physiotherapy, exercise recommendation and patient education, surgical/invasive procedures, and medication had been proposed. The data proposed in these four classes were similar to the MDS of disabilityTreatment of spinal canal stenosis depends on the clinical conditions of the patient, undergoing physiotherapy, patient education, exercise, epidural steroid injections, and surgical treatment.For a complete registry of the surgical intervention data, in addition to the surgical/invasive procedures class, a separate class had also been considered for registering the complication surgical procedure. In the international registry of vertebral column Spine Tango,The discharge status class has been proposed for registering the information on the treatment outcome in hospitalized patients, including two data elements of discharge data and duration of hospital stay. The duration of hospital stay is a kind of useful data for comparing various surgical techniques and evaluating their outcomes.5The MDS proposed in this study is designed to support a comprehensive registry of administrative and clinical data of patients with spinal canal stenosis. In this MDS, attempts were made to first emphasize the epidemiological aspects of the disease, and provide the possibility of registering and collecting patient data for various research through a clinical approach. Moreover, the possibility of data exchange between the registry information system software and HER is considered, besides using new classification systems such as ICHI. In this regard, two stage of Delphi technique was conducted by the cooperation of 25 experts in various related fields including neurosurgeons and physiotherapist besides the specialists in health information management and medical informatics. The developed model included 120 data elements in two major branches of administrative data and clinical data, each involved 27 and 94 data elements, respectively. The application of this MDS can contribute to establishing a spinal canal stenosis registry system in Iran. It can also provide a higher quality registration of patient information in different healthcare centers.Javad Zarei: Conceptualization; funding acquisition; project administration; supervision; validation; writing—review and editing. Ali Mohammadi: Data curation; methodology; project administration; writing—review and editing. Mohamad Reza Akrami: Conceptualization. Azar Jeihooni Kalhori: Data curation; formal analysis; investigation; software; writing—original draft.The authors declare no conflict of interest.The ethics committee of Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran approved the study with the ethical approval code: IR.AJUMS.REC.1400.311. All patients were guaranteed their information would be kept confidential.The lead author Azar Jeihooni Kalhori affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned  have been explained.


Workplace wellness has gained new meaning and significance in the healthcare workforce in the face of the COVID-19 pandemic. Healthcare workers across the world have carried the burden of responding to the public health crisis by having to work under new pressures and constantly changing environments, take on additional shifts, risk their own health and lives, and cope with the ongoing psychological and emotional strain. The purpose of this paper is to articulate a workplace wellness model applied across hospitals in the Illawarra Shoalhaven Local Health District, a regional area in New South Wales, Australia. The description of the development, components, and lessons learned from the SEED Wellness Model illustrates one possible solution about how to provide better care for the staff thus not only preventing staff burnout and turnover, but also creating lasting organizational benefits. The detailed model description can assist in developing a larger and more rigorous evidence-base to improve staff wellness in healthcare settings, both within Australia and internationally. Work takes up a significant amount of time in most adults' lives. The impact of work on physical and mental health has been extensively studied identifying risk factors for illness and injury , 2. As aThe Global Wellness Institute  defines Workplace wellness has gained new meaning and significance in the healthcare workforce as a result of the COVID-19 pandemic. Healthcare workers across the world have carried the burden of responding to the public health crisis by having to work under new pressures and constantly changing environments, take on additional shifts, risk their own health and lives, and cope with the ongoing psychological and emotional strain . StudiesThe purpose of this paper is to describe a workplace wellness model called SEED applied across healthcare settings in the Illawarra Shoalhaven Local Health District, a regional area in New South Wales, Australia. The Illawarra Shoalhaven Local Health District (ISLHD) extends across Yuin and Dharawal Country , about 250 km along the south-east coastline and services a population of more than 400,000 residents . ISLHD iIncreasing workplace related illness and injury among healthcare staff are becoming a global concern for healthcare systems . BurnoutConstantly changing work environments and added pressures emerging from COVID-19 are contributing to greater levels of stress and feelings of burnout and apathy experienced by healthcare staff , 26. SpeThere is growing evidence to suggest that addressing staff wellness in healthcare can have lasting benefits for individual staff members, their patients, and the organizations they work within –32. The Although wellness is sometimes perceived as an individual responsibility that should be addressed outside the workplace , organizA shift to wellness promotion instead of a sole emphasis on responding to burnout requires a different focus from healthcare organizations. Workplace change is dependent on leadership, strategic, policy and operational support to embed and sustain new or altered practices . In AustThe ETHE program supports personalized staff interactions with each other, patients, and carers because this can significantly influence patients' and carers' experiences of care. While the NSW Ministry of Health has a state-wide focus, ETHE also aims to understand local contexts that staff work in to facilitate culture change. This includes place - the workplace environment, resources, community; processes - communication, feedback, and technology; and people – leadership, governance and staff experience . HoweverIncluded in the ISLHD Strategic Directions is supporting, developing, and inspiring the workforce and enhancing the workplace culture . These sMilton Ulladulla Hospital, a small hospital in the southern part of ISLHD, played a critical role in supporting the local community. As a large portion of the hospital staff reside in the same community and were personally affected by the bushfires and floods. The Chief Executive of ISLHD mobilized additional resources to respond to the psychological impact on the staff. The result was a locally designed and implemented wellness program the staff called SEED  .The SEED initiative was led by a Senior ISLHD staff member with experience in social work, change management, and leadership education in close collaboration with the Director of Nursing/Operations Manager and all staff of the Milton Ulladulla Hospital. The Program Lead initiated focus group discussions and individual consultations with hospital staff to learn about their needs and their vision for workplace wellness following the bushfires. Forty-one staff were consulted within 2 days, and 84 suggestions were themed into five workplace wellness initiatives. The co-design of program initiatives and the immediate follow-through resulted in the staff sense of empowerment, trust, and investment in the process . A finalAs other hospitals in the district expressed an interest in SEED, the peer support initiative quickly grew to a workplace wellness model, with a longer-term focus on staff wellness and the development of a workplace culture of connection, compassion, and gratitude . As one SEED is a workplace wellness model that strives for staff to experience more meaning, happiness, and connectedness at work. SEED was designed to produce and promote holistic wellness, a wellness of individual spirit, a wellness in community, a collective wellness of belonging, and a connection to land after the bushfire. The underpinning philosophy of SEED uses a strengths-based approach to ascertain the needs of staff and implement staff-led wellbeing initiatives that build resilience and aid recovery processes. In a strength-based approach the emphasis is on doing more of what works rather than trying to change deficits . The folThree important characteristics of my own leadership style have guided me throughout this time: mindfulness, compassion, and service. Practicing mindfulness and daily reflection has supported me in becoming more self-aware and focused. Compassion for me is not about being soft, but the ability to understand people at an emotional level, and truly caring about their wellbeing. Being committed to serving others during this time has helped me provide the space and support for my colleagues to thrive .SEED is modeled around authentic participation  as well Some of the SEED initiatives that were implemented across different ISLHD sites include:Quiet Room - a space inside the hospital for staff to take a moment each day for a quiet reflection.Reflection Tree - hand-crafted wooden tree placed on the hospital wall signifying the growth of the hospital community following the bushfires. It has been adapted in other hospitals to a Kindness Tree, Gratitude Tree, Hope Tree where staff write on sticky notes one act of kindness they experienced at work or something they feel grateful for at work and hang it on the tree.Coffee Buddies - a planned coffee break with a nominated staff member as a form of collective care for each other. Buddies are randomly chosen from all staff and not organized by role or seniority.Wellness Warrior Training - a dedicated group of health care staff trained in strengths-based ways of creating a supportive work environment. For example, purposefully spending time listening to colleague's concerns and experiences without jumping to solutions.24/7 Wellness - facilitating 24 weekly wellness sessions in the workplace to promote staff wellbeing .(S)Crap book- a unique communal journal designed by the staff and placed in the tearoom for front line staff to take a moment of reflection. The book aims to facilitate externalizing their unique experience and stressful stories occurring during the pandemic.New ideas or adaptations of the existing ideas are encouraged at each site to respond to the unique needs and circumstances of the staff.Finally, SEED is also inclusive of the leadership teams by 1) inviting leaders to all SEED activities and 2) holding leadership meetings and workshops to create space for leaders to reflect on their leadership style, interactions with staff, and vision around staff wellness for the future. Leaders are welcome to join any wellness activities and are free to disengage at any time. Importantly, SEED has been intentional in not replicating the hierarchical relationships while engaging in SEED activities; as explained by the Program Lead: “wellness is a space where we sit as equals” . The SEESince the conception of SEED in January 2020, over 600 staff and 40 leaders have been involved in SEED activities and events. SEED sessions have been conducted to create awareness around the concept and importance of workplace wellbeing. Other sessions have included mindfulness, mentoring, facilitation, education sessions and information sessions. At a local level, the community has become involved in SEED initiatives. As the COVID-19 pandemic forced intensive care nurses into isolation, community members cooked and delivered meals to them after SEED participants put out a call to friends and neighbors. The most recent SEED events were the World Kindness Day celebrations in hospital wards and the coming together of 35 staff and few community members to be part of a Visual Story Telling event. The collective story captured the journey of SEED, its personal impact as shared by participants and identified where this group visualizes SEED moving forward including expanding to new sites.via an IT platform called HOPE . The SEED model approaches PRMs implementation by firstly focusing on staff wellness, which in turn may help them engage more effectively with their patients. Recognizing that constant workplace change causes stress and uncertainty for staff, SEED will support the pilot wards to enhance staff wellness as a prerequisite of effectively using HOPE. This SEED initiative is now part of a PhD study in collaboration with University of Wollongong (UOW) to formally evaluate the role of staff wellness in HOPE implementation.Ways of sustaining and growing SEED has been a focus of 2021. SEED is now part of change preparedness activities as staff are introduced to the collection and use of Patient Reported Measures (PRM) in the inpatient settings. ISLHD is the first site in NSW to launch PRMs More broadly, SEED has garnered interest at a state government level with several SEED wellness sessions delivered to staff at the NSW Ministry of Health. The concept of SEED has been presented at three major conferences and several celebration days including World Social Work Day and The Compassion Revolution Conference. Other ways of sharing the SEED model have included creating audio visual materials that portray staff experiences and articulate ways SEED has been practiced. For example, three podcast episodes have been completed and launched on The Social Work Stories Podcast in November 2021 , a 30-miSEED design and implementation has not been without challenges and there are several lessons that were learnt in the process. SEED began immediately after a bushfire disaster and there was a high level of suspicion and reluctance expressed in the start-up phase from the hospital staff and management. Strong consultation and facilitation skills from the founding SEED team were thus essential to work through those initial responses and encourage people to become involved. Still, the wellness activities were voluntary and not all staff participated, leaving some staff expressing disconnection and exclusion. The lesson here has been to work closely with those staff experiencing disconnection, and to ensure that all staff are given explicit permission and encouragement from the hospital leadership to look after their wellness during work time. More importantly, organizational measures need to be put in place that alleviate a sense of guilt that staff may feel when they prioritize their own wellness in work hours. To mitigate some of these issues, SEED wellness activities were scheduled at a time where there was one-hour overlap between changing shifts, meaning theoretically no floor staff should have been burdened by scheduled wellness activities. Still, the timing and the types of wellness sessions were not able to accommodate everyone in what was a diverse staff group.A further challenge encountered was that the staff-led and organic nature of SEED did not fit neatly into the way healthcare settings usually operate. The participatory methodology of SEED required flexibility, patience, and was process-oriented, creating potential clashes with the tick-box, outcome-oriented healthcare culture. Questions therefore present in relation to the potential expansion of SEED beyond the original hospital – how do you scale a staff-led program up without losing its organic and situated character? Although ideas of wellness activities have been described in this article, all SEED activities are formulated by the staff themselves, making them unique to their setting. Accordingly, to stay true to its core principles, SEED cannot be manualised and summarized into a step-by-step approach. Although there are core SEED practices that can be followed, each team/ward/hospital must “plant its own SEED” by designing its localized SEED wellness activities.A final challenge SEED encountered was related to resources. Although SEED is a relatively low-cost workplace wellness intervention, it requires certain human, physical and fiscal resources including a facilitator or a team of facilitators, depending on the size of the workplace, who can guide the start-up phase at each site. The length of this phase varies depending on staff availability and engagement. SEED follows the “train the trainer approach” as it identifies and trains staff at each site who can take the lead in implementing and maintaining SEED activities. In addition to covering the cost of the facilitators and staff attendance at the consultation and training sessions, workplaces need to be willing to dedicate a certain number of hours weekly to the identified staff members to organize and implement the SEED activities. If the site is understaffed, as has been the case in many hospitals during the COVID-19 pandemic, the likelihood of prioritizing staff wellness decreases. SEED has encountered resourcing challenges at various stages and sites have had to look for alternative ways of ensuring the continuity of the wellness initiatives, such as community and local university support. The spread and sustainability of wellness initiatives thus depends in large part on the ongoing access to resources.The description of the development, components, and the process of the SEED Wellness Model illustrates one possible solution about ways to provide better care for healthcare staff thus not only preventing burnout and turnover, but also creating lasting organizational benefits. While starting prior to the NSW Ministry of Health Elevating the Human Experience strategy, SEED has operationalized the strategy by creating a localized (place), staff designed, and leadership supported (people) wellness plan (process) that is human-centered. The organic development of the SEED wellness model as a collective crisis response; and its subsequent staff engagement and repurposing for new sites demonstrates an appetite for such initiatives among healthcare staff.Although there is a growing number of workplace interventions to promote wellness such as the 5 Ways to Wellbeing , the PERThe detailed model description provided in this article can assist in developing a larger and more rigorous evidence-base to improve staff wellness in healthcare settings, both within Australia and internationally. An empirical study which examines SEED practices and outcomes in response to pandemic-related stress is already underway. This study is using qualitative methods to explore SEED participant's experiences of the program. But there remains a need for more research. Specifically, research investigating the barriers and enablers to SEED, identifying what are core components in all sites and evaluating the impact of SEED using staff and organizational wellness measures, including calculating cost effectiveness, will refine the model and facilitate transferability. A stepped wedge cluster randomized trial at eight SEED implementation sites is planned for 2023.Created to respond to the needs of hospital staff in the aftermath of bushfires, the SEED Wellness Model has now been applied across four hospitals in the Illawarra Shoalhaven Local Health District and is gaining state-wide attention in Australia. The practices that have underpinned the growth of SEED have successfully been adapted to a variety of contexts. These practices include hospital leadership being open to listen in a way that identifies the collective needs of staff, creating wellness interventions that respond to these identified needs, and enabling staff to become “wellness warriors” who are open to companioning their colleagues by listening to their experiences of hurt and trauma. The practices of SEED have resulted in creating positive workplace cultures where staff have described a sense of human flourishing. Staff designed wellness programs can offer healthcare organizations an alternative to ameliorating burnout amongst healthcare workers, particularly during a crisis such as a natural disaster and pandemic. Just as we need to prevent natural disasters such as the Australian Black Summer, we need to strive to prevent healthcare staff burnout. As SEED has demonstrated, promoting and maintaining wellness initiatives is perhaps the best way to go about it.PP, KO, and JA developed the paper scope and aim, wrote initial drafts, and finalized the submission. AK, MM, MF, LK, and AH each drafted a section of the manuscript, reviewed drafts, and approved the final version. All authors agree to be accountable for the content of the work.This project was jointly funded by the University of Wollongong 2020 Community Engagement Grant and the National Health and Medical Research Council (NHMRC) through the Medical Research Future Fund (MRFF) 2020 COVID-Mental Health Research Grant MRF2005659.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.