The YOUth cohort study aims to be a trailblazer for open science. Being a large-scale, longitudinal cohort following children in their development from gestation until early adulthood, YOUth collects a vast amount of data through a variety of research techniques. Data are collected through multiple platforms, including facilities managed by Utrecht University and the University Medical Center Utrecht. In order to facilitate appropriate use of its data by research organizations and researchers, YOUth aims to produce high-quality, FAIR data while safeguarding the privacy of participants. This requires an extensive data infrastructure, set up by collaborative efforts of researchers, data managers, IT departments, and the Utrecht University Library. In the spirit of open science, YOUth will share its experience and expertise in setting up a high-quality research data infrastructure for sensitive cohort data. This paper describes the technical aspects of our data and data infrastructure, and the steps taken throughout the study to produce and safely store FAIR and high-quality data. Finally, we will reflect on the organizational aspects that are conducive to the success of setting up such an enterprise, and we consider the financial challenges posed by individual studies investing in sustainable science. The rationale and design of the YOUth study are provided by The primary aim of the YOUth cohort study is to understand the development of social competence—the “ability to engage in meaningful interaction with others”—and self-regulation—“the ability to control one’s emotions, behaviour and impulses and to adapt to rules”. These competencies are thought to rely on various neurocognitive abilities. The interaction of biological, child-related and environmental factors guides the development of these neurocognitive abilities. This interaction, however, is poorly understood. The YOUth cohort gathers data that may enable the construction of predictive models of behaviour from environmental and biological determinants by measuring biological, child-related and environmental factors, as well as abilities and competencies throughout development and in various contexts.The cohort is divided into two sub-cohorts, focusing on different age groups: YOUth Baby & Child, from gestation to around the age of six, and YOUth Child & Adolescent, from around the age of nine to around the age of 15. The aim is to include 3000 and around 2000 children and their parents in these two sub-cohorts respectively. Inclusion for the sub-cohorts is done in parallel. Participants visit our Child Research Center (CRC) at regular intervals (“waves”) and measurements are repeated at each wave. Participants are recruited in various ways, e.g. through hospitals, midwifery practices, daycare centres, and primary schools. Recruitment began in July 2015 and is ongoing.YOUth collects biological material and body measurements, and measurements of children's development through computer tasks, questionnaires, eye-tracking experiments, EEG experiments, (f)MRI scans, video recordings of parent-child interaction, 3D ultrasound sweeps of the foetal brain and video tasks . Some, such as genetic data and information on religious beliefs, are legally classified as special categories of personal data by European legislation  art. 9). These data should thus be processed with particular care, requiring extensive technical and legal measures to ensure the privacy of participants.Finally, we aim to provide high-quality data. We investigate children from a wide age range using a plethora of research methods and procedures that are often technically complex and may be prone to error or malfunction. YOUth therefore employs extensive procedures regarding data collection and monitoring of data quality to ensure that high-quality data are collected.Realizing these three ambitions requires collaborative efforts of multiple parties. The YOUth cohort is a joint research effort by a number of research organizations. Therefore, the data infrastructure in which these procedures are realized must be a joint effort as well, combining components of different organizations into a unified and integrated system. Furthermore, partner organizations with the necessary expertise, personnel and resources to facilitate research data at scale had to be included. In our case, we partnered with (among others) the Utrecht University Library (UUL) and the Utrecht University Information and Technology Services department (ITS).In the spirit of open science, YOUth will share its experience and expertise in collaboratively setting up a high-quality research data infrastructure for sensitive cohort data. In this paper, we present a model of data quality control and data stewardship that meets the criteria outlined above and puts YOUth, as a large and complex cohort study, at the forefront of proper data infrastructure and management procedures, and at the forefront of using the FAIR principles in the context of sensitive cohort data. In what follows, we will explain how the development of our data infrastructure was guided by the FAIR principles as well as data safety and quality goals. First, we will discuss how we applied the FAIR principles, as this required the largest infrastructural investments. Next, we will describe additional measures we took to ensure optimal safety and confidentiality. Finally, we will discuss the procedures we developed to enhance data quality and close with a discussion on the lessons we learned throughout this endeavour as well as future opportunities and challenges.2In recent years, academic institutions and funding agencies, such as the Dutch Research Council , have beA key element in producing FAIR data is proper data management. The YOUth data pose various data management challenges. For example, due to the wide range of measurements, the YOUth data are composed of a wide variety of data sources and formats. Some of these data, such as those obtained through questionnaires, can be stored in tabular data storage solutions (i.e. databases), while other data, such as videos of parent-child interactions and MRI scans, are not suited for tabular storage. In addition, biological samples are collected, which have to be stored physically. The management of the YOUth data is further complicated by the fact that the data collection effort spans across different legal entities. The research data are not just collected by YOUth researchers at our CRC, but also by partnering academic institutions, both regionally ) and nationally (e.g. a food questionnaire administered by Wageningen University (WUR)). This imposes additional regulatory burdens on the data collection, such as data processing agreements. Furthermore, the size, continuity and duration of the data collection demands high levels of storage space, throughput, reliability and durability from the data infrastructure. An estimated 63 GB of data is collected per week, with a projected total size of approximately 26 TB.storage of the data from source systems into centralized data repositories, the structure in which the source data are stored, the integrity of the data transfer, and the integration of the different storage systems into a unified whole . An overview of our data infrastructure is found in The topics to address in developing the data infrastructure itself concerned the 2.1We sample tabular data (e.g. questionnaire responses), non-tabular data (like EEG or MRI measurements), and biological material, each requiring a dedicated storage solution. A facility for the storage of biological samples was already available in the Utrecht Biobank. Tabular data are stored in the UMCU Research Data Platform (RDP), which is part of the UMCU’s enterprise data warehouse solution, allowing us to extend pre-existing business intelligence capacities for advanced querying and selection of the data. For non-tabular data, ITS—informed by the needs of the YOUth study—developed Yoda,2.2Data storage needs to be organized in a way that optimizes findability and retrieval. This is of fundamental importance, for without properly organized data, other requirements, such as data removal requests, cannot be met. In consultation with ITS, the YOUth data are organized by means of four characteristics: wave, experiment code, pseudocode (participant identification code) and version. The wave is the life-stage at which the participant visits us (e.g. at 5 months or 12 years of age), the experiment code is a shorthand for the experiment name (e.g. “infsgaze” for the Infant gaze cueing eye-tracking experiment), the pseudocode is a code consisting of a letter that identifies the subcohort (A for Child & Adolescent and B for Baby & Child) followed by a five-digit random number that uniquely identifies a participant, and the version indicates the version of a data set (e.g. raw data as obtained through the measurement computer or data further processed from these raw data). Since the participant can only take part in each experiment once per wave, the WEPV  combination can uniquely identify a data set. The internal identifiers are thus assigned to (yet) unpublished datasets. When data sets are published, they are supplied with a globally unique identifier in the form of a DOI (of which the URL is pointing to a Yoda landing page). These DOIs are exposed through DataCite.2.3As our data are sampled through different source systems (such as lab computers and online questionnaires) and need to be transported to their centralized data repositories for permanent storage, procedures are required that safeguard the integrity of the data transfer. We have developed such procedures, tailored to each data source. For example, for the non-tabular data collected through lab computers at the CRC, a script was written that calculates a cryptographic hash2.4As explained above and shown in We solved this by adding two additional components. First, we used the SLIM (Study Logistics and Information Manager) cohort administration system, developed and operated by the UMCU. This system enables us to survey and control the data collection and to coordinate communication with our participants. Second, we aggregated the metadata of all collected data into the RDP. We thus created a centralized database with an overview of all data collected, which we can subsequently query to retrieve specific information about our data (e.g. how many MRI scans do we have of children whose mothers smoked during pregnancy).2.5The variety of measurements within YOUth come with a variety of data formats in which the data are stored. To ensure interoperability and long-term accessibility, we use non-proprietary output data formats preferred by the Data Archiving and Network Services organization (DANS) of the Royal Netherlands Academy of Arts and Sciences  and by t2.6findable (by a computer) in the first place. Detailed, well-structured and machine-readable metadata are key to increasing the findability and the assessment of the reusability of data. Metadata with respect to research data consist of any information about the context in which those data were produced, e.g. organizational information about the cohort itself or the researchers involved. The metadata will also allow a deeper understanding of the data itself by providing relevant information about the experimental setup. This is, for example, realized by including (DOI-based) references to important underlying papers, i.e. articles that provide insight into the rationale behind the experiment that is actually performed. Furthermore, the metadata provide an unambiguous identification of equipment used, a description of the measurement methods that were applied, and keywords for the identification of phenomena involved in the experiment.YOUth data may be requested for use by researchers , technical information  or detailed descriptive tags .High-quality metadata are available for all experiments performed. However, they are currently mostly scattered through the Yoda file system in the form of folder names, settings files, and metadata headers for specific binary formats. Therefore, in collaboration with the metadata specialist of the Utrecht University Library, we developed a script to aggregate, validate and store our metadata in an explicit metadata structure, thereby allowing a mapping towards the Data Documentation Initiative  standard where applicable. This script runs on the data in the Yoda vault and does three things. First, it extracts metadata from various sources (e.g. WEPV information from the folder name and eye tracker device identifiers from settings files). Next, it validates the extracted metadata against a predefined schema  our data can be granted, we have written and published a data access protocol. When  researchers wish to request YOUth data, they fill out our data request form, which then goes through an extensive evaluation process by the YOUth Executive Board, the data manager, and the Data Management Committee. Data requests are assessed on whether they fall within the YOUth framework , and within the limits of the informed consent provided by the participants of YOUth. Moreover, requests are evaluated in terms of the specificity of the research question, hypothesis, proposed method, and analysis plans, and on whether the requested (combination of) data may pose risks to the privacy of participants. Access to biological materials can only be granted after additional approval from the Biobank Review Board (Toetsingscommissie Biobanken) of the UMC Utrecht. A detailed description of (further) terms, conditions and procedures is available in the YOUth Data Access Protocol.92.8As the scope of the YOUth cohort is broad and its data is thus of potential interest to a broad range of researchers, we need to be prepared for frequent data requests. In addition, as outlined above and detailed in the YOUth Data Access Protocol, the handling of a data request is a multi-step procedure involving multiple actors.To streamline the handling of data requests and increase the ease of accessibility of the YOUth data, we developed an automated data request processing system as an extension to Yoda (expected to be available summer 2020). This system implements the flow of the procedures specified in the YOUth Data Access Protocol. It allows researchers to submit data requests online, and facilitates the actions requested from the people involved in the evaluation and transfer procedures. By developing this system as an extension to our main data storage facility, we are able to combine the request, staging and transfer of data within a single system, simplifying the process for all actors involved. The requesting researcher is automatically kept up to date on the progress of the data request. All information and documents needed to establish an audit trail are captured by the system.2.9https://www.openarchives.org/pmh/.Open Archives Initiative Protocol for Metadata Harvesting. See 3The safety of our participants and their data are our highest priority, especially since we are collecting data from children. In this section, we describe how we protect their privacy, confidentiality, and safety throughout and after their participation in YOUth.3.1The data from the YOUth study cannot be stored anonymously since the study involves subjects repeatedly visiting the research centre. Therefore, a participant administration has to be kept for purely logistical reasons. A first safeguard of the confidentiality of the data we collect is that the systems developed and operated by ITS (i.e. Yoda) conform to the security requirements specified by the Utrecht University Information Security Policy , which iBesides these technical data safety measures, data transfer agreements are used to restrict the use of data by third parties, legally binding them to only process the data on secure systems under their control and to securely destroy the data when they have served their purpose (e.g. the production of research output).3.2All our procedures are approved by the institutional review board of the UMCU. As the YOUth cohort involves many different tasks and measurements, we split up the approval into a framework protocol and an amendment to the framework protocol for each of the waves. This construction allows us to modify our protocols in order to keep up with changing privacy legislation and to make necessary adjustments to our tasks and measurements over the course of many years of data collection. In addition, we developed a series of Standard Operating Procedures (SOP).3.3The GDPR legally requires us, under certain conditions, to comply with data removal requests (GDPR art. 17). Participants are also free to revoke their consent and to require removal of their data. Consent revocation forms are available to participants (on paper and on the YOUth website), allowing them to revoke their consent temporarily or permanently, and allowing them to decide whether the data already collected are allowed to remain available for study or should be destroyed. However, in order to make verification of published results possible, data that have been used for published research before the removal request arrives will not be destroyed but marked as unavailable for future research instead. A withdrawal can be permanent  or temporary (for a specific wave), and can apply to one or more family members. The consent revocation is administered in SLIM and in the RDP, the latter enabling the data manager to remove data from source systems when requested.3.4The post-GDPR world has renewed attention for and concerns about data privacy. Simultaneously, the digital threat landscape has gotten more hostile as opportunities to maliciously exploit intrusions of internet-connected systems have evolved . FurtherThe personal health train approach goes a step beyond VREs in terms of data security by preventing the third party from directly interacting with the data at all. Instead, the desired analysis is performed where the data reside , after which the results of the analysis are transmitted to the researcher. As an addition to the PHT approach, we propose that a data set may be made publicly available that is identical to the real data set in structure and file formats , but whose actual data consists of (plausible) randomly generated data or data from a set of test runs. This allows third parties that are interested in testing particular hypotheses against the YOUth data to develop appropriate analysis scripts in the absence of the actual data. The hypothesis and accompanying analysis script are then submitted to YOUth for review and, if approved, are granted execution privilege, after which the analysis results are returned to the third party.4Ensuring that our data are of high quality requires the measurements and experiments to not only be well-constructed, but also their data output to be subject to regular data quality control. Three aspects of the YOUth cohort make this especially important. First, being a longitudinal study, we are particularly interested in differences between waves. Therefore, any change to a task or experimental setup may confound the interpretation of differences found between waves. Second, due to the complexity of some of the experimental setups and equipment, there are risks of unintentional adjustments or defects during data collection. These can degrade or compromise the collected data. Third, the rapid and continual pace of inclusion means that defects of experimental setups have near-immediate consequences.The YOUth cohort includes experiments and measurements from across the spectrum of cognitive (neuro)science. While responsibility for the logistic quality controls of all data  is centralized in the data manager, it is undesirable to delegate all quality controls to a single person or group because of the domain-specific expertise required. Therefore, we designate domain-responsible researchers to monitor the quality of output data falling within their domain . The implementation of this process is designed by the domain-responsible researchers themselves, using their expertise and the common practices in their respective fields.•The development and implementation of a dedicated eye-tracking setup capable of obtaining high-quality data with multiple age groups. The setup is explained in detail in •The training of research assistants as to the proper use of the experimental setup. This includes watching a series of instruction videos and observing measurements conducted by more experienced research assistants.•The creation of an open atmosphere in which research assistants are comfortable sharing potential anomalies or errors to the YOUth manager of logistics, who will then discuss these with the domain-responsible researcher.•Online monitoring during the recording of the estimated gaze position on the computer screen, using a separate screen connected to the stimulus computer. This allows research assistants to estimate the data quality as they are being recorded.•In-person observation of research assistants' measurements by the domain-responsible researcher or a delegated party (about once every two months).•Control of the newly collected data using eye-tracking specific indicators of data quality  the optimization of the experimental setups, (2) the training of the research assistants, (3) the monitoring of the quality of the obtained data, and (4) the implementation and registration of adjustments to experimental setups or data-collection procedures. Specific steps that have been implemented for the eye-tracking domain are:For all domains, periodic quality control reports are written by the domain-responsible researchers, documenting any potential anomalies and proposing potential countermeasures. These reports are delivered to the YOUth executive director so that centralized overview and control of the data quality is maintained.Although quality control is executed rigorously in this manner, fully automated quality control is one of our ambitions. Automated data quality control integrated into the entire data pipeline  would circumvent the manual step of having to access new data by the domain-responsible researcher to run quality control scripts, and would allow researchers and research assistants to continuously monitor data quality. In some of our domains, great steps have already been taken to implement this. For example, a data-quality control pipeline as just described is already operational within the MRI domain, including interactive reports of quantitative and qualitative measures generated immediately after data acquisition  funding for projects that produce large amounts of high-quality, FAIR data that is securely stored and managed is therefore crucial if we want to make science more sustainable. A return on such investments could at least partially be made by reuse of the data. For many academics in human research the collection of new data is a standard element of the scientific cycle. While for many research questions new studies may indeed be necessary, there are also many research questions for which the reuse of large and high-quality (existing) datasets will be essential, for example in stimulating (multidisciplinary) cooperation. As a bonus, reusing data might cut the cost for data collection. Subsidising the implementation of safe, FAIR and high-quality datasets is therefore in the end a scientifically, and potentially also economically, sound investment.Gravitation programme of the Dutch Ministry of Education, Culture, and Science and the Netherlands Organization for Scientific Research (NWO grant number 024.001.003).The YOUth cohort is part of the Consortium on Individual Development (CID), which is funded through the The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


The field of preclinical models is a very vast arena, in which finding connections among groups acting in apparently very distant research areas can sometimes prove challenging. An osmosis of mindset and competencies , along with a comparison of different standpoints, is always an opportunity to reflect on where one’s work stands in a wider scenario. The goal of this Special Issue is to collect information, and ultimately share ideas and foster debate about different approaches to translational model research. The eleven papers composing this issue will be of interest to researchers looking for an update of the currently heterogeneous panorama of preclinical models and to those in search of inspiring ideas in the field.Out of eleven papers, six are based on animal models ,3,4,5,6,In this context, the issue raised by some authors about the translational validity of a certain animal model, in this specific case the Reeler mouse, is very timely. Central to the debate is the rare occurrence of the very conditions for which mice homozygous for the Reeler mutation have been created, and the objective difficulty of fully validating the mice expressing the heterozygous genotype as a translational model for more frequent diseases such as autism and schizophrenia .After all, animal models are often suspended “halfway” between being widely accepted as good tools for basic research and being recognized for their translational potential. Therefore, this issue should always be considered when somebody, whether experimenter or modeler, decides to work with them. In this regard, one paper focuses on the improvement of cellular and animal models of chondrosarcoma. The authors  provide Cancer, and more specifically the usage of nanoparticles (NP) both for multimodal imaging and as contrast agents (CAs), is the topic of a review  which hiThe centrality of interdisciplinary synergies is further highlighted in a paper  specificThe “from bench to bedside” path is also the leitmotif of an article  addressiwww.mdpi.com/2077-0383/8/12). The article, presented by a group active in the field of dermal substitutes [Good news from the field of skin regeneration: the work on bioengineered skin substitutes has been selected by the editorial board as the cover story of the issue of December 2019  in tissue engineering [in silico models capable of exploiting patient-specific data to build personalized medical treatments, such as three-dimensional mathematical models of tumors [in vivo experiments and in silico representations to obtain more powerful descriptive and predictive models is also emerging: for instance, the integration of microfluidic devices and computational modeling to better study vascularization dynamics in cancer [An important contribution might come from ineering . Anotherf tumors . The urgn cancer . The harmonization of data coming from different fields ,20 and t


Efforts are ongoing in order to test this hypothesis in clinical trials. Some studies demonstrated no evidence of efficacy, whereas in some cases results were retracted after reporting. Despite the lack of scientific validation, support for the use of these compounds continues from various influencers. At the cellular level, the lysosomotropic drug chloroquine accumulates in acidic organelles where it acts as an alkalizing agent with possible downstream effects on several cellular pathways. In this perspective, we discuss a possible modulatory role of these drugs in two shared features of neurodegenerative diseases, the cellular accumulation of aberrantly folded proteins and the contribution of neuroinflammation in this pathogenic process. Certainly, the decision on the use of chloroquine must be determined by its efficacy in the specific clinical situation. However, at an unprecedented time of a potential widespread use of chloroquine, we seek to raise awareness of its potential impact in ongoing clinical trials evaluating disease-modifying therapies in neurodegeneration.On the verge of the ongoing coronavirus pandemic,  Soon afin vitro . The mosin vitro . Likely e daily) , in a SAThe EUA permission and revocation of the use of CQ/HCQ has caused a stir in the scientific community and beyond during this unstable and delicate pandemic situation. While we acknowledge the natural tendency to dismiss uncomfortable facts and the keenness to move away from CQ, reflecting on possible short and long-term neurological side-effects caused by its use are worthy of a more comprehensive scientific consideration. In particular considering that CQ was, and still is, used as a putative off-label drug to treat SARS-CoV-2, highlights that the response to this pandemic has not always been ruled by a rational and scientific approach. Nonetheless, the possible consequences of using CQ should instigate discussion and warrant a more cautious approach if a similar situation should arise in the future. Here we provide a perspective on the potential interaction of CQ and the neuronal dyshomeostasis observed in common degenerative disorders such as Alzheimer's or Parkinson's disease. We consider the pharmacodynamics and pharmacokinetic attributes of CQ, and its potential effects on the nervous and immune systems.Historically recognized for its undeniable utility in malarial prophylaxis and treatment , CQ is aPlasmodium . Although a causal relationship has not yet been demonstrated, there are studies reporting a correlation between prolonged treatment with non-steroidal anti-inflammatory drugs and decreased risk for Alzheimer's and Parkinson's disease , 41. Act+ T cells  is worth considering. However, the use of CQ and its analogs must be determined by clinical need, so that prescribing CQ may be opportune and take priority depending on specific clinical context. However, at a time of a potential widespread use of CQ, in order to mitigate the risk of potential misinterpretation in ongoing clinical trials evaluating disease-modifying therapies in neurodegeneration, we seek to raise awareness and caution that the use of CQ and its analogs needs to be clearly documented and carefully considered in interpreting trial outcomes in this arena and beyond.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.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.


Our main finding illustrates that in low-intensity ICUs, collaboration between CNSs as head nurses and intensivists may reduce patients’ length of ICU stay.Certified Nurse Specialists (CNS) are advanced practice nurses that often play a role in management. This study aims to investigate whether cooperation between CNSs in the position of Intensive Care Unit (ICU) head nurse and intensivists change the length of stay for ICU patients. A single centered retrospective cohort study design was followed. A multivariable regression analysis was performed to determine whether there is a difference in patients’ length of ICU stay for two years before and after CNS as ICU head nurse and an intensivist started collaborating. The patients’ diagnosis, age, gender, scheduled/emergency admission, surgical history, length of ICU stay, usage of ventilator, and details of ICU treatment were collected from the institution’s electronic medical records. During the study period (April 2015 to March 2019), 3,135 patients were admitted to ICU, with 1,471 in the before collaboration group and 1,664 in the after-collaboration group. Collaboration between the CNS as head nurse and intensivists was significantly associated with shorter length of ICU stay (coefficient -0.03 ,  A low-intensity ICU employs a system in which only doctors in each medical department treat patients in the Intensive Care Unit (ICU) and intensivists get involved only at the request of the attending physician or surgeon.  In such An APN has a master’s or doctoral degree and contributes to the development of bedside care through evidence-based direct care, multi-professional collaboration, and education. Certified Nurse Specialist (CNS) is one of the titles recognized as an APN in Japan. A CNS received education in a graduate school master’s program and performs nursing practice with the background of knowledge in nursing management, nursing education, and nursing research, as well as their specialized field. The system is modeled on the same principal as that of clinical nurse specialists in the United States. ,8Similar to other countries, the CNS in Japan is expected to provide advanced nursing practice and education and provide care and decision support to patients with complex clinical problems as well as multi-professional teams experiencing difficult issues. Approximately 20% of CNSs work as nurse directors, vice nursing directors, and head nurses .In low-intensity ICUs where no intensivists are stationed, it is necessary to combine the expertise of each profession to treat and care for patients and to improve their condition. Therefore, CNSs who specialize in critical care not only support collaboration among different professions and provide advanced care to patients based on their specialized knowledge, but also participate in organizational management as the head nurse of the ICU.As their chosen career, experienced CNSs sometimes manage wards as head nurses. The duties of a head nurse include organizational development by being responsible for interpersonal relationships between nurses and patient care, work planning, intrinsic motivation, workload, unit size, and leadership to improve the job satisfaction of nurses and quality of the care.  MoreoverThe CNS as head nurse has a background of expertise in managing both the organization and patient care. In this position as a clinical care specialist, multidisciplinary collaboration and interdisciplinary collaboration for organizational management are combined. In ICUs, treatment and care are especially critical. Effective collaboration between physicians and nurses is needed as the first step in multidisciplinary collaboration to ensure that appropriate knowledge-based and evidence-based care is provided to improve patient outcomes and the quality of treatment and care. Outcomes and goals are set in collaboration between the head nurse, who is responsible for the ward, and the doctor, who is responsible for the treatment, enabling the entire organization to deliver treatment and care in the same direction.However, no study has examined patient outcomes associated with intensivists’ and CNSs’ collaborative management of an ICU. The aim of this study is to investigate whether CNSs as head nurses can work with intensivists to make changes to patients’ length of stay in low-intensity ICUs.A single centered retrospective cohort study was conducted at the ICU of a Japanese Hospital during a 4-year period (April 2015 to March 2019).The ICU in the target facility has 10 beds and is a general ICU that accepts patients with sudden changes in their health status from the hospital’s other wards; mainly postoperative patients and tertiary emergency patients. As this is a low-intensity ICU, surgeons were concurrently in charge of the ICU until March 2017; however, from April 2017, the anesthesiology department  became the center of the ICU’s management and started participating in the treatment of ICU patients while concurrently performing surgery.In an interview with CNS, several intensivists, and surgeons about the changes in management, the following points were clarified after CNS as head nurse and intensivists were included in the management of the ICU.The system of providing medical care in the ICU was changed from a system in which each department provided medical care by itself to a system in which the attending physician consulted with the intensivists when necessary .  Prior toThe CNS as ICU head nurse and intensivists now play central roles in providing nursing education through the preparation for changes in ICU management and the preparation and implementation of various protocols. This involves providing advice and support for treatment in each department and arranging consultations, coordination, and conferences concerning long-term patients and cases with ethical problems.In regular morning meetings, the conditions of all the patients in the ICU were outlined/communicated to the intensivists.Considering ICU bed control, the CNS comprehensively examines the severity of the patients’ conditions and the necessity of daily life support in the ICU to select patients to enter or leave the ward, while the intensivists examines the medical necessities to make the final decision.The CNS as head nurse serves as the link between the primary physician and the intensivists, as well as between the ICU nurse and the anesthesiologist.As a result of the implementation of these items, the ICU—in which the primary physician used to decide on the treatment plan—has been transformed into a collaborative ICU, in which the CNS and the intensivists determine the treatment plan and the nursing policy of the medical team .This is a secondary study that uses datasets collected during a previous related study.  This meaResearch ethics approval was obtained from the internal review board of Kyoritsu Women’s University (approved ID: KWUIRBA#19011) and the internal review board of the Tokyo Saiseikai Central Hospital (Approved ID: 30–88). Consent was not required from participants due to the de-identified nature of the data and the retrospective study design.The severity of each patient’s condition and the extent of their required medical and nursing care were determined. The former was assessed using a scale that measures the degree of dependence on medical care for patients admitted to the ICU created by the Japanese Ministry of Health, Labour and Welfare .The study period was divided into two periods: before collaboration (April 2015 to March 2017) and after collaboration (April 2017 to March 2019) between CNS as head nurse and intensivists. The two periods were compared using a Fisher’s exact test for categorical variables and a Mann-Whitney U test for continuous variables. To determine whether the collaboration between the CNS as head nurse and the intensivists was associated with long-term admission of ICU patients, a multivariable regression analysis was performed. The independent variables were age, gender, and variables that were significantly different in univariate analysis. The dependent variable, the length of ICU stay, was translated logarithmically. This is to avoid affecting the data owing to some long-term ICU admissions. In addition, variables with a Variance Inflation Factor (VIF) value of 10 or more were excluded. Prior to the analysis, the difference in the assignment of ICU nurses between the two periods was examined to consider the possibility of the assignment of ICU nurses affecting the study results. The difference was significant/non-significant with a p < 0.001) and respiratory (p < 0.001) diseases. However, the establishment of a new 10-bed ICU in the hospital as a result of ward reorganization led to a decrease in the number of patients with cardiovascular disease (p < 0.001). As the number of patients admitted to the hospital after surgery increased, the severity of patients’ medical and nursing needs evaluated by item A of the scale increased (p < 0.001), while those evaluated by item B decreased (p < 0.001). These scales were weakly correlated in the analysis with Spearman’s rank correlation coefficient (r = .254 p < .001). An increase in the number of elective surgery patients also led to a decrease in their ICU length of stay (p = 0.001), the number of ventilator users (p = 0.001). Furthermore, we aimed to determine whether there was a difference in the number of nurses between the two periods and found that there was no difference between the two groups.Included in the analysis were 3,135 patients admitted to ICU during the study period: 1,471 in the before group and 1,664 in the after group. The patients’ characteristics are summarized in p < 0.001, t-statistic -3.29). Further, there were fewer long-term ICU admissions of males than of females . Emergency admissions , patients on mechanical ventilation , and the degree of severity of ICU needs item A score  and item B score  in patients with cardiovascular, gastrointestinal, and respiratory problems were significantly associated with length of ICU stay.The results of our multivariable regression analysis to determine the length of ICU stay are shown in This study aimed to investigate whether collaboration between a CNS as ICU head nurse and intensivists changed the length of ICU stay. The period of collaboration between the CNS as ICU head nurse and intensivists in a single center was shown to be associated with shorter ICU stays for admitted patients.Prognosis based on knowledge and experience and multidisciplinary treatment and care may not only save the lives of ICU patients with severe and complex conditions, but may also influence their subsequent activities of daily living and quality of life. Intensivists have a high level of expertise in managing the condition of critically ill patients, while CNSs in critical care also performs advanced nursing care, education, and research against the background of their own clinical experience and specialized medical and nursing knowledge –15. ThisAs a care provider, the CNS as head nurse can clearly explain the nursing perspective to intensivists, surgeons, physicians and other medical personnel and discuss their positions. By predicting the patients’ prognoses and physical/mental function based on the comprehensive judgment of the various personnel members, it is possible to ensure that patients’ treatment and care moves in the best direction from an early stage. Moreover, because CNSs are also APNs, the quality of ICU care will be improved by coordinating treatment policies and nursing care with the physician and intensivists. The CNS as head nurse also sets appropriate unit goals and outcomes while managing and monitoring the unit to improve the quality of care. , 17As a head nurse, the CNS is able to set more detailed goals and outcomes in managing the organization and make better use of human, physical, and financial resources, thereby attempting to improve care. When the CNS assumes the role of head nurse, they are able to set more detailed and realistic goals and outcomes by utilizing the perspective of an APN. This allows human, physical, and financial resources to be utilized more effectively to enhance patient care.In a low-intensity ICU, the health care team  needs to have a solid basis and to employ teamwork, with the CNS as head nurse and intensivists managing the organization as the decision makers based on advanced medical and nursing practices. Goals and policies for personnel providing bedside care are realistic and are therefore likely to gain staff acceptance. Moreover, the CNS, in their role as a manager, can seek better policies for each patient by discussing patient conditions and ICU management with the physician, nurse, and other medical personnel from a neutral standpoint, together with intensivists. In addition, by discussing treatment policies among multiple professions, the ICU staff can learn about the interests and perspectives of multiple professions, which is expected to have an educational effect.This study suggests that intensivists—who were not in charge of patients as primary care physicians—and the CNS as head nurse made a comprehensive change to patients’ conditions and the burden of nursing care. As a result of fair and unbiased treatment and bed control, timely patient flow management in the ICU may be related to reducing the length of ICU patient stay.A system in which intensivists advise on the treatment of critically ill patients, the CNS manages the ICU as a head nurse, and the patient is treated and involved in complex problems by an APN can be a useful model for low-intensity ICUs. It can contribute to solving patients’ problems through elective care consultation, intervention in teams and personnel facing difficult problems at the appropriate time, advanced care, goal setting, and efficient organizational management.This study is a retrospective study that utilizes data from one situation; therefore, it may be difficult to apply this result to other institutions. Moreover, the long-term ICU admission of patients is complicated by a number of factors and even though the results point toward collaboration having a positive effect, it cannot be determined whether the collaboration between the CNS as head nurse and intensivists directly affected the long-term ICU admission of patients.Therefore, it is necessary for future studies to increase the number of target facilities and investigate the details of the collaboration between the CNS and intensivists. There may also be confounding concerning outcomes other than those assumed here. In the future, it will be possible to pursue an ideal ICU while simultaneously dealing with reality by accumulating reports on efforts to improve the quality of medical care and their results in low-intensity ICUs.In low-intensity ICUs, collaboration between intensivists and the CNS may change the overall ICU package and reduce the length of ICU stay for patients.S1 Table(XLSX)Click here for additional data file.S2 Table(XLSX)Click here for additional data file.


Health promotion and disease prevention often take the form of population- and individual-based interventions that aim to reduce the burden of disease and associated risk factors. There is a wealth of programs, policies, and procedures that have been proven to work in a specific context with potential to improve the lives and quality of life for many people. However, the challenge facing health promotion is how to transfer recognized good practices from one context to another. We present findings from the use of the implementation framework developed in the Joint Action project CHRODIS-PLUS to support the transfer of health promotion interventions for children’s health and older adults identified previously as good practices. We explore the contextual success factors and barriers in the use of an implementation framework in local contexts and the protocol for supporting the implementation. The paper concludes by discussing the key learning points and the development of the next steps for successful transfer of health promotion interventions.  Health promoters are well aware of the challenges faced by people with chronic disease, as well as the health systems’ efforts to meet these challenges . In the In response to these challenges, the European Commission and Member States funded the CHRODIS-PLUS Joint Action. Joint Actions are a funding instrument under the third EU Health Program 2014–2020. They are designed and financed by Member State authorities and the EU to address specific priorities under the EU Health Program. The goal of CHRODIS-PLUS is to support Member States through cross-national initiatives identified in CHRODIS Joint Action (2014–2017) to reduce the burden of chronic disease, while assuring health systems sustainability and responsiveness. CHRODIS-PLUS aims to promote the implementation of recognized good practices with demonstrated success in different contexts. Joint Action (JA) CHRODIS-PLUS is a three-year initiative funded by the European Commission that started in 2017. Working with 22 partners from 14 EU Member States, the health promotion and primary prevention area aims to improve the knowledge and practice on health promotion and disease prevention. It builds on the successful results from the previous Joint Action CHRODIS that identified good practices. This study is part of the health promotion and primary prevention work package in CHRODIS-PLUS. The aim is to examine the possibility of implementing good practices identified in CHRODIS in different contexts with the aid of the implementation strategy, designed especially for CHRODIS-PLUS. The specific aim of CHRODIS-PLUS is to promote the implementation in several countries of innovative practices for patient empowerment, health promotion, and primary prevention, as well as quality management of chronic disease. In this paper, we focus on cross-national transfer of two good practices, Active School Flag and multimodal training. Both represent practices that promote physical activity and seek to change the environments and the motivation of the target group. A good practice is not only a practice that is good, but a practice that has been proven to work well and produce good results, and is therefore recommended as a model. It is a successful experience, which has been tested and validated, in the broad sense, which has been repeated and deserves to be shared so that a greater number of people can adopt it.” Each Member State partner identified and documented three or more highly promising and/or evidence-based practices with the collaboration of relevant ministries, institutes, and civil-society institutions. Special attention was given to practices with a focus on vulnerable populations and that were shown to have a positive impact on the health or health behavior of the target population.A recognized good practice within CHRODIS-PLUS is based upon work carried out in JA CHRODIS. This involved more than 30 organizations from 13 EU Member States to identify 41 promising interventions and policies on health promotion and chronic disease prevention based on a jointly developed set of criteria. The identified interventions fed into a “Platform for Knowledge Exchange”, an up-to-date repository of good practices for disease prevention and chronic care stakeholders. The JA CHRODIS defined a “good practice” in accordance with the definition by the Food and Agricultural Organization of the United Nations: “An issue within efforts to reduce the burden of chronic disease is that there is a wealth of knowledge of what works but a lack of knowledge on how to implement good practices and programs ,5. The WImplementation science is the field of work that attempts to solve a wide range of implementation problems. Its origins are in several disciplines and research traditions . The fieAn important element for implementing good practices is context . ContextIn 2016, the WHO affirmed that the interplay between an intervention for chronic disease and its local context can affect successful implementation . HoweverAnother key element in implementation research is the focus on working with actual populations that will be affected by an intervention, in contrast to selecting beneficiaries who may not represent the target population of an intervention as is often the case with randomized controlled trials . In addiTherefore, implementation research has many challenges for health promotion . This isThe paper is set out as follows: firstly, we briefly describe the methodology used in implementation of the good practices in CHRODIS-PLUS. Secondly, we detail two examples from CHRODIS-PLUS work in health promotion on good practices and how they applied the implementation strategy. Thirdly, we describe the contextual success factors and barriers to the transfer and implementation of a good practice for health promotion. Finally, we conclude by outlining the key learning points from the implemented programs and the development of the next steps for successful transfer of health promotion interventions.The implementation framework in CHRODIS-PLUS consists of the implementation strategy and the protocol for supporting the use of the implementation strategy.The implementation strategy in CHRODIS-PLUS consists of three phases. The preparatory phase operated through September 2017 to August 2018 and included situation analyses, feasibility assessments, and getting the pilot action plans ready. The implementation phase, which recently ended, operated from September 2018 to January 2020. In the implementation phase, implementing sites monitored the progress of implementations and collected data. During the post-implementation stage, the implementers of the good practice will evaluate if the implementation was successful or not and report the experiences from the whole project. It will operate from February 2020 to September 2020.The protocol for supporting the use of the implementation strategy was specially designed during the preparatory phase by the executive board of the project with the help of the project leaders and experts. The implementation strategy was developed in CHRODIS-PLUS to support intervention transfer and implementation in new contexts. It was designed to be feasible enough according to the resources of the project see . The strStep 1: Scope AnalysisIn the scope analysis, each local implementation working group selects the specific aspects of their planned intervention. These aspects are identified according to the local context: the health situation of the local population and local needs, interests, and capabilities. A structured group discussion is used. It proceeds in five steps: (1) identify and describe the problem/challenge, (2) describe the general purpose of the intervention, (3) describe the target population, (4) analyze the intervention’s components and identify the central features that are essential to achieve the desired results, and (5) select the components from the proposed good practice that will be locally implemented. Step 2: SWOT AnalysisSituation analysis—“strengths, weaknesses, opportunities, threats” (SWOT)—is used to identify the respective organizations’ internal strengths and weaknesses, as well as external opportunities for, and threats to, implementing the interventions based on the selected model elements. SWOT is designed to help with both strategic planning and decision-making in relation to the planned intervention. SWOT was chosen as a tool because it is a structured, well-known, and easy-to-use method. During the SWOT analysis, the local working group in each implementing site considers the strengths, weaknesses, opportunities, and threats to the implementation of a good practice across five dimensions: (1) sustainability, (2) organization, (3) empowerment, (4) communication, and (5) monitoring and evaluation. A template was developed in CHRODIS-PLUS to facilitate discussion. All implementing sites prepared a document that presented the most important strengths, weaknesses, opportunities, and threats for their organization, with an overview of major issues, priorities, and strategic actions needed in relation to their planned intervention.Step 3: Elaboration of Pilot Action PlansThe pilot action plans are developed and improved by the implementing sites during the face-to-face meetings between the members of the local implementation working groups. An action plan provides a concrete set of steps and activities that need to be conducted in order to implement their respective health promotion interventions.An adapted version of the iterative cyclic nature of “collaborative methodology”  was usedStep 4: Plan–Do–Study–Act (PDSA) CycleThe plan–do–study–act (PDSA) cycle presents a pragmatic scientific method for testing changes in complex systems. The four stages mirror the scientific experimental method of formulating a hypothesis, collecting data to test this hypothesis, analyzing and interpreting the results, and making inferences to iterate the hypothesis ,24,25. TThe steps of the PDSA approach are as follows: (1) plan: plan the actions defined in THE PILOT ACTION PLAN TO TEST THE changes. Detail actors (who), functions and roles (what), timeframe (when) and setting (where); (2) do: test the action and, once finished, data are collected and any problem or unexpected observation is documented; (3) study: the data obtained during the testing step are analyzed. The obtained results are compared to the predictions. Learning is summarized; (4) act: based on the lessons learned changes are refined. Modifications are determined. This improved change is then re-implemented in a new PDSA cycle.Process: We study the implementation of two good practices - Active School Flag (children in schools) and multimodal training intervention (older people) in new countries and contexts. In the first year, all partners involved reviewed and agreed on the common use of the CHRODIS-PLUS implementation framework. The good practice implementers completed a scope analysis, SWOT analysis, and an action plan. This involved recognizing the existing structures and local resources where the good practice is to be implemented. The implementers assessed and adjusted the intervention implementation to their local working culture and situation.Roles: CHRODIS-PLUS project leaders, researchers, and good practice owners supported the new implementers, provided tools to complete implementation strategy steps, and facilitated group discussions. There was use of an external expert who commented on the pilot action plans in order to give insight and to make them more effective. Work package leaders monitored the implementation process during the implementation period. The methods used for support and monitoring were site visits and active communication through bimonthly meetings, email, and social media channels. Data: Documents from each implementation strategy step, notes from the meetings, site visits, recorded webinars, and other documentation from the communication were stored. This qualitative data were analyzed to gain understanding of factors associated with the implementation process.The Active School Flag (ASF) is an Irish initiative which aims to enhance levels of physical activity for children through developing a physically active and physically educated school community. The ASF is a nationwide initiative focused on supporting a whole school approach to enhancing physical activity. The ASF mirrors other “active school” models operating throughout Europe and internationally, for example, the Centers for Disease Control and Prevention Comprehensive School Physical Activity Program in the United States (US). The target group is school-going children between the ages of five and 18 years. It is open to all primary, post-primary, special needs education schools, and youth-reach centers. Schools are recruited to the program by invitation and, once engaged with the program, they are supported on a program of action planning and self-evaluation. Schools are required to review their current provision across the areas of physical education (PE) and physical activity, as well as to commit to a number of improvements. The review areas include elements of planning and PE curriculum, professional development, school PE resources, activity during break times, cross-curricular and extra-curricular activity, inclusive physical activity, and active travel.Azienda Sanitaria Locale di Collegno e Pinerolo , via the Piedmont Regional Health Promotion Documentation Center (DORS) transferred and implemented the ASF in at least two schools in the Piedmont SHE Network. This network involves 100 schools in the region and aims to promote a whole school approach to improve the health and well-being of all pupils, as well as teaching and non-teaching staff. They implemented the ASF in one school in a rural area and one in an urban area. This was based upon voluntary recruitment. Their implementation incorporates some of the Irish self-evaluation instruments in a locally specific context. The number of children involved was 330.The Institute of Hygiene  works with a network of Public Health Bureaus who are the main institutions promoting and initiating the implementation of public health interventions at the municipal level in Lithuania. Two of the bureaus  implemented ASF in four schools to enhance the level of physical activity of their children through the development of a physically educated school community. The number of children involved was 1468.Multimodal training interventions are of special interest for older individuals, because of their high rate of disability, functional dependence, and use of healthcare resources. Multimodal training is a six-month multimodal intervention, with nutrition and health counseling on different variables, such as on functional fitness, body composition, and cardiometabolic risk factors. The participants are healthy older individuals of 71–90 years old. The intervention consists of daily endurance training (ET) and twice-a-week resistance training. This is supported by three lectures on nutrition and four on health-related topics. The ET consists of daily walking over the intervention phase. The duration of the training session increases progressively through the six-month training period.HI (Lithuania) implemented the Multimodal Training Intervention in two municipalities  through its network of Public Health Bureaus, which are the main institutions promoting and initiating the implementation of public health interventions. They are currently implementing a cardiovascular disease prevention program in cooperation with family doctors who refer people at risk to a training program. The bureaus organized the training programs, facilitated lectures on nutrition and physical activity, and provided individual consultations to enhance lifestyle changes. The number of adults involved was 250.El Instituto de Salud Carlos III , collaborating with the Aragon Institute of Research in Health Sciences, implemented the multimodal training intervention in the Aragon region. The multimodal training intervention was carried out at existing sporting facilities and community or social activity centers for over 65-year-olds in the municipality of Utebo. The target population of the intervention were residents, 65 years of age or older, with adequate conditions  to begin a promotion program of physical exercise. The number of adults involved was 52.The Directorate of Health  implemented the multimodal training intervention in four municipalities, thereby ensuring a good mixture of villages, towns, and cities. The program was promoted in geriatric centers and local papers and it was open to everyone aged 65 and older. After each implementation phase (six months), the approach was reviewed and adapted. The training phase included daily endurance training (30 min) at least once a week with a trainer, and strength training sessions at least twice a week with a trainer. Training programs were individualized, but participants trained together as a group and received monthly lectures about nutrition, training, aging, and physiological changes. The program was implemented as an element of the Icelandic Health Promoting Community program, and the number of adults able to participate was at least 91% of the over 65 population .Our results on the use of the implementation framework are based on qualitative data collected during the implementation process. Knowledge exchange is vital for the successful transfer of a good practice in health promotion. The sharing of experience and evidence from lessons learned enable the implementer to avoid similar missteps or to develop plans to adequately counteract them. The use of existing knowledge is used in health promotion prior to the start of the implementation because the “pre-implementation” phase involves consultation with delivery mechanisms and organizational networks . For exaIn CHRODIS-PLUS, we conclude that knowledge exchange was key to all implementers. We organized knowledge exchange in the form of site visits. This is where the implementers of the good practice visit the good practice in situ. This enables good practice implementers to become more familiar with the implementing site, and they are, thus, better able to provide advice that suit the local needs. These site visits were identified as crucial for the implementing of the good practice see . The multimodal training intervention implementation relies on specific technical capacities of the implementers. This involves testing strength, blood, and other corporeal capacities. This is an example of the need of more extensive pre-implementation knowledge exchange, achieved through site visits and a return visit from the good practice owner to the field site where implementation is being conducted (we return to this in the discussion). Site visits were organized between multimodal good practice owners from Iceland and implementers in Lithuania and Spain.The Icelandic partners  had the opportunity in both of these countries to take a look at the training facilities and help out with fitness level measurement-days. They also gave lectures for the participants (in Lithuania) and had a meeting with decision makers in Klaipeda District Municipality and decision-makers in Utebo-Zaragoza in Spain. During and after the visit, the Icelandic partners developed a set of recommendations for the implementers in Lithuania and Spain for further improving the physical training of this good practice project for those aged over 65.Site visits between the Irish good practice owners of ASF and the implementors in Italy were conducted in June 2018 in Ireland and in October 2019 in Italy. Based on the experience from the owners of the good practice and implementers, these site visits were key moments to enter the process, to share experiences, and to receive suggestions and directions from donors. They recognized that there is a need for one site visit to implementers at the early stage of the process for the understanding of the specific features and characteristics of the context and one at the middle/end of the process to redirect activities and introduce any changes/additions to the implemented activities. A missed opportunity involved the unforeseen moments of connection, comparison, and reflection between different implementers sites . For example, specific meetings with implementers and donors would have been enriching for everyone.Communication was found to be a central element of the successful transfer and implementation of health improving programs . In our What were you doing during this month?What was recorded ?What were the successes?Were there any barriers?Was any support needed?What are you planning to do next month?What was the assessment during the current period ?What were the perceived barriers?How certain are you that you will achieve what you are planning to?Webinars and meetings with topics like the different implementation strategy methods were organized during the implementation phase for the implementers of the good practices in different countries. The implementers and the good practice owners held bimonthly meetings during the implementation period. Meetings were held with videoconferencing systems; thus, they were easy to attend in different countries. A template for reporting the progress was developed. It was filled in by the good practice implementors regularly. Not every group was able to hold meetings as often as first planned , but there were regular meetings, with at least three or four each year per implementing site. There were some challenges in finding a suitable video-conferencing system for everyone and also finding time when working in different time-zones. In the future, when designing implementation projects, one should take into account working connections and agree beforehand on which video-conferencing system is used and also plan a budget for it. In the template, is the following short questions were asked:The good practice owners also kept contact with the implementors through emails. For example, multimodal training good practice implementors also had a closed Facebook group for sharing. In the Facebook group, it was very easy to share photos of the local implementation groups and messages of the challenges and successes. The use of new channels of communication eases the burden on language skills and also helps to spread success stories that might not be reported in any other way. An aspect of the implementation strategy that must not be overlooked is the recognition of a problem. In the implementation strategy, the use of scoping analyses enables implementing organizations to assess their current activities, workload, and resources. It also involves the identification of potential facilitators and barriers. As highlighted in the literature on implementation science, these are key elements in the successful transfer of a new program . They arIn the implementation projects that we conducted in CHRODIS-PLUS, the identification and support of influential decision-makers was important. We found, through the implementation framework that includes assessing barriers, facilitators, and threats, that active support by senior figures is necessary but must extend deeper than written policies. This is because the organization and delivery of health promotion programs can be experienced as an additional responsibility for those involved in the implementation. Those at the delivery end are unlikely to want extra burden if it is perceived as risky for their professional life, personal well-being, or work–life balance. The pathway of program introduction and delivery needs to be both paved  and sheltered  .Local context is key, and this was emphasized in the literature ,11. ThisSecondly, the addition of a new factor to a good practice feeds back into the buy-in of senior decision-makers and local concerns . For exaThe findings from our implementation projects suggest that the transfer of a good practice is not straightforward. We established that attributes of the good practice, preparation for transfer, and program affinity play an important role in the process. The decision to implement an existing good practice is an active and dynamic process. Our study supports the literature that argues that the effectiveness of implementations is critically influenced by their given context ,13. In oWe identified essential replicable mechanisms that impact the successful transfer and implementation of a health promotion program. An element that was important in our implementing sites was the need for an amount of conformity between current activities and the proposed health promotion program ,14,26. AWe found that it was essential to have participation by key decision-makers throughout the process of preparing for transfer and implementation . HoweverEnvironmental and individual barriers that prevent the successful transfer of good practices include a lack of peer support, competition with other programs (saturation at schools for the Active School Flag is a particular concern), and staff turnover see . The barThere are several strengths of the implementation strategy . We applA limitation of the study we presented in this paper is that we focused on implementations that promote physical activity, and there could be different challenges facing different types of programs when they are implemented. Moreover, the implementation process was limited to 12 months so as to align with the timeframe of the three-year CHRODIS-PLUS joint action. Therefore, various aspects might reflect this relatively short intervention period . HoweverIn this paper, we ascertained some key features of successful transfer of good practices. Firstly, it is essential to develop an action plan of key activities and to plan carefully how the support of the implementation is organized during the implementation period. Secondly, embedding the good practice within existing structures and resources is crucial, as is recognizing the specific characteristics of each local context where the good practice is to be implemented. Thirdly, site visits during the implementation period were found to be extremely useful both to the implementers of the good practice and the good practice owners. After a site visit, it is easier to guide the implementation since the knowledge of the specific issues in the local context is better understood and key relationships are established. However, in future implementation research, a clear budget for translation and travel is required. This is of particular importance when implementing programs in a country with a different language and regulatory environment. Our research into the transfer of good practices helps to develop the knowledge base for health promotion and disease prevention activities. In doing so, it develops our understanding of how health promotion works in different contexts and the health promotion landscape within Europe . However


Three personality types  have been repeatedly verified across different languages and cultures, different personality models, and different stages of development. Undercontrollers are socially maladapted types with high impulsivity and low self-control. Research shows they are at risk for externalizing problems, such as aggressiveness, impulsivity, and antisocial behavior. The aim of this study was to develop an intervention to reduce externalizing problems of undercontrolled personality types in primary school students. Participants were 69 undercontrolled primary school students from two primary schools in North China. The experimental group underwent 14 weeks of systematic experiential mental health activities, while the control group performed typical daily classroom activities. Personality and externalizing problem behaviors were measured before the intervention, at the end of the intervention, and 4 months post-intervention. The results showed that the intervention significantly reduced the level of externalizing problems of undercontrolled primary school students. The effects of the intervention were maintained at the 4-month follow-up. This study provides some reference and suggestions on how to intervene in the externalizing problem behaviors of undercontrolled primary school students. A significant body of evidence has revealed that personality not only affects individuals’ current academic achievements, health, and peer relationships but also has a positive predictive effect on future life and income . PersonaUndercontrollers are socially maladaptive, with high impulsivity and an inability to adjust their self-control in relation to situational demands . UndercoEvidence from various studies has suggested a certain degree of specificity in the relationship between personality traits and behavior problems . For insPersonality development is influenced by social and environmental factors, thus suggesting that personality intervention is feasible . PersonaThe study outlined above was variable-centered and was only able to examine the average level change of a certain personality trait in the group in isolation. The study of personality types from a person-centered perspective supplements the study of personality traits from a variable-centered perspective . A persoThe current study aimed to develop and test an intervention for primary school children, designed to reduce externalizing problem behaviors displayed by individuals characterized as undercontrollers. Based on earlier work, we hypothesized that (1) the externalizing problem behavior of undercontrolled primary school students would be reduced by enhancing the personality traits of conscientiousness and agreeableness; (2) 4 months after the end of the intervention, the effects of the intervention would be maintained.This study is different from previous studies in several ways. First, in order to understand the specific behavior of undercontrolled primary school students’ externalization problems, we interviewed primary school teachers. Second, we also referred to previous research and designed intervention curricula suitable for 10-year-old children. Third, regarding the intervention of externalizing problem behaviors, a large number of previous studies have focused on specific personality traits. This study focused on personality types and intervened on a certain type with problem behaviors. Fourth, we designed intervention curricula based on personality traits related to the externalizing problems, with the aim of improving the undercontrollers’ problem behaviors. It also has a clear intervention purpose and is easily administered. Finally, we examined the effects of the intervention curricula four months later.We selected two primary schools in North China to issue the questionnaire. The questionnaire was used to evaluate 234 primary school students  in two schools, with an average age of 10 years old. Latent class analysis (LCA) was used to classify the personality type among 234 primary school students. The intervention is normally influenced by some variables. Thus, we intervened in the natural class where undercontrolled type students were located. This study was approved by the local ethics committees of Liaoning Normal University. Written informed consent had been obtained from the parents/legal guardians of all participants. All participants were volunteered to join the experiments, and informed consents were signed by their legal guardians.Teacher rated their students’ personality on the Personality Inventory for Primary School Student . The perParents rated their child’s problem behavior with the Chinese version of the Child Behavior Checklist CBCL; . The CBCBased on previous research, we selected the dimensions of conscientiousness and agreeableness for personality-targeted interventions. These two personality dimensions are also closely related to externalizing problems in this study see . Under tThe undercontrolled children engaged in a 14-week intervention in natural classes of twice a week for 45 min each time. We chose system experiential mental health activities as the best carrier. These mental health education activities were mainly carried out in an experiential way in accordance with system theory. According to system theory, interventions should occur in the environment where the child with the problem behavior is located. By locating the intervention in the child’s environment, good peer relationships are established, which helps to reduce problem behaviors . For priGuided by the intervention goals, we designed a 14-week intervention curriculum. First, for each of the seven facets of conscientiousness and agreeableness, we designed two intervention goals see . Two actp < 0.05. LCA and its fit indices such as AIC, BIC, adjusted BIC, entropy, LMR, and BLRT output by Mplus were used to identify primary school students’ personality types ; 14 weeks later, immediately following the intervention (T2), and 4 months after of the end of the intervention (T3). We analyzed the effectiveness of the intervention by means of repeated measurement ANCOVAs . In the control of unrelated variables, we took the following measures. First, we applied a homogeneity test on the pre-test group to ensure both groups’ developmental level of personality and externalizing problems. Second, while the experimental group underwent intervention in a mental health class, the children in the control group engaged in mental health lessons prescribed by normal teaching. To prevent students, parents, and teachers from guessing the experimental expectations, this study intervened in the entire class of undercontrolled individuals. During each assessment, parents and teachers assess each student in the class without knowing which class is the experimental one. Additionally, other daily activities remained the same. Uniform requirements were imposed on all teachers, and teachers were not allowed to impose additional activities on the children. Fourth, the intervention and test subjects remained the same throughout the experiment. Fifth, we conducted a survey during the pre-test to ensure that there were no additional relevant interventions outside the primary school environment.p-value for LMR is not significant for three-class model and four-class model, other fitting indices are more ideal than two-class model. The results show that AIC, BIC, and adjusted BIC decrease monotonically with the increase of classification categories. Entropy is relatively large in three and four classifications, which indicates that the correct rate of personality type classification is higher see . AlthougOne-way ANOVA and multiple comparisons are used to describe the characteristics of each personality type see . The firF = 21.19, p < 0.001, η2p = 0.24]. The externalizing behavior score of the experimental group was significantly higher than that of the control group . It can be seen that in the scores of conscientiousness and externalizing problems, the two groups are not homogeneous. In a realistic educational situation, in order to respect the authenticity of the research and the feasibility of reality, we allow the two groups of subjects to be heterogeneous.The scores of children’s personality and externalizing problems at three points are shown in Before the intervention, there were significant differences in data between the experimental group and the control group, so the pre-test data were used as covariates. The results of the repeated measurement ANCOVAs are given in In the conscientiousness, agreeableness, and externalizing problem behavior, the main effect of Time and the interaction between Time and Group were not significant. The main effect of Time indicated that there was no significant difference in the scores between T2 and T3. The main effect of Group was significant. The main effect of Group indicated that experimental groups individuals reported higher scores on conscientiousness and agreeableness, but lower scores on externalizing problems than control group individuals in general.The results revealed that the intervention not only improved the level of conscientiousness and agreeableness, but also reduced the level of externalization problems. The effects of the intervention were maintained at the 4-month follow-up.The intervention goals play a guiding role in the experimental process . TherefoWe targeted intervention goals to the externalizing problems that undercontrolled primary school students experience in their actual lives. Through qualitative research, we collected examples of specific behaviors that are thought to be associated with seven facets under the two personality dimensions. For example, in terms of self-control, “Learning and doing things often go halfway and it is difficult to stick to one thing” and “Contradictions with classmates and inability to control impulses” are behaviors exhibited by undercontrolled personality types that have been found in previous research . For theThe results showed that the intervention realized the goal of reducing externalizing problems by changing the personality dimensions of agreeableness and conscientiousness. There are two main reasons for this result. One is to select the systematic experiential mental health activities as the best carrier. These activities can fully attract children’s interest and attention, so that children with problem behaviors can gradually internalize positive behavioral performances. The second is to compile the system experiential mental health activity program. The activity program is compiled under the guidance of intervention goals. The intervention goals were designed around the specific seven facets under the two personality dimensions that have a significant relationship with externalizing problems. Our findings support the idea that targeting intervention to these personality dimensions can effectively improve the externalizing problem behavior of undercontrolled children. For example, to target the self-control facet in the conscientiousness dimension, we designed the “Self-control skills of martial arts” activity. In this activity, we first presented a conflict situation, and then, the students role-played the situation. After this experiential activity, students discussed the situations in which impulsive behavior tended to occur and the consequences. Finally, we asked the students to summarize their strategies for controlling their impulsive behaviors, which they compiled as “martial arts secrets,” and to then stick them on their desk to remind themselves to reduce the occurrence of impulsive behaviors.Four months after the intervention, we tested the personality and externalizing problem behaviors of undercontrolled primary school students again. The results showed that in the conscientiousness, agreeableness, and externalizing problem behavior, the main effect of Time was not significant. It can be seen that the effects of the intervention were maintained at the 4-month follow-up. In the process of interviewing the teachers, we found that the undercontrolled children had little or no more impulsive and aggressive behaviors through intervention. When there are conflicts in the class, the undercontrolled children also actively mediate the conflicts and advise him or her to think from the other’s perspective. The reason is that when the undercontrolled children perform well, teacher’s encouragement and praise will play an important role in the efficacy of the intervention. It may also be that children adhere to internalized moral values, which might make them show prosocial behaviors such as generosity and helping others after participating in the intervention activities . In addiThere are two main limitations in this study. One of the limitation is the Personality Inventory were responded for teachers, while the CBCL were responded for parents. Both scales were used to assess the effects of the intervention on improve externalizing problems. Teacher’s assessment of children was based on their performance in school. Parent’s assessment of children was based on their performance at home. However, children may exhibit diametrically opposite behaviors or different degrees of similar behavior in two different environments. Parents and teachers have different assessment because of the different perspectives of knowing children. This may have a certain impact on the research results. Another limitation is that this study used only questionnaires to measure the effect of intervention, and although they were multi-source, the results could have been supported by the application of other data collection techniques such as continuous observational records from parents or teachers and real-time data collection through apps.Results showed that the system experiential mental health activity can reduce externalizing problems of undercontrolled children by enhancing the personality traits of conscientiousness and agreeableness. Furthermore, 4 months after the intervention, the system experiential mental health activity demonstrated a sustained promotion effect.The datasets for this article are not publicly available because the topic is not finished. Requests to access the datasets should be directed to the corresponding author.The studies involving human participants were reviewed and approved by the Committee of Liaoning Normal University. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.YY, LY, and YS designed the experiment, prepared the materials, and performed the experiment. YY, LY, CJ, and YZ analyzed the data and wrote the manuscript.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.