Literature has shown a tendency of inadequate dietary intake among youth, consequently, nutritional interventions are required. The transtheoretical model (TTM) classifies individuals based on their readiness to change. This model is widely used for health education interventions with proven efficacy.This review aimed to weigh the strength of evidence about the TTM usage in nutritional interventions for adolescents and its effectiveness regarding dietary intake.This study followed the PRISMA guidelines. Eligible studies were input into Mendeley software. The Adolec, Google Scholar, LILACS, PsycINFO, PubMed, Science Direct and Web of Science databases were searched. Only full original articles written in English, Spanish or Portuguese on randomized controlled trials and quasi-experimental designs that applied the TTM in the design of nutritional interventions targeting adolescents were included, with no restrictions on publication date. The quality and risk of bias was evaluated with the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies.The initial search yielded 3779 results. Three studies were rated as strong, six as moderate and five as weak. The final sample of 14 articles included adolescents that were mostly recruited from schools, with interventions ranging from one month to three years. The TTM was used alone or combined with other behavior-change theories and most of the interventions involved digital technology. The nutritional topics covered included fruit and vegetable consumption, low-fat diet, and cooking skills. Four studies presented improvement in fruit and vegetable consumption and four progressed through stages of change. Participants from two interventions reduced fat intake. At the end of one intervention, all the participants were in action and maintenance stages.The TTM seems to be a successful strategy for nutritional intervention aiming at improving dietary intake in adolescents. Its application in different contexts shows that the TTM is flexible and possible to be implemented in many settings. The use of the model is shown to be restricted to the stage of change’ construct. Further studies should use all constructs of the TTM in the design and compare the TTM with other behavior-change theories to better understand its effectiveness. Adolescence is a period of intense biopsychosocial changes and involves specific nutritional needs , 2. HealThe transtheoretical model (TTM) describes change not as an individual event but rather as a series of steps that take place according to a person’s degree of motivation. The four constructs of TTM are the stages of change, the processes of change, self-efficacy, and decisional balance . The mosDifferent processes are involved in progression through the stages of change. For example, to cross from precontemplation into contemplation, consciousness raising must occur, and this process mostly applies to initial stages. As individuals progress through the stages, their self-efficacy is expected to increase, i.e. how capable they feel of changing, including recognition that there are more pros than cons to changing, as stated in decisional balance .This model is widely used for health education interventions, such as physical activity , fruit aThere has not yet been a systematic review of adolescent nutritional interventions that adopted the TTM as a theoretical model in the design of the intervention. Moreover, this model consists of many constructs, so it is applied in different ways by different authors. Therefore, this review aimed to weigh the strength of evidence about the TTM usage in nutritional interventions for adolescents, by describing how the TTM  is applied to nutritional interventions for adolescents and evaluate its effectiveness regarding dietary intake.This study followed the PRISMA guidelines  and is rThe following databases were searched for articles in English, Portuguese, or Spanish: Adolec, Google Scholar, LILACS, PsycINFO, PubMed, Science Direct and Web of Science. The search was updated twice, once after thirty days and again about a year later to find recently published articles. A librarian from the University of Brasilia assessed the quality of the primary search by filling out the Peer Review of Electronic Search Strategy form. Figure Only randomized controlled trials and quasi-experimental studies that included adolescents between ten and nineteen years who had been exposed to any type of nutritional intervention that used at least one TTM construct in the design were eligible. When the original article only mentioned the use of self-efficacy, it was reviewed if the TTM has been used in the design of the intervention or if another construct of the model has been applied. This criterion was adopted since self-efficacy is a construct of other behavioral change theories as well. No other restrictions were applied, including publication date. Studies involving adolescents were included even if they have included children or young adults. The exclusion criteria were interventions that targeted specific health conditions or diseases, such as type 1 diabetes, cancer, and eating disorders, studies that only classified participants according to stages of change as a variable , and studies in which the intervention had not yet been implemented. Studies that targeted individuals with obesity were not excluded.A total of 3779 titles and abstracts found in the database search were input into Mendeley software. Duplicates were removed and assessed manually by the first reviewer. Two reviewers performed the study analysis, which included reading the titles and abstracts and discarding those that did not match the inclusion criteria . Each full paper was read separately by both reviewers . Disagreements between reviewers were resolved by an expert (NT). One reviewer assessed the reference lists of the included studies to find other related articles (JN). An updated search was performed in the databases by one reviewer (JN), and both reviewers assessed the eligible studies for inclusion . Figure The data were extracted using a table based on the Centre for Reviews and Dissemination for Undertaking Reviews in Healthcare instructions . Data weThe initial search returned 3779 results, from which 119 duplicates were removed. Of the remaining abstracts, 3572 did not meet the selection criteria and were excluded. Thus, the full texts of 88 articles were read. Of these, 77 did not meet the eligibility criteria for reasons described in Fig. Five interventions were classified as weak , 30, 33,One study recruited adolescents from youth service agencies , anotherThe sample sizes varied from 16 to 2983 participants. A total of eight randomized controlled trials –30, 33 aThe majority of the interventions involved digital technology , 26, 28.Six aimed at improving fruit and vegetable consumption , 28, 32,All studies but one used the stages of change in the development of the intervention . The majBoff et al. scheduled 12 meetings conducted by professionals in different areas, such as psychology, nutrition, physical therapy, and physical education. The meetings were based on the stage of the intervention group . Brick eThe TTM was used in all included interventions, although some of them were based on other theories as well. Two studies used a combination of Health Promotion and TTM , 22, oneIn one study the participants were exposed to the intervention only once , while fThere was an improvement in fruit and vegetable consumption in the intervention groups of four studies , 26, 32 There were positive results in intervention groups of Haerens et al. and Freen et al. regarding fat intake reduction , 23. NevAll the participants in Filgueiras et al. were in the action or maintenance stages by the end of the intervention . In the This is the first systematic review to collect data on how the TTM has been applied to design nutritional interventions for adolescents. This review also showed the effectiveness of each intervention. Although five studies were considered weak in the quality assessment, one of the reasons for it is the fact that the tool for assessment takes into account the blinding, which is hardly feasible in studies with this type of intervention. The majority of studies used the TTM, most specifically the stages of change, to develop a tailored intervention program. According to Celis-Moralez et al., tailored interventions that incorporate behavior change techniques are more effective than conventional interventions for dietary behavior change . This shAt all times the processes of change were used in combination with the stages of change and also with the aim of tailoring the content of the intervention, except for Jalambadani et al. , which iThis review points out the fact that decisional balance and self-efficacy are mostly used as a measure of outcome, rather than a tool for the development of interventions. Only one study  used theUsing the constructs as a measure shows to be positive for interventions. The literature shows TTM as a more sensitive measure of progress for a dietary intake change, and even when the food consumption is not altered, an increase in decisional balance or self-efficacy, or progress through the stages of change can represent a positive outcome .Many studies recruited adolescents from schools, a normal setting for health programs , and ninAll the studies focusing on low income populations had significant results regarding dietary intake, such as increased consumption of fruits and vegetables, decreased consumption of fat and progress between stages –23, 31. Two interventions focused only on girls, and both had positive results , 24. A sGuerra et al. found that interventions with longer durations have more positive results . AccordiSome of the studies used a combination of the TTM and other behavioral change theories. To provide a more detailed explanation of health behavior and to reduce complexity, researchers have been trying to integrate diverse theories . CombiniThis review reinforced the flexibility of the model, since it was applied in different contexts and in a variety of ways: the interventions occurred at schools, dietetic clinics, youth service agencies and online, and the strategies included printed materials, nutritional counseling, group meetings, classroom lessons and digital technology. Many studies used information and communication technologies in their interventions, including strategies involving websites, videos, and CD-ROMs. This is a positive point because these media are highly acceptable among adolescents. Moreover, using digital media facilitates stage-based tailored interventions .Although the effectiveness of the TTM was addressed in the included studies, they had significant methodological differences, such as the outcome of interest, setting, forms of delivering the intervention, and other characteristics. No studies compared the effectiveness of different theoretical models for changing dietary intake or even if it is better not to use them . In addiThis review showed that most authors use mainly stages of change when developing nutritional interventions, although a study has shown that it is possible to use the less explored constructs in the design of the intervention . These iA meta-analysis could not be performed due to the heterogeneity of the studies. Non-representative samples, low frequency, and exposure to the content of the intervention, and short length of follow-up assessment, that were aspects related to the poor quality of the articles included, were the main limitations of the selected studies. A limitation of this review is the fact this present study was aimed at evaluating effects only on dietary intake. However, an individual’s eating behavior involves several determinants, which were not considered in this review.The TTM seems to be a successful strategy for nutritional intervention aiming at improving dietary intake in adolescents. Besides, its application in different contexts shows that the TTM is flexible and possible to be completely implemented in many settings. It is expected that interventions using TTM focusing on a single dietary intake component show better results. The use of the model in the development of the intervention is shown to be restricted to the stage of change’ construct. Although the effectiveness of the TTM was addressed in the included studies, they had significant methodological differences, such as the outcome of interest, setting, forms of delivering the intervention, and other characteristics. No studies compared the effectiveness of different theoretical models for changing dietary intake or even if it is better not to use them . In addiThis review showed that most authors use mainly stages of change when developing nutritional interventions, although a study has shown that it is possible to use the less explored constructs in the design of the intervention . These iAdditional file 1.Additional file 2.


BJPsych International on community mental healthcare in the diverse cultures of Greece, Cambodia and Malawi.This editorial introduces three papers in  In this issue we begin with reflections on the provision of community mental healthcare in three diverse cultures. First, in Greece, where following the disestablishment of in-patient asylums little progress has been made in building an alternative model of care. Second, in Cambodia, where the entire mental health system was destroyed in the 1970s by the Khmer Rouge, and services have had to be redeveloped from scratch. Third, in Malawi, where the community already provides care through the medium of traditional healers but where the management of serious mental illness requires better integration with psychiatric expertise.1 Greece came under the influence of the British, through their occupation of the Ionian islands in the early 19th century. The country's first psychiatric hospital was built in Corfu, although later mental health legislation was influenced by the French. Michael Madianos writes about psychiatric reform in Greece over the period 1999–2019.2 He emphasises that a mental healthcare system that was originally established nearly a century ago has changed relatively little, despite the considerable political developments that Greece has experienced in recent decades. Deinstitutionalisation, and the establishment of community care for mental disorders, began recently compared with Northern European countries, and reform has been slow to take root.The management of people with severe mental illness by incarceration in public asylums was the norm for many Western societies until relatively recently and was adopted by countries elsewhere in the world too, if they had been colonised by a power such as Britain or France.3 Rebuilding those services did not begin until the 1990s. The authors review progress in their article. Unfortunately, despite generous international funding soon after the Paris Peace Agreement was signed in 1991, this source of support has diminished in magnitude. There is a wish to develop community care for the many who have no access to services, but implementation of the strategic goals of the Cambodian government is still some way off.In Cambodia, which gained its independence from France in 1953, there was a single psychiatric hospital, containing 2000 patients, at the beginning of the Khmer Rouge period during which, as Sarah Parry and Ewan Wilkinson describe, mental health services were totally destroyed.4 The asylum's origins lie in the local prison, where it was established in 1910; it has existed in its current form since 1953. Criticism of the in-patient system, in the context of Malawian society, was made by a senior government psychiatrist at the hospital nearly 30 years ago.5 Dr Lilford spent some time there, and in another psychiatric facility that is attached to a general hospital. She reflects on the relationship between in-patient care and the local community, which still looks to traditional healers for support and guidance as a first resort.Philippa Lilford describes, in vivid terms, her experiences as a junior psychiatrist in Malawi, which has but one mental hospital, in Zomba.All three papers have important points to make about the relationship between asylum and community care, and all three provide stimulating reading.


InCharge is a newly developed school-based health intervention aimed at older adolescents. It aims to promote a healthier lifestyle by increasing self-regulation skills. After the InCharge program’s effectiveness was previously investigated in a pilot study, the content of the program was adapted.This study describes the protocol of a cluster randomized controlled trial that aims to investigate the effectiveness of the InCharge program.A cluster randomized controlled trial including 70 classes with older adolescents (aged 16 years or older) in the Netherlands will be conducted to test the effectiveness of the InCharge program. After schools are recruited, randomization occurs at the class level. The trial consists of the following two conditions: an experimental condition and a control condition. Participants in the experimental condition will be given the InCharge intervention, consisting of four lessons of 50 minutes, with each lesson containing three assignments of approximately 15 minutes. While participants in the experimental condition will receive InCharge, participants in the control condition will receive regular academic school courses. Surveys are administered 1 week before the intervention (baseline), 1 week after the intervention (posttest), and 12 weeks after the intervention (follow-up). Variables of interest include, but are not limited to, self-regulation; predictors of snack intake, physical activity, and alcohol use; and interpersonal communication regarding these health behaviors. In addition to surveys, observations will be conducted during the first and fourth lessons, teachers will be interviewed, and focus groups will be held with a selection of students from the intervention condition.Enrollment started in September 2017. As of June 2019, a total of 1216 participants were enrolled for this trial. Findings will be published in peer-reviewed journals and presented at conferences. The trial has been approved by the Ethics Review Board of the Faculty of Social and Behavioral Sciences of the University of Amsterdam (reference no.: 2017-PC-8244).In this study protocol, the design of a cluster randomized controlled trial is described, which assesses how effectively the school-based intervention InCharge stimulates healthier lifestyles in late adolescents. We hypothesize that participants in the experimental condition will consume less alcohol, eat fewer unhealthy snacks, and be more physically active compared with participants in the control condition.Netherlands Trial Register (NL6654); https://www.trialregister.nl/trial/6654RR1-10.2196/17702 Health and mortality are strongly affected by behaviors such as excessive alcohol use, a poor diet, and physical inactivity . Some heIn the past decades, numerous health promotion programs have been developed in order to prevent the rapid increase of unhealthy behaviors during adolescence. The majority of these programs take place in the school environment, because many adolescents can easily be reached by school-based health interventions. Several studies have suggested that these interventions can indeed promote healthier lifestyles, such as a healthy diet  and physFurthermore, most health promotion programs include several different components, and in most evaluation studies, the exact relationship between these intervention components and their effects remains unclear. In order to understand which program components contribute to healthier lifestyle behaviors and which components do not, several authors conducted meta-regression analyses. For example, previous research demonstrated that self-regulation, which is defined as the capacity needed to resist temptations and impulses , was an Therefore, the school-based health intervention investigated in this protocol study also incorporated self-regulation as the main prevention strategy to promote healthier lifestyles. The intervention, called “InCharge,” is newly developed by the Trimbos Institute . The InCharge program is developed for older adolescents and aims to promote healthier lifestyles by improving self-regulation skills . The program helps students realize what is important to them and how certain temptations can hinder them from achieving these goals, teaches them that self-regulation can be used to resist certain temptations , trains self-regulation skills by formulating an action plan, and helps them practice self-regulation through various assignments. Finally, alcohol is introduced as a temptation, and students formulate action plans for responsible alcohol use in order to stimulate healthier drinking behaviors.This protocol study also investigates potential factors that determine the effectiveness of the InCharge school-based health intervention, because previous studies have found large heterogeneity in the effectiveness of these types of interventions . In partThe InCharge program is based on several psychological theories such as the social cognitive theory (SCT) , the theThe InCharge program is developed by taking into account the developmental characteristics of older adolescents. The primary developmental tasks of late adolescence are forming an identity, planning the future, and acquiring the necessary skills to transition into adulthood . As oldeThis study describes the protocol of a randomized controlled trial (RCT) including 70 classes with older adolescents, which aims to evaluate the effectiveness of the InCharge program. Baseline, posttest, and 3-month follow-up measures will be conducted to determine whether the program successfully influences the determinants of health behaviors. After completing the program, students in the intervention condition are expected to refrain more from binge drinking and eating unhealthy foods, such as snacks and sweets, and to be more physically active than students in the control condition.Other aims of our study are to understand the mechanisms through which the InCharge program has its effects. We investigate whether the effects of the program on health behaviors can be explained by increased self-regulation, which is expected to be one of the core mechanisms of the program. Additionally, as previous research has shown the importance of interpersonal communication in mass-mediated health interventions , our stuThe InCharge effectiveness study is a cluster RCT including the following two conditions: an experimental condition (the InCharge program) and a control condition (no intervention) . ParticiThe Municipal Health Services and prevention departments of regional institutions for the treatment and care of addiction help to implement the InCharge program in schools. From these Municipal Health Services and regional institutions, 47 prevention practitioners are trained by the Trimbos Institute to instruct teachers on how to deliver the program and are asked to provide us with a list of schools in their region interested in participating in the InCharge study. The research team contacts these schools to explain the objective and design of the study. First, schools receive an invitation and an information brochure via email, and thereafter, schools are contacted by phone to discuss participation in the study. Schools are allowed to select the number of classes participating in the study, with a minimum of two classes because randomization occurs within schools. To create comparable research conditions, schools are instructed that a minimum number of two classes should be from the same educational level of the field of study. Classes are eligible for inclusion in the study if they contain older adolescents and the level of education is intermediate vocational education, higher general secondary education, or preuniversity education. Students are recruited by class participation. In collaboration with the schools, students’ parents are informed about the study objectives and receive passive informed consent forms. Written active informed consent is obtained from all participating students.We randomize the participants at the class level, and classes within schools are matched on the school level in order to obtain more comparable research conditions. Classes are randomly allocated to the experimental or control condition by means of repeated coin tossing. For each selection of matched classes within schools, classes are assigned to the experimental condition if the coin toss shows heads and to the control condition if the coin toss shows tails. The coin toss procedure is continued until all matched classes are assigned to a research condition, such that as many matched classes as possible are assigned to the experimental and control conditions. Randomization is carried out centrally, with two researchers present to monitor the procedure.d=0.2) [α=.05 and a power of (1–β)=0.80, 393 students are required per condition. However, as students are nested in classes and the program is delivered to classes of students, observations of students in the same class are not independent. Therefore, the required sample size is corrected for clustering. Assuming an intraclass correlation of 0.025 and an average class size of 16 participating students, the required sample size increases to 560 students in 35 classes per condition. Calculations are made using the downloadable procedure “clustersampsi” from Stata (StataCorp).Effect sizes are difficult to estimate for the InCharge program because the program is newly developed. As school-based prevention programs generally have small effects , we based=0.2) . In ordeThe experimental intervention is a school-based program named InCharge, which has been designed for older adolescents. The main objective of the program is to stimulate healthy lifestyle behaviors, such as increased physical activity, and to decrease unhealthy behaviors, such as binge drinking and eating unhealthy foods. These objectives should mainly be obtained by means of increasing students’ self-regulation skills.The InCharge program consists of four 50-minute lessons, and each lesson contains three assignments of approximately 15 minutes. Teachers are trained on how to work with the program material by prevention professionals from Municipal Health Services or regional institutions for the treatment and care of addiction. Materials, such as worksheets, videos, and a web-based quiz tool, are available on a digital teacher platform. In addition, a specially designed app for the smartphone  is used to help students complete the program.In the first assignment of the first lesson, students visualize their goals for the next 5 years by thinking about what they want to achieve in life and why this is important to them. In the second assignment, students discuss the biggest temptations in their lives. For this assignment, the teacher clears a space in the classroom and draws an imaginary line. Students are asked to position themselves alongside this imaginary line according to how tempting they assess certain temptations, such as chocolate or sweets, alcohol, and staying in bed in the morning. After each temptation, the teacher asks the students to explain their position. In the third assignment, students visualize how their goals would be affected by repeatedly giving in to their biggest temptations or repeatedly resisting their biggest temptations.In the second lesson, the concept of self-regulation is introduced . First, students watch and discuss a video of the marshmallow experiment to understand the role of self-regulation . In thisIn the third lesson, first, the results of the 7-day challenge are discussed. During the second assignment, students reflect on their original plan to complete the challenge and discuss how these plans could further be improved. The third assignment addresses peer pressure, as peers have been shown to strongly influence the health behaviors of adolescents ,32. In oThe final lesson elaborates on alcohol use. At first, students watch a video of partying adolescents who are consuming large amounts of alcohol. The video shows a group of friends who are having fun at first, but the situation ends with a conflict and an injury as a result of excessive alcohol use. Thereafter, students discuss the role of peer pressure in excessive drinking. Second, in order to make them aware of current social norms, students discuss the social acceptability of binge drinking by means of an interactive web-based quiz. Finally, the students identify situations in their own life, where it is important to be careful with alcohol, and come up with strategies to do so. A more thorough description of the assignments can be found in An overview of all measurements is provided in The InCharge program aims to stimulate a healthier lifestyle in general among older adolescents by increasing self-regulation skills. In terms of outcome measures, the study focuses on the following three outcome behaviors: alcohol use, snack intake, and lack of physical activity. A pilot study of the program has shown that these behaviors are most prevalent among older adolescents. The main outcomes that are measured for alcohol use, snack intake, and physical activity are the actual behaviors and predictors of the behaviors. Snack behavior and physical activity are operationalized as the number of times adolescents consume snacks and are physically active in an ordinary week as well as in the past 7 days . AlcoholAdditional measures are general self-control, assessments of various temptations, interpersonal communication about the three health behaviors and the intervention, and evaluation of the program and teacher. First, we assess self-control using an adapted version of the Brief Self-Control Scale , which aObservations are conducted during delivery of the first and fourth lessons of InCharge to provide information on the classroom processes and how the program is delivered  and 3. TThe topic list of the focus groups with students includes interpersonal communication about temptations, evaluations of the InCharge program, and evaluations of the teacher. For interpersonal communication, we investigate the motivation to discuss temptations with the teacher, friends, classmates, and parents, and reasons why students did not discuss temptations with these conversational partners. The content as well as the valence of the conversations about temptations is investigated for interpersonal communication both within class and outside class. For the evaluation of the program, we aim to understand what parts of the intervention students find helpful or not, whether students actively complete in-class and homework assignments, and whether students think the intervention helps them to deal with temptations in the future. Lastly, we ask students about whether their teacher clearly explains the assignments during the intervention, who should ideally be given these interventions, and their perceptions of their teacher’s support for the intervention.The topic list of interviews with teachers includes interpersonal communication, teacher perception of students, and evaluation of InCharge. For interpersonal communication, we assess the content and valence of conversations with students about the InCharge program, both during the intervention and outside class, as well as conversations that teachers have overheard among students. For teacher perception of students, we investigate how teachers perceive students’ participation and enjoyment. Finally, we discuss the health intervention with the teacher in order to find improvements for the program.The background variables of the students  will be checked to assess whether these variables are successfully randomized across the experimental and control conditions. Unsuccessfully randomized variables will be included as covariates in further analyses to control for potential confounding. Our data have a multilevel structure because participants are nested within classes, and these classes are nested within schools. Therefore, participants in one class or school are more similar than participants in other classes or schools. To account for this potential dependency in the data, we will correct standard errors and parameter estimates for clustering.In order to determine the effectiveness of the health intervention, an intention-to-treat procedure and completers-only framework will be used to analyze the data. An intention-to-treat analysis of the data implies that participants will be analyzed under the condition that they are initially assigned, whereas completers-only framework analyzes only participants who are present at all time points. Using multilevel analyses, the three behavioral outcomes  will be compared between participants in the experimental condition and those in the control condition at posttest and follow-up to determine the effects of the program. In the experimental condition only, multilevel analyses will be conducted to investigate the influence of treatment integrity on the predictors of the three health behaviors at posttest and follow-up. For missing data in multilevel models, maximum likelihood estimation will be used. As self-regulation is an important concept in InCharge, we will test whether the potential effects of InCharge on the health behaviors are explained by self-control. Additionally, relations between interpersonal communication with teachers, friends, classmates, and parents  and health-related outcomes, such as a mediating role between the conditions and outcomes, will be tested. As the program is delivered by teachers, we will also test in the experimental condition whether teacher communication relates to the evaluations of the health intervention and the three behavioral outcomes, using structural equation modeling. For structural equation models, expectation maximization will be used to impute the data.For the qualitative data, interviews with teachers and focus groups with students will be analyzed on the strengths and weaknesses of the program in order to adapt the program. Furthermore, qualitative data will be used to determine the content of interpersonal communication with regard to the InCharge program and various temptations.No patient is involved in this study.The trial has been approved by the Ethics Review Board of the Faculty of Social and Behavioral Sciences of the University of Amsterdam (reference no.: 2017-PC-8244), and the trial is registered with the Netherlands Trial Register (NL6654). Manuscripts reporting the effectiveness of the health intervention and our other aims will be submitted to peer-reviewed journals for publication.The recruitment, inclusion, and randomization of participants  started in the spring of 2017 and was continued in the spring of 2018, and data are being collected during the following two consecutive school years: 2017-2018 and 2018-2019. As of June 2019, a total of 1216 participants have been enrolled for this trial. This study is part of a PhD project and is expected to be completed in November 2020.The goal of this paper is to describe the study protocol of a cluster RCT that aims to evaluate the effectiveness of a school-based health intervention named InCharge. The goal of this program is to stimulate healthier lifestyles by improving the self-regulation skills of older adolescents. We expect that adolescents will be more inclined to refrain from binge drinking and eating unhealthy foods and to be more physically active after following the InCharge program compared with adolescents in the control condition.Given that InCharge is a school-based health intervention, the potential to reach a large number of adolescents is an important strength of the program. Second, the underlying mechanisms of InCharge are based on several often successfully tested and relevant theories such as the SCT  and the Our study has some limitations as well. The unit of randomization was classes instead of schools. The presence of both experimental classes and control classes within the same school could result in contamination between conditions because students from the experimental and control condition could have shared information about the intervention. However, as classes within the same school are generally more similar than classes from different schools, we expect that randomization at the class level will result in more comparable research conditions than randomization at the school level. Another limitation relates to the fact that the questionnaire data are obtained through self-reports. A disadvantage of self-reported data is that participants likely want to present themselves favorably, and hence, this might influence how they respond to surveys . One exaThe InCharge study evaluates the effectiveness of the program, and its findings will help to further improve the program. The study also investigates whether including self-regulation as a key component in a school-based health intervention promotes healthier lifestyles among older adolescents. If findings reveal that improving self-regulation skills decreases unhealthy behaviors, such as alcohol use and snack intake, and increases healthy behaviors, such as physical exercise, the findings may aid the developers of health interventions in designing effective behavior change programs for older adolescents. In addition to the content of the intervention, investigating how teacher communication relates to the three health behaviors can provide information on how to communicate for a school-based health intervention. This information can be used to formulate communication guidelines in order to improve the delivery of school-based health interventions and, ultimately, healthier lifestyles. Promoting healthier lifestyles is especially important for older adolescents because unhealthy behaviors generally peak during late adolescence ,5. FinalThis protocol study uses an RCT to assess the effectiveness of InCharge, a newly developed school-based health intervention for older adolescents. As previous research has shown that utilizing self-regulation is an important prevention strategy, the goal of InCharge is to promote healthier behaviors, such as physical activity, and discourage unhealthy behaviors, such as alcohol use, by enhancing self-regulation skills. The program will be improved based on the findings of the effectiveness study.


Marketers have found new ways of reaching adolescents on social platforms. Previous studies have shown that advertising effectively increases the intake of unhealthy foods while not so much is known about the promotion of healthier foods. Therefore, the main aim of the present experimental pilot study was to examine if promoting red peppers by a popular social influencer on social media (Instagram) increased subsequent actual vegetable intake among adolescents. We used a randomized between-subject design with 132 adolescents (age: 13–16 y). Adolescents were exposed to an Instagram post by a highly popular social influencer with vegetables (n = 44) or energy-dense snacks (n = 44) or were in the control condition (n = 44). The main outcome was vegetable intake. Results showed no effect of the popular social influencer promoting vegetables on the intake of vegetables. No moderation effects were found for parasocial interaction and persuasion knowledge. Bayesian results were consistent with the results and supported evidence against the effect of the experimental condition. Worldwide, youth do not consume the recommended amount of fruit and vegetables, making it important to examine if mere exposure or different forms of food promotion techniques for healthier foods are effective in increasing the intake of these foods. Eating sufficient nutritious foods is essential for a healthy growth and development. More specifically, vegetables protect against many illnesses and chronic diseases and improves psychological well-being ,2. Next Next to that, the popularity of social media among adolescents keeps rising and following blogs and vlogs (video blogs) has become hugely popular among millions of young people worldwide, thereby significantly influencing their daily behavior . Due to The exponential growth of social media has given rise to so-called microcelebrities, such as bloggers or vloggers, who have gained fame on social media through self-branding and mere exposure . These nBased on general cognitive and developmental psychology ,17, one’In addition, the Processing of Commercial Media Content Model (PCMC-model ) has proMore specifically, adolescents’ motivation and ability to critically process the marketing message of the social influencer will be relatively low in comparison to more traditional forms of advertising because the advertising cues in social influencer messages are highly integrated in the entertaining content. Therefore, the cognitive resources of adolescents’ automatically will be used to process the entertaining aspect of the message, while additional sources are needed to activate skepticism towards the advertising element of the message. Considering that most adolescents will not be motivated to do so, skepticism will not be activated among the recipients .According to the Differential Susceptibility to Media Effects model (DSMM ), the lePrevious studies have shown that multiple advertising techniques are effectively increasing the intake of unhealthy foods, also by social influencers , while nOne theoretical framework that aims to predict and explain the effects of the promotion of healthy foods is the Promotion of Healthy Food Model . This thIndividual susceptibility to advertising messages effects may in particular be considered when it comes to influencer marketing by social influencers, as these social influencers specifically design their messages for existing community of engaged and young followers, thereby reducing their persuasion knowledge activation and increasing the parasocial interaction, leading to a more positive attitude towards the advertised product and increasing purchase intentions ,41,42. IFor advertising on Instagram, where social influencers often involve viewers in their personal life, for example, by sharing intimate personal stories, this identification process is often reinforced and can lead to conformity among the viewers, through parasocial interaction . SimilarThe main aim of the present experimental pilot study was to test if promoting red peppers by a popular social influencer on social media (Instagram) increased subsequent actual vegetable intake among adolescents compared to adolescents who were exposed to the promotion of energy-dense snack by a popular social influencer on social media or to the promotion of nonfood products by a popular social influencer on social media. The expectation was that adolescents who were exposed to the promotion of red peppers were more likely to choose vegetables than the adolescents who were exposed to the promotion of energy-dense snacks or nonfood products. Furthermore, it was expected that the level of parasocial interaction and persuasion knowledge moderates this effect.In the current experimental pilot study, we used a between-subjects design with three conditions (type of Instagram post: vegetables vs. energy-dense snacks vs. nonfood products). The manipulated posts were all derived from a highly popular Dutch social influencer, named Kalvijn, and were identical regarding the amount of likes , reactions (N = 65), and the explanatory text, except for the products presented. The Instagram post was integrated in a paper questionnaire that was distributed to the adolescents. Adolescents were randomly assigned to one of the three conditions. The vegetable condition was an Instagram post by Kalvijn of red pepper. The energy-dense condition was an Instagram post by Kalvijn of finger foods. The nonfood condition was an Instagram post by Kalvijn of sunglasses. One of the vegetables provided for consumption was also used in the Instagram post (red pepper). The dependent variable in this study was vegetable intake. Adolescents could choose of three vegetables, namely small red peppers, cucumbers, and cherry tomatoes. These snack foods are very popular among adolescents in the Netherlands. Adolescents (N = 132) were told that they could choose freely from the vegetables and could take as many as they wanted. We used more vegetables snacks than were shown in the Instagram post because previous studies have shown that food advertising leads to spillover effects as well ,25,26. IAll adolescents were in the first or second grade of secondary school. Adolescents participated collectively within their own group, during school hours in the presence of their teachers and the research assistant. Before the assessment, we emphasized to both parents and the adolescents that all of the data for this study would remain confidential and that adolescents could cease participation at any time. The experiment took approximately 15–20 min. The study protocol was reviewed and approved by the Ethical Board of the Communication Science Department at the Vrije Universiteit Amsterdam. Data for this study were collected in May 2018. The data that supports the findings of this study are available from the corresponding author upon reasonable request.After obtaining written consent from both schools to participate in the current study, we sent all parents a letter with detailed information regarding the study and we asked them to actively consent for participation of their child(ren). Before the assessment, we emphasized to both parents and the adolescents that all of the data for this study would remain confidential and that they could cease participation at any time. The cover story was that we were interested in the media use of youth. Adolescents in both grades filled out the questionnaires in a classroom individually with the research assistant present to clarify potential difficulties. Adolescents could not see other adolescents’ answers because the set-up of the classroom was conducted so that every adolescent was seated at a separate table, with enough room between tables.The questionnaire consisted of two different parts. In the first part, adolescents answered questions regarding sociodemographical questions, such as age and gender, followed by a question about their hunger level . Next, their general usage of Instagram, familiarity with social influencers, and whether they follow any of these social influencers were assessed. Subsequently, adolescents were exposed to the Instagram post at the end of this part of the questionnaire. Participants were told that they should pay attention to the post because subsequently questions regarding the post would follow, which took 1–2 min on average. After finishing the first part of the questionnaire, they handed in the questionnaire to the research assistance, where they could take a snack . The research assistant explained that they could take as much snacks as they liked, ad libitum. Then, the research assistant provided the second part of the questionnaire to the participants. When the child returned to their seat, the research assistant coded (encrypted) which and how many vegetables were consumed by the participant without notifying the adolescents that this was coded. The second part of the questionnaire consisted of questions related to parasocial interaction with the social influencer, persuasion knowledge, general vegetable intake, favourite vegetable, and the manipulation check.Vegetable consumption: The dependent variable was vegetable consumption. Actual consumption was assessed by counting the type and amount of vegetables that were consumed as a snack.Parasocial interaction. Parasocial interaction was assessed by thirteen statements that were adapted for the current study, derived from the Audience-Persona Interaction (API) Scale , also usPersuasion knowledge. Persuasion knowledge was assessed with five items on a seven-point scale, derived from Carter et al. . Items wp > 0.05), so no covariates were included in the analyses.First, data was tested for normality and homogeneity of variance (Levene’s test). Next, before testing our hypotheses, we conducted randomization checks with a multivariate analysis of variance (MANOVA) for gender, age, hunger, parasocial interaction, and persuasion knowledge. p value that was considered significant was 0.05.In addition, univariate analysis of variance (ANOVA) tested the effect of the type of Instagram post on total vegetable intake and multivariate analysis of variance (MANOVA) tested the effect of the type of Instagram post on intake of the three types of vegetables. To further test for the (non)existence of the main effects of the experimental condition, Bayesian ANOVA was performed with the statistical program JASP . Evidencp > 0.05), so randomization seemed successful. The manipulation check consisted of one question assessing which product the child had seen in the Instagram post. The results showed that 89% answered correctly on this question. More specifically, 91% in the vegetable condition, 93% in the energy-dense condition, and 82% in the nonfood condition answered correctly. A Chi-square analysis showed that the results were not significantly different between the conditions. Distribution of the data was normal and the Levene’s test showed no significant differences in homogeneity of variance.In the current study, 132 adolescents participated . No significant differences were found between the experimental conditions for gender, age, hunger, parasocial interaction, and persuasion knowledge . Bayesian ANOVA was consistent with this result and supported evidence against the effect of the Instagram post (BF10 = 0.095). In addition, the MANOVA showed no significant effect of type of Instagram post on the three individual vegetable consumption (p > 0.05).The results from the ANOVA showed no significant main effect of type of Instagram post on vegetable intake  was observed. Next, no significant interaction effect of type of Instagram post and persuasion knowledge on vegetable intake  was observed. Again, Bayesian ANOVA was consistent with these results and supported evidence against the effect of the Instagram post and the interactions, respectively (BF10 = 0.014) and (BF10 = 0.031). These results do not confirm the hypotheses.In addition, no significant interaction effect of type of Instagram post and parasocial interaction on vegetable intake  increased subsequent actual vegetable intake among adolescents compared to adolescents who were exposed to the promotion of energy-dense snack or nonfood products. The expectation was that adolescents who were exposed to the promotion of vegetables were more likely to choose vegetables than the adolescents who were exposed to the promotion of energy-dense snacks or nonfood products. Furthermore, it was expected that the level of parasocial interaction and persuasion knowledge would moderate this effect.The results showed no effect of the popular social influencer promoting red peppers on the choice or intake of vegetables. In addition, no moderation effects were found for parasocial interaction and persuasion knowledge. Bayesian results were consistent with the results and supported evidence against the effect of the experimental condition. A great amount of research has shown that food marketing affects actual consumption, but studies examining the effects of the promotion of healthy foods is limited ,24. TakiIn order to improve adolescents’ eating behavior and to reduce the number of adolescents that become overweight or obese, it is necessary to test effective methods to make healthy foods more appealing and to subsequently increase the intake of these food products, preferably substituting energy-dense foods . ExistinOne of the strengths of the current pilot study is that it is one of the first investigating the effect of a social influencer on the intake of vegetables. A large number of studies have been conducted examining the effects of unhealthy food marketing on the attitudes, intentions, preferences, and actual intake of adolescents , but First, one important line of research could for example examine the mechanism underlying the effects of food promotion techniques on actual intake. More specifically, it is important to investigate whether the promotion of fruits and vegetables influences an increased attention for these foods and, if this reinforces the perceived value and actual craving, by studying physiological and psychological responses when children are exposed to these promotional techniques . For exaPrevious studies have found an effect of the promotion of healthy foods on intake among adolescents ,57,58,59Second, future research should examine whether and how the accumulation of food promotion techniques for healthy foods influences the classical and operant conditioning of food cues and subsequent intake of healthier foods among adolescents. Theoretical models that explain the effects of food marketing on intake consider the effects of food promotion techniques on food intake (via cue-reactivity) as a process of classical and operant conditioning ,10, but Third, although multiple individual  and contextual factors  have been investigated that affect the influence of food promotion of unhealthy foods on eating behavior ,10, it rTo conclude, in the food marketing domain, some experts counsel against using the same promotional techniques that are used by food companies that market unhealthy foods because of their potential to undermine intrinsic motivation to obtain and consume healthier foods. As a result, using such techniques may backfire for some adolescents as well ,10. Ther


Dementia is a growing issue in modern society. Non-pharmacological interventions such as music are suggested as the primary methods for symptom management. Therapeutic potential may also be found in sound/mechanical low frequency vibrations (LFV) that share the core characteristics of music, but these are lesser understood. The aim of the proposed scoping review is to explore the responses of persons with dementia to LFV, e.g., vibroacoustic therapy or whole-body vibration. The scoping review will follow the Joanna Briggs Institute methodology guidelines. An extensive search in BMC, CINAHL, Cochrane Central Register of Controlled Trials, EMBASE, ERIC, MEDLINE (OvidSP), Pedro, ProQuest Central, PsycINFO, Scopus, Web of Science, and grey literature sources in Clinical Trials, Current Controlled Trials, Google Scholar, and manual search of relevant journals is planned to find all relevant research papers. The paper selection, full-text assessment, and data extraction will be performed by two independent reviewers. Participants’ responses to the interventions and the experiment designs, including methodological challenges, will be analysed and compared. Results may highlight potential gaps in reporting and comparing sound and mechanical vibration approaches and promote better understanding of their potential for managing the symptoms of dementia. Furthermore, the possible relationships between LFV and music-based interventions may become clearer.  Dementia is a broad umbrella term used to describe a range of progressive neurological disorders associated with cognitive impairment and language and problem-solving issues including Alzheimer’s disease, frontotemporal dementia, vascular dementia, and mixed dementia . The annPharmacological intervention is typical for managing the behavioural and psychological symptoms of dementia (BPSD). Yet, according to the Lancet Commission on Dementia, medication should only be applied in severe cases and only when psychosocial intervention alone is insufficient . CurrentTherapeutic listening and other music interventions are generally referred to in the literature as music therapy although certified music therapists may not be delivering the intervention. Music therapy comprises a goal-oriented, music-based intervention within a therapeutic relationship as defined by Bruscia , whilst In this study, we suggest that there is a close link between music and tactile low frequency stimulation. Approaches based on low frequency sound vibration are sometimes classified under receptive music therapy techniques ,21. HowePerceiving and making music involves several cognitive processes which influence attention, memory, motor action planning and communication; music also has an impact on emotion processing and regulation . The eleNeural rhythmic oscillatory activity has been proposed to play a role in neurodegenerative diseases and neurorehabilitation . Memory Vibroacoustic therapy (VAT) comprises tactile, low frequency, sinusoidal sound vibration (20–100 Hz) combined with music listening and a therapeutic relationship . This apWhole body vibration (WBV) is another tactile vibration method sometimes used in conjunction with exercise/physiotherapy, in which persons stand on an oscillating platform (either performing exercises or passively receiving the stimulation). It has been shown to be beneficial for improving balance and mobility in institutionalised elderly persons and in general health , as wellCurrently, there is no overview of the characteristics of tactile low frequency sound or mechanical vibration used for managing the symptoms of dementia, which represents a gap in knowledge. Because fewer results are expected and there are potentially valuable reports from clinical practice and non-research papers, a scoping review design was deemed more appropriate than a systematic review with meta-analysis, focusing on precise investigations of the effectiveness of an intervention using specific outcomes. Furthermore, the aim of this review is to identify the available evidence, highlight and analyse the gaps in current knowledge, delineate the key aspects and definitions in the literature and report on how the research has been conducted . In the Clinicians and researchers planning to design and implement future studies may benefit from a summary of how low frequency vibration is used for therapeutic purposes within and outside the context of music-based interventions, especially given the Lancet Commission Report’s findings . MoreoveThe aim of this scoping review is to summarise the research on tactile low frequency sound and mechanical vibration approaches that have been carried out with adults with dementia. We are interested in participants’ responses to, and the properties of, the interventions. This includes, for example, how participant responses have been collected and analysed . We are also interested in how methodological challenges related to the clinical aspects of dementia and how issues in applying vibration as a therapeutic medium were solved by different authors. Based on the critical appraisal of the studies and exploration of the research experiments, we will make recommendations for future studies. In the proposed scoping review, we will not limit the search strategy to a particular type of research or study design, with the intention of obtaining an inclusive map of the field. Therefore, the scoping review design was chosen as the most appropriate for these purposes .Furthermore, we want to address interdisciplinary questions concerning the relationship between approaches using sound/mechanical vibration and music-based interventions. VAT is sometimes defined as being a receptive music therapy method   paradigm was used to establish the focus of the review:Population (P): Adults with dementiaConcept (C): Tactile low frequency sinusoidal sound or mechanical vibrationContext (C): Not limited RQ1: What participant responses  are reported in studies on tactile low frequency vibration and dementia and how have they been measured?RQ2: What intervention characteristics  are reported in studies on tactile low frequency vibration and dementia and how do these compare or differ across the approaches?RQ3: What are the specifics of the research experiments in studies on tactile low frequency vibration and dementia?These were then used to formulate the review questions:The proposed scoping review will be conducted in accordance with the JBI methodology for scoping reviews  and accoParticipants: Adults with all types of dementia, both genders, patients with any level of functioning. The age limit is not set, so as to include all studies reporting on adults of any age with dementia, and types of dementia affecting younger adults . Studies of dementia patients with various comorbidities will be included if the intervention is focused on dementia.Concept: Studies addressing the use of tactile low frequency vibration e.g., VAT, with or without music listening and with or without a therapeutic relationship for managing the symptoms of dementia. Studies reporting on whole body vibration (WBV) or interventions using local mechanical vibrations will also be included, along with papers using these interventions in multisensory environments, if the participants’ response to low frequency vibration may be distinguished from responses to other stimuli. Studies based on electrical vibrations, e.g., transcranial magnetic stimulation, or low tone natural sounds  will be excluded.Context: There will be no limitation on demographic context or settings. We will search for studies from all over the world done in residential care homes, hospitals, private setting, etc. The search will be limited to articles written in English, German, and Czech. The language of the study will be recorded in the data extraction table.Types of studies: All types of quantitative, qualitative and mixed-methods studies including systematic and scoping reviews will be included. Designs of quantitative studies will include experimental studies, quasi-experimental studies, observational studies, case series/case studies, cross-sectional studies, and case reports from clinical practice. Qualitative studies will not be limited by the paradigm, although mainly phenomenological studies are expected to be found in this area.The inclusion criteria, defined based on the PCC paradigm and the review questions, are as follows:The search strategy will aim to locate both published and unpublished studies. An initial limited search of EMBASE, CINAHL plus and MEDLINE (Ovid PS) was undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles, were used to develop a full search strategy for the databases see . The seaFollowing the search, all identified citations will be collated and uploaded into Zotero 5.0  duplicates removed. Following a pilot test, titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review . The full text of potentially relevant sources will be assessed in detail against the inclusion criteria by two independent reviewers. Reasons for exclusion of sources of evidence at full text that do not meet the inclusion criteria will be recorded and reported in the scoping review. Any disagreements that arise between the reviewers at each stage of the selection process will be resolved through discussion or with an additional reviewer/s . The results of the search and the study inclusion process will be reported in full in the final scoping review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses for Systematic Reviews (PRISMA-SR) flow diagram . Articles selected for retrieval will be assessed by two independent reviewers  for methodological quality and, based on the character of the identified full texts, the reviewers will consider performing a full critical appraisal using standardised critical appraisal from JBI . Any disData will be extracted from papers included in the scoping review by two independent reviewers  using a data extraction tool developed by the reviewers see . We willThis section will present the data in tabular form supported by a narrative, structured according to the review’s research questions. Review question 1 will address the participant responses to the interventions and how these responses have been investigated. In the data extraction table, we plan to classify the responses according to the type of response, e.g., physiological, behavioural or psychological responses, quality of life, depression, agitation, activities of daily living, etc. Additionally, sub-group analyses will be conducted according to types of dementia, reported age groups of the participants, and intervention/approach used and whether its application was whole body or local. Outcome measures and other methods used to gather the data will be reported and classified into specific categories according to the type of measure, e.g., questionnaires or observation, and the purpose of the measure, e.g., BPSD or quality of life. The intervention characteristics and their similarities/differences across interventions will be reported in answer to Review Question 2. We expect that the studies will mention at least the brand name of the technology used, the locality of body application  and the frequencies (in Hz) of low frequency sound. Furthermore, all the relevant information related to the intervention and other low frequency vibration characteristics will be added and compared across the studies. In answer to Review Question 3, we will analyse the specifics of the research experiments depending on the design of the study. The JBI codes for different levels of evidence in quantitative research will be used here . In qualFurthermore, we expect to gain insight into the current gaps in the literature regarding study designs and methods as well as authors’ recommendations for future research and the limitations of these studies regarding, e.g., valid controls, suitable study designs, and the potential impact of age in designing low frequency studies. An overview of data related to the year of publication will show the research trends in this area. These results may be significant in highlighting the potential gaps in reporting (such as intervention characteristics) which could lead to more transparent reporting and a better understanding of the implications of LFV in dementia symptom management. Moreover, a better understanding of the intervention characteristics may shed light on how they may be defined, their relationship to music interventions and their potential as a non-pharmacological intervention. The limitations of these interventions, possibly related to study design, difficulty in delivering the intervention to frailer older adults, or dosage, will also be reported. The possible auditory music listening stimulus as part of vibroacoustic therapy sessions will also be discussed and juxtaposed with receptive music therapy and music medicine interventions to contextualise the scoping review outcomes. This affords the possibility of comparing this intervention with mechanical tactile vibration interventions within the framework of the Lancet Commission on Dementia report . VAT is The reported responses of patients with dementia on tactile low frequency sound and mechanical vibration will be investigated in this scoping review. We aim to gain greater understanding of interventions using low frequency vibrations and the methodological specifics and challenges of researching low frequency vibrations in people with dementia. Based on this analysis, this review could be beneficial in formulating recommendations for future research in terms of the selection of study design and outcome measures, music selection, a stricter focus on reporting the concrete effects of these stimuli, choice and transparent selection of the stimulus parameters  applied in research, and specifically those used with persons with dementia.


Community-based participatory research (CBPR) is a mine field of moral dilemmas. Even when carefully planned for and continuously critically reflected upon, conflicts are likely to occur as part of the process. This paper illustrates the lessons learned from “Building on Strengths in Naujaat”, a resiliency initiative with the objective of promoting sense of belonging, collective efficacy, and well-being in Inuit youth. Naujaat community members over time established strong meaningful relationships with academic researchers. Youth took on the challenge of organizing community events, trips out on the land, and fundraisers. While their creativity and resourcefulness are at the heart of the initiative, this paper explores conflicts and pitfalls that accompanied it. Based on three themes – struggles in coming together as academic and community partners, the danger of perpetuating colonial power structures, and the challenges of navigating complex layers of relations within the community – we examine the dilemmas unearthed by these conflicts, including an exploration of how much we as CBPR researchers are at risk of reproducing colonial power structures. Acknowledging and addressing power imbalances, while striving for transparency, accountability, and trust, are compelling guiding principles needed to support Indigenous communities on the road toward health equity. Ever failed. No matter. Try again. Fail again. Fail better.” This literary quote from Samuel Beckett  epitomizThis paper reflects on lessons learnt from “Building on Strengths in Naujaat”, a community-based participatory youth suicide prevention initiative, with two main goals: to understand the pitfalls of reproducing social and health inequalities, and to contribute to moving mental health promotion in Inuit communities forward. The method chosen for this study was reflection, postulated as a valid element of social inquiry, which explicitly recognizes the socially constructed character of knowledge about human realities. “Building on Strengths in Naujaat” commenced as a collaboration between Naujaat youth and University of Manitoba researchers . It origThese ideas of approaching the issue of suicide in a different way, while acknowledging the colonial context, made the academic partners consider a community-based participatory research (CBPR) approach. It was regarded as a good fit because it considers dignity, autonomy, and assets of a “community” as a frame of reference that guides research . The InuThis article renders insights into challenges and learning opportunities from “Building on Strengths in Naujaat.” To this end, it analyzes the team's reflections through the lens of three overarching themes: the need to bridge conflicting expectations and pressures of academic Qallunaat  and Inuit community partners; the inherent danger of perpetuating colonial power structures; and the challenges of navigating complex layers of relations within the community. Through analyzing our respective narratives, experiences and thoughts from an equity perspective, the three themes are placed in a theoretical context. The purpose of this paper is to explore how much we as CBPR researchers, while intending to promote collaboration, collective efficacy, and social and health equity, are at risk of reproducing power imbalances. Our reflections are intended to help prepare teams for CBPR with marginalized populations, to support critical reflection of their roles, and to contribute to discussions among the academic community . Most imIn section Materials and Methods we describe a brief history of the “Building on Strengths in Naujaat” initiative, including its conceptual grounding in CBPR principles, and the method of reflection. In section Results the themes illustrating conflicts and dilemmas encountered in the process of implementing the initiative are presented. In section Discussion we summarize the lessons learnt.“Building on Strengths in Naujaat” is a youth suicide prevention initiative that came together as a response to a need formulated by community members. Young people, their parents and grandparents, nurses, and teachers expressed the pain of losing a family member, a friend, a patient, or a student to suicide and wished to contribute to a future with an emphasis on hope, creativity, and better opportunities for youth to live up to their fullest potential. This made CBPR a perfect framework for engagement. “Building on Strengths in Naujaat” involves community members and Qallunaat researchers as partners at all stages of the initiative. The goal is to build capacities,including a deeper appreciation of Inuit ways of knowing and knowledge of the Inuit concept of well-being for academic partners, as well as coping skills collective agency and efficacy for community partners, and to eventually achieve community ownership of the project.The initiative is guided by an all female team [observed to be common in coproduction research ], compriThe academic partners  formulated the written portion of this paper; however all ideas and lessons learned were co-produced and reviewed in oral discussions with the community co-authors . Naujaat based co-authors requested to be the voices of the youth group without standing out. We agreed to avoid mentioning their opinion directly, as it was perceived as possibly threatening future employability at the Health Center, as well as reigniting family conflicts. Other members of the youth group who contributed to our discussions chose not to go on record out of similar concerns.The idea for this study was formulated in dialogue with Naujaat Hamlet Council, Naujaat Health Committee, and Naujaat Elders. It was repeatedly stated by Elders that looking at the positives, at strengths and hopes, is crucial for building resilience. We outlined that the academic partners could help by supporting the youth in developing their visions of a healthy community. Our target population were young people residing in Naujaat between the ages of 16–25 years. Their wishes and ideas received a central role in the design of the study as the starting point of all project activities. Inuit youth were designated as co-creators of the action plan. Collaboratively, community and academic partners chose activities, applied for funding, executed them, and reflected on the benefits to the individual, the family, and the community. The ultimate goal of this youth suicide prevention initiative was to co-produce a sense of agency and ownership that will promote Inuit self-determination and well-being, in accordance with National Inuit Strategy on Research .focus groups in April 2017. Two of the authors (SP & SI) helped to shape the questions for the focus groups, recruited participants and co-led the focus groups together with our colleague Dr. Maria Bronson, PA and EG. Themes that emerged from these groups were cultural identity and pride, sense of belonging, plans and visions for the future. To refine and consolidate these themes we conducted 12 individual interviews with group members. (A detailed description of the methodology and findings from the focus groups and interviews will be reported elsewhere.).To illuminate the wishes, hopes, and dreams of the youth of Naujaat as a first step, the project started out with a series of six After finishing the focus groups, weekly youth group meetings developed; they built on the themes to co-produce interventions. Initially, a Qallunaat high-school teacher helped organize weekly meetings. After she left the community, the meetings stopped for several months, and resumed after a new teacher took on the organizing task. The reasons for a designated organizer were multilayered. Initially, the meetings took place in the Public Health Room of the Health Center, and the nurse in charge insisted on an “adult”  supervisor. Later, the meetings took place at the Tusarvik Elementary School, and a teacher was needed for supervision. Additional reasons for a designated organizer were capacities to contact group members, buy snacks, and help with provisions for trips out on the land. As youth juggle responsibilities of school, work, raising children  and helping family Elders, this coordinating role was more manageable for a volunteer teacher.The “Building on Strengths in Naujaat” youth group organized activities that included various sports tournaments, fundraisers, sewing circles, a presentation series, and trips out on the land (ranging from day trips to three night camping trips). One of the authors (SP) was in charge of an athletic committee that applied for Tusarvik gym use, recruited community members, appointed referees, and announced rules and awards for the spontaneously built teams. Soccer, floor hockey and volleyball tournaments were put together. All teams were passionate and the audiences cheered; fun was the ultimate measure of success. Other committees took on organizing fundraising bake sales, penny sales, and sewing circles.trips out on the land, with staff of the community health care center. Youth group members who were otherwise hard to engage took on leadership roles. Academic partners and health staff needed guidance every step of the way. Youth decided what provisions to take, who to hire as guides, and how much gas was needed. On the way, stories were told about other trips, challenges, tragedies, and legends. Youth who were branded as trouble-makers in the community flourished while camping. They looked out for others, fetched water for the kettle, and refilled gas in the common stove. In the non-clinical setting clinical measures for protective and risk factors were replaced by a sense of purpose, a sense of belonging, and group cohesiveness. Seeing resilience in action transformed our partnership. Experiencing and sharing valuable moments became a fundamental goal of our collaboration.The most exciting activity proved to be The COVID-19 pandemic suspended all group activities. Youth group meetings, interviews and collection of qualitative outcome measures will resume after the pandemic restrictions have been lifted.This paper reflects on the experiences, challenges and insights of the “Building on Strengths in Naujaat” team. To this end it draws on ongoing reflection and evaluation processes that accompanied the project's implementation. These include the research team's observations and discussions, and informal unrecorded conversations with youth, their parents, and grandparents, Hamlet Council, Elders, Hamlet administrators, as well as Non-Inuit teachers, and nurses, who resided in the community between 2017 and 2020.Reflection has been described as an important mode of learning in action-oriented and community-engaging types of research. It figures centrally in cyclical processes of “(1) action, (2) concrete experience, (3) reflective observation, (4) abstract conceptualization, and new action” . CriticaMinkler  characteIn line with this concept of reflection, the “Building on Strengths in Naujaat” team has retrospectively collected pertinent episodes in the project implementation process, identified key challenges, conflicts and learning moments, and discussed related cognitive and emotional experiences. The discussions led to a mapping of the different episodes and experiences around three themes: conflicting values, expectations and pressures of academic and community partners; the dangers of reproducing colonial power structures; and the challenges of navigating complex layers of relations within the community. These three themes posed challenges for our collaboration and at the same time taught us valuable lessons about the role of relationship building as the foundation of CBPR with marginalized populations.The following section will elaborate on these three themes and ultimately relate them to the overarching question of how CBPR can avoid reproducing colonial power structures, and instead address (current and historic) conflicts, faults and failures to live up to its promise of contributing to greater equity.The world of academia and the world of our community partners march to very different beats . ThroughIn the early phase of this project, senior researchers attempted to dissuade us from embarking on this journey by pointing out that the time investment will not pay off in terms of publications. Their prediction was accurate. Five years later, this is our second paper. Most of the academic partners' time is invested in relationship building and re-building amidst changing composition and context of the youth group, and the management of conflicts and logistic challenges. Extracting publishable results is a painstakingly slow process, when it happens at all.All the while, the academic partners were still going too fast for the community partners. In the clinical milieu, the question “How long have you been coming to Naujaat?” is commonly asked of psychiatrists. For some patients the right answer is “three years”, and others do not view outsiders as trustworthy, even after 8 years. Youth and academic partners spent time together, shared snacks and Caribou burgers, while jointly formulating interview guidelines. Nonetheless, the answers given in both individual interviews and focus groups were mostly safe, indicating that the youth perceived the process as rushed. We realized that more consistent and reliable relationships were required to ask deeper questions. According to Attachment Theory, exploration starts after a secure attachment has been established. A pattern of consistent reliable interactions in tune with the needs of the individual will generate a safe haven from which exploration can be launched .In order to get permission to “dig deeper” into the youths' dreams and visions for a better future, we had to figure out how to visit the community; that is, how to be present, attend to, and take part in ordinary life. Visiting is an essential part of community cohesiveness in Naujaat. The doors are unlocked, no one is expected to knock or ring a bell. Coming over does not require a purpose, you can just come to spend time together. Being together does not require talking. People are comfortable with silence. We also had to learn how to present ourselves at these occasions: whether and how to show vulnerability, humility, and helplessness. When one of the authors (PA) brought her daughter to attend first the Tusarvik Elementary School and later Tuugaalik Junior High, it helped her to connect in many different ways as a parent and as a non-professional human being. Leaving behind the Qallunaat attributes of talking fast and talking too much, finishing other people's sentences, and having the answer for every question, proved to be very beneficial. It is through slowing down and refocusing our efforts from collecting “useful data” to getting to know each other, that the diversity of opinions, the complexity of intergenerational respect and estrangement, and the dynamic systems of working within the colonial institutions and resisting their uniformity came to light.Differences in values (unconsciously) held by the academic partners and the community threatened to undermine the initiative before it had even started. The academic partners approached the Hamlet Council to help identify youth with leadership potential in order to begin recruiting participants for the youth group. To their great surprise, this request was turned down, even though the Hamlet voiced unequivocal support of the initiative. As it turned out, “leadership” is not a universally positive concept. For the Inuit community the concept of leadership implies “singling out” individuals and thus runs counter to their values of equity, cohesion, and mutual help. Following consultations with Qallunaat high school teachers, the academic partners came up with a draft list of names (including the co-authors' names SP & SI); and the Hamlet Council gave its approval without hesitations.In addition to addressing the discrepancies between academic timelines and Inuit etiquette, and between Western and Inuit values, another challenge stemmed from the partners' divergent expectations and pressures. From the initiative's beginning, the academic partners endeavored to generate funding in order to ensure the initiative's continuation. However, as with many participatory projects, securing sustainable funding proved extremely tedious, with the lack of precise outcome measures being the main reason for rejection of grant proposals. Presetting outcome measures, however, contradicted the Inuit youth's legitimate demand for an opportunity to their own visions and plans. And while the academic partners fully supported a process where the community partners would identify their path toward a better understanding of Inuit resiliency and well-being – the pressure remains to ensure the initiative's sustainable funding within existing funding structures.Similarly, academic and community partners expect different outputs from the initiative. Academic partners need publishable research results, which are, however, abstract and irrelevant for the community partners (unless they provide travel opportunities like conference presentations). For the members of the youth group, in the short run, the excitement of going out on the land as a group, the joy of being in charge, smiles and happiness of braving the cold on the qamutiik , were important signifiers of success. In the long run, SP and SI expect concrete results on the ground. The initiative will eventually be measured by the job opportunities and recreational resources created, training courses completed and translated into respectable jobs, and housing crises resolved. Anything less than that will be viewed as a let down.At different stages of the initiative, the academic partners felt that both individual-level factors  and socio-political context made them tread a thin line between guiding the initiative and facilitating youth agency. Within that area of tension, the second theme reflects on a confrontation that ensued around issues of space and agency. Initially, “Building on Strengths in Naujaat” used the large Public Health Room in the newly constructed Naujaat Health Center. However, with new Health Center administration, the group no longer had access to the Health Center. For some time, meetings were held at a private residence of an Elder, which was problematic, because not everyone was comfortable entering the home. When the regional health authority representative offered to provide space for the group, it seemed a plausible solution at first. The youth group was offered a chance to embed its activities in existing health service infrastructure. This would also mean that participant recruitment and the scope of activities would be determined as part of a collaborative effort of the group and the health services.The group's integration into existing health service infrastructure could have helped to resolve material challenges for the group. However, both the academic partners and the youth each had a separate set of concerns. The youth noted that the space on offer was not a safe space. They were also wary of aggressive recruitment of new group members from part of the health staff, as this would jeopardize the sense of safety within the group that had been created over time. Nonetheless, the youth were undecided whether to accept the offer.The academic partners perceived the health services' offer as a risk of institutionalized takeover. Their main concern was that the (non-Inuit) health staff would not pay attention to the needs of the group and would impose a different structure and set of goals. From the academic partners' point of view, the initiative's main goal at that stage was for the group to learn to be in charge of all activities. The concept of enhancing a sense of agency in the young people appeared to be at risk of being sacrificed for convenience and structural support.The academic partners eventually “protected” the youths' autonomy and ownership of the project and declined the offer on behalf of the group. As much as the youth group explicitly agreed with the decision, this step raised complex ethical questions ultimately related to colonial legacy of the health care system , 31. YetThe third theme includes disagreement with community Elders over the distribution of project resources. A main goal of the initiative is that the youth group lead processes of decision-making each step of the way. They are encouraged to come up with ideas for activities, plan and implement them. By this token, among other activities, the youth organized sewing circles that would bring together Elders (as sewing instructors) and youth. Sewing circle planning included details of which materials to purchase, and which Elders would accompany the sewing circles. Hours and hours were spent on debating the details of fur trim, lace, warm lining, and zippers. The anticipation was mounting, everyone was looking forward to a week of creating new jappas (fur-trimmed winter jackets). Yet, without warning, anticipation turned into a whirlwind of frightened phone calls from youth and teachers to the academic partners, a perfect storm of misunderstandings. It turned out that several community Elders who were included in the planning from the start, and strongly supported giving youth autonomy and promoting agency in youth, expected to be given the project funds along with the autonomy to distribute them based on their personal preferences. While this was inconceivable for the academic partners, every youth group member explained how important it is to listen and not to contradict Elders.This conflict was emblematic of the dual loyalty of Naujaat youth. Respecting Elders is one of the cornerstones of Inuit identity. In addition to the lived experience that would help people learn to survive out on the land, close to 75% of Inuit parents and grandparents are first or second generation residential school survivors. They are revered by the youth not only for their resilience, courage, and overcoming trauma, but also as keepers of the past who have learned how to deal with the present. Against this backdrop, it was not surprising that the group members capitulated and stated that they would be fine with giving away all the resources allocated to the sewing circle to the Elders. We were facing the prospect of antagonizing a group of Elders, with potentially devastating consequences for our standing in the community. The alternative, appeasing the Elders, would come at a cost to the integrity of the group process, not to mention risking the transparency of the funding distribution.One of the authors (PA) was chosen to talk to the Elder she had the strongest relationship with, to clarify the misunderstanding, and explain that detailed plans were debated by the youth group and why it would be crucial to the spirit of youth empowerment to execute them accordingly. Strong emphasis was put on the fact that we must follow the protocol submitted to the funding authority and therefore this was the only action permissible within the funding mandate. The conversation was heated, albeit respectful. The sewing circles moved ahead as planned by the youth group and were a huge success, with the participation and support of Elders who were not involved in the dispute.In this particular incident, the goal of empowering Inuit youth to make their own decisions collided with the more culturally rooted expectation of not contradicting Elders. Insights into the origins of this disagreement, how it unfolded, and its sequalae are an invaluable experience of what youth are reporting as complex negotiations between tradition  and fast-moving renewal of cultural identity (“My commitment to the group/my workplace/my own future requires me to contradict.”). Being caught between “old” and “new” rules, integrating IQ principles into workplace commitments, educational aspirations, and family planning is hard. This ambivalence offers a fertile ground for emotional blackmail , threats (“If you don't let me collect your paycheck…”), and alienation that has been commonly associated with families of residential school survivors . The impThis article reflects on the risks of reproducing inequalities through CBPR, the researchers' best intentions notwithstanding. It does so through the exploration of three themes, which describe challenges encountered in the process of “Building on Strengths in Naujaat”, a participatory suicide prevention initiative with Inuit youth.The first theme puts the project's lengthy and non-linear development in the context of conflicting demands of academic funding and career advancement on the one hand, and longitudinal relationship-building in communities on the other hand. University career and funding structures promote research that yields pre-defined and immediate results; whereas Inuit etiquette values spending time together, listening respectfully, watching, and participating. It takes years to understand the diversity of voices and the significance of connections to family and land, and to engage in dignified creation of trust. This painstaking process is unattractive for funders; and it does not pay off in academic credit. If ignored, however, the research process is liable to miss its target and leave communities with a (legitimate) sense of exploitation .Academic communities could help to diminish the tensions between academic and communities' demands. If universities, funding agencies, and scientific journals genuinely believe that community participation and diversity  are valuable assets for science, better accommodation for participatory research and for a plurality of voices ought to be built into the design of career pathways, stipends, grants, and publications. At the same time, we also call on the participatory research community to step up efforts to facilitate the inclusion of participatory research in mainstream academia. Among other contributions, co-production researchers can act as reviewers for grant proposals and manuscripts; and they can formulate frameworks to help unfamiliar reviewers, editors, and readers assess the quality and outcomes of participatory research initiatives. The question of making academic findings relevant to the community remains the core task of the co-production process.The first theme furthermore draws attention to CBPR researchers' need to be able to step out of themselves and critically reflect on the basic values that inform their actions . This fiThe second theme points out a “parallel process” of reproducing colonial protectionalism while fighting a colonial approach to institutionalization. “Building on Strength in Naujaat” has hitherto missed the opportunity to engage the team in a critical exploration of the colonial legacy of the health care system . In hindThe third theme illustrates that Elders who welcomed our vision of enhancing the capacity and agency in young people at the same time expected us to adhere to the traditional way of respecting Elders. Accommodating the Elders' wishes would have produced resentment among the youth, with potentially destructive effects on the group process. This conflict caused major disruption, injury and pain for all partners involved. It showed us the limits of collaboration, dealt a blow to a strong collaborative spirit that included our relationships with the Elders, and their participation in the genesis of the group. Moreover, it strained familial ties for some of the youth. The conflict epitomizes the complexity of being embedded in a community with strong cultural values that pose irresolvable dilemmas when faced with Western norms. According to Harari , contradThe limitations of this reflection paper include the imbalance of academic perspective receiving more attention than the community co-authors' perspective. Spending less time together as a team due to the COVID-19 pandemic contributed to this imbalance. We wholeheartedly support Alethea Arnaquq-Baril's proclamation that all research in Inuit Nunangat (Inuit Homeland) should be led by Inuit, should be relevant to Inuit, and should benefit Inuit communities . Her staWe continue to believe that CBPR provides an important framework for mental health collaboration and suicide prevention in Inuit Nunangat. Following lessons will help guide theory and practice in the future:Paying attention to ongoing relationships on the ground (SP).Continuous presence in the community furthers the development of relationships (SI).Critical introspection/reflection on values is a vital aspect of the CBPR process (NG).Ongoing discussion among team members on expectations and pressures as they arise is crucial.Conference and workshop travel is an enriching and eye-opening experience that would otherwise not be available to community members (SP).Awareness of historic and current conflicts with institutions, and how they may affect the work in the community is necessary .Ongoing recruitment of new members is important in that it allows for growth and development of the youth group .Overall, “Building on Strengths in Naujaat” taught us that co-production with community partners is a worthwhile yet tenuous balance between a mutually rewarding collaboration and potential damage to the community and to research integrity; between promoting change and undermining community values; and between mobilizing resources and reinforcing inequalities. The promotion and development of mental health in Inuit Nunangat must take into account these opposing forces. If we don't pay attention to the dilemmas created by colonization and traditional values, we run the risk of reinforcing dysfunctional patterns. “Building on Strengths in Naujaat” was established with the objective of providing a group of Inuit youth with the experience of agency and ownership of the initiative. This was to promote a sense of belonging, resiliency, collective efficacy, and ultimately well-being. Framed by the wider context of colonization, issues of conflicting demands, autonomy from existing power and community structures, and cultural values in relationships with community members all impact the initiative's process and outcomes. However, from our experience, acknowledging the mine field of power imbalances while openly addressing current and historic faults and failures, provides learning opportunities that can help make Indigenous mental health collaborative research a more effective resource to support communities on their meandering path toward greater health equity.All relevant data is contained within the article. To protect the confidentiality of our community partners, no further data will be made available.The studies involving human participants were reviewed and approved by (1) Human Research Ethics Board, University of Manitoba (2) Nunavut Research Institute. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.All authors contributed to the conception, formulation, and revisions of this article.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.