In South Korea, car insurance that includes medical coverage of traditional Korean medicine (TKM) has increased exponentially. Clinical practice guidelines (CPG) for traffic injuries were established in 2016. We aimed to revise and update de novo CPG and distribute the adapted CPG to TKM practitioners and patients. Clinical key questions from previous CPG were identified and updated regarding the grade of recommendation and level of evidence using additional evidence from the literature obtained through a systematic search and the use of the Grading of Recommendations Assessment, Development, and Evaluation methodology. The dissemination and implementation of the updated CPG were conducted at the CPG Center of Korean Medicine. Ultimately, 25 recommendations based on 13 clinical key questions were developed: 2 for diagnosis, 22 for TKM treatments, and 1 for prognosis. After recognition by professional societies and certification by the CPG Center of Korean Medicine, leaflets, card news, and infographics for TKM doctors in South Korea were produced and distributed. These are the only TKM CPG for patients who have experienced traffic injuries. They are expected to contribute to standardized and evidence-based treatment using TKM and similar interventions. Moreover, disseminating the adapted CPG will promote treatment reliability and strengthen insurance coverage. The Global Status Report on Road Safety 2018 launched by the World Health Organization in 2018 indicated that approximately 1.35 million people die yearly because of traffic injuries and 50 million suffer non-fatal injuries [In South Korea, the average number of traffic accidents during the past 5 years was approximately 210,000, thereby increasing the overall auto insurance cost to USD 20 billion annually by 2020 ,4. The nTKM refers to traditional approaches to medicine practiced in South Korea and includes acupuncture, moxibustion, Chuna manual therapy (CMT), pharmacopuncture, cupping, herbal medicine, and physiotherapy . Korean We aimed to present updated previous CPG as well as the contents of the dissemination including standardized and effective TKM treatment. These CPG are the most systematic and standardized TKM CPG developed for traffic injury. Although these CPG are based on South Korea’s medical system, they have value as a reference for CPG development in other countries using similar interventions including acupuncture and moxibustion. Additionally, the development and implementation of CPG reduce unnecessary medical costs and increase the return-to-work rate after traffic injuries, ultimately contributing to improvements in the quality of TKM practice.After de novo development of CPG , the GKoThe development committee was led by professors of Korean medicine rehabilitation who consulted clinical experts in each field and completed the entire process of CQ development, performed a systematic search for evidence, an analysis of the quality of evidence, GoRs, and revisions of the CPG for traffic injuries. A review and advisory committee consisting of external experts in clinical, academic, and methodological studies examined whether the clinical status in South Korea was reflected in the developed CQs and literature evidence to ensure that the LoE and GoR assignment process was correctly performed. After the development of the CQs associated with the previous CPG in 2016, the results of an evaluation performed by external reviewers and additional literature evidence obtained from a systematic search revealed that the previous CQs were vaguely described, thus necessitating reorganization and segmentation. Hence, the existing CQ section focusing on patients and interventions was preserved; however, the section focused on pain was subdivided, and the evidence was updated based on further literature and systematic research findings from February 2020 to April 2020. Additional surveys, qualitative research, and an economic evaluation have been conducted to obtain sufficient evidence during the CPG development phase ,11,12. TThe LoEs and GoRs of the guidelines were evaluated following the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach developed by Cochrane’s GRADE Working Group . Each idThe revision that incorporated the external reviewers’ feedback was made after the external review of the draft CPG for traffic injuries by the GKoM in October 2020. An external evaluation was conducted by 11 members of the GKoM committee and the external monitoring committee, including methodology and CPG development experts, to ensure that the CPG modification plan was complete and followed the aforementioned process.The CPG for traffic injuries were approved by six related societies: the Society of Korean Medicine Rehabilitation, the Korean Acupuncture and Moxibustion Medicine Society, the Korean Pharmacopuncture Institute, the Korean Society of Chuna Manual Medicine for Spine and Nerves, the Korean Society of Oriental Neuropsychiatry, and the Society of Sports Korean Medicine. To obtain academic approval, professional societies reviewed the academic and external feasibility, strict development, content validity, applicability, and the feasibility of recommendations. Academic certification results were submitted to the GKoM.The certification of CPG for traffic injuries was evaluated by a special review and assessment committee formed by GKoM members. After a systematic review of the South Korean medicine clinical procedures exhibiting methodological rigor and external validity, the CPG for traffic injuries obtained final certification from the GKoM under the auspices of NIKOM in 2020.The developing committee produced pamphlets, card news, and infographics regarding standardized Korean medicine treatment to increase the use of CPG for traffic injuries at clinical sites by both Korean medicine doctors and patients.After the reorganization process, the revised recommendations increased from 13 to 25 . Each reRecommendation 1: Collaborative medical treatment may be considered for patients of all ages suspected of having whiplash-associated disorder (WAD) III and WAD IV after a physical examination (GoR/LoE: C/very low). A survey of medical collaboration using TKM and conventional medicine in 2019 indicated that 80.5% of patients with traffic injuries thought that collaboration was necessary to enhance their treatment outcomes . South KRecommendation 2: Blood stagnation syndrome is the first pattern to occur after traffic injury for patients of all ages. Depending on the patient’s condition or the doctor’s judgment, more detailed pattern identification according to qi–blood, viscera–entrails, cold–heat, and yin–yang may be considered (GoR/LoE: C/very low). The frequency of the classification of TKM pattern syndrome according to two questionnaire surveys of Korean medicine doctors has been presented previously ,11. TKM Recommendation 3-1: A combination of usual care and acupuncture treatment should be considered instead of other usual care interventions for the improvement of neck pain experienced by patients with WAD I and WAD II (aged 19–70 years) (GoR/LoE: B/moderate). There was a statistically significant difference in pain  in the control group who received concurrent sham acupuncture and usual care and pain of the group that received usual care alone; however, there was no significant difference in disability  ,17,18. NRecommendation 3-2: The combination of usual care with acupuncture treatment may be considered for low back pain and function improvement in patients with WAD I and WAD II (aged 19–70 years) (GoR/LoE: C/very low). Acupuncture and electroacupuncture are common treatments for low back pain and function improvement in patients with traffic injuries in South Korea. Because no randomized controlled trials focused on the treatment of low back pain and disability with acupuncture, the LoE was rated very low. Based on the literature findings and clinical experience of the CPG development committee, it was assigned a grade of C.Recommendation 3-3: A combination of usual care and electroacupuncture treatment should be considered instead of other usual care interventions to improve neck pain experienced by patients with WAD I and WAD II aged 19–70 years) (GoR/LoE: B/moderate). Concurrent treatment with electroacupuncture and usual care substantially reduced neck pain compared with sham electroacupuncture or usual care for adults ; however, there were no significant differences in the disability index  –70 years. SeveralRecommendation 3-4: The combination of usual care with additional electroacupuncture treatment may be considered for symptom improvement of low back pain for patients with WAD I and WAD II (aged 19–70 years) (GoR/LoE: C/low). The combination of usual care with additional electroacupuncture treatment did not provide significant improvement of the pain  or disability index  . The devRecommendation 3-5: The combination of usual care with the motion-style acupuncture technique (MSAT) should be considered instead of other usual care interventions to improve neck pain experienced by patients with WAD I and WAD II (aged 19–70 years) (GoR/LoE: B/moderate). The MSAT is a TKM technique that reduces musculoskeletal pain by combining breathing exercises and acupuncture treatment . For patRecommendation 4-1: Pharmacopuncture may be considered instead of acupuncture treatment alone for the alleviation of neck and low back pain experienced by patients with WAD I and WAD II (aged 19–70 years) (GoR/LoE: C/very low). Pharmacopuncture combines the principles of meridians and pharmacotherapy and is widely used at TKM institutions. No clinical study found that pharmacopuncture has a better therapeutic effect on neck pain or low back pain after traffic injuries than usual care or sham pharmacopuncture alone. However, because it is currently included in the medical coverage provided by auto insurance in South Korea, the CPG development committee assigned a GoR of C based on clinical experience and the literature.Recommendation 4-2: The combination of pharmacopuncture with usual care instead of acupuncture treatment alone should be considered for the improvement of neck pain for patients with WAD I and WAD II (aged 19–70 years) (GoR/LoE: B/moderate). Three trials that compared pharmacopuncture and usual care with acupuncture treatment alone for neck pain after traffic accidents included pain intensity and disability index assessments. Three studies found statistically significant differences in pain intensity when pharmacopuncture was used in combination with usual care  ,25,26. ORecommendation 4-3: The combination of pharmacopuncture with usual care may be considered for the improvement of low back pain experienced by patients with WAD I and WAD II (aged 19–70 years) (GoR/LoE: C/very low). The LoE was rated as very low because it included only one study. Even though a small number of trials failed to find statistically significant effects on the pain intensity  and disability index , concurrent pharmacopuncture treatment was frequently used for low back pain alleviation and function recovery after traffic accidents. The CPG development committee assigned a GoR of C [Recommendation 5-1: CMT alone may be considered to alleviate neck pain and improve the function of patients with WAD I and WAD II (aged 19–70 years) (GoR/LoE: C/very low). CMT is popular in South Korea, where other manipulation methods, such as osteopathy, chiropractic, and other manipulative therapies, were developed . HoweverRecommendation 5-2: The combination of CMT with usual care may be considered for the improvement of neck pain for patients with WAD I and WAD II (aged 19–70 years) (GoR/LoE: C/low). When a control group who received concurrent CMT with usual care was compared with a group who received usual care alone, there was no statistically significant difference in pain  or disability  ,30. HoweRecommendation 5-3: A combination of CMT with usual care may be considered for the improvement of low back pain experienced by patients with WAD I and WAD II (aged 19–70 years) (GoR/LoE: C/low). One study found a significant difference in the pain index when comparing patients with back pain induced by traffic accidents treated with CMT plus usual care and patients treated with usual care alone  . No seriRecommendation 6-1: Moxibustion alone may be considered for the alleviation of neck and low back pain experienced by patients with WAD I and WAD II (aged 19–70 years) (GoR/LoE: C/very low). No clinical study has found that moxibustion alone has a better therapeutic effect on neck or low back pain after traffic injuries than usual care or placebo alone. Hence, the CPG development committee set the LoE as low. However, a GoR of C was assigned because moxibustion is frequently used in South Korean clinical settings to alleviate neck and low back pain intensity and function recovery.Recommendation 6-2: The combination of moxibustion (indirect) with usual care may be considered instead of usual care alone for neck pain experienced by patients with WAD I and WAD II (aged 19–70 years) (GoR/LoE: C/low). Compared to usual care alone, routine care combined with moxibustion substantially relieves neck pain and improves the function of adult patients  . A previRecommendation 6-3: The combination of moxibustion (indirect) with usual care may be considered for improving low back pain experienced by patients with WAD I and WAD II (aged 19–70 years) (GoR/LoE: C/very low). No clinical study has found that concurrent treatment with moxibustion and usual care improves low back pain after traffic injuries. Despite the lack of clinical research corresponding to the CQ, the development committee assigned a GoR of C and a very low LoE based on the literature and the clinical experience of the CPG committee.Recommendation 7: Cupping alone or concurrent therapy with cupping and usual care may be considered for patients with WAD I and WAD II (aged 19–70 years) to improve neck and low back pain and function (GoR/LoE: C/very low). No clinical study has found that cupping therapy alone results in improved neck and low back pain and function after traffic injuries. A GoR of C and a very low LoE were assigned based on South Korea’s clinical settings, the literature, and the clinical experience of the CPG development committee.Recommendation 8: Korean medicine physiotherapy alone or combined with usual care may be considered for patients with WAD I and WAD II (aged 19–70 years) to improve neck and low back pain and function (GoR/LoE: C/very low). No clinical study has found that Korean medicine physiotherapy alone or in combination with usual care results in improved neck and low back pain and function after traffic injuries. A GoR of C and very low LoE were assigned based on South Korea’s clinical settings, the literature, and the clinical experience of the CPG development committee.Recommendation 9: Herbal medicines alone or in combination with usual care according to pattern identification may be considered for patients with WAD I and WAD II (aged 19–70 years) to improve neck and low back pain and function (GoR/LoE: C/very low). No randomized controlled trial has shown that herbal medicine alone or in combination with usual care results in improved neck and low back pain and function after traffic injuries. The frequency of herbal medicine use has been evaluated using questionnaire surveys completed by Korean medicine doctors . A GoR oRecommendation 10: Korean medicine treatments alone or in combination with usual care may improve pain and function of patients (aged 19–70 years) with fractures caused by traffic accidents (GoR/LoE: C/very low). No large-scale clinical trials that satisfied the CQs have been performed, and only a few simple case reports have been published. TKM is frequently used in combination with usual care to treat fractures caused by traffic accidents to provide conservative treatment or rehabilitation, and better results can be expected. Therefore, the CPG development committee assigned a very low LoE and a GoR of C based on the current state of TKM and expert agreements.Recommendation 11: Korean medicine treatment alone or in combination with usual care may improve psychological symptoms experienced by patients (aged 19–70 years) with acute stress disorder and post-traumatic stress disorder (PTSD) after traffic accidents (GoR/LoE: C/very low). A survey of the prevalence of acute stress disorder and PTSD for patients after traffic injuries and the validity of screening tests conducted by the development committee found that the stress response after traffic accidents often leads to PTSD . FurtherRecommendation 12-1: The combination of CMT and pharmacopuncture may be considered instead of CMT alone or pharmacopuncture alone to improve neck and low back pain experienced by patients with WAD I and WAD II (aged 19–70 years) (GoR/LoE: C/very low). Regarding low back and neck pain induced by a traffic accident, no randomized, controlled trials have compared the concurrent treatment of CMT and pharmacopuncture to CMT alone and pharmacopuncture alone. According to the results of a survey of Korean medicine doctors conducted in 2016, CMT and pharmacopuncture were often used simultaneously, and 58.4% of the respondents reported that concurrent CMT and pharmacopuncture were not covered by insurance in South Korea. Although no study matching the CQ was found, a very low LoE and a GoR of C were assigned based on the literature and the clinical experience of the CPG development committee.Recommendation 12-2: The combination of pharmacopuncture with usual care  may be considered instead of usual care to improve neck pain experienced by patients with WAD I and WAD II (aged 19–70 years) (GoR/LoE: C/low). One study reported that compared to usual care alone, the combination of pharmacopuncture with usual care substantially relieved neck pain  . BecauseRecommendation 12-3: The combination of CMT with usual care  should be considered instead of usual care alone for improving neck pain experienced by patients with WAD I and WAD II (aged 19–70 years) (GoR/LoE: B/moderate). Compared with usual care alone, concurrent CMT with usual care substantially relieves neck pain  . When thRecommendation 13: Korean medicine treatment alone or concurrent treatment with usual care may improve the rate of return to normal life and work for patients with traffic injuries (GoR/LoE: C/very low). Although several survey studies have been performed, no clinical trials have found matching rates of returning to life and work associated with TKM treatment alone and with concurrent treatment with usual care. According to a survey of Korean medicine doctors in 2016 and 2017 and another survey of patients with traffic injuries in 2018, patients (65.7%) and Korean medicine doctors (31.4%) indicated that the severity of the traffic accident was a factor affecting the prognosis for patients ,11,15. Thttp://www.nckm.or.kr, accessed on 12 November 2021).The CPG development committee produced and distributed CPG infographics to the community of Korean medicine doctors during annual academic conferences. It also produced and distributed online branding card news and patient handouts to the general public in 2020 . AdditioTraffic accidents have costly consequences. Medical expenses for traffic accidents in Korea have increased to KRW 2.337 trillion (approximately USD 20 billion) and are steadily increasing. The increase in medical expenditures associated with traffic accidents has also resulted in social and economic costs. In South Korea, where a binary healthcare system exists, the number of Korean medical institutions for traffic accident patients has continuously increased since 2016, when the research and development of TKM CPG began. These institutions are responsible for half of all traffic accident medical expenses. As a result, the demand for standardized treatment was always increased as the number of traffic accident injury patients accessing Korean medical institutions grows, as does medical expenses.There are clear limitations to applying conventional treatment when there is no clear reason for its use despite the inconvenience of pain or poor function after traffic accidents. After a traffic accident, pain and other problems can exist despite the absence of damage to the musculoskeletal system or nervous system. However, there is a limit to the application of conventional treatment for symptoms, such as dizziness and pain. Therefore, patients with traffic injuries may benefit from diagnosis and therapy using TKM, which combines the total structure and function of the body based on individual constitutional traits. Because many patients with traffic injuries are satisfied with the treatment and management provided by TKM institutions, the number of patients opting for TKM is increasing. Moreover, patients who experience pain that persists after treatment at other medical institutions often resort to TKM treatment.Various CPGs address traffic accidents in other countries; however, in South Korea, none existed. South Korea has a unique medical system divided into conventional medicine and TKM. Although the need for standardized and systematic guidelines has steadily increased in South Korea, Korean medicine doctors consisting of methodological and clinical experts have not gathered to prepare CPG for traffic injuries that consider TKM until now. For this reason, about 50 CPG related to TKM are being developed under the guidance of the South Korean government. The CPG for traffic injuries were created to focus on the therapeutic concepts that Korean medicine doctors expect to enhance the clinical application of Korean medicine treatments on a practical level, including acupuncture, pharmacopuncture, and CMT for patients with traffic injuries. The CPG was developed based on the research methodology used for treatment guidelines, and recommendations were made based on various CQs related to traffic accidents. Compared to interventions currently used by Korean medicine doctors, more standardized treatment methods are recommended by the CPG. This is significant for creating treatment procedures and a cost-effective TKM treatment system on national and international levels. This CPG for traffic injuries have been approved by relevant professional Korean medicine societies and the GKoM, demonstrating their usefulness.Since 2016, when the de novo development of CPG for traffic injuries using GRADE methodology began, there have been numerous recommendations with unacceptable GoRs and insufficient LoEs because of the lack of relevant medical literature. The development committee has addressed these constraints by organizing and commencing multi-center, randomized clinical trials and submitting research papers for publication. It was necessary to search for evidence in the literature, including studies other than randomized, clinical trials, to support clinical considerations before the CPG could be adapted. However, more systematic and well-designed clinical studies are required to confirm the adapted CPG.De novo CPG for traffic injuries was approved and published in 2018, and the adapted CPG for traffic injuries were certified in 2020. However, two surveys conducted after the de novo CPG found that it was difficult to communicate and promote this CPG to TKM doctors at clinical sites. Therefore, the development committee has tried to communicate and promote the updated CPG through various domestic and international conferences, card news, infographics, and leaflets to inform TKM doctors of the systematic treatment procedures. Additionally, the following attempts were made to convey the patients’ perspectives. Qualitative and retrospective studies of the experiences of patients with traffic injuries and a search of the literature were performed. Surveys of patients visiting TKM institutions in South Korea have also been conducted to reflect patients’ opinions of the adapted CPG. Furthermore, a poll found that medical practitioners need to provide appropriate information, such as the precise diagnosis and treatment techniques to the patients; therefore, this was cited as a recommendation and clinical consideration.This CPG has a few limitations. First, it is difficult to develop evidence-based CPG based on standardized diagnosis and treatment principles because diagnoses vary according to individual patient characteristics, constitutions, and symptom patterns. Thus, the majority of evidence is insufficient to support recommendations due to the lack of well-designed RCTs. Additionally, regional constraints, with most of the studies taking place in China or South Korea, lead to some difficulty in developing evidence-based CPG. More well-designed RCTs are required. Therefore, it was difficult to adequately reflect the clinical reality of TKM using only existing clinical research methods.The second limitation of CPG is that conducting clinical research to generate evidence is frequently challenging because of institutional constraints. Additionally, it was not possible to objectively evaluated whether the dissemination brochures, infographics, and online branding news were sufficiently delivered to patients or TKM doctors.One of the strengths of this study was the continuous searching and updating of evidence after the de novo development of CPG. In addition, the CPG aims to synthesize and describe research findings to best reflect the characteristics of TKM. This guideline will be recommended widely for use and provide evidence for areas that need to be supplemented through step-by-step research in the future. This CPG will assist in increasing the treatment efficacy of TKM as it is disseminated to actual clinical settings, thus increasing the clinical application of TKM.We revised and updated the previous CPG for traffic injuries to include TKM and disseminated them in various ways so that they can be used by more TKM doctors. This guideline is the only CPG for patients with traffic injuries treated with TKM. The adapted CPG will be widely used in clinical practice and enhance the reliability of TKM to strengthen national insurance coverage in South Korea. We expect this CPG will contribute to all practitioners using similar interventions, including acupuncture, moxibustion, CMT, and cupping.


Animal species are named social when they develop the capability of complex behaviors based on interactions with conspecifics that include communication, aggression, mating and parental behavior, crucial for well-being and survival. The underpinning of such complex behaviors is social memory, namely the capacity to discriminate between familiar and novel individuals. The Medial Septum (MS), a region localized in the basal forebrain, is part of the brain network involved in social memory formation. MS receives several cortical and subcortical synaptic and neuromodulatory inputs that make it an important hub in processing social information relevant for social memory. Particular attention is paid to synaptic inputs that control both the MS and the CA2 region of the hippocampus, one of the major MS output, that has been causally linked to social memory. In this review article, we will provide an overview of local and long range connectivity that allows MS to integrate and process social information. Furthermore, we will summarize previous strategies used to determine how MS controls social memory in different animal species. Finally, we will discuss the impact of an altered MS signaling on social memory in animal models and patients affected by neurodevelopmental and neurodegenerative disorders, including autism and Alzheimer’s Disease. Establishing meaningful relationships among individuals is crucial for well-being and survival of social species. Social cognition includes a variety of complex behaviors that span from aggression and avoidance to cooperative and mating actions. All these functions rely on the capacity of an individual to recognize another, namely social memory, which is thought to be perturbed in various neuropsychiatric disorders, including schizophrenia, autism and neurodegenerative diseases.Among different brain networks contributing to social memory formation, the medial septum-diagonal band of Broca complex (MS) has recently emerged as a relevant region , γ-aminobutyric acid (GABA) and glutamate . They establish bidirectional connections with several brain regions including the hippocampus, entorhinal cortex (EC), amygdala, hypothalamus, and brainstem. MS outputs ultimately form unidirectional synaptic contacts within the medial and lateral habenula, the mediodorsal nucleus of thalamus and cortical regions such as the pyriform and anterior cingulate cortex  and Alzheimer’s disease (AD).ASDs are neurodevelopmental disorders characterized by reduced social interactions, communication deficits, and stereotyped behaviors. Autistic individuals show substantial social impairments, having a difficult time interacting with others and paying attention to social stimuli.Mecp2 deletion in glutamatergic and GABAergic neurons but a reduced anxiety-like behavior. In addition, ChAT-Mecp2-/y mice show social memory deficits that seem exclusively related to cholinergic dysfunction  and differently affect network activity in MS targeted regions. This complexity is increased by the fact that MS neuron activity is modulated by non-canonical neurotransmitters including dopamine, serotonin and noradrenaline, released by axon terminals originating in the Ventral Tegmental Area, Dorsal Raphe Nucleus and Nucleus Coeruleus, respectively. These neuromodulators can act on a longer time scale as compared to classical glutamatergic and GABAergic neurotrasmitters, thus influencing MS integration time window, output and internal brain states leading to an extensive flexibility in social behavior outcome. Thereby, future investigations are needed to determine how such different neuromodulatory systems interact in controlling incoming GABAergic and glutamatergic inputs and the rules of synaptic plasticity within MS local circuit and its target areas. A new generation of sensors that show an unprecedented spatial and temporal resolution combined with advancements in imaging methods that allow to investigate the activity of deep brain structures will help in dissecting out the contribution of single neuromodulators during behavioral tasks assessing social memory.MS is one of the most connected regions of the brain and recent evidence suggests that it takes part in the “social brain” network. Previous evidence indicates that neurons in the MS are engaged in social memory, meaning the capacity of an individual to recognize a previously encountered conspecific. Studies using opto-chemogenenetic tools to control selected MS neuronal populations have allowed clarifying the key role of MS in controlling social memory. However, how MS neurons integrate synaptic inputs from SuM, LS, and EC carrying social information relevant for memory encoding is virtually unknown. SuM and LS inputs drive excitation and inhibition to both cholinergic and GABAergic neurons in the MS, respectively. Hence, the net effect on hippocampal theta oscillations and sharp wave ripples, known to be controlled by MS, would be opposite and possibly involve different phases of social memory . EC inputs trigger both excitation and, to a minor extent, inhibition in the MS that in turn controls EC activity MG and DP wrote the manuscript and DP generated the figure. All authors contributed to the article and approved the submitted version.This work was supported by Fondo Ordinario Enti (FOE D.M 865/2019) funds in the framework of a collaboration agreement between the Italian National Research Council and EBRI (2019–2021).


This study aimed to investigate the relationship between social support and exercise adherence among Chinese college students during the COVID-19 pandemic, as well as the mediating effects of subjective exercise experience and commitment in the relationship, in order to provide a reference for improving exercise adherence among Chinese college students during the COVID-19 pandemic. The Perceived Available Support in Sport Questionnaire, Subjective Exercise Experience Scale, Exercise Commitment Scale, and Exercise Adherence Scale were administered to 459 eligible college students in Jinan, Shandong Province, through convenience sampling. Results showed that social support positively predicted exercise adherence among college students. The separate and joint mediating effects of subjective exercise experience and commitment between social support and college students’ exercise adherence were significant. This study demonstrated that social support can positively predict exercise adherence among college students. In addition, subjective exercise experience and commitment played mediation roles between social support and college students’ exercise adherence, both separately and jointly. Therefore, enhancing social support and improving the level of subjective exercise experience and exercise commitment among college students may be an effective strategy for improving exercise adherence among Chinese college students during the COVID-19 pandemic. Since the emergence of COVID-19, many countries, including the Chinese government, have implemented various levels of prevention and restriction measures, such as containment and isolation, to slow or stop its spread. However, due to the COVID-19 pandemic and its related control measures, the exercise behavior of college students has been negatively affected in many ways , and mayExercise adherence is a persistent behavioral tendency exhibited by individuals during physical exercise . The lacPrevious research has found that exercise behavior is influenced not only by rational decision-making processes, such as cognitive decisions, but also by irrational factors . Among tExercise commitment may mediate the relationship between social support and exercise adherence. Exercise commitment refers to the psychological state of physical exercisers’ desire and determination to engage in physical activity, which is reflected in psychological attachment to physical exercise and behavioral intention to persist in exercise . Many scMany studies have suggested that subjective exercise experience may be related to exercise commitment. Social learning theory suggests that the experience of feeling in a particular situation can have an impact on psycho-cognitive decision making . The subThe prevalent lack of exercise adherence among Chinese college students during the COVID-19 pandemic has had a serious impact on their physical and mental health. In the context of the normalization of epidemic prevention and control in China, understanding the key factors and mechanisms affecting exercise adherence among Chinese college students could help them cope with the possible adverse psychological and physical problems caused during the COVID-19 pandemic. Although some studies have shown that social support is positively associated with exercise adherence among college students ,11,12,13Hypothesis 1:Social support positively predicts college students’ exercise adherence.Hypothesis 2:Subjective exercise experience mediates the relationship between social support and exercise adherence among college students.Hypothesis 3:Exercise commitment mediates the relationship between social support and exercise adherence among college students.Hypothesis 4:Subjective exercise experience and commitment mediate the chain between social support and exercise adherence.http:www.wjx.cn, (accessed on 1 November 2020). We recruited participants in the following ways: (1) disseminating the questionnaire through social media; (2) identifying a teacher at each school as a contact person and using the teacher’s dissemination to get students to scan the questionnaire link and fill out the questionnaire. A total of 488 enrolled college students eventually participated in the questionnaire, and all participants who took part in the survey gave their informed consent to the study. The Institutional Review Board of the School of Shandong Institute of Sports approved this study. After excluding invalid questionnaires, such as missing answers and insufficient time for testing, 459 valid questionnaires were finally recovered, with a recovery efficiency of 94.06%. At this point, the sample size met the statistical requirement of being at least 5–10 times the number of scale items [A convenience sampling method was used to select college students enrolled in several universities in Jinan, Shandong Province, during the COVID-19 pandemic, and questionnaires were distributed to them through the platform of Questionnaire Star  was used to perform descriptive and correlation analyses on the data of this study. In addition, considering that the sociodemographic variables of gender and grade may differ significantly among the variables, independent samples Multiple regression analysis was conducted using Model 6 in the SPSS PROCESS macro program (version 3.5), prepared by Hayes. The bias-corrected percentile bootstrap method (5000 replicate samples) was selected to estimate 95% confidence intervals (CI) for the testing of mediation effects . If the The results of the unrotated principal component factor analysis showed that the first factor variance explained 20.260%, which was less than the critical criterion of 40%, indicating that the common method deviation was within acceptable limits. Therefore, there is no serious common deviation in the survey data of this study.t-test showed that there were significant differences in the scores of subjective exercise experience , commitment , and adherence  among college students of different genders. The results of one-way ANOVA showed that college students of different grades had significantly different scores on social support  and exercise commitment  among college students of different grades. Therefore, we controlled for gender and grade in the following mediation analyses.The means and standard deviations of each variable on the gender and grade dimensions are shown in p < 0.01), a significant positive correlation with exercise commitment , and a significant positive correlation with exercise adherence . Exercise adherence was significantly and positively correlated with subjective exercise experience , and it was significantly and positively correlated with exercise commitment . Subjective exercise experience was significantly and positively correlated with exercise commitment . There was a significant two-by-two correlation between the study variables, thus satisfying the statistical requirements for conducting a mediating effects test.As shown in β = 0.120, p < 0.01). After including social support and subjective exercise experience as independent variables and exercise commitment as dependent variables in the equation, social support  and subjective exercise experience  both significantly and positively predicted exercise commitment. After including social support, subjective exercise experience and commitment as independent variables and exercise adherence as dependent variables in the equation, social support , subjective exercise experience , and exercise commitment  all significantly and positively predicted exercise adherence.The results of the regression analysis  showed tThe results of the mediated effect analysis  showed tThe findings of this study confirmed hypothesis 1, in which social support was a significant and positive predictor of exercise adherence among college students. This is consistent with the results of previous studies ,37 and, The findings of this study confirmed hypothesis 2, that subjective exercise experience mediated the relationship between social support and exercise adherence among college students. The results support the previous findings that social support is positively related to subjective exercise experience. The results support the previous findings that social support is positively correlated with subjective exercise experience , and subIn addition, this study also found that exercise commitment mediated the relationship between social support and exercise adherence among college students, and hypothesis 3 held true. Previous research has shown that, in the absence of internal motivation to exercise, perceived social support by college students reinforces their intrinsic motivation, which, in turn, triggers higher levels of exercise commitment . Higher Finally, the findings of this study also confirmed hypothesis 4, i.e., that subjective exercise experience and commitment mediated the chain between social support and exercise adherence. Subjective exercise experience can have a direct predictive effect on exercise commitment, as suggested by the dual-system processing model of decision making: rational psychological factors cannot be reinforced and activated by irrational factors on the subject’s decision making . CollegeThis study had the following advantages. (1) The data were primary data obtained through questionnaire collection. (2) The instruments used in this study were a validated and proven scale, and the relationship between social support, subjective exercise experience, exercise commitment, and exercise adherence among college students was further explored with the help of the instruments. In the context of the COVID-19 pandemic, this study explores the exercise adherence of college students, as well as its relevant factors and potential mechanisms, with important theoretical and practical implications. At the theoretical level, this study clarifies the important effect of social support in enhancing exercise adherence among college students, in the context of the COVID-19 pandemic, a global public health event, which actually enriches and expands the ecosystem theory. In addition, this study also confirmed the chain mediating effect of subjective exercise experience and commitment between social support and college students’ exercise adherence, which helps us to understand the potential mechanisms of action between social support and college students’ exercise adherence. At the practical level, firstly, multiple parties, including parents, teachers, and schools, should pay attention to the lack of exercise adherence of college students during the COVID-19 pandemic, which seriously affects their physical and mental health, and provide them with objective material help and subjective emotional support in time to enhance their exercise adherence. Specific measures to increase and develop this social support include the frequent use of affirmative forms of praise-based assessment for students  and freqIn addition, there are some limitations and shortcomings in this study. First, the study used a cross-sectional design, and the causal relationships among the variables need to be further verified through longitudinal follow-up and experimental design. Second, this study only considered the mediating effects of subjective exercise experience and commitment; however, there may, in fact, be other mediating variables, such as autonomous motivation, exercise climate, and self-efficacy, that need to be further explored. Third, the number of male participants in this study was higher. This should be noted in the interpretation. Fourth, the questionnaire distribution in this study was conducted through the internet only. Follow-up studies should attempt to incorporate offline questionnaire distribution. Fifth, this study focuses on the important role of social support on exercise commitment and exercise adherence. However, the importance is only one aspect, and future research based on this study should pay attention to more in-depth and extended research on how to increase and develop social support. Sixth, the results of this study were derived in the context of the COVID-19 pandemic, which should be noted in the interpretation. Whether the results of this study can continue to be applied beyond the end of the COVID-19 pandemic will require further studies in the future to confirm. Finally, the study used self-reported measures of the variables, so bias may be introduced, and more objective indicators need to be included to measure the study variables in the future.This study explored the relationship between social support and exercise adherence among college students during the COVID-19 pandemic and its internal mechanisms of action through a chain mediation model. The study showed that there were significant differences in the scores of social support, subjective exercise experience, exercise commitment, and exercise adherence among college students by gender and grade level. The study also showed that social support had a significant positive predictive effect on exercise adherence among college students. In addition, subjective exercise experience and commitment partially mediated the effect between social support and exercise adherence, which consisted of three pathways: the separate mediation of subjective exercise experience and commitment and chain mediation through subjective exercise experience and commitment. The strongest mediating effect of the three mediated pathways was produced by exercise commitment separately. This shows that social support, subjective exercise experience, and exercise commitment are all key factors predicting exercise adherence among college students and have a positive impact on exercise participation and the development of exercise habits during the COVID-19 pandemic.


Healthy work environments that maximise the health and well-being of nurses are essential in achieving good patient and societal outcomes, as well as optimal organisational performance. While studies have been conducted on healthy work environments, there is no available evidence that an integrative literature review summarising best-practice recommendations related to healthy work environments has been conducted before. This review aimed to summarise existing best-practice recommendations related to a healthy work environment for nurses. An integrative literature review following the approach adapted from Whittemore and Knafl was used. Existing guidelines related to healthy work environments for nurses were searched. EBSCOhost , Biomed Central, Science Direct, PubMed and Google Scholar and organisational websites via Google were searched, followed by a citation search. Twelve guidelines were identified for data extraction and synthesis, and themes were subsequently formulated. Four themes emerged from the integrative literature review regarding a healthy work environment for nurses: (1) the need for effective nursing leadership, (2) effective communication as central to enhancement of a healthy environment, (3) effective teamwork as an integral part of a healthy work environment and (4) the need for professional autonomy. In summary, a healthy work environment for nurses requires leadership, effective communication, teamwork and professional autonomy.The findings can be used to conduct quality studies related to healthy work environments for nurses in comprehensive health care settings, particularly those dealing with resource constraints. This can inform evidence-based recommendations and guidelines in these settings, as such guidelines are currently lacking. Healthy work environments that are caring and supportive to health professionals, including nurses, within their respective health organisations are vital  = NursesI- (Intervention) = Guidelines for a healthy work environmentC- (Context) = Comprehensive health care settings O- (Outcome) = Nursing staff that is supported and cared for.The review question that was formulated to search for the relevant literature was the following: What existing guidelines are available regarding a healthy work environment for nurses in comprehensive health care settings?The following sources (both electronic and print) were accessed: EBSCOhost , Biomed Central, Science Direct, PubMed and Google Scholar. Organisation sites, such as those for the RNAO and National Institute for Health and Care Excellence (NICE), were searched via Google using a combination of key words. This was followed by checking of reference lists of relevant guidelines for further relevant literature. The search was conducted in March 2017 and updated in August 2021.The following key words were used to facilitate the search: ‘healthy OR positive work environment’ AND ‘best practice guidelines’ AND ‘nurse*’ AND ‘health care’. An experienced librarian was consulted to ensure a comprehensive search strategy.The selection of the eligible evidence-based best-practice guidelines to be amalgamated into the research study was guided by the following inclusion and exclusion criteria. All Level I available evidence-based guidelines, according to LoBiondo-Wood and Haber’s Levels of Evidence hierarchy , focusinThe selection process involved reading titles and abstracts of the guidelines. Full texts of potentially relevant guidelines were obtained and read, using the inclusion and exclusion criteria to determine inclusion in the review. A total of 15 guidelines on healthy work environment for nurses were identified in the initial search. Of the 15 guidelines, two were duplicated and one was not considered for the study as this guideline did not meet the inclusion criteria (the population was not nurses). Thus, a final 12 guidelines were included in the critical appraisal process see .Relevant guidelines were critically appraised by the first author and independent reviewer, using the Appraisal of Guidelines for Research and Evaluation (AGREE II) Instrument  were developed in Canada by two organisations: RNAO (n = 9) and Government of Alberta (n = 1). The Workplace Health Association Australia (WHAA) and the Health Workforce Advisory Committee of New Zealand (HWAC) each developed one guideline.As outlined in Effective nursing leadership and teamwork were referred to most frequently as part of a healthy work environment for nurses, while professional autonomy was least mentioned. Five guidelines included all four themes HWAC , 2016, wOf the 12 best practice guidelines, 11 guidelines considered nursing leadership as playing an important role in creating a healthy work environment , and reduces conflict that is responsible for errors – all of which lead to enhanced patient or client safety, satisfaction and, therefore, an improvement on the overall care of patients RNAO :32. FurtOf the 12 best practice guidelines reviewed, nine guidelines support the notion that teamwork is critical to the enhancement of a healthy work environment  RNAO :24 and iIn a collaborative work environment, safety and quality patient care depend on teamwork which includes health professionals, patients and their families to enhance each professional’s care expertise, and extends to include teamwork between employers and unions RNAO :26. TeamTeamwork also embraces collaborative leadership, which is referred to as ‘a people- and relationship-focused approach’ RNAO :26, as wFive of the 12 guidelines suggested that professional autonomy was a vital component of a healthy work environment because nurses felt empowered by autonomous practice HWAC , 2016. AFurthermore, autonomy also refers to ‘acting in the best interest of the patient or client’, which includes the ability to carry out appropriate care, aligned with standards of practice, a code of ethics as well as organisational policies RNAO :34. ProfThe guidelines included in this review support the importance of effective nurse leadership, communication and teamwork, and, to a lesser extent, the need for professional autonomy in creating a healthy work environment for nurses in comprehensive health care settings. The identified recommendations related to leadership, communication, teamwork and professional autonomy were found to be interdependent in achieving and supporting a healthy work environment for nurses in these settings. Similar findings were reported by a qualitative study by Huddleston and Gray , describNurse leaders seem to play a significant role in facilitating effective or authentic leadership, which can only be done through effective communication, for example, through open and honest communication, providing opportunities for (negative) feedback and being able to listen (Hartung & Miller Enhancing a healthy work environment while considering the aspects of leadership, communication, teamwork and professional autonomy is important as it has direct impacts on job satisfaction and retention of nurses (Blake et al. It is expected that the identified recommendations related to effective nurse leadership, communication and teamwork, and the need for professional autonomy maximise the health and well-being of nurses, quality patient or client outcomes, organisational performance and societal outcomes as per RNAO’s definition RNAO :2. HowevFinally, in order to create and maintain a healthy working environment for nurses in comprehensive health care settings, the identified recommendations related to nurse leadership, communication, teamwork and professional autonomy require the support and commitment from all stakeholders within the healthy work environment (Harmon et al. Although a comprehensive search of various electronic databases and grey literature was conducted with the assistance of an experienced librarian, limited databases were available and some organisations or developers of guidelines were not subscribed to by the University, and thus some guidelines may have been missed. Furthermore, although the guidelines included in this review were the most recent versions, they have not been updated with the most recent literature, and therefore gaps were identified, as reflected in the discussion. Additionally, the guidelines and evidence-based recommendations identified in this review were supported by studies predominantly from developed comprehensive health care settings, which differ from similar settings in resource-constrained environments, often found in developing countries (World Health Organization This integrative literature review summarised evidence-based recommendations of available guidelines and provided findings related to the enhancement of healthy work environments for nurses in comprehensive health care settings. The review identified four interdependent concepts required for a healthy work environment, namely, effective nurse leadership, effective communication, effective teamwork and the need for professional autonomy. There is a need for more research to support evidence-based recommendations, particularly targeting those comprehensive health care settings that deal with resource constraints. The findings of this review could be considered in the development of an evidence-based best-practice guideline promoting healthy work environments for nurses in resource-constrained settings, as such a guideline currently does not exist.


Schizophrenia and related disorders are highly disabling and create substantial burdens for families, communities, and health care systems. Although pharmacological treatments can often lessen the psychotic symptoms that are a hallmark of schizophrenia, they do not lessen the social and cognitive deficits that create the greatest impediments to community engagement and functional recovery. This study builds on prior research on psychosocial rehabilitation by comparing the effectiveness of two treatments demonstrated as efficacious in improving social and community functioning, Cognitive Enhancement Therapy (CET) and a version of Social Skills Training (HOPES/SST).The study uses a randomized cluster design in which a pair of clinicians at community- and hospital-based mental service centers deliver either CET or HOPES to at least one group of 6-8 eligible clients for 12 months. Clinicians are trained and then supervised weekly, with ongoing process measurement of treatment fidelity, attendance, satisfaction, and retention, and use of other services. Measures administered at baseline and at 6 and 12 months while in treatment, and then at 18 and 24 months after treatment include social adjustment, quality of life, social skills, positive and negative symptoms, and neuro- and social cognition. We hypothesize that CET will be associated with greater improvements than SST in both the primary outcome of community functioning and the secondary outcomes of neuro- and social cognition and social skills. Secondarily, we hypothesize that more cognitive impairment at baseline and younger age will predict more benefit from CET compared to HOPES.Resource shortages endemic in mental health services and exacerbated by the pandemic highlight the importance of identifying the most effective approach to improving social and community functioning. We aim to improve understanding of the impact of two efficacious psychosocial treatments and to improve clinicians’ ability to refer to both treatments the individuals who are most likely to benefit from them. We expect the result to be programmatic improvements that improve the magnitude and durability of gains in community functioning.NCT04321759, registered March 25, 2020.ClinicalTrial.gov  Schizophrenia (SZ) and related disorders occur in between .4-1% of the population across the world—about 2 million individuals in the United States, with 100,000 new cases diagnosed each year. They are highly disabling, create substantial burdens for their families and communities , and cosAn array of psychosocial programs to improve social skills and cognitive functioning have been developed in recent decades. Social skills training (SST) is a common approach to improving social functioning, most often provided in a group format, aimed at teaching more effective interpersonal skills. Skills are taught based on the systematic application of social learning theory, and include the following steps: breaking complex skills down into smaller steps or components, demonstrating (modeling) the skill for participants in a role play, engaging each participant in practicing the skill in role plays with each one followed by positive feedback and suggestions for improvement, collaboratively developing home assignments for participants to practice the skills on their own, and in vivo community trips to practice the skill. Considerable evidence supports the efficacy of SST in improving social and community functioning as well as reducing negative symptoms , 24.Cognitive remediation (CR) programs take a different approach to improving functioning, with a focus on enhancing cognition through practice of computer cognitive exercises, coaching in strategies designed to improve performance on the cognitive exercises, and teaching self-management (or compensatory) skills to improve cognition in day-to-day situations. Although most cognitive remediation programs have produced moderate gains in overall cognitive performance , 32, by d between .4- 1.0, averaging .8) on cognition, social cognition, and community functioning in both early course and multi-episode patients with SZ (see Table The Patient-Centered Outcomes Research Institute (PCORI) funded Project SUCCESS, Schizophrenia: Understanding and Comparing Cognitive Enhancement and Social Skills training to fill this knowledge gap and thus inform the treatment decisions of clinicians, individuals with SZ, and other stakeholders. Meta-analyses and independent randomized controlled trials (RCTs) of comprehensive CR treatment, including Cognitive Enhancement Therapy (the one we will provide) indicate moderate to large effect sizes  . These adaptations do not change the treatment elements or research methods described in this article.Overall, we believe that the proposed comparative effectiveness trial addresses a key knowledge gap for the field and a decisional dilemma facing clinicians seeking to improve community functioning in schizophrenia. Given that schizophrenia is one of the most disabling illnesses in all of medicine, the public health significance of the research is substantial.


While coral reefs in Australia have historically been a showcase of conventional management informed by research, recent declines in coral cover have triggered efforts to innovate and integrate intervention and restoration actions into management frameworks. Here we outline the multi-faceted intervention approaches that have developed in Australia since 2017, from newly implemented in-water programs, research to enhance coral resilience and investigations into socio-economic perspectives on restoration goals. We describe in-water projects using coral gardening, substrate stabilisation, coral repositioning, macro-algae removal, and larval-based restoration techniques. Three areas of research focus are also presented to illustrate the breadth of Australian research on coral restoration, (1) the transdisciplinary Reef Restoration and Adaptation Program (RRAP), one of the world’s largest research and development programs focused on coral reefs, (2) interventions to enhance coral performance under climate change, and (3) research into socio-cultural perspectives. Together, these projects and the recent research focus reflect an increasing urgency for action to confront the coral reef crisis, develop new and additional tools to manage coral reefs, and the consequent increase in funding opportunities and management appetite for implementation. The rapid progress in trialling and deploying coral restoration in Australia builds on decades of overseas experience, and advances in research and development are showing positive signs that coral restoration can be a valuable tool to improve resilience at local scales . RRAP is focused on creating interventions to help coral reefs at multiple scales, from micro scales  to large scales  to resist, adapt to and recover from the impacts of climate change. None of these interventions aim to single-handedly restore the entirety of the Great Barrier Reef, nor do they negate the importance of urgent climate change mitigation action. Historically, management of coral reefs in Australia has focused on reducing local and regional stressors. These include, for example, overfishing (mainly through zoning and enforcement), mining for oil and gas exploration, coastal development , and poor water quality (through land management and improved technology). Apart from targeted crown-of-thorns starfish (COTs) control, which has since 2013 become an important part of reef management on the Great Barrier Reef (GBR) ), coral Porites spp., away from a harbour development site to avoid physical damage from dredging activities -1) and cWith the promising outcomes of larval-based restoration trials on the GBR, a pilot capacity building project called Boats4Corals investigated whether boats and crews from the reef tourism industry and Indigenous Traditional Owners in the Whitsundays region could undertake larval restoration operations using modified larval culture pools on reefs , 46, ini2) onto devices for deployment, aims to assist reef recovery and restoration by enhancing the low natural survival characteristic of post-settlement and post-deployment phases  the ability to manipulate the benthic community surrounding the coral to control settlement inducers and competitors, (iii) the opportunity to overcome challenges associated with natural settlement processes on degraded reefs, including a lack of appropriate settlement cues or available substrate [Coral seeding, defined as the settlement of coral larvae or the attachment of small fragments or micro-fragments (<1 cmiewed in ). While ubstrate –55 and tubstrate –58, and ubstrate –63. Coraubstrate  or speciubstrate  and 3D pubstrate . More reubstrate . BuildinAcropora tenuis spat survival three-fold over featureless devices [Acropora millepora, Acropora muricata and Montipora aequituberculata were deployed across three sites in the inshore Keppel Islands in January 2021 (~ six week old spat). Surveys of devices in April 2021 indicated early survival yields averaging 50% on plugs and >95% on devices, and differences in survival amongst sites. Ongoing surveys of devices are planned for throughout 2021, and aim to identify the drivers of site and species-level differences in survival and growth to allow future optimisation of coral seeding restoration efforts. Taken together, these projects demonstrate the capacity to improve the survival of deployed spat and coral fragments above natural rates and suggest that seeding devices may offer an additional tool that, when combined with other techniques and advances in automation and high throughput technology, may offer a valuable tool for the reef restoration toolbox.Recent research, funded by the Australian Institute of Marine Science (AIMS), has identified some functional features, such as wide grooves in the settlement surface, that improved  devices , 63. A s devices . BuildinThe Reef Restoration and Adaptation Program (RRAP), was initially funded by the Australian Government to scope existing and novel technologies that could help support the resilience of the GBR, and to deliver an investment case for further research and development of reef interventions , 67. ThiThe RRAP feasibility study found there was no single solution to supporting the Reef’s resilience , 68. RatThe targeted research and development program will balance minimising risk with maximising the opportunity to save coral species and values to create a suite of interventions that would take an integrated, three-pronged approach: 1) cooling and shading the reef to help protect it from the impacts of climate change 2) assisting reef species to adapt to the changing environment, and 3) supporting the recovery of degraded reefs through restoration; over seven intervention research and development subprograms . The focThe envisaged final phase of RRAP would be an implementation phase which could overlap with the research and development phase as early as five years from commencement, depending on the specific intervention. This would include commercial transfer of the reduced set of candidate intervention measures, including the construction, operation, and deployment of full-scale systems.The current and projected rates of climate warming combined with the devastating effects of heat-induced coral bleaching on reef health indicate that corals need to rapidly adapt to become more thermally tolerant if they are to survive into the future. Assisted evolution is a collective term for several interventions aimed at improving coral performance through the acceleration of naturally occurring evolutionary processes . To dateThere are three main approaches to assisted evolution:Managed or selective breeding refers to approaches based on sexual reproduction, such as cross-breeding between distinct populations of the same species  or between species , and the cross-breeding of comparatively heat tolerant colonies from the same population [pulation . These apulation –77 especpulation .(Pre)conditioning is the exposure of organisms to sublethal stress which may elicit an increased tolerance to subsequent stress exposures. Prior exposure to elevated temperatures can reduce bleaching susceptibility in adults  and and(Pre)s . Ho. Ho(Pre)Microbiome manipulation or microbiome engineering is the manipulation of individual microbes, microbial communities, or their hosts . Promisgnition, . The devgnition, , but thignition, –91.A less often discussed assisted-evolution approach is the managed formation of coral chimeras, for instance through the use of microfragments of full siblings to reskin dead skeletons of large, massive colonies . Close rCurrently, assisted evolution for corals is in a research and development phase and is not yet implemented on the GBR. The feasibility of assisted evolution has mostly been tested under laboratory conditions and in small field trials (Acropora impacted by recent heat waves) can exist along broad latitudinal gradients stretching >2000km, exposing species to >7°C temperature difference. Such broadly distributed coral species typically exhibit different thermal optima tuned to local conditions  that apns (e.g. . Reefs ins (e.g. ). Whilstns e.g. , 103), “, “Acropons  mangrove lagoons, are exposed to variable environmental conditions including changes in pH , extremes in temperature, and amplified metabolic activity , 109. Thgenation , yet appgenation ). These genation , 111).Together these various examples of naturally heat tolerant corals demonstrate existing natural variation in thermal tolerance and therefore provide important genetic reservoirs to support reef restoration and adaptation activities. However, key knowledge gaps remain. For example, the impacts of selective breeding on genetic diversity and local adaptation, or the capacity for corals to maintain traits among generations still warrant further studies. Reciprocal transplant and gardening experiments of populations and genetic crosses of corals are now underway to understand genetic and environmental drivers of coral fitness among reefs . UltimaRecent studies clearly describe how the impacts of climate change, such as major bleaching events, are keenly felt by reef users and visitors. They report diminished experience quality, less confidence that their own actions will matter, and emotional responses consistent with ‘ecological grief’ . These iWithin Australia, as elsewhere, there are programs of community action and partnerships between citizens and researchers that encourage participation in monitoring of coral health and in coral restoration activities. These efforts often intersect with long-standing marine citizen-science programs that are sponsored by non-governmental organisations, education and research providers or agencies with responsibility for marine park management. This can contribute to environmental literacy and citizenship amongst participants . FurtherWhen approaching politically and socially contested proposals such as large-scale restoration and adaptation of the GBR, there are a number of complex social and institutional considerations. The first of these is understanding the social acceptability (or otherwise) of proposed restoration interventions amongst the broader community, key rights-holders such as Indigenous Traditional Owners, stakeholders such as reef-using or reef-dependent economic sectors, and other engaged interest groups. The second challenge is assessing how proposed interventions (or non-intervention) are likely to affect the diverse social and cultural values, uses and benefits for those groups that associate with the Reef. Third, there is a need to develop appropriate and meaningful ways to engage different groups and interests in the design, deployment and evaluation of proposed interventions or technologies over time. A recent review identified several distinct types of challenges researchers face when working on assisted regional ecosystem adaption including scientific conflicts and debates over the “facts”; social and governance challenges; epistemic challenges, and ontological conflicts . AddressThere are normative reasons  and instrumental reasons  why understanding social acceptance, assessing likely impacts on diverse values, and designing appropriate engagement processes are important. They are normatively important because there are democratic, moral and ethical obligations to involve people in decisions and actions that may affect their livelihoods or future well-being. They are also instrumentally important in that good participation or co-design can lead to enhanced performance of the planned environmental intervention through better tailoring to local conditions, the use of local and traditional knowledge and reduced stakeholder conflict . CriticaSince 2017, there have been approximately 19 in-water coral reef restoration projects, and a rapidly growing field of research into coral restoration and adaptation on the GBR including RRAP. This reflects an increasing urgency for action to confront the coral reef crisis, and an increase in funding opportunities and management appetite for the implementation of interventions. Generally, there has been a collaborative, positive spirit, and coral restoration has brought together stakeholders who rarely work together . However2 of coral reefs [Australia has about 50,000 kmal reefs  and no eal reefs . It is nal reefs . Coral rAdditionally, there is also value in small-scale interventions, particularly at high-value sites where objectives of restoration align with economic and/or cultural incentives through increasing community engagement or the amenity value of tourism hotspots. Since 2018, at least ten tourism organisations have been actively involved in coral restoration projects on the GBR, motivated by the desire to be proactive in improving the condition of the reefs they use . While tThe novelty of the many intervention strategies presented here represent an important shift in the use of coral restoration—away from assessing the feasibility and efficacy of individual techniques, towards developing a holistic approach that includes coordinated and practical solutions with specific objectives linked to long-term outcomes in a changing climate. In Australia, this shift is greatly facilitated by large investments through the RRAP Program. There has also been a shift from research and development to implementation. This approach requires research partnerships that span beyond the coral research space to include Traditional Owners, engineers, social scientists, modellers, economists, infrastructure development experts, and project managers.The rapid progress in trialling coral restoration methods in Australia builds on decades of overseas experience. Australia is now investing considerable time and money into developing novel interventions and consequently, is fast becoming an emerging leader in this space. There are great advantages to continuing to actively collaborate with researchers internationally and with other sectors not currently involved in coral reef management. This could be facilitated through coordinating organisations and networks such as the Coral Restoration Consortium, the International Coral Reef Initiative, RRAP, the United Nations, and the International Coral Reef Society to hasten the optimisation of reef restoration interventions and their contribution to future increases in reef resilience.The challenge for the future include: (1) demonstrating that active restoration can play a meaningful role in improving reef condition through supporting resilience and increasing adaptation when other, less interventionist, management strategies have not worked, (2) implementing these interventions at larger scales, and (3) understanding and mitigating any potential risks from active restoration. At any scale, coral restoration and adaptation interventions do not take away the need for urgent reductions in greenhouse gas emissions.S1 Appendix(DOCX)Click here for additional data file.


Enabling Veterans to remain safely in their homes is a Department of Veterans Affairs (VA) priority. Informal caregivers play a critical role in supporting Veterans with functional impairments through their own efforts and the use of home and community-based services (HCBS). The Elizabeth Dole Center of Excellence (EDCoE) for Veteran and Caregiver Research was created in 2018 as part of the VA Choose Home Initiative to expand VA capacity to deliver integrated, Veteran- and caregiver-partnered, data-driven approaches to care through a set of complimentary projects. The EDCoE is a virtual center, with its multi-disciplinary team spread across the country at 5 different VA Medical Centers. The team also collaborates with other VA caregiver researchers. Finally, the EDCoE is closely networked with national, regional, and local operational partners, allowing for rapid dissemination of findings. In this symposium, we will first discuss the mission and vision of the EDCoE. We will then discuss multiple projects that are led through the EDCoE. Paper 1 (San Antonio) will identify measurement gaps to guide monitoring and improving HCBS. Paper 2 (Miami/Canandaigua) will describe a national survey of 8000+ Veterans and 3500+ caregivers. Paper 3  will describe caregivers’ barriers to accessing VA and non-VA HCBS. Paper 4  will describe the results of latent trajectory analyses of administrative data to identify groups of Veterans who use different combinations of HCBS and institutional services. Our results are used by VA operational partners and policymakers to improve services for Veterans and informal caregivers.