Native American youth, primarily living on reservations, suffer the highest burden of suicide of any racial group in the USA. Implementation and sustainability of culturally grounded, evidence-based interventions are needed to address suicide in Native American populations. For nearly 40 years, Montana has ranked at or near the top nationwide for suicide. Fort Peck Tribal leadership declared a state of emergency in 2010 after six suicides and 20 attempts that occurred over a 5-month period.We used a community-based participatory research approach for adapting the Celebrating Life (CL) program with a specific focus on long-term sustainability, which has demonstrated efficacy in addressing suicide with the White Mountain Apache. The aims were to (1) adapt the CL program intake forms through roundtable discussions, (2) conduct asset and resource mapping to identify community and cultural resources to leverage for the CL program within the Fort Peck context, and (3) develop a sustainability plan for CL in Fort Peck through qualitative approaches informed by the Program Sustainability Assessment Tool.Roundtable discussions resulted in adapted intake forms that capture variables relevant to the Fort Peck context. Asset mapping identified 13 community assets and 10 cultural resources to incorporate within the CL implementation process. Focus group discussions yielded four key themes that were incorporated into a plan for sustainability: (1) strategic partnerships, (2) long-term funding, (3) communication planning, and (4) workforce planning and engagement.This paper outlines an avenue for using culturally adapted tools to design an implementation system driven by community and cultural assets within tribal communities and for integrating program planning for sustainability early in the implementation process.The online version contains supplementary material available at 10.1186/s43058-022-00376-1. Contributions to the literatureWe utilized community-based participatory research methods and a strength-based approach to adapt a suicide surveillance program for implementation.The methods described provide a process for planning prior to implementation to increase acceptability, sustainability and engagement with community assets, factors shown to be critical for long-term program sustainability.Findings demonstrate the importance of cultural and contextual adaptations prior to program implementation.Native American (NA) (American Indian/Alaska Native) youth living on reservations and in rural settings suffer the highest burden of suicide of any racial group in the United States (US) . Key risResearch and programs implemented in NA communities experience the common challenge of long-term sustainability. It is a familiar and persistent problem that promising programs wither when funding ends, which is demoralizing for tribal communities . While iAssessing sustainability capacity, or the ability to maintain programming and its benefits over time, should be an integral step in research and program implementation as evidence-based programs in virtually all settings are challenged with sustaining activities over time. Understanding factors that contribute to long-term viability can prevent early closure of crucial public health programs, particularly in low-resource settings . The ProAsset mapping, which is the process of collecting, recording, analyzing, and synthesizing community and cultural resources, and networks supports capacity-focused development, is in direct contrast to “needs assessments,” which are often deficit-oriented. Further, deficit-oriented approaches often exclude communities from active roles, thus perpetuating structural inequities and failing to secure lasting change . CommuniCelebrating Life Suicide Surveillance and Case Management System. Celebrating Life (CL) involves implementation of a reservation-wide, tribal-mandated reporting system that prompts assignment to a case manager and appropriate referrals, and longitudinal follow-up. Over the past decade using six caseworkers and a supervisor, CL has shown increases in (a) reports to the system over time, demonstrating greater community awareness of the system and self-efficacy about how to report; (b) the ability to locate people at increased risk, indicating greater skill among the CL team to work with individuals on a sensitive, sometimes stigmatized issue; and (c) referrals to mental health services and improved linkages to care. Over the past 20 years, CL has provided services to over 2000 individuals and yielded decreases in suicide attempts and death rates over time. During the first 6 years that the CL surveillance and paired case management system was implemented, the all-ages Apache suicide rate decreased by 38.3%, and the rate for 15–24 years old decreased by 23%. Additionally, the annual number of attempts decreased from 75 to 35 in the years 2007–2012  but we are doing it in a manner that is exciting to youth. And then we are, really focusing on not just the individual, but families as a whole” (FGD 1 participant)This response emphasizes the importance of active engagement with the community and families. Participant suggestions to include youth included leveraging the Tribal Youth Council and hiring recent master’s graduates who have expressed interest in this work. They will be an important connection to youth and are comfortable with social media communications, which will bolster engagement.We used a participatory, asset-based, and community-engaged research approach for adapting and planning for the long-term sustainability of an evidence-supported suicide prevention program. The three aims focused on specific programmatic adaptations and considered larger cultural and contextual factors that will support successful implementation and sustainability of effective prevention programming. Several themes emerged that will guide the implementation of CL and case management at Fort Peck. The planning work presented here was unique in that it takes a strength-based approach, by exploring both community and cultural assets, and considering long-term sustainability from inception. While the PSAT tool was initially created to evaluate sustainability of existing programs, our process speaks more to feasibility and long-term sustainability prior to program implementation.Our initial adaptation process began with revising the intake and case management forms, which was helpful for familiarizing participants with the CL program and engaging them to gather their unique input about what factors are most important to collect from the surveillance system. Suggested changes resulted in a more extensive intake form. Moving forward, we will monitor if this results in data that are more comprehensive or presents a barrier to rapid reporting. Asset mapping familiarized the TAB members even further with the program and helped garner community engagement and motivation; previous strengths-based research studies have also reported benefits to community engagement , 33. TheThe inclusion of sustainability planning in the development process was a crucial step often forgotten in planning for implementation of evidence-supported programming. Prospectively planning for sustainability if done is often done during implementation of programs . HoweverIn the White Mountain Apache community, maintaining and sustaining CL has succeeded due to continuous renewal and expansion of the tribal mandate; a strong network of health and human service providers, tribal members, respecting and supporting the mandate; ongoing monitoring of the system to demonstrate its impact; and public and private funding that has been attracted to the ongoing need and success of the system , 31. It In the end, participants and the TAB identified three critical next steps for implementing and sustaining CL at Fort Peck: (1) addressing the Tribal misdemeanor law for suicide risk; (2) implementing a tribal resolution that mandates reporting suicide-related behavior within tribal jurisdiction, similar to the White Mountain Apache model; and (3) exploring program sustainability through third party billing. Our findings have some important limitations. First, sample size was small due to inclusion criteria requiring experience with systems of care for suicide. This criteria prevented input from the wider community and youth at this pre-implementation stage. Further, participants in underserved populations are often difficult to reach due to remoteness and distrust . Thus, wCommunity and cultural asset-focused program development strategies engage local strengths to promote effective community interventions that last. Suicide is a complex problem, and even more so in remote NA communities that have experienced decades of fragmented, under-resourced, and culturally incongruent systems of care that, like NA suicide inequities, are the direct result of colonization and its aftermath. The aforementioned development process for implementing and sustaining the CL system can be used as a model by other tribes for their own unique public health programming. If tribes are not positioned to conduct this resource-intensive process, the key themes from these efforts may be considered when adopting CL or other similar programs. This CBPR study serves as an exemplar for adapting, building, and sustaining culturally congruent interventions in ways that empower historically marginalized communities.Additional file 1. COREQ.


Teacher emotions are essential for teaching effectiveness and teachers’ professional development. Studying teacher emotions during a program in today’s world is crucial, where teachers are commonly involved in professional development programs. From an ecological perspective, this study employed a case study method to examine the emotions of two Chinese high school mathematics teachers in a 4-year teaching improvement program. Semi-structured interviews, teacher emotion logs, researcher memos, and informal dialogues were all used to collect data. This study aimed to better understand the emotions that Chinese high school mathematics teachers developed and the processes that generated them in their interactions with various ecosystems within a specific professional development program overlay. The study’s findings revealed that the two teachers triggered 65 emotions in their interactions with the various ecosystems over 4 years—A describing 51 and B describing 46—with an overall predominance of positive emotions. They triggered the broadest range of emotions in the mesosystem, particularly during interactions with program companions. During the early, medium, and late stages, their internal psychological factors and interactions with each system changed, resulting in significant changes in their emotions. They all went through phases of mixed sadness and happiness, ending in a state of delight and calmness. Finally, we recommended teachers’ professional development based on the study’s findings. Teacher emotions have emerged as an important research topic in psychology and education, and they are critical for teacher’s identity, teaching quality, teacher–student relationships, student performance, and even educational reform . TherefoGaokao  programs when such participation is widespread e.g., . AlthougTherefore, due to the lack of attention paid to the emotions of high school mathematics teachers, especially from an ecological perspective, the emotions of mathematics teachers in a PD program are studied in this paper. This research pays attention to the emotions of high school mathematics teachers participating in a four-year PD program. Bronfenbrenner’s ecological systems theory  has beenSince the turn of the last century, ‘emotion’ has been a significant topic in educational research . From phAs teacher emotion research has advanced, many researchers have begun to detect and discover from comparative studies that teacher emotions reflect differences at different key stages in school education, as well as disciplines. In terms of the key stages in school education, Overall, these studies revealed the multifaceted, complex, and variable nature of teacher emotions in primary education and the focus and characteristics of research on teacher emotions. It is necessary and meaningful to conduct more focused research on teacher emotions in high school mathematics, considering the differences between disciplines and key stages in school education.For an increasing number of teachers, PD has become an essential part of their professional lives, and participation in a PD program within or outside of school is becoming more common . As PD rPrevious research has focused on the emotions generated by teachers’ interactions with partners in PD , with thIn addition, with the recent rise of lesson study , the teaMore and more research has suggested that teachers’ emotions are generated by interactions with people and events at various levels of the environment . They aremotional knowledge is an inseparable part of their knowledge ecology, called emotional ecology. individual plane, relational plane, and sociopolitical plane. He applied this model to a case study of four preservice primary school teachers’ emotional ecology and pedagogical content knowledge (PCK). However, At the beginning of this century, Following In terms of research methods, the majority of studies on teacher emotions that employed Bronfenbrenner’s ecological systems theory used qualitative research methods , with onFrom the above literature review, it can be seen that examining teacher emotions from an ecological perspective is a relatively new development, but it has become a hot topic of research. Bronfenbrenner’s ecological systems theory has been widely used, allowing researchers to analyze and comprehend teacher emotions at different fine-grained levels. However, very few studies have examined the emotions of high school mathematics teachers in teaching improvement programs from an ecological perspective, and this study will attempt to do so.Through a review of research on teacher emotions, we found that the previous studies had following gaps: first, most of studies on teacher emotions had been focused on English teachers or elementary and college teachers, with fewer studies on high school mathematics teachers; second, most of studies on teacher emotions in PD programs had failed to distinguish the unique emotions that teachers generated in PD programs; finally, very little was known about the different types of emotions experienced by high school mathematics teachers in specific PD programs.Based on above gaps, this paper aims to conduct an in-depth and detailed study of the emotions of high school mathematics teachers in a specific PD program, to achieve the following research objectives: (1) to identify the emotions experienced by high school mathematics teachers in a specific PD program; and (2) to depict how these emotions have emerged, especially through which interactions have these emotions been generated in the PD program.Based on these two research purposes, we believe that the case study approach can assist us in gaining a deeper understanding of the development mechanisms of emotions of high school mathematics teachers in PD programs, because both these emotions and the emerging contexts are very complex, requiring rich data and careful analysis. Therefore, this research has been focused on two teachers in a four-year high school mathematics teaching improvement project, given that these two teachers had generated various emotions through the extended program participation. We expect that data analyzed from numerous sources for the two teachers will provide insight into what emotions high school mathematics teachers have experienced when they actively participate in a PD program over time and how these emotions have originated. This could demonstrate a model of emotional development for high school mathematics teachers under a specific PD project.Specifically, this research hopes to address the following research questions:What emotions did Chinese high school mathematics teachers develop when they interacted with each ecosystem during the teaching improvement program?How did these emotions emerge?After the two teachers in this study joined the teaching improvement program, they interacted with different elements in different environments and identities. Their individual emotions were influenced by a complex mix of sociocultural and environmental factors. The ecological framework proposed by Within the ecological framework, teachers’ interactions with their environment span from close to far . The speThe microsystem refers to “the structures and processes taking place in an immediate setting, containing the developing person ” , p. 80. The mesosystem includes connections with the microsystem , p. 80. The term “exosystem” refers to “the linkages and processes taking place between two or more settings, at least one of which does not ordinarily contain the developing person, but in which events occur that influence processes within the immediate setting that does contain that person” , p. 80. The macrosystem is defined as “an overarching pattern of ideology and organization of the social institutions common to a particular culture or subculture” , p. 81. The chronosystem permits “one to identify the impact of prior life events and experiences, singly or sequentially, on subsequent development” , p. 83. This research aimed to investigate the emotional development of Chinese high school mathematics teachers who participated in a teaching improvement program. The research object was selected using the principle of purposeful sampling to identify information-rich cases to analyze and illuminate the research questions , p. 230.Two teachers, Ms. A, with 20 years of teaching experience, and Mr. B, with 15 years of teaching experience, both in the middle and late stages of their careers, taught in two high schools in Shanghai, China. In the spring semester of 2018, a university in Shanghai organized a teaching improvement program for secondary school teachers to recruit participants. This teaching improvement program was intended to encourage high school teachers to integrate the history of mathematics into mathematics teaching, consequently improving students’ mathematical knowledge and literacy. From 2018 to 2022, the program was conducted in two phases, each lasting 2 years, and it was a nonmandatory program organized by the noneducation administration. Participants volunteered to take part in the program, and they all adopted value recognition and eagerness to integrate the history of mathematics into mathematics teaching. Thirteen senior secondary mathematics teachers joined the first phase, and this number increased to 27 in the second phase, with both A and B participating in two consecutive phases. All teachers were required to select materials from the history of mathematics provided by the program and then use them for teaching practice. Throughout the program, they prepared lessons, discussed, observed each other’s trial and formal teaching lessons, and conducted post-lesson evaluation activities. At each stage, the program mentors (university professors) and other researchers  supplied them with teaching materials, evaluations, and suggestions. On average, the program held one group seminar and two class observations every month, each followed by a lesson evaluation activity. The four-year program experience allowed A and B to interact closely with the program’s personnel and experience rich life events that have caused complicated emotions. A and B believed that their participation in the program had aided their teaching practice and PD, and they were eager to share their experiences and emotions from the program and to engage in the additional data collection required for this study. The principal and some researchers in this program were included as researchers in this paper. The researchers’ acquaintances with the participants enabled them to obtain more profound knowledge of their emotions and related events, facilitating the collection of more accurate and reliable data for this study , p. 140.Based on the above considerations, the two participants experienced wealthy emotions during their long involvement in the program, and they were willing to share their emotions and the context in which they arose. We believed that they matched well with the needs of the participants in this study and that they were valuable cases worth researching.This study employed a case study as a research method to explore participants’ interactions with the environment and the emotions they experienced. A case study is empirical research that delves into a phenomenon within its real-world context , p. 16. Throughout the four-year program, the data on the emotional development of the two teachers were diverse and rich. Semi-structured interviews, teachers’ emotion logs, researcher memos, and informal dialogues were used as the data sources for this study. All data collection methods were ethically approved and checked by the Committee on Human Research Protection of East China Normal University.First, the two participants provided three individual emotion logs totaling over 9,000 words. In these three emotion logs, participants recorded their main experiences, the emotions that emerged, and the events that triggered emotions in the early stage (for the first year), medium stage (from the second to the third year), and late stage (for the fourth year) of their involvement in the program. These emotion logs were adapted from the teachers’ reflection logs based on their continuous recordings over the past 4 years, and as a result, the experiences of the events in them were clearer.In-depth, semi-structured interviews were the most significant sources of data for this study. Two teachers participated in in-depth semi-structured interviews lasting 4–6 h in the form of one-on-one online meetings. The interviews were divided into two main parts: in the first part, using the emotion logs offered by the teachers as a cue, the interviewees described their emotional development experiences during the program in chronological order, and the interviewer pursued the details and emotional experiences; in the second part, the interviewees described their most salient emotional experiences during the different stages of the program and the context in which they emerged. With the participants’ permission, all interviews were audio-recorded and transcribed verbatim, yielding about 170,000 words of interview material.Researcher memos and informal dialogues were secondary data sources primarily used for data triangulation , p. 297 To analyze the extensive interview data, we employed thematic analysis  and threTo ensure reliability in the data collection and analysis process, we first formed a data triangulation , p. 297 Through coding and analyzing the data, the researchers revealed that 65 emotions were triggered in the two teachers’ interactions with each ecosystem over the four-year program’s participation, with 51 stated by A and 46 expressed by B. The teachers’ emotional development in different ecosystems was distinctive, and we described the teachers’ emotions and the contexts in which they emerged in each environment.Teachers who participate in the program must develop new classroom practices based on the program concepts. This style of classroom differed from that of a regular classroom and presented challenges for both teachers and students. Therefore, more frequent interactions between teachers, students, and the teaching task were formed in this classroom, eliciting diverse emotions. Among their interactions with students, the two teachers recorded 16 emotions, predominantly positive emotions and less negative emotions. Both teachers experienced complex emotions while interacting with the teaching task, describing 38 emotions.satisfaction. Both teachers indicated that they had a good rapport with their students and that the teacher–student interaction was excellent. When they tried to incorporate program ideas into their classes, their students were interested, which made them feel satisfied and delighted.Regarding interactions with students in the classroom, the emotion most frequently described by the two teachers was encouragement and firmness in his teaching practice using the program concept.Teacher B also stated that the students’ enjoyment of the teaching method gave him much “When I started these classes, the kids appreciated it, and to be honest, … students’ favor was one of the main drivers for me,” he continued. “Well, certainly, it is their enjoyment that keeps you going” (B-Interview).disappointed because the students completed the task perfunctory; in the second assignment, she was surprised and moved because the kids took the assignment seriously and were motivated by her to think deeply about mathematics.The emotions elicited by Teacher A’s interactions with the students were more tortuous and varied. During her participation in the program, she designed two assignments on mathematical writing in which students read literature on mathematical culture and submitted short essays. In the first assignment, she was “I was both surprised and moved,” she said. “Well, sure, because these 17 (student) essays contrasted sharply with the summer reading I had assigned a year before. After only over a year, the students could generate such a stark contrast, and their comprehension of mathematical culture and the application of mathematical history far exceeded my expectations” (A-Interview).pleased that the students were cooperating with her more and more. This cooperation is evident not just in students’ academic performance but also in their active participation in class. She was at ease when her students could follow her teaching ideas. The program team occasionally arranged for her to teach unknown students, which made her worry about the students’ cooperation and pity for their lack of tacit understanding.She was liked the student–teacher interaction. She is also proud that the students admire her for her involvement in the program.Finally, Teacher A stated that students often asked about her experiences after participating in the program. She Teaching tasks are the most significant component of every teacher’s life since they engage with these tasks frequently and intimately. Teachers construct and complete teaching tasks to better practice teaching under program concepts. Both teachers experienced conflicting feelings of sadness and joy during the program.satisfaction, relaxation, delight, and confidence and more frequent negative emotions in dissatisfaction, confusion, uneasiness, and stress. The two teachers repeatedly mentioned these emotions in their interviews and emotion logs.In their interactions with the teaching tasks, the two teachers reported more frequent positive emotions in Positive emotions mainly came from the teachers when they accomplished their teaching tasks and performed well. Additionally, some knowledge, skills, and conceptual upgrades generated positive emotions for them during the teaching design process.satisfied and delighted after completing her first teaching task under the program concepts, which was her first official teaching attempt after 1 year of participation in the program. She felt exhilarated even before class, which she considered a new starting point for her PD.Teacher A felt delight in that” (A-Interview).Teacher A said, “It is finally a job well done. I’ve finally had a high school mathematics presentation class that integrated the history of mathematics; there is still some more confident and relaxed in her teaching tasks and more carefree in completing them. Additionally, she had grown to like this type of teaching and become more firm in her mind under the program concepts.Positive emotions emerged in Teacher A’s teaching practice whenever she believed that she had fulfilled the established teaching objectives and that class performance was more effective. She became more familiar with teaching tasks using this method as she achieved success in completing teaching tasks and her sense of program concepts. As a result, she became more satisfaction and delight, even pride and love, in accomplishing the task effectively. He also felt more confident and relaxed after gaining experience. Furthermore, he found the process of completing the task rewarding. Teacher B was likewise a person who continually and deeply considered the problems of the task in teaching preparation; he was delighted when he solved them and satisfied when he incorporated his unique teaching objectives into teaching design and anticipated his teaching effectiveness. For example, Teacher B included traditional Chinese culture in his teaching design for classical models of probability, which is his longstanding teaching aspiration. “Then this class, I think one of the highlights for myself is that I blended this traditional Chinese culture very effectively with this lesson,” he explained (B-Interview).Similarly, Teacher B’s emotions emerged. He felt dissatisfied with the poor teaching effectiveness, uneasy and confused because they were unfamiliar with the relevant historical material and practice methods, and stressed in the preparation process.However, teaching practice was not always smooth. Two teachers experienced negative emotions while preparing for and implementing their teaching. They both felt worried about her teaching effectiveness. She was cautious and confused about preparing her designs and even nervous during class.Furthermore, when Teacher A first began practicing, she frequently felt unprepared and incompetent, which made her anxious, fearful, and nervous about the unknown teaching effectiveness when preparing the teaching design. He spent a lot of time thinking about the task to accomplish it excellently, which he discovered was hard and distressing.Teacher B was The mesosystem connects two or more microsystems. The two teachers involved in the improvement program interacted in the mesosystem, primarily with the microsystems at the school and program levels.The school serves as both an organization and a workplace for teachers. At the school level, teachers have more frequent connections with colleagues and administrators, and these interactions can trigger their emotions.Teachers interact most closely with their colleagues in the workplace. After participating in the program, the two teachers developed 12 emotions in their interactions with their colleagues.satisfaction, calmness, and unhurried.Initially, the two teachers were the only ones at their schools engaging in this PD program. Their colleagues were unaware of the teaching concepts and professional knowledge of the program. However, these two teachers had relatively good mental health and did not develop too many negative emotions. The most often stated emotions were calmness and sympathetic. She was indifferent to her colleagues’ comments. Although her colleagues could not assist her PD, she was satisfied that her colleagues spiritually encouraged her in the program.Teacher A stated that each teacher held various views on mathematics education. When colleagues who did not comprehend her concepts made casual comments about her teaching attempts, she remained “It is okay if colleagues do not make a professional evaluation or comprehend my teaching concepts; it’s normal… They are willing to lend me this class, right? They are willing to devote time to supporting me. All of these are priceless to me” (A-Interview).unhurried and not eager to argue. However, his lack of communication with his colleagues made him feel dreary.In addition to Teacher A’s emotional experiences, Teacher B experienced some more emotions. During the program’s medium-stage teaching attempts, Teacher B was occasionally criticized by more sophisticated teachers among his colleagues for poor teaching effectiveness, but his strong sense of identity allowed him to be dreary at times. When you want to discuss an issue, you might not find somebody to talk to” (B-Interview).“It gets satisfied, delighted, and more relaxed. He felt proud, especially when the colleague who had previously criticized him turned to praise him.The situation altered during the program’s late stage when Teacher B’s teaching effectiveness improved and his colleagues recognized his teaching concepts, and even younger colleagues were expected to join the program, making him feel satisfaction and rejoice in the teachers’ interactions with the administrators.School administrators play a crucial role at the school level, and their support and approval are essential sources of sustainability for the teachers. The two teachers’ school administrators strongly supported classroom practice under the program concepts, resulting in highly positive emotions of satisfied.Two teachers stated that the school administrators have been highly supportive of them since the beginning of the program and have made their teaching practice more convenient. For example, when teachers were required to present open lessons in school (which meant that many teachers from outside the school came to observe), the administrative staff were very helpful in adjusting the teachers’ schedules, and the logistics staff provided them with space. All of these made them feel rejoiced” (B-Interview).“Our president was a special-grade math teacher,” Teacher B added. “So, even though we were busy then, he was supportive of us (in the program)… The president has a unique perspective in these fields… I believe I am still quite rejoiced to have such a president and felt satisfied when the president praised him for his progress in teaching.He felt Once the teachers were involved in the teaching improvement program, they interacted with each other more frequently by talking and discussing their classrooms with others in the program. Both teachers generated rich emotions from their interactions with the program mentors and their program companions.Two teachers generated 11 emotions during their long-term interactions with the program mentors.Admiration was a common emotion described by the two teachers. They admired the program mentors’ extensive knowledge and high-quality teaching guidance. At the same time, Teacher B rejoiced to have met the team mentors and accepted their guidance. “We could meet a lot of big names in person, could not we?” Teacher B explained, “For example, I said we got to meet the living Professor P, right? We get to meet the celebrity in the flesh, unlike others who can only read articles (and never meet the professor in person), right?” (B-Interview). The mentor’s authority in the history and pedagogy of mathematics also made him more unhurried in conducting his teaching practice.uneasy in her interactions with the mentor. However, the mentor’s patient guidance and approachable manner made her feel delighted and flattered.In contrast, Teacher A’s emotions were enriched by her interactions with the mentor. To begin with, Teacher A felt her poor professional level, which made her confident. Over time, she was often encouraged and reassured about her classroom practice. It is worth noting that she was occasionally resistant to rejection when she disagreed with her mentors. She gave an example of an exchange in which “the two mentors gave me this one piece of advice. At the time, I was quite rejected because I thought it did not seem to have much relevance to my secondary school teaching” (A-Interview).Whenever a mentor guided Teacher A’s teaching design, she felt more delight, admiration, like, and excitement, whereas negative emotions were less frequent, comprising mainly pity, stress, and self-abasement. The two teachers highlighted other, more neutral emotions, such as amazement and thrill.During their participation in the program, the two teachers interacted most with their program companions. During the four-year program participation, the two teachers and their program companions studied teaching materials, performed teaching seminars, and observed mathematics classrooms together, making memories and evoking many emotions—a total of 36. The most frequently reported positive emotions were admiration and delight emotions. Two teachers admired the sophisticated mathematics teachers’ wealth of teaching experience and knowledge. At the same time, interacting with these excellent program companions made Teacher A feel excited, and Teacher B was rewarded. When some expert teachers approved the team companions, Teacher A was particularly excited, and Teacher B was delighted.During their interactions with their program companions, the two teachers were most moved by amazed by the ingenious teaching design and splendid class effectiveness of their companion’s classroom design, as well as delighted and admired by the class observation process. Teachers A and B mentioned their companions who had only been teaching for 2 years at a class observation. The colleague’s class was very creative and had an active atmosphere. The students’ feedback was interesting. It was newness for B, and the two teachers were thrilled and liked the creative teaching method. They also gained confidence and encouragement from their young companion’s successful teaching experiences.During the program, the teachers observed and discussed each other’s classrooms. When observing classes, they were often amazed to observe his class because he was so good. He’s so young and so at ease in the classroom that you’d never guess he’d actually just graduated” (A-Interview).“I was delighted, comfortable, and moved. As a result of this like-minded exchange, Teacher B was more firm in the program. He was particularly interested in his program companions’ equal and unfettered communication. He was particularly amazed and moved by the fact that during his first teaching practice with the program concepts, one of his Ph.D. companions traveled a long way to his school to listen to and interact with him. Teacher B said in his emotion logs, “I was quite moved by the fact that Dr. X traveled a long way to listen to my lesson during the trial lecture” (B-Reflective Report).In addition, many of the program companions formed great friendships over time, and Teachers A and B drew close to other like-minded program companions, which triggered tender emotions in them. Teacher A said the friendship made her feel self-abasement due to their companions’ excellence, or they may experience stress when observing their exceptional mathematics classes. When they do not receive a response to a teaching query from their companions in a seminar, they may feel pity.During the process, some negative emotions may occur. The teachers may experience Overall, the program companions’ amicable and friendly connections have left both teachers with many excellent and profound memories as well as positive emotions from their four-year program participation.In the exosystem, teachers have direct or indirect connections with people or organizations outside the school and the program, and these groups in the exosystem can also trigger teachers’ emotions. For both teachers, parents, other peers, and the district’s teaching and research department in the exosystem had an impact on their emotions.delight, firmness, and encouragement.The two teachers had little minimal direct interaction with their students’ parents and mostly interacted with them through their children. The two teachers generated only three emotions in their interactions with the parent community: delighted. This trust from the parents also enabled her to make daring teaching attempts.Specifically, Teacher A said that she always had a wonderful rapport with the students’ parents, who were of a similar age to her and shared many of the same ideas, allowing them to communicate as friends. Aside from teaching, they discussed life topics. This mode of interaction made her feel delighted about it.Teacher B’s teaching skills were outstanding at school, and he was very popular with the parent community. Many parents asked their children to be in his class. Teacher B did not describe the emotions that came with this parental love, but his tone suggested that he was encouraged him to remain with these teaching concepts, giving him a greater sense of firmness in this practice. “The students enjoyed my lesson,” he said, “and parents believed my classes were fairly good based on their children’s feedback” (B-Interview).Teacher B mentioned that during his program participation, his teaching style became more recognized and liked by parents and that this recognition unhurried, delighted, unstrained, and confident.When executing teaching practice under the program concepts, the teachers were occasionally influenced by peers outside of the school and program, which led to emotional fluctuation. Fourteen emotions were developed by the two teachers in their interactions with other peers, with the more frequently reported emotions being confident in the classroom. Teacher A expressed gratitude and delight for their peers’ selfless assistance. She also admired her sophisticated peers. She said, “So, I have more admiration for him, and the counsel he provided me was precious” (A-Interview). Teacher B indicated that he was more unhurried and firm with their support.Positive emotions were primarily derived from peer support and positive comments. When preparing their teaching designs, the teachers occasionally discussed teaching issues with other teachers outside the program and school. Moreover, with the assistance of sophisticated peers, they felt more stressful when presenting their classrooms to their peers.However, the two teachers received negative feedback from their peers. Like their colleagues at school, many of their peers were unaware of the program’s teaching concepts, and some sophisticated teachers among their peers criticized them, either directly or indirectly. In this peer environment, they felt unhurried. When faced with queries, they were unstrained. Teacher B explained, “When someone presents a query, I hold on to my opinion” (B-Interview).However, after a long time of practice, they were more assertive on the inside and were not bothered by their peers’ opinions. When confronted with the question and puzzle, they could remain satisfaction, rejoice, dissatisfaction, moving, excitement, and nervous.In China, each administrative district includes an education department, often referred to as a “teaching and research section,” and the professionals in charge of teaching and research in the discipline are known as “teaching and research councilors.” The local teaching and research section also influences teachers’ teaching practices, which might trigger teachers’ emotions. In this study, the two teachers developed six emotions that arose from their interactions with the section: satisfied with this support.The two teachers stated that the district teaching and research section was supportive of teachers’ participation in various teaching improvement programs, and the teaching and research councilors were very positive about their participation in this program and the program mentors. As a result, when they were practicing teaching under the program concepts, the district teaching and research section provided them with many opportunities to offer open lessons at the district level. The two teachers felt nervous and excited. Teacher A’s school had never had the opportunity to conduct district-level activities prior to joining this program. She was moved by the teaching and research councilors’ encouragement of her teaching practice. She felt rejoiced in the district’s teaching and research model, which encouraged teacher development. She noted, “The other teachers would have their research directions” (A-Interview).Teacher A had more to say about this than about satisfaction. When it came time to deliver a district-level open lesson, Teacher A was dissatisfied with this model.Conversely, Teacher B believed that the teaching and research activities guided by the district education and research section were too formal and did not enhance his teaching practice; thus, he felt pity, worry, rejoice, and satisfaction.Social, cultural, and political factors in the macrosystem influence teachers’ teaching and thus affect their emotions. The two teachers produced the least number of emotions (4) in the macrosystem: rejoiced in a city with such cutting-edge teaching concepts.Shanghai, where the two teachers work, is one of China’s most economically developed cities and one of the most culturally open and advanced places in terms of thinking. Against this societal backdrop, teaching concepts in the Shanghai region are in the vanguard of China as a whole, which is one of the reasons this teaching improvement program has taken root in Shanghai. Teachers A and B Teacher A explained, “Because, compared to Shanghai, you can be sure that many things from other cities, including the concepts, are not as avant-garde as Shanghai” (A-Interview).satisfied him.Teacher B specifically said, “I think Shanghai’s Gaokao  orientation is still relatively good … it focuses on the mathematical understanding I think is particularly good … because we can use the mathematics history material to deepen students’ understanding of the discipline” (B-Interview). Shanghai’s environment also satisfied her.Teacher A also indicated that, according to the teacher’s management system, high school teachers had more liberty in teaching design than elementary school teachers (many primary school teachers in China prepare lessons in a unified way in a preparation group). She had more opportunities to experiment with different kinds of teaching, which Gaokao’s pressure in China. Students’ examination results are utilized as a significant indicator for evaluation, from society to schools and from parents to school administrators, under the strain of the Gaokao. Even if new educational concepts are advocated locally, this test-oriented strategy makes it impossible to have a large-scale impact. When Teacher B initially began teaching under the program concepts, he was worried about being questioned by the outside world, and he often felt pity that so few other teachers around him shared his concepts.The negative emotions in the macrosystem are primarily the result of In short, both teachers’ emotions were influenced by their environment’s cultural atmosphere, teaching concepts, evaluation orientation, and institutional environment.The teachers’ internal psychological factors and their interactions with diverse systems were altered over time. The emotions triggered by the two teachers evolved throughout the program. self-abasement. She spent most of her time observing and learning. Her emotional resources were diverse, including teacher–student interaction and interaction with program mentors and companions, which made her satisfied and delighted. She also experienced uneasiness and nervousness due to doubts about her abilities. Teacher B used the term “confusion” (B-Interview) directly to sum up his emotions during this period. He initially believed that teaching practice under the program concepts would be simple, so he began experimenting with classroom practice as soon as he joined the program. However, while preparing for the teaching task, he found the practice difficult and felt confused in many areas. When his first classroom practice ended in failure, he felt unpleasant and frustrated.During the early stage of the program, two teachers were strange to the new teaching concepts and entirely unfamiliar with the teaching practice under program concepts. Teacher A characterized herself as “an observer and tester” (A- Emotion Log), experiencing positive and negative emotions. Teacher A had been participating in the program for about a year before beginning her teaching practice due to her stressful, but they were delighted when they were successful. In this regard, Teacher A described herself as an “immersive pedagogue” (A- Emotion Log), experiencing rich emotions, whereas Teacher B described himself as “distressed but delighted” (B-Interview).During the medium stage of the program, the two teachers were actively engaged in teaching practice. However, they were not yet able to design their teaching independently and often had to seek assistance from others, and they frequently experienced emotional fluctuations due to their interactions with others. Their classroom teaching had positive and negative effects, and the emotions that were generated varied. They found the process of preparing teaching designs extremely relaxed, and they truly enjoyed the teaching process. Interestingly, Teachers A and B used the same term to describe the overall mood at this stage .During the program’s late stage, the two teachers gradually integrated the program concepts into more common classroom situations. They could primarily design their teaching independently, with few emotional fluctuations due to others’ comments. This made them feel The two teachers in this study generated emotions during program participation, which were primarily positive, with only a few interactions eliciting negative emotions. This research differs from the Under the guidance of program concepts, the two teachers were required to design and implement the integration of mathematics history into classroom teaching during program participation. They entered a new set of environmental systems overlaid by the program environment see . In the Gaokao  in China, which was also reflected in studies on teacher pressure in China  through their interactions with different microsystems at the school and program levels. In particular, the richest emotions in the mesosystem were generated during learning, communication, classroom observation, and teaching evaluation with program companions, whereas the simplest emotions were generated during interactions with school administrators, with only two emotions. Interactions with parents, other peers, and the district education administration all triggered emotions in the exosystem, with peer interactions being the most significant source of emotional triggers in this system. The macrosystem, the furthest away, elicited the fewest emotions, with only four. The culture atmosphere, teaching concepts, evaluation orientation, and institutional environment all impacted these emotions. For the chronosystem, the two teachers experienced changes in their internal psychological factors and interactions with the systems during the early stage, medium stage, and late stage, resulting in significant changes in their emotions, with conflicting feelings of sadness and joy during this program and ending up in a state of delight and peace.Based on further reflections on this study, we have gained some insights about teacher education.First, teacher education should place a premium on developing teachers’ personal emotional competence. As the two teachers in this study became more firm and confident, they were less likely to develop negative emotions due to criticism from others. This emotional competence can assist teachers in better coping with events in their environment, reducing negative emotions and focusing on their development.Second, teacher educators can offer a broader range of PD programs from which teachers can choose. When teachers are free to choose PD programs based on their interests and teaching concepts, they can develop more positive emotional experiences and thus be more persistent. Through the program, they are also better able to improve themselves.Finally, teacher educators should strive to create a collaborative and communicative environment for teachers. When teachers can work positively with colleagues, companions, mentors, and administrators, they develop very positive emotions, which can motivate them to teach carefully and practice positively. Otherwise, they may generate negative emotions.This study primarily used a case study method to analyze the emotions of two teachers. The case was limited to a Shanghai high school mathematics teaching improvement program, and its findings lacked generalizability, which is a general limitation of the case study method . Second,The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by University Committee on Human Research Protection of East China Normal University. The patients/participants provided their written informed consent to participate in this study.PL contributed to whole design of the study, data collection and analysis, and draft writing. SH contributed to the conceptual framework, data interpretation, and draft writing. WK contributed to data collection and analysis. SL contributed to the conceptual framework. XW contributed to the conceptual framework and monitored the program. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The empowerment of families raising children with disabilities (CWD) is crucial in maintaining their health. We developed an evidence-based, family empowerment intervention program focusing on social resource utilization and reducing care burden.This study aimed to determine the program's effectiveness in promoting family empowerment.We compared an intervention group that started the online intervention program a week after initial evaluation and a group that received delayed intervention (waitlist-controlled group) at three time points: initial (T1), post-course (T2), and follow-up (T3). The required sample size was 52.n = 29) or the waitlist-controlled group (n = 30). Those who responded to the baseline questionnaire  comprised the final sample. Among them, 20 members of the intervention group and 20 of the waitlist-controlled group attended all four sessions . The attendance rate for sessions 1–4 was 94%, 89%, 81%, and 83%, respectively. The participant numbers in each session ranged from 5 to 18 per month. The baseline outcome score did not differ between the groups. The primary outcome, family empowerment, measured using the family empowerment scale (FES), was significantly higher at T2 for the intervention group than in the waitlist-controlled group and was sustained in the sensitivity analysis. The intervention group's FES, in the family relationships (FA) and relationships with service systems (SS) subdomains, increased significantly, unlike involvement with the community (SP). The intervention group experienced lower care burden and higher self-compassion, especially in the isolation and over-identification items of the self-compassion scale-short form (SCS-SF). The intervention group's FES  and SCS-SF  changed significantly between T1 and T2, and all, except common humanity, were sustained up to T3; this group's FES (SP) and SCS  changed significantly between T1 and T3. The waitlist-controlled group's FES  and SCS  changed significantly and were sustained between T2 and T3.There were 60 participants who applied to the program. One participant dropped out due to scheduling issues, and the others were assigned to either the intervention group .This study is registered as a clinical trial in the UMIN Clinical Trials Registry ( Raising children with disabilities (CWD) requires more time and skills than raising healthy children . TherefoThis cannot be achieved through public services alone, and it is essential to promote the independence of families living and raising their children in the manner they desire. In this context, family empowerment—families' ability to control their lives and promote the collaborative raising of CWD—has garnered considerable attention . Koren eIn Japan, owing to advanced medical care, children with severe disabilities are increasingly receiving care early on. The number of children needing medical care after acute treatment is increasing rapidly, many of whom live with their families . These fIn previous studies, to comprehensively identify the factors in the family empowerment model (FEM), we conducted in-depth interviews with 34 families  of children with severe motor and intellectual disabilities living at home , and a qIn the current study, through implementation research, we verified whether an intervention program employing the previously identified factors—increasing families' awareness of social resource utilization and reducing caregiver burden—could increase family empowerment. Further, we determined which aspects of FEM—“family  (FA),” “service system (SS),” or “community (SP)”—are empowered by the intervention. We developed a family empowerment intervention program by focusing on family empowerment-related factors, mainly “(awareness of) social resource utilization” and “reduction of caregiver burden.” The program's pilot test revealed its efficacy in empowering families raising CWD at home . SeveralThis is a non-randomized, waitlist-controlled trial, comparing the group starting the family empowerment program a week after initial evaluation (intervention/early group) and the group receiving the delayed intervention (waitlist-controlled/delayed group). The program commenced in July 2021 in Japan, with participants being recruited between April and December 2021. This study is registered as a clinical trial in the UMIN Clinical Trials Registry (UMIN000044172). The study protocol was prepared following the Standard Protocol Items: Recommendations for Intervention Trials (SPIRIT) 2013 statement . The triF-tests (ANCOVA) using G*Power software version 3.1.9.7  and its later amendments. This study was approved by the Institutional Review Board of Tsukuba University .Using the intervention mapping (IM) approach, we developed a peer support program for promoting behavioral change and empowerment of families raising CWD . As the via mail about 1 week before beginning the program, to allow advanced checking of the content. All participants gathered online at the beginning of the sessions and during the summary time and were divided into small online rooms (breakout rooms) of two to four groups (three to six participants in each group) for sharing and exchanging ideas at other times. When there were less than five participants, the entire session was conducted in one group (no breakout rooms) to avoid constraints on group dynamics due to limited participants. In the first session, participants were grouped based on similarity in disability type of their CWD. The main program facilitator and researchers decided on the subsequent groupings considering participants' comments and responses, with the objective of allowing interactions among several participants and parents of children of different ages, disabilities, and developmental stages. Here, we aimed to promote the exchange of experiences and opinions from different perspectives and provide self-monitoring opportunities.Four group sessions were held every Saturday afternoon on Zoom®. Participants received their program materials In the first session, each participant created and shared an eco-map  describiIn the second session, participants shared the life chart they had created as homework after the first session, identified issues in their lives, and spent time envisioning their personal and their family's desired life. In the third session, participants set clear goals for their personal and their family's desired life, planned and verbalized specific action goals for each level, FA, SS, and SP, and exchanged opinions among themselves. In the fourth session, participants shared opinions on what they worked on as homework after the third session and reflected on the entire program .Throughout the program, attention was paid to clear goal setting based on the characteristics of families raising CWD, providing information, understanding the barriers to benefits, informing them of health and life-related risks, encouraging self-monitoring, peer support, self-compassion, and recognition of family empowerment.In each session, two groups of four to six researchers were created, who carried out sessions on a rotation basis for 5 months. The main facilitator was fixed for each month, and three to five sub-facilitators promoted work sharing and opinion exchange among participants in the breakout rooms. As video conferencing was used, in each session, one researcher was assigned to assist participants with their online communication status and file sharing.Three types of tools were prepared for the program: (1) a text workbook, (2) a supplementary reader with illustrations and descriptions of family empowerment elements, and (3) instructions for an online conference system; (1) and (2) were mailed 1 week before the first program, and (3) was made available online. To facilitate participation, the workbook was printed in color for readability and the homework was printed in large font for usability. A certificate of completion was included at the end of the workbook, and to enhance self-compassion, the researcher emailed a PDF certificate to participants after the last session concluded. Additionally, illustrations in the supplementary reader were used as tools to promote awareness of family empowerment. The three levels of family empowerment were explained and illustrated so that participants could easily refer to them during the program and identify family empowerment elements in their situations.All facilitators were professionals involved in pediatric care, educators, or researchers in pediatric or family nursing. Breakout room facilitators were professionals with a comprehensive understanding of CWD and their families or experienced in working with CWD and their families in clinical settings.Further, to standardize program implementation, a “facilitation book” was created. This facilitation book's contents explained the program in written scenes, the time required for each task, and guidelines for maintaining facilitation quality.Group intervention programs were organized every month from July to December 2021; each consisting of four group sessions, with one held every week. After applying, participants were assigned to either the intervention or the waitlist-controlled group and informed of the month they would undertake the program. To prevent biases in their responses due to beliefs about the assigned group, participants were only informed of their participating month, and not whether they were in the intervention or the waitlist-controlled group.The data were collected through online surveys. The contact person sent three emails requesting participants to respond to surveys per the following schedule: For the intervention/early group, the initial assessment (T1) was conducted before the first session, in the preceding week of the program initiation. The post-course assessment (T2) was conducted immediately after the 4-week program (within 1 week). The follow-up assessment (T3) was conducted 1 month after T2. Participants who did not complete any survey were reminded to do so at least once. The schedule was the same for the waitlist-controlled group, for whose members the program commenced 4 weeks after it commenced for the intervention/early group. Thus, the waitlist-controlled group responded to the T1 survey 5 weeks before the program commencement, T2 immediately before the program, and T3 immediately after the program's completion.Participant responses were directly imputed into an online survey system. The password-protected datasets were only accessible to the research team and backed up every 2 weeks. The correspondence table for assigning participants to the intervention/early and waitlist-controlled groups was maintained by an investigator other than the one conducting the analysis. Participants were assigned IDs linked to their response data, and each participant's T1–T3 responses were linked. In cases of multiple responses (duplicates) from the same person at the same time point, we used the latest one, considering it to be the revised response. After the T3 survey, the data were downloaded from the system and stored as primary raw data.The main outcome, family empowerment, was measured at T1–T3 using the Japanese version of the family empowerment scale (FES) . This 34The secondary outcomes were caregiver burden, awareness of using social resources, self-compassion, and the QOL of primary caregivers. Caregiver burden was measured at T1–T3 using the short form of the Japanese version of the Zarit Caregiver Burden Interview (J-ZBI-8) . The ZBIFurthermore, two new sleep-related items, found in previous research  to assesBased on previous research  and discSelf-compassion was measured at T1–T3 using the short form of the Japanese version of the self-compassion scale (SCS) . The 12-Primary caregivers' QOL was measured at T1–T3 using the Short Form-8 (SF-8) , an eighAdditionally, data on the following participant attributes were collected at T1: relationship with the child, age (in 10-year increments), marital status, cohabitation with partner, highest education level, occupation, annual household income, and cohabitant family members. The child's attributes assessed at T1 were as follows: gender, age, diagnosis, age at diagnosis, school enrollment status, disability status, and care required. At T2 and T3, any changes in the information provided were to be reported in detail. To avoid forcing participants to respond, a “no response” option was provided, allowing them to proceed without responding.Furthermore, for program evaluation, the surveys were taken immediately after taking the program and 1 month later to assess participants' feelings toward the program. This was to find out whether they had told their family members about its content or learnings, whether they would recommend the program to friends, how the program should be propagated, and recommendations about its dates and length, and additional space was provided to record any other responses.The primary outcome was FES total score at T2. The secondary outcomes were improvement in the family empowerment subdomains , aspects the program worked on directly , and the comprehensive effects of the program . The persistence of the intervention effect at T2 (each outcome at T3 in the intervention/early group) and its reproducibility observed in the intervention/early group (each outcome at T3 in the waitlist-controlled group) were also validated.t-test, Mann–Whitney's U test, or Fisher's exact test. The attributes and outcome scores at T1 were compared only for participants with valid responses for the FES total score at T2.Responses with which outcome scores could be calculated were considered valid responses. Data from participants deviating from study protocols, such as being absent for sessions, were used in the originally allocated groups for intention-to-treat (ITT) analysis. First, descriptive statistics were calculated for participants and their children's attributes, with outcome scores at T1. Mean and standard deviation were calculated for interval scales, and frequency and proportion were calculated for ordinal and nominal scales. The groups were compared using Welch's In the primary analysis, we used the FES total score at T1 as the covariate and compared the groups using analysis for covariance (ANCOVA), with the FES total score at T2 as the dependent variable. As a premise for ANCOVA, we confirmed there was no significant interaction between the independent variable (intervention/early or waitlist-controlled group) and the covariate . In case of a significant interaction, the groups were compared using ANOVA without considering the score at T1. The level of statistical significance was set at 5%. Subgroup analyses were performed on children with severe motor and intellectual disabilities, children depending on medical care, and single parents. The point estimate and 95% confidence interval of the intervention effect in each subgroup were compared to zero and the clinically meaningful change (CMC) score. Furthermore, we examined whether the increase in the FES total score from T1 to T2 was clinically significant. The CMC for FES was not computed. Based on a review  suggestiU test. A paired t-test was used to examine the sustainability of the intervention effect at T2, by comparing T1 and T3 scores of the intervention/early group. A paired t-test was used to assess the intervention effect's reproducibility in the intervention/early group in the waitlist-controlled group by comparing the T2 and T3 scores of the latter.For secondary results, the outcomes at T2 were compared in the same way through ANCOVA or ANOVA. Outcomes from ordinal scales were compared using the Mann–Whitney We performed a sensitivity reanalysis on our primary analysis in which the change in the FES total score for those who dropped out between T1 and T2 was zero. A per-protocol analysis was performed on participants who attended all four sessions (group) and the other participants (group). Attributes with differences between the groups at T1 were treated as covariates in ANCOVA, and subgroup analyses were also performed.n = 29) or the waitlist-controlled group (n = 30)  . Those wWe did not compare background attributes and outcome scores at T1 between respondents and non-respondents, as only a few participants dropped out of the study. Imputation of missing values was not performed for the analysis. Almost all participants were mothers, in their 40s, had higher education, and lived with a spouse or partner. Their employment status and incomes varied, but there were no other significant differences between the groups . ConcernAbout 70% of the children were boys between the ages of 2–20 years. The waitlist-controlled group was significantly older. The age at diagnosis ranged from prenatal to 15 years, with diagnoses including chromosomal abnormality, autism spectrum disorder, Down's syndrome, psychomotor retardation, intellectual disabilities, higher-order brain dysfunction, epilepsy, and cerebral palsy, among others. The intervention group had many children with motor function difficulties and a significant majority had severe motor and intellectual disabilities. There was no difference in the score of “Severe Motor and Intellectual Disabilities-severe Medical Care Dependent Group” . CWD of parents in both groups received similar levels of varied medical and non-medical care  .The outcome scores at T1 were not significantly different between the groups . Figure Regarding the secondary outcomes, the FES subscale scores for FA and SS were significantly higher in the intervention group . Our proThe FES  and SCS-SF  scores were the outcomes that changed significantly from T1 to T2 in the intervention group. Except for the common humanity subdomain, changes in all the outcomes were sustained until T3 in the intervention group. Furthermore, FES SP and SCS negative scores and over-identification changed significantly from T1 to T3 . The effOf those outcomes, the significant changes in the FES total, FA, and SCS total scores could be reproduced from T2 to T3 in the waitlist-controlled group .Most participants rated the program positively. The intervention group members who responded with “not very good” at T3 stated that they were already experiencing emotional distress and that they found attending the weekly sessions exhausting, causing them to feel depressed. More than 80% of the participants told their families about the program's content—most during the program (until T2) and some during the first month after the program ended (between T2 and T3). Most said they would recommend the program to their friends. Common reasons for not recommending were lack of friends; difficulty in using the online system, Zoom; the belief that people would not be interested in family empowerment; and the prior existence of a support system. While many participants suggested making the program available to people who want it, some suggested establishing a system that everyone could participate in, as an effective way of reaching those unable to obtain information on their own.Some participants reported wanting to attend before their child started school; others said people should be able to attend based on their preference. Several participants suggested that groups should have wide age ranges. None of the participants felt that the number of sessions should be reduced .Most participants in our study were mothers. In many families, mothers are the primary caregivers for CWD. In cases of needing much medical care with severe disabilities, mothers commit their time mainly to childcare and housework and do not hold formal jobs –36, a reIt is notable that our program had few dropouts. Mechanisms to prevent participant dropout during programs are needed. Measures to encourage participation included aligning program goals with participants' motivations, facilitating accessibility by offering flexible hours and locations, and providing opportunities for exchanging opinions in a group . In anotAfter the program, the intervention group's FES FA and SS scores increased, possibly due to participants' improved understanding of how they can collaborate with their families, with service providers, and practice problem-solving techniques. This was our intention behind designing this family empowerment program. Strategies for boosting access to information, counseling, and community support services are likely to empower families and optimize their health and well-being . These fHowever, the FES SP score did not increase significantly. SP is composed of the initials Social/Political. It is one of the three aspects of FES, meaning “involvement with the community”.Previous studies confirmed floor effects in several SP items, especially in Japanese suburbs . Unlike In our study, the intervention group's care burden lessened. Studies have reported a negative correlation between parental stress and family empowerment . CaregivConversely, there was no effect on the awareness of social resource utilization, possibly because our focus was on participants' awareness of their use of services rather than the types of services being used. It is difficult for caregiver families to search for and find appropriate social resources to meet their requirements and use social welfare systems , 43. TheWe found that the self-compassion of participants improved, especially in the isolation and over-identification domains. Caring for a child with a disability creates physical, psychological, and social stress as well as feelings of self-reproach and low self-efficacy , 44. CarThe effects on FES FA and SS and isolation persisted even after the program ended. While the impact of intervention programs is limited to the intervention period , this stWe demonstrated that a program developed using the evidence-based methods of the IM approach and BCTs, based on theoretical foundations of previous studies, can improve family empowerment. Due to COVID-19, medical and welfare services that support CWD have been shifted online , 46, andFor caregivers of CWD, using the online platform eliminated the barrier of traveling to another location. We could take advantage of the benefits of online meetings to demonstrate the program's effectiveness.As participation was voluntary, only caregivers with an active interest in participating in online programs may have been included. However, this program was intended for all caregivers. The generalizability of the program's effectiveness could be enhanced by including people who are not Internet savvy, are reluctant to participate in such programs, or lack the resources to participate.The questionnaires were self-administered. Although it provided subjective assessments, changes in participants' situations also need to be understood objectively. In future studies, we intend to conduct third-party surveys through other family members and service providers to obtain a multifaceted assessment of our program.The subgroup analyses had small sample sizes that were insufficient for examining associations among multiple attributes and their impact on the program's effects. While continuing its implementation, further investigation of the effects of people's attributes on their participation in the program is needed.In this study, using the IM approach and BCTs, we deployed an online peer support program to promote behavioral change and empower families raising CWD all over Japan, and tested its effectiveness.After the completion of the program, participants' family empowerment increased, especially for family coordination and service utilization. Backgrounds of the increase were self-compassion improvement and easing their care burden. The program's effect on family empowerment and self-compassion was sustained even after 1 month of the program. Results demonstrated the program's effectiveness in promoting family empowerment; hence, full-scale social implementation of the program in the future can be expected.However, the program had no effect on recognizing the use of social resources, which is an important element that contributes to care burden reduction and family empowerment. Thus, the program content should be examined with a focus on this element.Our online program may have promoted the ease of participation for caregivers of CWD who find traveling difficult, by allowing them to attend the program regardless of region or type of disability and facilitated the expansion of their care network. However, the challenge ahead lies in achieving full-scale social implementation of this program, accumulating and generalizing the effects, and performing a multifaceted evaluation of the program and its effects.