Purpose: Parkinson’s disease (PD) is associated with motor and non-motor symptoms that negatively influence the person’s quality of life. To reduce illness and increase quality of life, alternative treatments of PD such as dance might be experienced as beneficial. The aim of this study was to explore experiences of how a dance program in Sweden influences perceived physical, social, and emotional wellbeing in persons with PD.Method: A qualitative method with semi-structured interviews and content analysis was used, and 10 participants with variations in age, gender, and how long they had been diagnosed with the disease were interviewed.Results: The results showed that dancing was experienced as improving health, which implied feeling both calmed and excited, getting better sleep, and being able to move with more focus and freedom. The dance program was experienced as a social context through the importance of community, feelings of togetherness, and being able to compare oneself with others. Experiences of self-support included experiencing increased self-esteem and joy, but also a sense of being confirmed and having structure, which gave meaning to everyday life.Conclusions: To reduce illness and increase quality of life in persons with PD, it is important to investigate alternative treatment methods, and this study shows the importance of participating in a dance program in Sweden for the life situation and health of people with PD. Approximately 18,000–20,000 persons mostly aged over 65 in Sweden are estimated to have Parkinson’s disease (PD)  have similarly reported sensorimotor consequences such as improvements in movement quality .This was a qualitative study with an inductive approach using semi-structured interviews.The dance program took place at a dance studio, a place that does not have connotations of rehabilitation or exercise. The dance program was based on the concept of “Dance for Parkinson”. The sessions were held on the same day every week for 12 weeks, and each session lasted 90 minutes and usually had 10–15 participants per session. The dance program was led by a dance leader with a solid background in performing art and who had been educated in the concept of “Dance for Parkinson” ”, “What made you start with the dance program”, “If you think about how your life looked before you started dancing, what significance has dancing had for you”, “Can you describe how dancing affects your attitude”, and “How do you see your future regarding dancing”. Follow-up questions were asked as needed for further probing and for clarification “They also felt that they were getting more energy and that they were becoming more spirited. The music was a contributing factor that could feel encouraging.The music is very encouraging … It is very uplifting.” (Interview 9)“Positive psychological effects were expressed as a better night’s sleep after the dance program.“And it’s nice because you sleep better at night too.” (Interview 1)PD negatively influenced the participants’ health, and the dance program gave a sense of liberation when they had a moment to think and focus on something else besides their disease. They perceived that they could shift their focus from themselves and their illness to instead listening to and following the music and the dance leader. Following the movements and focusing on them instead of their disease gave a sense of liberation and an insight that it was not so hard to move as expected. Thinking about something else also led to increased certainty about the movement pattern.“You concentrate on one thing, and you focus on following the music and the movements. Everything else disappears.” (Interview 4)“You are free from the notion that it’s hard to move, because that´s how it feels.” (Interview 5)To experience community and togetherness and Being able to compare yourself with others.Meeting others living with PD created a sense of context for the participants and gave them the feeling that they could be themselves. It was also experienced as an opportunity to jointly find a relationship based on more than just a common disease. The sub-categories were The social community was something that permeated all of the interviews. It meant a lot for the participants who felt that the activity had an accepting climate and that it was positive to get out and meet people. Being able to meet others with the same illness meant that they could be themselves and could feel connected with others without thinking about the symptoms of PD as much. The sense of community also made the participants feel empowered to struggle a little more.“When you think this was nice, this was fine, and that … Yes, a community. Everyone, that we know each other more or less now, oh, so that, oh, that’s positive.“ (Interview 3)“But here it doesn’t matter. Here we all are … everyone is the same. You can be yourself.“ (Interview 8)The community was also a factor that encouraged the participants to attend the dance program every week. They felt that it was important to get away from home and that it felt nice that there was someone who cared and someone who asked how they were.“Then it´s very nice to get some stimuli, to follow others. It’s not as fun to sit by yourself and make these moves, it’s the company that does it.” (Interview 1)It was considered a relief to meet others with the same disease in order to be able to compare situations. The participants saw those who were worse off and gained an understanding of their own illness and a sense of gratitude for their own situation. At the same time, there could be a fear of meeting others who were worse off because this might give an indication as to how the disease might affect them in the future. However, this fear disappeared in the meeting with the other participants because it became clear that there were those who had both worse and better situations.“Yes, but since I’m so healthy I just got depressed by seeing how I would progress. When I went here to dance, I felt that it was a relief because there are both those who have it worse, who are worse than me, and those who feel better.” (Interview 5)“But it’s good to meet others as I said. Eh, partly because you get an idea of what’s going to happen next … and partly it’s good to get an explanation for other people’s behaviour.” (Interview 9)To experience increased self-esteem, To feel joy, To feel confirmed, and Getting structured.The participants felt that it was important for them to go to the dance program regardless of their daily condition because the activity gave them more than just physical satisfaction—it created a sense of being needed and of being valued. The sub-categories were “Then you’ve thought, ‘I’m doing really well today’. Then you become satisfied with yourself.” (Interview 6)The participants expressed how they had experienced increased self-esteem from the dance program. They felt that they could manage more than they had expected to and that it was a positive feeling to be able to challenge themselves and to be content with their own body. Many participants reported that dancing made a positive change in how they perceived themselves and how they began to think that the disease is not a disease that kills and that it was good to make the most of the situation.“And you can see that this is a good thing, that it still has an impact both on the mood … on the mood and physically.” (Interview 5)“But I think the dancing, it’s like a lift and you feel purely euphoric when you leave, in a good mood.” (Interview 4)Despite differences in the course of illness and functional level, the dance program contributed to increased health in all participants. Many experienced that it was nice and positive to move to music and that it had a positive impact on their mood and that it was nice to feel that it was possible to participate without the demands for achievement despite various opportunities to perform. The participants also experienced a positive sense of coping with more than they thought they could.“You feel good when you are there anyway. You look more positive when you leave. More positive in some way.” (Interview 10)The dance program was described as positive. It provided joy and well-being both before, during, and after the activity, and several participants expressed satisfaction in the feeling they had done something.“I feel better about the dance and the music. I do. Because it’s the combination I think, I just think the dance and the movements without music, so I would not have felt the same.” (Interview 4)The combination of dance and music was significant and contributed to prosperity, joy, positivity, and the creation of a community.“Yes, I feel it’s fun to go there. I look forward to it every time.” (Interview 10)The participants experienced the dance program as meaningful, and it was clear that they looked forward to it because it had positive effects and gave them a sense of satisfaction.“He (the dance leader) sees us, we are different, but it feels very positive when I get there, I think.” (Interview 10)The participants thought the dance program created an open climate where they felt confirmed by the other participants as well as the dance leader, and they experienced a sense of being seen that contributed to their sense of well-being. It also gave a sense of confirmation that the dance leader knew everyone’s name. To see that a person is participating even while sitting in a wheelchair shows the acceptance and accessibility that the dancing contributed to.“It’s nice to have something on a regular basis.” (Interview 9)The participants felt that it was important to have dance activities once a week in order to create a sense of security in the familiar meeting with other people. They also expressed that the dance program helped them come out and meet like-minded people, and it felt important to have something that made them leave their homes.We found that people felt physically better after participating in the dance program, and the effect could last for up to several days. Our participants expressed a shift in focus from their illness to instead following the music and the dance leader, which was experienced as a relief and led to feelings of increased safety and improved mobility. This is in line with another qualitative study reporting that persons with PD experienced that music with a rhythmic beat enabled them to manage so-called “freezing of gait” episodes, and hearing footsteps while dancing facilitated them in feeling safer and moving more easily (Rocha et al., Participating in a dance program creates a strong sense of community for persons with PD. This Swedish study showed the importance of meeting others with PD and how this gives a feeling of togetherness and at the same time an opportunity to compare oneself with others, as also demonstrated by Kang and Ellis-Hill . The parParticipating in a Swedish dance program increased self-support in persons with PD. Our results showed that dancing contributed to improved self-esteem, and activation of the body created a positive impact on the emotional difficulties that the disease implied. Improved self-esteem when dancing could be interpreted by the tide model, which argues that life conditions affect mental health and that it is important to use the person’s own resources to implement changes. Supporting the person to use their own resources increases their sense of self-esteem Barker, . This stA qualitative method was used because such a method focuses on interpretations of the text and is commonly used in healthcare research (Lundman & Hällgren-Graneheim, Some interviews were short, which may have been influenced by the symptom from PD and its effects on cognitive functions. The participants repeatedly expressed difficulties in articulating themselves and in responding to questions about their emotions and mood. They also expressed difficulty in understanding the questions, and the questions could therefore have been reformed with more focus on emotions and experiences. However, a final question was asked to catch if there was anything that the participant experienced that we did not cover or that they would like to add. The participants had varied disease symptoms, which meant that there were those who wanted to bring somebody with them to the interviews, either as support or to clarify what was said. The choice to include the participants who needed some kind of assistance was made due to the fact that it felt important to include their opinions as well. The data processing took place by the two first authors and was validated with the third author to ensure the quality of the study and to gain a deeper understanding of the content.This study showed that persons with PD experienced improved health by participating in the Swedish dance program. The dance program had positive physical and psychosocial effects through an increased sense of togetherness and community with the other participants. The participants also experienced increased self-esteem and happiness by having the chance to activate their body, and this contributed to their improved mood. The results regarding the impact of dancing on the health of persons with PD might lead to better allocation of resources in order to offer alternative treatment methods for health promotion purposes. The results of this study and similar studies need to reach the healthcare professions through education and information in order to offer persons with PD the opportunity to participate in dance activities in Sweden and thus be able to share in the positive effects that such activities provide. It is important to further investigate alternative treatment methods in PD to increase health and quality of life.


Migrant communities are often under-served by mental health services. Lack of community engagement results in missed opportunities for mental health promotion and early intervention, delayed care, and high rates of untreated psychological distress. Bilingual clinicians and others who work with these communities lack linguistically and culturally appropriate resources. This article reports on the implementation and evaluation of a community-based group mindfulness program delivered to Arabic and Bangla-speaking communities in Sydney, Australia, including modifications made to the content and format in response to the COVID-19 pandemic. The program was positioned within a stepped-care model for primary mental health care and adopted a collaborative regional approach. In addition to improved mental health outcomes for face-to-face and online program participants, we have documented numerous referrals to specialist services and extensive diffusion of mindfulness skills, mostly to family members, within each community. Community partnerships were critical to community engagement. Training workshops to build the skills of the bilingual health and community workforce increased the program’s reach. In immigrant nations such as Australia, mainstream mental health promotion must be complemented by activities that target specific population groups. Scaled up, and with appropriate adaptation, the group mindfulness program offers a low-intensity in-language intervention for under-served communities. The increasing number of international migrants and refugees worldwide presents a challenge for the delivery of health services and health promotion programs in destination countries. In 2020, there were 281 million international migrants . At the In 2016, multicultural Australia was home to people with more than 300 different ancestries and speaking over 300 different languages . Such diMental health is a state of wellbeing whereby individuals recognise their abilities, are able to cope with normal stresses of life, work productively and fruitfully and contribute to their communities . MigrantAustralia has long been a leader in mental health policy and service development, with a strategy of ongoing national reform . The NatIn the Fifth National Mental Health and Suicide Prevention Plan 2017-22, all Australian governments committed to working together to achieve integration in planning and service delivery at a regional level ,19. As sThe stepped care model for primary mental health care is summarised in The CALD Mindfulness Program is an ongoing program of research involving the development, implementation, and evaluation of mindfulness-based interventions (MBIs) tailored for migrant and refugee communities. MBIs, such as mindfulness-based stress reduction, can significantly alleviate depression, anxiety and stress and improve physical and psychological functioning ,23. The The Arabic Mindfulness compact disc (CD) is a cultural adaptation of a resource produced by Dr Russ Harris, whose self-help books and CDs are very popular in Australia. The educational CD is 60 min in duration and contains five tracks . During Subsequently, the Central and Eastern Sydney Primary Health Network (CESPHN), commissioned the SESLHD Multicultural Health Service to deliver the group mindfulness program to CALD communities in their region. Within the stepped care model, the program corresponds to Step 3 . The objectives were to deliver the program to Arabic speakers and Bangla speakers in the CESPHN region in order to reduce psychological distress, depression, anxiety, and stress; to provide in-language resources to support the program; and to train bilingual mental health clinicians and community workers in MBIs. The third study aimed to establish whether the group mindfulness program produced expected outcomes under normal operational conditions and to test its transferability to a second language group (Bangla) and scalability . The proIn March 2020, following the outbreak of COVID-19, health services ceased all face-to-face groups. Program resources were initially adapted to support the Arabic-speaking community through regular text messages that encouraged mindfulness practice at a time of changing and challenging circumstances. Additionally, the clinical lead  recorded a short video introducing mindfulness concepts and linking to the existing audio resources, which was disseminated through social media and community networks. The group program (Arabic and Bangla) was adapted for online delivery via videoconferencing (four sessions with a focus on stress management). It was also offered as a one-off refresher session for previous participants and as an open one-off session for new participants. Since December 2019, the mindfulness audio resources in Arabic, Bangla and English have been publicly available on the NSW Multicultural Health Communication Service website . ResourcThis article reports new findings from research with the two language groups that have been the focus of the CALD Mindfulness program to date (Arabic and Bangla), including online group outcomes, referrals to other mental health supports, diffusion through social networks, and in-language resource downloads. Additionally, it presents findings from a follow-up evaluation of the workforce capacity-building component of the broader project and interviews with community partners.Central and Eastern Sydney Primary Health Network (CESPHN) is the second largest of the 31 Primary Health Networks across Australia, with a resident population of approximately 1.6 million. The region is characterised by cultural diversity, with 40% of residents born overseas, 38% speaking a language other than English at home, and 6.9% not speaking English well or at all . There iArabic speakers have a significant cultural presence in Australia and in Central and south eastern Sydney where this work took place ,29. BangThe 4-week online program, introduced in response to the COVID-19 pandemic, was a modification of the 5-week face-to-face group mindfulness program described elsewhere ,26. Box Box 1Group session 1: Introduction and DebriefingAim: To discuss signs of stress and vulnerabilities experienced by participants, identify helpful and unhelpful stress responses and provide a set of motivating and practical stress management skills.Video: Mindfulness in Challenging Times.Mindfulness practice: Grounding exercise with sensory awareness.Mnemonic: HOPEFUL + L, a set of cognitive and practical tips to stay afloat during stressful times.Group session 2: Stress Experiences and Responses, MindfulnessAim: To educate participants about stress from an evolutionary perspective, introduce mindfulness concepts and explore their cultural and spiritual applicability, and provide a set of mindfulness stress management skills.Mindfulness practice: Mindfulness breathing exercise.Mnemonic: Five ‘A’s of mindfulness—awareness, acknowledgement, actions, acceptance and appreciation.Group session 3: Mindfulness Based Stress Reduction StrategiesAim: To promote participants’ awareness of the interconnectedness of thoughts, feelings and behaviours, differentiate themselves from their thoughts, introduce mindfulness-based stress management skills.Mindfulness practice: Leaves on a stream exercise, Body scan exercise.Mnemonic: BE PRESENT, a set of mindfulness-based stress management skills and practices to help reduce distress.Group Session 4: Loving Kindness and Self-Compassion, ReviewAim: To define sense of self, emphasise self-care practices through loving kindness and self-compassion and review stress management skills learnt throughout the program. To reflect and recap topics and discussions from previous sessions.Mindfulness practice: Loving kindness and self-compassion exercise.Mnemonic: REFLECTION, a program summary.Originally derived from Buddhist practices, mindfulness has become a popular evidence-based tool for managing mental health problems in Western countries. Mindfulness is often taught through a variety of meditation exercises and MBIs usually incorporate meditation practice together with various cognitive and/or behavioural techniques . The groThe first of the four online sessions was primarily designed to create an emotionally safe space for group participants to share and normalise their experiences in the context of the COVID-19 pandemic. In particular, guided discussion in the online session assisted participants in recognising helpful and unhelpful strategies they had been applying in managing pandemic-related stressors . Both programs were facilitated by a bilingual mental health clinician (psychologist) with support from a bilingual community worker.Community partners were responsible for taking registrations, keeping attendance lists and general organisation. For the online program, only women were recruited due to high demand and gender sensitivity. Referrals for further mental health care were managed in various ways. Linguistic and cultural needs and preferences and financial and personal circumstances were taken into consideration as well as clinical needs. All participants who scored 30 or above on the K10  or as ‘severe’ or ‘extremely severe’ on the DASS21 were contacted by the clinical lead ,36. If tSince the Arabic Mindfulness CD , a suiteAudio resources ) were provided to group participants to assist with their ongoing mindfulness practice and later uploaded to the MHCS website. Individuals are able to use them as a self-help resource by downloading the tracks and completing the mindfulness exercises in their own time. Short videos, ‘Mindfulness in Challenging Times’, were produced to support community members during the COVID-19 lockdown. They also introduce the CALD Mindfulness Program.Workforce capacity building was designed to increase the reach of the CALD Mindfulness Program, with free training offered to bilingual mental health professionals, community workers and others interested in facilitating future mindfulness groups. The full-day workshop was divided into four sections: introduction to mindfulness and background to the CALD Mindfulness Program; stress management and the observing self; loving kindness and self-compassion; and managing painful emotions. Training materials included a copy of the CALD Mindfulness Program Participant Handbook, handouts, and scripts for six mindfulness exercises .Methods and tools used to evaluate the face-to-face group program have been published previously ,26. A siWhile the face-to-face program utilised two translated and validated mental health outcome measures (DASS21 and K10+), the online program employed only the K10+ to reduce the evaluation burden on participants. In addition to a global measure of psychological distress (K10), the K10+ includes four questions asking about the individual’s ability to work and carry out day-to-day activities, the number of times the person has seen a doctor or other health professional due to mental health issues, and how often physical health problems have been the main cause of these issues . All othAnalyses were conducted separately for Arabic and Bangla speakers. Sociodemographic and attendance data for the online groups were summarised using descriptive statistics. Pre- and post-measures of mental health were compared using the nonparametric sign test for paired samples (two-sided) as the data were not normally distributed, using SPSS v27 . The nulReferrals were counted for all face-to-face and online group programs held between March 2017 and September 2021. We distinguished between referrals made for the participant themselves  and referrals made for a family member . Destination of referral was classified as ‘private psychologist’, ‘General Practitioner (GP) for referral’, ‘family therapist’ or ‘other’ . Destination percentages were calculated after excluding those already receiving mental health care. Referrals that involved reconnection with a previous service provider were noted. Specific needs for referral (beyond anxiety or depression symptoms) were noted also.p value of 0.5. Further, we estimated extent of spread from the number of recipients/beneficiaries reported with each relationship category. To manage this, if a participant indicated a single person from a particular category  we counted one. If a participant indicated more than one person from a particular category  we counted two, although in practice it could have been more. The resulting totals were, therefore, conservative.We counted the number of participants who reported sharing the mindfulness skills and examined both the pattern and extent of spread. We classified reported recipients/beneficiaries according to the following categories: ‘any family’, ‘family unspecified’, ‘immediate family’ , ‘extended family’, ‘friend’ and ’other’. We also coded sharing with a ‘person overseas’ when it was reported. We then counted the number of participants who shared the skills across the various categories. We used the chi-square statistic to examine if language group (Arabic vs. Bangla), delivery format (face-to-face vs. online), gender  or age group (16–35 years vs. 36 years and over) were associated with skills transfer (not shared vs. shared); adopting a Unfortunately, we did not keep a complete record of the number of Arabic Mindfulness CDs distributed to program participants and, more widely, on request and through community events . USBs were produced in Arabic (60), Bangla (60) and English (20). We counted the number of downloads of the online audio resources from 1 July to 31 December 2021 and video views on the SESLHD YouTube website since June 2020.The training was evaluated through feedback forms distributed at the end of the workshops and an online follow-up survey. The feedback forms focussed on training content and delivery (process). The survey asked about key learnings and application of the learnings (outcomes and impact). Both were anonymous.The feedback form contained 13 statements to which trainees were invited to show their level of agreement using a 5-point Likert Scale (‘strongly disagree’ to ‘strongly agree’), followed by two open-ended questions asking what they like most and what could be improved. In October 2019, people who had attended any of the first six workshops (delivered between August 2017 and May 2018) were invited by email to complete a questionnaire created on Survey Monkey. The survey contained nine questions with a mix of pre-coded and open-ended responses. Questions 1–5 covered gender, language spoken, role, primary work setting and date of training. Questions 6–7 asked about key learnings and applying the learnings. Question 8 asked how much impact the training had on their practice using a 5-point Likert Scale (‘no impact’ to ‘high impact’). Likert Scale responses and answers to the pre-coded questions were tabulated (frequencies and percentages) in Microsoft Excel. Responses to the open-ended questions were systematically coded and tabulated by Ilse Blignault (IB).We sought a better understanding of the role of community partners in supporting program rollout and reach through a series of interviews with facilitators, co-facilitators, and community workers. Individuals who had been involved in one or more face-to-face or online programs in the last two years were invited to take part in a 30-min semi-structured telephone interview conducted by a project officer recruited for this purpose. The interview guide contained 12 open-ended questions, two of which asked: “As an employee of [partner organisation], how do you think your contribution has supported the delivery and influenced the program outcomes?” “What were some of the challenges encountered as a partner organisation?” The interviews were not recorded; however, the project officer took extensive notes that informants were given the opportunity to review. Responses to the two questions were closely examined by HS to identify common experiences and issues, and the emergent findings reviewed at a research team meeting  and project officer).Between March 2017 and September 2021, 43 in-language group programs were facilitated across the region: 37 face-to-face and 5 online. They attracted a total of 489 participants, 397 of whom completed the program. Additionally, ten one-off online stress management sessions were conducted in Arabic and Bangla (results not reported here).Forty-four Arabic and Bangla-speaking women aged 16 years and over enrolled in the online program and 35 (73% of Arabic speakers and 94% of Bangla speakers) completed it. The five groups ranged in size from 7 to 11 people.Of the 26 Arabic-speaking women recruited, most were aged 26 to 55 years. All but two were born overseas, mostly in Lebanon, Syria, or Iraq, and all but three were Muslim. Thirteen had lived in Australia for under nine years. Seventeen spoke mainly Arabic at home, the rest Arabic and English. Eighteen possessed a post-school qualification, either trade or university. Pre-intervention, 20 scored as ‘moderate’ (25–29) or ‘severe’ (30–50) on the K10. All 19 women who completed the program attended at least three of the four sessions. Reasons for dropping out included health and family issues. Lack of access to technology and unreliable internet also affected participation.Of the 18 Bangla-speaking women recruited, we have pre-program data for only 17. Most fell into the 26–35 age group. All but one were born in Bangladesh and all were Muslim; eleven had lived in Australia for under nine years. Twelve spoke mainly Bangla at home, the rest Bangla and English. All possessed a university qualification. Pre-intervention, 11 scored as ‘moderate’ or ‘severe’ on the K10. All 17 women who completed the program attended at least three sessions. One woman dropped out for work reasons.p < 0.001) (p < 0.01)  . For Ara < 0.01) .All program completers reported that their experience of the program was positive. Across both language groups, 85% indicated that the effect on their overall wellbeing was ‘very good’ or ‘excellent’ and 97% rated their experience of the program as ‘very good’ or ‘excellent’. Box 2Online group 3, Arabic“I am aware of my thoughts and able to let go.”“My son is doing his [final exams] and I learnt to manage my anxiety so I don’t impact him.”Online group 4, Arabic“I am very happy to have found this program in my language and culture. I am able to better understand and relate to the topics.”Online group 5, Bangla“I used to live in the past I now live in the moment and I enjoy it.”“I have learnt a lot and I am applying them in my daily life.”“This is very much needed in our community.”Online group 6, Arabic“I saw a psychologist but never benefitted like this, despite this is being virtual.”Across the face-to-face and online programs combined, 302 Arabic and 187 Bangla speakers were recruited, including 444 women and 45 men. The Bangla participants tended to be younger than the Arabic speakers, most of whom were aged 36–55 years with a sizeable number aged 56–55 years. They had also spent less time in Australia on average (Bangla 8.6 years vs. Arabic 20.3 years).2 .At program commencement, 8.7% of face-to-face and 15.9% of online program participants were already receiving mental health care. In both delivery formats, Arabic speakers were more likely than Bangla speakers to be receiving such care . The ove2  = 8.79, p < 0.01). Over three-quarters (78.3%) of all referrals were to a private psychologist due to language needs. Four participants were reconnected with a service provider whom they had previously seen, usually a private psychologist. Six were referred to a family therapist  and four were referred to their GP to obtain a psychiatrist/psychologist referral. Sixteen were referred elsewhere: to a general health, social service, or community organisation  of program completers reported sharing with a family member . A minor2  = 24.02, p < 0.001); while Arabic speakers were more likely to share with their child, 37.0% vs. 15.9%, X2  = 19.80, p < 0.001). Similarly, younger participants (16–35 years) were significantly more likely than older participants (36+ years) to share with their spouse, 44.4% vs. 25.2%,  = 13.04, p < 0.001); while older participants were more likely to share with their child, 39.7% vs. 10.4%, X2  = 37.57, p < 0.001).The percentage of participants who reported sharing their new skills did not differ significantly by language (93.8% Arabic vs. 97.4% Bangla), group format (95.0% face-to-face vs. 97.1% online), gender  or age group (96% 16–35 years vs. 94.7% 36+ years). However, Bangla speakers were significantly more likely than Arabic speakers to share with their spouse, 47.0% vs. 22.9%, XThe web-based in-language audio and video mindfulness resources expanded the CALD Mindfulness Program’s reach within Australia and internationally. Since June 2020, the ‘Mindfulness in Challenging Times’ video in Arabic has received 2837 views and the English video 1275 views. Since October 2020, the Bangla video has received 1006 views.Between August 2017 and December 2019, seven full-day workshops were offered across the region, attracting a total of 83 participants, including a few from outside the region connected through professional networks. Another workshop was run in June 2021 with 15 participants (results not included below).The great majority (88.0%) of trainees were women; 45.8% were bilingual community workers and 35.0% were bilingual mental health professionals, mostly psychologists and social workers. Arabic (49.4%) and Bangla (24.1%) were the most commonly spoken community languages. Other trainees spoke Cantonese, Greek, Hindi, Indonesian, Macedonian, Mandarin, Nepali, Russian, Sinhala, Spanish, Tamil, or Urdu. Eighty-two (99%) of the trainees provided post-workshop feedback, all of whom found the training engaging and the content both practical and relevant.Seventy-one of the trainees from the first six workshops were emailed the follow-up survey, the others being uncontactable. Forty-five (63%) responded. Comparison on gender, role and language spoken suggested that the follow-up sample was reasonably representative of everyone trained. Key learnings related to core mindfulness concepts and techniques and how cultural and religious tailoring of MBIs enhances acceptability to CALD communities. Nearly three-quarters (73%) of respondents indicated that they had applied mindfulness skills for self-care. Both bilingual mental health professionals and bilingual community workers had facilitated mindfulness groups, with 19 (42%) facilitating at least two groups. They incorporated mindfulness into their clinical/counselling sessions and community wellbeing programs, and as an adjunct to mental health care and other interventions. All indicated at least ‘moderate impact’ on their practice and 60% ‘significant impact’ or ‘high impact’.We identified 17 people who met the eligibility criteria from the 15 community partners and were able to interview all but one: 10 from the Arabic speaking community, 4 from the Bangla speaking community, and 2 English-speakers who were employed by a community partner . Twelve were community organisation staff while the other four, including two psychologists, worked independently. Thirteen of the informants had attended the 1-day training on MBIs for CALD communities.All community partners reported that they were kept busy before, during and after the program, with completion of tasks often taking longer than expected. Being aligned with the organisation’s operational plan and having committed and supportive management and dedicated staff  and resources  were important enablers of success. During the program, depending on their role, the community partners facilitated, co-facilitated, or provided support to the group by encouraging participants to ask questions, contributing to the group discussion, and helping to explain the presented concepts using culturally and religiously appropriate anecdotes. The presence of a familiar face also made participants feel comfortable. The bilingual community workers provided assistance with completing the evaluation measures in the first and final sessions when required, and technical support for the online groups.Common recruitment challenges experienced by the partners included promoting and explaining mindfulness, which was a novel concept for most people, mental health stigma and geographic restrictions under the funding agreement. Recruiting homogeneous groups  presented an additional challenge. It took time to educate and reassure community members who were hesitant to discuss mental health-related issues outside their family by emphasising group confidentiality. Once the program was established, word-of-mouth proved to be the most effective means of promotion and limiting the number of participants in the group was sometimes a problem. Adhering to the program’s geographical boundaries resulted in difficult conversations for community partners and led to feelings of abandonment and marginalisation among community members who lived outside the CESPHN region. All activities took time. Maintaining weekly contact between sessions to keep participants motivated and follow-up calls to gauge their experience with the program and its impact on their day-to-day lives could involve several phone calls. Helping participants to complete relevant paperwork and supporting online participants with technical issues added an extra burden on under-resourced and already stretched individuals and community organisations.It was apparent that relationships were fundamental to successful community engagement and program outcomes. ‘Trust’ was mentioned repeatedly, e.g., “Having an established relationship with the community and having their trust [in] providing beneficial programs” and “Participants trusted the facilitator and felt more comfortable to seek support following the program”. Community partners commented on the professionalism and expertise of the clinician facilitators from the same cultural and linguistic background and their skill in tailoring the program to make the content relevant and accessible, with consideration of each group’s unique needs (often conveyed by partner organisation to facilitator).The population health framework underpinning Australian mental health policy and practice recognises that there are a complex range of determinants and consequences of mental health and illness across diverse population groups . MainstrAchieving high-levels of recruitment, retention, and adherence to protocol in community-based interventions is challenging for mainstream health services, particularly when dealing with marginalised populations . Trauma-Australia’s multicultural health and community workforce is an important national resource. By training 98 bilingual mental health professionals and community workers in MBIs and cultural tailoring, the CALD Mindfulness Program has strengthened individual, organisational and community capacity to respond to mental health issues in CALD communities in the CESPHN region. In the follow-up survey, 63% of respondents indicated that the training had positively influenced their practice. The fact that 73% of respondents reported applying mindfulness skills for self-care provides further evidence of relevance and cultural acceptability. Over the course of the CALD Mindfulness Program, the bilingual (Arabic/English) clinical lead has supervised three bilingual (Arabic/English) psychology interns.Community partners have played a major role in promoting the program, engaging individuals from the target communities, and encouraging weekly attendance and mindfulness practice. Interviews with 16 community partners reinforced the importance of weekly contact by a trusted person for retention. Shared culture and language convey cultural safety which has been defined by as “an environment that is spiritually, socially and emotionally safe for people, where there is no assault, challenge, or denial of their identity, of who they are and what they need”  (p. 213)Culturally competent mental health promotion and care must address the social and cultural determinants of health ,47. SincCompared to face-to-face, more of the online participants possessed post-school qualifications . It is likely that education and digital literacy account for some of the difference in retention between Arabic and Bangla speakers in the online program. While most are keen to return to the face-to-face format, it is clear that the online format, or possibly a blended format, has a place in responding to mental health needs, particularly for Bangla and other language groups who embrace this technology. Through sharing experiences of the pandemic, wellbeing was nurtured, and cultural identities and connections celebrated. A place  that is respectful, engaging, and supportive is more likely than a mainstream service to be used by minority groups and those most in need .Although online interventions typically have relatively high attrition , the onlA minority of participants (8.7% face-to-face and 15.9% online) were already receiving mental health care. In both delivery formats, Arabic speakers were more likely than Bangla speakers to be receiving such care. The Arabic community in Sydney  is much larger and longer established, so has greater knowledge of the health system and more resources and networks to draw upon, including a cohort of bicultural/bilingual health professionals who have been educated and trained in Australia. As a result of all group programs, an additional 106 referrals were made for specialist mental health care, the majority to bilingual psychologists in private practice: an indicator of previously unmet need.In addition to program participants who benefited directly through a process of dissemination , many other people benefited through a process of diffusion  . As partOur research has demonstrated that the group mindfulness program provides an effective and culturally acceptable low-intensity mental health intervention for the target communities as is capable of integration into the wider health system . GeograpThis research has strengths and limitations. On the strengths side, the large multicomponent intervention, which was refined and extended over several years, had evaluation embedded across all aspects and employed mental health outcome measures translated and validated with Arabic and Bangla speakers. Referral numbers, based data collected over 43 group programs that attracted 489 participants, are likely to reflect population need. Retention and program adherence were high in both the face-to-face and online formats. We achieved a good response to the follow-up survey of trainees from the mindfulness workshops and the community partner interviews. Limitations include the small number of participants  in the pre-post study of the online program. In the absence of a control group, it is impossible to conclusively demonstrate causality; however, the results are consistent with a pre-post study with a wait-list control group for the face-to-face program . We did The CALD Mindfulness Program, which was designed to address the mental health needs of under-served CALD communities in metropolitan Sydney, has proved very successful. This innovative community-based program, with its emphasis on promotion of mental health and wellbeing, sits well within Australia’s stepped care model for primary mental health care. The in-language and culturally tailored mental health self-help resources, and low-intensity interventions delivered face-to-face and online through a collaborative regional approach, were readily adopted by participants from the target communities (Arabic and Bangla speakers) and shared with others in their family and community networks. The program provides a non-stigmatising soft-entry point to mental health services for the Arabic and Bangla communities who live in the CESPHN region. Future directions include extension of the CALD Mindfulness Program to other language groups, further exploration of technology mediated MBIs, and further integration of the program across the health system.


BackgroundMetrics were evaluated between academic plastic surgeons from different tiered training programs to determine promotion predictors within tiers and between tiers for those seeking promotion from assistant professor, associate professor, to full professors.MethodologyWe performed a retrospective, cross-sectional study by collecting 61 variables from full-time plastic surgery faculty affiliated with United States residency training programs during the 2020-2021 academic year. Surgeons were stratified into nine cohorts for comparison by professorship  and Doximity-ranked institution program tiers . Univariate followed by multivariate regressions with reciprocal transformation were performed to determine predictors more likely associated with promotion or lateral movement.ResultsA total of 98 programs listed 851 surgeons. T1/T2/T3 surgeon promotion predictors included more years in practice  and greater number of last-author publications . T1/T3 surgeon promotion predictors included higher h-indexes . T1 surgeon promotion predictors included being on journal editorial board (p = 0.040). T2 surgeon promotion predictors from assistant to associate included non-white race (p = 0.010). T3 surgeon promotion predictors included residency director (p = 0.009) and greater number of citations (p = 0.026). Promotion predictors from assistant, associate, and professors for T3/T2/T1 programs included greater number of last-author publications . Movement from assistant and associate between T3/T2/T1 programs included plastic surgery department . Movement from assistant between programs included attending Top 10 US News medical schools (p = 0.012), attending more favorable Doximity-ranked research programs (p < 0.001), greater number of first-author publications (p = 0.017), and greater number of citations (p = 0.023). Movement from associate between programs included attending more favorable Doximity-ranked reputation programs (p = 0.017) and higher h-indexes (p = 0.017). Movement from professor between programs included receiving any American Association of Plastic Surgeons (AAPS) award (p = 0.039) and greater number of AAPS awards (p = 0.012).ConclusionsPromotion Ladder of Academic Plastic Surgery.Promotion predictors provided evidence to synthesize the Doximity-tiered  Promotion in an academic surgical career is categorized by three subsequent stages of professorship. One typically starts his/her career as an assistant professor, advances through promotion to become an associate professor, and finally becomes a professor. Excellence is the basis for promotion demonstrated by five classic principles that define an academic surgical career. These principles include teaching, clinical productivity, administrative duty, community service, and research . TeachinThese differences often create challenges when comparing professorship and faculty metrics from one institution to another. Categorizing institutional programs with similar characteristics into a tiered system may clarify institution-specific metrics for academic plastic surgeons and provide promotional insight. Metrics can then be compared within each institutional tier to predict promotion from assistant professor to associate professor to full professor for a surgeon advancing his/her career within the same institution, and lateral movements among institutional tiers for a surgeon changing institutions. Identifying recent objective metrics from academic plastic surgeons across different institutional tiers may provide an updated guide for students, trainees, and junior faculty who plan to pursue and/or advance their careers through academic plastic surgery. The purpose of this study was to evaluate metrics among academic plastic surgeons from different training programs to determine predictors and guide prospective surgeons seeking promotion or changing institutions.Study designWe performed an Institutional Review Board-exempt, retrospective, comparative, cross-sectional online review to collect data from full-time academic plastic surgeons affiliated with the United States Accreditation Council for Graduate Medical Education (ACGME)-accredited integrated and/or independent residency training programs during the 2020-2021 academic calendar year. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines were used throughout the review .Study populationPlastic surgeons included full-time faculty from training programs available through the American Council of Academic Plastic Surgeons (ACAPS) website during the 2020-2021 academic calendar year. Each institution’s plastic surgery residency website was queried for faculty rosters. Non-plastic surgeons, adjunct faculty, and faculty without publicly available professorship statuses were excluded from the study.Academic plastic surgeons were stratified into nine cohorts for comparison by professorship status  and institution program tier . Tiers were determined by publicly available Doximity plastic surgery program research rankings  (Appendix 1). Doximity determined research metrics by collective h-indexes of program alumni. Research metrics were prioritized over reputation metrics to maximize objectivity .Variables analyzedA total of 61 publicly available variables were measured for each of the three professorship statuses and three program tiers based on full-time plastic surgeon faculty positions at ACGME-accredited institutions during the 2020-2021 academic year. Variables were manually searched and collected for each plastic surgeon from institutional websites, Doximity, LinkedIn, private-practice websites, organizational websites, research databases, and National Institutes of Health (NIH) websites from October 1, 2020 to November 19, 2020. A variable was considered if publicly available for each plastic surgeon. Four study members extracted study variables . Following variable extraction, one of the four study members confirmed extracted variables for accuracy.Variables included physician demographics , current faculty academic institutions, medical degree backgrounds, advanced degrees, residency training, fellowship training, number of years in practice, program division or department status, residency and fellowship directorship, editorial board status, ACGME board membership, officer/director of the American Board of Plastic Surgeons (ABPS), regional society/association presidencies, national society/association presidencies, research metrics , NIH grant funding, and American Association of Plastic Surgeons (AAPS) awards (Appendix 2).Statistical analysisDescriptive statistics were used to compare medians, interquartile ranges (IQR), ranges (minimum/maximum), odds ratios (OR), 95% confidence intervals (95% CI), area under the curves (AUC), frequencies, and percentages between variables based on the non-parametric population distribution assessed using the Shapiro-Wilk test. Analyses were performed to compare different professorship cohorts within the same tier , followed by the same professorship cohorts between different institution tiers (e.g. T1 assistant versus T2 assistant versus T3 assistant). Dichotomous variables were assessed using Fisher’s exact cross-tabulation tests followed by the post-hoc Bonferroni tests with an α of 0.008 to determine which cohorts were different [Promotion Ladder of Academic Plastic Surgery: Tier 1 assistant, associate, and professor; Tier 2 assistant, associate, and professor; Tier 3 assistant, associate, and professor; assistant Tier 1, Tier 2, and Tier 3; associate Tier 1, Tier 2, and Tier 3; and professor Tier 1, Tier 2, and Tier 3.A total of 951 full-time plastic surgeons were evaluated from 99 ACGME-accredited plastic surgery programs. Of the 951 plastic surgeons, 851 reported professorship status  from 98 programs. Tier 1 programs included 114 assistants, 87 associates, and 97 professors. Tier 2 programs included 124 assistants, 61 associates, and 79 professors. Tier 3 programs included 139 assistants, 80 associates, and 70 professors. The following comparisons were performed to provide evidence for the Doximity-tiered Tier 1 assistant, associate, and professorUnivariate comparisons were performed to identify differences between T1 program assistant professors, associate professors, and professors , if on a journal editorial board , a greater number of last-author publications , and higher h-indexes . Plastic surgeons were as likely to be promoted to associates and professors with a greater number of citations .Tier 2 assistant, associate, and professorUnivariate comparisons were performed to identify differences between T2 program assistant professors, associate professors, and professors . Plastic surgeons were more likely to be promoted from assistants to associates and professors with more years in practice  and a greater number of last-author publications .Tier 3 Assistant, Associate, and ProfessorUnivariate comparisons were performed to identify differences between T3 program assistant professors, associate professors, and professors , being a residency director , a greater number of last-author publications , higher h-indexes , and a greater number of citations .Assistant Tier 1, Tier 2, and Tier 3Univariate comparisons were performed to identify differences between T1 assistant professors, T2 assistant professors, and T3 assistant professors Table .Following multivariate analysis, plastic surgeons were more likely to move laterally from an assistant at a T3 program to a T2 program and T1 program if they attended a Top 10 US News medical school , if they attended a more favorable Doximity-ranked research program , with a greater number of first-author publications , with a greater number of last-author publications , if they had a greater number of citations , and if plastic surgery was a department at T2 and T1 programs .Associate Tier 1, Tier 2, and Tier 3Univariate comparisons were performed to identify differences between T1 program associate professors, T2 program associate professors, and T3 program associate professors Table .Following multivariate analysis, plastic surgeons were more likely to move laterally from an associate at a T3 program to a T2 program and T1 program if they attended a more favorable Doximity-ranked reputation program , a greater number of last-author publications , if they had higher h-indexes , and if plastic surgery was a department at T2 and T1 programs .Professor Tier 1, Tier 2, and Tier 3Univariate comparisons were performed to identify differences between T1 program professors, T2 program professors, and T3 program professors Table .Following multivariate analysis, plastic surgeons were more likely to move laterally from a professor at a T3 program to a T2 program if they were a chief/chair . Plastic surgeons were more likely to move laterally from a professor at a T3 program to a T2 program and T1 program with a greater number of last-author publications , if they received any AAPS award , and a greater number of AAPS awards .Promotion Ladder of Academic Plastic SurgeryPromotion Ladder of Academic Plastic Surgery from three Doximity program tiers (Figure Six multivariate regression models were combined to synthesize the s Figure .Independent predictors of promotion from assistant to associate to professor within a program tier correspond to bottom-to-top advancement up the promotion ladder. Independent predictors of promotion from T3 to T2 to T1 programs correspond to left-to-right advancement across the promotion ladder.Promotion Ladder of Academic Plastic Surgery.We evaluated objective metrics between academic plastic surgeons from three Doximity program tiers to determine predictors and guide future and/or current surgeons seeking promotion from assistant professors to associate professors to full professors. Furthermore, we evaluated academic plastic surgeons at the same professorship level from three different tiered programs to guide those seeking lateral movement between programs. Independent predictors following comparisons were used to synthesize the Doximity-tiered Increasing the number of last-author publications was the most impactful method that predicted promotion at every intersection of the promotion ladder. By increasing the number of last-author publications, a plastic surgeon can advance up and across the promotion ladder. Traditionally, first authorship designates a junior team member who collected data and synthesized the manuscript, while last authorship designates a senior faculty member who contributed intellectual property through experience . In addiH-indexes are bibliometric measurements used to assess the quality of publications ,2,7-10. Dedicating more years in practice predicted promotion up the ladder within all program tiers. Years in practice were measured from the time of first becoming an attending physician to the 2020-2021 academic calendar year. More years in practice increase the opportunities of achieving excellence in all five classic principles that define an academic surgical career ,12. We wPlastic surgery programs designated as departments have the autonomy to eliminate bureaucracy and layers of administration, directly engage in educational decisions with the dean of the medical school, implement educational plans, and use surplus revenues to recruit and maintain faculty . DepartmInstitutional programs were stratified into three tiers by Doximity research rankings. Doximity determines rankings by current resident and recent alumni satisfaction data, reputation data, and objective data . SatisfaPromotion Ladder of Academic Plastic Surgery.Academic plastic surgeons should follow institution-specific promotion criteria. While we realize our model may not fit all institutions, our comprehensive data collection and rigorous methodology provided a generalized framework to assess independent predictors associated with promotion and lateral movement in academic plastic surgery from the 2020-2021 academic calendar year. Independent promotion predictors provided evidence to synthesize the Doximity-tiered Promotion Ladder of Academic Plastic Surgery.Academic plastic surgeons were more likely to be promoted from assistant to associate and professor at T1 programs with more years in practice, being on a journal editorial board, a greater number of last-author publications, and higher h-indexes. Promotion from assistant to associate was more likely at T2 programs if surgeons were non-white. Surgeons were more likely to be promoted to associate and professor at T2 programs with more years in practice and a greater number of last-author publications. Surgeons were more likely to be promoted to associate and professor at T3 programs with more years in practice, as a residency director, a greater number of last-author publications, higher h-indexes, and a greater number of citations. Assistant professors at T3 programs were more likely to move laterally between T2 and T1 programs if they attended a Top 10 US News medical school, attended a more favorable Doximity-ranked research program, with a greater number of first-author publications, a greater number of last-author publications, a greater number of citations, and if plastic surgery was a department at T2 and T1 programs. Associate professors at T3 programs were more likely to move laterally between T2 and T1 programs if they attended a more favorable Doximity-ranked reputation program, with a greater number of last-author publications, higher h-indexes, and if plastic surgery was a department at T2 and T1 programs. Professors at T3 programs were more likely to move laterally to T2 programs if they were a chief/chair. Professors at T3 programs were more likely to move laterally between T2 and T1 programs with a greater number of last-author publications, if they received any AAPS award, and a greater number of AAPS awards. These Independent predictors were used to provide evidence and synthesize the Doximity-tiered


Residency positions are highly competitive. Pharmacy students who are familiar with the ideal qualities of residency candidates and the expectations of residency programs may be more likely to obtain one of these coveted positions. This study identifies the characteristics that residency program directors (RPDs) and preceptors use to define an ideal residency candidate.This is a cross-sectional, descriptive study that surveyed pharmacy RPDs and preceptors across the Kingdom of Saudi Arabia. The questionnaires are comprised of two sections: demographic information and characteristics of the residency candidates. Over a five-month period , the survey was sent electronically to the participants.Of the 78 surveys returned, 68 surveys were included  and 12 surveys (15.17%) were excluded due to incompleteness. Number of RPDs responded to the survey represents (65%) of the total RPDs in Saudi Arabia. The mean response scores from the results of the Likert scale [strongly agree (1) - strongly disagree (5)] — suggest that a candidate’s performance during the interview (mean score = 1.5), their professional appearance (1.5), an alignment between a candidate’s interests and the program focus (1.6), and previous hospital experience (1.8) mattered most. While being from the same region (3.4), having an advanced degree (2.8) and the cumulative Grade Point Average (2.7) mattered the least. We find that previous hospital experience (29%), familiarity with the program (16%), research experience (15%), Saudi Commission for Health Specialists aggregate score (10%), and letters of recommendation (4%) are considered the top five factors.Residency candidates should focus on training in clinical settings. Offering mock interviews and Saudi Pharmacist Licensure Examination practice tests and involving pharmacy students in clinical research may increase their chance in securing a residency position. An increasing number of applicants are not receiving nominations or getting matched to a residency program. Obtaining and securing a residency position is highly competitive. There are many reasons for this. First, there are a limited number of residency positions available within Saudi hospitals — with only a few new positions added each year . Based oPharmacy students who possess the ideal qualities of residency candidates and understand the expectations of residency programs are more likely to obtain one of these coveted positions. The earlier students become aware of the qualities they must demonstrate and the expectations these programs have, the easier it is for them to obtain the necessary experience and skillset needed to succeed in a residency program. Faculty and hospital preceptors should also be aware of the factors considered when selecting pharmacy residents. That way, they are well-positioned to guide prospective residents and offer them opportunities to develop the proper skills before graduating.The existing process for applying to pharmacy residency programs in Saudi Arabia is conducted through the Saudi Commission for Health Specialists (SCFHS). Residency applicants are nominated, interviewed, and then the program ranks candidates. SCHFS nominates potential candidates based on their aggregate scores. These aggregate scores include: the Saudi Pharmacist Licensure Examination (SPLE) score, Grade Point Average (GPA), and student portfolios  5AD. SPLTo date, no studies exist that identify the characteristics of an ideal clinical pharmacy residency candidate in Saudi Arabia. The same cannot be said about residency candidates applying to the United States (US) programs. Indeed, many studies in the US have assessed the qualities that residency candidates must exemplify . One stuUnderstanding the factors used by residency programs to rank candidates could make a great deal of difference. Knowing these factors could allow candidates the opportunity to plan for residency beforehand; this helps ensure they excel during the residency application process. In this study, we hypothesize that identifying the characteristics of a good pharmacy residency candidate helps applicants prepare for the residency application process and increase their chance of matching with a hospital. The study identifies the characteristics that residency program directors and preceptors use to define an ideal residency candidate.2This is a cross-sectional, descriptive study that surveyed the directors and preceptors of SCFHS accredited pharmacy residency programs across the Kingdom of Saudi Arabia. The study surveyed all current and previous residency program directors and preceptors of SCFHS accredited residency programs in Saudi Arabia. An electronic questionnaire was adapted by the study’s authors and reviewed by four experienced faculty in post-graduate pharmacy training. Some of the questions were taken from a study conducted by Hillebrand and colleagues . Each faThe questionnaire consists of two sections: (A) demographic characteristics and (B) characteristics of the residency candidates. Section (A) is comprised of 12 questions assessing the directors and preceptors’ demographic information. This information includes questions related to their residency programs. Section (B) is comprised of 22 questions that evaluate applicant characteristics that are considered by the participants during the candidate selection process. The answers in section (B) are based on the five-point Likert scale .All residency program directors and preceptors who participated in the selection process in Saudi Arabia were invited to respond to this self-administered questionnaire. To move forward in the survey, the participants were required to respond to each question; a respondent could stop the survey at any time. The survey was created using Google Forms, online survey software, and sent to the participants electronically over a five-month period . If they did not complete the entire questionnaire, respondents were excluded.A descriptive analysis was performed to assess the frequency and percentage of respondents’ demographic characteristics and responses to each criterion. The responses on the 5-point Likert scale were visualized as a Gannt chart using Tableau Software. For each question, these responses were reported as the mean and percentage of agreement or disagreement. Data management and statistical analyses were carried out using SAS version 9.4 statistical software .3After five months of data collection , 78 of the directors and preceptors responded to the survey. The 68 responses that were completely filled out by current directors and preceptors were included. The study participants represent the geographic diversity of residency program directors located in Saudi Arabia. All of the current program directors and preceptors from SCFHS accredited residency programs across Saudi Arabia were contacted via email and sent an introductory email and electronic survey. Overall, 36 of the directors responded to the survey which represents (65%) of the total program directors in Saudi Arabia. That is, there are approximately 55 PGY-1 and PGY-2 residency program directors in Saudi Arabia. The remaining respondents were the preceptors from SCFHS accredited residency programs across Saudi Arabia. Overall, most of the respondents (60%) were located in the central region followed by the western region (32%). The vast majority of the respondents were directly involved in the resident selection process (89%). Respondents varied in their residency program types and levels as they were engaged in post graduate year 1 (PGY-1) (39%), in PGY-2 (11%), and in PGY-1 and PGY-2 programs (48%) .Table 1DOverall, the survey assessed several factors that are prioritized during the resident’s selection process. Using the mean response score from the results of the Likert scale  — indicated that candidate’s performance during the interview (1.5), their professional appearance (1.5), an alignment between a candidate’s interests and the program focus (1.6), and previous hospital experience (1.8) mattered most. According to the respondents, these criteria were the most valued candidate attributes. In addition, language-related factors were highly valued in the selection process. In particular, English language and writing skill proficiencies were determined based on the quality of residency application documents.More than 52% of the respondents did not consider the region a candidate came from as an important factor in the selection process. The majority of the respondents were either neutral or disagreed with the idea that candidates should possess advanced degrees. Moreover, of all of the selection criteria, a candidate’s cumulative pharmacy school GPA was ranked at the bottom of the hierarchy . AlthougWhen the directors and preceptors were asked to rank the factors based on their importance in the candidate selection process, previous hospital experience ranked first (29%) followed by a pre-existing relationship with the residency program (16%). Research experience (14%), SCFHS aggregate score (10%), and letters of recommendation (4.4%) also ranked among the most important factors .Fig. 3To4We aimed to identify the characteristics that residency program directors or preceptors use to identify an ideal pharmacy residency candidate. We believe that identifying these characteristics can help pharmacy residency applicants in Saudi Arabia prepare for the residency application process.By querying pharmacy program directors, several studies conducted in the US investigate which factors matter the most in the selection of pharmacy residency . Pick etIn this study, when selecting a candidate for a residency position, most of the preceptors and program directors claim that previous hospital experience matters. Indeed, previous hospital experience ranked first with 29% of respondents choosing it as the most important factor. Pick and colleagues, reported that previous work experience  ranked third among the most important characteristic in the residency process (4% of the of respondents consider it as the most important factor) . Gohlke In this study, familiarity with the program ranked second and previous research experience came in third. Prior familiarity with the residency program ranking second emphasizes how important it is to carefully select rotations during the last year of pharmacy school. Also, students should be encouraged to volunteer in these institutions to increase their knowledge of that program, form meaningful relationships, and make a good impression. It also serves as an opportunity for the students to determine whether this environment is suitable. Therefore, the internship year may be considered as a great time for pharmacy interns to build up this experience. In addition, PGY-1 pharmacy residents may also build up this experience by taking a rotation in their desired PGY-2 residency program. After all, students have different goals and ambitions when pursuing residency positions. In addition, residency programs seem to value letters of recommendation highly . This reThe respondents, when asked about “performance during the interview” — they said it was important, but it was not ranked among the top five factors. Indeed, we expected that the residency interview to be one of the top five factors — given that applicants are already pre-screened before they reach the residency interview stage. Several schools in the US recognize how critical it is to prepare for the residency interview. Therefore, they offer “mock interviews” and other preparatory resources for students who are interested in enrolling in residency programs . By posiIn Saudi Arabia, pharmacy schools focus more on preparing the students for the SPLE exam, which is required for obtaining a pharmacist license. This is understandable given that the pass rate on the exam affects a school’s reputation but also because the SPLE score comprises 50% of the SCFHS aggregate score. Of course, this aggregate score ultimately decides who is promoted to the residency interview stage. In our study, according to the residency program directors and preceptors surveyed, the Likert scale did not show that the SPLE score was an important factor. Moreover, the SPLE score did not rank among the top five factors. Still, the SCFHS aggregate score was the fourth most important factor (10.29%), which is heavily affected by the SPLE score. For that reason, schools should offer mock SPLE exams. Perhaps, then, more attention could also be given to those interested in residency — since the higher the score they receive, the higher their SCFHS aggregate score.One of the main strengths of our study was the inclusion of the majority of the program directors . However, the response rate among the preceptors cannot be identified given the nature of electronic surveys. Another strength is the inclusion of preceptors who were heavily involved in the selection process of residency candidates, which was not the case with previously published studies. This study is not without limitations. First, it is possible that we missed some characteristics that the residency programs might also consider important. Second, we did not specify in our survey the type of rotations a student performed. It is conceivable, then, that some rotations are preferred by some residency programs or for certain residency positions. Finally, we did not specify the source of the letters of recommendation. It is possible that a letter of recommendation from clinical preceptors are preferred by some programs.5The existing literature lacks studies that identify ideal candidates’ characteristics for residency programs in Saudi Arabia. Our study highlights the aforementioned characteristics by surveying program RPDs and preceptors. Our goal is to help ensure candidates are well-prepared for the application process. Using the Likert Scale, we found that candidates’ performance during the interview, their professional appearance, alignment between a candidate’s interests and the program’s focus, and previous hospital experience are the most valued candidate attributes. We report that previous hospital experience, familiarity with the program, research experience, SCFHS aggregate score, and letters of recommendation are considered the top five factors.To increase their chances of success, residency candidates should be encouraged to train in clinical or hospital settings as well as to plan ahead so they can receive the training in hospitals that host the programs they are most interested in. Students must contemplate and then decide whether a program aligns with their specific career goals. In addition, pharmacy interns and students should work on developing research skills and try to conduct research during internships or pharmacy school. Again, pharmacy colleges should provide mock interviews to students who are interested in applying to residency programs. The fact remains that there is still a need for studies that compare the perceptions of pharmacy interns with those of residency program directors and preceptors.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr. Alhossan and Dr. Aseeri are affiliated with residency programs that received our survey, but they did not participate in completing the questionnaire. The other authors have nothing to disclose.


New parents face increased risks of emotional distress and relationship dissatisfaction. Digital interventions increase support access, but few preventive programs are optimized for both parents.Baby Care) and information plus an interactive program (Baby Steps Wellbeing) were compared from the third trimester baseline to 3 and 6 months subsequently.This study aims to conduct the first randomized controlled trial on universal self-guided digital programs to support positive perinatal adjustment of both mothers and fathers. Effects of childcare information . All assessments were web-based self-reports: the EPDS and psychosocial quality of life were primary outcomes; relationship satisfaction, social support, and self-efficacy for parenting and support provision were secondary. Linear mixed models provided intention-to-treat analyses, with linear and quadratic effects for time and random intercepts for participants and couples.The study recruited 388 co-parenting male-female adult couples expecting their first single child (26-38 weeks’ gestation), using web-based registration. Most  were obtained from prenatal hospital classes. Couples’ randomization was automated and stratified by Edinburgh Postnatal Depression Scale (EPDS) scores (50% couples scored P<.001). The EPDS, quality of life, and social support did not show differential improvements between programs, but Baby Steps Wellbeing gave a greater linear increase in self-efficacy for support provision  and lower reduction in relationship satisfaction  than Baby Care alone. Mothers had greater linear benefits in parenting self-efficacy over time than fathers after receiving Baby Steps Wellbeing rather than Baby Care . However, the inclusion of program type in analyses on parenting self-efficacy and relationship satisfaction did not improve model fit above analyses with only parent gender and time.Selection criteria were met by 63.9% (248/388) of couples, who were all randomized. Most participants were married , tertiary educated , employed full time , and born in Australia . Their mean age was 32.2 years, and average gestation was 30.8 weeks. Using an EPDS cutoff score of 13, 6.9% (18/248) of men, and 16.1% (40/248) of women screened positive for depression at some time during the 6 months. Retention of both partners was 80.6% (201/248) at the 6-month assessments, and satisfaction with both programs was strong (92% ≥50). Only 37.3% (185/496) of participants accessed their program more than once, with higher rates for mothers  than fathers , the effect only occurred for mothers, perhaps reflecting their greater program use. Increased engagement will be needed for more definitive testing of the potential benefits of Baby StepsWellbeing for perinatal adjustment.Three secondary outcomes showed differential benefits from Australian New Zealand Clinical Trials Registry ACTRN12614001256662; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=367277 Psychological distress before and after childbirth is common in both parents. Although recent meta-analyses estimate that 12%-17% of recent mothers become depressed . Depressd=0.54)   ). HoweveAt baseline, each parent reported their age, marital and employment status, education level, country of birth, years living in Australia, and indigenous background (where applicable). The assessment at 3 months after childbirth included weeks of gestation at birth, birth type, baby’s sex, and information about any inpatient care of the baby.α=.93; corrected interitem correlations=0.73-0.91).The number of log-ins, modules viewed, the number of saved action plans from baseline to 6 months, and the period between the first and last log-in to the program were downloaded from the program’s database. Overall program satisfaction and the program’s perceived relevance, usefulness, and ease of finding what the participants wanted were self-reported at 3 months on a scale from 0  to 100 (extremely), and average scores across these four items are reported below , all self-reported outcomes used unweighted sums or averages of items. The primary outcome measures were the scores derived from the 10-item Edinburgh Postnatal Depression Scale (EPDS) ,25, whicα=.94; corrected item-total correlations=0.78-0.95). Self-efficacy for support provision to their partner used a single item  that was moderately related to the CSI-16  and inversely related to the EPDS . Data on income, work time, productivity, and health care were also collected but will be reported in a separate paper.Relationship satisfaction was measured using the 16-item Couples Satisfaction Index (CSI-16) , which gBaby Care trial arm received the four informational modules giving information and tips on getting prepared, feeding and soothing their baby, and improving their baby’s sleeping habits. A Get Help tab provided a list of relevant digital or telephone support services.The participants randomized to the Baby Steps Wellbeing could also access modules on physical and emotional self-care, their relationship with their partner, changing roles, and interacting with their baby, as well as the module meant especially for fathers . For either Baby Care tips or the ones in other modules, the participants in Baby Steps Wellbeing could identify goals, solve problems, develop a plan, set times to take action, and record their successful completion. A list of successfully completed plans was available. A web-based scrapbook was used to store photos of good times with their baby, and their dashboard presented due dates for their action plans, together with a rotating quiz question about baby care, a tip, and a scrapbook photo. The database for Baby Steps Wellbeing was hosted at the Queensland University of Technology. The participants were not given advice on the number of modules to access, and there was no limitation on the pace of module access. No changes to either program were made during the study, and no major technical issues were encountered.The participants receiving Baby Steps Wellbeing participants also included a recommendation to review their goals and plans. A final SMS text message was sent to all participants, thanking them and expressing the hope that they found the website useful.All participants received automated text messages at 2, 4, 7, and 10 weeks after allocation, reminding them to log in to the program and select tips to apply. Texts sent to the After the volunteers for the study registered on the web, they were emailed a link to the web-based consent form and eligibility screen. Prospective participants could also email or call the research team to ask questions about the trial. After informed consent and initial automated confirmation of eligibility, they were given a link to self-complete the baseline assessments. Both these and later measures were delivered through Qualtrics  and stoand father ≤5; screening positive: mother >7 or father >5) [The web-based completion of baseline measures by both the father and mother triggered a fully automated random allocation of the couple to a treatment by Goji, a web-based trial management system developed at Queensland University of Technology . Randomither >5) . These cAt 13 and 26 weeks, the participants were sent automated emails with links to self-complete assessments on the web. All outcome and economic measures were readministered, together with details about the birth, a check on marital status, and ratings of program satisfaction. Nonresponse resulted in emails or calls by a research officer, who was blind to the treatment, to provide further reminders. The participants were given a retail store voucher for Aus $20 (approximately US $16) for each completed follow-up assessment.The primary analyses adopted an intention-to-treat approach using RStudio version 1.3.1093 lme4 , which provided mixed models analyses of data over the three measurement occasions . Given the potential for correlations within couples, each analysis incorporated random intercepts for both the couple and individual participant. Preliminary analyses demonstrated that the inclusion of a first-order autocorrelation between test occasions did not improve predictions; therefore, it was not included in the reported analyses. As mothers are somewhat more vulnerable than fathers to issues with perinatal mental health and well-being , but test tests used the Satterthwaite method, and the degrees of freedom were calculated using the Kenward-Roger method. The effect sizes in these analyses use Cohen d, with difference scores being divided by shared baseline SD units .In the primary analyses, we compared two models: (1) a hypothesized model, examining the relative impact of the two programs, controlling for parent gender  and (2) the full factorial model, testing all potential effects. Post hoc analyses were also undertaken to examine a model that only included parent gender and time. The reported The CONSORT diagram is presented in Baby Steps Wellbeing entered the study a little less than a week earlier in the pregnancy compared with those receiving Baby Care , but there were no other significant differences between the treatments in terms of demographic characteristics. Tests of any differences between the fathers and mothers in the study are presented in On average, the participants receiving The participants had a median age of 32  years, and 80.6% (400/496) were married. Most had a university degree , were employed full time , had been born in Australia , or had lived in Australia for a substantial period . Using a cutoff score of 12/13 on the EPDS  were useBaby Care and 37.9% (94/248) of Baby Steps Wellbeing participants  accessed programs on two or more occasions. While 53.6% (133/248) of the mothers used a program at least twice, only 21.0% (52/248) of the fathers did so . Among the Baby Steps Wellbeing participants, 44.4% (55/124) of the mothers set a goal, whereas only 12.9% (16/124) of the fathers did so . These parent gender differences were observed for all continuous variables related to program use (Baby Steps Wellbeing could access more than twice the number of modules (nine) than those receiving Baby Care (four), fathers only accessed an average of just one module in either treatment. The significant interaction between treatment and parent gender  was a reflection of the fact that the mothers took greater advantage of the additional modules, although on average they still accessed fewer than half of those in Baby Steps Wellbeing , but there were no statistically significant differences between the treatments in terms of log-ins or duration of use .Satisfaction with the program was high among the participants who accessed it at least once . Accordingly, the subsequent main analyses on this variable used the full factorial model, whereas the hypothesized model was used for the remaining outcome variables. Results for each variable using the nonpreferred model are displayed in Initially, a comparison was made of model fit from the hypothesized model and from a full factorial model. With the exception of parenting self-efficacy, the hypothesized model gave a better fit than the full factorial model in terms of both Akaike Information Criterion (AIC) and Bayesian Information Criterion (BIC), and the simpler model did not result in a significantly poorer likelihood ratio . In the In additional post hoc analyses, we also tested the fit from a model with only parent gender and time to assess whether any significant effects for treatment resulted in an improved model fit overall (d=0.37) and a lower average quality of life on the AQoL-8D Psychosocial Super Dimension than the fathers (Cohen d=0.27). The EPDS scores did not significantly change across the sample from baseline to 6 months, but the mothers’ depression had a greater tendency to peak soon after childbirth, as shown by a significant parent gender×quadratric time effect (d=0.27), which once again was modified by an interaction between parent gender and quadratic time : the psychosocial quality of life of the fathers increased by 0.16 SD units more than that of the mothers. However, there were no significant interactions between treatment and time on either primary outcome when the hypothesized model was used.The effects for each outcome variable from the preferred model are displayed in e effect . For exad=–0.36), especially for the mothers (Cohen d=–0.46 vs –0.26 for the fathers). However, the reduction in relationship satisfaction was less in Baby Steps Wellbeing than in Baby Care (Cohen d=0.20). Significant interactions with treatment were also observed in the two self-efficacy measures. In the case of self-efficacy for support provision, the Baby Steps Wellbeing participants showed a greater linear increase over time than those in Baby Care (Cohen d=0.26). Across the whole study, the mothers had lower scores than the fathers (Cohen d=–0.33), but their scores improved to a greater extent over the study period (Cohen d=0.34 vs 0.08 for the fathers). The interaction of time and parent gender was not further modified by treatment. In contrast, the mothers had higher scores on parenting self-efficacy than the fathers on average (Cohen d=0.17), as well as showing a greater linear improvement over time (Cohen d=1.12 vs 0.72 for the fathers). In this case, there was also a three-way interaction: as presented in Baby Steps Wellbeing than in Baby Care (Cohen d=0.26), but the reverse was the case for the fathers (Cohen d=–0.25). The only secondary outcome not showing any interactions between treatment and time was social support on the Short MOS-SSS. The mothers scored somewhat more highly than the fathers across the study period (Cohen d=0.22), but there were no other significant effects.Relationship satisfaction on the CSI-16 fell over the course of the study  compared with the rates in meta-analyses  to allow a post hoc examination of whether more sustained or intensive program use would have provided stronger results, but this study’s results clearly suggest that these should be goals for future research. Our program had already attempted to maximize ongoing program engagement in multiple ways: (1) by recruiting couples who might reinforce each other’s engagement in program use and resultant actions; (2) by providing information related to baby care, which we expected to have salience late in the pregnancy; (3) by repeatedly reminding participants to log in and giving brief tips that changed at each visit; and (4) by offering opportunities to upload photos that would cue memories of good times with their baby and make it pleasurable to visit the site. We timed entry into the study and initial program exposure while the women were pregnant because of the time pressures experienced after childbirth, but solutions to childcare or general well-being issues might not have immediately seemed relevant to an unselected sample at that time. Furthermore, recruitment primarily through prenatal classes could have resulted in redundancy in some baby care information. In fact, a median of 1-2 website visits suggested that many participants may have regarded the program as just one of many web-based information repositories on baby care, which they only used once.There were insufficient couples who both accessed and set goals for multiple coaches who might offer some features that approximated human interaction  [The absence of a predetermined, sequential progression through the program’s modules might have been a significant factor in the limited use of the program ,34. Gamif tasks) , even iff tasks) , a brieff tasks)  or empowProblems with engaging fathers in prevention or treatment of mental health conditions are endemic, both perinatally and more generally ,9, and oThere were several indications that the mothers reported more pronounced mental health and well-being issues than the fathers in this study, particularly in the perinatal period. They had higher average EPDS scores as well as lower psychosocial quality of life and self-efficacy for support provision over the course of the study, together with a greater tendency for their EPDS scores to peak. Their quality of life rose less strongly soon after childbirth, and their relationship satisfaction fell over time. Although they had slightly higher average social support over the course of the study and (not unexpectedly) were more confident about their parenting skills than the fathers, these gender differences further substantiate the particular vulnerability of new mothers to issues with mental health and well-being -3.To our knowledge, this is the first controlled trial that specifically attempted to engage fathers in a digital perinatal intervention and provided an interactive module especially for them. The trial had a substantial sample size and a very high retention in postbaseline assessments. Randomization was performed through an automated trial management program that ensured equivalence between treatment groups of the EPDS scores at baseline. All assessments were conducted on the web, and the follow-up research staff were blinded to the participants’ allocation. We conducted intention-to-treat analyses, with secondary analyses examining effects in the participants who accessed the program. However, the study’s predominant recruitment through prenatal classes and the sample’s high rate of university education mean that the results may not be generalizable to populations that are less highly educated or less engaged in learning about birthing and childcare. Although recruitment during the third trimester was intended to maximize the perceived relevance of the content, this may also have reduced its perceived novelty as well as excluding parents with early births or pregnancy complications from the sample. The exclusion of parents who were not cohabiting, were not in a male-female relationship, were aged below 18 years, or were expecting multiple infants also restricted the potential application of this study.Baby Steps Wellbeing program, although these benefits were more consistently seen in the mothers than in the fathers, and the effect sizes were relatively small. A major contributor to these results may have been the low level of use of the self-guided program, especially by the fathers. Increasing this program’s use will be a prerequisite for more accurate future estimation of the degree of potential impact of the Baby Steps Wellbeing program on the well-being of new parents.There was some evidence of differential benefits from the full