The Extension for Community Health Outcomes (ECHO) model has been used extensively to link care providers in rural communities with experts with the aim of improving local patient care.The aim of this qualitative research study was to assess the feasibility, acceptability, perceived needs, and contextual factors to guide implementation of a hypertension focused ECHO program for Community Health Extension Workers (CHEWs) in the Federal Capital Territory, Nigeria.From September 2020 to December 2020, key informant interviews were performed with seven global organizations (hubs) providing ECHO training focused on cardiovascular disease or nephrology to identify contextual factors and implementation strategies used by each hub. In February 2022, seven focus group discussions were performed with 42 frontline healthcare workers in the Federal Capital Territory to inform local adaptation of a hypertension ECHO program. Directed content analysis identified major themes which were mapped to the Consolidated Framework for Implementation Research. Qualitative analyses were performed using Dedoose, and results were synthesized using the Implementation Research Logic Model.We found both barriers and facilitators across the Consolidated Framework for Implementation Research domains that mapped to a number of constructs in each one. The results of these analyses confirmed that the core components of the ECHO model are a feasible and appropriate intervention for hypertension education of healthcare workers. However, implementing the ECHO program within the Federal Capital Territory may require strategies such as utilizing communications resources effectively, developing incentives to motivate initial participation, and providing rewards or recognition for ongoing engagement.These results provide valuable formative insights to guide implementation of our proposed hypertension ECHO program for CHEWs in the Federal Capital Territory, Nigeria. This information was used for key decisions around: 1) scope and content of training, 2) format and frequency, 3) selection of implementation strategies, and 4) building a community of practice. Hypertension is a major health challenge in Nigeria, with an estimated 25–40% prevalence among adults based on blood pressure ≥140/90 mmHg or using blood pressure lowering drugs 145. At th4Supplemental Table 1). Subsequent in-person and hands-on training sessions and quarterly site supervision visits by Hypertension Treatment in Nigeria Program study team members aimed to address these knowledge gaps.Before the Hypertension Treatment in Nigeria Program commenced, in-person training was provided at the University of Abuja Teaching Hospital (January 2020 to March 2020). These sessions aimed to educate two to four CHEWs from each participating primary healthcare center. The training included a two-hour didactic review of the program and an in-depth six- to eight-hour introduction to cardiovascular disease, blood pressure measurement, and hypertension treatment. Training materials were sourced from the Centers for Disease Control and Prevention Hypertension Management Training Curriculum and the World Health Organization . EvaluatThe current model of in-person training is unsustainable for ongoing education, knowledge reinforcement, and training new CHEWs and other healthcare workers (HCWs). Contemporary and sustainable professional education among frontline HCWs to provide high-quality and robust hypertension care may be achieved through implementation of a telementoring program, such as the Extension for Community Health Outcomes (ECHO) model 89. The E88912Concurrent with the ongoing Hypertension Treatment in Nigeria Program, we proposed to adapt, implement, and evaluate a hypertension ECHO program for CHEWs within enrolling primary healthcare centers in the Federal Capital Territory, Nigeria. We conducted this qualitative formative study to assess the feasibility, acceptability, perceived needs, and contextual factors for implementation, and to guide adaptation and selection of implementation strategies for the hypertension ECHO program. This innovative application of the ECHO program has the potential to improve primary care-based management of hypertension Nigeria by equipping HCWs with necessary knowledge and skills through telementoring.The ECHO model was prospectively selected as an evidence-based intervention for delivery of hypertension training to CHEWs in the Federal Capital Territory, Nigeria. Adaptation, implementation, and evaluation of the hypertension ECHO program follows the ADAPT-ITT framework, which guides systematic adaptation of evidence based interventions  14]. In. In14]. Appendix A) [Appendix B). Neither interviewer knew any of the interview participants.Project ECHO hosts a global public database of all active ECHO hubs and the domains in which each hub offers trainings . We searendix A) 17. Hubs An ECHO program focused on non-communicable diseases was offered in 2021 by mDoc Healthcare – an ECHO hub based in Lagos, Nigeria – and advertised on social media with an open invitation for participation. Members of the Hypertension Treatment in Nigeria Program team and clinicians at the University of Abuja Teaching Hospital who were known to have joined one or more ECHO sessions were invited to participate through convenience sampling. A single FGD was conducted with the aim of understanding necessary adaptations to pedagogy and delivery of the proposed hypertension ECHO program.Supplemental Figure 1). Among the 33 sites that were eligible to participate, stratified random sampling was used to select two primary healthcare centers from each local government area council. Six FGDs were conducted; one within each local government area council. All HCWs within the selected primary healthcare centers were invited to participate.In central Nigeria, the Federal Capital Territory is divided into six local government area councils, across which there are over 240 primary healthcare centers. Sixty of these primary healthcare centers were previously selected through a multi-stage, stratified random sample for the Hypertension Treatment in Nigeria Program . Sites wThe University of Abuja Teaching Hospital research team recruited HCWs by phone. Team members contacted HCWs, explained the study aims and procedures, and assessed interest in participation. The HCWs who participated in the FGDs were all adults (age 18 years or older), able and willing to provide informed consent, and English-speaking. The experience and seniority of HCWs who agreed to participate were documented.Appendix C and Appendix D) [FGDs were conducted in English , by Hypertension Treatment in Nigeria Program members trained and experienced in qualitative research . The interviewers consisted of both male and female academic researchers  who knew the FGD participants through the Hypertension Treatment in Nigeria Program. The FGD guides included introductions for the participants about the goals and reasons for conducting the FGDs. All HCWs were able to speak comfortably in English, and no translation was needed. FGDs were centrally completed at University of Abuja Teaching Hospital, and participants were compensated with 2000 Naira as well as the cost of transportation. All participants provided written informed consent to participate and for audio recording. After providing informed consent, participants shared brief demographic information , which was documented on paper. We used the Consolidated Framework for Implementation Research (v1.0) to structure the FGDs, and prospectively developed questions based on selected domains (endix D) . Each FGKIIs and FGDs were audiotaped and transcribed verbatim by Zoom (KIIs) or QualTranscribe (FGDs). Transcripts were read several times by study team members and were not shared outside of the analytic team. A codebook for the KIIs was developed for deductive coding based on the interview guide, and KIIs were analyzed by a single reviewer (ASB). Codebooks for the FGDs were developed based on Consolidated Framework for Implementation Research constructs from the interview guides, and analysis followed a directed content approach. Each FGD was analyzed in duplicate , with discrepancies resolved through consensus coding. Dedoose software  was used to assist with organizing and analyzing the qualitative data. Major themes across the KIIs and FGDs were organized under Consolidated Framework for Implementation Research constructs and identified as either barriers or facilitators of the prospective hypertension ECHO program with CHEWs. These were then mapped to strategies using mechanism mapping and documented with the implementation science tool, Implementation Research Logic Model .Self-reported participant characteristics were summarized using SAS . Characteristics are reported as median and interquartile range for continuous variables and frequency and percentages for categorical variables.The reporting of this study adheres to the Consolidated Criteria for Reporting Qualitative Research guidelines . The proSupplemental Figure 2). Two-thirds  responded to the survey invitation. Those that did not respond were either non-functional  or could not be reached after three attempts . Most respondents were from hubs located in the United States  were CHEWs and among which the median (range) age was 42 (24–58) years. Over half of the participants  were female, and an identical proportion was employed full-time . Occupation and education varied across groups with differences driven by intrinsic selection of medical doctors and nurses for the FGD with prior ECHO participants . None of the prospective participants who were approached declined to participate.Characteristics of FGD participants are reported in We found both barriers (–) and facilitators (+) across the Consolidated Framework for Implementation Research domains, all mapping to a number of constructs in each domain as outlined by the Implementation Research Logic Model . Quotes Engagement with well-recognized experts brings credibility, expertise, and trust to the ECHO hub. Having well-recognized experts facilitate ECHO sessions makes the training sessions more valuable and ensures that participants receive reliable and high-quality information. Their involvement contributes to the overall success and effectiveness of the ECHO hub in addressing knowledge gaps and supporting the professional development of healthcare workers.The ECHO hubs underscored the advantages of online training including increased accessibility, convenience, and the ability to reach a wider audience. Utilizing platforms (such as Zoom) for online training facilitates synchronous sessions where participants can actively engage, ask questions, and receive immediate responses, creating an interactive learning environment. Among FGD participants, there were mixed beliefs about the effectiveness, convenience, and feasibility of online training versus in-person training. Multiple participants suggested a hybrid approach. Most CHEWs agreed that having training in-person would be convenient and conducive to learning.Across the ECHO hubs who participated in KIIs, participation in the trainings was universally voluntary for health workers. Voluntary participation can empower health workers to choose relevant trainings and foster motivation, enthusiasm, and active engagement. On the other hand, some health workers may be hesitant or reluctant to participate voluntarily due to various reasons such as time constraints, workload, or skepticism about the benefits of the training. Challenges such as competing demands and potential resistance to voluntary participation should be addressed to ensure optimal involvement and maximize the benefits of the training programs. Efforts were made by the hubs to motivate participant involvement through rewards, incentives, and recognition.The presence of multiple ad-hoc programs can offer diverse training opportunities and access to different knowledge sources. However, challenges such as fragmentation, lack of coordination, sustainability issues, and competition among programs need to be considered to support HCWs’ training needs and effectively utilize resources. The existence of multiple ad-hoc programs can create a competitive environment among different initiatives, potentially leading to redundant efforts and inefficiencies in resource allocation.The ECHO hub plays a crucial role in facilitating knowledge sharing, improving skills, and providing ongoing support for health workers. During our assessment of ECHO hubs, we found that four hubs  had become non-functional over time, likely due to barriers such as funding, staffing, and competing initiatives – all of which were mentioned as challenges by the hubs we interviewed.At the ECHO hub level, the availability of adequate resources is critical. Therefore, it is crucial to address any potential limitations or barriers to access to maintain uninterrupted operations. Beyond funding and staffing, having access to training curricula, case studies, and continuing education materials, enhances the learning experience and professional development of the participants. Several hubs mentioned challenges in obtaining specific case studies for the training sessions, which can hinder the depth of discussion and learning. FGD participants largely agreed that the effectiveness of the ECHO program would be contingent on the availability of adequate resources  for them to participate.ECHO hubs strive to create a conducive environment for learning and knowledge sharing. This is achieved through interactive and participatory training sessions, open discussions, and opportunities for collaboration and networking. FGD participants identified that the effectiveness of the ECHO program would be contingent on lack of distraction, appropriate timing, alleviating competing clinical demands, as well as the availability of a quiet and private space. There were mixed opinions shared by HCWs on the timing of the training .ECHO hubs acknowledged that health workers face multiple competing demands in their clinical work, which can make it challenging for them to actively participate in training programs. Hubs reported making efforts to accommodate HCW schedules and provide flexibility in training sessions. Healthcare workers noted that the ECHO program may not be effective if the participants are joining training sessions from the clinic during a time when patients are seeking care.The ECHO hubs recognize the need for ongoing and broader training to address the evolving healthcare landscape. The hubs aim to provide continuous learning opportunities, regularly revising training curricula based on identified knowledge gaps. A number of training gaps were identified by FGD participants, such as gestational hypertension, comorbidities, and emergency cases. HCWs also professed the need to have cross-trained staff which can seamlessly provide full coverage patient care in the case of individual absences from the healthcare center.ECHO hubs reported the positive impact of healthcare workers’ eagerness to learn. Their enthusiasm and motivation to acquire new knowledge and skills are valuable assets that drive continuous improvement in their practice. FGD participants similarly demonstrated eagerness to learn more about hypertension, and specifically noted that this would enable them to better care for their patients.Collaborating with a functional ECHO hub can provide a valuable network of expertise, support, and resources. Partnering with such hubs can enhance the effectiveness and sustainability of training initiatives. All ECHO hubs who were interviewed were partnered with one or more organizations for long-term support and had transient and focused partnerships with additional organizations, both global and local, for targeted trainings and support.The results of these analyses confirmed that the core components of the ECHO model are a feasible and appropriate intervention for hypertension education of HCWs, and that the ECHO model itself  may be adopted without significant adaptation. Implementing the ECHO program within the Federal Capital Territory, Nigeria, for CHEWs may require adaptations to overcome resource constraints, such as developing incentives to motivate participation, providing rewards or recognition for active engagement, and utilizing existing resources effectively. It is critical to create a conducive environment for the ECHO program, including raising awareness among HCWs about the program’s benefits, addressing any resistance or skepticism, and fostering a culture of continuous learning and knowledge sharing.These results were used to inform selection of implementation strategies for the hypertension ECHO program. We used mechanism mapping to identify strategies that would address barriers or leverage facilitators .Build a coalition with organizations for support: Partnering with an established ECHO hub that has experience and resources can provide valuable support and guidance during the implementation process. Collaborating with a functional ECHO hub can help leverage their expertise, established protocols, and access to well-recognized experts. We chose to collaborate with mDoc Healthcare for development and delivery of the hypertension ECHO program.Conduct a local needs assessment to inform trainings: Identify the specific knowledge gaps and training needs of healthcare providers in the specific setting. This assessment will help tailor the ECHO program to address the most pressing issues and increase its relevance and effectiveness.Create a learning collaborative through WhatsApp: Facilitate and encourage uptake and sustained engagement in the training sessions by empaneling HCWs in a WhatsApp group for promotion of the training sessions.Involve local opinion leaders as didactic experts: Engage local experts from healthcare providers, institutions, professional societies, and government agencies as experts to lead didactic sessions and facilitate case studies. Their involvement and input will contribute to engagement and reputation of the program.Intervene with HCWs to enhance uptake and adherence: Develop strategies to motivate and incentivize healthcare providers to actively participate in the ECHO program. This can include offering certificates of completion, providing continuing education credits, recognizing active participants through awards or recognition ceremonies, or providing credit for data usage.Prepare HCWs to be active participants: Engage selected sites to participate through case-based presentations to encourage active discussion and ownership in the ECHO sessions.Promote adaptability to session content and participation methods: Ensure that the ECHO sessions are delivered through accessible platforms, taking into consideration internet connectivity limitations. Explore options for offline access or asynchronous participation to accommodate healthcare providers with limited internet access.Tailor strategies based on local context and participants: Tailor the training content to address the specific needs and context of the resource-constrained setting. Incorporate locally relevant case studies and practical examples to enhance applicability. Consider adapting the training curriculum to the local language or cultural context, if necessary.Use mass media to increase uptake: Promote the ECHO sessions through mass media channels and varied platforms to encourage broader reach, knowledge sharing, and collaboration. Foster a supportive environment where participants can learn from each other, exchange best practices, and build a community of practice.We found that ECHO was a feasible and appropriate evidence-based intervention to address knowledge and capacity needs of CHEWs in relation to hypertension diagnosis and treatment. One of the identified critical facilitators was the presence and availability of experts and organizations with which to partner. KII participants emphasized that engagement with well-recognized experts not only enhances the program’s reputation, but also contributes to participants’ motivation and active engagement. Other research on Project ECHO has similarly identified the benefits of faculty recognition in promoting engagement with training sessions 21. KII pOnline training was viewed as both a barrier and facilitator compared to in-person sessions. While online platforms (such as Zoom) offer convenience and flexibility, there are challenges to overcome for sustained engagement. KII participants mentioned difficulties in obtaining case studies and encouraging active participation in live sessions. This suggests a need for consistent application of strategies to ensure meaningful engagement, such as incorporating interactive elements, utilizing multimedia resources, and promoting participant-driven discussions . FGD par22The voluntary nature of participation emerged as both a benefit and a potential pitfall. While voluntary engagement allows for motivated and eager learners who actively seek knowledge, our discussions also highlighted challenges in consistent attendance and active engagement. Other ECHO programs and participants have similarly reported that time constraints and scheduling are primary barriers to participation 252627. S2526HCWs in all sectors and locations face numerous competing demands, which are a barrier to long-term engagement. To encourage engagement, the hypertension ECHO program will seek national and international experts to facilitate didactic trainings, empanel the HCW participants in a WhatsApp group, and provide incentives for sustained participation.A key limitation of this phase is that hypertension training may be offered by ECHO hubs that do not self-identify as cardiovascular or nephrology hubs. This may have biased our selection of hubs to survey and interview. Other ECHO hubs that were not included may offer trainings more suited to participants with lower levels of formal education akin to the target population for our hypertension ECHO series. Responses from ECHO hubs and willingness to participate may have varied based on location (primarily based in the United States), experience, or other factors which may limit application of these results within the Nigerian context and for implementation strategies for use with CHEWs. Despite these limitations, we were able to interview or contact 75% of existing ECHO hubs that focus on cardiovascular disease or nephrology, and have a set of rich interviews for analysis, including several hubs that offer trainings to community health workers. Further, our selection of implementation strategies and adaptation of the ECHO program was performed through a team-based process utilizing the expertise of our Nigerian collaborators. It is possible that some HCWs who participated in the FGDs may not have been willing to be open and honest in their responses. Selected primary healthcare centers and CHEWs may not have been representative of all HCWs participating in the Hypertension Treatment in Nigeria Program, and may therefore limit the generalizability of these results.The findings of this qualitative study provide valuable insights into the implementation of our proposed hypertension ECHO program for CHEWs in the Federal Capital Territory, Nigeria. These results were used to inform key decision points around: 1) scope and content of training, 2) format and frequency, 3) selection of implementation strategies, and 4) building a community of practice.The datasets analyzed during the current study are not publicly available because the data collection, as approved by the Ethics Committee and Institutional Review Board, did not include having them become publicly available. The data can be made available to other researchers by contacting the corresponding author and with Ethics Committee and Institutional Review Board approval.The additional files for this article can be found as follows:10.5334/gh.1277.s1Online Supplement.Supplemental Figures 1–2 and Supplemental Tables 1–2.10.5334/gh.1277.s2Appendix.Appendix A to D.10.5334/gh.1277.s3COREQ Checklist.COREQ  Checklist.


The aim of this study was to assess the 12-week group version of the mentalization-based Lighthouse Parenting Program for child maltreatment prevention. Parents who might be facing mentalizing difficulties due to challenges in the parent–child relationship were invited to participate in the program. The aim of the program was to promote mentalizing—to encourage parents’ curiosity about their children’s minds and their willingness to reflect on their own feelings, thoughts, and behaviors. Study participants were 101 parents . Parenting practices and parental and family adjustment were assessed using the Parent and Family Adjustment Scale and mentalization was measured using Mentalization Scale at pre- and post-intervention assessments. Parents’ feedback on the program was gathered after the program. Results revealed that mentalization, parental adjustment, and family functioning improved while coercive parenting practices decreased after the intervention. Study results provide preliminary indications of the benefits of the 12-week Lighthouse Parenting Program for parents referred or self-referred for mental health services due to their own or their child’s difficulties. Adverse childhood experiences (ACEs), in particular, childhood maltreatment, is one of the major risk factors for a variety of negative developmental consequences, such as emotional or behavioral problems in childhood  and adulParenting programs are widely used in the prevention of child maltreatment ,12. MetaIn recent years, one of the most promising approaches in parental support is the focus on the impact of mentalization in the parent–child relationship . MentaliThe Lighthouse Parenting Program (LPP) is an adaptation of mentalization-based treatment (MBT) with a specific focus on parental mentalization. It was initially developed for parents whose children are at risk for maltreatment . The proIn the current study in Lithuania, we assessed the 12-week group version of the Lighthouse Parenting Program  for pareThis was a one-group pre–post intervention study which was pre-registered . The inclusion criteria for participants were as follows: (a) parents with at least one child aged 12 or younger; (b) parents themselves or their child had been referred or self-referred for mental health, psychosocial, or psychoeducational services due to their own mental health problems, interpersonal difficulties, family issues, child rearing problems, and/or emotional, behavioral, or developmental problems of their child; (c) parents spoke Lithuanian; and (d) parents agreed to participate in the study (to attend the parenting group and fill in questionnaires before and after the group sessions). Exclusion criteria were current mental health needs that needed to be addressed in inpatient treatment , significant intellectual disability, other needs or problems incompatible with the parenting group intervention format, and/or participation in other continuing parenting groups.Study participants were parents, with at least one child aged 12 or younger, who chose to participate in one of the Lighthouse parenting groups and agreed to fill in the study questionnaires. Informed consent was obtained from all the participants in the study. The program was recommended to parents by the specialists working with families, parents, or children, or parents self-referred.n = 101) who started the program were included in this study ). Most of the parents lived in urban areas (94%) and the majority had higher education (89%), 8.9% had secondary education, and 1 participant had lower-than-secondary education. Regarding marital status, 78% of parents were married or cohabitating, 10% were separated/divorced, 8% were single, 2% were widowed, and 2% were in a long-term relationship, not cohabitating. As for occupational status, 81% of the parents were employed, 6%  were on parental leave, 10% were unemployed, and 3% were college or university students. Just over half of the participants (54.5%) had 2 children, 23% had 1 child, 18% had 3 children, and 5% had 4 children. It is important to note that 73% of the participants reported having experience of seeking mental health services, and 44% had been receiving some kind of mental health services at the time they started the group. In addition, 73% had sought professional services for their child’s mental health or developmental problems, and 45% had children who were receiving services when the parents started attending the group.All parents . All participants filled in the informed consent forms before participating in the study. The study was approved by the Vilnius University Psychological research ethics committee. Both assessments (baseline and post-intervention) were carried out online. At baseline, participants received the link to the online questionnaires and filled them in before the individual introductory session of the program. After the intervention, participants received the personalized link for the post-intervention questionnaires from the researchers. The Lighthouse Parenting Program aims to promote parental mentalizing—to encourage parents’ active curiosity about their children’s minds and their willingness to reflect on their own feelings, thoughts, and behaviors . In thisAt least two facilitators were required to lead a group. All facilitators were qualified psychologists who had received Lighthouse program facilitator basic training from the program author. The training covered the main principles and main modules of the Lighthouse Parenting Program, the use of the program manual, the importance of mentalizing in parent–child relationships, core mentalization-based treatment (MBT) competences, and Lighthouse-specific competences. Part of the training was experiential; facilitators had a chance to take part in several exercises from the program to better understand what it might be for parents to participate in them and to have experience of the MBT stance and skills themselves. Training also consisted of interactive discussions, role plays, and group reflection sessions. Weekly group supervision was provided for facilitators by the program author and by another Lighthouse supervisor during the study. The program was delivered in organizations providing mental health and psychosocial services. In total, there were 9 groups with 7–14 parents in each group. Parenting practices and parental and family adjustment were assessed using the Parent and Family Adjustment Scale (PAFAS) . The invParental ability to mentalize was assessed using the Mentalization Scale (MentS) . It is aHow do you rate the benefits of the program you have attended? Participants were asked to choose the most suitable rating on a Likert scale from 1, which meant “Not at all useful”, to 7, “Very useful”.How likely are you to recommend it to other people? Participants were asked to choose the most suitable rating on Likert scale from 1, which meant “Would definitely not recommend”, to 7, “Would definitely recommend”.In the post-intervention assessment, we asked two closed and two open questions about parents’ experience, opinion, and evaluation of the program. We included two Likert-type questions about the parents’ evaluations: We also used two open questions to gather parents’ perceptions and reflections on the program and its impact on them: “What was most memorable, useful and important for you?” and “Now that you’ve finished the group, what else would you like to share about the program, your experience?”t-test for PAFAS and MentS scores. To evaluate the effect sizes of these changes, Cohen’s d was calculated. The significance level was p < 0.05 for all analyses. SPSS27  was used for quantitative analysis. Descriptive analysis of the demographic characteristics of participants and parents’ evaluation questions about the program was performed. To assess group differences , we applied the Chi square test for categorical variables and Mann–Whitney for age and PAFAS and MentS scores. To evaluate the changes in outcome variables  from a baseline (pre-intervention) to post-intervention, we applied a paired samples For qualitative analysis, we analyzed answers to both open-ended questions about the program, in conjunction focusing on emerging themes. First, the initial analysis was performed to capture possible themes. The initial themes were discussed between authors (L.G.-P and R.B.), and material was analyzed again to decide on the final topics/categories. We categorized topics into two broader categories and subcategories with descriptions of the main aspect of each subcategory. When assigning answers to the “Mentalization” category, we used theoretical and clinical understanding and facilitation experience of the Lighthouse program, mentalization theory, assessment of mentalization, and mentalization-based therapy. Finally, we performed a final analysis assessing what subcategories emerge in every answer. The quotes from parents’ answers were used to illustrate categories and subcategories. The analysis was performed by the first and last authors. From 111 participants who initially registered for the program and filled in questionnaires at baseline, 101 participants started the program, 89 (88%) completed the program, and 77 filled in the post-assessment questionnaires (86.5% of participants who completed the program) see . n = 89) the program and who discontinued (n = 12). In most demographic characteristics, groups did not differ significantly, except in occupational status . Comparisons of mentalization and parenting scores revealed no significant differences between completers and non-completers of the program. First, we compared the demographic characteristics of parents who completed (p = 0.034). Secondly, we compared the demographics of parents who completed the program and filled in post-assessment questionnaires with the ones who completed the program but did not fill in the questionnaires after the program. Significant differences were found in terms of sex (a higher percentage of mothers completed and a higher percentage of fathers did not complete the post-assessment questionnaire) and education, where the difference was that the only participant who had lower-than-secondary education did not complete the post-assessment questionnaire. Interestingly, comparisons of mentalization and parenting scores showed that parents who had not completed the post-assessment questionnaire reported more positive encouragement pre-test (mean rank = 30.13) compared to the parents who completed the post-test assessment . Interestingly, the parental perception of parent–child relationship quality did not differ significantly after the program. In the family functioning domain, the scores improved significantly in all subscales. Parents’ emotional adjustment increased most significantly, with an effect size of 0.78. The general capacity to mentalize also improved after the intervention . Parenting and mentalization comparisons: Further, we compared parenting and family adjustment and mentalization scores at baseline with post-intervention scores . The mosn = 16) rated it a 6 (second-highest rating). Parents’ ratings of how likely they were to recommend the program to other people ranged from 3 to 7. The most common answer was “Definitely” , and 16.0% (n = 12) chose 6 (second-highest rating).Parental evaluations of the program: The range in parents’ ratings on how beneficial the program ranged from 3 to 7 (7 being the highest score). Fifty parents (66.7%) rated the program as very useful, and 21% : Parents’ answers about what was important or what they wanted to share after the program contained a lot of positive feedback, with varied levels of detail in parental reflections about the experience or impact of the program on themselves or their children. The main emergent topics from what they shared were categorized into two broad categories, which we called “Mentalization” and “Parental experiences and functioning”, with three subcategories in each. These are presented in The “Mentalization” category represents parents’ answers where they directly mention any aspects of mentalization or there are indicators of mentalizing in their answers, or they indirectly write about mentalization, not referring to special terms or theory. The first subcategory (1) which emerged was the metaphors. Participants noted that metaphors helped them increase their understanding and analyze the behavior of their children and themselves better. Metaphors resonated with parents and were perceived as easily remembered and applicable in everyday life. The second subcategory (2) encompassed answers where parents indicated that psychoeducation about mentalization was important to them, or they noted their improved mentalization or described an improved mentalization process in themselves. The last subcategory was dedicated to parents’ answers on the importance of (3) understanding the connection between their past experiences and present relationships and reactions in parenthood. This link provided deeper insight into possible reasons for their reactions and, for some parents, showed that their past experiences can serve as a basis for the expanded understanding of their child.We named the second broad category “Parental experiences and functioning”. Here, we assigned answers describing perceived impact on parental emotional state, parental self-view, or perceived changes in relationship with a child or in a family and important aspects of experience in the group. One of the subcategories within this domain touches upon self-reported parental changes in their improved emotional state and self-perception (subcategory 4). It includes mentions of improved well-being and changes in how parents view themselves in a parental role. Another subcategory (5) was defined as perceived changes in relationships or in attitude towards relationships. Here, parents shared what they noticed being different in their relationship with their children  or with other people . The last category (6) was related more to experiences in the group. Many parents emphasized the importance of the shared experience; the fact that they are not alone with their troubles and concerns in parenthood, a sense of togetherness, and unity in the group came up a lot in their answers. The importance of the opportunity to share, to listen, and to be heard was also named by parents as being very important.Moreover, quite a lot of parents shared that they felt the need for some kind of continuation of the program . There were parents who experienced the 12-week program as being too short. They felt that they had just started feeling the therapeutic impact, were getting somewhere, were understanding what was offered in the program, and/or were establishing connections with the group, but the program stopped. Some of them shared that they anticipate the need to be reminded of LPP principles and the mentalizing position in future. One more common topic which emerged in the answers was parents’ view that the program should be offered to many more parents and be available more widely.The aim of this study was to evaluate whether parents’ mentalization, parenting, and level of parental and family adjustment changed after a 12-week group Lighthouse Parenting Program and to analyze the parental experiences of the program. Study results revealed that mentalization, parental adjustment, and family functioning improved, while coercive parenting practices decreased after the intervention. These results provide preliminary indications of the benefits of the 12-week Lighthouse Parenting Program group version for parents referred or self-referred for mental health services due to their own or their child’s difficulties.Firstly, there was a significant decrease in coercive parenting practices after the program. Coercive parenting encompasses parental interactions with the child that can be harsh, negative, and hostile such as shouting, getting angry with the child, arguing with the child, using guilt and shame to teach a lesson, and using physical punishment for misbehavior . The latIn addition to that, the results show that, after the program, parents used more positive encouragement with their children when they behaved well. Even though the program does not specifically teach it, this might also indicate that the program increased parents’ understanding of the importance of seeing children when they behave well and to communicate to them that they are being noticed behaving well. This might suggest the impact of modeling: in the MBT group, facilitators aim to notice and label successful mentalizing  in parenContrary to our expectations, the change in the quality of parent–child relationships was not significant. This finding can be anchored in the data provided in other similar studies. What can be seen from the studies on MBT parenting interventions is that most indicators of relationships are assessed through observational measures ,22, and Moving on to the parents’ well-being, we measured overall emotional adjustment to the parenting role, which encompasses experienced levels of stress, depression, and anxiety . Our resFamily functioning and a sense that parents work as a team increased after the program. Mostly only one parent from the family participated in the program, but it seems that, at least through the perspective of the participating parents, there was more support and positive interactions, fewer conflicts, and less criticism in families after the program. In those parents who were coparenting, the sense of parental teamwork improved. It might be possible that there was a change in how the participating parent interacted in the family during and after the program, which influenced family relationships.Parenting practices, family functioning, and parental emotional adjustment are outcomes which are quite often included in studies of different parenting programs within the field of childhood maltreatment prevention. In general, our results showing the decrease in coercive parenting and increase in positive encouragement echo the effects of other parenting programs ,13. RegaFinally, the LPP program is specifically tailored to increase parents’ capacity to mentalize, i.e., ability to understand behavior in terms of mental states . TherefoFurthermore, the importance of mentalization theory and change in mentalizing abilities emerged often in parents’ reflections on the program, with three separate subcategories. Firstly, it seems that metaphors were memorable and useful for parents. They served as an aid for mentalizing children and parents themselves. During the LPP, focus is also placed on increasing parents’ awareness that their current reactions and experiences in parenthood can be related to their past attachment or other significant interpersonal experiences. Parents’ answers illustrate that, at least for some parents, this was a very important insight which stood out for them. This whole category on mentalizing shows that the concept and experience of mentalizing made an impact on parents and reached them, not only cognitively but also emotionally.The current study provides encouraging indications regarding the acceptability of the intervention by participants. Parents’ evaluation of the program was very positive, with most of them giving high ratings on the benefit and their probability of recommending the program to others. The retention rate can be also considered to be one of indicators of acceptability , and in Our findings about parental experiences echo findings from a small sample of parents  where siSome limitations of the study and relevant future directions should be mentioned. The first limitation is the absence of a control group, which impacts the generalizability of the results. A study with a control group would be highly important in obtaining further results on the effectiveness or efficacy of the LPP. Moreover, self-report measures were used for parenting, family functioning, and mentalization. This means that we rely on information from one source—the parents themselves. When possible, behavioral measures on parent–child interactions, interview-based measures of mentalization, or the multi-method assessment of mentalization could allow for more reliable and wider understanding of possible outcomes. Studies with more assessments on mentalization and follow-up assessments could also analyze whether increased mentalization in parent–child relationships contributes to improved parenting practices providing important knowledge about possible mechanisms of change. One more limitation of our study is that we did not use one of the PAFAS scales—Parental Consistency—which showed low reliability, so this also should be investigated further in the Lithuanian sample.The Lighthouse Parenting Program shows initial indicators of preliminary effectiveness and demonstrates that it might be a promising intervention in the prevention of childhood maltreatment with decreasing coercive parenting and increasing parental and family adjustment. One of the specific aims of the program is to increase parental mentalization, and the results are encouraging, as they provide some preliminary evidence that the program improves the general level of mentalization in parents.


Results suggest that the CFC program shifts the organizational culture, teaches staff skills for recognizing and supporting others in distress, and supports those staff who are already providing these services informally. Findings suggest that staff distress resulted primarily from external factors and secondarily from internal organizational stressors. External stressors were exacerbated by the COVID-19 pandemic. Although the program has promise for addressing staff burnout, other organizational efforts are needed to simultaneously promote staff wellness. Ultimately, psychosocial peer support programs for health care workers are feasible and potentially impactful, but also require other systemic changes within a health care system to improve and sustain staff well-being.Health care workers in the U.S. are experiencing alarming rates of burnout. Furthermore, the COVID-19 pandemic has worsened this issue. Psychosocial peer-support programs that address general distress and are tailored to health care systems are needed. A Care for Caregivers (CFC) Program was developed at an American metropolitan university hospital and outpatient health care system. The CFC program trains “Peer Caregivers” and managers and has four components: the identification of colleagues in need of support; psychological first aid; linkage to resources; and the promotion of hope among colleagues experiencing demoralization. Qualitative interviews ( Health care workers in the U.S. are experiencing alarming rates of burnout, with 35–54% of nurses and physicians experiencing substantial symptoms of burnout . BurnoutThe 2019 National Academy of Medicine consensus report found that burnout is caused by an imbalance in the clinician’s job demands and the available supportive resources in the organization. Work demands that contribute to burnout include excessive workload, unmanageable work schedules, and inadequate staffing; administrative burden; workflow, interruptions, and distractions; inadequate technology usability; time pressure and encroachment on personal time, moral distress, compassion fatigue, and patient factors. In addition to work demands, individual factors such as work–life integration and the combination of personal and professional responsibilities and activities also contribute to burnout. Furthermore, the external environment such as structural changes in the health care industry; the laws, regulations, and standards for the oversight of clinicians; and changing societal values and the clinician–patient relationship, has an impact on health care worker burnout  was okay, [but] somewhat disingenuous. Many people come at this with sort of a jaded attitude, so I think you know more than boostering, you have to kind of dig a little deeper…you have to find out what are people’s problems with the [university health care system]”.As for organization-wide wellness initiatives other than training, only participants (primarily the four stakeholders) who were involved as leaders in developing staff wellness initiatives were aware of them and the other participants interviewed did not mention any wellness initiatives that they were aware of. Of the participants who did mention their involvement in wellness initiatives, they listed initiatives such as a wellness committee, a virtual covid peer-support group, a speakers’ bureau where they discussed wellness-related topics, student and resident wellness initiatives, staff survey on wellness needs, a creation of a list of community wellness resources, a workplace violence initiative, and the newly formed medical school resiliency and well-being program. This signifies that there is a need for organization-wide staff wellness initiatives to be more widely marketed to raise awareness of these opportunities and continue to demonstrate the shift toward a culture of wellness within the university health care system.“Interviewer: Okay. So, have you been involved in any staff wellbeing initiatives at [the university health care system]? And if so, can you describe them?Participant: Um, I’m gonna say, no, um not anything that I can recall. Not anything that I can recall”.A few participants mentioned being involved in departmental wellness initiatives such as departmental staff days, 2-min of mindfulness as a department at the beginning of the pandemic, a team yoga class, adding color to team spaces, and more general emphasis of teamwork, support, and wellness among their departments.“So, for my team, one of the things that we did was a yoga class, so we did it as a team and I thought that that was really great to do because we got to know each other in a different way, it was something that kind of helped with team morale, it was a way of also keeping us accountable for taking that break or staying mentally and physically healthy”.The university health care system has an Employee Assistance Program (EAP) where all employees have access to a wide variety of resources. In general, Managers tended to be more knowledgeable than Peers and Stakeholders about EAP resources, but they had mixed experiences utilizing the services themselves or referring staff.“I know we do have a resource of EAP. What they offer and what they do … I’m not sure it meets the needs of our current employee population”.“And that was one of the good things that I saw that the EAP has, there’s a lot of resources there for finances for counseling, or anything like that … And I didn’t want to pry but I just wanted to make, you know, just make sure [my staff member in distress was] aware that, hey, try this resource. They’re there to help you”Non-management staff knew that EAP benefits and resources existed, however, beyond that, they were not knowledgeable about what was provided. In general, all participants knew that there was a phone number or website where they could find the employee resources. Staff learned about the EAP resources during orientation, from their managers, all staff emails, or from information sent out during the open benefit enrollment period.“Um, um, I’m gonna be honest, if they’ve mentioned [the EAP resources] before, if somebody really asked me, if we had it, I probably wouldn’t have denied it. But I wouldn’t have been able to confidently confirm it either”.Among those who did know something about the EAP benefits, by far the most common EAP benefit the participants were aware of was the free counseling sessions. A few participants said that there was some hesitancy around using and referring staff to the EAP benefits, particularly counseling, because of the fear of retaliation from their employer, stigma, and information “staying in your file”. Other specific resources that some participants mentioned being aware of included free access to the online and app-based meditation site HeadSpace and other wellness apps; legal support; funeral resources; child/elder care services; free exercise classes; and the online nutrition shop. Participants also mentioned outside resources they referred their colleagues to such as group therapy, hobbies, local events, legal services, and pastoral care.“I think that’s a real concern that here’s like I don’t want to go to HR and somehow, it’s in my file. Or I don’t want to go anywhere close, and someone sees me, so just a fear and the stigma about getting help is a big one, so I think sometimes just offering them inside help, but then also like okay, and if you don’t feel comfortable, here are some options too”.In addition to the free counseling via the EAP, some participants mentioned that financial concerns, specifically the lack of employee insurance coverage, was a barrier to seeking outside mental health counseling when more intensive or long-term care is needed from a psychologist or psychiatrist.“To be honest, I don’t even know if our health insurance covers therapy, largely because I haven’t looked into it. And also, because it’s terrible. So, I assume it doesn’t”.Some common themes arose about how the CFC program will benefit the university health care system. The CFC program will shift the organizational culture by signifying the leadership’s commitment and creating a more supportive environment for staff, resulting in better job performance and patient care.“We want to be available to people, but even just knowing that a program like this exists, I feel like will help people to feel supported so that even if they don’t need it right now, or ever, possibly, just knowing that [the university health care system] cares to the extent that they’ve developed this program and their fellow colleagues are participating in it, I feel like that itself goes a long way”.Participants discussed how the staff that supported others were burnt out, so it will be helpful to have a wider net of Peer Caregivers and someone to support them. Furthermore, having Peer Caregivers in different departments will help to address the privacy and confidentiality concerns some staff had with talking to staff in their departments or their own managers.“Sometimes I wish I had somebody else here that I could go to, that will want to extend to me what I love extending up, do you know what I mean? So, I can find my [participants name], if I see their badge, you know, if I know that we have this program out here, I don’t always have to be the one helping. I can actually go to someone for you know, just support”.A few participants discussed how the training re-ignited their drive to support colleagues in distress and saw it as part of their role.“[the CFC training] came at a perfect time for me because I was feeling really burnt out. And, it kind of just like, rejuvenated that feeling of like, this is like a service, this is what you need to do. This is kind of how your role plays itself out. So, I think it was like a great reminder of that, for me, especially when we’re on like round 12 of the pandemic or something”.Themes also arose related to the most helpful skills and knowledge that the participants gained from the Peer Caregiver training and Managers Orientation. Specifically, the participants mentioned that the training would help them to better identify their colleagues in distress, improved their listening skills, improved their ability to communicate, gave them tips about the dos and do nots of providing peer counseling, and made them feel more confident in having difficult conversations. A few participants discussed how the training helped them recognize that it was acceptable to create personal boundaries.“I think just thinking about how it shows up in the workplace and how they want support is important. Um, because everyone doesn’t want the same type of support and recognizing that and being able to pivot when necessary”.Another theme was that the training helped to make those already providing support to colleagues in distress feel less overwhelmed and prepared for these conversations. Formalizing and clarifying the role of Peer Caregivers helped to make the supporting staff feel less overwhelmed. Additionally, raising awareness about referral resources helped to alleviate the stress of the Managers and Peer Caregivers because they had something to provide staff as a next step.“But to me that was the most enlightening part to know that, after you’ve done your part, you can always give further instructions for further help”.In general, the participants also gave positive feedback on the training logistics. Most commonly, the participants mentioned that the interactive activities that were built into the training helped to improve their skills and made the training engaging. A few participants said that having a diverse group of staff attend the training from different levels and professions within the organization helped to make the training feel more inclusive and made the discussions interesting.“I think [the role plays] really kind of helped work through, you know, like real life scenarios and how to implement the training, in a way that, you know, just listening to a presentation wouldn’t work for me”.The most frequently cited potential concern that participants had with the CFC program was that they anticipated some general skepticism from staff about the CFC program. Some of the reasons for this skepticism included: (1) resistance to the program because of it merely being a new program; (2) staff might not appreciate the program until they need it so might not immediately see the value in the program; (3) because staff work within the health care field, they might be more critical of services; and (4) staff might be aware of other failed initiatives.“I think they’re gonna think it’s good. But a lot of people are gonna say, but I don’t need it. But it’s not for me. And, but I do believe that is going to be that background thing in your head, like, I do have this… It’s always good to know that you have something, but I’m not sure what it’s going to take to make it real for people to share, if that makes sense”.Another potential barrier discussed was the staff’s fear that the information disclosed to Peer Caregivers might not remain confidential and the fear of consequences (such as being fired) for the information they shared with the Peer Caregivers. Because this was brought up in the stakeholder interviews, it was incorporated into the Managers Orientation and Peer Caregiver training curriculum. However, even with messaging around respecting confidentiality and privacy in the training, the participants continued to have concerns that it would impact the staff’s decision to speak with a Peer Caregiver or their Manager.“I think there may be some initial maybe concern or hesitancy but if there’s like hopefully there’s some word of mouth, or you know if there’s reassurance on confidentiality, I think the main concern is like privacy … I think it would depend on how its presented and maybe like word of mouth … And it may be initially challenging to get people to use something like that, within the workplace, yeah”.Another theme was that some participants anticipated the Peer Caregiver’s skills, or lack thereof, as potential barriers to the program. A few participants discussed how people could not be trained for every situation, the retention of content might be a challenge, and complex situations might be outside the Peer Caregiver’s scope. Others talked about the importance of carefully recruiting Peer Caregivers and avoiding training those without the innate skills and personality to support others.“Um, I mean, I think that maybe there are some people who would not be as appropriate to be trained in these types of things just because of either, you know, their personalities or their workload may not permit for those types of interactions. But otherwise, I think it’s good for most people”.An anticipated barrier to program implementation is that staff will not have the time to become Peer Caregivers, support staff as Peer Caregivers, or utilize the Peer Caregiver services when they are in distress:“I’m, afraid that we may have that opportunity for them to actually go and talk, but they won’t have the time to be able to do that. So that, that would be one of my fears, and, might be one reason why is, they may not be encouraged to actually be a part of it, because their time is already consumed”.Two participants mentioned that one barrier to engagement in the program was the organizational culture within MFA, describing it as “sour” and “a lack of social trust”.“I think that because the culture is a little bit sour, that, you know, people are not often trying to go out of their way to be helpful, just because they already feel so taxed with everything else that they have to do”.Another challenge for the implementation of the CFC program mentioned by a few participants is the lack of physical space in the clinical office building for private conversations. Where to have private conversations was addressed during the training because it came up during the stakeholder interviews, however, it was mentioned by a few participants in later interviews, even with the content incorporated into the training.“I worry a little bit about where to like talk to people. I think yeah, I mean I know space is like super short in the hospital everywhere for everybody, so yeah, I think that’s a big one of like, how do you have private conversations?”Participants were asked about how the CFC program could be improved, and the most common response was that raising staff awareness is essential to the success of the CFC program. Marketing the program encourages staff to be trained and it also encourages staff to utilize the Peer Caregivers as a resource. Ideas for raising awareness included recognizing Peer Caregivers in the staff newsletter, sending out designated emails about the program, encouraging those who have been trained to make announcements during team/department meetings, social media campaigns, posters in staff breaks, announcements in staff town halls, including the training in staff orientation, and having a “Peer Caregiver” sticker on staff badges who had been trained. Many of these suggestions were incorporated into the CFC program marketing as they were suggested.“I think it’s more so exposure, the more people know about it, is, the more they will want to be involved with it, those who want to be from the side of the caregiver, to those who want care, to those who need care, when they realize that there is a resource available, I think that it’s going to open up, you know, the floodgates, in essence, for people to come in”.Some participants gave feedback on the format and logistics of the CFC training. Participants suggested the training group size should range from 4–15 people. A few participants had suggestions related to the training length and structure. Suggestions included expanding the training to three hours (rather than 2) to allow for more role-play and an “open forum” for participants to ask questions as well as breaking up the training into shorter sessions spread over three days.“I think the [training] could actually be maybe a little bit longer and have, you know, more like hands on type of stuff. Because that was really very good. And I just felt like, even though you know, going into it, that the two hours is, you know, like, oh my gosh, and most meetings are half an hour, an hour, and it’s always gonna be a long time, it actually went by very quickly”.Participants also suggested additional resources that could be incorporated into the training. Suggestions included shortening pre-work videos into shorter clips and “cheat sheets” to be referred to when having a conversation with staff in distress. The “cheat sheets” could include common scenarios and statements from staff in distress and a checklist of signs of distress along with possible responses and next steps.“My suggestion is to have sort of a cheat sheet, so if we are going to sit down with somebody, I like to be prepared, so I’d want to probably memorize that or at least be really familiar, so that we can effectively help. I think, relying on your sort of personality and skills to you know help others isn’t always the greatest of ideas, you want to have a structure”.Another theme was the importance of training. Ideas for new audiences that should be trained as Peer Caregivers included medical students, residents, and making it available to all staff in both management and not in management roles.“Probably if others have access to the training as well. Not just those on a managerial level, I think it will be helpful for others”.Participants discussed the need to carefully assign staff to Peer Caregivers to address hierarchical and confidentiality concerns. Suggestions were to have Peer Caregivers available in other departments or to have multiple Peer Caregivers in each department, assigning one Peer Caregiver to a group of staff, a unit, or a department, or to have group peer counseling sessions, available to anyone in the Peer Caregiver’s department, in addition to the option to have one-on-one conversations.“Because of the privacy concerns and confidentiality like if people are not paired with people within their department … I think that may be better and people you don’t see like every day because I think that was a concern … having space between whoever you are going to talk”.A few participants highlighted the importance of ongoing support and training, after the initial Peer Caregiver and Manager training courses. Participants suggested that these could be either formal monthly or bimonthly booster sessions with additional training and collaboration among the Peer Caregivers to share experiences or informal mentorship with a structure at the programmatic level for that mentorship to take place. In response to this feedback, regular supervision sessions were built into the program.“I think monthly or bimonthly booster calls, where maybe a particular topic is discussed … it might just be an opportunity for some like ongoing training collaboration if, perhaps, you know, there’s a way to share … in a confidential way about experiences people have had as part of the program, as the Peer Caregiver. Things like that might be helpful”.Participants mentioned organizational changes, resources and services, outside of the CFC program that could improve staff distress. Three common themes arose. First, the participants discussed that there was a need to create a culture of recognition and valuing staff within the organization. Concrete suggestions included sending cards for important events , monthly kudo or recognition emails, and following up on feedback.“Oh, I believe we need to start pouring into our employees, which, in my understanding, we have not done in many years at the MFA … And I don’t mean pour into them financially, right? I mean rewards and recognition, creating a culture of—a just culture, a culture where they can speak up and they feel valued and that they’re heard”.Second, there is a need for more intensive referral resources to refer staff who are experiencing more complex issues than the Peer Caregivers and Managers are equipped to handle. Participants suggested social workers, an occupational health department, emergency services, and/or psychiatrists.“It would be nice to have perhaps, this is like a dream world, employee based like social workers or a health department. Maybe our occupational department has some kind of branch to it”.The last common theme that came up regarding the organizational changes and resources was that there was a need for more communication to staff about what wellness resources were available. Specifically, participants discussed reviewing wellness policies with staff on a regular basis, reminders about who staff can talk to when they are in distress, and general reminders about the available resources and for staff to prioritize their wellness.“But I also think that in terms of, of wellness overall, that that’s something that is lacking is kind of a review of policies and things from a higher level that may benefit employees, if there were some changes to policy”.Other organizational changes to improve staff wellness that were suggested by only one participant included more flexibility on task deadlines, scheduling, and tele-work, a relaxation room for staff, mandatory lunch breaks, giving staff a “wellness day-off”, ensuring work was more evenly dispersed, more timely response to staff requests , manager training on management skills, and a general culture shift where working after hours was discouraged.The qualitative interview findings suggest that there is a strong need for the CFC program at this metropolitan university health care system. Contrary to what the researchers expected to find, external factors outside of the organization such as the participants work–life integration and external environmental factors were more commonly discussed as contributing to staff distress than internal organizational factors. This differs from previous research that mostly emphasizes internal organizational issues as the main cause of burnout . FurtherOverall, the participants had a positive experience with the Peer Caregiver training and Managers Orientation. Specifically, the participants appreciated the interactive elements. The findings suggest that the training will help participants better recognize distress, have difficult conversations, listen actively, set personal boundaries, and provide referral resources. Although participants generally thought it would be well-received by other staff, general skepticism, confidentiality concerns, the Peer Caregiver’s skills, staff having competing priorities, staff’s large workload, and lack of physical space for private conversations were anticipated to be barriers to the CFC program adoption. Marketing and raising awareness of the CFC program was found to be essential to the program’s success and adoption within the organization.General skepticism to new programs was discussed by a number of participants and resistance to change within organizations and its relationship with burnout is a highly researched topic. A 2017 study of Canadian health care staff who were involved in a large-scale organizational change found that job control/autonomy and supervisor support protected from the factors leading to burnout caused by organizational change . This suPeer Caregivers, Managers, and Stakeholders described one of the biggest benefits of the CFC program as shifting the organizational culture of the university health care system by signifying the leadership’s commitment to staff wellness and creating a more supportive environment for staff. The results of this shift in organizational culture will result in better job performance and ultimately, better patient care. This is similar to findings from other peer-to-peer health care worker support programs where they had a positive effect on organizational culture ,9.An interesting finding was that an informal support network of staff providing support to their colleagues in distress already existed prior to the CFC program. This is in-line with the Agency for Health Care Research and Quality’s “Care for the Caregiver Program Implementation Guide” where they suggest identifying “natural” second-victim supporters and those individuals who are already supporting their staff . Our quaFor the CFC program to be successful, there is a need for more widespread organizational efforts from the university health care system to address staff well-being. This “culture of wellness”, described by many participants, can help to address many of the factors that contribute to staff burnout and can work in conjunction with the CFC program. See There were several limitations to the qualitative portion of the study. Because of the volunteer sampling method, one limitation of the study is self-selection bias. Those program participants who volunteered to be interviewed might have different views of the CFC program from those who did not volunteer. Similarly, with hand-selecting of the stakeholders, there might be some bias in who was invited to be interviewed. Additionally, there was an over representation of the faculty clinical practice employees in both the training attendance and qualitative interview participants, meaning that the findings might be more relevant to the faculty clinical practice rather than to staff directly employed by the medical school . Another limitation is that some program participants were only available to be interviewed once after the training, so their responses might have been impacted by having already attended the training.Subsequent evaluations of the CFC program should focus on short-term and long-term impacts of the training on staff burnout and patient care. Meta-analysis comparing different peer-support programs and training curricula are needed to find the most effective program elements. Further research is needed to independently study external factors to the workplace causing stress and burnout within the workforce. In general, other institutions and health systems should be encouraged to adopt and customize staff wellness programs, and those with peer support elements are recommended.These findings suggest that the Care for Caregivers program implemented at a university health care system helped to shift the organizational culture, taught staff skills for recognizing and supporting distress, and supported the staff who were already providing these services . Furthermore, the Care for Caregivers program was found to be needed to address the staff distress resulting primarily from external factors as well as internal organizational stressors that were exacerbated by the COVID-19 pandemic. Although the program has promise for addressing staff burnout, other organizational efforts are needed to simultaneously address organizational contributors to staff distress.


A number of real-world digital literacy training programs exist to support engagement with mobile devices, but these have been understudied.The purpose of this study was to examine the effectiveness and program acceptability of a digital skills training program among middle-aged and older adults (aged ≥50 years) and to gather participants’ recommendations for lifelong digital skills promotion.The Gluu Essentials digital skills training program includes learning resources to support tablet use. Through pre-post surveys, this study assessed mobile device proficiency, confidence in going online and in avoiding frauds and scams, the frequency of engaging in online activities, program engagement, acceptability, and suggestions for continued support.P<.001), whereas confidence was unchanged. Participants also reported going online more frequently to shop (P=.01) and access government services (P=.02) at follow-up. Program engagement varied considerably, but program acceptability was high. Participants’ recommendations included the need for providing ongoing programs for support and training because technology constantly changes, reducing costs for technology and internet access, and keeping learning resources simple and easy to access.A total of 270 middle-aged and older adults completed baseline surveys. Of these 270 participants, 145 (53.7%) completed follow-up surveys. Our findings indicate that mobile device proficiency increased  among middle-aged and older adults. Although the internet can provide access to important financial, health, and social resources and information [In Canada and in many nations, there has been an increase in technology reliance, with many aspects of life now optionally or necessarily being navigated in digital terms; for example, online banking has become the norm in managing financial matters, and virtual health care options are becoming increasingly more available. We use the term ormation , the agiormation . In 2022ormation . Accordiormation . To meanormation , or the ormation .Mobile and smartphone devices afford greater access to connectivity even in rural areas , yet oneHowever, extant literature reported that older adults face numerous barriers to digital technology adoption, such as a lack of confidence ; negativTo date, the majority of digital literacy programs have been focused on increasing technology acceptance, adoption, use, or interest, with some success -21. As tstick and are not forgotten. A report on a national digital literacy program that incorporated the Gluu Essentials courses  outlined a number of best practices for program delivery, including community-based and flexible program delivery [Indeed, in Canada, a number of digital literacy training programs exist, yet often these have been understudied. More research is needed on the impact of digital skills training on middle-aged and older adults’ digital engagement. Gluu Society is a Canadian nonprofit organization that provides free digital skills training to middle-aged and older Canadians . Gluu isdelivery ; howeverdelivery ; howeverdelivery .The primary objective of this study was to examine the effectiveness of the Gluu Essentials training program for improving participants’ mobile device proficiency. The secondary objective was to explore the impact of the training on the frequency of participants’ engagement in online activities ; their confidence; and their satisfaction with, and acceptability of, the program.This study used a pre-post cross-sectional survey design in which data were collected from middle-aged and older adults in rural and urban communities in Canada before and after participation in the digital skills training program.The digital skills training program was developed by Gluu Society and delivered in partnership with local community organizations and volunteer coaches. Gluu’s target audience consisted of adults aged ≥50 years. The Gluu Essentials resources included (1) printed student workbooks; (2) support for coach volunteers: training, lesson plans, and teaching resources; and (3) online support for participants and volunteers.The Gluu Essentials courses included learning resources to help middle-aged and older adults use Apple iPads or Samsung Galaxy tablets. Courses were centered around these devices because they are top sellers; have user-friendly interfaces; and their manufacturers emphasize security, ensuring that users have a safe digital experience. The printed workbooks included a 96-page Gluu Essentials iPad Student workbook and a 96-page Gluu Essentials Samsung Galaxy Tablet Student workbook . Within Organizations in 23 communities across Canada  were interested in partnering with Gluu to deliver digital skills training. A total of 820 paper surveys (in batches of 10-60) were sent to the community organizations along with the printed Gluu Essentials workbooks. The paper surveys included postage-paid return envelopes addressed to the University of British Columbia (Okanagan Campus) research team. Approximately half of the organizations  fully engaged with the Gluu Essentials program ; of the 10 organizations that stayed connected to Gluu one-third  provided lessons in person , and two-thirds  had volunteers who provided support to learners from a distance . At least 1 other organization that we were aware of delivered the workbooks and training in-person and without Gluu support, but we were unable to track how programming was delivered by the remaining organizations that did not stay connected to Gluu. The online survey was also advertised on Gluu’s Facebook page in fall 2022, emailed to Gluu’s mailing list, and sent through a provincial community response network with >85 rural community affiliates. Online survey participants were individually mailed their preference of Gluu Essentials iPad or Samsung Galaxy Tablet Student workbooks. In terms of inclusion and exclusion criteria, although the recruitment advertisements were targeted at middle-aged and older adults, they only specified that participants must be Canadian residents; however, only participants aged ≥50 years were recruited for follow-up and included in the study analysis.yes were sent up to 5 follow-up invitations by email, and those who provided mailing addresses were mailed paper follow-up surveys with postage-paid return envelopes. To promote participation, three CAD $100 (US $75) draw prize incentives were advertised after the completion of baseline data collection and again after the completion of the follow-up survey.On the baseline survey, participants were asked to check whether they were willing to be contacted for a follow-up survey. Those who selected All participants provided informed consent before completing the survey. This study was reviewed by, and received ethics approval from, the University of British Columbia’s behavioral research ethics board (H21-02116).Sociodemographics, participant characteristics, and postal codes were gathered at baseline. Self-report measures of mobile device proficiency, confidence, and the frequency of engaging in online activities were collected at both baseline and follow-up. Finally, several questions exploring program engagement, acceptability, and suggestions were completed at follow-up only. t tests were used for continuous variables, and Mann-Whitney U tests were used for ordinal frequency of going online for different activities variables.Data were analyzed using SPSS for Windows  . The bast tests were used to compare baseline and follow-up Mobile Device Proficiency Questionnaire (MDPQ) and confidence variables. Wilcoxon signed rank comparisons were conducted to compare the baseline and follow-up frequency of online activities variables. In addition, separate linear mixed models for repeated designs were conducted following the intent-to-treat principle to compare baseline and follow-up MDPQ scores, as well as frequency and confidence variables to provide confirmation of the findings from the t tests and Wilcoxon signed rank comparisons. The models included a fixed effect for time and an unstructured covariance structure .Separate paired samples 2-tailed t tests were used to compare changes in MDPQ scores according to program engagement variables. All variables were inspected for normality and outliers. A P value of <.05 was considered statistically significant. Open-ended responses were analyzed by 2 research team members (CS and KR), and inductive thematic analysis was used to code and determine central themes.Furthermore, change in MDPQ scores was calculated by subtracting baseline scores from follow-up scores, with higher numbers representing greater increases in proficiency. Independent samples 2-tailed A total of 275 participants completed baseline surveys . Of these 275 participants, 5 (1.8%) aged <50 years  were removed, and 6 (2.2%) subsequently dropped out, resulting in 264 (96%) enrolled in training at baseline. Of these 264 participants, 145 (54.9%) completed follow-up surveys . ParticiThe mean age of the participants was 72.93  years, and they were primarily female, White, and residing in the province of British Columbia  and accessing government services (P=.02) increased, whereas the frequency of going online for email (P=.47), banking (P=.10), information (P=.96), and emergency services (P=.42) did not change significantly. The frequency of going online for COVID-19–related information significantly decreased (P=.01). Inspecting the distributions of responses to these ordinal scales showed that many of the participants who had selected never at baseline seemed to have instead selected some frequency above never at follow-up (except in the case of going online for COVID-19–related information). To aid the interpretation of these ordinal scales, never at baseline and follow-up.The comparison of the groups  shows that the frequency of going online for shopping (smartphone or laptop), and 7 (5%) did not receive or use a workbook. Having a digital coach, using a printed workbook, and following Gluu on social media were all unrelated to change in mobile device proficiency; however, participants who reported still accessing Gluu resources had a greater change in mobile device proficiency than those no longer accessing these resources.Change in mobile device proficiency , ranged from −0.94 to 2.78 . The negative numbers denote that, for some of the participants , the MDPQ scores actually decreased slightly from baseline to follow-up. Nevertheless, the MDPQ scores increased for the majority of the participants , with the greatest increase being 2.78 points on the 5-point scale. Change in mobile device proficiency also varied with some program engagement metrics. above average) to the Gluu Essentials program.Participant feedback on the Gluu Essentials training program was positive: 88% (82/93) reported being satisfied with Gluu Essentials digital skills training, 82% (75/92) reported learning new things about their device, 78% (73/93) reported learning new things about digital security, 78% (74/95) agreed or strongly agreed that the printed workbook was important, and 69% (60/87) stated that they were more likely to use technology to support their aging plan . System usability scores ranged from 25 to 90 , with 76 (79%) of the 96 participants who completed this scale assigning a score of >68  and on their confidence, as well as to assess their satisfaction with, and acceptability of, the program. Overall, participants’ mobile device proficiency was higher after the program than at baseline, and they were going online more frequently for some activities; however, confidence was unchanged. Program acceptability was high, and participants who started or completed some lessons as well as those who were still accessing the Gluu Essentials resources had the greatest changes in proficiency.Participants in the Gluu Essentials digital skills training program were middle-aged and older adults interested in learning about tablets; indeed, the Gluu Essentials program is targeted at basic tablet skills specifically, although there are a few broader digital skills touched on, such as digital security as well as Facebook and Zoom basics. As such, we found positive changes in mobile device proficiency after the program. Overall mobile device proficiency reflected increases primarily in the subscale competencies of mobile device basics, communication, internet, and troubleshooting. The increase in troubleshooting scores is noteworthy because it reflects participants’ growing capacity to problem solve issues that arise without dependence on others, such as family and friends. In a recent scoping review, the lack of technical support that included troubleshooting was highlighted as a barrier to using technology for older adults . Gluu Eshandy, participants increased the frequency with which they went online for these activities. By contrast, going online for COVID-19–related information was reduced after the training, which was likely a reflection of the timing of most of the follow-up surveys because COVID-19–related measures lessened in Canada in the summer of 2022, although the COVID-19 pandemic was not officially downgraded until May 4, 2023 [In addition to increased mobile device proficiency, we found that there were increases in the frequency of going online for shopping and accessing government services among the participants. It is possible that having achieved greater mastery of their devices combined with the fact that mobile devices are  4, 2023 . Similar 4, 2023 ,42, we fLikewise, confidence in going online and avoiding fraud and scams was not significantly higher at follow-up than at baseline. It could be that training targeted more to these specific skills  is needed to improve confidence in these areas because digital security was only a small component of the Gluu Essentials program. Indeed, the Gluu Essentials digital skills training program and manual were intended to build proficiency—the essentials of actually using a tablet. Nevertheless, it is perplexing that confidence in going online did not increase, especially because the participants were going online more frequently for some activities. Other similar digital skills training programs for older adults improved self-efficacy . ResearcOf the 143 participants who responded, 117 (81.8%) made use of the printed workbooks  that accompanied the training, and 78% (74/95) believed that the workbook was an important component of their learning; in addition, qualitative feedback from the workbook users indicated their need for it and its helpfulness. This aligns with qualitative evidence that older adults prefer using self-training text materials, such as a manual . HoweverAlthough the majority of participants  reported increased mobile device proficiency at follow-up compared with baseline, notably, several participants  reported a slight decrease in proficiency. It is possible that some participants did not have the one-to-one support that they were asking for or felt overwhelmed with the unpaced volume of information and how they could practice as was noted in some open-text responses. Furthermore, engagement with many of the program components was not related to mobile device proficiency, and this may reflect the smaller number of participants who reported engagement , or it could reflect the variability among learners ; however, encouragingly, those who engaged with the 12 Gluu Essentials lessons did report a greater increase in mobile device proficiency than those who did not start any lessons, reflecting the impact of the workbook. Indeed, engaging with the content or lessons might be considered foundational to all other program resources; other program supports (such as coaches) cannot provide optimal support if learners have not engaged with the lessons. Furthermore, continuing to access the Gluu Essentials resources was related to increased mobile device proficiency; therefore, ongoing engagement and practice are likely important for success.above average. Continued research is needed on middle-aged and older adults’ attitudes toward, and satisfaction with, digital skills training, specifically with individual training components, to inform the development of relevant and acceptable programming [Despite variation in self-reported program engagement, the majority of the participants did find the program acceptable, with more than two-thirds reporting being satisfied , having learned new things , and being more willing to use technology for their aging plan . Likewise, 79% (76/96) rated the usability of the Gluu Essentials programming as gramming ,48.second-level digital divide, namely having the skills and literacy to access information and communication technology [This study focused primarily on what has been referred to as the chnology ; howeverreal world, that is, community organizations and participants adopted the training, and the program was delivered voluntarily. This allowed for an assessment of the potential and effectiveness of digital skills training in a natural environment, which may be influenced by external variables  that are not necessarily apparent in highly controlled or specific settings. Furthermore, the assessment of program engagement allowed us to examine the impacts of different program components on change in mobile device proficiency, illuminating the importance of engagement with the core programming .This study has several strengths. The Gluu Essentials digital skills training program was implemented in the never went online for each activity at baseline (just proportionately fewer of them). We also observed increases in mobile device proficiency and the frequency of going online for 2 activities, and linear mixed model analyses suggested that the observed differences could have been even greater if more participants with lower scores at baseline had been retained at follow-up.Despite these strengths, this study has several limitations. Participants were motivated to learn digital skills, and although training was free, participants had to have their own device or have a means of obtaining a device ; therefore, the results may not generalize to other populations. In addition, as this was an ongoing and freely offered community organization–delivered program, we were not able to use a randomized controlled study design. Relatedly, owing to challenges with the organizations tracking the distribution of the paper surveys, we were unable to report the baseline survey response rate as well as the total number of participants engaged by the community organizations during the study period. Likewise, our inability to document how and in what structure the organizations offered the training was another limitation. Despite efforts to mail follow-up paper surveys to participants who had completed paper surveys at baseline, more participants who had completed paper surveys at baseline were lost to follow-up overall. However, those lost to (survey) follow-up did not necessarily drop out of training; all paper baseline survey completers received a printed workbook and had some level of support from their community organizations. Engaging community organizations to distribute paper follow-up surveys may have improved response rates. Follow-up survey completers also had higher mobile device proficiency scores at baseline; despite this, our follow-up participants represented the full range of mobile device proficiency scores (ranging from 1 to 5). Likewise, we retained some participants who This study is unique in that we examined the impact of an existing digital literacy training program on middle-aged and older adults’ digital engagement. Middle-aged and older adults participating in a real-life implementation of the program had higher follow-up scores on mobile device proficiency and greater frequency of going online for shopping and accessing government services compared with the baseline. The Gluu Essentials program was an acceptable and effective approach to digital skills acquisition, and future efforts should focus on strengthening program delivery to ensure that all components are available to all participants. Altogether, these findings advance the understanding of middle-aged and older adults’ digital skills acquisition, particularly with respect to learning to use mobile devices, and have implications for other programs designed to engage and support middle-aged and older adults.