Hospital admissions due to the acute exacerbation of chronic obstructive pulmonary disease (AECOPD) are costly for individuals and health services. Pulmonary rehabilitation (PR) is known to reduce hospital readmissions when delivered after hospitalization, but the uptake and completion of PR following hospitalization remains poor (<10% of those eligible in the UK audit data). A web-based platform of the SPACE (Self-management Program of Activity Coping and Education) for COPD (chronic obstructive pulmonary disease) has previously shown promising results in patients with stable COPD but has not been tested following an AECOPD.This study aims to assess the feasibility and acceptability of a web-based self-management program.A nonrandomized feasibility study for patients with confirmed AECOPD who were deemed web literate was conducted. All patients consented during their hospitalization and received access to the website following discharge in addition to usual care. The program aims to facilitate patients to better understand and manage their condition through education and home-based exercises. Participants were asked to complete the Bristol COPD Knowledge Questionnaire at baseline and after 6 months. A total of 14 participants were also interviewed  regarding their experiences with the web-based program and trial. The interviews were analyzed using thematic analysis.In total, 2080 patients were screened for eligibility, of which 100 patients  were recruited (4.8% of those screened). The main reason for ineligibility was a lack of web literacy . In total, 18% (18/100) of patients had completed the web program by 6 months, with others still registered in the program , and more than half did not register . There was a mean change in Bristol COPD Knowledge Questionnaire scores at 6 months of 7.8 (SD 10.2) points. Qualitative interviews identified three main themes: preparing for, engagement with, and benefits of the study and program. A total of 57% (57/100) accepted a referral to PR on discharge and 19% (19/100) had completed the program after 6 months.On the basis of the challenges of recruiting, retaining, and engaging participants in a web-based self-management program, it is not a feasible approach to roll out widely. This study acknowledges that this is a challenging time for patients with an AECOPD to engage in exercise and self-management education. However, for patients who were able to engage in such an intervention, the completion rate of PR was double the previous audit estimates from the United Kingdom, disease knowledge improved, and the intervention was of value to patients.ISRCTN Registry 13081008; https://www.isrctn.com/ISRCTN13081008 Hospital admissions for the acute exacerbation of chronic obstructive pulmonary disease (AECOPD) represent a huge burden to the individual in terms of muscle dysfunction, breathlessness, and inactivity . FurtherDespite this guidance and the established benefits of PR, access to, uptake to, and completion of postexacerbation rehabilitation are very poor. In the United Kingdom, less than 10% of all hospital discharges for the AECOPD completed posthospitalization PR . More reThe reasons for nonuptake and poor completion are underpinned by complex reasons; some are related to the organization and system of delivery and others to patients’ individual choices ,13. A keTo address the problem of uptake, over the past 10 years, we have developed home-based alternatives to attending a traditional center or community-based PR. These remote models have become increasingly relevant in the era of COVID-19, as the social distancing measures taken in many countries to suppress transmission of SARS-CoV-2 have had an immediate and profound effect on the provision of PR services . SPACE . To assess this, we asked patients about the types of devices used, the time spent on the web, and the types of web-based activities for each patient . A decision on web literacy was at the discretion of the recruiting clinician. The program was predominately delivered via a tablet. Patients could use their own device or borrow an Android tablet, for instance, if they usually borrowed a family member or did not have access for the duration of the study. Borrowed devices were locked , other than for access to the SPACE for COPD website. People with significant neuromuscular or cardiovascular comorbidities limiting physical activity  and those who were unable to read and write in English were excluded. Currently, the website is available only in the English language.Patients were given access to the SPACE for COPD program as an inpatient. A passport card with log-in information and staff contact details and a user manual were given to the patient on discharge along with a verbal introduction to the program  by the COPD nursing team.ask the expert facility (to email the COPD nursing team). The ask the expert emails were monitored by the specialist COPD nursing team during working hours . Prompts to log on to the website and record activity were automatically generated by the program and sent via email if patients failed to record activity for 7 consecutive days. Patients also received a telephone call from specialist COPD nurses within the first 5 days following discharge .SPACE for COPD is an interactive web-based program that offers a comprehensive package of exercise and self-management education. The program was structured to guide the user through four stages, each of which has specific tasks that the user needs to achieve before progressing to the next stage. Tasks included creating and updating their own short-term goals, completing knowledge tests on COPD and exercising safely, and reading or watching videos on specific topics, such as inhaler techniques or healthy eating. The program was described in detail by Chaplin et al . In stagUsual care, including referral to and attendance at PR, was not affected by this trial; patients received a telephone call from the COPD nursing team within 5 days of discharge and had a scheduled follow-up appointment with a consultant within 3 months of discharge.The primary outcome was the feasibility of the intervention . This questionnaire was chosen because the authors felt that it was the least likely to be influenced by illness and natural recovery following the AECOPD. The secondary outcomes were the acceptability of the intervention and trial , intervention engagement (web usage statistics: number of log-ins and use of web features captured directly from the administrator section of the website), and uptake to outpatient PR (uptake and completion rates in those referred). All outcomes were assessed at baseline  and 6 months following enrollment in the study, regardless of whether the patient had engaged with the web-based program or PR during the 6-month period.Data are described as mean (SD), median (IQR), or frequency (%), as appropriate. No inferential statistics were obtained owing to the feasibility nature of the trial. As is convention with feasibility studies, a formal sample size is not required . A totalTo measure patients’ views on the acceptability of the web-based program and the study, qualitative interviews were conducted with completers and dropouts on a purposive sampling basis  to obtain a sample of 100 patients. The proportion of patients recruited as 4.8% of those screened (100/2080). The predominant reason for exclusion in approximately  of cases was that patients were not web literate or did not have an email address. Of the participants recruited, the mean age of participants was 71 (SD 9) years; they had severe disease and a mean smoking pack-year history of 50.2 (SD 31.0) years . There wThe change in the BCKQ score was 7.8 (SD 10.2) points, an increase of 21% . This was done in 42 patients who returned the questionnaires at 6 months.preparing for, engaging with, and benefits of the web-based program.Qualitative interviews with a sample of 14 patients  identified three themes, with a total of eight subthemes. The relationships between the themes are presented in The patients described a number of reasons why the web-based program incited their internal motivation to engage with a telerehabilitation program. Some studies have described the fear they experienced from a recent COPD exacerbation as a catalyst:...when you’re recovering from something that frightens you to death, you say yes to everything. So that’s why I said yes.Participant 69, completerThey also felt that the program offered an opportunity to learn how to manage their condition more successfully through the ongoing support of health care professionals:I wanted to learn more and to see if there was anything that would be beneficial to the breathing obviously. Because I mean we know that the rehabilitation works. I can vouch for that. Unfortunately it has a very short shelf life unless you continue it. So I was hoping that just get information because there really isn’t that much information. Your own GP doesn’t seem to have, I mean I’ve got a fantastic GP, but he hasn’t got a lot of information on COPD. If you have a problem, he’ll refer you to the respiratory nurse who comes about once a year.Participant 39, completerThe appeal of a home-based program was also evident among patients. They felt it offered them the ability to complete the program at their own pace, and this flexibility allowed them to fit it into their established routines:...she said you can do it at home on your laptop and in my own time. I haven’t got to go out the house, well I’ve got to go out the house to walk.Participant 100, noncompleterA subset of patients described external influences as factors that motivated them to engage in the program. Some felt that the reassurance health care professionals offered was what they needed to engage with the program. Others felt that their families were instrumental in encouraging their engagement with the program. One patient described how the support of her family gave her the confidence to engage:but I thought—like my children said to me, if you’re not doing that mam, what are you going to be doing. Thought well, yeah, they’re right, why shouldn’t I do it.Participant 52, completerFor another, the program was viewed as an opportunity to share the learning materials with their loved ones in an effort to improve both their health:...I was hoping that at the end of it I would have a bit more information as to - because my missus had got COPD as well and there was something we could learn from it.Participant 39, completerOverall, patients felt that their computer literacy skills were vital to their ability to engage with the program. Despite the assessment of computer literacy skills before enrollment in the study, some patients felt that their age or generation acted as a barrier to their ability and many lacked confidence in their skills:I mean for you and for your generation, you don’t even think about it do you, you just do it. For us, we never had it. It was chalk and slate!Participant 39, completerAll patients felt that the program was complex in nature and learning to navigate it felt like a steep learning curve. Some felt it was too steep a learning curve for their computer literacy skills, which resulted in reduced motivation to engage with the program or, for some, to disengage from the program entirely:...you spend more time on the computer than walking. So that defeated the object with me anyway.Participant 100, noncompleterTo tackle this issue, some patients sought help from family members or health care professionals but still found the interface challenging and at times overwhelming:It wouldn’t let me in. I tried it on Safari and it kept refusing me and then I finally got on...And I just couldn’t get on with it. I got it on in the end with the help from my daughter and then all the questionnaires, never ending, just one page after another...what’s your lung capacity? How do I know? What is it when you breathe in, what is it when you breathe out?—terrible!Participant 100, noncompleterFor those patients who persevered with the program, they felt self-discipline, self-motivation, and allocating time to learn how to navigate the program were essential to their progression:As I say, after about three to four weeks I was very confident or confident, I’ve never been very confident at any of it, confident, but I must be honest it did take me about that long before I felt happy doing it. You know, I did it and I’d sit there for ages doing it and my missus would say to me have you done it yet? But, you know, you’d persevere....Participant 39, completerSome patients expressed frustration due to the interaction they had with the program, particularly the email reminders to exercise daily as they felt it lacked the acknowledgment of their individual internal and external barriers to exercise:I found myself getting a bit wound up when I’d not carried out certain tasks to the satisfaction of the, you know, the interaction was you haven’t exercised this week. No I haven’t because I’ve not been well!Participant 69, completerlittle nudge, as it helped them develop exercise habits:Other patients embraced the exercise reminders and enjoyed the I found it very good because you’re doing it at your own pace. And it wasn’t excessive and it just gave you that little nudge in the back of your mind. You’d look at your emails and it would come up SPACE and you’d think oh ah. It were more like, not a guilt trip, that’s wrong, but it just give you that little nudge and you think. But once you got into it, you know, you did it automatic which was a good thing.Participant 39, completerA further facility to initiative interaction with health care professionals was the teleconferencing option, but this was not used by any participant. Some patients felt it was too advanced for them, others felt it lacked a personal approach from staff, and some were unaware of this option:I think I did see it, but that, I’m not, I’m better off person to person, not person to screen.Participant 78, noncompleterFor patients who reached the exercise component of the program (stage 2), many felt goal setting was beneficial, as it motivated them to exercise more, which in turn had a positive impact on their quality of life:Yeah, my breathing is better when I’ve done the exercises, when I’ve done the walking. It don’t feel at the time, I’m gasping like hell. Later in the day you feel the benefits of it. It always clears your lungs out, it clears your lungs doing the walk. And I enjoy that.Participant 100, noncompleterThe daily recording and monitoring of the patients completed also helped some to identify patterns in their exercise behavior, and from these patterns, they could identify earlier onset of COPD exacerbations:And what was interesting with that was if you were honest and put it down on the programme, you started to see a pattern building up. And I don’t know what the pattern meant or whatever but you could see when you were coming up to, you know, one of the and you needed the antibiotics, you could see it before.Participant 39, completerHowever, patients felt that their ability to exercise was restricted by factors outside their control. For example, some did not prioritize exercise if they felt unwell or if the weather was deemed inclement. However, one patient who faced this scenario did not let this deter him from exercising:I go on my bike when I can’t go out then I’ll stand and do a few knee exercises, stretches and bending and things.Participant 100, noncompleterOverall, patients felt that the education component developed their understanding of COPD and increased their knowledge and skills regarding self-management. They felt that the program highlighted the importance of exercise and gave them important practical skills:The breathing, the way that you breathe. The necessity to exercise is the thing that comes out of all of it, even if it’s only small amounts. And if you can’t hit what you set yourself to do, don’t beat yourself up with it. Just do it, do the best you can, and that’s the thing that came out of it. If you can’t do what you want to do on that particular day, do what you can do.Participant 39, completerSome patients felt that the program also helped them understand the relationship between COPD and mood. This understanding helped them recognize their feelings as a natural reaction to living with a long-term condition:...one of the other things that came out about it was things like getting depressed. I don’t tend to get depressed, I tend to get fed up with it all and you think is this it, whatever? Which is again very normal but you don’t know that and you think what’s happening? They tell you that.Participant 39, completerSome patients felt that their ability to complete the program was affected by factors outside of their control, which reduced their motivation and level of discipline. Exacerbations of COPD, comorbidities, and becoming a caregiver for a loved one were all described as reasons for noncompletion:So once I got used to it I didn’t really have a problem with it. And I followed that religiously. And then we hit a snag, but it was nothing to do with the course. My missus had to go into hospital for three months because she had a brain haemorrhage. So when she came out, she still needed, we needed to put the time in to get her back to normal again, which was three, four, five months. So that then took a little bit of a backseat and I found then I couldn’t quite catch up.Participant 39, completerPatients who engaged in the program felt it gave them a focus and drive to take control of their health. Patients felt that the program helped them reassess their illness perceptions, which, in turn, made them feel less self-conscious, more confident in self-managing their COPD, and gave them hope for the future:I feel in control of it. Instead of it controlling meParticipant 52, completerSome patients felt that the program inspired them to challenge their health behaviors and encouraged them to make positive changes. Patients attributed increases in daily exercise to the program, and others found affirmation for smoking cessation:[I’ve learned] Never to smoke again.Participant 88, completerProgram completers and noncompleters all felt that the program helped them find enjoyment in exercise, and this encouraged a continuation of exercise following program completion. To facilitate this, some patients purchased exercise equipment, downloaded fitness apps, recorded their daily exercise, and began to embed exercise into their daily routine. This increase in exercise meant that some participants were now more capable of carrying out their daily activities:I managed to do all my garden last year instead of having a gardener...I can now have a shower and I wash everywhere down.Participant 52, completerNone of the participants used videoconferencing or blog facilities. The median number of log-ins per person was 14 and emails to the team was 1. Patients generally recorded more than one goal throughout the course of the program, an average of 3.6 (SD 2.4) per person, and an average of 16.5 (SD 32.7) of the exercise sessions were recorded.At 6 months, 18% (18/100) of participants had completed the web-based program, 27% (27/100) were still registered, and 55% (55/100) had not registered, despite prompts by email and a phone call from the nursing team within the first 5 days following discharge. The fact that one-fourth were still registered at 6 months suggests that the acute population may need longer to complete the program compared with a stable population.Of the total 100 participants in the sample, 57 accepted a referral for rehabilitation. Of these, 47 were assessed, and 35 started a program; 19% (19/100) of the total population completed either a hospital or community outpatient rehabilitation program.On the basis of the challenges of recruiting, retaining, and engaging participants in the SPACE for COPD web-based self-management program, it is not a feasible approach to roll out widely. In the face of organizational pressure to provide health information on the web and despite statistics suggesting otherwise, digital literacy in this group was lower than anticipated, as evidenced by the low number of patients deemed to be web literate.by improving self-efficacy and engagement and by supporting health care professionals to practice preventative care provision. However, we are aware that, although web usage among people aged >75 years is increasing [Engagement in the program was poor. At 6 months, only 18% (18/100) had completed the web-based program, 27% (27/100) were still registered, and 55% (55/100) had not registered, despite prompts via email and phone calls from the nursing team. The fact that one-fourth of participants were still registered at 6 months perhaps indicates that an acute population takes longer to complete the program compared with a stable population  study , in whiccapability, opportunity, motivation, and behavior model of behavior change [These results suggest that patients’ exercise behavior was influenced by their intention to exercise, and this was further negated by their internal and external motivation, their opportunity to exercise, and their physical ability to exercise. These findings support the r change , which dHowever, in those recruited to this study, the completion rate of PR was 19%. This is double the previous audit estimates from the United Kingdom and significantly higher than the 1.9% proposed recently from the United States . In addiTherefore, we would conclude that web-based strategies may be a viable stepping stone to postexacerbation PR in those able and willing to engage with the program.The main limitation of the study is that it was not an RCT; therefore, the effects of natural recovery were not considered. However, we chose to look at disease knowledge as a secondary outcome (rather than an outcome such as exercise tolerance or muscle strength), which is less likely to be influenced by exacerbation recovery. Furthermore, as this was a feasibility study, we did not intend to infer clinical effectiveness. We accept that postal returns of questionnaires are not the most reliable way to return data, and we followed this up with a phone call prompt to increase data completion. It may have been interesting to examine the differences in outcomes such as hospital readmission and uptake to PR in a matched usual care–only cohort , but we did not seek ethical approval to do this.This was also a single-center study, which may introduce selection bias and decrease the generalizability of the findings to other settings. Further concordance of qualitative themes between the four coders using statistical methods  would have strengthened these data further.As stated previously, patients or recruiting clinicians may have overestimated the patients’ ability to navigate the web program. This was despite strictly adhering to our screening criteria , a validated digital literacy measure would have been useful to aid screening.The timing of enrollment in the study and introduction of the intervention were pragmatic and not standardized. We tried to do this as close to discharge as possible, but this was not always easy to predict in practice. We appreciate that a hospital admission may not be the best time for patients to be receptive to new information. In particular, it appears that cognitive function is specifically impaired during exacerbation but may recover . Therefoall comers. Therefore, it is likely that these participants had a personal interest in self-management of their disease. In addition, because the web-based program acted as a graduated transition into outpatient PR, there may have been participants who stopped using the web-based program when they started PR or vice versa . We have not been able to tease out these nuances in our data.Although the completion of postexacerbation rehabilitation in this study is impressive, it is of course with the caveat that these were self-selecting, enthusiastic research participants rather than Several gaps still exist in the literature on the topic of increasing access to and participation in PR. There may be instances where completion rates for PR are buried within manuscripts as a secondary outcome, but as it is not the primary outcome, it is unlikely to change guidance. This may be because we have no idea what an acceptable level of uptake or completion would be; therefore, studies tend to choose primary outcomes based on the quality of life or exercise measures, where we already have a wealth of data or minimum clinically important difference values. Therefore, high-quality research is needed to review complex interventions with uptake or completion as the primary outcome. In addition, we might assume that many centers have adapted their programs in pragmatic service improvement initiatives to increase acceptability without robust testing of these methods. This would account for the gaps in the literature.P=.37), with no differences in secondary  or safety (readmissions and death) outcomes. Unfortunately, 40% (6/15) of participants interviewed did not recall receiving the video.Since we have completed our study, one RCT has been published, which evaluated the effect of a co-designed  education video as an adjunct to usual care on posthospitalization PR uptake. PR uptake was 41% and 34% in the usual care and intervention groups, respectively  uncertainty regarding the timing of PR; (2) tailored and flexible manner to deliver PR programs with a gradual start; (3) education for all; and (4) logistical, disease-related, and psychological barriers. Theme 2 is particularly interesting and aligns well with this study, as the web-based intervention may be thought of as a bridge to start a formal PR program. Theme 4 chimes with some of the participant quotes from our qualitative work.A recent qualitative work by Janaudis-Ferreira et al  has beguOn the basis of the challenges of recruiting, retaining, and engaging participants in this web-based self-management program, the SPACE for COPD web-based self-management program is not a feasible approach to roll out widely following an AECOPD. It appears that the COPD population may not be equipped and ready for digital self-management interventions following an AECOPD, without additional training or support. This work acknowledges that this is a challenging time for patients with an AECOPD to engage in exercise and self-management education. However, for patients able to engage with such an intervention, the completion of PR was double the previous estimates from UK audit or research data, disease knowledge improved, and it encouraged positive behavior change and was of value to patients. Therefore, with further refinement, web-based (or other home-based) strategies may be a viable stepping stone for PR. Identifying the patients most likely to benefit from such strategies is warranted, particularly if social distancing measures for COVID-19 are to continue.


The number of persons with dementia is steadily growing, as is the number of individuals supporting persons with dementia. Primary caregivers of persons with dementia are most often family members or spouses of the persons with dementia, and they are more likely to experience increased stress and other negative effects than individuals who are not primary caregivers. Although in-person support groups have been shown to help buffer the negative impacts of caregiving, some caregivers live in isolated or rural communities and are unable to make the burdensome commitment of traveling to cities. Using an interdisciplinary approach, we developed a mobile smartphone support app designed for primary caregivers of persons with dementia, with the goal of reducing caregiver burden and easing stress. The app features a 12-week intervention, largely rooted in mindfulness-based self-compassion (MBSC), because MBSC has been linked to minimizing stress, depression, and anxiety.The primary objectives of our program are twofold: to explore the feasibility of a 12-week mobile support program and to conduct an initial efficacy evaluation of changes in perceived caregiver burden, coping styles, and emotional well-being of caregivers before and after the program.Our feasibility study used a 2-phase participatory pretest and posttest design, focusing on acceptability, demand, practicality, implementation, and efficacy. At phase I, we recruited 57 primary caregivers of persons with dementia , comprising spouses , children , and friends or relatives  of persons with dementia, of whom 29 (51%) completed all measures at both pre- and postprogram. The content of the program featured a series of MBSC podcasts. Our primary outcome measure was caregiver burden, with secondary outcome measures including coping styles and emotional well-being. Daily ecological momentary assessments enabled us to ask participants, “How are you feeling today?” Phase II of our study involved semistructured follow-up interviews with most participants (n=21) who completed phase I.P=.04), and emotion-based coping significantly decreased (P=.01). Participants generally considered the app or program to be a helpful resource.Our findings suggest that our app or program meets the feasibility criteria examined. Notably, participants generally accepted the program and believed it could be a useful resource. Emotional well-being increased significantly  and can provide a much-needed resource for primary caregivers of persons with dementia. In the subsequent version of the program, we will respond to participant feedback by incorporating web-based weekly sessions and incorporating an outcome measure of self-compassion. Dementia is a growing health concern that currently affects approximately 47 million people worldwide . More thAlthough stress can often be alleviated through conventional education and counseling programs -14, partTo improve access to programs for caregivers who are not able to attend in person, the delivery of psychoeducational support programs through a mobile app is a promising, scalable solution. The ubiquitous nature of smartphones provides unprecedented opportunities for both content delivery and data collection. A systematic review  of mobilAlthough extensive research has focused on developing programs to alleviate burden in primary caregivers of persons with dementia ,21, acceFor primary caregivers of persons with dementia, mindfulness-based interventions -27 have The overall objectives of this project are to: (1) explore the feasibility of a 12-week mobile support program, and (2) conduct an initial efficacy evaluation of changes in perceived caregiver burden, coping styles, and emotional well-being of caregivers before and after the program.This feasibility study used a 2-phase participatory pretest and posttest design. Feasibility studies, which are considered particularly relevant to real-world settings, help to determine whether an intervention is appropriate for further testing and to identify the modifications in the research methods and protocols required . Areas oEthics approval for this study was obtained from the University of Saskatchewan . Phase 1 involved the co-design of a mindfulness-based self-compassion (MBSC) intervention developed specifically for primary caregivers of persons with dementia. Our interdisciplinary team comprised researchers from the disciplines of nursing, nutrition, and computer science, as well as community representatives. Community advisors included one staff member from the Alzheimer Society of Saskatchewan (ASOS) and 2 patient family advisors (TH and BW). The advisory members helped to ensure all facets of the project reflected the values and interests of primary caregivers of persons with dementia and contributed to the ecological validity of the project . Two cerOn the basis of caregivers’ lived experiences and preferences, the expertise of our self-compassion consultants and our review of the literature, the content for a 12-week MBSC and support program was co-designed within a 6-month time frame, incorporating existing web-based caregiver support resources developed by the ASOS or other reputable advocacy agencies , as appropriate. MBSC consultants developed the original material for this program in the form of 14 podcasts, 12 meditations, and 4 body-based practices. The program was delivered using the Ethica platform co-designed and codeveloped by the coauthor NO and Ethica Data Services. The Ethica platform is designed to aid in the creation, delivery, and data collection of smartphone-based apps ,37. A coTalk to yourself like you would to someone you love) were developed to allow participants to access positive messages about coping and center them in a mindful and self-compassionate mindset.Daily ecological momentary assessments (EMAs) sampled participants’ responses to the question “How are you feeling today?” The program offered a range of MBSC tools  with varying lengths between 1 and 20 minutes that caregivers could incorporate into their lives in ways that worked best for them . Coping Phase 2 consisted of a pre- and posttest design using validated instruments delivered through the app and qualitative data from postprogram individual interviews. The target sample size was 40 individuals. Information on demographic characteristics and current participation in support groups was collected after informed consent was obtained at enrollment. The Ethica app was installed on participants’ smartphones, and they received proper instruction on the use and privacy guarantees of the technology, including how to temporarily pause data collection. The duration of use data was gathered through the Ethica app use functionality. At the conclusion of 12 weeks or at termination of the program, participants were offered the opportunity to participate in individual telephone or Zoom interviews focusing on the experience of using the app.Caregivers were recruited by the ASOS using direct contact and social media, by linking the research team with ASOS caregiver programs in the province, and through media coverage and broadcast interviews. The eligibility criteria for this study included self-identification as a primary caregiver of a community-dwelling family member who has memory loss consistent with dementia, aged ≥18 years, able to read and speak English, and access to a smartphone. Participants received a CAD $100 (US $80.4) gift card to a grocery store of their choice to offset the data plan costs associated with using their personal devices during this study.Caregiver burden, the primary outcome, was measured using the Burden Scale for Family Caregiving (BSFC)  at baselThe secondary outcomes included changes in coping style and emotional well-being. Short questionnaires were delivered daily via the app to the participants on a rotating basis. One 2-item scale from the Brief-COPE instrument ,44 was dIn addition to the Brief-COPE, the World Health Organization (WHO)-5 Well-Being Scale was completed weekly. The WHO-5 is a short, commonly used, psychometrically sound measure of positive emotional well-being with a single cumulative score, where 100 represents the best possible quality of life .This paper summarizes data from field notes kept by research assistants during enrollment and program delivery, as well as interview data related specifically to the technical aspects of the app in terms of acceptability, practicality, and implementation for the 72% (21/29) of participants included in the quantitative analyses who also completed the final interviews.P value of <.05 was considered as statistically significant. All statistical analyses were conducted using the SPSS version 27 (IBM Inc). Content analysis ...even simple instructions are too much.” Three participants withdrew after several weeks because of busy personal schedules or other priorities and another was found not to own a smartphone.A total of 77 participants were enrolled in the study, although 16 did not open the app. One of these individuals indicated: t tests (age) and chi-square analyses , and no significant differences were detected.A total of 53 participants  with a mean age of 58.0 (SD 13.6) years were recruited into the study between September 2019 and March 2020. The persons with dementia for whom participants were caring included spouses , parents , and other friends or relatives  with a mean age of 77.6 (SD 12.0) years. Complete baseline and final data sets  were available for 51% (29/57) of participants who completed all questionnaires at both baseline and the end of the program and were included in the data analysis below. Demographic characteristics of excluded participants were compared using 2-tailed Understanding the acceptability, practicality, and implementation of using an app to deliver a psychoeducational program targeted at caregivers of persons with dementia was central to this study, especially because of the wide variation in possible caregiver ages and comfort with technology. Participants generally found the app easy to use and user-friendly, although several required additional assistance from the research assistant to address navigation problems early in the program. One participant noted:I’m not a very techy person, so I was really nervous about it at first...But anyway, once I got that it was fine.Many participants noted the convenience of having the content available on their phones:I liked that it was on my phone. I liked that I could access it at my convenience. And I do use my phone pretty much like my right hand all the time.The availability of multiple types of content was very appealing to many participants:It’s got a variety of different things in one place. I like that. It’s like a one stop shop.The incorporation of EMAs has received numerous favorable comments:The most useful part was the, “How are you feeling,” survey, every day. It made me sit down and think about the last few hours, and was how stressed I really was, or maybe I wasn’t as stressed as I thought I was. And I’ve come to look forward to that, so I actually have a minute to sit down and say, “Well how was just the last bit?” I found that really, really helpful.Incorporation of appropriate YouTube videos was appreciated by most participants, but several participants did not like the automatic redirection to alternate videos that were not part of the program. Several commented that they wished that the program could also be available on their computers to improve readability.Over the 12 weeks of the program, participants’ mean hours of app use were 15.60 (SD 28.83) hours with a median time of 5.31 hours (IQR 3.0-11.1).As there was minimal variability in the BFSC, WHO-5, and Brief-COPE subscale scores obtained midprogram and at the end of the program, this study compared only baseline and the final scores obtained on these instruments.r=−0.40; P=.03) and positively correlated with the use of avoidance-based coping  and the number of behaviors exhibited by the persons with dementia . There were no correlations between BFSC scores and caregiver age , duration of providing care ; age of persons with dementia , emotion-focused coping , and problem-focused coping .At baseline, the median BFSC score was 45 . Most participants were categorized as having either no to mild burden  or moderate burden , with 3% (1/29) reporting severe burden. r=−0.40; P=.03) and positively correlated with the use of avoidance-based coping  and the number of behaviors exhibited by the persons with dementia . There were no correlations between BFSC scores and caregiver age , duration of providing care ; age of persons with dementia , emotion-focused coping , and problem-focused coping .P=.04) increase in emotional well-being as measured by the WHO-5 was noted. No differences were evident in the Brief-COPE scores for problem-based or avoidance and dysfunctional coping, but the decrease in emotion-focused coping was statistically significant (P=.01).one-stop shop approach of having a range of MBSC practices (acceptability) available on their personal smartphones  that could be used to support them in their caregiving challenges. A few technical problems were experienced, and the app was considered easy to use (implementation). This is especially important in studies such as this, where participants are anticipated to lack the high comfort and smartphone skills  of digital-native generations [This study examined 4 aspects of feasibility  in relation to a co-designed web-based support program for primary caregivers of persons with dementia delivered via an app on a smartphone. Our deployment results revealed that participants valued the erations .The interdisciplinary collaboration between health care researchers and computer scientists afforded a unique opportunity to capitalize on the expertise of multiple disciplines and to deploy a program in a reasonably short window. Although each discipline has its own unique body of knowledge and jargon, ongoing discussions between team members allowed all the voices to be heard in a respectful manner, to achieve consensus on key aspects of the project, and to undertake a study that no one team member could have achieved without such a collaboration.The participatory, co-design approach to this project ensured that the perspectives of key stakeholders such as primary caregivers of persons with dementia and the Alzheimer’s Society were incorporated into content and program development, which we consider a strength of our project. The value of co-designed programs has been amply demonstrated in the literature, notably in the field of technological support for chronic diseases and/or ailments, given the purposes of our research ,49. DespBy incorporating perspectives of primary caregivers of persons with dementia and members of the Alzheimer’s Society in the development process of our support program, we adhered to the guiding principle of integrated care . In addiThe content and data collection instruments were successfully delivered via the smartphone as planned, but only 51% (29/57) of participants completed all questionnaires. Although data collection using smartphones offers the advantages of ecological validity and real-time data, missing data in these types of studies is a well-recognized problem . The parEvaluation of the short-term efficacy of this intervention to support primary caregivers of persons with dementia yielded mixed results. During this feasibility study, participants chose their own level of engagement with the content of the program, and the hours spent on the content varied widely, as did the content that was accessed by participants. As this study sought to establish the feasibility of delivering this program via smartphones, the duration of the program and follow-up period were relatively constrained.No change in caregiver burden scores was detectable immediately following the program, which may be attributable to several factors. As caregiver burden is influenced by diverse factors , includiP=.57), we conducted a post hoc reliable change index analysis in an effort to detect individual changes. The results of the reliable change index showed that 7 participants had a statistically significant reduced burden, whereas 1 participant had a significantly increased burden from baseline to post intervention.As there was no significant reduction in caregiver burden, our primary outcome measure, from baseline to post intervention  of participants scored lower than 50 on the WHO-5 and met the criteria for screening for depression, highlighting that caregivers are at risk for adverse emotional sequelae.Emotional well-being of participants showed a small, but statistically significant improvement, although this failed to meet the 10% change in scores recommended to signify a Our study enabled primary caregivers of persons with dementia to access resources from the convenience of their smartphones that they may not otherwise have been able to use, especially considering that some of the content was developed specifically for this project . Although it is possible that some of the primary caregivers of persons with dementia could attend in-person support groups where similar content could be available, others cited their geographic isolation in remote communities or rural settings as a barrier to doing so, and that having the material so readily available to them was particularly helpful, as was the user-friendly nature of our app and content. In addition, with current COVID-19 restrictions, in-person support group meetings may be less prevalent in various locations.One potential shortcoming of our research is rooted in the nature of feasibility studies, as not all possible outcomes can be measured. To reduce the burden on respondents, we did not measure changes in MBSC, which have typically been evaluated using the Self-Compassion Scale (SCS) . HoweverBecause of missing data, only half of the questionnaires could be included in the final analyses, although we found no differences in the demographic characteristics of those who completed all questionnaires and those who did not.The experimental nature of our study ensured that we assessed measures pre- and postintervention. However, a control group was not included in our study, which can be considered a limitation. The rationale behind our decision to not include a control group was to ensure that participants were not deceived, particularly given their vulnerable status as primary caregivers of persons with dementia, and also to better assess the feasibility of our program by enrolling all participants in it. Ultimately, we wanted to know if the core elements of our program were well received by participants, although we acknowledge that it might be advisable for future iterations to include a control group. In addition, a 1-month postintervention follow-up assessment is recommended to researchers to examine whether intervention effects can withstand the test of time. In this study, we interviewed participants approximately 1 month after they completed the program to collect their thoughts on its acceptability, implementation, and feasibility, although quantitatively assessing primary outcome measures would be advantageous.An additional limitation is that the vast majority of participants were female , meaning that although the program was received favorably overall, its generalizability is somewhat unknown. For instance, the male primary caregiver of persons with dementia might reject our program initially or they might not find it effective. However, there was male representation among our patient family advisors , though perhaps future iterations of the program should be informed by a more equal representation of males and females across varying age groups.Our program as currently structured has value and utility for primary caregivers of persons with dementia, as evidenced by our results and in postintervention interviews with our participants. However, we acknowledge ways that our program could be improved in future iterations, starting with usability. Specifically, some participants expressed that they felt burdened by certain inclusions , whereas others valued these inclusions. Accordingly, we recommend that future versions have optional EMAs, for example, where participants can choose the number of daily EMAs . We also encourage researchers to use a version of our program to include a measure of MBSC—specifically, the SCS—at each time point, as a way to determine whether mindful self-compassion levels increase following the MBSC intervention.expert in the field from the research team to ensure that participants’ questions were addressed or answered. In addition, a postintervention focus group wrap up session could be delivered virtually, where the primary caregivers of persons with dementia could connect with the experts and one another. Finally, as communicated by participants, more coping cards and a clearer layout of each week’s content should be introduced.Other considerations for future iterations of our program include weekly web-based meetings among small groups of participants via breakout rooms, to enhance a sense of community and/or support that was lacking in the current version. These breakout rooms could be moderated by an As noted in a thematic literature analysis by Rampioni et al , collaboOur study is one of the first to co-design and deliver an MBSC program for caregivers of persons with dementia using a smartphone. We believe that the findings of this study have demonstrated the feasibility and demand for this type of web-based program and identified the key challenges to be addressed in future studies. Specifically, it is our view that an MBSC program for primary caregivers of persons with dementia, like the one presented in this study, can be particularly helpful for individuals in rural or isolated communities, with limited access to support groups. In addition, this feasibility study has helped identify key outcome variables that were left out of this version , while also enabling us to address intervention elements that can be altered  or incorporated in the next installment of our intervention . Our findings will inform the development of future iterations of the MBSC program and will contribute to the evidence on strategies to better support caregivers of persons with dementia.


Healthy Beginnings is an established nurse-led early childhood obesity prevention program that promotes healthy infant feeding practices and active play in the early years of life. To improve engagement with culturally and linguistically diverse populations, the Healthy Beginnings program delivered by telephone was culturally adapted and implemented with Arabic- and Chinese-speaking mothers in Sydney, Australia. The cultural adaptation process has been published separately. In this article, we aimed to evaluate the feasibility of the culturally adapted program.In 2018–2019, the culturally adapted Healthy Beginnings program was implemented with Arabic- and Chinese-speaking women recruited from antenatal clinics in Sydney. At four staged timepoints (from third trimester until 6 months of age), mothers were sent culturally adapted health promotion booklets and text messages and offered four support calls from bi-cultural child and family health nurses in Arabic and Chinese. A mixed methods evaluation included a) baseline and 6-month telephone surveys, followed by b) semi-structured follow-up interviews with a subset of participating mothers and program delivery staff. Main outcomes of this feasibility study were reach (recruitment and retention), intervention dose delivered  and acceptability .n = 8 withdrew) and 83% completed the 6-month survey (n = 70 Arabic- and n = 65 Chinese-speaking mothers). Most mothers  completed at least one nurse support call. The qualitative analysis of follow-up interviews with 42 mothers (22 Arabic- and 20 Chinese-speaking mothers) and 10 program delivery staff highlighted the perceived value of the program and the positive role of bi-cultural nurses and in-language resources. Mothers who completed more nurse support calls generally expressed greater acceptability.At recruitment, 176 mothers were eligible and consented to participate. Of 163 mothers who completed the baseline survey, 95% completed the program (The culturally adapted Healthy Beginnings program was feasible to deliver and acceptable to Arabic- and Chinese-speaking mothers. Our results highlight the importance of in-language resources and individualised bi-cultural nurse support by telephone for supporting culturally and linguistically diverse migrant families with infant feeding and active play. These findings support the potential for program refinements and progression to an effectiveness trial.The online version contains supplementary material available at 10.1186/s12889-021-11226-5. Women from culturally and linguistically diverse backgrounds who migrate to high-income English-speaking countries, such as Australia, can face challenges accessing child and family health services. This is partly due to language barriers, unfamiliarity with a different health system and cultural differences –3. With In Australia, women and infants from culturally and linguistically diverse backgrounds, compared to Australian-born women, are less likely to use health services , more liInfant feeding practices and active play are among the known early-life modifiable factors for healthy weight gain and the prevention of obesity –12. A reIn Australia, children from culturally and linguistically diverse backgrounds experience higher prevalence rates of overweight and obesity when compared with English-speaking Australian-born children . Early iHealthy Beginnings is a child and family health nurse-led early childhood obesity prevention program providing individual support for mothers and their infants . At stagIn 2018–2019, we undertook a project to culturally adapt the Healthy Beginnings telephone-delivered program (CHAT), herein referred to as the culturally adapted Healthy Beginnings. Arabic and Chinese language groups were the focus for the adaptation as these languages are most commonly spoken after English in central Sydney . The culThe first stage included assessing the underpinning theories and core components of the Healthy Beginnings program. These core components included: a) key focus areas related to infant feeding, active play, sedentary behaviours and sleep; b) behaviour change techniques; and c) delivery mode. The second stage included reviewing scientific literature and consulting with Arabic- and Chinese-speaking mothers, as well as child and family health professionals. The findings highlighted the importance of family, bi-cultural doctors and culturally sensitive health services for supporting infant feeding , as wellreach among the intended population;engagement in the nurse support calls; andacceptability among participants and delivery staff.Feasibility studies are essential for exploring relevance and acceptability of complex interventions , particuThese findings will guide program refinements .We followed CONSORT reporting guidelines for reporting of this non-randomised feasibility study  nurse call were moved to a ‘no-calls’ group but continued to receive the program booklets and two-way SMS messages.Women were eligible if they were aged at least 18 years, 28–36 weeks pregnant, owned a mobile phone and were able to speak and read Arabic or Chinese-Mandarin. Exclusion criteria included having a self-reported medical condition that might affect feeding plans or a known foetal abnormality. All program delivery staff were eligible for follow-up interviews.From August until December in 2018, eligible women who attended antenatal clinics in three local health districts in Sydney were invited to participate by bi-cultural research staff or English-speaking research staff with professional medical translators. All participants were informed about the research and provided translated study information and consent forms. Eligible and consenting women completed a registration form with research staff and arranged a suitable time to complete the baseline telephone survey. Mothers were provided a $20AUD grocery voucher for each telephone survey completed (baseline and 6-months) and for participating in an interview.n = 12) were emailed an invitation to participate in a brief demographic survey and an interview to discuss program adaptation and delivery. Voluntary participation was emphasised. Staff did not receive compensation.Program delivery staff directly involved with participants during the program  , and also allowing for anticipated attrition of approximately 20%, based on the Healthy Beginnings trial . As the Follow-up interviews were conducted with a nested sample of approximately 20 mothers from each language group. This target was based on project resources and availability of interpreters. The sampling was purposeful; quantitative survey results and administrative data were used to seek a mixed sample of mothers who: a) were first-time mothers or had more than one child (multiparous); b) completed 0–1 of the telephone support nurse calls (lower intervention dose) or 2–4 of the nurse calls (higher intervention dose); c) were living in Australia for less time (0–5 years) or more time (6+ years). All staff who consented and were available were interviewed.Administrative data, such as participation in nurse calls, were recorded by bi-cultural CFHNs and project staff. Mothers who withdrew from the study were invited to provide a reason, which was recorded. All data capture and management were via REDCap (Research Electronic Data Capture) for conducting online surveys, hosted at Sydney Local Health District, Australia .Mothers participating in the program were invited to complete a telephone survey (approximately 20–30 min) at baseline (28–36 weeks gestation) and at the end of the program (infant age 6 months). The survey questions were based on previous Healthy Beginnings research protocols , 24 and Surveys in English were translated into Arabic and Simplified Chinese by professionals accredited by the Australian National Accreditation Authority for Translators and Interpreters. The translated surveys were tested for face validity with two Arabic- and Chinese- speaking mothers of young children not participating in the study, and bi-lingual project team members made refinements to ensure clarity of meaning. The process was guided by survey translation and adaptation methods . TrainedMothers who participated in the programDuring the 6-month survey, mothers were invited to participate in a follow-up telephone interview in Arabic or Chinese to talk about their experiences being part of the program. A purposive sample was invited to interview. The interviews followed a semi-structured guide with open-ended questions about mothers’ views of the program generally; their thoughts about program booklets, SMS messages and nurse calls; and behaviour changes related to the program Program delivery staffInterviews were co-facilitated by English-speaking staff members, SM or MK, with bi-lingual staff member NT or one of two professional Arabic interpreters from Sydney Local Health District Interpreter Service. SM, MK and NT are all experienced health promotion practitioners with research training. Co-facilitators were briefed about the study and the interview guide. The role of the interpreter as co-facilitator is a recognised approach for engaging participants in cross-cultural research . The co-For staff who were available and consented, interviews were over the telephone or in-person at their workplace. A semi-structured guide was used to ask open-ended questions about their experience generally; their thoughts about the program booklets, SMS messages and nurse calls; and project implementation . Interviews were professionally transcribed, and SM checked all transcripts for accuracy.The outcomes investigated in this cultural adaptation feasibility study are outlined in Table Reach and dose delivered were assessed using administrative and survey data including participant enrolments, demographics, nurse calls completed and retention at the 6-month survey. The demographic variables included age, parity, country of birth, years in Australia, marital status, education, income and religion.We defined acceptability according to the Theoretical Framework of Acceptability (TFA) , where aThe quantitative and qualitative data were equally weighted, linked between data collection points and mixed at data interpretation stages. The goal of mixing quantitative and qualitative methods was to enhance our understanding and interpretation of the feasibility of the culturally adapted program. We took a pragmatic paradigmatic lens when analysing and interpreting the data, emphasising social experience to prioritise actions .Quantitative data was transferred from REDCap to IBM SPSS Statistics . DescripQualitative data were analysed using descriptive thematic analysis following the Framework Method . SM analTranscripts were then imported into NVivo 12 for data management. SM continued to code the data, starting with the mothers' interviews, and refining the coding framework until the final staff interview was coded. SM then charted the data, from mothers and staff separately, into matrices for each TFA construct, applying further codes as required. For coding consistency, initial transcripts were revisited for additional coding. SM made notes to interpret the data, continually comparing findings for the mothers based on number of children, nurse calls completed and years in Australia. Our intention with these comparisons was to explore any differences, as we hypothesised experiences and opinions of the program may have been more varied. SM then developed themes within the TFA constructs to represent shared meaning across participants. Co-author group meetings were held throughout this process for generating ideas, discussion and refining themes. The co-author group agreed upon the final themes presented.n = 94 Arabic- and n = 69 Chinese-speaking mothers). Eight mothers withdrew during the program. Most mothers  completed at least one nurse call, and one third  completed at least three of the four calls. A small group of mothers (n = 23 Arabic- and n = 5 Chinese-speaking mothers) could not be reached for the first nurse call after four attempts and were moved to a ‘no-calls’ group. Of mothers who enrolled, 135 completed the 6-month survey ; a retention rate of 83%.Mothers’ participation in the study is presented in Fig. n = 30; Lebanon n = 29; Egypt n = 7; Syria n = 6; Iran, Jordan, Sudan n = 2; Kuwait, Libya, Saudi Arabia, Morocco n = 1). Chinese-speaking mothers were born in four different countries or regions .Demographic characteristics of the mothers who completed the baseline and 6-month surveys are presented in Table n = 94) and the 6-month (n = 70) surveys showed significant differences in their years in Australia (p = 0.036) and religion (p = 0.018). There were no significant differences in demographic characteristics of the Chinese-speaking mothers who completed baseline (n = 69) and 6-month (n = 65) surveys.The demographic characteristics of the Arabic-speaking mothers who completed the baseline (n = 22 Arabic- and n = 20 Chinese-speaking mothers) and with program delivery staff (n = 10). Additional file At program completion, interviews were conducted with program participants (n = 12) and had completed either one nurse call (n = 10) or two or more calls (n = 12). Few were first-time mothers (n = 4). Approximately half of the Chinese-speaking mothers interviewed were newer arrivals  (n = 10) and first-time mothers (n = 10). Most had completed two or more calls (n = 19). While we sought greater representation of Arabic-speaking mothers who were first-time mothers and Chinese-speaking mothers who completed fewer calls, however not all mothers agreed to the interview nor could be contacted, and our interview sample characteristics were reflective of the total sample.Approximately half of the Arabic-speaking mothers interviewed were newer arrivals  (n = 5), and half were project officers/assistants (n = 5). Staff had an average of 5 years of experience in a similar role (range 1–11 years). Most were fluent in languages other than English (Arabic n = 4 or Chinese n = 4).Program delivery staff who participated in interviews were involved with the cultural adaptations, recruitment, survey administration and/or nurse calls. Half were CFHNs  constructs, we developed themes based on the data to represent shared meaning Table . GeneralThe TFA has seven constructs and after inductively coding the data using these constructs as overarching categories, we found that five were represented with our data . Some mothers explicitly spoke of the importance of cultural congruence with the nurse: “It was easier and flowing because also we’d talk about culture or traditions, […] so we were able to discuss any topic possible in regard to health and culture” . Staff endorsed the value of the program, emphasising the importance of cultural support offered to mothers: “Because I understand her. Because with more understanding you actually give more empathy” .Mothers commonly identified ease and preference for using their first language, regardless of how many years they had lived in Australia and their English language proficiency: ““The booklet for me is the evidence for me to show that this is correct. I find it helpful” . Some mothers, particularly those who had been in Australia for longer, talked confidently of using the booklets as a tool for advocating for new behaviours with family members: “When I gave my mother the booklets to read, she got convinced and said this is your era and we are from a different era [laughs]. So now she understands why you feed the way you do” . This was especially relevant when family members had differing views, for example, introducing solids around 6-months and tummy-time practices: “So mainly my in-laws and my mother, they don’t support the tummy-time ideas. They find [that] the baby’s too small, you shouldn’t do that” . Staff interview data did not represent this theme.Mothers described the program booklets as useful for sharing the program information and discussing new ideas with fathers, family members and friends: “Because I knew nothing and these people who wrote the information, they have the experience” . Additionally, some mothers referenced the value of evidence-based information: “During my pregnancy, I have seen in Australia a lot of research on how to raise a baby […] the research can be trusted. Like in China, it is just like old experience, I think” . Staff interviews supported this view: “They believe that health departments provide the correct, most updated information” ; especially the perceived acceptability of the program being delivered by a nurse: “A nurse is a very acceptable profession by many cultures” . Staff also found that trustworthiness was important for recruitment: “I would introduce myself and show my New South Wales Health ID just to trust me” .Mothers regarded the culturally adapted Healthy Beginnings program as trustworthy and credible, being developed and delivered by the government health service and health professionals: “At first, every bit of information is helpful, from the three different types of support. Because the book is comprehensive, a bit of the tailor-made answers from the nurses, even the SMS is similar to the apps, you get some other extra bits” . For mothers who received calls, this was overwhelmingly the preferred element of the program: “It was very useful. I preferred to have the telephone calls, because I am able to ask questions” . Many mothers and staff appreciated the paper-based resources, but there were several suggestions to add a website or app so that mothers could easily search for relevant program information online. Few suggested other modes such as social media groups  or face-to-face groups, however opinions differed about the uptake of these formats.Many mothers described the suite of offerings from Healthy Beginnings as suiting their needs and they liked that the content was consistent across the nurse calls, booklets, and SMS messages: “She spoke to me a few times, I was very moved. The nurse initiated the call and picked up in my voice; she noticed that I must be tired. I was the only one looking after the baby. [The nurse] asked whether there’s any issues and initiated help” . This was especially relevant when family supports were not present: “In my case, I don’t have any relatives around me and very limited friends. So, yeah, it was nice to have that call from [Healthy Beginnings nurse] that time” .Many mothers expressed appreciation that the nurse gave time and patience to address their specific questions, and all mothers valued having the calls available in their language. The bi-cultural CFHN was important for providing emotional support for mothers: “I find that [the nurse’s] help is very good, because it is helpful to talk with someone, and for her to give me a call and spend quite good time with me. This conversation gave me some comfort” . The CFHNs commented that they felt their calls were especially helpful for first-time mothers with many questions, and earlier in the program when mothers were more in-need and motivated. They also felt that more nurse availability could increase their support: “I think maybe because I’m speaking their language, it’s the first, sort of people they want to talk to. So, I would actually, I know it’s probably a luxury, but recommend to have a full-time nurse and be able to do these things full-time. That would be wonderful. That will be providing more service for them” .Compared to experiences with the doctor or nurses at Community Health Centres, the bi-cultural CFHN discussed maternal as well as infant health and could give more time to building rapport and addressing mothers’ concerns: “I learned about the baby’s stages of their growth and development each month, and what sort of skills they acquire, how to deal with them, and how to feed them” . Anticipatory information seemed to reduce stress for some mothers, irrespective of having previous children or number of years in Australia: “The information is helpful to prepare with what to expect. When things happen, I wasn’t as concerned and not so anxious” . Staff supported this view: “The information is quite age appropriate, that’s what I feel. Like, this is basically what we need to transfer to the parent in that specific period” .Generally, mothers felt the timing of information was appropriate to their baby’s development: “I tried the way they teach me, and my milk increased a lot. Still, I had to use formula as well as breastfeeding the baby. But my milk eventually increased a lot more compared to the beginning. I’m really happy about it. I didn’t breastfeed my first baby but this time, I had help from booklets and phone call. I have built up a lot more milk compared to last time with my daughter” .Most mothers who completed nurse calls talked positively about their experiences with the bi-cultural CFHN – describing the nurse as helpful, providing new information and strategies to help overcome problems. The most common examples were related to breastfeeding challenges such as milk supply, latching, damaged nipples and expressing milk. Other examples included managing shared care with family, strategies for settling and resolving problems with tummy-time positions. One mother described her experience with breastfeeding difficulties: My baby was about five weeks and she stopped feeding completely. She just turned off, you know. She didn’t want to take the breast at all […] I didn’t know what was happening, and I didn’t know where to go to” . This ties in with a reflection of one of the bi-cultural CFHNs about needing to consider additional supports, such as online resources, for mothers to also seek their own answers too: “Rather than relying on the nurse or relying on the booklet, we also want them to be proactive to be able to look for the information driven by their needs […] I think that’s the skill as a healthcare professional we should promote” . This links with suggestions to include program advice online . Yet, when making a direct comparison with the bi-cultural CFHN, mothers often referred to them as having more time, specialised advice and support: “the family doctor will give me medicine, but [the Healthy Beginnings nurse] was different. She made me feel mentally comfortable” . Few mothers attended Community Health Centres (CHC), but those that did said that the CHC face-to-face visits were useful for demonstrations and growth measurements, but that the consultations were more generalised and time-limited. Mothers who did not attend their CHC talked about barriers such as being busy, not knowing the location, uncertainty of nurses’ language, and difficulties using medical terms: “With the nurse outside [at CHCs], although you speak English, can have simple English conservation, sometimes the medical terms are not easy, you also have to go through a lot of travelling time, and pre-book an appointment” . Compared to the doctor and the CHC service, mothers highlighted that the bi-cultural CFHN nurses offered convenience over the phone (relates to Construct 4) and specialised parenting advice. In terms of advice and problem solving, the bi-cultural CFHNs made reference to doctors’ advice and were particularly concerned about mixed messages: “A good portion of the mums have said their GP [general practitioner/ family doctor] has said to start solids now at 4 months” . For staff, this emphasised the need for mothers to receive the nurse calls and consistent messaging, acknowledging many mothers faced challenges accessing the CHC-based universal services.Almost all mothers visited their family doctor, who was often bi-cultural, for medical advice, immunisations and physical checks. Arabic- and Chinese-speaking mothers referred to the importance of the doctor’s role, particularly for urgent assistance: “[the booklets] were all useful and they all contained useful information” . Staff all endorsed the general usefulness and content of the booklets. One staff member reflected on her own experience: “Like for me, each time I look at these booklets, I said ‘wow, that’s really perfect’ because I would get pregnant here if this was the kind of service” – and went on to say that the booklets could be enhanced: “Sometimes women ask for information which is not in the booklet […] if you include more information it will be more excellent” . The suggested additional content included formula feeding, allergies and infant feeding during Ramadan (a month of fasting that is practised in Islam).Most mothers reported usefulness of the program SMS messages and booklets: “This is the first time I find this information […] the main thing was the sleeping time for the baby and how to understand signs when the baby needs something” . Many mothers, especially first-time mothers, wanted more detailed information about introducing solids, including recipes. Several mothers, with a range of years living in Australia, talked about learning the importance of timing for introducing solids, however, there was still some confusion. Starting solids around 6 months was often different to what they had heard from their doctor or friends and family  (relates to the previous theme).Most consistently, mothers highlighted the most useful content related to breastfeeding, baby cues, responsive feeding, tummy-time, sleep and settling. Arabic-speaking mothers more commonly also highlighted the value of learning about communicating with baby, related to responsive practices: “I like the SMS, I find that it’s helpful, because it sort of serves as a reminder, reminding of what is happening, what to do, because it usually matches the age of development, so I know what to do with the baby’s age” . However, some mothers, with multiple children particularly, felt that the SMS messages were too simple and brief: “There wasn’t much information in the SMS, like for example, ‘breast feeding is good for the baby’” .Mothers found that generally the SMS messages were a useful reminder and prompt alongside the nurse calls and booklets. “For me it more served as a reminder, maybe for the first-time mothers it would be more useful” . Staff also perceived that the service was particularly relevant for first-time mothers: “I find that the first-time mothers tend to be more motivated. And they need the service more than others and they would follow advice through” . Yet, mothers with multiple children also commented on how they found the program useful and many gave examples of increased knowledge and behaviour changes particularly for introducing solids, settling techniques and tummy-time practices: “So this is the first time I find this information, useful information, in regard to caring for the baby - the main thing was the sleeping time for the baby and how to understand signs when the baby needs something” . These mothers were also able to make comparisons with their previous experiences; several mothers talked about noticing increased strength of their baby (participating in the program) as a result of tummy-time practices: “Tummy-time is really useful for my second baby; he is very strong compared to my daughter” .Some mothers spoke of the Healthy Beginnings program being especially important for first-time mothers who are new to motherhood: The new mum who is new in this country and doesn’t have any relatives or who really, really struggle” . Many staff also expressed this opinion: “Some of them were just married and this is their first child, and they don’t have enough experience. They just came to Australia. When you are on your own without family, without parents, so you start to worry, how will I get this information […] So when they find this information, they felt comfortable” .A few mothers in both language groups, particularly those living in Australia for a longer period, said the program may be more useful to mothers more newly-arrived in Australia who experience language barriers and limited social support: “If there are more available times or opportunities that I can talk that will be much better, because I like to talk with [the nurse], and I think she only works on Thursdays” . Suggestions were also offered related to scheduling: “[the program] could be improved a little bit better if they tell the times the nurse would be available. I’m not sure what time I need to contact her” . One mother was not satisfied with the response time from the nurses: “I understand that I can organise the nurse to call, but for me, I think that waiting for one to two days is a bit too long” . Mothers who received all four nurse calls did not comment on any logistical issues or burdens to participation. Program delivery staff suggested more staff time for the nurse calls: “I know that the telephone support calls became less frequent, I think that was only because it was an issue of staff. I think that the participants really benefited from the telephone support calls, they really enjoyed them, I think it was the standout” .Some mothers who received fewer nurse calls commented on not being able to talk to the nurse for reasons such as nurse availability (1 day per week), call scheduling, and uncertainty of contact numbers. Mothers offered suggestions related to bi-cultural CFHN availability: ““I have two babies and I’ve not had the time to go the doctor or a nurse to ask about questions but through the booklets I’ve learned about the development stages of the baby because I used to receive them every month, like as the baby was growing.” . One mother commented that the phone-based service made her more comfortable: “Because I can ask any questions, and I can book a time with her more suited to my time. I don’t have to go to a particular clinic […] I can still ask questions; I am more relaxed and more comfortable” . Program delivery staff also spoke of the convenience of the nurse calls and having more time to talk with mothers: “Usually in a Centre you’d be assessing the mother and the baby, like you’d be talking to the mum, but you’d be weighing and measuring the baby and stuff like that as well. Whereas on the phone you can concentrate on what you’re doing” .Most mothers described the phone-based support as convenient for them. They mentioned there being no need to pre-book, wait in a waiting room nor arrange transport. Some mothers made comparisons with visiting a clinic: After birth, for 1-2 months, I was very busy, I did not have time to follow [the advice]. I haven’t got time; everything was a mess” . Mothers made comments about time for support generally too: “I know there is a local clinic that I can go to, but because of how busy we are as mums …we don’t have time to take the baby and go to the clinic whenever we have a question” . Staff also noted this: “mothers when they have new babies, they don’t have time to talk […] the majority, they put their family life first.” . The support calls are primarily for establishing health behaviours as opposed to resolving urgent problems, and one of the nurses reflected on this: “I feel that adult learning is more sort of purposeful orientated, so we don’t just learn anything we learn something that we want to learn. So, as a parent, when they have a baby they say, ‘oh, my gosh, I don’t know, what should I do’, that’s actually the time that they search for the information” . This relates not only to time for the program involvement, but motivations and relevance of the program to mothers’ needs at that time.Some mothers did not find it easy to participate in the program because they felt time-poor and busy with their new baby irrespective of how many children they had: “When I signed up, I expected more involvement and face-to-face involvement” . Other comments included uncertainty about whether the SMS messages were two-way and whether the messages were automated: “I thought the SMS message was just artificial, no human behind an automated message” . A staff member reported this also: “Sometimes I talk to the mothers, and then they didn’t know that they can actually send SMS to ask to speak to the nurse” . One mother, who did not receive calls, did not engage with the program fully she was not sure about the nurse’s language: “I wasn’t sure whether the nurse can speak Chinese” . The staff also found that some mothers were not sure of how the program worked and suggested more information be given at recruitment and throughout the program.There were times where mothers, particularly those who completed fewer nurse calls, were not sure about how the program worked and so engaged less in the program. For example, some mothers were not sure whether the program offered a helpline for immediate support. One Arabic-speaking mum who did not complete any nurse calls was expecting more support: “Our mixed methods findings demonstrate feasibility of the culturally adapted Healthy Beginnings program delivered by telephone, promoting early life nutrition and active play behaviours, and strong acceptability among participating Arabic- and Chinese-speaking mothers. Our study outcomes were favourable, affirming the preceding systematic cultural adaptation stages we undertook to modify the program for cultural relevance . This stOur retention rate (83%) is comparable to the mainstream Healthy Beginnings CHAT trial at 6-months among mothers who spoke a language other than English at home (79%) . Our retFrom our mixed methods findings, several key factors contributed to the feasibility of the culturally adapted Healthy Beginnings program among participating Arabic- and Chinese-speaking mothers.Generally, mothers valued the program, particularly that it was linguistically matched with culturally adapted written resources and with personalised support from bi-cultural CFHNs. Our formative research supported the importance of culturally sensitive care for mothers . Other eFor many participating mothers, the regular telephone support from bicultural CFHNs was valued and convenient. In the mainstream Healthy Beginnings program (CHAT), the nurse calls were also appreciated  and assoThere were demographic differences among mothers who participated in this study, which may partially explain some variation in feasibility outcomes. This also relates to intersectionality theory and the need to consider multiple dimensions of identity in health promotion interventions . Our quaOur findings also indicate greater engagement and retention among mothers who had more recently arrived in Australia. Newer migrants are in the early stages of adapting to a new country and culture , therefoThe follow-up interviews revealed that mothers who expressed uncertainties about the program were generally less satisfied with their experiences. Staff interviews endorsed the need to enhance the description of program involvement at recruitment. This aligns with recruitment experiences for other culturally adapted early life interventions . ProvidiThe Stages of Cultural Adaptation Fig.  was usedTable Based on our results, a trial to assess the effectiveness and cost-effectiveness of the culturally adapted Healthy Beginnings program is warranted  with only the English dialogue transcribed due to funding constraints. This may have limited the depth of the interview and analysis. To minimise participant burden, surveys were short, and we did not ask mothers about additional characteristics , which could have provided further insights about program engagement.The culturally adapted Healthy Beginnings program  for promAdditional file 1. CONSORT reporting checklist. CONSORT 2010 checklist of information to include when reporting a pilot or feasibility trial.Additional file 2. Program participant surveys administered by phone. These are the English versions of the surveys with mothers before the program (28–36 weeks gestation) and after the program (infant age 6-months). The surveys were professionally translated and reviewed, then trained bi-cultural research staff administered the surveys in language over the phone with mothers.Additional file 3. Interview guide for follow-up with participating mothers. English version of the interview guide with mothers who had participated in the program. Interviews were conducted in language and English. Interviews were co-facilitated by English-speaking staff members and with a bi-lingual staff member or one of two professional interpreters.Additional file 4. Brief survey and interview guide for follow-up with staff. Brief survey and interview guide with staff who implemented the program. Interviews were conducted in English.Additional file 5. Mothers’ satisfaction scores. Participant satisfaction with overall program experience using the Client Satisfaction Questionnaire (CSQ-8) measured at the 6-month survey. Bivariate analyses to assess association between potential explanatory factors and the satisfaction score.Additional file 6. Demographic characteristics of mothers involved in interviews. Demographic characteristics of mothers who agreed to be contacted for an interview at program completion, and those who competed a follow-up interview.