A global initiative has emerged in recent years to highlight early childhood education and care as a foundation for later learning and development. The goal of this study was to investigate the choices that Saudi Arabian parents made for their children’s preschool education. In a qualitative, exploratory study, we investigated parental selection of preschool programming in Saudi Arabia. Guided by a phenomenological approach, we conducted semi-structured interviews with 12 Saudi Arabian women that had preschool-aged children. Although some research has examined the constraints and factors affecting parental selection of preschool programming, it remains unclear when these constraints and factors are considered by parents during the decision-making process, and how the decisions are made. The interviews revealed that parents consider not only educational reputation in the selection of preschool programming, but also instructional use of Arabic and English, religious foundation, teaching quality, classroom preparation, program scheduling, tuition costs, and physical security of the preschool environment. The results suggest that improving information collection is essential for empowering parents to make wise decisions, with the child’s happiness and academic growth having a significant impact on those decisions. The discussion addresses the importance of identifying the factors that affect parental selection of preschool programming, so that educational professionals may better meet the needs and expectations of parents in Saudi Arabia. The benefits of early childhood education have been summarized by Field  and AlleThe values and beliefs of parents affect their selection of a childcare environment . AlthougSaudi Arabia has recently enacted several policies regarding non-compulsory early childhood education. The relevant goals are to introduce children to a school atmosphere at an early stage rather than leaving them to experience only the conditions in the home environment . NeverthAlthough some previous research has explored parental knowledge of childcare practices, no previous research has investigated parental perceptions of preschool programming in the Saudi Arabian context, paying special attention to identifying the factors that parents consider important when making decisions about preschool programming for their children. Thus, the current qualitative, exploratory study investigated Saudi Arabian parental views on preschool programming for their children, with the goal of identifying the factors that affect parental decisions about where to enroll their children.In the UK and the US, the respective governments have renewed a focus on parental choice of preschool education for their children . InsteadThe factors that affect the parental selection of preschool programming have been indirectly addressed in studies conducted in the UK as part of a times series data collection effort intended to review the effectiveness of government policy directives 1997–2010) ..11]. AddThe views and experiences of UK parents, with respect to formal and informal preschool programming, were assessed by Bryson et al. . The finAccording to the 2011 Daycare Trust survey , UK pareThe current research was a qualitative, exploratory study intended to investigate how Saudi Arabian parents arrive at decisions regarding the choice of preschool programming for their children. Identifying the factors that affect the parental selection of preschool programming may inform educational professionals and policy developers so that they can better meet the needs and expectations of parents in Saudi Arabia.This study used a constructivist phenomenological paradigm, which is frequently employed for naturalistic studies that describe the exploration, reconstruction, or comprehension of a phenomenon from the perspective of the participant ; most quThe study used a qualitative approach to allow for an in-depth and more detailed understanding of the factors that affect parental selection of preschool programming. A qualitative approach allows the researcher to secure a rich and often more comprehensive understanding of a phenomenon . In the The study sample comprised a purposive, non-random sample of Saudi women, specifically mothers with a child enrolled in a preschool program. This sampling method was used to allow for the collection of comprehensive and in-depth information and was chosen due to the ease of access to the study community. Interviews were conducted with 12 women, whose ages ranged from 25 to 45 years, whose educational qualifications ranged from a bachelor’s degree (8 women) to a masters degree (4 women), and the majority of whom were employed outside the home (11 women). The interview lasted between 45 min and 1 h. The participants were interviewed in locations that were comfortable for them so that they felt free to express their opinions and experiences concerning their children and the preschool program. We did not secure information about the socioeconomic status or class of the participants. Time constraints and the other research and teaching commitments of the researchers necessitated that the data collection would be concluded following completed interviews with 12 participants. Interviews were conducted from August 2020 to December 2020. This study adopted a semi-structured interview method for several reasons. First, this method allows the researcher to investigate specific aspects of a phenomenon, allowing for the opportunity to delve more deeply into the research topic. Second, semi-structured interviews allow participants the relative freedom and time to express, in their own words, their experiences, ideas, and points of view without restrictions. Third, semi-structured interviews are flexible, enabling the researcher to direct or clarify questions to the participants in addition to adding or removing questions as needed . A semi-The research proposal for this study was reviewed and approved by the King Abdulaziz University Ethical Review Committee . Participants confirmed that they were willingly participating and signed a statement of informed consent, available in English and Arabic, prior to the interviews. There was no coercion to participate, and the participants were informed of their right to withdraw from the study at any point and for any reason without penalty. Anonymity and confidentiality were ensured through the use of pseudonyms and codes in the dissemination of results.It is obviously important to ensure the accuracy of the interview data . TherefoA qualitative analysis relies on an in-depth and rich interpretation of the content . QualitaAll transcribed audio interviews were copied into a Microsoft Word document, then the data were manually reviewed to ensure that information was not lost. The data were then read several times to outline keywords and identify repeated statements. Finally, the data were organized and arranged in a table, facilitating the presentation of the results in a narrative style.To identify the factors that affect the parental selection of preschool programming, we generated open-ended questions. These included questions about what information is available to parents that helped them select a preschool program, how a program is identified, and we posed a direct question about the factors that the parents considered when selecting a program.As noted and see , the ageThrough the responses of participants to the study questions, several factors were identified as important in the parental selection of preschool programming, including the information available for considering and selecting a preschool program. We address these factors in the next section.When the participants were asked about the information available to select a preschool program, they could be divided into two groups based on their responses. The majority relied on family and friends to obtain information, and the remainder relied on researching the programs.The majority of the participants reported that they relied on the available information and experiences of other parents with preschool-aged children, especially the experiences of female relatives and close friends. One of the participants, Bushra, recalled the source of her information about the program that her daughter joined: “Through my sister, she is a teacher in the elementary school, and she provided me with information about the school’s interest in students and the quality of education they have in the preschool program”. Doaa also said that she followed her sister’s suggestions, noting, “I took my sister’s experience with her children in the preschool program”, meaning that her choice depended on the information provided by her sister. The experiences of female relatives who are also parents was an important factor that affected parental selection of a preschool program. These sources are considered to be especially reliable by the participants as they are perceived to be very likely to share all negative and positive experiences related to the program, giving parents a comprehensive assessment of the preschool environment.Some of the other participants relied on self-guided research and obtaining information on their own initiative from the program administration. Bdoor stated that she got to know the preschool program she selected in this way, saying, “Close to my workplace, I went to the headquarters of the program and went to the administration. I asked them about the type of program, the fees, the educational and administrative staff, and some of the policies related to the program”. Thus, some mothers do not rely solely on relatives or friends for information about preschool programs and seek to acquaint themselves with a program’s management and educational staff.In a different context, Sawsan sought information on preschool programs in a different way, saying, “We contacted the Ministry of Education to provide a list that includes the names of preschool programs that are accredited and trusted by them”. The focus on preschool programs accredited by the Ministry of Education is notable; preschool education programs are subject to permanent supervision to ensure their quality and to ensure that they perform their role in accordance with educational policies, rules, and regulations. In other words, this participant sought to ensure a healthy and sound environment for her child, one that was in line with the regulations, standards, and values of Saudi society.When directly questioned about the factors that play an important role in the selection of a preschool program, most participants identified a religious foundation, Arabic language use, English language instruction, teacher quality, student preparation in the classroom, hours of operation and instruction, program work, tuition and fees, and safe and child-friendly environment. We discuss these factors next.The majority of participants identified that teachings from and about the Qur’an were an important determinant of selecting a preschool program for their children. For example, Nada emphasized the use of Arabic language and teaching of the Qur’an as factors that were important in determining the preschool program for her child: “The program relies on focusing on the Holy Qur’an, so that they had specialized teachers, one of them for the Qur’an and the other for the Arabic subject, and as for me, the correct foundation for my child is the Arabic language”. Aziza also emphasized religious values in determining her child’s preschool program. She recalled being proud of her son, “because he repeats Islamic remembrances, whether when leaving the house, eating, etc”.A few participants noted that the teaching of and use of the English language was a key determinant in selecting a preschool program. Bdoor said, “The most important thing for me is that the preschool program is international and teaches the British curriculum because it is strong in both spoken and written English”. In the same context, Sawsan considered the primary determinant for choosing a preschool program as, “the English language and also for teachers to speak English as their native language”. This focus on English language use as a determinant of preschool program selection by a minority of the participants in this study is surprising. However, the English language has gained increased importance in Saudi society, and thus mastering it is now perceived by many parents as an important life skill. This applies to children, especially in early education. Thus, in hindsight, some parents seek this feature of preschool programming so that their children can keep pace with the rest of the world, given that English is the primary language in most developed countries. Mastering the language will contribute to consolidating and enhancing their ability to acquire related language skills, such as reading, writing, listening, and speaking.Many of the participants emphasized that a strong factor in their selection of preschool programming was that the program had staff with high-quality educational training and experience. Bushra inquired about the qualifications and specialization of the teachers who would instruct her daughter through the program agent before registering. She said, “I learned that the teachers have experiences and special education in kindergarten and they have specializations in general psychology and also in developmental psychology, which increased my desire to register with them”. In the same context, Mashael said that she visited a program twice, adding, “I discovered many teachers’ attitudes related to the children and how they dealt with children, that they have experience and qualifications, so my heart was reassured by my daughter’s registration”. We highlighted the importance of the teachers’ specialization and experience because the parents perceive teachers to provide a vital role in the educational process. We also noted that the importance of experience does not diminish the importance of their mastery of the scientific material. In other words, experience refers to the mastery of both the educational material and methods of teaching. The teacher must understand the information and be able to effectively communicate it.Many participants stressed the importance of having only a small number of students in the classroom, as they felt that this is important for the interaction of the children with the teacher, as well as the teacher’s ability to sufficiently attend to all of the children in the class. Nada reported that one of the main factors that affected her selection of a preschool program for her daughter was the small number of students in the class. She added, “One of the daughters of my close friend is in one of the preschool programs, and the class contains more than 25 students. Her child was suffering from a hearing deficiency and the matter was exacerbated by the students, so that the teacher always complained about the child’s neglect and not hearing the directions, which led to the neglect of this problem of the child and delayed solution to the problem that the child suffers from”. In the same context, Bushra stated her expectation “that the number of students in the classroom does not exceed 12 students”. Furthermore, she said, “Every child has potential and abilities, and the teacher must focus on all children and give each child the opportunity to develop his or her talents”.Many of the mothers participating in the interview discussed the importance of the working hours of the preschool program as a factor in their selection of a program. This is because almost all participants are employed outside of the home, thus it is important for them to find a program available during the morning and noon periods. Aziza said, “The program availability is suitable for me as a working mother, as they operate from 7 a.m. to 9 p.m. If I am late in my shift, I am reassured about my child being able to stay with them”. Working mothers want to leave their children in a school that cares for them so that they are reassured and do not have concerns if, for example, they are late in picking up their children.Many of the interviewees mentioned another determinant of selecting the program, namely the location and proximity to the parents’ workplace for easy access. Bdoor said, “The proximity of my child’s preschool program to my workplace is a factor that was important in selecting it”. Many mothers emphasized the importance of the school’s location in relation to their workplace, which offers both convenience and the ability to save time and money from reduced travel.During the interviews, a few participants highlighted another component that was important in selecting a preschool program, namely that it was affiliated with and located in their workplace. Mona expressed how the program’s location at the workplace “allows me to check on my daughter, as my daughter suffers from diabetes, so I can be close to her and can follow her continuously in taking medicine and the quality of food, and also provide support and share with her during her school day”. We note that some mothers have an especially strong attachment to their children, especially if the child suffers from a specific disorder or disease. Thus, for this specific participant, having her daughter in a program at her workplace makes her feel close to her child, allowing her to check on her daughter during working hours and giving her feelings of reassurance and comfort.For a group of participants, tuition costs played an important role in determining the preschool program. Doaa, for example noted, “The cost of the program is very reasonable, which means approximately 12,000 Saudi riyals per year for the child”. In contrast, Sawsan stated that the high costs of a preschool program helped her select that program. She stated, “The high costs indicate the high social and economic level of the students attending the school and they are the ones who will engage with my child and influence and be affected by them”.Most of the interviewees noted the importance of a safe and appropriate environment for their children as a determinant of selecting a preschool program. They specifically referred to the building and the availability of emergency exits, the presence of a large roofed yard, protection from the sun, classroom capacity, and first aid facilities. Sawsan recalled that, in part, it was important for her to select a preschool program based on “the modernity of the building and its continuous maintenance, as well as the presence of entrances and exits for emergencies in the event of accidents or fire, the availability of fire extinguishers, and the presence of a private room equipped with first aid”. Sawsan also expressed, “My child spends about 8 h a day inside the building, and all of that makes me comfortable with my child there”. In the same context, the role of an appropriate environment for the child is important in selecting a preschool program for many interviewees. Bushra stated, “I found large playgrounds; their classrooms are large and equipped with modern means, … and when I took a tour of the school, I found that, so I was excited to register my child”. Meanwhile, Doaa said, “The squares are large and all of them are roofed to protect children from the sun”. Many participants noted that the school is the second home in which the student spends most of their hours of activity; thus, a healthy and safe environment is an important criterion for selecting a preschool.The results of this study revealed that the majority of respondents relied on family and friends for information about preschool programs. Furthermore, partly basing their selection of a preschool program on the previous experiences of relatives and trusted parents increased the confidence and security of the parents in their selection. A minority of respondents relied on their own research and inquiries about the programs.The results of this study suggest that Saudi mothers focus on academics, religious instruction, teaching quality, the school’s characteristics, environment and facilities, convenience, and safety. However, several studies have shown that academic priorities are often paramount . The curOther results from the current study indicate that the parental choice of preschool program is affected not only by factors related to the location and cost, but also by those associated with the quality of teaching, as is reflected in the literature that has addressed Western preschool selection ,36. MeanMany participants in the study expressed their desire that the preschool programs appoint educationally qualified people to teach rather than relying on high school graduates. This is consistent with the results of research with Western parents, which documents that parents’ decision-making about a school is affected by the quality of the academic staff. Western and Saudi parents alike prefer professional academic teaching staff who are highly skilled, on the presumption that such staff are best able to educate their children ,38,39.Parents in this study stressed the importance of having a small number of students in a class, so that their child receives sufficient and directed attention as well as sufficient care and time. To a degree, preparing the students in a classroom depends on reducing the size of larger classes—as a form of educational reform—which increases the number of individual interactions between the student and the teacher. The aim is to improve student learning and achieve order and discipline in the classroom while providing an atmosphere that allows for dialogue and discussion that respects the opinions of others. This facilitates equality in the classroom, so that each child receives appropriate attention, care, and time. This supports the findings of previous studies of Western parents on the teacher–student relationship e.g., ,41). Sma. Sma41])The program’s operating hours and suitability with respect to the parents’ employment commitments is important, as is the location of the program and its proximity to the parents’ workplace. Proximity to the workplace reduces transportation time and costs. Moreover, a report by the International Labor Organization  proposedThe importance of a safe and appropriate environment for the child resides in the fact that it serves as a second home for them, and it is the place where they spend much of their waking hours. A healthy and safe environment is important, meaning that emergency exits and first aid must be available, while the presence of covered yards for protection from the sun is an additional criterion that was identified by Saudi parents for the selection of a preschool program. Badri and Mohaidat  contendeThe current study was unable to explore how parents from various socioeconomic backgrounds select preschool programs. By the researchers’ subjective estimation, most of the interviewees in the current study were middle class. Hence, additional studies on this topic could produce a more comprehensive understanding of this area. Furthermore, we only interviewed a small sample of 12 women. Future research may assess a larger sample. Finally, we encourage future research to investigate factors that affect fathers’ preferences for preschool programming. We attempted without success to recruit men as participants. Although we anticipate many similarities between the factors identified to be important by mothers and fathers, it is possible that men and women may weigh some factors differently; for example, fathers may weigh tuition and fees more heavily than mothers.


The changes in the EG after the program showed the inverse relationship between Flow and Anxiety. Two important theoretical factors of both variables , such as worry and the feeling of lack of control, could be involved. The results are under discussion and future lines of research are proposed.Positive Psychology has turned its attention to the study of emotions in a scientific and rigorous way. Particularly, to how emotions influence people’s health, performance, or their overall life satisfaction. Within this trend, Flow theory has established a theoretical framework that helps to promote the Flow experience. Flow state, or optimal experience, is a mental state of high concentration and enjoyment that, due to its characteristics, has been considered desirable for the development of the performing activity of performing musicians. Musicians are a population prone to health problems, both psychological and physical, owing to different stressors of their training and professional activity. One of the most common problems is Musical Performance Anxiety. In this investigation, an electronic intervention program was carried out for the development of psychological self-regulation skills whose main objective was to trigger the Flow response in performing musicians and the coping mechanism for Musical Performance Anxiety. A quasi-experimental design was used with a control group in which pre- and post-measures of Flow State, Musical Performance Anxiety and, also, Social Skills were taken. Sixty-two performing musicians from different music colleges in Spain participated in the program. Results indicated that the intervention significantly improved Flow State ( From the Positive Psychology approach, the study of emotions has been addressed to try to understand how they influence people’s health, performance, or their overall life satisfaction .In a review of 12 school-based interventions to foster student well-being and academic performance, following a Positive Psychology approach, it was found that implemented programs were consistently related to student well-being, social relationships, and academic performance . In the Framed in Positive Psychology, Flow theory  has estaIn the same line of thought, for a few years now, the need for musicians to develop self-regulation skills has been considered, which would complete an education focused on eminently technical-performance aspects .It has been noted how musical performance poses multiple simultaneous demands at the cognitive , affectiRecent studies have suggested that the psychosocial work environment of musicians may be considered more demanding than that of other occupations . For exaOne of the most common and specific problems of performing musicians is Musical Performance Anxiety (MPA). MPA is the experience of strong and persistent anxious apprehension related to a musical performance, which manifests as a combination of affective, cognitive, somatic, and behavioral symptoms. It is triggered in different performance contexts, but it is more intense when (a) the performer is overly concerned about their image, (b) there is fear of evaluation and judgment from others, and (c) there is a fear of making mistakes. Although it can be specific, focused on musical performance, it can also occur alongside other anxiety disorders, for example, social anxiety disorder . NumerouOn the other hand, it has been suggested that anxiety has a negative relationship with a Flow state . This haFlow State (FS) is a subjective state of mind in which a person is involved in what they are doing, highly focused, carefree, and with a positive emotion of gratification . People It has been noted that it is important to properly operationalize FS as an optimal state of consciousness that is relatively rare in daily life, intrinsically rewarding and differentiated from the conditions that cause it  .Flow state has been investigated in different fields. In the field of Sports Psychology, it is a widely researched construct and the works of Susan Jackson have been considered as a reference , 2004. BFinding FS relationships with other variables appears as a research area that can help to understand ways to promote FS. According to Flow theory, there is the concept of “autotelic” personality which suggests that certain personal characteristics may represent a greater disposition to undergo the Flow experience . There aA systematic review has also shown that there is a small to moderate relationship between FS and performance. The results show that such a relationship is consistent in both games and sports activities .Other factors related to FS are emotions. FS is related to a positive emotional state and is one of the factors that has been identified as a determinant of subjective well-being . In musiIn fact, Flow theory provides a framework to promote a more positive and satisfying relationship with performing an activity and preventing MPA. Most forms of performance anxiety are difficult to treat, and a person’s anxiety level after undergoing treatment is rarely reduced to the anxiety levels experienced by non-anxious people . For thiAlongside the research that has focused on identifying the problems that occur in the field of musicians’ health, there has been an increased focus on the prevention of these problems and the promotion of artists’ health during their musical and artistic education . Prior tOther interventions for the treatment of MPA have also been studied, such as biofeedback , yoga K, the AleRecently, research has been presented that has studied the effects of psychological interventions for the treatment of MPA such as acceptance and commitment therapy  or expreWithin an approach that is more focused on the prevention of MPA problems and the promotion of adaptive coping habits for this problem, and due to the many common characteristics of sports and musical performances, research has been presented that studies the effects of specific intervention programs. These interventions place an emphasis on psychological techniques such as mental rehearsal, goal setting, focusing on strengths, with the ultimate goal of reaching FS or a full immersion experience in a performance . Some inOne challenge in evaluating the effects of intervention programs for the development of psychological skills for performance is the difficulty of implementing these programs over a long period of time and that, in addition, they are linked to the curricular activities of schools. The results of the analysis of a vast amount of research in the field of socio-emotional learning (SEL) in compulsory education, indicate that for effective learning of self-regulation skills, regular and consistent practice of these skills is necessary and, furthermore, that involvement of different educational strata is needed for optimal implementation . AccordiA recent article has reviewed the benefits of integrating various approaches to MPA prevention or treatment and how it can contribute to the musician’s psychological training and performance preparation process. In this article, the contributions of emotion psychology and emotional regulation are shown as key elements for an appropriate approach to the MPA phenomenon, without forgetting the role of clinical psychology, performance psychology, and positive psychology .Another recent study has found a strong relationship between MPA, social anxiety, and perfectionism, suggesting that some musicians with MPA also show symptoms of a co-morbid social phobia that is not specifically related to performance . EvidencSupporting this relationship with social anxiety, a recent study has found that social avoidance is among the set of MPA predictors . In factPrevious studies show the importance of interpersonal relationships and social skills for performing musicians, as well as associations between MPA and social anxiety. However, interventions carried out to address the problem of MPA tend to focus on aspects of the individual  and are generally focused on performance. A broader perspective would be for interventions to implement strategies for musicians to develop emotional and social awareness and regulation skills beyond specific performance preparation.On another note, Internet use has expanded the way mental health interventions are implemented . FindingFurthermore, for the first time, the global impact of the COVID-19 pandemic has increased the demand for mental health services, and internet-based interventions may be particularly suitable for this purpose . For theThe main objective of this research was to evaluate the effects of a program designed to promote FS and deal with MPA through the development of self-regulation skills. The program was aimed at a group of students and professors from a music conservatoire who are active performing musicians. Two dependent variables were considered: (a) FS and (b) MPA. As a secondary objective, the program’s effects on the variable Social Skills (SS) were studied.The following hypotheses were made:(1)The existence of significant differences in FS between the control group and the experimental group (EG) will be determined.(2)The existence of significant differences in MPA between the control group and the EG will be determined.(3)The existence of significant differences in SS between the control group and the EG will be determined.(4)Significant differences in any of the variables considered in the control group will not be determined.This research was carried out using a quasi-experimental design that use both control groups and pretests. Specifically, we used the untreated control group design with dependents pretest and posttest sample. This design is frequently called the nonequivalent comparison group design, that is, may be, the most common of all quasi-experiments .m = 27.58 and de = 10.56). 32% (n = 20) were men (mean age = 30.25 and DE = 10.94) and 68% (n = 42) were women (mean age = 26.31 and DE = 10.26). The participants were divided into two groups based on the information collected in the form they completed and where the requirements for participation in the program had been explained. The participants who met all the requirements and agreed with the commitment of participation were part of the EG. Of the rest of the participants, those who met the basic requirements of being of legal age and performing musicians (senior students or active performing teachers), and agreed to the commitment to respond to the forms 3 months later, were part of the control group (CG). The rest of the participants were excluded from the research. EG consisted of N = 28 . CG was made up of N = 34 . Senior music students or active performing teachers who had an internet-connected device and a Gmail email account were able to apply to participate in this program. They also had to consent to the research and agree to a declaration of commitment and sincerity to the program see . In addi-Flow State Scale for Musical Performers (EFIM in its Spanish acronym) . This is-KMPAI-E , is the -Social Skill Scale, SSS . Two sub-Form for obtaining sociodemographic data. A Google form was used that can be programmed so that none of the questions are left unanswered. As The project was endorsed by the Department of Behavioral Sciences Methodology in the Faculty of Psychology at the National University of Distance Education (UNED in its Spanish acronym). Further, the study was conducted in accordance with the latest declaration of Helsinki .In order to distribute the information among their students and teachers, 1 month before starting the program, they contacted music colleges in different areas of Spain. Details were given of what the program consisted of, how it would be developed and the form to be completed by the participants was attached.Some personal and sociodemographic data were requested in the form and the three scales were included to evaluate the variables of interest. It was suggested that the completion of the questionnaire evaluating FS should be done after carrying out a public performance (audition or concert) or to respond to this questionnaire considering the last performance or audition performed as a performative situation. In the case of post-test measures, EG responded to the form after carrying out a self-organized public performance (audition or concert) or using a performance planned in their schedule, but under criteria established in the program see . While CThe Self-Regulation Skills for Performing Musicians (HAMI in its Spanish acronym) program was designed for participants to complete through the online platform Classroom (by Google). A combined approach was used, that is, they carried out the activities independently, but with contact and individualized feedback from the psychologist responsible for the program through the same platform. The program lasted 12 weeks where, on each school day, between 3 and 20 min had to be spent carrying out a task. In absolute terms, there were 60 days in the program.The program’s objectives were to have a direct impact on each of the components of Flow see , and alsDifferent exercises were carried out to develop the self-regulation skills that made up the program’s objective. These exercises were designed from the evidence of different strands of scientific psychology. Specifically, from CBT , Mindfult-test were performed. In all cases, the Levene test was performed to verify the assumption of homoscedasticity of the variances of the two groups and was carried out in all the contrasts except those indicated (a). Statistical analyses were performed with LISREL 11  . The modISREL 11 , PRELIS ISREL 11 , SPSS foISREL 11 .Initially, 91 performing musicians accessed the program. Thirty-one were discarded shortly after starting the program because they did not give any sign of following it, they neither marked the tasks nor established any type of communication with the person in charge of the program. One of the explanations for this behavior would be that they were people interested in seeing the program rather than participating. On the other hand, throughout the program, 32 musicians didn’t follow the pace that had been established to do the tasks and did not finish the program on time. However, it cannot be said that they abandoned it, they remained in the program to do it at their own pace, but they did not enter the investigation. Finally, 28 (EG) participants completed the proposed program and completed the subsequent forms that were considered for data analysis.A demographic analysis of program completers versus non-completers was conducted to assess their future suitability. In general terms, standardized values of skewness and kurtosis out of the range –2 to 2 could be indicating significant deviation from normality . The majOn the other hand, the Kolmogorov–Smirnov test showed that the EF, AEM, HHSS and the subscales of EF , were normally distributed. However, this result was not found in concentration, time and autotelic see .p < 0.01). The correlation between FS and MPA showed a coefficient of r = –0.40; between FS and SS of r = 0.45; and MPA and SS of r = –0.61. These correlations remained relatively stable with slight variations in the post-test measures . Although, if we look at the size of the effect of the correlations  = 3.94, p = 0.05, η2 = 0.06]  = 6.45, p = 0.01, η2 = 0.10] and MPA , but not in SS . In the FS dimensions, there were statistically significant differences between the two groups in the post-merging measures , concentration  control , and consciousness ; but not in time , nor in autotelic   = 4.23, p = 0.04, η2 = 0.07], and a statistically significant interaction between the group and time . As for MPA, there was a statistically significant decrease over time , and a statistically significant interaction between the group and time . Regarding the SS variable, there was no statistically significant difference over time , nor was there a statistically significant interaction between the group and time   [.02] see .F = 4.28, p = 0.04, η2 = 0.07], however, it did not show a statistically significant interaction between the group and time ; in the “concentration” dimension, there was no statistically significant difference over time , nor was there a statistically significant interaction between the group and time . Regarding the “control” dimension, it showed a statistically significant increase over time , and a statistically significant interaction between the group and time . Regarding the “consciousness” dimension, it showed a statistically significant increase over time , and a statistically significant interaction between the group and time . Finally, in the “time” and “autotelic” dimensions, there were no statistically significant differences over time, nor was there a statistically significant interaction between the group and time  = –2.41, p = 0.02, d = 0.36, 1-β = 0.45], MPA , “control” , and “consciousness” . Therefore, there is sufficient evidence to conclude that the participants in the program showed higher levels of FS and lower levels of MPA after their participation in the program.Student’s t(33) = 0.44, p = 0.66, d = 0.08, 1-β = 0.07], MPA , “control” , nor in “consciousness” . Therefore, there is sufficient evidence to accept the fourth hypothesis of the research, which stated that CG will not show differences between the pre-and post-measures of any of the variables considered.Regarding the CG results, they did not show statistically significant differences in FS [For One of the most common and specific problems for performing musicians is MPA. According to Flow theory, it has been noted that anxiety could have a negative relationship with FS , which hFlow state is a widely researched construct in different fields, especially in the field of Sport Psychology cf. . In the To that end, the main objective of the present research was to evaluate the effects of an electronically implemented psychological program, aimed at performing musicians, and designed to promote, mainly, the state of Flow, through the development of self-regulation skills and coping with MPA.To evaluate the results of the intervention program, the factorial and measurement invariance between EG and CG was first analyzed for the three dependent variables in the baseline measurements. The results showed equivalence between the two groups with adequate overall goodness-of-fit indices see . This reThe results showed that EG and CG were homogeneous in FS, SS, and the six dimensions of FS in baseline measurements, however, the musicians who participated in the intervention had, prior to it, a lower level of MPA than the musicians in CG see . This bar = –0.40) that increased in the post-test measure (r = –0.54), strengthening the negative relationship between the two variables. However, in the partial correlations, in the pre-measures, the partial correlation between FS and MPA presented a weak, non-statistically significant association when the effect of SS was eliminated. In addition, the partial correlations showed that each association between each pair of variables was more or less influenced by the effect of a third, depending on the moment in time. In the post-measures varied with respect to the pre-measures, both in FS-MPA and in FS-SS. This result points to the intervention program’s effect on FS-specific and MPA-related components (such as “control” and “consciousness”) but independent of SS, which is reflected in the differences between the partial correlations of the pre-and the post; specifically, in the post-measure’s increase between FS and MPA and, on the other hand, the decrease between FS and SS.Regarding the bivariate correlations between the FS, MPA, and SS variables, the results showed statistically significant median associations between each of them see , and theHowever, the stability of the partial correlation between MPA and SS in the two temporal measures suggests that the development of SS could contribute to reducing general social anxiety and factors of social phobia that, in turn, could be an advantage for coping with MPA, results that, on the other hand, would support studies that highlight the importance of SS in the context of music education and performance .d = 0.36). Similarly, EG experienced a decrease in MPA that was also found to be statistically significant, with a small effect size (d = 0.24). It has already been mentioned that EG showed lower MPA levels than CG in the pre-measure. As mentioned above, this result could be related to a greater knowledge of psychological skills that the EG musicians could have developed prior to the intervention. However, although EG had shown lower MPA levels than CG in measures prior to the intervention, those levels decreased even more after the program. On the other hand, CG did not show statistically significant differences between the two temporal measures, neither FS nor MPA. Unlike the study by Regarding the intervention program’s effects on the FS, MPA, and SS levels of the participating musicians, the results showed that the increase that EG had experienced in FS levels was statistically significant, with a small to medium effect size (d = 0.47) and large for “consciousness” (d = 0.70)  remained stable in the two temporal measurements in CG see . However = 0.70) . Regardi = 0.70) , they diOn the other hand, these results could be linked to studies that suggest that FS dimensions could be grouped according to whether they refer to cognitive functions or emotional aspects . In thisIn fact, this research’s intervention program proposed tasks that could directly or indirectly potentially improve the cognitive dimensions; tasks to improve attention and concentration, tasks to regulate thoughts, fears, or self-criticism, tasks to develop self-confidence, emotional regulation exercises, etc. And, transversally, tasks were also proposed that promoted self-care, spending time enjoying various experiences , enhancing positive emotions, as well as positive relationships with others. But, as presented in the results, the dimensions that showed statistically significant differences were “control” and “consciousness.” Although it may seem that the tasks intended to increase enjoyment were not effective, in reality, there is a possible explanation. It is difficult to assess whether and in what way these more cross-sectional tasks affected each of the FS dimensions, however, it is now recognized that emotional aspects have an influence on cognitive processes. Cognitive functions are facilitated by positive emotional states   components, that is, on “control” and “consciousness.” It has been suggested that “consciousness” plays an important role in achieving FS. Students who do not self-destructively criticize themselves achieve more Flow than those who have a self-destructive attitude . On the m = 24.79; post, m = 24.36). In different research projects, “time” shows weak correlations with the rest of the dimensions  in the post-measure decreased from 0.45 to 0.30; and, in the partial correlation, when the variance that FS and SS shared with MPA was removed, the correlation between the two variables (FS and SS) was basically zero. On one hand, the mean values of these two variables in CG remained the same between the pre- and post-measures . Instead, it was EG that showed a statistically significant increase in FS and only a slight non-significant increase in SS.Regarding the SS variable, the results suggest that the activities that were designed to promote better interpersonal communication, self-confidence in social situations, empathy, and positive feelings toward others, did not cause changes in the SS of the participants see . It shouTherefore, this change in the post-correlation between the two variables (FS and SS) suggests that the FS level increased independently of SS. A future line of study regarding SS would be to study its relationship with FS and MPA through structural equation models that would permit an analysis of the type of effects that occur between these variables.In summary, results indicated that the intervention significantly improved FS and decreased Music Performance Anxiety of the participants in the EG, but not CG. This suggests that programs whose designs incorporate a combination of all the techniques and methods that were used in the program and that come from scientific psychology could be useful to treat the problem of MPA or to prevent it; and, in addition, they could facilitate FS, greater enjoyment during a performance and potentially better performance quality. The results are consistent with the consideration of integrating various approaches of Psychology for the prevention or treatment of MPA, such as the psychology of emotion and emotional regulation, clinical psychology, performance psychology, and positive psychology .Furthermore, through the electronic implementation, satisfactory results have been obtained. Although the program, which was carried out with programs whose objective is to treat depression , anxietyLimitations and possible future lines of research have already been discussed. But it is necessary to discuss the limitations regarding the generalization of the results because the selected sample is a target population chosen based on some characteristics, not selected randomly. Also, it needs to be emphasized that, the selection procedure was conditioned by the characteristics of working in “life itself” and not working in a research center. In fact, this study, more than usage research, offers the results of the evaluation of the implementation of a self-regulation skills training program. The investigation that was carried out is nothing other than the evaluation of that program. Another limitation is that 63 musicians who entered the program did not participate as planned. As mentioned in the results, about half showed no signs of following it and the other half did so at their own pace. Probably, the first ones were interested in seeing the program, but not doing it. However, in no case did they communicate that they wanted to leave it. In fact, they received the notification to perform the tasks every day until about the middle of the program. On the other hand, 32 musicians freely followed the program and expressed their interest in following it without the pressure of time. Therefore, it is possible that a longer time to complete the program means better results in terms of its completion.It is also necessary to consider that no performance measures were taken. The pandemic situation complicated communication and collaboration with music institutions in order to take performance measures. But it would be especially interesting to take these measures since another issue that is not yet clear is whether the correlations between performance and FS are due to a good performance generating FS or a FS facilitating performance . HoweverRegarding the assessment of whether the program’s specific design  contributed to the improvements in FS and MPA, it is impossible to say. In order to prove it, it would have been necessary to compare it with other programs (which had been carried out by other groups of participants) and which differed in some element of the design, while controlling the other elements. For example, doing the program by dedicating each school day to carrying out some exercise, compared to doing the program by controlling all other factors, but doing one or two classes a week for the same amount of time. This could be a future line of research that would allow the analysis of whether daily regularity contributes to acquiring self-regulation skills more quickly and efficiently than practice which is more spaced out over time. Lastly, the participants had individualized support and feedback throughout the program (unscheduled). The platform was adjusted so that there was only individual interaction between each participant and the person in charge through private messages. However, the time each participant received from the responsible psychologist was not recorded. Taking this variable into account can improve future research.Future research could study whether Internet-based programs with the aim of promoting FS , show similar efficacy compared to face-to-face programs, as well as whether they present a greater (or lower) dropout rate. Or also, to introduce a third possibility in these studies, that is, the design of a program with a combination of the two (electronic and face-to-face). This line of research could be very interesting because elements can be introduced into the design of the electronic intervention program which can be difficult to introduce into group face-to-face student classes . Likewise, the electronic program could also suffer from shortcomings, such as, for example, the hands-on practice of social skills in the classroom with classmates or the close contact  of the professional in charge of the program. So a combination of the two possibilities (electronic and face-to-face) could be an advantage for the development of these skills. In any case, the presence of these psychological skills development programs in music schools seems necessary for the comprehensive education of performing musicians. Probably one of the most relevant reasons to promote the Flow response in performing musicians would be its relationship with subjective well-being and the quality of the experience during the performance. As long as the institutions and people responsible for educating musicians promote this experience, they will be addressing the need to enjoy the performing activity itself and promoting the mental health of the performing musicians .The original contributions presented in this study are included in the article/The studies involving human participants were reviewed and approved by the Department of Behavioral Sciences Methodology in the Faculty of Psychology at the National University of Distance Education (UNED) and were conducted in accordance with the latest declaration of Helsinki . The patLM-B: conceptualization, methodology, formal analysis, investigation, data curation, and writing – original draft preparation, review and editing. AL and MP-L: methodology, writing-original draft preparation, writing-review and editing, supervision, and project administration. FH-T: methodology, formal analysis, writing – review and editing, and supervision. All authors read and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Friendship Bench (FB), a problem-solving therapy (PST)–based program that was successfully implemented among patients with CMDs in primary health settings in Zimbabwe and Malawi for use among people living with HIV on methadone maintenance treatment (MMT) with CMDs in Hanoi, Vietnam.The prevalence of common mental disorders (CMDs) among people living with HIV and people who inject drugs is high worldwide and in Vietnam. However, few evidence-informed CMD programs for people living with HIV who inject drugs have been adapted for use in Vietnam. We adapted the This study aimed to describe the adaptation process with a detailed presentation of 4 phases from the third (adaptation) to the sixth (integration) of the Assessment-Decision-Adaptation-Production-Topical Experts-Integration-Training-Testing (ADAPT-ITT) framework.The adaptation phase followed a qualitative study design to explore symptoms of CMDs, facilitators, and barriers to conducting FB for people living with HIV on MMT in Vietnam, and patient, provider, and caretaker concerns about FB. In the production phase, we revised the original program manual and developed illustrated PST cases. In the topical expert and integration phases, 2 investigators (BNG and BWP) and 3 subject matter experts  reviewed the manual, with reviewer comments incorporated in the final, revised manual to be used in the training. The draft program will be used in the training and testing phases.The study was methodologically aligned with the ADAPT-ITT goals as we chose a proven, effective program for adaptation. Insights from the adaptation phase addressed the who, where, when, and how of FB program implementation in the MMT clinics. The ADAPT-ITT framework guided the appropriate adaptation of the program manual while maintaining the core components of the PST of the original program throughout counseling techniques in all program sessions. The deliverable of this study was an adapted FB manual to be used for training and piloting to make a final program manual.This study successfully illustrated the process of operationalizing the ADAPT-ITT framework to adapt a mental health program in Vietnam. This study selected and culturally adapted an evidence-informed PST program to improve CMDs among people living with HIV on MMT in Vietnam. This adapted program has the potential to effectively address CMDs among people living with HIV on MMT in Vietnam.ClinicalTrials.gov NCT04790201; https://clinicaltrials.gov/ct2/show/NCT04790201 Injection drug use is the main cause of the HIV epidemic in Vietnam, resulting in a high HIV prevalence among people who inject drugs, 15% in 2017 ,4. HIV aFriendship Bench (FB), developed by Chibanda Dixon in 2006  are stable or not. We may have to change to others if we choose them.FGD_01In addition, although peers might receive training to do the job, they lack practical experience in caring for patients with different types of mental problems. A dominant theme among the patient respondents was the importance of the personality traits and counseling approach of the program provider. Patient respondents stressed the need for counselors who are gentle, empathetic, and understanding:Someone like me needs affection, gentle speech, even a slightly unappropriated attitude will lead to my rejection. I need them to be considerate and gentle.Patient_IDI_303Considering the insights from interviews and FGDs in the adaptation phase, the study selected health care providers and people living with HIV or community members who were trusted by the study participants to work as study counselors in the RCT.All clinic directors, health care providers, family members, and 9 participants  reported their concerns about what time to implement the FB program. They all shared that as many patients work, it might be challenging to find a suitable time for them to attend the FB program. Most of the patients suggested that the counseling sessions should be in the morning when they come to take methadone:Because we usually take the medicine in the morning and after that, we can do activities. In the afternoon, we can’t wait, at that time we have to go home, so the most convenient time is the morning.Patient_IDI_301A patient shared that many patients could not sit for a long time, which would affect their participation in the counseling sessions. The patient believed that the counseling time should be arranged to suit the patient’s employment and examination time, such as on weekends. For clinic directors and health care providers, apart from patients’ employment, the timetable for clinic providers is very strictly scheduled; thus, time arrangement for the clinic providers to join the FB program is problematic. Providers thought that it is best to conduct FB during office hours to ensure convenience and safety for counselors and patients:If we do it outside of office hours, we should consider the safety of people here. If something happens, we are also affected. So we should do counseling in the daytime, not nighttime because we can’t control if they do something bad or not.FGD_01However, it is necessary to arrange counseling time in advance so that clinic staff do not have many overlapping tasks and have enough time for counseling patients:So if we have such a programme then we have to have a better management of our time so that we can do it.FGD_01All directors and most health care providers said that the place of program should be at the MMT clinic, as this is the place MMT patients visit every day. At MMT clinics, there were examination rooms; therefore, confidentiality and privacy would be ensured during the counseling sessions. Counseling outside the MMT clinic might be noticed by community members, which patients feared would cause them to be disliked. In addition, it is illegal for drug addicts to congregate in public spaces:It’s not possible to gather in the community. It is against the law, they are already drug addicts, if they gather that is against the law, and people in the community don’t like that, so the methadone treatment facilities are the most suitable places. In the community, there are also a few places like that, but I only see their family come, I never see them [patients/people on treatment]. So, the medical facilities are still the best place.Director_IDI_D03Half of the patients  and almost all family members  preferred to receive counseling in MMT clinics for convenience and safety for both counselors and patients, ensuring privacy for patients and having timely and relevant health services if needed. The other respondents expressed that they needed to have a private and confidential place for counseling. They also suggested that the program only needs to designate a random room in the clinic as the counseling room and that it would be great if the room could have materials or visual aides to refer to or use.All 4 directors mentioned that the program should be facilitated by the medical leadership. According to the directors and health care providers, to have the FB program implemented, it is crucial that the program follows all the administrative procedures of the MMT clinics before starting it. It should have a clear and detailed work plan, in which who, how, where, and when to conduct each activity are specified. Importantly, it is necessary to know about the people living with HIV on MMT and the severity of their CMD symptoms to have appropriate approaches and program sessions for them:If the programme is implemented in the clinic, in general, in terms of administrative procedures, I also said earlier that there must be a direction. As for the implementation, first, you must have purposes and goals, then it is necessary to train staff, then find the target group we need to consult, and then plan a schedule for specific activities, jobs.Director_IDI_01From the perspective of patients and their family members, though they believed that patients would benefit from a program such as FB, they thought the patients would participate in the program if they received compensation for their time and effort in participating in FB sessions  and did not have to pay or have any additional restrictions for program participation :If only he participates without any condition from the programme, that’s very good.Family_IDI_1011Participants thought that not having any additional challenges related to employment , financial issues , and transportation  would facilitate participation. Patients expected the program to be new and be organized interestingly and attractively:I can’t imagine it yet, but I want new and interesting methods. We will love it and if the programme have people like you, we will join.Patient_IDI_101Family members and patients discussed the following recommendations: the program materials should be easy to understand; fruits, cake, and drinks should be provided; patients who actively participated in the program activities and adhered to treatment should be rewarded and praised; and if possible, the program could assist patients with job opportunities or friend-making.Both clinic providers and patients agreed that they preferred to delicately, rather than directly, discuss mental health to help patients feel comfortable. A health care provider suggested the use of words and language that is familiar to patients to help them feel more comfortable joining the program:I think their language when talking together is very important, they want to release and use their language to feel comfortable but they can’t do that when talking to medical staff.FGD_01A patient even suggested excluding the name of the program if possible. None of the suggestions for the language surrounding FB included “mental illness” in the program name.From the perspective of family members, words in Vietnamese that are simple and easy to understand with positive meaning were preferable, and sensitive words that might worsen patients’ mental state should be avoided. A health care provider and a patient thought that the name “Friendship Bench” was beautiful and acceptable, as it did not mention the problem and had a pleasant feeling:The Friendship bench name is also very beautiful and good.FGD_F01The results of the qualitative research in phase 3 were presented in a web-based meeting with 2 investigators, 2 creators of FB, and 1 expert from HMU to reach a consensus on the necessary adaptation of the FB manual. The original FB was adapted for use by both health care providers and lay counselors in Vietnam. Common Mental Disorders to refer to a collective term of depression, anxiety, and stress-related disorders instead of “kufungisisa” (Zimbabwean for depression and anxiety), replacement of SSQ-14 to DASS-21, and suicide risk assessment and management procedures, which were used in the study in Vietnam. In addition, we excluded sessions on abuse of bronchodilators, alcohol and pregnancy, and information about antipsychotics, as they were not related to the study population. Information about the use of FB on tablets was removed, as the Vietnam FB program used paper forms to record counseling session information. Information on HIV transmission through injection, substance abuse disorders caused by injecting drugs, and amphetamine-type stimulants, which were common issues of people who inject drugs—the study population in the RCT—was added.We retained the content of 8 out of the 23 chapters in the original manual. The 8 chapters included PST, counseling skills, FB cards, emotions, stabilization, strong emotional reactions, men’s health-seeking behaviors, and self-care. We completely removed 6 of the 23 chapters, namely epilepsy, belief in supernatural powers, psychosis, home visits, group circle, and proverbs. We edited the contents in 8 of the 23 chapters. Key edits included using the words All cases were revised, and the PST case was rewritten. In the original FB, the PST case featured a common problem in the Zimbabwe community, and the main character was a person with an unknown HIV status, a person with SUD, or a woman experiencing domestic violence. The new character in the adaptation was people living with HIV who inject drugs with short-term, solvable problems about employment, family matters, finances, and relationships with neighbors.The first English version was sent to 2 investigators, 2 creators of FB, and 1 expert from HMU for viewing and editing. All of them are associate professors with intensive expertise in the areas of mental health, HIV or AIDS, and substance use. They have led clinical studies and trials on a global scale. Experts advised correcting cases of PST to adjust them to Vietnamese culture. They recommended not changing the in-person counseling procedures and having up to 6 individual counseling sessions for each patient. An FB creator wrote scripts for the counselors to be included in the draft. The creator also advised maintaining the PST structure, with 4 main parts in each counseling session. The 4 main parts were the following: open your mind, make a list of problems, plan to solve the problem according to the Specific, Measurable, Achievable, Realistic, and Timely method, and encourage the clients to implement the plan. The 4 main parts of the PST were implemented into 7 small steps: (1) How does the client deal with problems? (2) How to recognize a problem? (3) How to select a problem, find the goal, and define the problem? (4) How to brainstorm for solutions? (5) How to select a solution? (6) How to make a Specific, Measurable, Achievable, Realistic, and Timely action plan? and (7) Did it work?On October 20, 2021, a meeting was held on the web with 3 content experts, the study team in Vietnam, and 2 investigators. The investigators agreed on continuing to revise the case example of a typical people who inject drugs who encounters common mental problems in their life. These problems should be specific, simple, and solvable within 1 week. For example, “I want to quit using drugs for the next 1 year because next week is my son’s birthday.” The study team agreed to remove the group discussion portion, as it would be ineffective where MMT clinics are far from each other, without finding additional study resources. The study team then synthesized the expert revision to create the second draft in English. Illustrations of Vietnamese people were added to the second English version to make the third version which was sent to 3 content experts and 2 investigators to review and finalize. The third English version was translated into Vietnamese with the same content and images. A Vietnamese topical expert reviewed the translated third version to ensure conceptual equivalency.This study successfully illustrates the process of operationalizing the ADAPT-ITT framework to adapt to a mental health program in Vietnam. The outcome of this study was an adapted FB manual to be used for training and piloting to create the final program manual.We note that our study departs from the standard ADAPT-ITT framework by selecting an EIP that does not come from the CDC database of EIPs  and by aThe application of the ADAPT-ITT framework for the systematic adaptation of EIP can vary depending on the program, population, and resources ,30,39. AThe results from phase 3 informed the program procedures built upon the existing resources and administrative strength of MMT clinics . As a reRegarding the content of the manual, the ADAPT-ITT framework guided the appropriate adaptation of the program while maintaining the core components of the PST of the original program throughout the counseling techniques in all program sessions ,26. The This study has some limitations, the first being that the process of adaptation and production has not yet tested the feasibility and acceptability of the adapted manual. In addition, the semistructured interviews had not presented the original manual to the study participants. Therefore, we did not have comments from them on the content of the manual. Instead, the content of the manual was reviewed and revised in detail according to the study team’s revisions and experts’ comments. There might be challenges such as following the structure of FB counseling sessions, applying relevant counseling skills required in FB, following PST methods for health care, and lay counselors using the adapted manual as a resource material in conducting PST counseling sessions as they first work with this approach. As such, the adapted manual will be used to train counselors and piloted with the study participants of the future RCT to receive feedback to finalize the manual. Study participants and counselors can provide their feedback during the pilot phase. Future RCTs will test the acceptability and fidelity of the finalized adapted program.This initial exploratory study demonstrates a successful process of following the ADAPT-ITT to adapt a proven mental health program for people living with HIV on MMT in Vietnam. This study selected and culturally adapted an evidence-informed PST program to improve CMDs among people living with HIV on MMT in Vietnam. The adaptation of the program through qualitative interviews and discussions with stakeholders and study participants and the use of feedback to tailor the program procedures allowed us to identify and preemptively address potential barriers to implementation. The production, integration, and expert input phases were used to tailor the manual to reflect typical manageable problems that people living with HIV on MMT encounter daily. If the adapted FB manual is acceptable and feasible, it may be used in MMT clinics in Vietnam to reduce CMDs for patients on MMT, which would contribute to the effectiveness of drug treatment and ART.


Strong evidence exists for the benefits of pulmonary rehabilitation (PR) for people with chronic obstructive pulmonary disease (COPD), however the availability of culturally safe PR for Aboriginal and Torres Strait Islander (Indigenous) Peoples is limited. The study aims to determine whether PR can be implemented within Aboriginal Community Controlled Health Services (ACCHS) to improve outcomes for Indigenous people with COPD.BE WELL workshop and at 3, 6 and 12 months using a survey. PR participant measures will be exercise capacity , health-related quality of life and health status at commencement and completion of an 8-week PR program. Secondary outcomes will include: number, length and cost of hospitalisations for a COPD exacerbation in 12-months prior and 12-months post PR; local contextual factors influencing implementation of PR; specific respiratory services provided by ACCHS to manage COPD prior to project commencement and at project completion. Repeated measures ANOVA will be used to evaluate changes in knowledge and confidence over time of AHWs and EP/PTs. Paired t-tests will be used to evaluate change in patient outcomes from pre- to post-PR. Number of hospital admissions in the 12 months before and after the PR will be compared using unpaired t-tests.Multi-centre cohort study using participatory action research guided by the Knowledge-to-Action Framework. ACCHS supportive of enhancing services for chronic lung disease will be recruited. Aboriginal Health Workers (AHW) and the exercise physiologist (EP) or physiotherapist (PT) within these ACCHS will attend a workshop aimed at increasing knowledge and skills related to management of COPD and the provision of PR. Indigenous people with COPD will be invited to attend an 8-week, twice weekly, supervised PR program. Outcomes: AHW, EP/PT knowledge, skills and confidence in the assessment and management of COPD will be measured before and immediately after the Pulmonary rehabilitation is an essential component of best-practice management of COPD and is recommended in COPD guidelines. Indigenous peoples have limited access to culturally safe PR programs. This study will evaluate whether PR can be implemented within ACCHS and improve outcomes for Indigenous people with COPD.Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12617001337369, Registered 2nd September 2017 https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373585&isClinicalTrial=False Chronic obstructive pulmonary disease (COPD) affects 1.5 million Australians, including 1 in 13 people over 40 years of age . ImportaPulmonary rehabilitation (PR), a program of exercise training and education, is recommended as best-practice care for people with COPD  underpinIn Indigenous Australian communities there have been coordinated approaches to improve the management of other chronic diseases such as diabetes, cardiovascular and renal disease, however efforts to improve the management of chronic lung diseases, such as COPD, have been inadequate and inconsistent. A major reason for limited access to best-practice management of COPD is the perception by Indigenous peoples that PR programs offered in centre-based hospital outpatient departments are unwelcoming or culturally unsafe  due to rA recent systematic review of PR for Indigenous peoples with COPD in Australia, Canada, New Zealand and the United States of America found only one published study reporting the outcomes of PR,  highlighBreathe Easy Walk Easy, Lungs for Life (BE WELL) project is to evaluate the implementation of lung health services within ACCHS, particularly the provision of PR.The broad aim of the BE WELL program to enhance the knowledge, skills and confidence of Aboriginal Health Workers in the assessment and management of people with COPD and in the delivery of a culturally safe PR program that includes exercise training and patient education.Evaluate the ability of the Identify the structural, systems and other contextual factors that influence successful implementation and sustainability of PR programs within ACCHS.Determine the uptake of respiratory assessment and PR programs by ACCHSBE WELL PR program on health outcomes and health care utilisation and costs  of Indigenous people with COPD.Determine the impact of the The implementation objectives (1–3 in the list below) and the intervention objective (4 in the list below) of the study are to:BE WELL program in the Knowledge-to-Action Framework. The study has ethics approval from the Aboriginal Health and Medical Research Council of New South Wales, Australia (Project 1261/17). All participants will provide written, informed consent. Any protocol amendments will be approved by the ethics committee and reported on the Australian New Zealand Clinical Trials Registry.The study will be a cohort study using implementation science and participatory action research methods guided by the Knowledge-to-Action Framework –15. ThisACCHS in New South Wales, Australia will be invited to participate in the study with the aim of recruiting one ACCHS from each of the following regions: metropolitan, regional, rural, remote. These regions will be identified by the remoteness classification . InitialBE WELL project; (2) Aboriginal health workers (AHWs) who are nominated by the ACCHS to work within the local BE WELL team to develop and aid provision of a PR program; (3) Exercise physiologists (EP) or physiotherapists (PT) who are contracted by the ACCHS to provide the PR program within the ACCHS; (4) Aboriginal people attending the ACCHS who have a confirmed diagnosis of COPD by spirometry [ratio of forced expiratory volume in one second (FEV1) to forced vital capacity (FVC) of less than < 0.7] and who are referred to the BE WELL PR program.Within the ACCHS the following participants will be recruited: (1) ACCHS management who have oversight or involvement in managing any aspects of the BE WELL program in more detail. A focus group will explore the local structural, system level and other contextual factors that will influence successful implementation within the ACCHS. The discussion, guided by the Theoretical Domains Framework,  will visit each ACCHS at the start of the project to discuss the amework,  will enaBE WELL workshop at their site. The workshop will be provided by a physiotherapist experienced in pulmonary rehabilitation and adult education (JA). The workshop will incorporate the Aboriginal pedagogy of 8 Ways of Learning   , requireSD) 4.5] , with a SD) 4.5] ) with SDThis study aims to determine whether PR can be implemented in ACCHS to improve outcomes for Indigenous people with COPD. As stated in the 4th Atlas of Clinical Variation there is an unacceptably high rate of hospitalisations for people with COPD generally, and for Indigenous Australians in particular, and strategies known to improve the health of people with COPD need to be implemented . This isBE WELL project will provide a better understanding of what is needed within ACCHS to enable them to provide PR programs for their community members who have COPD.The availability of culturally safe PR programs for Indigenous people with COPD is minimal since mainstream PR services are usually provided in hospital outpatient departments which Indigenous people are unlikely to access given their distrust of the hospital system , highligBE WELL PR program so that it fits with the needs and the physical and staffing infrastructure of each ACCHS. As such, modifications to the delivery of the PR program can be made if needed, based on understanding the local barriers and facilitators to program delivery by partnering with each ACCHS. A further strength of the study is the focus on better understanding the requirements of the AHW workforce to upskill in the management of the major health issue of COPD. The BE WELL project will provide an understanding of the educational requirements and clinical experiences needed to upskill AHWs so that they can be actively engaged in this area of practice in ACCHS.A strength of the study is the implementation science and participatory research methodology using the Knowledge-to-Action framework . This stBE WELL program aims to ensure equity of access for Indigenous people to effective interventions for COPD.The findings of this study will contribute important information to the understanding of what enables an ACCHS to provide lung health services, particularly PR. Given the high burden and high cost of COPD for Indigenous people, improving quality of life and reducing hospital admissions and mortality through the delivery of PR is highly relevant to the major Indigenous health priorities to close the gap in life expectancy within a generation (by 2031) . The BE


The challenges of supporting the health and social needs of older adults and caregivers in rural and frontier areas are well-documented. It is common for rural older adults to experience barriers in accessing geriatric specialists, care coordination services, and caregiver support and education programs. The Wyoming Geriatric Workforce Enhancement Program (WyGWEP) is an innovative partnership comprising an academic geriatrics program, primary care delivery sites, single-unit on aging representing community-based organizations, and a tribal health program. This partnership, funded by the Health Resources and Services Administration, provides the infrastructure to assess needs, provide education and training, create programs to address gaps in care, implement practice innovation, and advocate for needs of rural older adults. This symposium includes five presentations detailing the unique projects of the WyGWEP partnership and the impact of this collaborative work on a variety of stakeholders. The results of a mixed-methods evaluation of the WyGWEP partnership will describe the benefits to the partners and areas for growth. A collaborative effort to assess the needs of older adults informs recommendations to support rural aging in place. Schenck et al. will describe the adaptation of the widespread ECHO model for use with dementia caregivers in rural and remote locations. Representatives from Wyoming’s only Program for All-Inclusive Care of the Elderly (PACE) will explain the cost of a recent decision to de-fund and close this important program. Finally, the impact of a novel Chronic Care Management implementation program will be discussed, including sustainable billing revenue produced by rural primary care clinics.


This presentation will trace the development of the Savvy Caregiver program from its beginnings as the Center for Nursing Research-supported Minnesota Family Workshop  through a further test as the Partners in Caregiving Program  to the Alzheimer’s Association-supported Savvy program . Three main developments occurred over this period: the program solidified its identity as a caregiver training program and its mechanism of action as that of self-efficacy development through an active learning approach; it sharpened its focus by concentrating on the principal family caregiver (moving away from a broader family approach and eliminating concurrent care recipient programming); and it developed interventionist training materials and programs to enable broader reach. Since 2002, Savvy has enjoyed wide dissemination as an evidence-based in-person psychoeducation program, fostered by support to sponsoring organizations by the Administration on Community Living.