Therapy dogs in educational settings have gained increase traction in recent years. Despite its potential benefits and popularity, there remain concerns of perceived risks such as sanitation, allergies, and safety issues, as well as a lack of guidelines, regulations and support resources available to school staff. Research is further lacking into the implementation process of therapy dog programs in educational settings. To construct a set of recommendations for school staff to achieve successful implementation of a therapy dog program, the present study investigated the perceived facilitative and impeding factors when implementing a therapy dog program. A total of 13 school staff and 2 coordinators from therapy dog organisations took part in an open-ended online survey and/or a semi-structured interview over the phone, with the aim of gathering their perspectives of implementing a therapy dog program in schools. The thematic analysis of the data indicated facilitative factors such as program flexibility, whole-school support, the need for communication and training for all staff, as well as dog welfare. Successful implementation of therapy dogs in an education setting appear to revolve around (1) flexibility of the dog therapy program to target school's needs, (2) qualities of program instigator, (3) whole-school support, (4) communication, training and education, (5) considerations for dog's welfare. Key barriers identified included a high workload, lack of guidelines on processes, lack of support from the school community, as well as the need for better understanding of the role of a therapy dog. The results highlighted the importance of a whole-school effort when implementing a therapy dog program, as well as the need for guidelines for assessing school readiness, key factors for consideration, and strategies to overcome challenges associated with program implementation. Therapy dogs in educational settings have gained traction in recent times. Increasingly, dogs have provided therapeutic support in early education settings, primary and secondary schools, as well as university settings to support students' well-being, promote a sense of belonging in school, reduce stress and anxiety, and even facilitate learning –3. AcrosSeveral terms describe how dogs provide therapeutic benefit. A therapy dog refers to a dog trained to provide therapeutic benefit mainly through Animal-Assisted Therapy (AAT), Animal-Assisted Intervention (AAI), or Animal-Assisted Education (AAE) . AAI, AnTherapy dogs are first selected for their temperament and subsequently trained together with their handler, usually by therapy dog organisations, to be calm and obedient such that there are able to provide emotional support, comfort, and companionship to different individuals in various educational, health care, and community settings . In AAT,There is preliminary evidence which suggests that therapy dogs can enhance children's well-being in a variety of settings from schools, hospitals, airports, and courtrooms. Therapy dogs have been found to reduce physiological symptoms of stress through lowering cortisol levels , increasIn addition, there is evidence indicating an association between well-being and learning outcomes –25. ChilDespite the potential benefits of a therapy dog program, there are several concerns and challenges which might arise from successfully introducing a therapy dog into a school context. Primary concerns by schools include legal implications and liability, allergy concerns, hygiene and sanitation concerns, safety concerns, cultural differences, fear of dogs, animal welfare, funding associated with animal maintenance and program implementation, as well as a lack of administrative support , 27–32.The most common objection for introducing a therapy dog into a school setting is sanitation concerns. There is a common perception that dogs can be potential carriers of diseases and infections which can then be transmitted to human beings . AllergiAnother barrier to implementing therapy dogs and programs into schools is funding as well as a lack of administrative and staff support. There are substantial costs involving a therapy dog. In addition to the usual costs associated with owning a dog, the costs associated with annual veterinary check-ups, vaccinations, as well as therapy dog training can be quite substantial . Most thImplementation science promotes research findings in healthcare, community and policy contexts . It seekA scoping review of program implementation in the education setting identified several key factors for consideration when implementing a program . They foIn addition, support for front-line staff was paramount for implementation success as educators often struggle when trying to apply the new practises in the classroom . SupportGiven the concerns and challenges associated with implementing a therapy dog program in schools, as well as the various factors for consideration when implementing any new practise, it is critical that schools have guidelines on key considerations and processes to help them navigate this implementation process. There are currently few resources available for accessing guidelines, procedures and standards for implementing a therapy dog program into various settings and populations –54. For While therapy dog programs have increasingly been incorporated in many school settings, research exploring the specific concerns and challenges associated with implementation in schools are needed. Moreover, guidelines, policies and existing research into therapy dog programs is lacking. The current study examined the following three research questions:What are the facilitative factors associated with implementing a therapy dog program in schools?What are the perceived challenges and barriers with implementing a therapy dog program in schools?What support is required when implementing a therapy dog program in schools?The results of the study informed a set of research-informed recommendations and guidelines outlining key factors for consideration when implementing a therapy dog program in school settings.A qualitative research design was employed using open-ended questionnaires in form of an online survey and/or semi-structured interviews completed over the phone.Data was drawn from two participant groups: (i) schools with an existing therapy dog program, (ii) schools considering implementing a therapy dog program, and (iii) therapy dog organisations. All participants were recruited via email and snowballing. Recruitment for this study began with schools which approached the principal researchers to express their interest in implementing a therapy dog program in their school. Further snowball sampling and comprehensive investigation online were conducted to identify participants in all three groups who were emailed to seek their interest in taking part in the study.Rapport building techniques were used, and a natural conversational tone was maintained by showing empathy, and using active listening skills . Probing questions gave school staff the opportunity to elaborate more than others depending on how much information they wished to share. For example, in one interview a participant stated they felt they were “flying-solo,” and the researcher followed with “What do you mean by flying-solo? Can you give me some more information on that experience?” The questionnaire questions see  were useN = 9, 1 male and 8 females) and participant group 2 consisted of schools considering the implementation of a therapy dog program .Participants group 1 and 2 consisted of educational staff working in a school setting which included teachers, assistant principals, principals, junior heads of schools, coordinators of early learning centres, school psychologists as heads of well-being and specialist student empowerment teams. Participants were from primary schools, combined primary and secondary schools, and early learning centres in Australia. In total, thirteen school staff across three states in Australia  took part in the study. Participant group 1 consisted of schools with an existing therapy dog program . The Story Dogs program is implemented mainly individually where a child reads one-on-one to a dog and handler team for ~20 min every week over at least two school terms. Dog and handlers may also be involved at whole of school assemblies on special occasions such as book week one or twice annually . Participants from therapy dog organisations (participant group 3) only completed the online survey. Both methods of data collection—the online survey and semi-structured interviews—involved similar questions. Three separate online surveys were constructed for (i) participants from schools considering a therapy dog program, (ii) participants from schools with an existing therapy dog program, and (iii) participants from therapy dog organisations. The Hexagon Tool developed by the National Implementation Research Network  was usedEthics was approved for the present study by the relevant University Human Research Ethics Committee as well as the Department of Education and Training. Participants who agreed to participate in the study via signed consent forms completed the online survey and/or indicated their interest to participate in a semi-structured interview. The online survey took around 15–30 min, while the semi-structured interviews conducted over the phone varied between 20 and 90 min.The online surveys and semi-structured interviews identified participants views of therapy dog program implementation, perceived facilitative factors as well as barriers in school based setting. Thematic analysis was used to analyse all qualitative data using the framework by Clarke and Braun , as summResults gathered from participant groups 1 and 3 indicated that the perceived facilitative factors to successful implementation of a therapy dog program in schools were: (1) flexibility of program to meet school's needs, (2) qualities of program instigator, (3) whole-school support, (4) communication, training and education, (5) considerations for dog's welfare.I wanted him  to grow up with the kids at the school and I think that's what made it even more special is the kids, like they feel Scruff [the dog] is theirs. We noticed over the five years that kids who struggled to transition to the next year got better because they had a dog at school, they wanted to come to school. They [the students] sort of built up their confidence and realised that Scruff is safe and he's not going to hurt them.” While participant 5 in the survey said: “The [dog-assisted reading program] is run slightly differently at every school. We are able to adapt to most needs of the school. Such adaptations might be the time of visits.”Schools found that having the therapy dog program evolve flexibly and organically according to the school's needs to be beneficial to staff and students, as well as fostered a sense of belonging. The dogs had the liberty and flexibility to roam free around classrooms at school and this allowed the dog's role to be adaptable to the needs of the students whenever it was required. The therapy dogs were also said to build trust with students, which formed meaningful relationships and fostered a sense of belonging to the school for students. For example interviewee 5 suggested “The qualities of the school staff who introduced and lead the therapy dog program was identified as critical in facilitating successful program implementation. This included being emotionally aware and considerate of the school community and its diversity, such as cultural sensitivities, differing perceptions of dogs, as well as taking into account the needs of those with allergies. Being cognizant of these differences , taking into account their different needs , and flexibly adapting the program .I did research and made sure I read some articles, and made sure we had the right blurp on the website…about the benefits of having a dog, and we made we got the right breed and called a couple of primary schools that had already implemented the therapy dog program. We made sure we had him prepared for school and for children from the beginning.”The willingness of the program instigator to take on responsibility and be invested in the program , being goal-orientated , as well as being adequately prepared  were also factors that were highlighted. Interviewee 7: “It's really that sense of community that helps. The parents are on board with the program. I think it would be very tricky to do it if the staff isn't in agreement with it. Being really supported by the school I think is absolutely necessary.” Interviewee 3: “The whole community has really got around it. The school council was definitely a support…having this you know it just affirms that I had the right idea for the community.”Participants expressed that the program was able to progress and develop with the help of parents and staff cooperation and from the backing of school staff, principal, and school council. The acceptance of the whole school community  facilitated the introduction of the dog to the school, as well as allowed the program instigator to be more confident in implementing the program. Interviewee 1: “Interviewee 3: “I've been very specific with the staff on this is what you need to do, this is how you need to approach so I'm constantly trying to refine that interaction and training as I go.” Survey 5: “(We) provide adequate information on our risk minimisation strategies, current insurance held, and emergency procedures… We have a coordinator assigned to support our volunteers. This coordinator organises a school orientation meeting to set up the program in a new school with a new volunteer. This meeting includes the handler and the dog, the coordinator, any teachers involved and the key liaison person for the school. The meeting works out a day, time, and place for the reading sessions. It also introduces the handler and dog to the school.”Sharing and discussing key information on the role of a therapy dog, its possible outcomes and benefits, the training both handler and dog undergo, roles and responsibilities of school staff, risk management, as well as building students' knowledge about dogs prior to program implementation helped facilitate acceptance amongst children, parents, and school staff. Therapy dog organisations that conduct dog-assisted reading programs with schools also assign a coordinator to support the school and handlers, provide information packs and an orientation meeting to discuss key information, as well as are in regular contact with schools and handlers to obtain feedback. We are lucky we've got bog green ground. So instead of sitting in a classroom and talking to a child about whatever is going on, we tend to grab the dogs and take them with us for a walk around the oval.”Ensuring that the therapy dog's needs and welfare are well-met and considered enabled them to thrive in the school setting. This included planning dog-specific and dog-friendly areas in the school, as well as scheduling down time and breaks for the dog. Interviewee 1: “The following challenges and concerns were identified (1) flying solo: the workload of the instigator and handler, (2) winging it: lack of regulations, guidelines or research on implementing in schools, (3) community acceptance and buy-in, and (4) laying down foundations and acquiring therapy dog education.I would've liked to do more but being a fulltime teacher, I just was restricted for time…and as it went on, I just got less and less support from staff involved…and the momentum stopped.”Most participants were both the therapy dog handlers and instigators of the program. Difficulties faced include time constraints and added workload in addition to being a classroom staff. Participants expressed that while they were dedicated and invested in the program, they struggled with managing the responsibilities alone in the implementation process. Some participants stated that they would have appreciated other staff to be extension handlers or to take on a leadership role to share the workload of program implementation. Interviewee 5: “It's a bit tricky on the policy side of things because of not having anything already existing for schools, I'm sort of working a little bit from scratch…it's just even trying to understand what it should be.” Survey 2: “No research to share with community ideas on how to introduce the dog to the community in a positive way.”Some participants stated that they had trouble finding regulations or guidelines that could facilitate implementation of their program, as well as finding little research or literature on implementing therapy dog programs into educational settings. The lack of regulations and guidelines as resources for school staff attempting to implement a program was one of the main challenges and impeding factors associated with stunted development in the implementation process. School staff expressed that without having any existing policies or guidelines to follow they had to figure out implementation on their own without any support in how to implement a therapy dog program. Interviewee 3: “The challenges would be people that maybe aren't dog people.” Interviewee 6: “Staff have said to me, ‘I wouldn't be happy with having a dog at the school… I don't think I would go ahead with a therapy dog unless I had a majority of buy-in from the staff.” Survey 5: “Increase in occurrence of a student in the school being anaphylactic to dogs, thus the program cannot start.” Managing the rest of the students' expectations was also identified as a challenge. Survey 5: “Every student wants to read to the dog and the majority of students in school will not get this opportunity.”All participants expressed the need for the whole school community to be open and accepting of the therapy dog program. They stated that without staff support, the process would be extremely difficult. Participants expressed that school staff's and students' resistance and reservations toward the program would be a key barrier. This included barriers like managing personal views about dogs as well as risk management . Survey 1: “I think we would need skills on how to use the dog effectively…so some sort of PD for staff of what the role and function of a therapy dog is, and probably educating staff before even looking at getting a dog, so laying a foundation.”A few participants identified the need for foundational knowledge about the role of the dog in the school as well as how best to involve the dog therapeutically and effectively in school. Interviewee 6: “Based on the qualitative analysis above of both the survey and interview data, as well as the literature the following factors are for consideration before implementing a therapy dog program:It is critical that the dogs receive appropriate certified training where they are rigorously trained and evaluated to be reliably non-aggressive to both people and other dogs regardless of circumstances, are highly adaptable, and can interact easily with people. During the training, handlers are also trained to meet welfare, safety and hygiene requirements for both the dog and students, and how to connect and engage with the dog therapeutically.Be personally and financially responsible for the dog's welfare and maintenance including safety, feeding, grooming, cleaning, and vaccination. In the event where the dog is involved in school programs regularly or in the long term, it is recommended for the handler to request financial support from school since the dog is part of an intervention employed for meeting the students' needs . In suchBe vigilant in identifying signs and triggers of injury, distress, or exhaustion for their dogs and be able to respond accordingly. Regular breaks should be given to the dog. Suspension of the program may be required if the dog shows a negative behavioural change, fearful behaviour during interactions, or has medical concerns.Trouble-shoot when an incident occurs , and adopt appropriate measures when needed .Handlers should be prepared to:To facilitate successful implementation of therapy dog programs in schools, handlers should also have a good understanding of the impact of therapy dogs and how they may participate in various educational settings. Establishing a clear goal/purpose of the inclusion of a therapy dog in different school activities is essential – e.g., desired outcomes, who might benefit, and how , 31 Fre.Leadership and whole-school support is essential in successful implementation of a therapy dog program . The fol° Briefly explain the idea of involving a therapy dog in school and goals° To obtain initial support° Learn of any dog-related allergies or phobias° Discuss and address any other concerns.It is recommended that a comprehensive handbook be constructed to clearly identify and explain the policies and procedures of how the dog will be included in the classroom and school activities .School staff's overall acceptance of the therapy dog – Inviting a dog into a school should not be a unilateral decision. The thoughts, concerns, and ideas of all stakeholders should be informally solicited by conducting preliminary meetings with administrators, parents, teachers and paraprofessionals and students early on to:Stakeholders are likely to have varied concerns. Buy-in from can be facilitated by preparing information ahead of time , providing opportunities to ask questions, and preparing to respond to any potential concerns . ObtainiPresence of 1 or 2 other school staff who can be involved in the therapy dog program to ensure that the handler is not the sole person managing the program. This is to ensure that the work load of undertaking a therapy dog program is balanced vis-à-vis other responsibilities the handler is fronting, collaborative planning and problem-solving of programs, and implementation of effective emergency protocols if more than one person is required .Logistical considerations such as appropriate indoor and outdoor areas for the dog and scheduling of activities and breaks for the dogSchool-wide protocols to address any sanitation or safety concerns, which would require training school staff and students on appropriate ways to interact with the dog and the training of emergency protocols .Communication plans for engaging parents and students about the program, addressing concerns , as well as obtaining consent and assent.Possible funding Adequate planning and preparation for introducing the therapy dog to school staff so that they are educated on appropriate animal care and behavioural expectations, and are able to step in when necessary in times of emergencies .Assessing the needs and suitability of students whom the dog might be working with is critical in ensuring that the therapy dog program goals are met, and student welfare is considered. This includes:Determining which students/classes are to participate in the therapy dog program – e.g., which students would benefit the most from this program? how should the program be structured to meet their needs best ? How does a therapy dog program value-add to existing programs in meeting the needs of these students?Making suitable alternatives for children who are unable to participate  Deciding how expansive the program will become as it is unsurprising for many other children or families who might wish to participate after learning about the program Adequate planning and preparation for introducing the therapy dog to students so that they are educated on appropriate animal care and behavioural expectations.As with engaging school staff, early engagement of parents is also essential once there is clear direction that a therapy dog program may be introduced in school. Common concerns parents have include safety, hygiene, and allergic concerns , how theSchools are advised to ensure that there is ample time to engage parents before the commencement of a therapy dog program. This includes parents who have provided consent to their child's participation and providing further information about the program and addressing concerns, parents who do not consent and need further information on how their children will be engaged in alternative ways, as well as parents of children who are not selected to participate in the program but wish to do so .The findings from this study highlight insights into implementing a therapy dog program in school settings, particularly a whole-school effort in optimising the program to meet unique school needs, garnering support, as well as overcoming systemic barriers. This includes ensuring the flexibility of the therapy dog program to meet varying student needs, dedication and commitment of therapy dog program coordinators/handlers, acceptance and training of all of the school staff, support from school leadership, as well as adopting a team-based rather than individual-effort in program planning and implementation.The findings on the importance of a whole-school approach are congruent with past research. Programs are more likely to excel when they are aimed to involve the whole-school community. Research indicates that positive program outcomes are facilitated when interventions are integrated into daily practise, the school culture and encourage collaborative efforts to include staff, families, teachers, and children , 62. WitAnother important feature is the support from leaders and a team-based approach in program implementation. Findings from this study indicated that it was mostly a single individual or program instigator/coordinator, often the dog handler and also school staff, who was solely responsible for the various stages of the program implementation, which contributed to heavy workload and potentially negative implications on the sustainability of the program. One of the key facilitative factors reported was for program instigators or coordinators to be willing to take on the diverse roles and responsibilities for successful program implementation, including acting as a promoter , as wellA team-based approach to program implementation includes the support from school leaders as well as acceptance and buy-in of other school staff. Strong leadership was indicated as a strong focus for successful therapy dog program implementation, and this is also shown to be a measure of general program implementation success. Findings implied school staff needed to be prepared and goal-orientated for their program to be successful and for student reap the most benefits to their well-being. Moreover, school staff had to maintain throughout implementation a vision and a purpose, engage the whole community and constantly meeting their aims and outcomes of the program. This is congruent with the literature detailing the importance of these leadership qualities to be a role model for other staff and will provide these front-line staff with clear expectations for the program , 48–50.Another key feature for successful implementation is having a strong support network from the school community, including staff, parents, principal, school council and students. School staff expressed that having the community's support and alignment of goals and purposes made introducing the program to their school easier and with fewer complications. This is congruent with the research on implementation programs requiring empowerment, participation and education of the community, and lastly, multiple actors in implementation process (obtain broad-based support of school staff) , 40.A major factor that caused difficulties for school staff who had experienced implementation of a program was a lack of guidelines and regulations available for schools. The findings imply that for future practise, there needs to be further research in regulations and guidelines into therapy dog programs for schools and government support to provide policies and guidelines for schools to follow. This highlights the gap in the literature surrounding guidelines on implementation and regulations of having a therapy dog at a school. Moreover, these finding align with research on necessary implementation strategies such as government support, policy documents , oversigAcknowledging the limitations of the findings of this evaluation is important. The study was small, and only the perspectives of selected school staff and therapy dog coordinators were gathered. As most of the school staff and coordinators interviewed were leaders and initiators of the therapy dog program, their feedback might be slightly biased as they had an invested interest in seeing their program be successful. As a qualitative project, the aim of data collection was not to achieve a statistically representative sample. Instead it is to attain what Glaser and Strauss call “saturation of themes” of data collection until no new themes are generated. Samples sizes have been chosen based on my extensive experience with qualitative projects of this kind .Obtaining information from other school staff who may not be directly involved in the program, students, as well as parents would be beneficial to gather a more holistic understanding of having a therapy dog program in school. In addition, each school is likely to have implemented their therapy dog program in different ways ; this information was not gathered in this study. Given different schools also ran their programs in different manners, potentially impacting program outcomes. It is unclear if the structure of the therapy dog program in each context could have also affected the findings. A potential limitation may be geographic/regional applicability of this study. Additional, survey participants may not have had an interactive, back-and-forth opportunity to clarify information as much as interviewees may have had in a semi-structured interview, it is unclear how this may have affected data collection. Nonetheless, this study albeit small and limited, has laid the groundwork for further research in this field.The overall findings from this evaluation highlight the facilitative factors and challenges, as well as key considerations when implementing a therapy dog program in schools, particularly the need to adopt a whole-school approach and involving multiple relevant stakeholders  in the process. Successful implementation of therapy dogs in an education setting appear to revolve around (1) flexibility of the dog therapy program to target school's needs, (2) qualities of program instigator, (3) whole-school support, (4) communication, training and education, (5) considerations for dog's welfare. The results have also underscored the need for guidelines for schools to assess their readiness/feasibility of such a program, key factors for consideration, roles and responsibilities of key stakeholders, as well as strategies to manage challenges.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Monash University. The patients/participants provided their written informed consent to participate in this study.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.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.


Mindfulness scores increased from pre- to post-intervention (M difference range = 1.0 to 10.4), with small-to-medium effects (d range = 0.18 to 0.55). Almost all aspects of self-compassion remained stable over time, with the exception of common humanity, which increased post-program . Preliminary findings from our small pilot trial suggest that telephone-based adaptations of MBSR may be a useful mode of delivery for healthcare employees; however, larger studies are needed to provide further evidence of feasibility, acceptability, and program effects.Healthcare employees often experience high stress and may benefit from accessible psychosocial interventions. In this pilot study, we explored preliminary feasibility, acceptability, and psychological effects of a telephone-based adaption of mindfulness-based stress reduction (MBSR) for healthcare employees. Eleven participants  were enrolled in an eight-session group-based MBSR program adapted for telephone delivery. Feasibility was assessed using rates of program attrition and session completion; acceptability was explored qualitatively via participants’ responses to an open-ended item about their program experience. Participants also completed pre-and post-program assessments on psychosocial outcomes , mindfulness, and self-compassion). We characterized mean change scores, 95% confidence intervals, and effect sizes to explore preliminary program effects. With regard to preliminary feasibility, one participant dropped out prior to the intervention; of the remaining 10 participants, 90% completed at least half (≥4) of the sessions; 70% completed at least three-quarters (≥6 sessions). Feedback reflected positive experiences and included suggestions for program delivery. Participants reported reductions in distress post-program (M difference range = −5.0 to −9.4), showing medium to large effect sizes ( Stress is common among healthcare employees ,2,3, witTo address stress and psychological well-being among healthcare employees, a number of workplace-based interventions have been developed and evaluated. One popular program is mindfulness-based stress reduction (MBSR). Mindfulness is defined as paying attention to the present moment purposefully and non-judgmentally ,14,15. TMindfulness has been shown to be an effective approach for decreasing distress and improving well-being across a wide variety of clinical and non-clinical populations ,19,20. WDespite evidence for the benefits of MBSR programs among healthcare employees, many of these programs report high attrition and drop-out rates ,23. For Therefore, the aims of the current study were to explore the preliminary feasibility, acceptability, and psychological effects of an adapted eight-week telephone-based MBSR program among employees in a healthcare setting. We hypothesized that the program would be feasible and acceptable, as explored through session completion rates and open-ended written participant feedback, respectively. Although our outcomes were exploratory, we hypothesized that there would be preliminary evidence of improved psychological outcomes  as described through pre- to post-program change on these measures and corresponding effect sizes. If successful, our study could demonstrate the potential benefits of offering an MBSR-based intervention via telephone in populations where this modality may be more appropriate than in-person sessions, such as among healthcare employees. Participants were recruited from a comprehensive cancer center in an urban mid-Atlantic city using flyers posted in public areas. Information about the program was also distributed via an electronic news bulletin that was sent by email to employees. Inclusion criteria included: (1) age 18 or older and (2) able to communicate in English. Exclusion criteria included: (1) Self-reported diagnosis of a psychotic disorder or major dissociative disorder and (2) presence of a cognitive deficit that would make it difficult to participate in an eight-week telephone program or complete the brief study measures. Individuals who were interested in participating contacted study staff for more information. After ascertaining eligibility, written informed consent was obtained by study staff. Enrolled participants then completed a baseline assessment see  MeasuresThe standard MBSR program is an eight-week program that meets in-person once a week for 2.5 h, and includes a full day of practice between the sixth and seventh weeks. Participants are also instructed to practice at home for 45 min each day using pre-recorded guided meditations. Adaptations to the standard in-person MBSR program were made in order to deliver the program by telephone. First, each session in the adapted program was shortened to 90 min, and the full-day retreat was removed. Second, participants were provided with extensive printed materials as a guide for each session, including a program binder with written handouts and detailed illustrations for yoga poses. Similar to the standard program, all participants received a CD with pre-recorded tracks to support home practice.The telephone-adapted mindfulness-based stress reduction (MBSR) program was led by an instructor with extensive experience in teaching MBSR across diverse settings. At study enrollment, participants were provided with the program materials, which included the program binder and CD with pre-recorded guided meditations. The sequence of practices was the same as the standard MBSR program, including the body scan awareness practice, sitting meditation with awareness of breath, mindful yoga, mindful walking, and loving-kindness meditation. The program was conducted via weekly group sessions over the course of eight weeks and was held on a weekday evening. Participants received instructions on how to call in to the group teleconference using a specific number and access code. During the program, participants were taught mindfulness techniques including the body scan, awareness of breathing, mindful yoga, and sitting meditation , which Two well-established measures were used to assess mindfulness and self-compassion: the Five Facet Mindfulness Questionnaire (FFMQ ) and theThe 26-item Self-Compassion Scale SCS ,31) is w is w31])d statistic, with d = 0.2 representing a ‘small’ effect size, d = 0.5 representing a ‘medium’ effect size, and d = 0.8 representing a ‘large’ effect size [To assess feasibility, percentages were used to describe post-enrollment drop-out rates and session completion. Participants’ feedback and comments from the post-program survey informed acceptability and opportunities for program refinement. Per recent recommendations for the reporting of preliminary data , means aect size . AnalyseTwelve individuals contacted the study team about participating in the program; eleven consented, but one declined to participate in the intervention due to the time commitment involved. The demographic characteristics of the study sample are reported in Among the 11 participants, one (9%) dropped out after the first week due to time constraints. The remaining ten participants completed, on average, 6.2 sessions in the eight-week program (range = 3-8 sessions). These rates of drop-out and average session completion are comparable to a previously published telephone-adapted MBSR study (among participants awaiting kidney transplant) . n = 9) of the participants completed at least half of the program (≥4 sessions), which is the suggested minimal number of MBSR sessions needed to observe a change in distress [In our study, 90% , and standardized pre-post effect sizes for each measure are presented in d = 0.68 to 0.70).Consistent with prior research, medium to large effect sizes were observed for psychological distress . Specifid = 0.55). Small to medium effects emerged for observing and acting with awareness, as well as for the overall FFMQ total mindfulness score. Finally, for self-compassion, participants reported increases in common humanity  with a very large effect size (d = 0.91) (d = 0.38), there was relatively limited change on the remaining self-compassion subscales.With respect to mindfulness as measured by the FFMQ, improvements were observed in non-reactivity, with a mean increase of 2.3 (95% CI −0.9 to 5.5) and a medium effect size ( = 0.91) . Other tOur findings suggest that a telephone-based format may be a feasible mode of delivery for an eight-session MBSR program for healthcare employees. Given the high rates of attrition observed among in-person MBSR programs for healthcare employees ,23, a teAlthough we had a small sample size, our preliminary outcome measures showed evidence of positive psychosocial changes consistent with the literature ,22,23,24While all mindfulness (FFMQ) subscale scores showed an increase over time , the largest effect size was observed for non-reactivity, which is the ability to allow one’s thoughts and feelings to come and go without being carried away by them ,43. ThisAn interesting observation that emerged was that common humanity seemed to increase the most among the self-compassion subscales, and it did so to a large effect. Common humanity is a sense of positive connection to those around you created through the recognition that suffering and personal inadequacy are shared human experiences . ImportaOur study had several limitations. First, our sample size was small and was not powered to find effects; thus, our results should be interpreted with caution. Larger sample sizes will be able to help provide additional evidence for the feasibility of a telephone adapted program. Second, while one strength of our sample was that it included a diversity of professional roles, it is possible that needs, preferences, and outcomes may differ among those in clinical versus support roles. Our sample was also largely comprised of female participants; thus, gender may indirectly impact our findings. Similarly, we did not measure previous experience with mindfulness, which could be important to include as a covariate in future studies. Future studies may wish to explore these questions further. Third, our study design was non-randomized; thus, direct causal interpretations should not be made. The absence of a control group limits our ability to provide comparisons for how psychological distress, mindfulness, or self-compassion may have changed naturally over time. Despite these limitations, the present study offers important suggestions for how MBSR can be adapted for telephone delivery, as this mode of delivery may facilitate increased participation given the greater ability to accommodate healthcare employees’ schedules and needs.Future research can build upon our study in several ways. To address our limitations, larger and more diverse samples  as well as a randomized study design  should be utilized. This would also allow for additional informative analyses such as whether certain demographic characteristics such as gender, education level, or profession are associated with intervention participation. In addition, future adaptations could include greater use of visual Supplemental Materials  to support home practice, and researchers may wish to gather more detailed data on practice adherence. If demonstrated to be effective, the application of a telephone-based MBSR program could be extended and evaluated among other populations for which in-person programs may be challenging, such as rural or low socio-economic populations, or those with severe illness. Furthermore, given that our sample did not report clinical levels of distress at baseline, future studies may wish to explore the application of a telephone-based MBSR program in a highly distressed sample. Finally, larger iterations of this study could also explore potential mediators, such as which mindfulness skills are key for improving emotional outcomes among healthcare employees.The purpose of the current study was to adapt and deliver a telephone-based format of MBSR among healthcare employees in order to assess its feasibility and acceptability. Our findings indicate that the program was feasible and largely acceptable; however, additional research is needed to optimize this mode of delivery. Nevertheless, our preliminary outcomes suggest that a telephone-adapted MBSR program may show promise for improving psychosocial outcomes, especially distress, depression, and a sense of common humanity among healthcare employees. Overall, facilitating the delivery of evidence-based MBSR programs to healthcare employees, a population that experiences high stress and professional burnout, addresses a significant need and may yield psychosocial benefits.


School health and nutrition (SHN) interventions are among the most ubiquitous public health investments and comprise a key mechanism for reaching populations that are otherwise difficult to reach through the health system. Despite the critical role of monitoring these multisectoral programs to enable data-informed adaptive programming, information to guide program implementers is scant. This manuscript provides an overview of how monitoring indicators can be selected across a SHN program's logical framework, with specific examples across five SHN implementation models. Adaptation of SHN programs in times of school closures, such as those currently being experienced globally due to the emergence of COVID-19, is also addressed. Key aspects of SHN program monitoring are explored, including: (1) why monitor; (2) what to measure; (3) how to measure; and (4) who measures. In situations of school closures, strategies to shift both program activities and corresponding monitoring mechanisms are critical to understanding the rapidly evolving situation and subsequently guiding policy actions to protect vulnerable populations. School health and nutrition (SHN) interventions are among the most ubiquitous public health investments worldwide, with more than 100 countries offering school-based or school-linked routine health and nutrition services . AlthougWell-designed SHN interventions align with critical periods of development and address social determinants of health for school-age children and adolescents . SHN intAs with any development program, it is important to monitor the implementation of SHN services, particularly as these represent significant investments. As an example, an estimated USD 41–43 billion is spent annually on school feeding programs alone . ProgramThere are varying approaches to deliver and monitor school health and nutrition services, and the range of relevant interventions to deliver can vary widely across contexts. As a result, there is no blueprint for delivering and monitoring high quality and equitable SHN programming and each monitoring system will be unique to the programs, interventions, and context. Carefully selected and measurable indicators help project planners and implementers assess intervention quality, inform mid-course revisions where needed, and ensure resources are being used effectively.The multisectoral nature of SHN interventions requires further careful planning and coordination to meaningfully capture monitoring data, as there are two or more, as is often the case for school feeding, sectors and stakeholders (such as parents and pupils themselves) to engage. This principle remains true even for monitoring interventions that have long engaged multiple sectors for school-based delivery, such as deworming, as there may be limited coordination between information systems to facilitate the transfer of information from one to the other. These governance and accountability challenges mean that countries may have limited ability to monitor implementation progress to inform future service delivery .This manuscript presents key principles for SHN program monitoring and provides broad guidance aimed at supporting the development and implementation of monitoring mechanisms within SHN programs. The discussion includes specific examples of indicators used to monitor the delivery of SHN interventions and considers monitoring responsibility and information flows between education and health sectors at the national, subnational, and individual level. Emphasis is also placed on governance and accountability of monitoring processes, such as responsibility of collecting data, and information flows between the health and education sectors to maximize data-informed decision-making. Although program monitoring is often complemented by program evaluation, this manuscript focuses on monitoring, given the paucity of information on the topic.Data collection for SHN services are often led by either the education or health sector. Baltag and colleagues categorized five delivery modalities for SHN services , with moProgram monitoring is just as important for documenting the reach of an intervention as it is for identifying when adjustments to the service delivery design are necessary to maximize their intended impact. For this reason, program monitoring should include a feedback loop that facilitates the flow of information from the subnational to the national level and vice versa, to guide policies and enable adaptive programming that promotes course correction. Though not specific to SHN programming, a successful example of adaptive programming based on a well-functioning feedback loop was seen in Malawi, when a community-based nutrition program successfully adapted its programming by using real time monitoring data, adding service delivery sites in areas with low attendance, following-up with participants who had repeated absences, and improving targeting of services to improve procurement efficiencies and achieve cost savings . MonitorPandemics, such as the one facing the world in 2020, and other types of socio-political or environmental crises that cause school closures, have further demonstrated the utility in adapting both the service delivery mechanism and the modality for collecting monitoring data in extenuating circumstances. Emerging evidence from the COVID-19 pandemic suggest that public health emergencies make accessing social services more difficult, and this is particularly true for those who depend on the education system as their delivery mechanism. An unprecedented number of countries worldwide closed schools to slow the transmission of COVID-19, with more than 192 countries mandating some form of school closures, impacting at least 1.6 billion children and youth and an estimated 63 million teachers , 23. In School meals and cash transfers constitute one example: recognizing that school meals provide immediate benefit for undernourished students, Thailand began to distribute shelf-stable milk to the homes of students who would otherwise receive meals in schools ; GuatemaAs discussed, given variations in program design, implementation, and monitoring, this manuscript emphasizes key principles to designing robust and effective monitoring systems, as opposed to prescriptive guidance on specific indicators or monitoring mechanisms. These principles include: (1) Selection of indicators to adequately measure the intended final impact and identification of appropriate data sources; (2) simplicity and feasibility for data collectors; (3) integration of monitoring data into other sources of information; and (4) clarity in all stages of the data collection, reporting, analysis, referrals and feedback processes. This section provides an overview of how to apply these principles to the specific considerations that program implementers must weigh when monitoring a multi-sector effort, such as a SHN program.Indicators drive resource allocation as well as all subsequent data collection, analysis, and reporting. As with the design and implementation of any program or project, the selection, monitoring, and validation of appropriate indicators specified within the results framework is critical to incentivizing not only the inclusion, but also the implementation of SHN services. The selection of specific indicators that make up the results framework are largely dependent on and closely aligned with the program's logical framework. In a country programmatic scenario, this logical model would require adjustments based on the specificity of interventions included in the basic package, activities needed to deliver them, and intended results of those. Indicators can then be categorized according to which programmatic process they measure along the program's logical framework, such as inputs, processes, outputs, outcomes, and impacts refer to . The selThe wide variation in SHN programs and delivery models render it difficult to be prescriptive about specific indicators to use. Program implementers must weigh several considerations when defining which indicators to measure and which data sources to utilize, frequency of data collection, roles for collecting and submitting data, and how to ensure the findings enable program adaptation. These include:1. Determine indicators along the results chain based on the intended final impactProgram planners are encouraged to develop a theory of change to define the expected results among key target groups, and intervention components that will enable their achievement. This mapping will also be critical to identifying the relevant indicators that need to be measured , which w2. Clarify the details of how indicators will be measured and assessed, with special considerations for defining your target population.Equally important to selecting the indicators of interest is ensuring the ability to analyze data along key equity dimensions (such as gender and age groups), as success is dependent on the quality, adequacy, and the reach of the interventions. As with any SHN program that includes delivery of commodities to specific population groups, like school-based HPV vaccination programs for girls ages 9–14 years, determining the total number of targeted beneficiaries is critical. When targeting is meant to be age-based, program planners may consider calculating their targets using grade-based eligibility instead, as determining age is difficult in contexts where birth records are not routinely available, school registers are inaccurate, and/or census data is outdated .3. Reflect on and clarify who is implementing and monitoring the programThe actors initiating and implementing SHN programs also influences the definition of indicators within each category of the logical framework. For example, for a government, an input-level indicator could be the number of supplies or commodities procured for program functioning, while for a donor agency, it may be the development of a SHN policy. National programs and monitoring generally operate under one ministry, while implementation may be led by technical bodies at the national or sub-national level, as is seen with school feeding , 19. It Beyond the considerations about the program implementer, it is equally important to specify the actors who will support programmatic monitoring and reach agreement on the process for collecting data and reporting against each indicator. Data collection should be standardized across the program regardless of service delivery point to facilitate data aggregation and analysis . This is1. Identify available data sources and whether these require further strengtheningRecognizing that national health management information systems may be too weak to be the sole source of data for programmatic monitoring, implementors can also consider complementary forms of data collection, such as through SMS or phone-based surveys and through innovative geo-enabled data collection mechanisms. Where needed, project funding can also include resources for support with data analysis, visualization, and use, or to strengthen the information system. To facilitate strengthened cross-sector collaboration and evidence-based decision making, data collected should routinely be shared, reviewed, and discussed between relevant sectors and institutions.2. Ensure an appropriate balance between minimum and ideal program monitoring and indicator selection standards to improve feasibility and minimize monitoring costs.Minimum standards are those which are necessary to achieve the desired outcome or to achieve country requirements, while ideal standards are more ambitious. In many cases, project teams might determine which indicators to prioritize based on what data collection systems are already in place or based on what can organically complement other efforts in the same space, rather than establishing siloed but more burdensome and costly approaches to collect an ideal indicator. As with any program, quality assurance mechanisms are essential for ensuring robust data collected against each indicator during collection, transfer, compilation, and analysis . This is3. Explore opportunities for integrating monitoring into other school-based sources of information.Monitoring by development partners is often program specific and not necessarily aligned to government programs or data sources, which places a significant data reporting burden on implementing entities and misses an important opportunity to build monitoring capacity at the central and local levels. Therefore, where possible, program indicators should be aligned to those of national programs and/or programs implemented by other development partners, as they will already be collected through existing monitoring systems. Not only should indicators be aligned, but ideally so would data sources and frequency of data collection. For example, in countries with schools providing comprehensive sexuality education, integrating questions into annual, national, and standard assessments administered to test students' knowledge of key topics covered can be a useful and independent source of data to monitor the program's impact. This approach allows for standardized, routine and repeated learning assessments, which can generate independent and longer-term program feedback and can be used to assess intervention feasibility and effectiveness.1. Ensure feedback mechanisms exist to enable program course correctionRecognizing that SHN programs engage actors across sectors, it is important to build in a feedback loop that connects education and health information systems, especially in cases where the monitoring responsibility is with the education system . It is important to ensure that there is a mechanism to track whether referred pupils were ultimately seen by a health or other relevant specialist . LinkageProgram monitoring is both a management tool and a powerful feedback mechanism. It is best practice to integrate project monitoring from the earliest stages of project design, in alignment with the program's logical framework. The selection of indicators drives resource allocation toward the areas being assessed and incentivizes their implementation.There are known gaps in the monitoring of SHN programs. At the global level, there is no repository of the health and nutrition status of children and adolescents nor of the breadth and coverage of SHN services provided in countries . Since cThere are key principles to develop a robust monitoring system that apply whether the service delivery is standalone or integrated with multiple services. In the context of school health and nutrition service delivery, multiple sectors will likely be engaged, and as such, each monitoring system will be unique to the programs, interventions, and setting. It is prudent that all engaged actors agree in advance on the process for collecting and transmitting data between levels and sectors, including, for example, interoperability between systems.The COVID-19 pandemic, and the resulting prolonged school closures, has forced innovations in education, health, and nutrition service delivery mechanisms, and similarly, has necessitated varied approaches to monitoring the reach and quality of adapted interventions. There are emerging examples of how service providers have pivoted to reach these populations, with examples of innovative school meal distribution and tracking methodologies described above. The current pandemic shows the importance of developing and routinely updating emergency preparedness plans that outline contingency protocols for service delivery during school closures and localized disease outbreaks. These protocols should include guidance for which metrics to prioritize and which actors to task with collecting the information. In the case of prolonged school closures, community members could be called upon to prioritize indicators to monitor and to engage in data collection activities to inform adaptive measures .Beyond the school closure period and as a country moves toward reopening, monitoring mechanisms may continue to need shifting and adaptation to respond to the new reality under which schools operate to comply with public health guidelines. For example, in the case of COVID-19, this includes coordination across sectors to implement mechanisms to monitor, report, and trace cases among students and teachers alike, monitoring and procurement of personal protective equipment and sanitation supplies to minimize spread within the school setting, and ability to track and respond to the broad spectrum of changing physical and mental health needs of adolescents as they return to schools after periods of extended closure. Many of the key principles outlined in this manuscript are increasingly relevant in such instances of sudden school closures, and again emphasize the need for rapid action, coordination, and innovation.The authors acknowledge the relative paucity of country-specific information published on this topic. As such, the illustrative country examples and the key principles presented within this manuscript represent the best attempt and most complete information that the authors were able to collate through a desk review. The authors recognize that there is wide variation in approaches and compositions of SHN services within and across countries, and as such, it is impossible to be prescriptive around SHN monitoring methodology. Instead, the authors deemed it more efficient to guide program implementers with key principles for program monitoring.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.LS and JR-B worked in tandem to equally contribute to the conceptual framing, research, writing, and editing of this manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


There are growing concerns on stress among nurses in low- and middle-income countries (LMICs) in South-East Asia. It is important to improve mental health among nurses in these countries. The objective of this study was to examine the efficacy of two types of newly developed smartphone-based stress management programs in improving depressive and anxiety symptoms among hospital nurses in Vietnam. This study was a three-arm (including two intervention groups and one control group) randomized trial. Participants were recruited from nurses in a large general hospital in Hanoi, Vietnam. Two types  of smartphone-based stress management programs were developed. Participants were randomly allocated to Program A , Program B , or a control group . The depressive and anxiety symptoms were measured by using the Depression Anxiety and Stress Scales at baseline, 3-, and 7-month follow-up surveys. 951 participants were randomly allocated to each of the three groups. Program B showed a statistically significant effect on improving depressive symptoms at 3-month (p = 0.048), but not at 7-month (p = 0.92); Cohen’s d was − 0.18 (95% CI − 0.34 to − 0.02) and 0.03 (95% CI − 1.00 to 1.05), respectively. Program A failed to show a significant intervention effect on any of the outcomes at 3- or 7-month follow-up (p > 0.05). Despite the small effect size, the present fixed-order iCBT program seems effective in improving depression of hospital nurses in Vietnam. A public health impact of the intervention can be scalable, when considering its accessibility and minimal cost.https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000037796Trial registration number: The study protocol is registered at the UMIN Clinical Trials Registry . Registered date of the protocol is 1st Jul. 2018.  With the population aging, the increased medical needs have caused a severe deficit in the nursing workforce, especially in South-East Asia including LMICs2. A shortage of health service providers such as nurses is already reported in many LMICs in South-East Asia3. In addition to increasing numbers of people requiring care, the growing demands from service users  for improved quality of care have put pressure on and have caused distress among nurses6. Also, in the recent pandemic of new coronavirus disease (COVID-19), nurses experienced extreme stress in caring for patients infected under the risk of their own infection7.Population in many low- and middle-income countries (LMICs) will age rapidly by 20508. A recent study reported that more than 45% of hospital nurses in Vietnam had any of depression, anxiety, and stress symptoms8. It is known that psychological distress  among workers results in substantial deterioration in workers’ quality of life and economic loss in the workplace, and in decreased work performance, especially quality of care provided by nurses13. There are growing concerns for mental health problems among nurses and other healthcare professionals in LMICs in South-East Asia14. It is important to manage work-related stress and to improve mental health among nurses to ensure health and well-being of nurses and the quality of care they provide.In LMICs in South-East Asia, including in Vietnam, healthcare professionals including hospital nurses have reported high stress16, including healthcare workers. In a healthcare setting, an individual-oriented approach such as CBT has been reported to be more effective than an organizational approach17. To deliver stress management based on CBT, a computerized CBT delivered via the internet (iCBT) has been shown to be an effective, low-cost and highly accessible approach20. One randomized controlled trial (RCT) reported that a web-based stress management program including cognitive behavioral techniques reduced perceived work-related stress among nurses in the USA21, while no significant effect was found on emotional or physical symptoms. There has been no RCT that has investigated effectiveness of this approach among nurses in LMICs. Recently, the smartphone penetration rate in LMCIs has rapidly increased: for instance, in Vietnam, the rate of people using smartphones was 68–84% from rural to urban area in 201722. In the “new normal” era during and after the outbreak of the COVID-19, it is strongly recommended to switch the mode of delivery of a stress management training from a face-to-face class-based program to an online program7. It is important and urgent to clarify the effectiveness of an iCBT program for improving depression and anxiety among nurses in LMICs, such as Vietnam.Especially in low-resource settings in LMICs, there is a substantial need for accessible and low-cost intervention programs. Cognitive behavioral therapy (CBT) has been shown to be effective for reducing depression and anxiety among workers18. A useful strategy to promote adherence in web-based interventions is incorporating tailoring23. An approach that may increase completion rates and effectiveness of iCBT programs is to allow participants to choose modules based on their preference. It has been reported that a free-choice program in European countries had a higher completion rate and was more effective than a fixed order program24. However, it is not clear whether these findings are applicable to countries in other cultures, such as those in South-East Asia. In addition to test the effectiveness of an iCBT program for improving depression and anxiety among nurses, it would be worthwhile to investigate which of free-choice or fixed order iCBT program could achieve better completion rate in Asian countries that have collectivism- and hierarchy-oriented organizational cultures25.A major challenge in implementation of iCBT interventions is low adherence. A systematic review reported a completion rate of iCBT programs in the workplace was approximately 40%26. While the latter approach often yielded greater effect size for mental health outcomes than the universal prevention in web-based psychological interventions in the workplace18, the universal prevention has a merit because it does not only improve symptoms in a symptomatic group, but also prevent the onset of symptoms among an asymptomatic group27. The universal prevention for mental health also has an advantage in its less stigmatizing nature28. Thus, it has been recognized as a promising approach in the workplace29. It is crucial to test the effectiveness of an iCBT program as the universal prevention among nurses in LMICs.Depending on a target population of an intervention, there are different approaches: (1) universal prevention that targets the whole population including those with and without symptoms; and (2) selective and indicated interventions that target high-risk or symptomatic groupsThe objective of this RCT was to examine the universal prevention effect of two types of newly developed smartphone-based iCBT stress management programs  compared with a control group in improving depressive and anxiety symptoms as primary outcomes at 3-month and 7-month follow-ups among hospital nurses in Vietnam, using a three-arm trial design.30. This manuscript conforms to the Consolidated Standards of Reporting Trials (CONSORT) guidelines31.This study was a three-arm (including two different intervention groups), parallel-group, treatment as usual (TAU)-controlled, non-blinded randomized trial. The allocation ratio of the intervention groups to the control group was 1:1:1. Follow-up surveys were conducted at 3- and 7-month after the baseline survey. The study procedures have been approved by the Research Ethics Review Board of Graduate School of Medicine/Faculty of Medicine, the University of Tokyo (no 11991) and the Ethical Review Board for Biomedical Research of Hanoi University of Public Health (no 346/2018/YTCC-HD3). The study protocol was registered at the University Hospital Medical Information Network Clinical Trials Registry (ID = UMIN000033139). All methods were performed in accordance with the approved study plan, as well as with relevant guidelines and regulations. Registered date of the protocol is 1st Jul. 2018. The protocol article for this trial is availableAll participants were recruited from a large general hospital in Hanoi, Vietnam. Participants received from the head nurse of each department in the hospital a self-administered questionnaire, return envelope, documents explaining the purpose of the study, the privacy policy, and an informed consent form. A clinical research coordinator  provided a briefing session for participants to fully explain the study objectives and procedures. Candidates were informed that their participation was voluntary, that even after voluntarily participating they could withdraw from the study at any time without stating the reason and that neither participation nor withdrawal would cause any advantage or disadvantage to them. After the explanation, written informed consent was obtained from all participants. Participants were given a small monetary reward (7 USD) for completing the baseline and follow-up questionnaires. The inclusion criteria at the baseline survey were as follows: (1) Currently employed full time as a registered nurse, and (2) Can access the internet via a mobile device such as a smartphone. The exclusion criteria were as follows: (1) Plan to change or quit the job in the next 7 months, (2) Assistant nurses and helpers, (3) Non-regular or part-time employed, (4) Sick leave for 15 or more days for a physical or mental condition in the past 3 months, and (5) Current treatment for a mental health problem from a mental health professional. However, in this study, exclusion criteria nos. 4 and 5 were withdrawn before the start of the baseline survey , cognitive restructuring (module 2), problem-solving (module 3), assertiveness (module 4), self-compassion (module 5), and job crafting (module 6). Participants chose one module per week in any order they preferred. Program B also included six modules that provide CBT-based stress management skills, including a transactional model of stress and coping (module 1), self-case formulation based on cognitive behavioral model (module 2), behavioral activation (module 3), cognitive restructuring (module 4), cognitive restructuring and relaxation (module 5), and problem-solving (module 6). The six modules were presented in a fixed order, with one module accessible per week, from module 1 to module 6. Major features of the programs compared to other smartphone apps for mental health33 are as follow: (1) Accessibility: These programs were accessible using smartphone apps downloadable from Apple App Store and Google Play, as well as from PCs and other devices connected to the Internet. (2) Program content: Both programs were developed based on previous evidence-based web-based stress management programs that showed the universal prevention effect on psychological distress or depression of office workers in Japan35. The program content was developed to primarily target nurses with none or mild symptoms of stress. (3) Adaptation to the target population: the programs were developed and modified with an extensive discussion with a group of senior nurses in Vietnam so that the content was relevant to and appropriate for the working situation and work culture of nurses in Vietnam. For instance, case stories used to illustrate the stress process and stress management were newly developed, considering common stressors in the target population suggested in the discussion with the senior nurses, such as job overload, role conflict, and work-family interference. (4) Other functions: The program provided a function for self-assessment of participants’ mood by using the Kessler 6 scale of psychological distress37 to motivate the participants to study the programs. No track system of behavioral or physiological parameters such as sleep or exercise was included. (5) Design and visual appeals: The program used cartoon characters35 who talked on the study topic and guided participants through the learning. The cartoon and other images were developed acceptable to the hospital settings and cultures in Vietnam. (6) Learning support: The programs were fully-automated and self-guided, provided without any professional or therapist support during the learning, to minimize the running cost. No primary task support, dialogue support, or social support was provided.Two smartphone-based six-module stress management programs were used. One (Program A) was a free-choice, multimodule stress management program in which respondents were allowed to select one module per week in any order they preferred. The other (Program B) was a fixed-sequence, multimodule stress management program in which respondents were required to study modules in a fixed order, one module per week. For both programs, it took about 15 minutes to complete each module. Participants in the intervention groups were invited to access and study the allocated program by using the app downloaded to their smartphones, while they were also able to access to the program from PCs or other devises. To develop these programs considering the working situation and work culture of nurses in Vietnam, 30 senior nurses of the target hospital (who were not participants in the study) were invited to a meeting with researchers to review and comment on the intervention programs based on their priorities, experience, and preferences. Full details of these programs may be found in the published study protocol paperParticipants in the intervention groups were required to complete Program A or B within 10 weeks after the baseline survey. Participants were provided with their own ID and password to sign in to the program. Before the start of the program, participants in the intervention groups were given a workshop on how to download the apps and to read an introduction module, which was identical for the two programs and provided a general overview and how to use the programs. They were asked not to disclose this information learned from the programs to others nurses. If participants did not complete any module on time, they were reminded by an instant message from the CRC. In addition, informal group chat  and hotline 24/7 by the research team facilitated the intervention groups to use the programs. The nursing department of the hospital and senior managers who did not participate in the study also sent message to the whole group to encourage the intervention groups to use the programs, although they were blinded to the group allocation. These technical support and reminders did not include professional support for studying CBT.Participants in the control group did not receive any intervention program during the intervention and follow-up periods (7 months). Participants in both the intervention group and the control group were able to use an internal employee assistance program service of the hospital as a TAU. Participants in the control group were provided the opportunity to use the intervention programs after the 7-month follow-up.All outcomes were assessed at baseline, 3-month, and 7-month follow-ups, using a paper-based self-administrated survey questionnaire. The questionnaires were distributed by an independent research assistant who was blinded to the group allocation and returned by participants in sealed envelopes.38. The DASS is a widely used screening tool to assess symptoms of depression, anxiety, and stress experienced in the previous 7 days in community settings39. The depression subscale measures dysphoria, hopelessness, and devaluation of life, among others. The anxiety subscale measures autonomic arousal, skeletal musculature symptoms, and situational anxiety, among others. Items were scored on a 4-point scale ranging from 0  to 3 . In order to yield equivalent scores to the full version of DASS (42-item), the total score of each scale was multiplied by 2 with ranges from 0 to 4239. The ranges of cut-off scores of the depression subscale (DASS21-D) are as follows; normal (0 to 9), mild (10 to 13), moderate (14 to 20), severe (21 to 27), and extremely severe (28 or more). The ranges of cut-off scores of the anxiety subscale (DASS21-A) are as follows; normal (0 to 7), mild (8 to 9), moderate (10 to 14), severe (15 to 19), and extremely severe (20 or more). A Vietnamese version of DASS 21 has been developed and tested, and its internal consistency  of each DASS21-D and DASS21-A subscale was acceptable  and validity has been confirmed40. According to that study, DASS21-D predicts depression with a cut-off score 10 or more, with good screening performance 40.The primary outcomes measured in this RCT were depressive and anxiety symptoms. To assess these outcomes, the depression and anxiety subscales of the short 21-item version of the Depression Anxiety and Stress Scales  were usedvery satisfied to very dissatisfied). In addition, participants in the intervention groups were asked to rate the usefulness of the intervention program at 3- and 7-month follow-up surveys using one item with five response options (very useful to very useless). To evaluate a difference in adherence to the two intervention programs, the usage rates  of the intervention programs were collected from the records of the apps system.Participants in the intervention groups were asked to rate their satisfaction with the intervention program at 3-month follow-up survey using one item with five response options  months (or any time after the baseline survey to the point of follow-up surveys), have you got to know information on stress management from your colleagues who used any smartphone-based stress management programs?,” with a response option yes/no. This scale was originally developed.Demographic data, such as age, gender, marital status, education, service years, and overtime hours during the past month were collected at baseline survey. Information on whether the participants had been diagnosed with any chronic diseases before the baseline survey was collected in the 3-month follow-up survey.19. To detect a small effect size  or more at an alpha error rate of 0.05 and a beta error rate of 0.15, the estimated sample size was 289 participants in each group. The statistical power was calculated using the G*Power 3.1 program41.A required sample size was calculated for the depressive symptoms assessed by DASS 21. Previous meta-analyses of web-based psychological intervention on improving workers' mental health in the workplace yielded effect sizes of 0.23 to 0.3740. A stratified permuted block random table was generated by an independent biostatistician. Enrollment was conducted by the CRC, and assignment was conducted by an independent research assistant. The stratified permuted-block random table was password protected and blinded to the researcher. Only the research assistant could access it during the work of random allocation.Participants who fulfilled the eligibility criteria were randomly allocated to one of the three trial arms (two intervention groups or control group). Stratified permuted-block randomization was conducted. The block sizes of this study were fixed to 3. Participants were stratified into two strata according to the depression subscale score of DASS 21 (≥ 10 or < 10) in the baseline survey42.For the main pooled analysis, a mixed model for repeated measures (MMRM) conditional growth model analysis with an unstructured covariance matrix was conducted using a group (intervention and control) × time  interaction as an indicator of intervention effect. For sensitivity analysis, a similar MMRM, but using the analysis of variance model, with an unstructured covariance matrix was conducted. In each analysis, the intervention effects for Programs A and B were simultaneously tested in a same model. A stratification factor that was used to stratify the participants into two strata  before the randomization was always included in the modelAt the baseline survey, if the number of missing items was less than half of the number of total items, the missing values were imputed applying values calculated according to the following equation: the mean value, timed the number of total items, divided by the number of missing items. Otherwise, if the number of missing items were more than half of the number of total items, the case was not imputed and treated as the missing. Missing values at follow-up surveys were imputed applying the maximum likelihood estimation using the MIXED procedure. An intention-to-treat principle was applied.2 test was performed to examine the difference between the two intervention groups. All statistical analyses were conducted using the SPSS Statistics V.22.0 (IBM).The effect size was estimated in two ways. First, we estimated a regression coefficient for a group (each of the two intervention groups vs. the control group) x time (baseline and two follow-ups) interaction using the MIXED procedure, which was converted to an effect size by dividing by a pooled SD at baseline and at follow-ups. Second, we calculated Cohen’s d among participants who completed surveys at baseline and each follow-up. The level of statistical significance for all analyses in this study were set at 0.05 (two-tailed), and 95% CIs were calculated. For process measures, the χSubgroup analyses were conducted separately among respondents using the stratification factor  according to a priori-defined subgroups (selective intervention effect).43.One major change made to the protocol was in the eligibility criteria. Originally, five exclusion criteria were set (see above). Before the start of this study, criteria nos. 4 and 5 were canceled due to the anticipation of a low participation rate and to minimize restrictions applied to select participants in order to know the effect of the programs in the real setting as a pragmatic trialRecruitment and the baseline survey were conducted in September 2018. The intervention and control groups were assessed at approximately 3 months (January 2019) and 7 months (May 2019) after the baseline survey. The participant flowchart is shown in Fig. Demographic characteristics are presented in Table The average scores of DASS depression and anxiety subscales decreased from baseline to 3-month follow-up, but increased again at the 7-month follow-up in the two intervention groups Table . ProgramAmong participants with higher depression subscale scores of DASS 21 (≥ 10) at baseline (n = 77 in each of the 3 groups), Program A or B showed no significant intervention effect on either of the two DASS subscales during the follow-up . The intervention effect of Program A or B was not significant at 3-month follow-up  or at 7-month follow-up  for Program B; the effect on anxiety: t = 0.64, p = 0.52, Cohen’s d = 0.08 [95% CI − 0.25 to 0.40] for Program A; t = 0.15, p = 0.88, Cohen’s d = − 0.06 [95% CI − 0.39 to 0.26] for Program B).2(3) = 1.98, p = 0.58). About the usefulness at the 3- and 7-month follow-up surveys, there was also no difference between two intervention groups (χ2(3) = 0.98, p = 0.81, and χ2(4) = 2.10, p = 0.72, respectively).Table Among 297 (93.4%) of the control group who responded to the question about contamination at 3-month follow-up, 37 (12.5%) answered that they heard about the information related to stress management from those who used the program(s). Among 288 (91.1%) of the control group responded to the question at 7-month follow-up, 90 (31.3%) answered that they did. Regarding the question about adverse events or unintended harm, 250 (78.9%) in the Program A group and 257 (81.3%) in the Program B group answered the question at 7-month follow-up. Out of those, 239 (95.6%) in the Program A group and 253 (98.4%) in the Program B group responded “No.”The present RCT found that Program B, an iCBT program with a fixed-sequential order of modules, showed a significant intervention effect on improving depressive symptoms at 3-month follow-up among hospital nurses in Vietnam, with a small effect size. Program A, an iCBT program with a free-choice order of modules, did not show a significant intervention effect on any of the primary outcomes. Completion rates were almost the same between these two programs (83.3% in Program A and 86.1% in Program B). There was no significant difference between the two intervention programs in terms of usefulness or satisfaction at the 3-month follow-up. The newly developed smartphone-based iCBT stress management program with fixed sequential order modules may be useful for improving depressive symptoms among nurses in Vietnam.21 and in the general working populations19. The small effect size of the program in the present RCT is attributable to lower intensity of the intervention because the iCBT programs in the present study were fully automated and self-guided. A previous systematic review reported that guided iCBT programs with support or feedback from professionals have usually shown a greater effect than non-guided iCBT45. This may also have led to a small effect size. However, a self-guided program still has merit because of the greater accessibility and lower cost46.To our knowledge, the present study is the first to examine whether a smartphone-based multimodule stress management intervention program can improve depressive and anxiety symptoms among nurses in a LMIC. A significant intervention effect was found for the fixed-order program on depressive symptoms at 3-month follow-up. The Cohen’s d effect size (− 0.18) for Program B at 3-month follow-up in this study was similar to or slightly smaller than effect sizes reported from previous universal prevention studies among nurses in the United States18. A possible reason is because the Program B (as well as Program A) was developed as a fully automated, self-guided program. It may be harder for participants already with depressive psychopathology to study CBT from the present program without a professional support or advice. In addition, because the program was developed targeting healthy nurses with minimal symptoms of stress, the program may be perceived by these symptomatic participants as less relevant to their situations. Such characteristics of the program may result in a lower effect on improving depression among those who already had the symptoms. The Program B may be useful when it is applied as the universal prevention rather than as the indicated prevention. Despite the small, limited effect size, the public health impact of the present iCBT program could be scalable in the primary prevention field, when considering its accessibility and minimal cost.Among participants with higher depression score, the intervention effect of Program B on depressive symptoms was not significant at 3- or 7-month follow-up, and the effect size was even smaller than that for the whole sample. This is contrary to previous findings that the effect size to reducing symptoms of stress such as depression was greater for the indicated prevention than the universal prevention in the working population47. Program B in the present study did not include any exposure technique. This may be among the reasons for the non-significant intervention effect on anxiety symptoms.In the present study, Program B showed no significant effect on improving anxiety symptoms at 3- or 7-month follow-up. A previous meta-analysis examining the intervention effect on anxiety and related disorders reported that interventions using exposure strategies had larger effect sizes than those using cognitive and behavioral techniques and cognitive techniques alone24. The superiority of a free-choice program may not be clear in a country with a collectivism- and hierarchy-oriented organizational culture25, such as Vietnam. In addition, Program A (free-choice) showed non-significant effects on depression and anxiety symptoms at any follow-up, which were smaller than Program B (fixed-order), which is also contrast to previous finding in Europe24. This may be attributable to the difference in the program content rather than the difference in the type of the programs . Program A contained similar cognitive behavioral techniques  as Program B, and half of the six modules were overlapped between the two programs. However, there are some differences between the two, which might explain their differential effectiveness on reducing depressive symptoms. With Program B, participants learned the cognitive behavioral model in an early module and then cognitive behavioral skills in later modules. This standard procedure of studying CBT may enhance participants’ understanding the CBT skills and lead to the significant improvement in depressive symptoms compared to the control, while Program A did not use the procedure. Furthermore, two modules of Program B provided the participants with intensive information about the cognitive restructuring skill, which was previously reported to be effective in reducing depression48. On the other hand, only one module of Program A was designed to provide this skill. This may make Program A less effective in improving depressive symptoms compared to Program B. It was impossible to make the content of the two programs identical, because the content depended on the type of the program to some extent; it was inappropriate to compare the outcomes between participants who only studied CBT components of Program A and those who studied Program B, because there were no participants who studied CBT components but did not other components of Program A. Further study is needed to compare the effectiveness of free-choice and fixed-order programs on depression and anxiety using strictly comparable free-choice and fixed-order programs in the Asian culture context.The proportions of intervention group participants who completed Programs A and B are similar, suggesting that a free-choice program is not better than a fixed-order program in terms of facilitating the use of this type of smartphone-based stress management program among hospital nurses in Vietnam. This is contradicted previous findings that a free-choice program showed a higher completion rate than a fixed order program in European countriesCompletion rates were high for both programs. This is attributable to intensive reminders by support staff via online communication tools including instant messages, online group chat, and a hotline telephone service. Satisfaction and usefulness were also high for both programs. This may be attributable to the fact that the programs were developed and culturally modified based on opinions from the target population . An iCBT approach may be acceptable and relevant to nurses in Vietnam, if culturally adapted. Not only selecting a case story representing a popular source of stress in the target group, but also selecting wordings and illustrations may be important to increase acceptance and relevance of an iCBT program. A future study is needed to standardize the procedure of cultural adaptation of iCBT programs considering the specific cultures of a country and occupation groups, and other socio-demographic characteristics.24. A possible reason is a difference in ways of tailoring between the previous study and the present study. While the previous study used a navigation program to direct users to the most appropriate program based on pre-determined responses concerning their needs and preferences, the present study simply asked users to select one of the free-choice modules. The procedure used here may develop sufficient commitment of users to a selected module for increasing adherence to the program. Another possible reason is cultural difference. In Western countries, selecting options based on one’s decision is a culturally preferred behavior; on the other hand, among Asian countries, the culture is more collectivist and hierarchically oriented, and people tend to feel comfortable to do as others do and to follow instructions49. In comparison with participants in Western cultures, participants in the target population might not find being able to select a module from multiple options to be appealing, which might have limited their willingness to commit to the program A. Again, it would be desirable to consider the culture of the target population in designing an iCBT program.The completion rates, satisfaction, and usefulness of the two programs were similar. The finding is inconsistent with a previous finding reporting a more favorable adherence to a free-choice program than a fixed-order program in European countriesThere are several limitations of this study that should be considered. First, participants were recruited from full-time nurses of one big general hospital in Vietnam. Most participants were females, married, and without chronic disease or depressive symptoms at baseline survey. Almost all participants had their own smartphone. The generalization of the present findings to nurses working under different contract conditions and work environments may be limited. Second, all outcomes were measured by self-report, which may be affected by the perceptions of the participants or by situational factors at work. Third, a slight difference in the content between the two intervention programs may also be a limitation in comparing the adherence between the free-choice program and the fixed-order program. The difference of the result between the two programs may be due to other factors than the difference of free-choice or fixed order. Fourth, 12.5% of participants in the control group at 3-month follow-up and 31.3% of participants in the control group at 7-month follow-up answered that they knew information about the intervention programs from their colleagues. This contamination could weaken the intervention effect.