A fundamental cornerstone of quality of healthcare is patient safety, which many people with life-limiting illnesses feel is being compromised. Perceptions of impaired safety are associated with the occurrence of psychological distress and healthcare utilization. However, little is known about how people with idiopathic Parkinson’s disease (iPD) perceive their own safety toward the end of life. The aim of our study was therefore to investigate factors that influence the perception of safety of patients with advanced iPD.We conducted semi-structured interviews with a purposeful sample of 21 patients with advanced iPD. Participants were recruited at the neurology department of a tertiary care hospital in Germany between August 2021 and June 2022. Data were analyzed using reflexive thematic analysis.iPD-patients reported relevant impairment of their safety. While most participants expressed safety concerns based on the manifestation of disease, our analysis identified enablers and barriers to establishing safety in patients with advanced iPD, in 10 additional domains: relationship to the disease, informedness, self-perception, utilization of support and care structures, healthcare professionals and structures, treatment, social interaction, social security, spirituality, and environment.This study provides new insights into safety perceptions of patients with advanced iPD, which extend well beyond the physical realm. The findings suggest that clinicians and policy makers should consider a holistic and multidisciplinary approach to assessing and improving patients’ safety taking into account the enablers and barriers identified in this study. Idiopathic Parkinson’s disease (iPD) is a common neurodegenerative disorder that increases with age, and in its advanced stages, is characterized by impairment of activities of daily living, symptom burden, and reduced quality of life . Given tThis knowledge contributes to the understanding that one of the pillars of high-quality healthcare is patient safety . Accordiare in a state where adverse events are rare, safety behaviors are promoted and risks are controlled,are able to recognize safety as a worthwhile goal and implement realistic options for improvement, andare able to use their innovation skills to achieve safety .Consequently, patients are assigned an essential role in defining and advancing patient safety . PatientNevertheless, despite the fundamental importance of patients themselves in establishing safety in the healthcare system, little is known about iPD-patients’ own perceptions of safety. A comprehensive understanding of this could yet be used to promote a differentiated and individualized approach to both safety assessment and the implementation of safety measures. This study set out to examine experiences of hospital patients with advanced iPD to ultimately gain knowledge on how to improve patient safety and, therefore, care for iPD-patients across the care continuum.We conducted a qualitative study to explore the experiences and views on perceived safety in order to identify enablers and barriers. The Consolidated Criteria for Reporting Qualitative Research (COREQ) guided reporting .We recruited iPD-patients with advanced disease according to current literature  under thcf.Participants’ socio-demographic data were collected prior to the interview. The research team with expertise in neurology, palliative care and medical ethics developed an interview guide for semi-structured qualitative interviews. The guide comprised open-ended questions aiming at the participants’ experiences and perceptions of safety cf..MAXQDA was used to assist in data management. We performed reflexive thematic analysis following six stages: (1) familiarization with data, (2) development and refinement of inductive codes, (3) constructing of initial themes, (4) development and review potential themes (5) refinement, definition, and naming themes, (6) reporting . For theWe approached 22 iPD-patients of whom 21 consented to participate. Interviews were performed between August 2021 and June 2022 and had a median length of 20 min (range 8–59 min). One interview had to be terminated early because the participant suddenly felt too unwell to be able to concentrate sufficiently on the questions being asked. However, the data already collected could be used for our analysis. Detailed participant characteristics are shown in We identified barriers and enablers to the implementation of patient safety in iPD-patients. These were related to 11 themes, which are presented in The relationship to their illness in terms of processing and acceptance was crucial for the participants’ perceptions of safety. In particular, coping with the disease itself was associated with an increased sense of safety. This was fostered, among other factors, by optimism, resilience and empowerment through achievement.“I didn't let the illness affect me and I didn't hang my head, in that sense. It was like this: I had the disease in a pocket. It was there, but I still lived normally.” For some, safety meant being open about the disease and its associated symptoms, as hiding the condition from others was associated with fear of discovery.“I always say that if you are open about it and if you also say: Hey, I'm not feeling so well today, that's easier than retreating into a quiet closet.” Almost all participants agreed on feelings of insecurity caused by symptoms of the disease. This was mainly the case for motor symptoms, where actual falls or perceived risk of falls were particularly emphasized.“I've already fallen a few times. Sometimes I feel a bit tingly. And my hands, I already have so much pain there, and my arms, I feel unsafe. Not as safe as it should be.” However, participants also attributed special relevance to non-motor symptoms in the experience of safety such as pain, constipation and incontinence. However, physical safety was rarely mentioned in this context; the safety affected by these symptoms was mainly deemed to be of social nature, which for some encouraged social withdrawal.“When you go travelling...that's not possible, if only because of the incontinence. I have pads that can absorb most of it. But you can see that the clothes, that it shows through.” Furthermore, some participants reported psychological safety concerns due to symptoms such as depression, panic attacks and delusions. For two participants, the psychological distress even culminated in suicidal thoughts, with one of them being admitted to a psychiatric hospital.“Because of these panic attacks that build up, I always think about suicide or 'Is my wife doing what we agreed in the advance directive? Will she make sure that I have a proper death?” Uncertainties regarding the future were another source of feeling unsafe. This mainly concerned fears about the course of the chronic progressive disease including the end of life, the associated need for care and unpleasant connotations with dependence.“Of course, I’m thinking about the future and how it will go on […] Those are the two insecurities. So one is experienced insecurities (.) and the other is fear of the future.” Being informed about Parkinson’s disease, but also having well-informed relatives, was perceived by many as promoting safety as it resulted in mental preparation and empowerment.“Yes, it is definitely important […] to say that this is the reason why this is the way it is, this is how it comes about. It's always better to be in the know, because if you only find out about it today or live according to it, you have been given a lot of quality of life.” Conversely, two participants reported that a lack of information about the disease and its treatment led to a relevant feeling of insecurity.“When you are given medication that you don't know, it makes you insecure as to how it is compatible with all the other medication that I have to take every day. I would have hoped for a bit more information, but you don't get a proper answer anywhere.” Participants also reflected on their own nature and role as actors in creating safety or insecurity. Some expressed safety concerns in their daily lives because they found themselves overwhelmed or uncomfortable being dependent on others. Most participants experienced a sense of safety as long as they were physically active as they felt more mobile and were less aware of the physical symptoms.“I usually feel safer when I move properly. When I walk, when I pace, I generally feel safer because then I feel active and I think to myself: 'Parkinson's is actually nothing. It can't affect me'.” However, one participant also stated that she had felt anxious and insecure all her life due to her personality traits, which provided a fragile foundation for her patient safety in the context of iPD.“Yes, it’s because I’ve always been afraid all my life, although it’s not a thing to be afraid of. I’m always afraid of Santa Claus in disguise, when I see his face.” Utilization of support and care structures was perceived valuable in providing safety. This included healthcare facilities and services, residential care and assisted living as well as informal support services such as support groups and volunteers.“So what gives me safety now is that I’m in a nursing home. I find that quite safe.” (Participant 6)Interactions with healthcare professional also played a major role in participants’ perceived safety. Professional expertise and, closely related to this, the trust placed in staff had a positive effect. In addition, however, patient-centered care encompassing empathy, dedication of time and holistic approaches was considered vital for the experience of safety.Participant: “Yes, they [care team] gave me safety.”Interviewer: “What was decisive for that?”Participant: “Humanity, ability, knowledge. (…) Yes, competence and humanity.” However, when these characteristics were absent in the staff-patient-relationship, patient safety could be compromised. In particular, many participants reported communication deficits, a lack of compassion and a feeling of not being heard. For example, participants reported that healthcare professionals - unaware of the fluctuating symptoms associated with the on–off phenomenon - blamed participants for being lazy when in fact they were suddenly unable to perform certain activities.“I rang the bell and said: “Can you please help me go to the toilet?” She hung her hands and said: “No, you can go yourself! I can’t help you! You walk during the day and you can’t walk at night.” And I said: “Yes, if I can, I’ll do it myself”. But I couldn’t go.” But structural deficits in care, such as work overload, lack of communication between professional groups or discontinuity in care were also among risk factors for reduced sense of safety.“But he [former treating physician] is no longer at the hospital and since he left, I have had different doctors all the time […] Everyone always tries their best and messes around [with DBS]. And that always worse.” The therapeutic success of the different non-medical and medical treatment methods alone brought a sense of security for many participants.On the second day after [DBS-]surgery, I danced with my friends in the hospital room. […] This experience that they were able to help me so well with this is the best thing I have against my fears. However, feared and experienced complications and side effects of the various therapy options could also be a reason for feeling unsafe.Every new [medication] adjustment is associated with a change and this usually makes you feel insecure. Mobility-enhancing aids, especially walkers, were seen by many participants as a way of improving safety in the face of the risk of falling.“I’m safer with the walker. I’m safer with it in my hand than without it. There’s no doubt about that. Also with the wheelchair, if things are not going well you can sit in it. You’re also better off with it.” Support of a practical and emotional nature from the personal environment of the participants, especially the family, was perceived as promoting safety.“When the partner is there! That’s very safe then! Or if siblings, close relatives or people who are close to me. I’m safe then.” Yet, weaknesses noticed in the family structure could contribute to a feeling of insecurity: lack of support, overburdened family carers, patient’s struggle to living up to the partnership, and family conflicts.“So I’m afraid (…) that I won’t be able to maintain the minimum with my wife, because I live with her. I am also afraid of that. I don’t think she would leave me, but (…).” While an understanding attitude of others toward the person with iPD was helpful, the participants often felt insecure due to shortcomings in social life. In addition to stigmatization, they frequently experienced the feeling of being overwhelmed when surrounded by other people.“We just choose what I can eat. A bread dumbling, my husband cuts it, he then cuts it into small pieces and I can eat it with a spoon. But that is difficult. At the beginning I thought: ‘Uh, now everyone is looking. The world is over.” Participants regretted that they felt alone or socially withdrawn, which had a negative impact on their sense of security.“You feel alone and abandoned. Before I couldn’t – I was willing to talk to some people. I don’t do that anymore. That questioning, that – I don’t know, I have a feeling of being unsafe already. But I don’t know what to do about it.” Some participants mentioned that social security through professional and financial stability gave them a feeling of safety as they believed to be prepared for the contingencies of an uncertain future.“If you have enough dough [money], it’s no problem, but that’s the prerequisite.” Others, however, saw their safety compromised in this respect due to the illness, complained about financial disadvantages as a result of being unable to work, taking early retirement or losing their job.“Because my job is dangerous, a crane driver. For example, I worked at the top in the cabin and downstairs there were 60, 80 people working at the steelworks and they said: ‘You can’t come in here, you’re not allowed to work.’ Well, the factory doctor said I ought to retire.” Two female participants even reported financial losses due to a gambling addiction most likely caused by the medication.“Yes, lots and lots of side effects. For example, shopping. I used to go shopping, I had everything at home, but still I went shopping at the shop. I always wanted to go to the casino. When I was in [city] in [country] I went to the casino twice a week. And I spent a lot of money.” No participants reported spiritual or religious challenges that affected their sense of safety. However, a few participants felt that faith supported their sense of safety in the experience of illness.“People need something to hold on to. Yes, even if you say that not everything can be like that, but I think there is a point, how should I put it, where you can hold on to it.” Environmental factors played a vital role in safety establishment. Thus, physical barriers in walking routes in the home and the public were perceived as a relevant threat to safety mostly due to increasing the risk of falls.“I have changed flats. Before, I had to go down steep stairs. Then I gave that up because there was too much danger of falling down the stairs and so on.” iPD-patients felt more comfortable in familiar surroundings whereas unknown environments created a sense of insecurity. In addition, routine in daily life beyond regular medication was given special importance whereas discontinuation of routine was perceived as a safety barrier.“Yes, I think that [routine in nursing home] is safety for me. You always have everything on time at the same time and so on. I think so.” .Participation in road traffic, especially as a car driver, but also as a pedestrian, was perceived as a safety hazard by some iPD-patients interviewed.“Until last year, I went to visit the children. I went by car, but that's no longer possible, they have to come to me. I don't like risk, I don't like it. It's a risk when I drive a car, if I'm not well adjusted with medication, the day doesn't go well.” Additionally, current world events such as the COVID pandemic were seen as a barrier to an intact sense of safety, as there were fears of an unfavorable course of infection.“Yes, it was all very scary. Although I was one of the first ones to go with this [...] AstraZeneca. And I was actually vaccinated so early and had to wait three months and that made me feel unsafe.” Two major conclusions can be drawn from our qualitative study: (i) the perception of safety in advanced iPD corresponds to a multidimensional construct, and based on this, (ii) a holistic and multi-professional approach in iPD care is indisputable to ensure safety.Advanced iPD is associated with higher disability and mortality . Our resParticipants shared challenges in engendering safety, as well as safety-giving measures during their journey through the healthcare system. Undoubtedly, our study revealed that motor and non-motor symptoms associated with iPD, as well as uncertainty and worries about the future course of the degenerative disease, can lead to feelings of insecurity. It is not surprising, therefore, that therapeutic efforts were considered to be of great importance for the generation of safety. In this context, however, thorough education about medication, including potential side effects, could enhance a sense of safety and promote patient empowerment. That being said, healthcare which deviates from patient needs or grievances have led to a loss of safety among iPD-patients . This phBut even as private individuals outside the healthcare system, people with iPD often felt their safety threatened when they were exposed to social challenges in society. Even though social safety schemas are assumed to develop early in life, these perceptions are shaped by the actual situations people face . In thisIn a North American study, higher spirituality was associated with less impairment of quality of life and less anxiety and depression in patients with Parkinson syndromes, suggesting a potential influence on feelings of safety . Given tIn summary, while the identified enablers and barriers to the safety of iPD-patients should be considered to ensure a holistic approach to care, our study also provides direct recommendations for healthcare professionals to promote patient safety. These include a sound knowledge of the disease and its treatment options, prescription of medical aids, as well as soft skills such as empathy, patient-centered communication, and teamwork. The basic prerequisite for understanding individual patient safety is, therefore, a thorough medical history that goes beyond the patient’s physical complaints to address unmet needs.Our qualitative approach supported explorative investigation of a variety of aspects that contribute to and hinder perceptions of safety in patients with advanced iPD. Nevertheless, there are some important limitations. Recruitment under heterogeneous clinical conditions and exclusion of patients with advanced iPD with severe cognitive impairment may have introduced selection bias. Moreover, given that recruitment took place at a single site in Germany, views may not be representative of patients from other geographical regions. Further research outside Germany could identify country- and health system-specific characteristics of patient safety. In addition, our interview study provided a snapshot; a longitudinal study might yield more information about the variability or persistence of feelings of insecurity.Our study shows that the perception of safety of people with iPD is subject to a holistic concept based on physical, psychological, social, and spiritual needs. In order to identify safety concerns and address safety issues, multidisciplinary approaches to the care of people with iPD should be adopted. This may include systematically assessing safety concerns and developing safety strategies for patients, taking into account individual characteristics and circumstances. The enablers and barriers identified by our research offer promising starting points for improving the quality of healthcare by informing safety-oriented practice. Nevertheless, complementary quantitative research projects are warranted to estimate the prevalence of individual safety concerns and thus their implications for the healthcare system, and to inform quality improvement initiatives by healthcare professionals and policy makers.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving humans were approved by Ethics Committee of the Medical Faculty of the Philipps University of Marburg. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.AP and DP conceptualized and planned the study. AP conducted the interviews and drafted the manuscript. AP and MvM were involved in the qualitative analysis of data. All authors provided critical comments on drafts of the manuscript and approved the final manuscript.AP received funding through the Support Fund for Female Doctoral Candidates and Postdocs with Family Responsibilities of the Philipps-University Marburg. Open Access funding provided by the Open Acess Publishing Fund of Philipps-Universität Marburg with support of the Deutsche Forschungsgemeinschaft .DP received payments as a consultant for Boston Scientific and as a speaker at symposia sponsored by Boston Scientific, Zambon and AbbVie. DP’s institution, not DP personally, received funding from the German Federal Joint Committee (G-BA), the German Federal Ministry of Education and Research, the Horizon 2020 program of the European Commission, Boston Scientific, the Parkinson’s Foundation, the Dr. Reinfried Pohl Foundation, and the German Parkinson Association (dPV). LT reports grants, personal fees and non-financial support from Medtronic, Boston Scientific, St. Jude Medical, UCB Schwarz Pharma, Archimedes Pharma, TEVA Pharma, Lundbeck Pharma, Desitin Pharma, Abbvie; personal fees and non-financial support from SAPIENS; grants and personal fees from Bayer Healthcare; personal fees from Medas Pharma, TAD Pharma; personal fees and non-financial support from GlaxoSmithKline, Orion Pharma; grants from Zur Rose Pharma, outside the submitted work.The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Intimate partner violence (IPV) is a prevalent public health issue associated with multiple physical and mental health consequences for survivors. Digital interventions can provide low-threshold support to those experiencing IPV, but existing digital interventions have limited efficacy in improving the safety and mental health of IPV survivors. Digitally adapting an integrative intervention with advocacy-based and psychological content holds promise for increasing the efficacy of digital interventions in the context of IPV.This study examines the needs, acceptability and usability of an integrative digital intervention for people affected by IPV. We used the think-aloud method and semi-structured interviews with a sample of six people with lived experiences of IPV and six service providers. We analyzed the data using thematic analysis.We identified the increasing general acceptance of digital support tools and the limited capacity of the current support system as societal context factors influencing the acceptance of and needs regarding digital interventions in the context of IPV. An integrative digital self-help intervention offers several opportunities to complement the current support system and to meet the needs of people affected by IPV, including the reduction of social isolation, a space for self-reflection and coping strategies to alleviate the situation. However, potentially ongoing violence, varying stages of awareness and psychological capacities, and as well as the diversity of IPV survivors make it challenging to develop a digital intervention suitable for the target group. We received feedback on the content of the intervention and identified design features required for intervention usability.An integrative digital self-help approach, with appropriate security measures and trauma-informed design, has the potential to provide well-accepted, comprehensive and continuous psychosocial support to people experiencing IPV. A multi-modular intervention that covers different topics and can be personalized to individual user needs could address the diversity of the target population. Providing guidance for the digital intervention is critical to spontaneously address individual needs. Further research is needed to evaluate the efficacy of an integrative digital self-help intervention and to explore its feasibility it in different settings and populations.The online version contains supplementary material available at 10.1186/s12889-023-16357-5. Intimate partner violence (IPV) represents a significant public health challenge that affects individuals worldwide . ResearcProfessional psychosocial interventions to support survivors of IPV include advocacy-based and psychological interventions , 20, whiUnfortunately, many people who experience IPV remain without professional help , 28. TheIn an effort to address these barriers, and encouraged by the challenges posed by the COVID-19 pandemic, research has increasingly focused on digital self-help support interventions for IPV survivors –37. DigiBased on the outlined positive evidence of higher intensity integrative interventions identified in the face-to-face context , 22, 26,In addition to semi-structured interviews, we use the think-aloud method, which is known from other fields to be particularly useful for exploring users’ experiences with digital interventions in an in-depth and nuanced way . In addiThis study uses the think-aloud method and semi-structured interviews with the aim to explore the acceptability, usability, and needs of people with lived experiences of IPV and service providers regarding a digital integrative self-help intervention. We report this study according to the Standards for Reporting Qualitative Research  and adhFreiburger Fachstelle gegen Häusliche Gewalt), which supported the study design and recruitment. An employee of this agency participated in the study as a service provider. We presented the study analyses and results at a conference of this agency, attended by experts and people with lived experiences to obtain their feedback and to increase the credibility of the findings. We have reflected on and acknowledged the researchers influence in the research process including data collection and analysis.The research team consisted of one Ph.D. student  and two graduate students . The team was supervised by LBS, a licensed psychotherapist and associate researcher, and received input and feedback from senior researchers , who have extensive research experience in this area. The study was conducted in collaboration with a professional IPV agency  fluency in German, b) a minimum age of 18 years and c) self-reported past experience of any form of IPV. For the professionals, inclusion criteria were a) fluency in German, b) a minimum age of 18 years and c) work experience with survivors of IPV. All individuals who met these inclusion criteria, were interested in study participation and gave consent were included. We stopped recruitment when saturation was reached, which occurred when the research team agreed that no new themes emerged during data collection.M = 39.00, SD = 12.51). All but one of the participants held a university degree and were currently employed. In terms of their IPV experience, all except for one participant had experienced multiple forms of IPV, including physical and psychological violence. Of the six IPV survivors, five had received informal support , and four had received professional support  related to their IPV experience. All participants reported using the Internet at least once a day.This resulted in a sample of six individuals with lived experiences of IPV and six professionals who provide psychosocial care to IPV survivors. Table M = 43.33, SD = 12.83). All professionals held a university degree and were currently employed. Three professionals were social workers and three were psychologists. One of them worked as an outpatient clinical psychotherapist, and the other experts worked in institutions specialized in IPV or related topics. The length of their working experience with IPV survivors ranged from 1.5 years to 25 years . None of the experts reported having experienced IPV themselves. All but one IPV expert reported using the Internet at least once a day.The six IPV experts included in the study identified as female and heterosexual. Their ages ranged from 26 to 63 years . We informed the study participants about the objectives of the study, the study procedures and data protection. All participants gave voluntary informed written consent to participate and were informed of their right to withdraw consent at any time, to skip uncomfortable questions, and to take breaks.Participants with lived IPV experiences were offered comprehensive written information about medical and psychosocial support services. If they expressed, or we suspected, psychological distress during study participation, we offered an immediate conversation with a licensed psychotherapist. Furthermore, we offered them contact referral to an outpatient psychotherapy clinic. However, no participant requested psychological support or contact referral. Participants with lived experienced of IPV received a gift voucher of €50 as compensation for their participation.The data records were stored on a secure server at the University of Freiburg, Germany, and were accessible only to authorized project staff who were bound by confidentiality.by my side). For the purposes of this study, we presented one of two sample modules to the study participants. Sample module 1 focused on the topic of the psychological impact of IPV and available support services, representing an advocacy-based intervention component. Sample module 2 had a more psychotherapeutic approach and addressed self-esteem. Table We conducted this study as part of the development process of an integrative digital self-help intervention for people experiencing IPV , the secondary interviewer (HMM) observed, took notes, asked supplementary questions and intervened in case of uncertainties. We provided participants with information about the study’s aim and procedures. Participants gave written informed consent and completed questionnaires on their demographics, digital literacy and IPV experience or work experience, respectively, using an online form .In the first part of the qualitative data collection, we used the think-aloud method, in which participants worked through a sample module and vocalized all of their impressions, thoughts and feelings . Particif4 software  would be something, I’d really like to recommend to my clients, because I would know, it provides useful support, is easily refundable by health insurance, of course I’d recommend this. I think it would be an enormous relief, especially for clients, where I’m afraid that they won’t even get on a waiting list for psychotherapy.” (E4)“This  also provides coping strategies in case I can’t access further help services. So, I thought, the goal is not only to say “here you can get help”, but to provide coping strategies within this digital format.” (S6)“I thought, the goal of the intervention should be to show how to handle the violence. Because […] psychotherapy or counseling is not accessible in a lot of cases. That’s why I had expected that it .” (S4)Participants emphasized that digital interventions should ideally serve as a bridge over to face-to-face psychosocial support, but acknowledged the limited availability of such support. As a result, they emphasized the need for digital interventions to provide longer-term psychological support, a room for self-reflection and coping strategies.“When I experience acute conflicts, of course, right in this moment, you can’t be on your phone, but right after I’d […] like to process this situation. For example, […] there could be suggestions on how to resolve the conflict, or input on, what I can do right know to calm down.” (S2)by my side] 24/7. The self-help-group is once a month, psychotherapy once a week. On the one hand, to me that is almost too often. On the other hand, it is never in the situation you urgently need advice. That’s why I think, a digital solution is a great […] addition.” (S3)“You can access it  It’s really good, that it’s so extensive, and that it provides all the relevant links and telephone numbers. But it’s nothing you can do on top [of your everyday life]. You need to resolve this conflict: it needs to be suitable for everyday life, you can work through it on the side, maybe even on your smartphone. Yet at the same time, it requires a lot, it is exhausting to think about yourself and to get into this work.” (E4)The psychological distress resulting from IPV, combined with everyday stressors, may interfere with the target group's ability to fully engage in and benefit from the intervention.“I don’t know if they [survivors of IPV] could handle this […] tool, or if they would break down and think ‘I’m a failure, why should I write anything here?’” (S5)Furthermore, participants expressed that working through the intervention could potentially cause psychological distress, for example if the content was too extensive or demanding, if the wording was too explicit, or if the prefabricated content did not match the user’s personal experience.“Of course, it can be dangerous, when I work through [this intervention] and my partner enters the room and sees what I’m doing. But I think that doesn’t speak against this support option, it rather reflects the reality of violence.” (E3)“If your partner controls everything, which is often the case in these relationships, when he tracks the browser and checks, which websites I have accessed. Of course, it is difficult. But it is also difficult to call somewhere, to make an appointment with a counseling service. That’s the point, when I’m locked up in a domestic control situation and my partner controls everything, then I don’t have a chance to get access to any service […], no matter which services you provide.” (E3)The persistence, form, and intensity of the violence experienced emerged as another relevant factor. Participants expressed that people experiencing IPV may be prevented from accessing the digital intervention if they lack a private and safe space, especially those who are acutely experiencing IPV. In addition, participants raised concerns about the safety of clients if the perpetrator found out about the intervention.“Some, they are insulted, but there is no acute threat. Yet, they suffer a lot. It’s also alarming. However, others, they are highly and acutely threatened, they get death threats, but they don’t realize how dangerous it is, and I could imagine that some people in this situation would think ‘oh, […] that’s interesting’ […], when actually something else is indicated.” (E4)Participants mentioned that the intervention needs to take into account the form and severity of IPV and the level of danger. This information needs to be assessed, considered, and effectively communicated within the intervention.At the same time, participants expressed concern that downplaying the seriousness of psychological IPV or "milder" forms of physical IPV could discourage people experiencing these forms of violence from using the intervention.“You need to differentiate in which situation the person is. Are they freshly separated? Not yet separated? Longer separated? Or separated for the fifth or seventh time?“ (S5)Participants noted that some of these concerns are only relevant for people who remain in the violent relationship, and therefore, it is important to consider whether the target user is separated.“A relevant point is [identifying as someone who is affected by IPV], but they won’t go to counselling services either. It’s about confronting yourself with your own misery and pain.” (E3)Related to this, participants considered the user's stage of awareness as relevant to the aim, content, and wording of the intervention. They emphasized the necessity of identifying as someone affected by IPV and in need of help as a barrier to accessing this support option.“It should be one aim of the intervention, to figure out ‘am I affected by violence?’ and it [the intervention] should support you during that process. Because, I think, otherwise, I wouldn’t have thought, that it [the program] actually addresses me.” (S6)Participants indicated that for people at an earlier stage of awareness of their own IPV experience, the intervention should provide a space for self-reflection and to receive information on IPV.“Wow, you are assuming a lot here. […] that’s a very, very long process of self-reflection […]. I think it took me months to understand this. I think if you have experienced violence and you are at this stage of self-reflection, then you’re really progressed. I don’t know, if you haven’t gone through this process of self-reflection, and you hear this sentence, wow, difficult.” (S5)For users at this earlier stage of awareness, some of the content provided may be too demanding and distressing, as it may take a considerable amount of time to fully grasp what is happening and to understand the causes and consequences of IPV.“I think that it is probably a good tool for people, who are already out of the situation, who have worked through some things already.” (S1)“I think, women who know words like ‘gaslighting’, they already worked on these topics intensely, they probably wouldn’t need an online tool anymore.” (E6)Participants expressed differing opinions about the usefulness of the intervention for individuals who have progressed in their self-reflection process.“I think, it’s important to separate the stages that someone goes through and then make individual offers to the individual stages.” (S1)“I basically think that for people who are actually in the situation, this word ‘violence’ or anything, is just what makes one shy away a little bit. I think, for people in this situation it would be more a wording like [...]: ‘Have you ever felt unsafe?’ [...] I think it helped me a lot to mention this feeling of fear or danger, because I was always a bit afraid of him. And I think something like that could be helpful to get started. But I really think that when the person is out of the situation and a little bit of time has passed or something like that, it’s actually good to hear: ‘Hey, you've been wronged’, sort of. I think I would in fact find it rather annoying if the perpetrator is not referred to as the perpetrator [...]." (S6)Participants requested that the intervention should be tailored to a specific target group, which should be clearly defined to ensure that the intervention meets the needs and expectations of the intended users.“On the one hand, […] a lot of them [survivors] are so distressed, it’s an acute conflict, I think it could be too much information for them. On the other hand, especially for them it’s so relevant that they get [this information on help options], that they are ask ‘how are you doing?’ Thinking about their own psychological symptoms, that’s the questions, is it good to do this right at the beginning, or is that something to do as a second or third step?” (E4)“Thinking about your self-esteem, that’s something it would start, hm, it’s difficult, probably after separation. But on the other hand, it could help you to find the energy to go through the separation” (S5)However, the participants were ambivalent about when certain content would be beneficial and when it could lead to distress.“Some clients, they need you to name it, so they take themselves seriously, because they can’t name it and they downplay it and they get stuck with this, but for other clients, you need to be cautious, so it’s not triggering. I think it has individual effects. Some may need, that you name it, that what happened was violence. But you have to detangle it before, how you define violence, especially psychological violence.” (E6)Survivors are so diverse. There is no ‘one-fits-all’-solution for intimate partner violence. It’s not one certain disorder, but one survivor is super resilient, she receives practical help for one week and doesn’t suffer any psychological consequence. Another survivor is highly traumatized, another survivor suffers from anxiety, so their needs are very diverse.” (E4)Furthermore, participants pointed out the diversity of the target group, which poses a challenge in defining distinct target groups with specific needs.Participants also expressed divergent opinions regarding the different components of the digital intervention. While they appreciated the empathy, support, and practical tips provided, they had differing opinions about the scope of the psychoeducation and self-reflection exercises as well as the helpfulness of the case examples. The participants suggested that the digital intervention should cover a range of topics in multiple modules, including basic information about IPV and safety, separation, children, help-seeking, mental health, emotion regulation, self-esteem, posttraumatic growth, and relationships. A detailed presentation of the feedback on the different components and required content can be found in Supplement Based on the participants input, we identified several design features that are critical to meeting the diverse needs of the target group while ensuring the usability of the intervention. We provide quotes from participants illustrating these required design features in Supplement In terms of functionality, participants emphasized the need for flexibility, and self-determination while working through the intervention. This included being able to choose the topics they wanted to work on and the desired extent of work they want to do. Participants also requested that the intervention content should be individualized based on their input. Other valued features included an interactive and multimodal design, with clear instructions to make the handling easy. Additionally, safety measures  should be implemented to ensure user safety.Regarding accessibility, participants highlighted the importance of an anonymous and low-cost intervention, that can also be accessed via smartphone. Additionally, promotion of the intervention was deemed crucial to increase awareness of the existence of this support option, with personal recommendations from fellow survivors or service providers being the preferred method. However, participants also emphasized the importance of public promotion and search engine availability, and suggested employing multiple search terms to increase discoverability.Inclusive language that addresses target users at different stages should also be considered both, in the public promotion of the intervention and within its content. Furthermore, the diversity of the content was considered relevant, including the representation of people from different cultures and educational backgrounds, people of all genders and with queer sexualities.Concerning the aesthetics of the intervention, participants valued a clear, neutral, and calming design that promoted a feel-good atmosphere, for example through warm colors, friendly pictures or soothing background music.Participants appreciated the logical structure of the intervention, including an overview at the beginning of each module that allowed them to anticipate what was coming next. They also appreciated a gentle start to each module.Regarding the language, many participants pointed out the need for a plain and personal, rather than scientific language. The wording should be clear and direct, while also being differentiated and sensitive, with an appreciative and positive tone. For example, when talking about the psychological effects of IPV, participants mentioned to avoid scientific terms such as ‘vulnerability’ or ‘psychological reactions’, differentiating that the user is not suffering from the psychological symptoms, but from the experience of violence, addressing the user directly with important messages and appreciating the user’s strengths and efforts. Participants liked the use of metaphors and analogies and found them helpful in depicting complex content.This qualitative study investigated the needs, acceptability and usability of an integrative digital self-help intervention for people affected by IPV with a sample of individuals with lived experiences and service providers. The findings suggest that digital interventions as a support tool for individuals experiencing IPV are well accepted and could complement the current support system in various ways. Space for self-reflection, the reduction of social isolation and the provision of coping strategies to mitigate the situation emerged as central needs of IPV survivors seeking help online, supporting the concept of the integrative self-help intervention. However, limited psychological capacities, potentially ongoing violence and different stages of awareness challenge the development of a digital intervention suitable for the target group. We have received concrete feedback on the components and content of the integrative intervention, and identified design features required for a high intervention usability.Our participants expressed an increasing acceptance of digital self-help tools due to the general societal shift towards digitalization. Digital interventions are particularly accepted as an easily accessible and privacy-preserving information source and entry point into the support system in the context of IPV , 37 and As a well-researched treatment measure for mental health disorders , 73, selThis is particularly important because, in line with previous qualitative research on SDAs, our participants expressed safety concerns when providing digital interventions to people acutely experiencing IPV. Preliminary evidence suggests that the perpetrator’s awareness of digital help-seeking did not lead to an escalation of violence . HoweverA related challenge is that potential users may not feel targeted by the wording of the intervention because they do not identify as someone experiencing violence. This can be an initial barrier to seeking help , 77, butThis problem extends beyond the wording and also encompasses the range and depth of topics covered in the intervention. To address different stages of change, some participants suggested defining a clear target group and providing accordingly tailored content. However, other participants pointed out that the needs of the target users are diverse, making it difficult to define a specific target group, which is consistent with prior research . Each reFinally, the intervention must consider the psychological capacities of the target group. In addition to everyday stressors, many IPV survivors must cope with safety-related, socioeconomic and legal challenges often associated with IPV . In lineWhile adhering to these design features may improve the acceptance and usability of the intervention, it is important to acknowledge that digital interventions are not without barriers and may exclude users with lower linguistic literacy, disabilities, limited digital literacy or limited access to a PC or smartphone. This is particularly problematic because those who are precluded from using digital interventions largely overlap with generally underserved populations, such as IPV survivors experiencing poverty or homelessness, survivors with disabilities, and survivors from cultural or linguistic minorities , 70, 84.On that note, and turning to the limitations of this study, it should be noted that all of our participants were well-educated, German-speaking and German-born, white, heterosexual, cisgender and mostly able-bodied women, who were willing to participate in research and to share their personal or professional experiences. The selective sample challenges the criterion of saturation, that we used to determine the sample size. Furthermore, the concept of saturation itself has been criticized . Given tAdditionally, the study only included psychologists and social workers as service providers, which may have influenced the results. Baird and colleagues  have criThis study investigated the needs, acceptability, and usability of an integrative digital self-help intervention for survivors of IPV. We used the think-aloud method and semi-structured interviews with a sample of people with lived experiences and service providers. Our findings suggest that an integrative self-help intervention with appropriate safety measures and a trauma-informed design could be a well-accepted complement to the current support system, reducing social isolation and providing space for self-reflection and coping strategies for people affected by IPV. However, the life circumstances and hardships associated with IPV experiences, as well as the diversity of IPV survivors, challenge the development of a digital intervention suitable for the target group. A guided and tailorable multi-modular intervention seems promising to meet the individual needs of IPV survivors. Future research should evaluate the efficacy of a guided integrative digital intervention and explore its usability and feasibility in different settings or populations.Additional file 1.


Purpose: The aim of the current study was to examine the feasibility of the SAFE pilot program as a mental health support to families by examining three feasibility objectives: demand, acceptably, and implementation. Method: Qualitative data from interviews, focus groups, and qualitative surveys involving service users, social work students, referring school board and university professionals (n = 37) were examined. Results: Demand for SAFE extended beyond the pandemic. A high-level of acceptance of SAFE was identified. Areas of success and considerations for implementation are outlined. Discussion: This study provides practice guidance on implementing this unique program, with potential to address gaps in service provision and the ongoing crisis in field education.The Support and Aid to Families Electronically (SAFE) pilot program was developed through a community–university partnership to support parents of elementary students in Ontario, while providing stable practicums for social work students in the midst of COVID-19 restrictions.  Research by Georgiades and colleagues in 2019 found that 18%–22% of children and adolescents in Ontario met criteria for a mental health disorder, with behavior and anxiety disorders the most common; only around a quarter of these children received mental health services, most often through their school. That same year, COVID-19 emerged, forcing widespread physical distancing and restrictions that profoundly impacted the delivery of mental health services and education from preschool to post-secondary. Nearly 1.6 billion learners representing over 90% of students around the globe were impacted by school closures . SchoolsThese closures, however necessary, placed a heavy burden on parents and caregivers who were suddenly and unexpectedly required to balance work, childcare, and education in the midst of increased financial stress, health concerns, and social isolation; all as access to support abruptly changed . MoreoveThe shift to remote service provision also caused significant disruptions to social work education. Practicum placements provide an essential component of social work education through which students gain practice skills while being supervised by professional social workers in the field . The addThe Support and Aid to Families Electronically (SAFE) pilot intervention was developed through a community–university partnership between the King's School of Social Work and the Thames Valley District School Board (TVDSB). SAFE was designed to address parental stress and mental health through free and immediate online counselling, while providing stable remote practicum placements for social work students. The purpose of the current study was to examine the feasibility of the SAFE pilot program as a support to families .COVID-19 disrupted the majority of field placements resulting in premature termination or transition to remote projects, limiting opportunities to engage in direct social work practice, previously a hallmark of practicum . In respCommunity partnerships filled a unique need where students remotely connected and provided psychosocial support to isolated populations during the COVID-19 pandemic . DespiteLevels of parental stress were exacerbated during the COVID-19 Pandemic . MoreoveA systematic review of approaches to supporting students at risk of poor mental health outlined the benefits of parental involvement in school-based approaches. There were also significant barriers noted to full parental involvement . Such baThe SAFE program emerged in partnership with the TVDSB, one of the largest school boards in Ontario, with 132 elementary and 29 secondary schools covering a diverse rural and urban area. Referrals to the program came through TVDSB social workers and counselors. SAFE was designed to address significant gaps in community-based parent and caregiver supports during the first phase of the COVID-19 restrictions and school closures. SAFE provided parents and caregivers of school-aged youth access to no-cost, low-barrier support provided by social work students. The SAFE pilot program was open to all elementary schools within the TVDSB, although families in which there were custody or access disputes or current justice involvement, were not eligible for service. The program was initially intended to run from January to June of 2021, however additional funding was secured to offer an extension through July and August to families who requested ongoing SAFE services through the summer.The SAFE program ascribes to a wholistic approach designed to meet service users where they are at through a comprehensive social work assessment, formulation, and collaborative treatment plan. This allowed for service provision that addressed the issues that families were dealing with through the flexible application of evidence-informed approaches across treatment modalities . SAFE stThe development of the SAFE intervention and the current research is in line with an integrated knowledge translation (IKT) approach. Knowledge users within King's Field Education Office and the TVDSB identified a problematic gap in both supports available to parents and social work student learning opportunities, and were in a position to act . ConsistSAFE is a unique example of a university-community partnership. While such partnerships can present unique challenges, there are significant benefits to the university, community, agency, students, and service users resulting in shared resources, expertise, and addressing mutual needs . The SAFThe objective of the current study was to understand the feasibility of the SAFE pilot intervention related to four main stakeholder groups: families, King's social work students, King's Field Education Office, and for the referring SB . FeasibiThe current study focused on the feasibility of the SAFE pilot intervention as a service to families, including the following feasibility objectives in line with The current study was a feasibility study using thematic analysis (TA) of qualitative data , 2021. Tn = 4 parents, n = 7 SAFE students, n = 4 King's professionals, n = 22 SB professionals)  and one research assistant, familiarized themselves with the data. During step two, interview transcripts, focus group transcripts, and Qualtrics survey responses were line-by-line coded by two independent coders. The focus was on inductively emerging coding categories. In step three, codes and potential themes were identified for each subset of data. In the fourth step, themes were reviewed and inconsistencies were discussed. In the fifth step, the team collaboratively defined and refined the identified parent themes and co-occurring subthemes of the entire data set, with the feasibility objectives of the study in mind. As per step six, the analysis was finalized in the current manuscript. To reduce coder bias and enhance reliability, trustworthiness, and credibility , an audiAs part of the sixth step of the TA process, the lead author analyzed and organized the inductively derived themes to answer each of the feasibly objectives. To understand demand and acceptability, the related themes were identified and are detailed in the results section. Analysis of data for the first objective, demand, involved TA as described above, as well as descriptive analysis of demographic data: presenting issues, how many families were served, and family demographics. The third feasibility objective was examined by analyzing the qualitative data to explore the success of implementation and reviewing the resource demands of the program.There was a total of 59 referrals to the SAFE pilot. Sixteen families did not follow through on their referral, seven families who completed the intake process did not engage in ongoing support, and 35 families received ongoing service with 11 of those continuing into the summer beyond the initial parameters of the practicum. Mothers were referred far more than any other caregiver group: Forty-two mothers (74.58%), 11 parental couples, one single father, and one grandmother were referred see . A majorOur TA of referral reasons found the most common referral reason involved child externalizing behaviors, aggression, and managing emotions ; followed by anxieties (14); family stress related to maintaining daily routines, boundaries, screen time or sibling conflict (10); difficulties with online learning or school attendance (5); and finally, specific situations such as grief, gender transitioning, or neurodivergent supports (4); three referrals had no referral reason.SAFE students and King's professionals noted that for the initial pilot year of the program the referral numbers were lower than anticipated, however, they felt that this was a reflection of the limited awareness of the program within the SB, as one student noted, “only a few social workers who were doing referrals at the beginning, so it gave me the impression that not everyone knew it was an option” (ST07). King's participants noted the challenge of ramping up during the pilot stage of implementation, “it's always a slow start as you’re getting clients onboarded” (K01). Another noted, “the referral numbers were the concern. I was very surprised… are there still barriers that are preventing families from being able to access” (K02). The data in this study however, supported the idea that it will take time for the full complement of referring professionals to become familiar with SAFE. The following SB participant comment reflects what close to half of the SB professionals noted, “I didn’t have a lot of experience about what the program was and what steps they might take if there is a difficult client to engage and those sorts of things” . SB participants were clear that they “will keep referring as long as you keep offering this support, as the feedback I received from the family who invested their time with you were very satisfied” (SB26).SAFE offered a complimentary service while filling a gap, a theme which informed both our demand and acceptability objectives. Supporting the work done in schools with children and increasing capacity to support the entire community was seen as relevant beyond the immediate response to COVID-19 that this pilot was initially addressing. As one school professional described, “our scope is so big of what we offer that the parenting is the one part that is really difficult. We might offer parenting programs, or we might offer drop-ins, but not the type of service that [SAFE is] offering” . Another SB participant noted the benefit of “somebody that's there supporting that parent through whatever the parenting needs are, that maybe aren’t necessarily related specifically into the school but do align” .Moreover, participants noted the benefit for the entire system, as one King's professional observed, “the SAFE program is not only supporting the students, not only supporting the families, but it's providing resources for the social workers…trying to manage the students that are in the classrooms and the teachers and all the rest of it” (K02). The long-standing stress on services was seen as extending beyond the SB, “our community has wonderful clinicians and services, we just don’t have enough so there's huge wait lists” (K04).Approximately half of the 20 SB professionals surveyed  felt that SAFE should continue past COVID-19 stating, “there will be a definite need in the community” (SB26), “[SAFE] helps address huge waitlists for services” (SB23), and “we are going to need more going forward not less” (SB02). The SB focus group was particularly clear about the ongoing demand for SAFE, “the objective of the program is exactly what our families need, and I would say that the stress, if we relate it back to why the program was developed, I think we’ll still have the reason to have the program. I would like to see it continue” .Overall, there was high acceptance of SAFE services, as demonstrated in this parent statement, “[my social work student counsellor] was amazing, like just with the ideas…to help our son get through his emotions, was amazing for us” (P05). Parent participants felt supported through their challenges and with their family's concerns; they felt their feelings and experiences were validated, they identified learning “a lot” about themselves, as well as being able to discuss their relationships and their own role in family dynamics. The SAFE students described their work as effective and valuable, as one stated, “I would say that it had a great impact on the families that were involved” . Our TA identified five themes related to perceived acceptability of SAFE: support to parents, new family dynamics, client directed and flexible, evidence-informed, and complimentary service that filled a gap.An important theme was the support SAFE provided parents, enabling them to support their children. As one King's professional noted, “It's all about the kids, except that…in order to be all about the kids, you have to be all about the people that are most important in their lives, which are the parents” (K02). Parents felt that the focus on them gave them, “something that I could do. It was a thing that I could control” (P06). Rather than services being provided only for their child, this parent felt that the parent focus “was probably the biggest thing that made it kind of move forward as quickly as it did” (P06). SB participants had consistent observations, as one noted, “when caregivers are stressed, children become stressed” (SB26).I could tell that each week…they were working on some really good parenting skills…one family in particular, had set goals and was doing some really concrete parenting and I could tell because she was sharing that with me… everything that this person was doing with her was working. The impact of the SAFE intervention however, went beyond families into schools, as described by one parent, “so far this school year, our son hasn’t been having too many issues with other peers like he normally would” (P05). The feedback from SB professionals was consistent, as revealed in the following:when you support the family wholistically, the change that is created for everyone, including the teachers in that classroom, including the other kids in that classroom, including the social worker who has to support that classroom, including the principal, including the parents, the ripple effect of families that are struggling is significant. The ripple effect of providing support to those families is equally impactful. (K02)The ripple effect of change that began within families was articulated by one participant,COVID-19 brought significant stress to families, which one SB participant described as, “increased emotional responses from students and families, ongoing and persistent activated stress responses leading to decreased coping and more reactive responses” (SB08). It was particularly notable, therefore, when parent participants identified significant changes in family tension and communication through their work with SAFE. These changes created new family dynamics that for one parent included “apologizing,” “talks,” and “a lot less arguing” (P01). This participant went on to describe increased “confidence” and “having more tools in your toolbox…to deal with situations” resulting in change throughout their family, “my son, he communicates with me more, he wants to hang out with me more. The rage is going down” (P01). SAFE students noticed changes in parents as well, “more present parents, that they are more calm parents…more strengths-based language with themselves, there's less tension in the families” (ST05).the whole reason for the referral was my son, we kind of branched out…and really looked at some of the roots of his behavioural problems and how that might relate to his relationship with his dad and my relationship with his dad…I was able to talk through so many issues. In a lot of ways, my feelings and my experiences were really validated. (P06)The service user directed and flexible approach at the foundation of SAFE's practice philosophy emerged as another important aspect related to the perceived acceptability of the intervention. As a student described, “we really ran the spectrum of anything that they perceived to be affecting their parenting, any length of time” (ST04). One parent described the efficacy of this approach,SAFE students applied an evidence-informed model that allowed the assessment and formulation to guide the intervention approach, which was found to include cognitive behavior therapy, narrative approaches, brief solution focused work, psychodynamic informed, among other approaches. As one participant from King's noted, “the service is flexible to the needs of the families. It's based on assessing the families as opposed to ‘we provide this service, so this is what you’re going to get’” (K02). For the referring professionals this was very beneficial as they knew when they referred a family they would receive the services they needed, as one noted, “it was just a one-stop sort of shop to say, here's what you’re looking for, here's what you need, and we can help you out with that” .Overall, the service was described as evidence-informed and structured to ensure students were educated, skilled, and supported to do the work. Parents found the SAFE students were “knowledgeable” and “experienced.” One parent particularly noted the evidence-informed approach was important for them, “there were suggestions made, based on research” (P01).I found it helpful to know upfront what her limitations might be and what she was going to do about those… that she was taking that back and talking to people who were more experienced than she was. So, I think all of that that was built into the program was really well thought out. (P06)Moreover, parents identified that a transparent and collaborative approach was employed in SAFE, in which students were clear about their limitations and how they were going to address these to meet the needs of a particular family. This approach increased trust in the program as one parent described,Moreover, the evidence-informed and transparent service provision built trust amongst the referring SB, as was discussed in the focus group, “I know the King's program and I know that there are people that the students consult with, and they have supervision regularly” , and “there was some confidence that I could help our families [by referring to SAFE]” .COVID-19 exacerbated an already stretched support system, increasing stress and workloads throughout the system, participants noted, “there is also a noticeable increase in the amount of school staff that require support, many feeling emotionally and physically exhausted, uncertain of the future, and some feeling burnt out” (SB06). Professionals articulated that the stress in the system resulted in “increased referrals because staff are overwhelmed” (SB26).The SAFE program was seen as filling an important gap in service provision. As one SB participant noted, “sometimes within the school system it's busy and we’re doing a lot of work with the students and sometimes we don’t have the ability to connect with the parents and do some of that core work that this program is able to offer” . The SAFE program provided complimentary services that involved the family in student support, as the SB professionals noted, “because then I knew I could focus on the student, and we know that their families were part of a system but we’re only one person and we’re stretched really thin, and we have very many roles in our school” . Moreover, as one King's participant noted, SB professionals “know that the service is going to be responsive…it's been co-created with the school board to meet the needs of the families that they care about, so that's huge” (K02).Participants identified five main areas as being important implementation considerations: the referral and intake process, communication, service delivery, accessibility, and the resources needed for implementation. Findings related to implementation, including strengths and areas for development, have been summarized in The SAFE program, including the referral process, was intentionally designed to be low-barrier for both families and the referring professionals, as one SB participant noted, “the referral form was perfect because it was short, it was quick, we could submit it right then and we heard back right away” . The SAFE students felt the separate intake role was important as “the first point of contact” (SB01), which decreased anxiety as students could, “prepare for the case that [the students] were going to take on, to feel some anxiousness relieved…knowing what they are stepping into” . Moreover, receiving referrals from the school helped to identify the most appropriate fit, as school staff identified, “being able to assess, is this an appropriate referral or not to make sure it's what is best for the family and for the program too” . Alternately, some felt that requiring referrals come through SB professionals created access barriers. One parent noted it took a year to connect their child to the school social worker, “to even get…to see the social worker…That's a barrier in itself which would create a barrier for [SAFE]” (P01). While the SB professionals felt they were in the best position to refer, they agreed, “if maybe they’re not as keen to refer to social work they may not be able to access this program” .Some participants suggested “a self-referral system” (ST02) could increase accessibility. One parent suggested that SAFE should be advertised within and outside of schools so families and professionals know how to access the resource, “draw attention to it, where it can benefit others” (P01). SB participants suggested: “a flyer” , “a website I could access and refer parents to look at” (SB27), “advertising” (SB30), or “a poster for families” (SB28).One of the benefits of SAFE is that it is outside of the school board. If families have a difficult relationship with their school or with the school social worker or the board… this is an arm's length support that they might feel more comfortable accessing. (K02)All participants identified that the formal channels of communication, specifically the intake process, worked well, however, opportunities to increase communication still existed. The SAFE students providing ongoing support noted, “we never got to talk to any of those referring social workers” (ST02). Likewise, the SB participants were interested in opportunities to collaborate, “my hope was that we connect both with the counsellor and the family together, we could talk about what their goals would be, we can integrate it into the school” . In particular, SB professionals being advised if a family had followed through on a referral and the possibility of a collaborative final meeting, “client led…and bring in the school…so that they can remember what they were working on” . It was noted however, that maintaining independence for SAFE would be important, as one participant noted,While virtual delivery was mandated because of the COVID-19 pandemic, it allowed flexible service provision. Moreover, there was consensus that virtual counselling provided benefit without sacrificing the therapeutic relationship, “I felt really connected and engaged” (P06). The online service helped eliminate other barriers including transportation, schedules, and childcare concerns participants identified. For example, parents said that the flexibility to log in where and when they needed to allowed them to schedule sessions during their lunch from work without losing time traveling, which as participants noted, “allows more people to use it, especially families without transportation” (P08) and “it's great for people in a rural area” (K04).Participants noted however, the importance of confidentiality and risk when working remotely. One consideration was the challenge of providing service when there is a “lack of privacy in the home” (SB27). Parents noted that while the flexibility that virtual provided was a benefit, finding a quiet space was a challenge, “it does take away… just that you’re not in that quiet room or whatever, away from everything” (P01). Moreover, remote work required particular attention was paid to potentially “unsafe home environments” (SB08) such as situations of intimate partner violence (IPV).Furthermore, participants acknowledged the need “to pay attention to the families that [online] might not work for” (K02). One parent participant identified that while not necessarily a barrier to service, remote was not the preferred method of receiving services, “I’m not an online person” (P05) and the SB professionals noted, “many families on my caseload do not have internet or reliable internet” (SB23). This concern was also noted by the SAFE students, in particular, “with the [online] consent forms” (ST06). Therefore, participants suggested that in the future, face-to-face options for some families might augment the service provision and suggested “community based hubs or coming into the school to meet a family member if there are barriers to virtual” (SB08).Additional options to expand service delivery were suggested, such as, “walk-in days or self-referrals days…psycho-ed webinar style groups or parenting groups” (ST02), and, as one SB participant described, “group parent support?…I think that can be helpful and just allow the ability to recognise that you’re not alone” .A standardized clinical assessment tool was integrated into the program to be administered at the outset and again at the conclusion of service. Although some students noted that the data that this tool generated was “helpful and beneficial” (ST05) and flagged the “high stress” of families appropriately (ST04), others found it “difficult to navigate the standardized tool that we were using and getting that to clients” , particularly with families for whom English was not the first language.As has been discussed throughout this paper, accessibility was foremost in the design of SAFE, which came through across the data. The combination of SAFE being “accessible, free and with unlimited number of sessions” (SB24), with “little to no wait time for service” (SB26) was highlighted. The efforts to eradicate a waitlist meant that “families…have access to services, access to support at a time when mental health is at its peak” (K02). The responsiveness of SAFE was particularly important during first waves of COVID-19, as one SB participant noted that wait times in the community had increased dramatically and few services were providing ongoing support, “waitlists are horrendous at most places, longer term services are more difficult to access as many services are based in crisis” (SB06).Participants therefore noted that in addition to the ongoing communication between the university and the SB regarding case flow, an ongoing implementation consideration was to balance the number of students with the anticipated referrals to ensure a ratio that will allow timely access to service, while at the same time, “you don’t want to have too many [students] because then you’re going to have very few clients” (ST03). Additionally, SB professionals noted the challenges related to parent/caregiver follow through on a referral, and with scheduled appointments, as one SB participant observed, “some families are overwhelmed and the thought of having another service provider calling them or having to make time, seems to be a challenge” (SB30).Further related to implementation, participants stressed the importance of SAFE as a free service, as one King's participant commented on the benefit of “having access to care that is remote, that is consistent, that is free and accessible” (K03). Participants did however, recognize that service users still had to manage the cost of internet and a device to log onto sessions. For some families, the school was able to provide “Chromebooks to families” (ST01).Unlimited and flexible sessions emerged as another implementation consideration that increased accessibility. Parents and students had flexibility to schedule appointments that fit the service users’ schedule, as one parent identified, “I was able to conveniently schedule it around where [my child] would most likely be napping” (P01), and as one student noted, “the stuff you’re working on is pretty complex, and not every client or case is the same, so it's hard to say eight sessions that's your hard cut-off” (ST07). As noted, additional sessions were offered to families over the summer. The flexibility and responsiveness of the program was highlighted by one King's participant who noted the following about the summer extension, “It's been able to pivot and respond to the needs of the families and the school board in a way that [in] other organizations it would be impossible to do” (K02).Finally, the SAFE program was able to minimize language barriers through interpreters. Both required paperwork and sessions were translated as one King's professional explained, “so that our clients could better access the services and meet with the students” (K03).The resource recommendations and considerations of the SAFE program are outlined in The SAFE pilot intervention was a unique response to the increasing need of social work services for families, made all the more pressing by COVID-19. In terms of demand for the program, there were 59 referrals, and 35 of the families who were referred received services. The majority of referred families identified as White and it will be important to understand why families of color were significantly less likely to be referred. There was little in the current data to inform this question, however the homogeneity of the sample, including the referring professionals, is noteworthy; future study is warranted. The demographic information however, demonstrated that SAFE was reaching women, and families residing in lower SES communities, both of whom were disproportionately impacted by COVID-19 and likely to need ongoing support well beyond the easing of restrictions.When considering the demand for SAFE beyond COVID-19, it is important to note that the most common referral reasons included concerns related to aggression and emotion regulation, followed by anxiety. Although both of these top referral reasons were likely exacerbated by the overall stress of the pandemic, these are consistent with the most prevalent mental health concerns for children and youth pre-pandemic , furtherMoreover, school and community partnerships that bring mental health services delivered by community-based agencies have long been used to augment school supports . InteresA number of themes emerged related to the high acceptability of SAFE; these themes are important to inform the SAFE program and broader social work practice. Firstly, providing support to parents and caregivers allowed these service users to address not only their parenting, but their own mental health needs and created space for them to be better parents. Secondly, working with the parents enabled the creation of new family dynamics that decreased tension and improved communication, a significant finding in the face of the profound stress experienced by families at the time of this pilot . ThirdlyIn exploring the implementation of SAFE, a number of practice recommendations emerged. The approach was service user centered, flexible, assessment based, evidence-informed, transparent, collaborative and, perhaps most importantly, free, with limited wait times. The focus on accessibility addressed preidentified barriers for parents accessing mental health supports . The impSAFE services were delivered through individual and co-parent virtual sessions. The findings of this study add to the growing knowledge base related to virtual service provision . ConsistSAFE students were educated on service user safety and confidentiality in the context of remote service provision, identified as an important ongoing consideration in our study and in the existing literature . Social One of the most important aspects of SAFE was its attention to accessibility. Participants identified a number of factors that removed barriers: timely response, no waitlist, free, unlimited sessions, virtual, attending to barriers posed by technology, extended summer sessions, and translation. While the virtual nature of service provision was seen as beneficial, providing flexible opportunity for support and reducing barriers to access, it was suggested that services could be offered both virtually and face-to-face in future, as determined by each family. This idea was echoed in the research, noting that remote, face-to-face, and hybrid placements will be necessary into the future .One of the most notable considerations was managing the case flow to ensure no waitlist, which required predicting the number of referrals and placing the appropriate number of students, considering both responsiveness of the program and student learning needs, all while taking into consideration potential drop-off rate for referrals.Additional considerations for social work program development are gleaned from SAFE being conceived and implemented through a university–schoolboard partnership that aligned with IKT. This facilitated a prompt response to service user and referring professionals needs and constant communication about implementation and service delivery. As participants pointed out, “the service is going to be responsive…it's been co-created with the school board to meet the needs of the families.” Notably, this included direct communication of the status of caseloads and referrals to ensure no waitlist and extending the program into the summer. Given the identified challenges related to caseloads and accessibility, this type of partnership, embedded in an IKT framework, is seen as particularly beneficial to the ongoing success of the program. Even if SAFE were to expand beyond the initial SB partnership of the pilot program, it is recommended that the Field Education Office continue this model of partnership moving forward, and that the resources needed to facilitate this are protected. Related to this is the discussion of resource needs for the program. Specifically, the development and ongoing delivery of SAFE was an additional demand placed on the Field Education Office.While the current qualitative study is not generalizable, the findings are consistent with extant literature and provide direction for future research. Participant engagement was a challenge, likely due to the additional stress on both parents and professionals during the COVID-19 pandemic. The online survey was developed in response to these stressors and as a qualitative data tool is not evidence based. While the current study provides a strong understanding of demand, acceptability, and implementation for the SAFE pilot program, this study took place during a unique time and further evaluation will help us understand the ongoing utility and feasibly of this program. In particular, it will be important to study barriers to accessing SAFE for communities not well represented in this pilot study, specifically Black, Indigenous, and people of color, as well as those for whom remote service provision may be a barrier rather than a facilitator to accessing service. Given the rapid rise of remote forms of social work service provision, ongoing research in this area is needed .The current study furthers the knowledge base of university-community partnerships in social work. It provides practice guidance for social work and similar programs looking to address the challenge of securing strong placement opportunities for students during COVID-19 and beyond. This has the potential to not only design programs that fill important gaps in service provision but address the mounting and ongoing crisis in field education .