Digital mental health interventions (DMHIs), which deliver mental health support via technologies such as mobile apps, can increase access to mental health support, and many studies have demonstrated their effectiveness in improving symptoms. However, user engagement varies, with regard to a user’s uptake and sustained interactions with these interventions.This systematic review aims to identify common barriers and facilitators that influence user engagement with DMHIs.A systematic search was conducted in the SCOPUS, PubMed, PsycINFO, Web of Science, and Cochrane Library databases. Empirical studies that report qualitative and/or quantitative data were included.A total of 208 articles met the inclusion criteria. The included articles used a variety of methodologies, including interviews, surveys, focus groups, workshops, field studies, and analysis of user reviews. Factors extracted for coding were related to the end user, the program or content offered by the intervention, and the technology and implementation environment. Common barriers included severe mental health issues that hampered engagement, technical issues, and a lack of personalization. Common facilitators were social connectedness facilitated by the intervention, increased insight into health, and a feeling of being in control of one’s own health.Although previous research suggests that DMHIs can be useful in supporting mental health, contextual factors are important determinants of whether users actually engage with these interventions. The factors identified in this review can provide guidance when evaluating DMHIs to help explain and understand user engagement and can inform the design and development of new digital interventions. Nearly 1 in 5 adults in the United States experience a mental illness at some moment in their life ,3. In adDMHIs can be delivered via smartphone apps, internet websites, wearable devices, virtual reality, or video games  and ranguser engagement refers to a user’s uptake and sustained interactions with a digital intervention, which includes interest in adopting an intervention as demonstrated by signing up for the digital intervention, initial uptake as demonstrated by engaging with features of the digital intervention as part of the study, at a minimum during a demonstration as part of the study, and continued use of an intervention.This paper aims to systematically review the literature on DMHIs to identify common barriers and facilitators that may influence user engagement with these interventions. There are different ways to define user engagement. For example, engagement can be referred to as the time a user spends on an intervention. However, the time spent on an intervention varies between different types of interventions, and little time spent using a DMHI does not have to be a negative feature per se. To get a comprehensive understanding of people’s use of DMHIs, we use a broader definition of user engagement. In this review, some factors that can influence engagement, given a particular technology or context, a review is lacking that brings all these findings together. It is important to investigate the multitude of factors to fully understand the reasons for high versus low engagement. Previous reviews have highlighted the variability in engagement and uptake, analyzing both DMHIs published in the academic literature [A range of factors can influence engagement with DMHIs, such as the relevance of information to the user provided by a digital intervention , a lack terature -11 and pterature . HoweverAlthough analyzing engagement metrics of commercial apps can be used to examine variability in engagement, user studies are valuable to understand the underlying reasons why people may engage with some interventions more than others. For the purpose of this review, we focus on reviewing the academic literature.Researchers and developers of DMHIs can use this knowledge to inform evaluations of engagement and the development of new digital interventions. In addition, it may provide insights into what services and facilitating conditions need to surround DMHIs to promote technology-enabled services and may help mental health service providers in selecting suitable interventions for their clients.This review focuses on common mental health issues, such as depression, anxiety, psychological well-being and distress, and stress. There may be different barriers or facilitators for user engagement with other specific, serious mental illness interventions  that are beyond the scope of this paper.The inclusion and exclusion criteria of articles for this review are presented in Report on an intervention aimed to improve mental health, psychological well-being, anxiety, depression, stress, and/or moodReport on an intervention delivered in a digital format, such as a smartphone app or websiteReport on some aspects of user experience Report on factors that affected user experienceInclude participants aged ≥16 years Report on an empirical study Be a peer-reviewed article Be written in EnglishReport on interventions that have a mental health component but do not have mental health as a primary intervention target Report on interventions that only serve as an appointment booking system for in-person therapyReport on interventions that are used as a component during an in-person session but cannot be used remotely outside of these sessionsArticles published before January 1, 2010The first exclusion criterion was added to identify barriers and facilitators that would be applicable to DMHIs. For example, a study that tests an app primarily focused on physical pain symptoms, with a mental health component, may find physical pain issues as a barrier to engaging with the app. It may not be clear from the study whether this is a common barrier related to DMHIs or interventions addressing physical pain.The second and third exclusion criteria were added, as these types of interventions were designed to be a part of in-person sessions. It may not be clear from these studies whether users would be willing or able to engage with DMHIs apart from existing and traditional in-person sessions.Finally, digital health interventions evolve rapidly ,18, and online and intervention).A literature search was conducted in multiple databases, including SCOPUS, PubMed, PsycINFO, Web of Science, and the Cochrane Library. On the basis of the inclusion criteria, a search query was developed to include an article if its title or abstract contained at least one keyword related to mental health, at least one keyword related to digital interventions, and at least one keyword related to user experience  AND TITL E-ABS-KEY ( ( online PRE/5 intervention* ) OR ( online PRE/5 treatment ) OR  OR OR ( mobile PRE/5 intervention* ) OR ( mobile PRE/5 treatment ) OR ( smartphone PRE/5 intervention* ) OR ( smartphone PRE/5 treatment ) OR ( web-based PRE/5 intervention* ) OR ( web-based PRE/5 treatment ) OR ( internet PRE/5 intervention* ) OR ( internet PRE/5 treatment ) OR ( computer PRE/5 intervention* ) OR ( computer PRE/5 treatment ) OR ( cyber PRE/5 intervention* ) OR ( cyber PRE/5 treatment ) OR ( electronic PRE/5 intervention* ) OR ( electronic PRE/5 treatment ) OR ( mobile AND program* ) OR mhealth OR ehealth OR mtherap* OR etherap* OR telehealth OR telemedicine OR “mobile app*” )AND TITLE-ABS-KEY The search results were uploaded to Rayyan , a web-bThe first author reviewed all titles and abstracts. Explicit inclusion criteria were determined between the first 3 authors a priori article selection to reduce coder bias. The coder (JB) was a PhD researcher with years of research expertise in user experience and thematic analysis.A total of 6146 papers were extracted for the review. After the removal of 77 duplicates, 6069 article titles and abstracts were screened by the first author and discussed with the second and third authors. Uncertainties about inclusion were resolved by discussion among the first 3 authors, and reasons for exclusion or inclusion of these articles were discussed.Furthermore, 480 full-text articles were reviewed, of which 208 met the inclusion criteria. Articles that were not available were either not available on the web or were behind a paid firewall. Article types that were out of scope did not report on an empirical study.Although there is a risk of bias in studies, the review considered all studies that met the inclusion criteria and included a large variety of different study methodologies, including qualitative studies with no reported quantitative outcomes. The primary focus of this review was to establish themes across the literature rather than extract the outcomes of quantitative studies. Therefore, the risk of publication bias with significant results is small compared with a meta-analysis of outcomes .A data extraction template  was deveOther extracted data were intended to document study and intervention characteristics, such as the type of technology and whether the intervention was publicly available, the target population, and the length of time that participants were able to engage with the intervention during the study.adequately reported if a “yes” was assigned to 2 or more of these criteria.To account for the methodological variety of studies, the quality of reporting tool by Carroll et al  was usedAn inductive thematic analysis  was usedWe used a single coder approach, in which the first author iteratively identified codes from the data and refined themes throughout the analysis. Single coder approaches are methodologically sound when they include checks on validity and reliability . For ourThe first author began the analysis by systematically reviewing each paper. For each paper, the following sections were analyzed: abstract, results or findings, and discussion. Individual codes were created each time a factor was described that affected engagement with DMHIs.Factors were considered a barrier or facilitator if it was explicitly defined as a facilitator or barrier by the authors of the paper and/or the description in the paper pointed to it being a barrier or facilitator. For example, “participants reported they did not use mental health apps because they had privacy concerns on what would happen with their information.” In this instance, privacy concerns are identified as barriers.personalize an intervention and customize an intervention, were grouped together and given more descriptive names. As an understanding of the data was developed, earlier data were revisited to refine and combine codes, revalidating the previously coded material. Finally, the final codes were grouped into broader themes .A spreadsheet was used to keep track of the emerging codes. Each spreadsheet row corresponds to a single paper. The row contains the raw text of the paper that includes the identified factors and the initial codes. These codes were iteratively reviewed and compared with the raw text they were extracted from. Codes that referred to similar concepts, such as the ability to As seen in Measures related to user engagement included time spent using an intervention, number of log-ins, usability, acceptability, and feasibility. The usability and acceptability of the technology were assessed using qualitative methods and standard measures, such as the survey based on the Unified Theory of Acceptance and Use of Technology , the MobFactors that influenced user engagement were assessed through surveys , interviews , focus groups , randomized controlled trials , field studies , workshops , analysis of app usage data , and analysis of user reviews , using both qualitative and quantitative methods. For example, qualitative methods gathered subjective user perceptions of what formed barriers and facilitators for them to engage with interventions. A quantitative approach explored associations between variables, such as sociodemographic factors and intervention usage data, user satisfaction, and/or interest in using DMHIs.The number of participants involved in these studies ranged from 6 to more than 2 million. In total, 6 studies conducted a secondary analysis of the usage data of an existing intervention or health database. For these 6 studies, the sample size was relatively large, ranging from 3158 to 2,171,325 users. Among the remaining 202 studies, the sample size ranged between 6 and 1558 users. For instance, 25% (52/208) of the studies had <18 participants, 49.5% (103/208) had <40 participants, and 75% (156/208) had <177 participants. The extent to which participants were exposed to an intervention ranged from a short demonstration before a focus group or survey to up to 1 year of usage.adequately reported , refugees, people who were homeless, veterans diagnosed with post-traumatic stress disorder, mothers with postpartum depression, patients being treated for a mental illness or another health concern, older adults, and caregivers and workers experiencing stress. Not all interventions specified the target population.important but rather indicate that more studies have reported on this topic. UserDemographic variables (31)Personal traits (5)Mental health status (59)Beliefs (55)Mental Health and Technology Experience and Skills (33)Integration into life (42)ProgramType of content (54)Perceived fit (61)Perceived usefulness (35)Level of guidance (40)Social connectedness (53)Impact of intervention (62)Technology and environmentTechnology factors (100)Privacy and confidentiality (47)Social influence (16)Implementation (39)User-related factors refer to factors related to the user, such as personal beliefs, skills, and experiences.Some demographic variables were found to be associated with DMHI engagement. Studies that found an effect of gender showed that women were more likely to adopt and engage with interventions ,52-68. OChudy-Onwugaje et al  found thOther demographic variables associated with user engagement were as follows: (1) employment status, with people who worked full time more likely to use the intervention than people who were retired  or unempCertain personality traits were associated with willingness and interest in using DMHIs. People who scored high on neuroticism and agreeableness of the Big 5 personality traits were more interested in using smartphone apps to reduce stress . In a diIn addition, extraversion was a predictor of lower likelihood to prefer web-based mental health services over in-person services . People A total of 59 studies reported that people’s mental health status plays a role in participants’ interest in and use of a digital intervention. First, certain mental health symptoms appeared to inhibit people’s motivation and/or ability to interact with an intervention. Depressive symptoms  and low Beliefs refer to preexisting beliefs the user has about mental health help-seeking , their nA positive prior experience with technology ,116, menMental health literacy refers to knowledge about mental health symptoms and appropriate treatment options . DigitalUsers reported that their engagement was affected by the extent to which they were able to integrate an intervention into their daily lives. Barriers that limited use included that participants felt they lacked time ,128-131 Access to a private space to access mental health resources also affected the extent to which participants could integrate an intervention into their lives. In 3 studies, participants mentioned that as opposed to going to a health care provider office, it was challenging to find a private space at home or work to use an intervention, which formed a barrier to engaging with it -138.Studies have also found difficulties among users in integrating the information and tips offered by the intervention into their lives. For example, Jonathan et al  evaluateIn summary, user engagement with DMHIs is partly influenced by factors related to the users themselves. Demographic variables such as age, gender, employment, education, and housing situation can affect user engagement. The personality traits neuroticism, agreeableness, openness, and resistance to change facilitated engagement, whereas extraversion was a barrier.If mental health symptoms were more severe, participants were more interested in using DMHIs, but symptoms related to depression, low mood, and tiredness prevented engagement. People’s beliefs about and past experiences with mental health services and technology were facilitators if these beliefs and experiences were positive, and they formed a barrier if these beliefs and experiences were negative. Participants’ literacy in understanding mental health and using technology facilitated their ability to use DMHIs, and any further engagement depended on the extent to which people were able to integrate it into their daily lives.The second group of constructs is related to the type of therapy or content offered through the DMHI.Higher satisfaction with the type of content and features offered increased user engagement. Uncertainty about the credibility of the information, which related to the evidence base of the intervention and the source of information, was a barrier ,140-143.Some interventions offered programs of a fixed length or time commitment, such as a CBT program consisting of 8 weekly sessions. The length of the program as well as the length of individual sessions played a role in participants’ satisfaction and their motivation to continue with the program ,147-151.Perceived fit refers to the extent to which users felt the intervention was appropriate and relevant to their culture and values and/or targeted to people similar to them, rather than a one-size-fits-all solution. This fit was, for example, facilitated by relevance of information to their current situation ,152-157 Perceived usefulness refers to the user’s experience with an intervention and their perceptions of whether the intervention would be useful to them. This perception was facilitated by whether users were able to understand the data presented to them ,117,170,The level of guidance refers to the extent to which users were guided to use an intervention, for example, through reminders or a web-based supporter, holding them accountable to regularly engage with the content. A facilitating factor in using DMHIs was whether the use of the intervention increased locus of control, meaning that users felt more ownership over their own health ,174,175.The effect that an intervention had on participants’ sense of social connectedness was found to facilitate user engagement. For example, being able to connect to peers or have regular contact with a personal therapist through DMHIs facilitated engagement in 18 studies ,184-194.Participants reported that the perceived changes they experienced in their mental health as a result of using an intervention affected their further engagement. Perceived symptom improvement facilitated further engagement ,197-199,Another facilitating factor was whether the intervention normalized people’s experiences ,190,201,In summary, the content offered by a DMHI had to be credible and ideally offered in more than one modality. Participants engaged with DMHIs if they felt the intervention was a good fit, which could be facilitated if content was relevant, and the DMHI was customizable, culturally appropriate, and used a language that was understandable to the participant. Engagement was facilitated by participants’ perception of whether a DMHI was useful, which included whether they were able to understand the data and how to use it, and whether a DMHI provided a clear advantage over resources they already had access to.Guided DMHIs had higher engagement than unguided interventions, and participants liked being able to connect with other people, although some studies identified concerns that DMHIs could be used to avoid in-person contact. The negative and positive impacts of DMHI use could form barriers and facilitators, respectively, to further engagement.The third group of constructs refers to factors related to the technology itself or the implementation of the technology.Technology-related factors refer to factors related to the technology through which the intervention was offered. The primary barrier to engagement noted in 25 studies was users’ experience of technical issues ,212-220,In addition to technical issues that formed barriers to engagement, there were also factors related to technology that facilitated the use of mental health resources and support. Facilitating factors made possible by the technology used were the flexibility of being able to access resources at any location ,127 at aPrivacy and confidentiality relate to how data were stored and shared and whether users felt safe and comfortable to disclose confidential information through an intervention. In 2 studies, participants were uncomfortable about their physical location being recorded ,234, andAccessing mental health resources via a digital platform raised concerns regarding privacy. Facilitators of user engagement and feeling safe to disclose information included assurance that the digital platform was private and participants’ information could not be easily accessed by third parties ,205,235.Participants in 5 studies expressed that concerns about confidentiality formed a barrier to engagement ,236,237.Anonymity was found to be both a facilitator and a barrier to engagement. Overall, 7 studies listed anonymity, meaning that users could share and receive information anonymously, as a facilitating factor to engage and encourage disclosure of information ,148,232.Users’ engagement was facilitated by whether the intervention was endorsed by other users  or peersmental health was disliked by participants [well-being and mental fitness rather than mental health [Although most studies in this review  primarily focused on factors related to the user and the intervention itself, 14 studies also described factors related to the implementation of the intervention. Examples included whether users received training on how to use the intervention ,247 and icipants , and parl health . Other il health ,129,211 l health ,122,135.In summary, although DMHIs introduced technical and usability issues that could form a barrier for participants to engage, the digital format also provided flexibility to access resources anywhere at any time and to have a record of health data. It was important that information was private and that participants could safely disclose information anonymously, although complete anonymity also made it more difficult to trust other people on the platform. Negative and positive opinions held by other people about DMHIs could form a barrier and facilitator, respectively, to engagement, and if DMHIs were to be used as part of ongoing therapy, the therapists’ past experience with DMHIs and the ability to integrate it into their practice played a role in user engagement. Finally, successful implementation facilitated user engagement. Providing training on how to use DMHIs and labeling an intervention for well-being or mental fitness  can help users engage with DMHIs more. Participants may be more engaged with DMHIs if they are just starting treatment, but the identified benefit of introducing DMHIs at a later stage is that users may be more knowledgeable about their health and better able to make sense of their health information.This study aims to synthesize the literature on DMHIs and summarize the identified factors affecting user engagement with DMHIs. This review identifies 3 key areas that all contribute to DMHI engagement: (1) user characteristics, such as severe mental health symptoms, can form a barrier to engagement; (2) users’ experience of the program or content, with participants more likely to engage if they perceive the program to be useful and a good fit to them; and (3) the technology and implementation environment, such as technical issues being a common barrier to engaging with DMHIs. Providing content that is relevant and customizable according to personal preferences and offering technical assistance and/or training are important to achieve engagement. However, although these considerations may increase interest and uptake of DMHIs, it is important to understand whether characteristics specific to the user, such as their symptoms, will affect motivation to engage with these interventions. We first discuss the 3 key areas in more detail in the following three subsections; compare our constructs with other models on user engagement; and then discuss implications for researchers, developers, and health service providers.Individual differences among users can affect engagement, including demographic variables such as age and gender, personality traits, mental health status, beliefs about mental health and DMHIs, experience with technology and mental health, and people’s ability to integrate DMHI use into their lives. Although the severity of symptoms may increase interest in engaging with health interventions , symptomThe contrasting role of symptom severity between studies highlights the importance of understanding how people who would be more interested in DMHIs and may benefit more from its use are not limited by their symptoms to actually engage with these interventions. The contrast also illustrates the importance of including users at various stages of the design process, as people may be interested in the concept of a DMHI but may not be able to actually engage with it because of the nature of their symptoms.Although studies looking at DMHI usage over 1 year found that younger people were more engaged with DMHIs, shorter research studies  found that older people were more engaged. Potentially, older adults perform better on study adherence, and younger people continue to engage more with an intervention long term, although the different interventions and settings make it difficult to make a direct comparison between these studies.Engagement with DMHIs was facilitated if participants liked the type of content; they perceived a DMHI to be a good fit for them and perceived it to be useful; there was a level of guidance on how to use it, it facilitated social connectedness, and it had a positive impact, such as improvement of symptoms.Guided interventions typically have higher engagement than unguided interventions. However, human guidance can be resource intensive, and it may not always be possible or feasible to provide the desired level of guidance. Although human support enhances engagement more than automated means such as email reminders , severalFurthermore, appropriate time commitments differ for self-guided exercises versus guided sessions. Participants across studies preferred shorter self-guided modules but longer guided therapy sessions. Finally, personalization may also meet different preferences. People who find videos or text-based material time consuming may be more engaged with shorter actionable exercises, whereas people with a preference for synchronous communication may engage more when they get dedicated time on one-on-one sessions. It would be worthwhile to further explore how engagement can be encouraged in self-guided interventions.An important facilitator was whether a DMHI facilitated social connectedness and enabled the user to interact with other people. Previous work has shown that social support through social networks not only increases engagement but may also have a positive effect on depression symptoms ,222. HowOffering mental health resources through technology offers both barriers and facilitators. Technical issues and concerns about privacy were common barriers, but technology also offered flexibility and could facilitate anonymity. Furthermore, the environmental context in which DMHIs are to be used are important to consider. Participants were more likely to use DMHIs if people close to them thought they should use it and if they received training on how to use it.Anonymity was a prominent topic among studies but engaging with an intervention anonymously was seen as both a barrier to and facilitator of engagement, sometimes within the same study. This difference can be explained by factors related to the user, the type of implementation setting, and the type of intervention features that were anonymous, as outlined in the following paragraph.First, a facilitating aspect of an anonymous intervention was that study participants found it less stigmatizing than seeing a live or in-person therapist. Anonymity may be an important facilitator for people who have experienced stigma and embarrassment, which is known to be a barrier to help-seeking for mental health concerns ,3. SimilThese differing perceptions shed light on an important trade-off. Should an intervention strive to be anonymous to address stigma and potential embarrassment or focus on allowing people to establish a trusted relationship with someone? This decision may depend on the objective of the intervention and whether anonymity is possible in the context in which it is to be used. Alternatively, a hybrid form or multiple options can be considered and offered. For example, forums with a larger number of users can be anonymous, whereas a private one-on-one session with a therapist can include telehealth options to allow for therapeutic alliance building between the user and therapist. The Supportive Accountability Model  also proA previous review of user engagement with mental health apps theorized that one reason for low engagement is that these apps do not consider user privacy . In our These differing experiences highlight that technology can overcome existing privacy barriers of seeking mental health care but can also introduce other privacy issues, and users’ situational context  should be taken into account.Some of the themes identified in this review overlap with previous models conceptualizing engagement with digital health interventions, as well as general technology acceptance and health behavior, such as the Efficiency Model of Support , Technolusability, implementation, fit, engagement, and knowledge. These broadly map to our constructs of technology factors, integration into life, perceived fit, beliefs, and experience, and skills. The implementation failure point in the efficiency model pertained to whether the user can apply knowledge gained from an intervention in their lives. Our review extends this concept, in that we found that an important issue is whether users can integrate the actual use of the intervention into their everyday routines.For instance, the Efficiency Model of Support  states tOur findings are in line with the Technology Acceptance Model, which explains that users’ decisions to accept and use a technology are influenced by perceived usefulness, ease of use, and social influence of others. The Health Belief Model explains that adoption of health interventions is, among things, influenced by a person’s belief in the severity of their illness or health symptoms and the perceived benefits of seeking treatment for these symptoms, which map onto our constructs of beliefs and impact of the intervention. Themes revealed in this review, which have not been highlighted in these previous models, are the level of guidance, integration into life, and social connectedness. This gap may be explained by the way in which mental health interventions were intended to be used. To be effective, most DMHIs were intended to be used regularly by users on their own. This characteristic introduces the challenge for people to integrate it into their routine and have the discipline to use it regularly; therefore, the level of guidance provided within the intervention may have a particularly salient effect on engagement. Social connectedness may be especially important for mental health interventions, as it can improve mood  and helpIn this review, we have synthesized the literature on DMHIs to identify common factors influencing user engagement. This synthesis can be described as follows.Researchers can use these factors to develop constructs that are important to measure when evaluating DMHIs. More concretely, it is important to capture user characteristics, users’ experience of the program and content, and details regarding the implementation setting. These constructs may help explain why someone would use one DMHI over another and may help evaluate how engaging a DMHI will be.Developers can use these factors to facilitate engagement with DMHIs. Specifically, when developing a DMHI, it is important to understand the specific characteristics of the target audience, for example, if the severity of the audience’s symptoms can form a barrier to engagement; to tailor the program to the audience, such as offering the option to customize content; and to address issues related to the technology and environment, for example, by mitigating technical issues and providing technical assistance.Mental health service providers, such as clinicians, can use this overview as guidance to select interventions that are appropriate for their clients or help guide their clients in selecting suitable interventions. For example, it is important to consider whether an intervention can be easily integrated into clients' lives and routines. In addition,The themes highlighted in this review identify factors that can facilitate engagement and barriers that should be considered to facilitate the successful implementation of a digitally mediated mental health intervention.We did not limit this review to particular study designs. As such, this review takes a much broader look at what factors influence engagement with digital mental health technologies rather than focusing on a single research method or technology. However, because of the heterogeneity of the included studies, we were unable to conduct a meta-analysis. In addition, there was inconsistency across studies in measures used to assess user engagement, such as the number of log-ins to an intervention, the length of continuing to engage with it, the total time spent using an intervention, or a self-reported measure of engagement by participants. This inconsistency has been found to be an issue in previous reviews on the user engagement of DMHIs ,256. ThiFinally, this review was conducted before the global COVID-19 pandemic. There may be unique factors that are pandemic related that make DMHI engagement more or less likely. For example, stay-at-home orders may exacerbate feelings of social isolation and make people more likely to engage with apps that increase social connectedness. On the other hand, it may also introduce additional barriers to finding a private space to use DMHIs if sheltering in place with others. The results presented in this review should be interpreted and used to understand DMHI engagement before and after the pandemic. A future review could be conducted solely during the pandemic period, and it could be compared with this review to understand DMHI use outside versus during a pandemic.Previous studies have shown the potential of DMHIs to improve mental health. However, for these interventions to be clinically effective, they require engagement by users in real-world settings. Across the studies reviewed, we identified 16 common factors that affect user engagement. Further research on DMHIs can use these factors as guidelines when evaluating interventions with users, and future interventions can be developed with these factors in mind. By understanding the factors that affect engagement, targeted strategies can be developed to overcome addressable barriers and work toward the successful implementation of these interventions.


Occasions of self-discharge from health services before being seen by a health profession or against medical advice are often used by health systems as an indicator of quality care. People self-discharge because of factors such as dissatisfaction with care, poor communication, long waiting times, and feeling better in addition to external factors such as family and employment responsibilities. These factors, plus a lack of cultural safety, and interpersonal and institutional racism contribute to the disproportionately higher rates of Indigenous people self-discharging from hospital. This qualitative study aimed to increase understanding about the causative and contextual factors that culminate in people self-discharging and identify opportunities to improve the hospital experience for all.Semi-structured interviews with five Aboriginal and/or Torres Strait Islander  people and six non-Indigenous people who had self-discharged from a major tertiary hospital in Brisbane, Australia, were audio-recorded, transcribed and thematically analysed.Study participants all respected hospitals’ vital role of caring for the sick, but the cumulative impact of unmet needs created a tipping point whereby they concluded that remaining in hospital would compromise their health and wellbeing. Five key categories of unmet needs were identified – the need for information; confidence in the quality of care; respectful treatment; basic comforts; and peace of mind. Although Indigenous and non-Indigenous participants had similar unmet needs, for the former, the deleterious impact of unmet needs was compounded by racist and discriminatory behaviours they experienced while in hospital.Respectful, empathetic, person-centred care is likely to result in patients’ needs being met, improve the hospital experience and reduce the risk of people self-discharging. For Indigenous people, the ongoing legacy of white colonisation is embodied in everyday lived experiences of interpersonal and institutional racism. Racist and discriminatory behaviours experienced whilst hospitalised are thus rendered both more visible and more traumatic, and exacerbate the deleterious effect of unmet needs. Decreasing self-discharge events requires a shift of thinking away from perceiving this as the behaviour of a deviant individual, but rather as a quality improvement opportunity to ensure that all patients are cared for in a respectful and person-centred manner.The online version contains supplementary material available at 10.1186/s12913-021-06880-9. Although relatively uncommon, occasions of people self-discharging from health services before being seen by a health profession or against medical advice are associated with increased patient morbidity and mortality, and greater risk of hospital readmission with associated personal, health system, and societal costs . People People who self-discharge are generally perceived as poor decision makers and castigated, either to their face or in their medical records, for behaving inappropriately . The verIn Australia’s major cities, Aboriginal and Torres Strait Islander  people are hospitalised at approximately the same rate as their non-Indigenous counterparts, but in 2017 were 5.4 times more likely to self-discharge . IndigenThis qualitative phenomenological study aimed to describe the lived experiences of people who had self-discharged from the Princess Alexandra Hospital (PAH), Brisbane, Australia. The PAH is a major tertiary health care centre and provides care in all major adult specialities except obstetrics . PhenomeResearchers from the Southern Queensland Centre of Excellence in Aboriginal and Torres Strait Islander Primary Health Care  led this research , in partnership with the Cultural Capability team from the then Aboriginal and Torres Strait Islander Health Branch (DW), Queensland Health. DA and WF, both female and both with PhDs, were qualitative researchers with experience in researching Aboriginal and Torres Strait Islander health. CK, a male, was a novice researcher, and DW, male, was an epidemiologist with broad health system knowledge and understanding. CK is an Aboriginal man, and DA, WF & DW are all non-Indigenous. All researchers had, at some stage of their lives, been admitted to a hospital, thus they and the research participants had a shared experience of being a hospital patient.Study participants were 18 years and older and were recorded in the PAH discharge database as having self-discharged from the PAH between 1 July 2013 and 28 February 2014. The discharge database records occasions of self-discharge as a standard category of discharge disposition. Patients with a principal diagnosis involving substance abuse or serious mental illness were not eligible due to the associated complexity of factors that increase their risk of self-discharge –19.To create the list of potential participants, Indigenous people who had self-discharged were initially identified – Indigeneity is also recorded in the discharge database. Non-Indigenous people who had self-discharged were then matched to the Indigenous people by discharge division, principal diagnosis, age, and sex in an attempt to maximise the structural similarities of participants’ inpatient experiences.Using patient contact details held by the PAH, CK, the Aboriginal Research Officer (ARO) working on this study, commenced telephoning the people on the list. He used a variety of telephones, including the office landline, a work mobile telephone and his personal mobile telephone due to awareness that many people are reluctant to answer unknown or private telephone numbers. When he connected with the potential participant, he explained the study’s rationale and approach, how their contact details had been obtained, and reassured them that the research and researchers were independent to the hospital. These telephone calls were the first contact between the researchers and the participant, except for one participant who was from the same Aboriginal and Torres Strait Islander community as CK and known to each other. Interviews were conducted at a time and place of maximum convenience for the participant. Participation was explained again, participants were invited to ask questions about the research, and informed written consent was obtained prior to any data collection. Participants received an AUD$25 supermarket voucher as acknowledgment of their contribution to the research.The PAH’s two Indigenous Hospital Liaison Officers (HLOs) were also interviewed as their roles aim to support Indigenous people while they are hospitalised, and to decrease incidents of Indigenous people self-discharging. The interview was guided by an interview schedule developed for this study and provided as Additional File Where possible, interviews were conducted face-to-face by the ARO (CK) and a second researcher (DA or WF) in participants’ homes or other location that best suited the participant. Telephone interviews were conducted if face-to-face interviews were not possible. The interviews were guided by an interview schedule that contained the broad topics to be covered. The schedule was developed for this study following a review of the extant literature, and was pilot tested within the research team. No alterations to the broad topics were required. The patient interview schedule is provided as Additional File Participants’ hospital medical records were reviewed to compare the documented version of the self-discharge event with the participant’s account.CK, WF and DA debriefed after each interview by sharing their reflections of the participant’s hospital experience and factors contributing to the decision to self-discharge, and compared these reflections with prior interviews. Additionally, the actual processes of the interviews were discussed to facilitate incorporation of any lessons learnt into subsequent interviews. Notes taken during these post-interview debriefs were included in the analysis.Interview transcripts were read and re-read by CK and WF to identify themes and sub-themes using thematic analysis . Followin = 1), alcohol abuse (n = 4), and suicidal ideation (n = 1)), resulting in a list of 84 people who were eligible to participate.During the nine-month study period, a total of 484 people were recorded as having self-discharged from the PAH, of whom 21 had subsequently passed away. Of the remaining 463, 61 (13.2 %) identified as Indigenous people. Following matching to their non-Indigenous counterparts, a list of 90 potentially eligible study participants was derived. On reviewing the principle diagnoses, six people were excluded ; 11 of whom agreed to participate –an effective recruitment rate of 44 % (11/25) .The communication barrier between health professionals and participants was also apparent in how participants responded to notification of their imminent discharge. For some participants, being told they were to be discharged was interpreted as being told they were free to go. In reality, there was often a lengthy delay between the telling and the completion of paperwork and receipt of medication which had to occur prior to the official discharge. Thus, some people were recorded as self-discharging whereas they believed they had been discharged. Other study participants recounted being informed they would be discharged the following day, but uncompleted paperwork, lack of communication between staff, or additional investigations precluded this from occurring. For study participants, the mixed messages and the lack of adequate communication coupled with apparent withholding of information contributed to an array of emotions such as anger, frustration, a sense of being targeted, and feeling demoralised and disheartened. These emotions, and the preceding events, triggered their decisions to self-discharge.Perceptions of a lack of communication between hospital staff and perceived disorganisation at the hospital level led some participants to question the quality of care they received during their admission. Some participants recounted occasions they had received conflicting information from different staff members. Two participants believed they had been wrongly diagnosed, and others recounted how their knowledge about their own bodies was disregarded and ignored, as if their knowledge was not as valid or as important as that of the health professionals. Similar to the participant quoted above, others also had planned procedures cancelled at the last minute because test results were not available. This sense of disorganisation at the personal and system level eroded participants’ confidence in the quality of care they received and gave rise to concerns about potential deteriorations in their health.no one seems to care anymore’(IDI4).As noted above, most study participants had been admitted to the PAH more than once, with some having had numerous admissions over the years. These participants reflected on both material and attitudinal changes that had occurred over the years, such as the bedside television no longer being free, patients no longer getting taxi vouchers, and not feeling supported and cared for while in hospital, with one stating that ‘it’s just the things on the side [that you notice]…” (IDI5). One Indigenous participant believed she had been subjected to inequitable access to transportation compared to non-Indigenous patients. Another recounted how she had presented to the hospital with chest pains, and a doctor observed her scratching her legs and diagnosed her with scabies. This participant spoke of being isolated without explanation until a food-service staff member informed her of the scabies diagnosis. The participant felt the doctor held beliefs about Aboriginal people based on negative stereotypical portrayals, which caused the doctor to automatically associate her Aboriginality and her scratching with a diagnosis of scabies. For this participant, the diagnosis and the isolation was reminiscent of her experiences of living through the eras of government policies of segregation and assimilation….Compounding these doubts about the quality of care for the Indigenous participants was their perception of being subjected to discriminatory treatment, with one stating “…You get them vibes … [felt] like we were back in the 60 or 70 s … it all came back again … because I’m Black, too, most likely, you know, scabies there … you get that all the time… (IDI1).“just [staff] being a little bit aggressive or grumpy or I haven’t got time for you today; what do you want? You’re ringing that buzzer again? What are you doing? So, we get a lot of that…”(HLOs). The HLOs did acknowledge that hospital staff are busy, and have stressful and challenging jobs but that the provision of attuned and compassionate care is required, encapsulated in the following extract….The HLOs also recounted episodes where they saw Indigenous patients being subjected to discriminatory and racist behaviours, including other patients staring and whispering, or staff being judgemental and intolerant. The HLOs believed that self-discharges could be prevented by hospital staff providing person-centred care and being attuned to individual needs of each patient. They spoke of the negative consequences for patients’ wellbeing of overhearing staff denigrating them to other staff, or staff not caring about patient’s needs… “…I know they’re busy with most of the other patients, but you have to be present with every contact, every attendance that you’re in, and you have to listen to what that person’s request is. So you’ve got to get rid of any conversation in your head about what your perception of this person is and just go and listen. So you can’t go in with preconceived … ideas… but the simplest thing is listening … clear your head … stop, get rid of the internal chatter, go in and BE with this person…” (HLOs).A recurrent theme was the perception that hospital staff lacked respect, humanity, compassion and basic kindness in their treatment and attitudes towards patients. A number of participants recalled episodes of staff being rude and disparaging, talking to them in a patronizing or condescending manner and ignoring them when they requested assistance or information. Participants described occasions where their relative powerlessness had been reinforced by the hospital staff, with one recounting how one doctor had given her a pass-out to spend Christmas Day with her family, and then another doctor ordered tests to be done on Christmas Day, therefore preventing her from going home. Her frustration and anger is evident in this extract….“…I still don’t know really why I had to have those tests that [Christmas Day] … she wanted to prove her authority, I could see that in the end. She was determined to make me stay there. And I was just as determined … to go…” (IDI3).“… [they] didn’t show any … no compassion at all and really, I was quite shocked, okay … no compassion, no consideration of people’s personal circumstances…” (NDI4).Another participant, who was not from Brisbane, recounted how staff appeared to arbitrarily interpret and apply hospital policies. On the first night of her admission, the ward staff allowed her husband to stay at her bedside throughout the night. However, without explanation, he was not permitted to stay at her bedside on the second night. Indeed, he was threatened with forcible removal by security if he did not go. The participant recalled begging ward staff to allow her husband to stay, but they would not allow it. Additional factors contributing to the stress of the situation was that the husband could not go home, had no money to pay for accommodation, and no friends with whom he could stay. The participant and her husband could not understand why the hospital policy was interpreted and enforced differently by different staff members, and felt the nursing staff capriciously determined how they would interpret policies and procedures. She stated….if you’re well enough to go out for a smoke, you’re too well to be here” (IDI2). His nicotine addiction was not acknowledged, nor were alternative sources of nicotine offered. Another Indigenous participant said that he was labelled as an alcoholic and treated with disdain, and another felt her Indigeneity negatively influenced her diagnosis and treatment.An essential element of treating people with respect and dignity is respecting people’s identity. For Indigenous people, their Indigeneity is a fundamental component of who they are and how they live in the world. However, the Indigenous participants felt hospital staff perceived their Indigeneity as problematic, and a predictor of poor health related behaviours and attitudes. They felt ‘labelled’ and judged by hospital staff. One Indigenous participant, a smoker, had attended the emergency department. While waiting to be assessed, he went outside for a cigarette. On his return, he found he had been labelled as self-discharged and told that “this is a white institution with white doctors’. Indigenous participants felt that staff lacked knowledge and respect of Indigenous culture, with one suggesting that instances of self-discharge could be prevented with “just a little bit more understanding cultural wise…”(IDI3). Interestingly, the HLOs reflected that the hospital is really just a microcosm of society and therefore mirrored how racism manifests in broader society….All Indigenous participants, including the HLOs, had experienced interpersonal racism and were impacted by the institutional racism in the hospital – as one HLO stated, ‘I think straightaway [the Indigenous patients are] the “Other”, just like they are out in the general public. So it’s just a microcosm type effect – it’s just the hospital here, but these guys, if they haven’t had a lot to do with Aboriginal people … they only know what’s on the media … they’re going to have this … belief that this is the story and decide how to fit an Aboriginal and Torres Strait Islander person into the created story … they’ll have a look and they’ll make their judgement on how that person is going to be treated … not all, but … I think straight up, yeah, they would treat them differently from non-Indigenous. (HLOs)Unmet basic physiological needs triggered self-discharge for some participants. Two participants described being unbearably uncomfortable in their hospital beds and others described how their financial insecurity limited their options while in hospital. For example, one participant could not afford the television and so just lay in his bed with nothing to do, and left when he felt better. Another had very particular dietary habits which meant he could not eat most of the food provided by the hospital. A staff member suggested he could purchase food from the cafeteria, however, he had insufficient money to do this. He reported being ‘famished’. He wanted to go home to eat and return the following day for the required care. This was not possible, and therefore he self-discharged.The hospital admission was but a moment in participants’ lives. For some, concerns for family left at home contributed to their self-discharge decision. One participant recounted how the image of his daughter as he was driven away in an ambulance kept replaying in his mind. He became increasingly worried about her, and discharged himself when he felt better.“…even when I was in there my concern was what was going on here at home. I’ve got a 15 year old daughter, mate. She was devastated when I got taken away in an ambulance…”(NDI6).Another participant, a single parent, recounted having to either leave her daughter at home alone or find other family members to care for her. Concerns for her daughter’s safety had driven her to self-discharge on previous occasions….“…but you still worry … a couple of times I’ve had to come home because we’ve had troubles around our house…” (IDI3).sick people all around” (NDI1) and a place where “you’re out of your comfort zone” (NDI1). Nevertheless, they respected the hospital’s role of providing specialised health care, and all but one stated they would not have self-discharged if they still felt unwell or were in pain. Interestingly, all participants, even those who had previously self-discharged, acknowledged that patients self-discharging can be problematic.These results need to be considered against the backdrop of participants’ fundamental belief in the importance of the hospital. They acknowledged that being hospitalised was not particularly pleasurable, with ““…It is a problem for people to be discharging themselves from hospital. It’s not something that I would recommend to anybody. You’re in there for a reason and you need to be there. Discharging yourself against doctors’ advice is not the best option for anybody…” NDI1.revolving door” of admissions and self-discharge. The HLOs had observed the declining health status at each admission for people in this category, as this extract highlights….The HLOs also viewed self-discharge as problematic, and did their best to support Indigenous patients to remain in hospital until they were discharged. The HLOs considered that broadly, Indigenous people who self-discharged fell into two groups. The first were those who had been told they were due for discharge, and simply left before all the discharge procedures have been completed. The second were those who were admitted due to acute exacerbations or complications associated with chronic diseases, and then self-discharged once the acute symptoms had resolved and they felt better. The HLOs commented that frequently people in this latter group have social circumstances that preclude adherence to a care plan, resulting in further exacerbations and admissions – creating a ““… so [patient] gets treated, gets well enough, goes, but doesn’t take any medication or look after himself … so then he comes back again; he gets treated, self-discharges and it’s a complete revolving door, and each time he comes [his health] level drops …“ HLOs.Contrary to common narratives that people who self-discharge do not care about their health, study participants cared deeply about their health and wellbeing. They also respected the important role of hospital in the provision of quality health care. Participants had a holistic understanding of health and of quality health care. They expected to be treated with dignity, respect and humanity; to understand their proposed care plan while hospitalised ; and to be confident in the quality of care and the competence of the health care providers. Additionally, although being hospitalised requires people to adopt a ‘sick role’ and largely rest immobile in bed , not allFor each participant, the decision to self-discharge was a rational act of reclaiming their personhood and personal power, and having agency over healthcare decisions that affect them. The power differential between participants while hospitalised and health service staff was reinforced in a multitude of ways, including the lack of timely or adequate communication, the stripping of personhood, and the assumptions made by staff that patients can simply purchase solutions to problems that arose while hospitalised. Consequently, each participant suffered as a result of their healthcare experience, whether it be through mistreatment or not being listened to, having to struggle for their health care needs and autonomy, feelings of powerlessness, or feelings of being fragmented or objectified . This suFor Indigenous Australians, the suffering caused by care while in a health care facility is exacerbated because of the divergence between Indigenous peoples’ holistic and collective understandings of health and the hegemonic western, biomedical, reductionist, and positivist view of health that informs health policy and praxis, and is embodied within health care facilities . These sInclusion of Indigenous and non-Indigenous people who had self-discharged enabled a deeper understanding of how the decision to self-discharge is impacted by issues arising during the current hospital admission and also to events in personal, familial and community histories, and for Indigenous people, their cultural history. However, despite matching participants on discharge division, age and gender, the Indigenous participants had all previously self-discharged compared to only one non-Indigenous participant who had done so. Prior hospitalisation and prior experiences of self-discharge have been associated with self-discharge , 31–33, Our findings are specific to one acute care hospital in Brisbane, Australia. The insights illuminated by our research may be relevant in other settings where similar contextual forces have shaped hospital care, but cannot fully account for why all patients self-discharge. A further limitation is that our participants had all self-discharged, and therefore their experiences may be negatively biased and not representative of all patients. The only hospital staff that we interviewed were the two HLOs who largely reinforced the perspectives of the Indigenous participants that institutional racism negatively impacted on Indigenous peoples’ hospital experience. Inclusion of other hospital staff in the research may have provided further insights into the contextual factors that determine how specific aspects of care are delivered, but given the focus on this research on understanding the patient experience, staff perspectives were not explored.The use of qualitative methods to understand patients’ experiences of self-discharge was an important strength of this research. Qualitative methods have increasingly been used for public health research  and are Although self-discharge can be associated with adverse health outcomes , competeAdditional file 1. DAMA Study: Indigenous Hospital Liaison Office Interview ScheduleAdditional file 2. DAMA study: participant interview schedule


N = 18) concerning the practices, emotions, and attitudes of social workers. Positioning theory enables scholars to approach the situation of encountering a survivor as a social event, which consists of the meaning-making activities of social workers. Professionals self-position themselves as one or a combination of the following: (a) a challenger of gendered oppression, (b) an advocator of women’s rights, (c) a facilitator of women’s empowerment, and/or (d) a self-reflector of personal emotions and attitudes. The findings suggest that the event of DV intervention is a discursive and contextually situated moral practice in which the distribution of rights and duties to say and do things is of particular interest. The act of self-positioning is constructed in relation to sociocultural settings. Social workers may take several positions during the meetings with survivors. Positions build our understanding of how social workers in violence-specific units make sense of DV, illustrating how the act of self-positioning may also define to the position of the survivor. Social workers experienced boundaries, and possibilities in responding to DV were explored. The study reveals that barriers should be addressed at a wider level by funders and policy makers to enhance the continuity of work and the implementation of women rights legislation in India.This article explores the self-positioning of Indian social workers who work with female survivors of domestic violence (DV). We know from previous research about the experiences of persons who have encountered DV, but more studies on the point of view of the professionals is needed. Relying on positioning theory and discursive analysis as a framework, we analyzed interviews ( This article addresses the insights that are gleaned from Indian social workers who work with female survivors of domestic violence (DV), emphasizing workers’ views on how they position themselves as professionals when responding to cases of DV. By analyzing discourses focused on work-related practices, emotions, and attitudes, the article examines the perceived rights and duties of social workers to intervene DV. In this article, we approach violence in Indian family structure, where several generations live together as a joint family. Thus, we use the concept of DV, which refers to the violence occurring among household members. India is an example of a powerful nation with relatively fast economic growth. However, concerns about human rights have become more visible globally in the 21st century. As an example, India has been criticized for its low level of commitment to international human rights treaties and for failing to protect women from DV .As authors, we are aware of the legacy of colonialism and resistance, which can be awakened by the oversimplified idea of “transplanting” Western principles and ideology to “empower” women in the Global South . Also, wSocial change, empowerment, and the liberation of people in the name of social justice and human rights are cited as central aspects of social work . Considering DV as a social problem and a human rights violation , the proIn addition to its physical form, DV may exist as emotional, sexual, financial, psychological, and social control, and, more generally, as any form of controlling behavior . AlthougIn 2005, the Protection of Women from Domestic Violence Act was passed, demonstrating a step toward committing to change. However, addressing DV remains challenging . As AhmeThe self-positioning of Indian social workers in response to DV cannot be understood without reference to the political, social, and occupational contexts of exercising practice. Social work involving charity and community work with a spiritual and ethical ideology started long before formal social work was institutionalized in the 1930s . The devSocial work practice in India in the field of DV differs from the roles and functions of practitioners in European countries for several reasons. Unlike in many Western countries, social work is not a registered profession in India. The state is often criticized for failing to regulate schools of social work in terms of curricular development . Also, mThe topics of the experiences, emotions, and attitudes of Indian social workers and their relation to DV are relatively unexplored. interactive positioning) or self-reports, when someone positions themselves (reflexive positioning)  . By identioning) —positionpositioning acts of the professional in any given social episode of interaction. Second are the actual positions that professionals occupy in relation to assigned rights and duties and adopted in these positioning acts. Third are the story lines that unfold as a consequence of professional interaction  during a 3-month exchange period in 2018 at an Indian university. With the help of local scholars, she recruited participants from local NGOs who specialized in working with DV survivors.The first author collected data from two focus group interviews and four personal interviews  were complied with. The interviewer discussed the research with the managers of NGOs, who recruited volunteer participants. In addition to receiving collective consent from the managers, the researchers received informed, oral consent from the participants after they had been told the aims of the research, how the information would be used, and how the data would be stored . VoluntaThe authors were aware of cultural tensions that can be caused when Western scholars conduct research in the Global South. To relieve such tensions , specialThe results of the study are summarized, using four differing positions that participant social workers occupied. They are illustrated with quotes and described with reference to the story line and response focus.In India, it’s a patriarchy. We have a very strong patriarchy, which gives men a lot of power. (I4)We listen to another woman, we feel that sometimes it’s very difficult … And we see them suffering, but we cannot do anything. They think that this is our life, we have to tolerate this … And we realize that the main cause of all this violence is gender discrimination. (I1)The challenger position is constructed in a dynamic fashion between the self-positioning of the social worker and the other-positioning of the survivor, who was assumed to be in a powerless position. Explicit self-positioning I remember one case, between [a] husband and wife there was no problem at all. It was the in-laws that tried to create problems between them so that they would be separated. And why? The girl did not bring enough of a dowry. It took us almost six months to understand the root causes … So, we could save the marriage but definitely we had to separate the in-laws from the husband and wife. (I3)A bride is expected to move into the matrimonial house, where several generations of the groom’s relatives live together. As part of the marriage arrangements, the bride’s family is typically expected to give some property  to the groom’s family, despite the existence of the Dowry Prohibition Act since 1961. Demands for dowries for several daughters may cause economically disadvantaged parents unreasonable distress, leading them to undertake desperate action. Ultimately, a girl child is brought up for another household and lineage; she will not be there to secure her parents’ welfare in their old age (we had to separate”) behind DV became evident. Their right to intervene was not explicated as being recognized before the intervention. Instead, by using third-order positioning when reflecting on the case afterward We try to make her understand her own rights, financial or mental. We try to make her understand and make her stronger to make her own decisions. To make her fight against abuse. (G1P4)The social worker’s position as an advocator is constructed through explicit collective positioning by emphasizing the duty of social workers to promote survivors’ self-awareness. Women’s acceptance of violence evolves from both cultural and legal norms. For example, marital rape is not an offense, and some religious laws prescribe having sex with one’s husband as a wife’s duty They always deny. It was her fault, she provokes me. She doesn’t treat the children properly, she talks with men, she came home late from work, she doesn’t do her housework, she complains about my mother. These same stories you hear from every abuser … They said that she burned herself, I didn’t do it, she’s lying. So actually, we call the abuser only to tell them “Hello, we are here now.” That’s the only purpose. To tell him that we are watching. It’s like a warning, a preventive strategy for further violence … We know, I know, that there’s no role I can play with abusers. (I2)An advocator position is constructed through explicit collective positioning (“We work”). Highlighting the complex nature of the work, the position concerns not only the social worker’s right to advocate but also their duty to hear both parties. This obligation was implemented in different ways, emphasizing the survivor’s safety and her willingness to cooperate as priorities. Some participants emphasized the importance of having regular meetings and a nonjudgmental mentality with perpetrators. However, the purpose of contacting the perpetrators can be simply to make them aware of the social worker’s presence. This also illustrates challenges when undertaking their duties: To encounter abusers brought up in a world of male dominance who express an unwillingness to admit to violent behavior. Interestingly, at the end of the latter extract, when the social worker ultimately dissociated herself from encountering the abusers, a shift in collective positioning from “we” to “I” occurs, illustrating an awareness of divergent views.The position of social workers as advocators in relation to women’s rights follows the story line of education unfolding into the juridical nature of the work. The positioning acts not only referred to survivors but also to men and network institutions, illustrating the psychoeducational aspect of work with survivors.e’s duty . Thus, wWe go to shelter homes, we go to other NGOs, we go to protection offices, we go to police stations, we go to the court to help the woman. Helping entitlement of their rights. (G1P2)In hospitals, social workers had an active role in preventive work when training nurses and doctors to launch routine DV screenings. Social workers from an NGO discussed how they gave a presentation to a parliamentary committee in the planning stage of the Domestic Violence Act, 2005. They also described how various training programs were organized by NGOs to tackle network partners’ negative attitudes, such as views of DV work as “extra work” and a lack of knowledge regarding DV legislation. Raising the awareness of women’s rights among the police was essential, because registration of DV cases is a prerequisite for survivors to receive further services such as free legal aid.But the police don’t respond properly. They don’t write the reports needed. They don’t write. They send them back. They say “Ok, this is your family matter, [unclear] you manage yourself, don’t come to us.” (I1)However, intervening in a private matter such as DV was critically defined as a task “beneath their [police] dignity” (I4). The previous extract demonstrates how social workers not only depend on infrastructure to support rights, but also a justification of the duty of social workers to advocate for women’s rights with the police.Discourses concerning interprofessional cooperation illustrate structural advocacy for women’s rights. That highlights the expert position and the social worker’s experienced right to educate and instruct.Social workers’ position as facilitators was constructed in relation to a woman’s agency. Following the story line of counseling, social work practice appears as psychosocial. Descriptions regarding client independence are illustrated in the next extract, whereas the two subsequent extracts discuss themes relating to individual decision-making.We try to provide information. We do that, so that women would be able to make decisions for themselves. Sometimes we also provide financial help, but it is very limited, because we want to make them independent. (G2P7)Above, the social worker constructs her position by describing the circumstances pertaining to women’s limitations in striving for independence. The core of personal empowerment was around processes during which a woman started to take control over her own life and achieve independence from her husband. Leaving home was not a prerequisite for independence. Instead, participants highlighted independence in terms of earning money, getting an education, getting peer support from self-help groups, or accessing health care for a better quality of life. The social worker’s duties are described through moral positioning, as the social worker describes the duty to avoid creating a situation in which the survivor becomes too dependent on the social worker. This suggests that, occasionally, it might be appropriate for social workers to distance themselves from survivors to facilitate personal responsibility and empowerment, even if this distance might contradict the moral position and the duties of social workers to always be available to their clients. This demonstrates the social worker’s views on the duty to help survivors as well as the right to step back.In discussions among social workers, women were often described as being dependent upon men in Indian patriarchal society. The duty of social workers was defined as supporting survivors in their move toward independence.They are not decision-makers. Since childhood, somebody else makes decisions. Very rarely do women make their own decisions. So, when you have to decide by yourself, it’s a big challenge for these women. But when she makes a decision and moves in that direction, the confidence that she gains is something that sustains her for life. (G2P8)However, as stated above, the subservient role with which women have been brought up posed challenges when workers shifted their position from expert to facilitator, aiming to give women the space to make their own decisions. Traditionally, Indian women are not treated as independent subjects in their communities. Thus, a situation in which women should suddenly start acting as if they have power over their own lives can be confusing. Accordingly, as described below, empowering a survivor was a process by its very nature.A client came to us on day one. Crying, crying, and crying. And then we can slowly, slowly see improvement, there is improvement in her self-esteem, confidence, that’s what we are talking about. That is something that then drives conclusions that [decisions] are made by them. Not by me. What I did was I facilitated the entire process. I let the client’s emotions flow—I didn’t stop her. (I3)So there are cases of counseling, counseling skills, definitely we use that. Catharsis to emotional ventilation the client. Definitely we provide … that it is our first goal. To get catharsis. (G1P4)In the first excerpt, the participant is referring to a previous episode, in which the social worker explicitly positions herself as someone who has succeeded in promoting personal empowerment by reflecting on her position in the process. Instead of merely describing the events and the position of the survivor, the position of the social worker in both extracts is reflected upon in relation to the moral order to support survivors and their personal empowerment. In this, enabling expressions of emotions aroused from the experiences of being exposed to violence is essential. This implies the social worker’s duty to help with the process, while having the right to step back and let the survivor take charge of her own life.In contrast, workers also explained their duty to take a more active expert position. Helping a person make as informed decisions as possible introduces the possibility for participating in the decision-making process. The duty was not in giving solutions, but in clarifying the possible consequences and providing support.When I sit there as a social worker, I have to believe her. Once I believe her, I trust her, that’s the most important thing. (I4)I don’t think any one of our counselors asks why didn’t you step out earlier … or what did you do to aggravate him. They will simply never ask. (G2P2)As a part of respecting the survivor’s autonomy, workers explicated the importance of avoiding requesting a survivor to leave a violent relationship against her own will and without in-depth consideration. A divorced woman living alone may be very vulnerable. By leaving home and living without her legal husband, a survivor may be at risk of being harassed. The high tolerance of survivors to violence was usually explained by the needs of their children. Staying in a violent relationship is seen as a better option than letting children grow up without a father. Besides, economic resources do not necessarily allow for new housing arrangements, which also affects the woman’s chances of getting custody. For example, only 61% of women in urban areas and 38.5% of women in rural areas had a bank account or savings of their own .In accordance with the story line of reflectivity, the theme of a social worker’s self-understanding helped to unfold participants’ attitudes and emotions regarding DV. In the participants’ explicit reflections, nonjudgmental attitudes were discussed. As can be seen below, this was highly valued, especially in situations in which a survivor was not yet able to leave her violent spouse.She said she had to go back because her children were there. So initially I was angry with her, but after that … power, that strength, that resilience … I realized, when working, that the entire belief that she’s a victim was totally shattered, because they are not victims, they are very strong people. I was very … inspired and shocked and surprised, because I used to think that they were weak … So, they don’t give up. Not even if the whole world is against them and everybody is blaming them, she is blaming herself but … she won’t give up. (I2)Here, self-reflection on one’s own emotions also took place in the context of identifying professional development. A participant reflected on a process during which her capability to see beyond feelings of anger and frustration evolved. Instead of labeling a survivor as a helpless victim, the participant focused on the survivor’s strength and ability to cope with a very difficult situation. This involved ways of adjusting emotional responses according to expectations relating to professional practice and conduct as can be seen from discourse below.We have to control our feelings. When we go home, we forget, leave things behinds us. (G2P7)As professionals, we talk with them [emotions] but we don’t involve … (G2P5)When you realized that you emotionally involved to your case, you kind of have to tell yourself it. It’s … It’s difficult … I think all the time we have to learn how to do it. See, we come up with the set of emotions, in any day, I mean there are issues that we are facing, in our personal lives also. So one way is that when you come here and start listen to other’s problem, you’ll forget your own problems, but chances that you’ll involve with your emotions and feelings of your clients are very high, especially in very sensitive cases. (G2P1)Emotions arising from personal experiences of violence were expressed in discussions, even if they were not explored as separate questions by the interviewer. As can be seen below, earlier life experiences, whether emotions of exceptionally strong safety or ultimate fear, influenced the participants’ current practice.For me, personally, violence was never a part of it, for generations. So … I know how happy my family is, how good a connection we have, that’s something I want to see. So, what I wish is that every woman was confident enough to not be dependent on somebody … So that’s what I hope my work means to somebody else. (G2P2)So, whatever they told me, I had experience of my own. I was also a victim … I could feel it [pain] because I was one of them. But I didn’t have the privilege of sharing my story, because you have to be a professional. I just tried to do my work, and it has made me who I am today. (I3)Feelings of safety and equality in childhood brought up a social worker’s personal work aims such as the drive to promote personally experienced independence. In contrast, one participant, as a survivor of long-lasting violence, based her strength as a professional on her process of overcoming the violence. The latter extract also demonstrates the juxtaposition between experience and professionalism. The worker had no right to express her personal experiences in client meetings. The possibility of sharing her experiences was referred to as a “privilege.” Instead, her duty to act professionally obliged her to put her own emotions aside. Earlier experiences of violence may have a negative effect on one’s professional work (Still, some participants expressed feelings of anger and frustration when a woman chose to go back to her violent partner. Nonetheless, these feelings did not necessarily indicate a victim-blaming mindset.nal work . This hinal work , which iThis was a small-scale study, and participants were recruited from NGOs located in an urban area in the state of Maharashtra. Individuals working in special DV units were presumed to have the best information on the topic, but the implications of the results for social work in the Indian public sector or in rural areas cannot be taken for granted. This research was conducted in a specific cultural context. However, universal themes—gendered power, women’s rights, women’s agency, and the worker’s self-understanding—are also applicable to practitioners in other cultural contexts as they make sense of DV and the rights and duties of social workers to intervene.In terms of the trustworthiness of this study, issues regarding credibility, transferability, and dependability e.g.,  should bIn addition, we made analytical generalizations of the data through category zooming and positioning . CategorThis study approached the question of how Indian social workers made sense of DV by investigating their self-positioning, including their emotions, attitudes, and practices in relation to their rights and duties. The findings show that professional self-positioning has potential implications for work with survivors. The self-positioning reflected political, cultural, and social themes, and the psychological dimensions in terms of the psychological impact of trauma were conspicuous by their absence. According to representatives of women. In advocating work with young boys and engaging male perpetrators to emancipation work with women, social workers encourage men to question traditions of masculinity/femininity to construct more egalitarian roles and responsibilities (see also However, as facilitators of personal empowerment, the position concerned the survivors’ personal growth and enhanced their agency by building their autonomy through self-determination and independent decision-making. Accordingly, elements of trauma-orientated work are apparent . The aspsee also .As challengers of gendered oppression, social workers see beyond individual factors and recognize those structural issues such as patriarchy that are causes of violence. However, by applying the concept of forced self-positioning , we ask The data generated from such a small-scale, qualitative study do not allow us to undertake investigation of the influence of gender and previous work experience on social workers’ rights and duties. However, the study does help to raise questions in relation to both points for further understanding of the social workers’ response in DV and the ways to develop existing service system.To sum up, the results of this study reveal that practitioners encountering survivors can be in an important societal position, when it comes to raising awareness of human rights in DV cases. In line with However, to improve practitioners’ opportunities to do their valuable work and exercise their professional positions, as presented in this article, importance of resourcing and supporting the implementation the Domestic Violence Act should is required. A wide range of state measures, such as social protection policies and programs for the vulnerable groups exposed to violence, should be enhanced. As a part of this initiative, the role of NGOs as key services providers should be acknowledged and resourced and collaboration and partnership between government and NGO sectors enhanced. To support