This article examines patients’ and doctors’ emotional and psychological entanglements with the development of appointment systems in British general practice between the 1948 and 1980. Waiting, especially in the form of the queue, has been subject to recent historical analyses. However, the focus has often been on negative emotional responses, on how waiting has been politicized, and on the disciplinary power of the waiting room. Frameworks of rationalization and discipline have also dominated historical and sociological assessments of temporal regulation, and especially the rise of standardized, ordered, clock and calendar time that appointments embodied. Though productive, focusing too closely on these processes in relation to time and waiting risks underplaying the complex affective life of regulatory technologies, for both their operators and their subjects. By focusing tightly on how myriad, often contradictory, responses to appointment systems operated within the setting of post-war general practice, this article looks to place such emotional and psychological relations in historical context. In so doing, it develops recent work on the emotional history of the National Health Service and, by extension, of the diverse affective and temporal modes of the British welfare state. In 1949, a Mass Observation researcher arrived at a general practitioner’s (GP) surgery, run from the doctor’s home in a ‘north-western suburb of London, near a large borough council estate and an extensive working-class shopping centre’. Although doors opened at quarter-to-nine in the morning, three women were already waiting outside at half-past-eight. Once inside, a bottleneck built. The GP ‘refuses to be rushed’ in consultation, with each patient seen in the order of their arrival. ‘Positions are worked out right from the beginning’ as ‘everyone adheres unquestioningly’ to ‘the discipline of the queue’. A full waiting room provides abundant opportunities for patients to interact, though ‘the place fixes a pattern’ on conversation: doctors and diseases take centre-stage. Eventually, the two-hour wait for some patients erodes any discussion. ‘Long gaps of yawning silence’ are broken only by complaints about unnecessary attendances and the doctor’s speed, and, ultimately, by an invitation to enter the consulting room.This scene, with its domestic setting, improvised queuing and potential lengthy wait, would have been familiar to many readers in the late 1940s. However, despite its persistence in popular culture, such experiences of waiting were increasing uncommon 30 years later. On the one hand, most GPs had moved into new, purpose-built accommodation by the 1980s.with one another in the waiting room, whilst enforced waiting for an appointment outside the surgery became more common.The introduction of full-time appointment systems for surgery sessions significantly disrupted how patients and doctors experienced time and waiting in British general practice at the level of the ‘everyday’.From a certain perspective, GPs’ deployment of appointment systems fits neatly within functionalist analyses of time-discipline, synchronization and rationalization.While the incorporation of general practice into modern structures of healthcare provides important context for the transformation of time and waiting, holding too fast to a rationalization framework risks erasing the complex affective life of appointment systems and the temporal regulation they helped inaugurate.This article, then, re-examines early debates about, and encounters with, appointment systems in general practice, using discussions prompted by their emergence to articulate how appointments were intricately intertwined with emotional and psychological life. It argues that waiting and temporal ordering were deeply affective practices—bound up with irritation, boredom, anxiety, guilt, relief, and pleasure—but that such experiences were themselves shaped by shifting post-war social structures, cultural expectations, institutional arrangements and political narratives. Questions of status, gender roles, race, professional ambition and duty, community dislocation, and discourses of modernization pervaded post-war Britain and its welfare state, and all impinged on what it meant to wait for the doctor.particular expectations and routines of a given context in shaping experiences of waiting and temporal regulation.Moreover, in making these arguments, this article combines and develops two nascent bodies of literature. First, it furthers recent historical scholarship on queuing and medical waiting in the twentieth century, in which issues of discipline, management and politicization have been central.did.Secondly, this article contributes to an emergent historiography on emotional histories of the NHS and post-war welfare state. Recent work has examined the ‘emotional landscapes’ of post-war surgery, trade unionism, and the affective life of the welfare state’s embedded racism, sexism and colonial inheritance.Indeed, this literature has rarely engaged explicitly with the history of emotions or critical orientations to affect theory.Combining these bodies of scholarship, therefore, this article shows that the intense ‘affective ecologies’ that developed around time and waiting in post-war general practice—the site of the vast majority of post-war clinical encounters between healthcare professionals and patients—had profound implications for the everyday work of the wider NHS.To make its case, this article begins with a brief history of open surgery sessions in general practice, and articulates the contrasting experiences of time such encounters generated for post-war patients and doctors. Using this as a point of comparison, section two explores how and why GPs turned to full-time appointments systems, and how patients responded—affectively and socially—to their new temporal management. The final section considers how feelings of frustration, anxiety and nostalgia circulated around the figures of the ‘family doctor’ and ‘receptionist’ after 1948. Though small in numbers, vocal critics associated appointment systems, and the increasing visibility of reception staff, with a loss of traditional family doctoring, and their critiques intertwined with broader anxieties about ‘modernisation’. They thus underline how responses to appointment systems were intertwined with a wider history of post-war social and cultural change, and how matters of temporal organization altered patients’ and practitioners’ affective relations to the NHS itself.To understand why GPs deployed appointment systems, and how appointments assumed particular meanings after 1948, it is first necessary to see how doctors and patients felt about the appointment’s predecessor: the ‘open’ surgery session. Appointment systems appealed to some doctors precisely because they regulated the overwhelming demands of open surgeries—hours at which any registered patient could attend for consultation, and during which they were entitled to attention provided they arrived before doors closed. In contrast, critics’ personal and cultural memories of such disorganized time positioned open surgeries as more personal than the over-regimented ‘inhumanity’ of appointments. The open surgery, therefore, acted as an emotional and temporal shadow to appointment systems, making it impossible to understand one without the other.ad hoc appointments outside surgery hours.Open surgery hours date back to at least the late-nineteenth century. As Anne Digby has noted, doctors seeking new markets for their services used fixed hours at surgery premises to attract patients.Daily Mail columnist described patients seated along the wall of the waiting room ‘in a terrible silence as though smitten dumb by Providence’. This ‘trance-like condition’ was supposedly the intended effect of waiting room design: uninteresting magazines, uncomfortably arranged seating, and nonsensical signs were all deployed to break ‘the patient’s spirit’ and prevent them from active participation in the consultation.Observer satirist offered similar tropes. His fellow ‘sufferers’ were ‘sunk in misery’, as the waiting room reduced the author to ‘delerium tremens’. Worse, however, was the tedium of waiting’s duration:Patients’ accounts of waiting in open surgeries before and after 1948 are rare. However, two contrasting versions of surgery waiting dominated popular representations. Most common was a vision of surgery waiting as drab, depressing and interminable. Recalling a visit to their doctor in 1955, one Remember ‘Waiting for Lefty’, Clifford Odet’s first play? … Well, then, how about ‘Waiting for Godot, by Samuel Beckett? … Lefty never got there. Neither did Godot. You have thoughts like these while waiting for a National Health Service doctor, which is not quite so long as waiting for a dead man  or God, but only about 20 minutes shorter.Although undoubtedly exaggerated for comic effect, such accounts offer glimpses into the experiences and psychological states of waiting NHS patients. Whether apocryphal or not, their publication presumed some resonance with their readers.However, a second, less common, representation of surgery waiting described it as a time when people might meet, interact, even fall in love.with.For patients, conversation may have been pleasurable socialization, but it also helped to manage the varied affective experiences of waiting. Read in light of Harold Schweizer’s work, for instance, it might be grouped with efforts at distraction—like reading or fidgeting—as a means to avoid existential musings that waiting could invoke, particularly in the aftermath of the Blitz and amid the Cold War.In this regard, waiting in the practice surgery may not have been so different to queuing in other situations, at least into the 1950s. Queuers, especially in the ration queue, also reported experiencing feelings of boredom and frustration, and they noted the friendliness, complaints, conversation and ‘entertainers’ among fellow waiters with a mixture of appreciation and disdain.In other respects, however, the surgery wait was a distinct experience. First, patients didn’t physically queue in the same way. Waiting rooms, at least into the 1960s, were generally adapted spaces (such as dining rooms or shop fronts), and patients in working-class industrial districts often complained of serious deficiencies in space, heating, and ventilation by ‘icy drafts’.Daily Mail (1955) reader suggested that there ‘should be priority tickets for workers’.Finally, the doctor rarely drew the same anger and disgust as other figures identified as causes for delay. As Joe Moran has noted, wartime and post-war suggestions that queuing marked a peculiarly English sense of decency, democracy and fairness were quickly challenged by those subjected to queuing.might have a carcinoma of the lung or the difficult maternity case or anyone who presents a real medical or psychological problem. If I average six minutes per patient I’m very lucky and a busy surgery then lasts two and a half hours’.In contrast to their patients, GPs often experienced open surgeries as overwhelming tides of physical, mental and emotional work. For a minority of commentators, GPs’ experiences of overwork were framed expressly within older frameworks of industrial fatigue and organizational reform.Such feelings manifested materially. When a GP felt a patient did not warrant their attention, frustration could lead to lax attention or treatment. This might come in the form of deferring a patient for another time, prolonging the unease prompting attendance. Of nineteen patients that one GP recorded seeing in a surgery session during the mid-1950s, a fifth were—in his words—‘fobbed’ or ‘put off’. Other patients received minimal attention—physical examinations or repeat prescriptions with no further probing, or reassurance offered ‘very scantily’.This apathy, irritation and stress was, however, historically structured. Frustrations with ‘trivia’ and crowded waiting rooms were often entangled with antipathy towards the NHS and its perceived effects on the work and status of general practice. Although some doctors who had performed significant amounts of NHI work saw little increase in their workload after 1948, this was not universal.Complaints about ‘free treatment’ continued into the 1960s. GPs in one study estimated a fifth of their surgery consultations were for ‘trivial, unnecessary or inappropriate reasons’.Of course, like much of the post-war British public, doctors were accustomed to surveys, and as their complaints required ‘going public’ they possessed a strong performative edge.For many GPs, social commentators and patient representatives, appointment systems provided a necessary corrective to the faults of open surgeries, at least initially. Systems varied but shared the basic mechanics. To consult a GP, patients were asked to no longer simply attend during surgery hours, but to make an appointment first (by telephone or in person). Once at the surgery, patients would wait by book rather than order of arrival. And if the doctor wanted another consultation, receptionists organized this as patients left.Change was gradual at first as appointment systems needed new resources. Particularly in larger practices, extra telephone lines were often necessary.Although GPs regularly suggested that full-time appointments systems improved their affective experience of surgery work, this was not always the primary rationale. Whether performative or sincere, advocates generally referred to the advantages to patients of reduced waiting, fixed times of consultation and the reduced risk of infection in less crowded spaces.Questions of productivity were not, however, divorced from questions of affective life. Advocates for appointments suggested the more ordered and efficient use of surgery time reduced physically and mentally taxing conditions inside the practice. As noted above, many GPs experienced more managed workflows as an ‘immediate lightening of the strain and burden of work’.Facilitating ‘work-life’ distinctions was not trivial. Particularly in industrial settings, general practice was physically and emotionally punishing. One medical union argued to a 1958 Royal Commission that 24/7 responsibility for patients made a doctor’s life ‘one of constant anxiety’.doctor’s own making’, appointment systems allowed GPs to reclaim some of this (imagined) lost status relative to their increasingly undeferential patients.Finally, advocates’ regular emphases on control over surgery hours implicitly tied questions of temporal autonomy to concerns about professional and social status. GPs disgruntled by the NHS’s universality regularly bemoaned what they saw as patients’ newly entitled attitudes. They grumbled about a minority treating them as a ‘servant’ or ‘supplier of medicine’, whilst criticisms of patients who asserted their rights—who ‘tell us what is wrong and what he wants for it’—were widely repeated.Guardian (1963), ‘must be set the saving of perhaps a hour or more in the waiting room’.Guardian in praise of a GP’s ticketing system, the arrangements facilitated the lifestyle and responsibilities of the non-waged, presumably white British middle-class housewife.Perhaps ironically, patients initially strongly supported new arrangements; emergent consumer groups even campaigned for them.Such framings demonstrate how irritations with delay—and the relief and appreciation felt following its reduction—assumed particular hues in the post-war decades. Undoubtedly, the reference to time being ‘wasted’ and ‘saved’ aligns with contemporary observations on frustrations with delay under modern capitalism—where timetabled productivity and accelerated social life pull the subject in multiple directions and time is economized as a resource to be spent.Patients’ acceptance of appointments might also have reflected the shifting cultural associations of queuing with national decline and political failure, as well as patients’ own growing familiarity with technologized and managed waiting across different areas of economic and social life. As Joe Moran has noted, between the 1960s and 1980s waiting itself was transformed through political, managerial and technological ‘revolutions’.The Lancet, ‘seem to have been exchanged for difficulties in seeing the doctor soon enough’.As GPs noted, appointments formed part of these transformations in waiting, becoming increasingly common in fields as diverse dentistry and hairdressing after the 1950s.For patients unable to be seen quickly, appointments extended, rather than resolved, anxious anticipation and waiting for care. Not only was the surgery wait itself a period of trepidation, but patients had often waited in uncertainty before deciding to consult a GP—whether to see if symptoms passed, or from concern for ‘troubling’ the doctor.Into the 1970s, national surveys of patient satisfaction with general practice returned overwhelmingly positive headline figures.Dissatisfaction with appointment systems formed only part of wider concerns with ‘modern’ healthcare and society. Over the 1960s and 1970s, associations were forged between appointment systems, forms of collective practice, and ‘new’ or ‘progressive’ care centred on improved organization.The Times railed against the day when ‘professional politicians, aided by doctrinaire doctors, will have squeezed out of existence the single-handed practitioner’. That would be ‘a pity’ because ‘they represent a long tradition of committed, conscientious personal relationship and service which nothing will replace’.Taken together, ‘modernisation’ amounted to, for some, reduced personal contact with their doctor. ‘Nobody disputes’, noted one reporter in 1973, ‘that doctors are less personally available than they used to be’.But for some critics, concerns about change tapped into broader anxieties, especially around the loss of imagined social and cultural idylls at the heart of visions of (white) Britishness.As a ‘symptom’ of modern life, then, concerns with appointment systems fed wider concerns, particularly those about the fate of the ‘family doctor’. Although the ‘family doctor’, as an omnipotent, tirelessly devoted, ever-available family friend and teacher, was likely more imagined than lived, this figure retained considerable cultural purchase in the post-war period.It is within this context that the intermediary figure of the receptionist as the object of patients’ aggression and disdain makes sense. Their visibility and centrality to appointment systems made receptionists the system’s human face. Doctors were aware that receptionists could generate resentment as a result, and that they would have to manage waiting patients’ emotions as much as the appointment book. GPs thus gave the character and temperament of the receptionist deep consideration. ‘Patients’, noted one reflection, ‘are likely to react strongly against an unfriendly or harassed bureaucracy’.Indeed, although psychosocial perspectives were slowly reshaping how some GPs understood their work into the 1960s, this emphasis on emotional labour meant doctors consistently saw reception work as a job for women.Despite most patients believing receptionists played an important part in ‘the smooth working of the practice’, these cultural tropes influenced the grievances that patients felt and reported to consumer bodies, researchers and GPs.As with the development of appointment systems more broadly, these experiences, discursive creations, and affective relations all influenced the everyday functioning of the health service, as well as how patients and staff felt about and experienced their work and care. As discussed, some patients delayed contacting the doctor due to difficulties getting an appointment and negotiating with reception staff. Equally, just as patients’ appreciation of the temporal autonomy and reduced waiting afforded by appointments had ensured most complied with new systems, a rejection of the new order could be fuelled by frustration or disappointment with its regulations and policing. Throughout the early operation of systems, patients continued calling outside of requested hours to make appointments, sometimes necessitating employment of more staff.Although pervaded with unintended consequences, the emergence of appointment systems over the first three decades of the NHS substantially transformed how time was ordered—and how patients waited—within post-war general practice. Open surgery sessions had been, in some sense, emblematic of the earliest temporal promises of the newly expanded health and welfare services; doctors, as state-contracted professionals, were made accessible whenever patients were in need, regardless of financial circumstances. A manifestation of ‘cradle to grave’ availability in the everyday.Appointment systems, however, were developed to address the perceived deficiencies of open surgeries for doctors and patients. For GPs, open surgeries were often experienced as an unmanageable torrent, creating anxieties, guilt and feelings of stress, strain and exhaustion. They intended appointments to regulate the flow of work, enhance doctors’ autonomy and working conditions, and even create new forms of leisure and family time. In a profession still dominated by white, male and middle-class practitioners, moreover, some even fantasized that new systems would deter the trivial, and recurrent attender who offended doctors’ (often fragile) self-image. Patients—particularly women and mothers—also harboured hopes that appointments would enhance a control of time already compressed by competing demands of waged work and unwaged reproductive labour.Financial support from a ‘modernising’ state sparked the widespread up-take of appointment systems, which had been supported, even promoted, by patients increasingly accustomed to managed, technologized forms of waiting. For many patients and GPs, new systems met their promises, introducing a reassuring sense of temporal autonomy and reducing the surgery wait. Class and age-related inequalities persisted into the 1980s, but systems retained broad support and proved flexible enough to function. As appointment intervals were gradually extended, some GPs even altered how they spent time with patients.Change, of course, was uneven. By the 1980s, a small number of GPs—mostly in rural and small-town settings lacking hospital facilities—retained older forms of organization.Nonetheless, as an intensifying cultural nostalgia for the known and ever-available ‘family doctor’ suggested, appointments also remade the very affective and material circumstances from which they emerged. They introduced new frustrations, anxieties, and stresses into attending the doctors’ for some, and—in remaking expectations and experiences of provision—simultaneously altered how patients and doctors related to one another. Crucially, patients were no longer guaranteed immediate attendance at surgery hours, but could now be deferred for a ‘reasonable’ period, as defined by the doctor.Such changes altered not only the affective landscape of the surgery, but also the interactions that took place within and without. Some patients simply deferred attending surgery due to the logistical and emotional challenges of engaging with new systems. Others, perhaps unwittingly, revived older practices of directly attending hospital, out of anxious uncertainty and frustration with the delays that appointments imposed.The transformation of time in general practice therefore had extensive everyday repercussions. As yearnings for traditional ‘family doctors’ and the ‘comraderie’ of the open surgery suggested, vocal—often socially conservative commentators and patients—began to relate to general practice as ever-more impersonal and remote.


Nonpharmaceutical interventions are important for addressing the psychosocial needs of children living with atopic dermatitis (AD). The current study aimed to investigate the effects of an integrative body–mind–spirit (IBMS) intervention on the subjective experiences of affected children and explore the mechanisms underlying the effects. Using a drawing-based, qualitative approach, the current study conducted two rounds of interviews with 13 children (aged 8–12 years) diagnosed with moderate or severe AD before and after they attended the IBMS intervention. Data were analyzed by using the thematic analysis method. The IBMS intervention worked by changing participants’ perceptions at the cognitive level, improving their coping strategies at the behavioral level, and constructing their social support network at the environmental level. Cognitive, behavioral, and environmental factors might mediate the relationships between the IBMS intervention and participants’ psychological and physical outcomes. This study highlighted the wider inclusion of child-centered qualitative research in the evaluation of the effects of psychosocial interventions designed for children. Atopic dermatitis (AD) affects 15–30% of children and adolescents worldwide ,3. NonphA disconnection between children and services provided to them might exist as the views of children have rarely been addressed in previous evaluations of the interventions designed for them. Although quantitative studies, especially randomized controlled trials (RCTs), could clearly detect the causal relationship between the interventions and predefined outcomes of children’s health, how children themselves perceived the effects of the interventions was unknown. Children’s outcomes have been most commonly rated by adults, particularly their parents or caregivers, rather than children themselves when measuring intervention effects in previous studies . Even whAccording to the United Nations Conventions on the Rights of the Child, children have rights to have their voices heard and to actively participate in all matters that are relevant for them . Given tThe current study aimed to listen to the views of children living with AD and investigate the impact of a psychosocial intervention on their subjective experiences. Based on the integrative body–mind–spirit (IBMS) model, a research team at the University of Hong Kong designed a psychosocial intervention for children living with AD and their parents in Hong Kong. The IBMS model emphasizes the balance among an individual’s physical health, emotion, spirituality, and large environmental systems . Using aThe current study employed a drawing-based, qualitative approach. Qualitative methodologies have been widely used to explore people’s subjective views and experiences in real-life situations . QualitaParticipants were recruited from the 55 children (aged 6–12 years) who registered and planned to participate in the IBMS intervention. Maximum variation sampling was employed to capture a wide range of perceptions of children. The background characteristics of the 13 participants (eight girls and five boys) are provided in Two rounds of semi-structured interviews combined with a draw-and-explain technique were employed to collect data . The firTranscripts were coded using NVivo v12. The two rounds of data were separately analyzed by using the thematic analysis method . After oThis section describes the changes in participants’ subjective experiences at cognitive level , behavioral level , environmental level , and outcome levels  over time before and after attending the IBMS intervention.Changes in the perceptions of AD. The image of AD was exclusively bad in the perspectives of almost all participants in the first interviews; while six of them reconstructed the meaning of AD and developed new, relatively positive understandings of AD after the IBMS intervention . For example, D06 perceived AD as an exclusively “bad person” in the first interview; however, she perceived it as “an ordinary person” in the second interview. In the first interview with C14, she perceived AD as a devil who stole the key to the lock of her interpersonal relationships since she experienced terrible peer relationships in school and the discrimination in the community. Comparatively, she perceived AD as having two sides, showing higher acceptance of her skin disease. She explained her second drawing:This (the pink one on the left side) is very itchy. This (the red one on the right side) is comfortable, not itchy. One is on the left side and one is on the right side… because AD is just one thing. It is the same thing but there are two sides… The pink one represents mildness and gentleness. The color is not that heavy… The red one represents bleeding, itchy, and sensitivity… They are dinosaurs because they are fierce. It (AD) is very fierce, but it has a gentle side… I am inseparable from both of them… I’m standing in the middle. It (AD) is both, an enemy and a friend… Inside Out to explain the role of AD in his current life:Many participants perceived living with AD as “very miserable” in the first interviews, while two of them reinterpreted the role of AD in their lives after the IBMS intervention . For example, G12 focused on only challenges and restrictions caused by AD in the first interview by drawing how AD greatly impacted his daily life, sports, and relationships with others. It seemed that he was overshadowed by his skin disease, and there was no way out. In the second interview, however, his spirit seemed to be transformed from restrictions to freedom. He drew Doraemon’s anywhere door and bamboo copter, which could help him break the shackles created by his skin disease. Additionally, he preferred the things he liked such as his hobbies instead of AD as his core memory. He used the film AD is not a core memory… It (AD) can be taken away…Core memory is a good thing… The core memory is an island. When I started playing football, I really loved it. The island is based on my preference. I like playing football, and then I have the football island… At the beginning, there are memories of AD, but as you grow up, only the core memory stays here… Some things can be forgotten. Changes in the perceptions of AD treatments. In the first interviews, most participants perceived the various frequent treatments as unbearable. After the IBMS intervention, however, three participants began to find benefits from treatments that they used to deeply hate . For example, in the first interview, G16 said that he hated the bitter Chinese herbal tea the most and perceived drinking Chinese medicine as the hardest challenge in his experiences of living with AD. However, he showed positive attitudes and described the benefits of Chinese herbal tea on his skin condition in the second one. Rubbing ointments was an issue that made most participants feel highly stressed out. Some of them complained of the “sticky” and “uncomfortable” feelings of applying ointments in the first interviews . Comparatively, three participants displayed different opinions in the second interviews . For example, E02 found additional benefits from applying ointments as she could spend more time chatting with my mother when rubbing ointments at night. Additionally, A12 recognized it as a necessary effort to gain better skin conditions:I think it (AD) won’t be cured, but it may be better… I really want it to be better. In addition to speaking, I must work hard… rubbing the ointments on and not being lazy. Changes in the perceptions of self. In the first interviews, participants usually presented an other-centered self as they paid considerable attention to other people’s comments and judgments. As a result, participants expressed self-hate of their skin and perceived it as “dirty” and “disgusting” . Participants also tended to deny themselves, identified themselves as being incapable and powerless, and saw themselves as victims of AD . Two even thought that it was reasonable for classmates and teachers to dislike them because they had AD . After the IBMS intervention, however, some participants showed more self-awareness and developed a larger sense of “self”. For example, A12 drew a person beside her who usually judged her skin in her first drawing while she did not draw this person in her second drawing. According to her, comments of other people that used to hurt her deeply seemed not to be that important. She paid more attention to herself and her own feelings in the second interview. Similarly, C14 wished that she could be an “ordinary person” or even a “foolish person” rather than a person with AD in the first interview. While in the second one, she said “I am I, even though I have AD.” A more positive self-concept might have resulted from positive interactions with other children in the IMBS group. For example, E02 described how her kindness to other children made her satisfied with herself:I learned to play with other people and learned social skills… Sometimes we went to choose some prizes, and a child wanted that color of the prize, I also wanted that color… I often give these to others… I feel very happy… because I make other people happy. I am very satisfied with myself. Increased strategies in coping with itching and scratching. Severe itching caused by AD provoked the desire to scratch, subsequently leading to an itch–scratch cycle. Two participants indicated that scratching was like “turning on a light” that could not be stopped even when they realized that they were injuring themselves . While four participants indicated that they learned strategies for handling scratching, such as distracting one’s attention, from the IBMS workshops . As A12 stated, “I may learn more about how to distract myself. Don’t focus on AD, and don’t scratch it all day”. H20 drew “itching” as the core theme in two interviews, but her responses to itching changed. In the first interview, she said that she could not stop scratching, and then she could not sleep. In the second interview, she proudly shared her creative strategy that she learned from other children in the group to prevent herself from scratching: “I pressed my hands with my buttocks because I use hands to scratch. Thus, I don’t let my hands scratch it”. Because of the new strategy, she could finally focus on what the teacher said in the class rather than her itchy skin.Increased strategies in coping with emotional stress. In the first interviews, most participants complained about intense and constant pruritus, which played an important role in determining their mood and emotions, causing irritability and stress. Three participants showed improved competence with emotion regulation compared with the first interviews . They indicated that they learned self-relaxation and calming through techniques such as mindfulness breathing in the IBMS group. As H10 said, “I learned how to calm down when I feel stressed, and something related to emotions”. Participants could also feel the effect of their relaxed emotions on their skin.I learned to relax myself. My mood is relaxed. I take a deep breath. I feel comfortable. My AD seems to be weak. Increased strategies for coping with bullying and discrimination. In the first interviews, almost all participants indicated that they suffered problematic relationships with peers as they experienced frequent verbal, social, and even physical bullying in their schools and discrimination and stigmatization in their neighborhoods. Participants felt helpless and overwhelmed due to deteriorated interpersonal relationships. After the IBMS intervention, nine participants found new meaning of interpersonal relationships . For example, D06 focused on her suffering of being isolated and discriminated against by classmates in the first interview while she developed new insights into the actions of people who bullied her in the second interview. As she said in the second interview:I think they are very mediocre. Sometimes people collectively say bad things about other people. Some people themselves are good, but they all join in. Being in a group (to bully) may be just for fun. Similarly, compared to the first interview, E02′s hatred disappeared as she developed a new understanding of true friendship and could forgive those classmates who discriminated and bullied her. E02 described her feelings in the second interview:I feel that normal people will not look at your skin or care if you have AD…If you have AD, don’t cover it. If you think that a person is really a friend, you can tell her directly that you have AD. Normally, if the person is a true and good friend, he or she won’t be particularly concerned about your appearance… Maybe these students (who bullied me) were too young at that time. They didn’t understand, and they couldn’t understand. This was also normal. I feel OK now. I am not angry now… It is actually a very small thing. Four participants preferred to face comments or discrimination with a mindful attitude . When classmates called C14 a grandmother because of her skin and face, she responded that, “I didn’t feel anything. Let him say it… I’d let it go. It doesn’t matter”. H10 also indicated that he learnt how not to have to fight with others when someone laughs at his skin. Some others preferred to explain their disease to others to gain more understanding when facing their questions or comments. For example, K07 was struggling in the first interview due to not having friend at school, while in the second interview, she said that she would explain her disease to classmates and let them know that AD was not infectious. Some preferred to directly revolt against difficulties. Additionally, B06 drew and described his vulnerability and helplessness in facing verbal and physical bullying at school due to his skin condition in the first interview. In the second interview, he described how he finally solved the problem of verbal bullying by his classmates:I left this annoying situation this month… I reported them for sending spam in the (WhatsApp) group… I destroyed this group… They verbally bullied me… I reported them and waited until the administrator removed this group. I feel very happy. Changes in parent–child interactions. Many participants focused on conflicts with parents about AD treatments in the first interviews as most parents tended to give instructions instead of working together with them in cocreation . Five participants said that their parents even criticized, blamed, scolded, and beat them when they were scratching . Conflicts with parents on treatments made children feel even more angry, distressed, and annoyed. In comparison, they obviously preferred to describe the positive interactions with parents during the second interviews. Most participants expressed that they enjoyed joint activities with parents in the IBMS intervention, including mindful jar making, problem-solving games, mutual gift presentation, and love/appreciation dialog. Three participants thought that making gifts together was the happiest activity, and gifts can be given to their own parents . As G16 described:I made the handicraft with dad. He helped me to make it, and we showed it in front of everyone in the class. It’s a gift that I prepared for dad. We went back home and mounted the gift. I feel very happy and proud. Three participants also indicated that they received more support and understanding from parents after attending the IBMS intervention . Due to the increased trust, three participants began to proactively communicate with parents about the difficulties they experienced at school, leading to more relaxed psychological and emotional status . As B06 indicated:They care more about me… (They did) less in the past. Now they care more than before. They are now often concerned about my condition in the school… If you didn’t talk about it (issues that happen at school) before, you always felt tired. I don’t know why. Now I’m not as tired after I say it. I don’t feel (as) tired as before. Changes in peer relationships. In the first interviews, almost all participants indicated that they suffered problematic relationships with peers. Most participants indicated that they had no friends at school and felt very lonely. Their classmates “completely ignored” them, and “avoided”, “dodged”, “stepped aside”, or “went away” when they saw them, “just like seeing a ghost” . They perceived being rejected and isolated by peers as a pervasive problem affecting them. Fortunately, they could play together with other children as a team in the IBMS group. By the end of the second-round interviews, when asking questions on the experiences or perceptions regarding the IBMS intervention, ten of 13 participants perceived playing as the most impressive component of the intervention . They vividly recalled and described various specific games they played in the IBMS group. Nine participants said that they made new friends in the group in the second interview . Being accepted by fellow members with the same skin conditions in the group produced feelings of warm and nurturing support for participants. For example, B06 indicated that he was very lonely in the first interview while he expressed his greater appreciation for his life as he could have new friends in the IBMS group. As he described, “My drawing is colorful, so my life is very colorful”. K07 and A12 also described their experiences of having new friends:All of them are friends… It It’s easy to get along with them… I felt very comfortable when chatting with them… We talked about a lot of things… I can chat with them very comfortably; there is not so much pressure… Everyone has AD, and there is not so much pressure when being together with them. We are friends… Maybe if they already have it (AD), they won’t mind others… I feel very happy. Changes in psychological experiences. In the first interviews, most participants showed great psychological disturbances caused by their intense itchiness, sleep disturbances, restrictions in daily life, school bullying, and discrimination in the community. Their predominant emotions were anger, annoyance, sadness, worry, fear, embarrassment, loneliness, and confusion. In the second interviews, many participants expressed much more positive emotions. They expressed their happiness and enjoyment of the group activities. As D06 said:I learned teamwork. We did some exercises and did that together. I feel happy… not only myself… working with other people (with the same illness) and not alone. Besides the positive emotions, four participants indicated that they felt less stress or anxiety in such a homogeneous group as they did not need to cover or hide their skin there . As E02 indicated:I felt that everyone has something in common, so I don’t have to cover up my AD… We could feel happier when playing together. We are not so constrained. There is no need to hide. Moreover, hope and expectations could be found in three participants’ drawings and verbal expressions in the second interviews . For example, poor school performance and interpersonal problems at school were the focus in the first interview with K07; however, she drew her “dream middle school” to express her hope for a new environment in the future in her second interview.Changes in physical experiences. Many participants experienced high levels of disease severity with a severe and painful rash extensively affecting their body. Most of them complained about constant pruritus and sleep disturbance in the first interviews. Whereas seven participants directly indicated that their skin conditions were better than before in the second interviews . For example, K07 described the following: “It (AD) seems to be better after attending this group. I feel better. My AD is getting better”. As a result, three participants indicated that they could sleep better . In the first interview with D06, she drew and described her powerlessness and helplessness due to frequent sleep disturbances in her lived experiences. Living with severe AD meant extreme distress and horror for her. In the second interview, she was so excited to share that she could sleep well now. She described her second drawing:This is what I am doing from 10:00pm to 7:00am. I won’t wake up… I used to wake up when I was itchy, but now I didn’t know as I was asleep. I am very happy… I have not slept well before, and I used to sleep very late. I was not happy. I was very sleepy when I was in class previously… I feel spirited in class now, so happy… I used to rub on the ointment before class, but now I don’t need to rub the ointment on at school…It is not that itchy. I am happy. My AD used to be very, very, very fierce… I thought AD in the past was a million times horrible. It is now ten times horrible. Nonpharmaceutical interventions for children living with AD are very important due to the extensive and pervasive impact of the disease on their psychological and social well-being . Using aThis study offered participant-driven insights into the effects of the IBMS intervention directly from the views of children living with AD. The views of children living with health problems have commonly been ignored in healthcare settings as they are usually seen as passive recipients . It is vBy considering the connections and interactions among codes and themes, the findings served to generate hypotheses regarding the mechanisms of the changes in the subjective experiences of children living with AD. In terms of the impact of its contents, changes occurred in participants’ perspectives on their disease, treatments, and themselves partially through the contents of the IBMS intervention. Children gained self-awareness from the self-identity session (session 1) of the intervention, which emphasized individual uniqueness, various personal strengths, and the sense of accomplishment. The philosophy throughout the disease identity session (session 2) of the IBMS intervention was to help participants face AD with a mindful attitude, cultivate equanimity in their disease journey, discover the meaning behind their sufferings, and embrace the vicissitudes in their lives, which also played an important role. Additionally, participants could also gain increased coping strategies with psychosocial difficulties and interpersonal difficulties partially from the contents of the IBMS intervention. Participants learned psychoeducational messages about body-mind connections, emotional regulation and simple mindfulness-based relaxation skills such as mindful breathing and mindful walking, and emotional management tools such as the mindfulness jar and emotional weather reports from the emotional expression session (session 3). By taking a precautionary approach, the IBMS intervention treated children as active participants with strengths. The resilience capacity session (session 4) and the personal strength session (session 5) of the IBMS intervention emphasized empowering participants’ internal capability and building resilience in adverse situations, especially when facing discrimination and school bullying. Moreover, the support networks session (session 6) played an important role in improving participants’ interpersonal relationships with peers and parents.Besides the contents of the IBMS intervention, this study also highlighted the importance of the parallel group format of the intervention in achieving its effects. Social isolation and discrimination, which cause profound psychological harm, have been pervasive problems for children living with AD . BesidesThe IBMS intervention worked by changing participants’ perceptions at the cognitive level, improving their coping strategies at the behavioral level, and constructing their social support network at the environmental level. Cognitive, behavioral, and environmental factors mediated the relationships between the IBMS intervention and participants’ psychological and physical outcomes. Participants’ positive self-identity combined with their mindful attitudes toward AD could not only reduce their anxiety about skin conditions but also encourage them to find meaning and benefit from AD treatments, leading to increased treatment compliance and decreased severity of AD. Participants applied their new coping strategies when handling physical difficulties such as scratching. Successful coping experiences could improve participants’ self-esteem, sense of control, and overall psychological well-being. The feeling of acting as a team with parents and new experiences in the homogeneous group not only played an important role in changing their understandings of AD but also brought positive emotions. They obviously felt happier and more satisfied with themselves in the new interpersonal context.There was an interactive and reciprocal relationship between participants’ psychological well-being and their physical symptoms. The presence of AD could increase the possibility of psychological distress among children; furthermore, the presence of emotional stress could in turn induce or exacerbate AD, creating a vicious cycle ,28. The First, the small sample size might limit the generalizability of the findings. To minimize this limitation, we used maximum variation sampling in terms of participants’ age, gender, and severity of AD. Second, drawing was employed as a child-centered research method rather than a therapeutic tool in this study. However, the therapeutic impact of drawing on participants might exist due to children’s self-expression in the process, which might confound the effects of the IBMS intervention in this study. Third, although we believe that the IBMS services induced positive impact on the lived experiences of the participants, some other factors might be possible reasons for their changes. For example, the changes in B06 might be because he had just left his previous school and moved to a new school environment. H10 indicated that she felt less stressed because she had just finished her final examinations. Fourth, the current study did not describe the impact of participants’ age (younger vs. older) and disease severity (moderate vs. severe) on their subjective experiences and the effects of the IBMS intervention. Children’s chronological age and developmental stage affected not only their drawing skills but also their performances in interviews. The severity of AD was associated with children’s subjective experiences. Characteristics of participants should be considered more carefully in future research on the effects of psychosocial interventions.With a drawing-based approach, this qualitative study contributed to an in-depth description of the impact of the IBMS intervention on the subjective experiences of children living with AD. This qualitative study highlighted the wider inclusion of child-centered qualitative research in the evaluation of the effects of psychosocial interventions designed for children. The current study also helped identify some active ingredients of the psychosocial intervention that should be implemented with fidelity when applying the findings to other settings.


Ambassadors are appointed by church leadership to lead the implementation of program activities. Data were collected concerning the levels of helpfulness, difficulty, usefulness, or utility of checklist activities and modifications and the ease of program implementation. The evaluation also assessed the COVID-19 pandemic’s impact on each church’s ability to implement activities and modifications. The survey results revealed that most required partnership activities and modifications were found to be at least moderately helpful. Some of the items (themes) that differed across church partners included barriers to implementing activities, the support provided and needed, and the use of program funding. This evaluation provides key insights to consider in developing and refining community-based, dementia-friendly communities (including faith communities). As implementation science expands and improves, the need to evaluate the implementation of programs continues to be highlighted. Our formative evaluation shed light on key areas in which modifications to our original programming would lead to program improvement and sustainability. Additionally, implementing the modifications identified in our evaluation will facilitate the achievement of the mission of Alter™ to improve the well-being of older adults affected by dementia and their families. Other programs would reap substantial benefits from engaging in similar formative evaluation efforts.Black churches have traditionally been a haven for Black American families; however, many churches do not currently have programs to support families living with dementia. Alter™ was established to assist faith communities in meeting the needs of these families and becoming a viable resource to promote their health and wellness. Alter™ achieves this aim through a three-pronged approach: (1) conducting educational sessions, (2) modifying Black churches to be dementia-inclusive spaces, and (3) providing ongoing support. The principal goal of Alter™ is to offer guidance to churches in adapting their community to reflect a supportive environment for families affected by dementia. Alter™ uses a partnership checklist to encourage activities that incorporate dementia education opportunities, environmental modifications, and dementia resources and support. This paper reports on a formative mixed-methods evaluation of church partners enrolled in Alter™. Church partner ambassadors within the faith communities participated in the evaluation survey ( In 2021, experts estimated over 6 million Americans were living with Alzheimer’s disease and other dementias ,4. BlackChurches have the capabilities to promote health within the community, communicate and disseminate health information, foster and maintain trusting, supportive environments for health, and offer relevant safe, culturally appropriate health prevention programs and care for the community without racial discrimination ,9. FurthBuilding dementia-friendly  communities is a growing priority to meet the educational and infrastructural needs of families affected by dementia . HoweverCurrently, there is a growing literature surrounding the science of implementation and sustainability strategies of health promotion programs ,18. As hAlter™ is a faith-based, dementia-friendly community program that equips Black churches with the tools needed to better support families affected by dementia . Alter™ n = 8), support (n = 6), community education and awareness (n = 4), and the worship experience (n = 6). Church partners agreed to implement at least 16 of the 24 suggested activities and modifications on the Alter™ partnership initiatives checklist over a 2-year period. The selection of activities to implement was performed by the respective church representative based on their ministry’s mission and strategic plan. The full list of activities included on the Alter™ partnership initiatives checklist is provided in Churches were recruited utilizing snowball and purposive methods. Purposive methods were used to focus enrollment efforts on under-resourced communities. During the enrollment process of the program, respective church representatives met with the program staff for an informational meeting. Upon enrollment to become a partner, churches received a welcome box accompanied by a memorandum of understanding and a financial contribution to assist with the implementation of partnership initiatives. The Alter™ partnership initiatives checklist was inclusive of dementia-related initiatives and environmental modifications, which provided church partners the framework to offer dementia support resources, dementia education, and meaningful worship experiences. The partnership checklist was divided into four domains: core  onto their corresponding evaluation questions. This process ensured that all data collected were valuable to answer the evaluation questions and addressed the overall purpose of the evaluation . The priProgram staff initially contacted church partners to inform them about the evaluation being conducted. The evaluation team contacted church partners with provided contact information to coordinate schedules and explain evaluation ethics, including that the survey and focus groups were voluntary and that responses were anonymous and would be kept confidential, and answered any questions from participants. The evaluation team then provided appropriate Zoom links for the survey and focus groups. The evaluator administered the survey, and their screen was shared with the participant using Zoom functionalities. All survey data were stored and secured on Qualtrics. An online survey was administered instead of a paper survey due to social distancing recommendations, thus eliminating the need for data entry. In addition, due to the guided nature of the survey, participants only needed to have an electronic device with Wi-Fi and Zoom capabilities. Focus group guides were developed based on preliminary results from the surveys in order to gain better insight into the overall experience of implementing Alter™ partnership initiative activities. All church points of contact participating in the evaluation survey were asked to schedule a time to participate in one of two focus groups. The program coordinator and program founder were also in attendance for both of the focus groups and helped guide the discussion. The focus groups occurred via Zoom and were led by the evaluation focus group guide and probes. Focus group sessions were transcribed verbatim, and all identifying information was removed.Data from the church partner surveys were exported from Qualtrics into an Excel spreadsheet. Team members (J.G. and J. T.) cleaned all data within Excel. Closed-ended and open-ended data from the surveys were organized into separate Excel sheets for data analysis. The evaluation team ran descriptive statistics on the quantitative data to obtain frequencies and percentages for categorical data. A content analysis was completed on the open-ended survey responses to understand the impact of COVID-19 on the church’s abilities to conduct program activities and modifications. Once all the descriptive statistics and frequencies were reported, the data from the survey were triangulated to extract salient themes. Transcribed focus group sessions were inductively and deductively coded to develop themes. First, an evaluation team member coded the transcripts based on previous knowledge. Then, the evaluator deductively coded, placing codes that align with the evaluation questions. The evaluator cross-analyzed the focus group data to formulate themes that were utilized during data triangulation. All codes and themes were presented to the other members of the program evaluation team and discussed for reliability. At the time of the program evaluation, nine faith communities were enrolled in the program (eight located in Georgia and one in Illinois). Of the nine church partners, eight completed the online survey. Church partners reported having majority Black congregations, and their congregant’s average socioeconomic status was middle income. Congregation sizes varied, as two reported having a small congregation (average weekly attendance of 50 or fewer people), five reported having a medium congregation (average weekly attendance of 51–300 people), and one reported having a “mega-church” size congregation (average weekly attendance of more than 2000). Overall, church partners described the age demographic of their congregation as the majority being older adults. Data were reported based on participants’ experiences implementing selected program activities. Program activities consist of Core Partnership Activities , providing support resources for families affected by dementia, providing community education opportunities to raise awareness about dementia, and implementing modifications to the worship service. Activities were assessed based on their level of helpfulness to the church becoming dementia-friendly, the difficulty of implementation, and the level of utilization (as appropriate). Church partners were required to select and attempt to implement all core activities of assign to a minister, building is well-lit, with large print signage, badges for support staff, physical support, quiet room/space, accessible pathways, and church leaders workshop. As part of the core activities, all church partners assigned the dementia-friendly initiative to a ministry at their church. However, other core activities had a 73% implementation rate. Participants reported 62% of core activities as being “completely helpful” to their congregants and assisting with their church being dementia-friendly. The majority of churches (91%) reported core activities being “not difficult at all (easy)” to implement . AdditioChurch partners were required to select and attempt at least three support activities. Four churches selected and implemented resource libraries and educational events, two churches offered support groups, one offered a respite care program, and one church offered social service coordination . AlthougChurch partners were required to select and attempt at least two educational activities. Six churches selected and implemented the provision of dementia resources and education on social media/websites, four churches offered a Memory Sunday, and one church offered dementia education with youth . AlthougChurch partners were required to select and attempt at least three worship modification activities. All eight churches shortened their service length to 75 min or less, six churches simplified sermons, five increased the amount of music, five modified worship service order of flow, and three included familiar bible verses. One church selected to have a support staff present but was unable to implement this activity . OverallChurch partners reported the COVID-19 pandemic as the main barrier to program implementation. Churches that were able to implement program activities reported conducting them before COVID-19 “stay at home orders”. Non-COVID-19 barriers were homogenous across most of the activities; therefore, we did not analyze barriers across activity types. The number of times a barrier was mentioned within the short answers of the survey was collected: the COVID-19 pandemic (f = 37); congregation members affected by dementia have not been identified (f = 7); lack of church personnel to conduct or lead activities (f = 7); unclear understanding of how to implement activities and modifications (f = 6); lack of marketing tools or knowledge of how to engage congregation members (f = 4); lack of space within the building to conduct activities (f = 3); perceiving the activity as not applicable for their church (f = 2); liability concerns (f = 1); not having enough funding to implement activities (f = 1).All church partners participated in at least one of the focus group sessions. Church partners were able to have more than one representative in the focus groups; thus, 11 participants across all churches participated in the 2 focus groups. Three themes emerged during thematic analysis: barriers to implementing activities, the support provided and needed, and the use of program funding. The themes describe findings related to church partners’ experience participating in Alter™.Participants expressed barriers to implementing activities while participating in Alter™. Barriers varied across churches; however, the COVID-19 pandemic presented as a significant barrier to implementing activities. Many church partners halted their implementation of various activities, as they were not able to be physically at the church. Participant 1 from focus group 2 expressed: “…once COVID came and then we shut everything down. So, we still have those things to do. You know? …, I think we would’ve been much further along had COVID not come.”Additionally, the COVID-19 pandemic presented other barriers, as it related to shifting the churches’ focus on prioritizing COIVD-19 information rather than disseminating information and resources related to dementia. “well, our organization have been so focused on trying to get back in the church as well as to bring education, ah, to their, ah, constituents, um, about COVID. And so, that’s been their primary focus and how they can, you know, really not lose their members during this time. … So, they have put the dementia back on the back burner, you know, during this time because that’s been their primary focus.”Participant 4, Focus Group 2Churches also expressed other barriers related to the implementation of activities and modifications, including lack of space within the church building for activities, not knowing how to find or approach those affected by dementia within their church congregants, and perceived liability issues with implementing a respite program at the church. Additionally, church partners expressed the need for the program at their church but were not sure if their efforts were reaching families affected by dementia because many families are not forthcoming with sharing their diagnosis. However, church partners remained positive in their preparedness to support families affected by dementia when they step into their church. “But right now, we just really don’t have that many, ah, people in the congregation, ah, who are actually dealing with, or living with dementia … I’m sure people will be coming or, you know, or things will be changing. So, that’s where we are in getting more things set up so that when, um, they’re needed, they will be available.”Participant 2, Focus Group 1Additionally, church participants noted there were activities they could have implemented, but they did not have a clear understanding of the activity. For instance, participant 2 from focus group 2 stated:“[W]hen we went through our survey [a] couple weeks ago, there were some things I think I could’ve implemented that I didn’t implement… I was like, “Oh, I… We could’ve did that.”Participants detailed their experience receiving support from program staff and provided suggestions for improvements. Due to the COVID-19 pandemic, the support provided by Alter™ staff was virtual . Many church partners expressed their appreciation to the program staff for the attentive support provided:“Keep on doing the good job that you’re doing in helping us to become, ah, great Faith Village [dementia-friendly] churches. Because, ah, it’s just a, it’s something that’s very much needed and, ah, the team has done an excellent job even, ah, with the COVID situation.”Participant 1, Focus group 1A participant recalled a time when an Alter™ staff member connected a family at a partnering church with dementia support resources.“Because the other day we had, um, someone and, and the, the father is member of our church. He’s, he’s older, but was doing very well, but has now moved back in with his daughter. And she had, um, she’s- she’s having to work from home and just some other things. But, ah, and I was able to, ah, connect her with [program staff], and it just really helped. Because we don’t know, well, let me speak for me. I don’t know all of the ins and outs and what may be available. I know with, with some of the information, but as far as talking to someone and seeing exactly where they are and what they need, then having her there has been just a tremendous asset.”Participant 2, Focus group 1Participants discussed the possibility of Alter™ incorporating a direct phone line, through which churches can call and receive dementia-related information for their congregation members. Participants agreed to have a point of contact who understands the needs of their congregations rather than someone who does not know the church well is vital. For instance, Participant 2 from Focus group 1 stated: “Because we’re dealing with people who—in most cases—are older.  “Okay, I’ve gotta dial a 1–800 number. What…?” The first thing that comes to their mind [is], “Okay, I may get in a loop… You know, it’s gonna be somebody who doesn’t necessarily care about me or whatever.” … but having you contact the sister the other day and being able to talk to her, letting her know you understood exactly what she was looking for, and I don’t even know if she found everything, but it was the fact that this is somebody who understands what’s happening here.”During evaluation focus groups, church representatives were able to exchange ideas and discuss challenges in implementing various activities. Participants appreciated being able to gather and discuss what each church has done for the dementia-friendly activities.“But I think it, it’s, you know, it’s good that we are talking and getting- getting to, to know each other… and or- or call or whatever and say, “Well, how did… how did this work for you? This is what we’re trying to do, but we’re running into a roadblock.” You know? And, and sometimes just-just having that, ah, because it’s just, it’s a lot we can do but then it’s a lot that we can’t do.”Participant 2, Focus group 1Alter™ provides a financial contribution to church partners to assist in the implementation of activities and modifications. Many church partners expressed challenges in spending the funding received. Although church partners have ideas about how to spend their funds, the COVID-19 pandemic presented a barrier due to many modifications not being able to be implemented.“Well, because of, ah, most of the churches been closed, ah, we haven’t used the money, ah, in The Alliance … So, um, it’s been beneficial, um, that, you know, we just hadn’t decided to use the money right now. We just doing, you know, we just doing what we do.”Participant 4, Focus Group 1Furthermore, participants expressed not spending their funds due to not being in the building and only focusing on activities that can be conducted virtually. “…but in the future. the church is not that big. Obviously, um, we do not have anything that we are doing that’s costing anything right now.”Participant 1, Focus Group 2Although many church partners expressed not being able to utilize program funds, one participant detailed their experience utilizing the funds to implement a caregiver support group and providing caregiver “support boxes” at their church. “And the toolbox had socks; it had, um, mints, nuts, um, a puzzle, a cross--no, word, word search puzzle. It had colored pencils for the colored, um, booklets. And just so happen, I went to the Dollar Tree, and they had those inspirational coloring books, and you could download the music, there was music to go along with the coloring books.”Participant 3, Focus Group 2Alter™ aims to provide a guiding light for faith communities in creating a dementia-friendly and inclusive environment. Informing Black churches of all sizes about the potential health needs of their communities, identifying church ambassadors and ministries who can implement health education initiatives, and providing churches with resources can be beneficial in building faith-based health programs ,23. Our On average, more than half of the churches implemented the core, support, and education activities and worship modifications listed in the checklist. We anticipated higher implementation rates; however, barriers, particularly COVID-19, deterred or delayed activities that required being in the church building, such as a quiet room or space for persons with dementia to worship, memory cafés, and onsite education events, including conducting education with youth. The Reframing Aging Initiative, a collaboration of aging organizations, encourages aging professionals to “innovate existing systems to reduce poor health outcomes during and after the pandemic” . Many AgHealth promotion programs seeking to address obstacles related to program sustainability would benefit from the development of an intake assessment tool measuring the need for their program activities and the capacity of their community partners to implement activities. Such a tool may ensure that community partners are able to implement selected activities to their intended extent. Assessing a community partner’s (Black church communities in the case of the Alter program) organizational readiness is essential for successful implementation ,27. An iThe level of helpfulness and usefulness of initiative activities perceived by church partners varied. Additionally, church partners expressed varying understanding of how to implement certain checklist activities and modifications. Thus, we believe providing community partners with a manual detailing how to implement program activities as well as expected outcomes may improve implementation efforts. For instance, a study assessing the impact of school-based education programs found successful interventions provided program implementors  with a program manual . AdditioChurch partners found value in the focus groups, as they could hear from other church partners about their challenges and successes. Similarly, designating structured time for program site leaders to discuss their experience in a program has been utilized within pediatric health interventions to guide individual site improvements . Thus, iUltimately, providing regular tailored support for community partners, and ensuring the organization is equipped with appropriate personnel such as health educators, is vital to a health promotion program’s success . Health The mixed-methods approach was a strength of this evaluation, providing an overview and detailed information. Additionally, the majority (83%) of participating churches in Alter™ completed the evaluation activities. However, the evaluation had notable limitations. One limitation of the structured interviews was participant bias when responding to survey and focus group questions. Several church partners were familiar with the principal investigator (F.E.), which may have caused them to refrain from offering harsh criticism upon answering specific questions. Participant recall bias was another limitation; however, due to administering the survey and focus groups at a similar stage among all participants, recall bias may have been minimized . AdditioTo enhance, expand, and sustain community-based programs, program leaders need to engage in rigorous evaluation of their community-based partners’ perceptions of the program’s implementation barriers and facilitators. Our evaluation of the Alter program revealed strategies to overcome identified barriers—namely, adapting health promotion programs virtually, assessing community organization capacity for programming, developing a program manual, conducting structured workshops for program implementors, and hiring health educators. These strategies will help ensure effective implementation for any program seeking to partner with a community-based organization.