Body Dysmorphic Disorder (BDD) is a severe and common disorder that consists of distressing or impairing preoccupation with nonexistent or slight flaws in one’s physical appearance. People with BDD typically describe themselves as looking ugly, unattractive, deformed, or abnormal, whereas in reality they look normal or even very attractive.Case StudyCase StudyMr. X is a 31 year-old male with history of Opiate  use disorder currently on maintenance  treatment. On admission, urine toxicology was positive for opiates and other drugs.CIWA score was 11. He was started on Lorazepam taper, Mirtazapine, Fluoxetine, and was started on Suboxone soon after. His cravings decreased and he was admitted for Rehab. He reports that anxiety associated with his “body image” related to ears, shape of head, eyebrows since he was in high school which made him “feel uncomfortable” going to school and concentrating in his classes. His coping mechanism was covering his head with hats, shaving eyebrows, substance use, and receiving an otoplasty.According to Houchins et al (2019), alcohol is the predominant substance used in BDD. It is interesting to note that only 6% of BDD patients had Opioid Use Disorder, but as this case demonstrates, can be a debilitating comorbidity that raises the risk for suicidality or hospitalization. However, little research has been done on the treatment of OUDs in patients with BDD or on the treatment of BDD in patients with an SUD, and this is an area of research that could benefit the modern population greatly.No significant relationships.


The current study aims to qualitatively identify determinants, barriers and facilitators of physical activity among a population with mental health disorders.Seventeen participants with moderate mental disorders were recruited. Semi-structured interviews were conducted to identify physical activity facilitators and barriers. Data were organized and analysed in ATLAS.ti, mainly based on a generic qualitative research approach.Most participants found physical activity important and expressed a positive attitude towards it. In general, higher self-efficacy and more social support were beneficial for participants’ physical activity levels. Reasons/facilitating factors to be more physically active were: having fun, good weather, progress, routine, self-compassion and a stimulating environment. Barriers were not having fun, being busy, mental complaints, lack of energy, procrastination and physical complaints.Future interventions could promote physical activity among people with moderate mental disorders to help them identify and overcome barriers. The newly identified determinant ‘self-compassion’ could be an interesting target for promoting physical activity in this group of people with moderate mental disorders. Physical activity is important for our physical and mental health   interventions to promote physical activity. The qualitative studies that exist investigate determinants among a specific group or physical activity such as alcohol and drug users . Inclusion diagnoses were mood- and/or anxiety-related disorders; somatic symptom and related disorders; attention deficit and hyperactivity disorder (ADHD); and general complaints . Exclusion criteria were personality disorders, psychosis, addictions, high risk of suicide, and complex trauma. They were excluded because they need more comprehensive treatment than Oh My Mood can offer, where the study was conducted. We aimed to recruit participants that were minimally exposed to treatment, so their physical activity level was minimally influenced and results are generalizable; 24 potential participants were contacted for an interview, of whom four did not answer the telephone, 17 agreed on participating and three were not interested in the topic or found treatment already intense. Recruitment stopped when data saturation was reached and participants were providing similar responses , so people could participate from home, only with the interviewer and participant present. After the interview was over, people could stay for a debriefing and ask questions. Participation in the interview did not affect potential treatment within Oh My Mood in any way. During the procedure, the therapist was always available for the interviewer and the client. Ethical approval was obtained from the Ethics Review Committee Psychology and Neuroscience (ERCPN-1880_10_02_2018).After people had their first contact with the mental health institution, they were contacted by the first author who was also an employee of the Mental Health institution. Only people that already gave consent for anonymous use of data in their treatment agreement were contacted about whether they were willing to participate in an interview about physical activity. During the invitation, people were informed about the study and gave their consent, after which an interview was scheduled. At that point, people did not have a diagnosis yet; however, by the time the interview took place they had an official diagnosis. All people met the inclusion criteria. Because of the COVID-19 situation, all interviews took place over a video call using the online platform ‘Whereby’  and an eight-step process was used for analysing the data see Fig. . One parSeventeen participants finished the interview . The participants had the following diagnosis: Depression (in any form except for a major depressive disorder), specific anxiety disorder, general anxiety disorder, attention deficit hyperactivity disorder, insomnia, post-traumatic stress disorder, panic disorder, obsessive-compulsive disorder and somatic symptom disorder. Participants’ definitions of physical activity can be interpreted on a continuum, ranging from ‘physical activity is everything that is not sitting or sleeping’ to ‘more moderate/vigorous exercises in combination with feelings of being satisfied’. See Appendix No consistent pattern was found in satisfaction level and actual physical activity level. The mental/physical circumstances of the person, negative thoughts, high demands on themselves and self-compassion seemed to play a crucial role in the satisfaction level. All participants, except for one, found physical activity important. The most important reason for participants to perform physical activity were physical reasons such as increasing aerobic fitness, increasing posture, healing past injuries, improving strength, losing weight and increasing physical appearance. The second important reason was to improve their mental health .‘Sometimes I have periods when I am in such a flow of doing a lot of physical activities, eh, yes then I really do feel better. Kind of an addictive feeling’ (P6). Explanations given for the positive attitude are: putting your energy into something, stress relief, taking your mind off it, giving your daily life meaning, feeling proud of yourself, and feeling happier afterwards. Most explanations are related to their mental health such as this participant explains: ‘Physical activity is progress on all aspects of life, you stay clear, fresh, it has a positive influence on your body and your mind, it helps to be more present’ (P2).The majority of the participants expressed a positive attitude towards physical activity. However, some of them experienced a negative attitude, especially against more moderate/vigorous physical activity. Often a threshold to start with physical activity is described, but when they started/overcame this threshold, they enjoyed it. One participant explained that she experiences a threshold, but sometimes she comes into a flow of performing physical activities. ‘Because I am lazy’ , ‘I lack self-discipline’ , and ‘I am not motivated enough’ , ‘I am not a sporty type’ , or a lack of confidence if they can perform the actual movement. Participants in the active during both groups showed more confidence than people that are not active at all or performed more daily movements. Participants who performed only moderate/vigorous physical activity experienced a low self-efficacy before they became more active.More than half of the participants talked about difficulties to start with physical activities. Different given reasons are ‘Even if it is a compliment or a “Hey you look good” or whatever, that is motivating, it shows that you are doing well’ (P4). Other people can function as a foot-in-the-door to commit to their intention to perform physical activity. An example is, ‘Then umh, there is someone, yes, a kind of social control. Someone is waiting for you, so it is easier once you have said “I am in to go.” Then you have to go. So that makes it easier for me’ (P9). A strong social norm in combination with having great demands on themselves seemed to be counterproductive for their physical activity level. So mentioned one participant: ‘Umh, but then I sometimes have the thought: “my mother is 60 and she can run 10 kilometres in an hour, so why can I not do it?” Because I basically have the same posture. So, I should be able to do so let’s say’ (P9). In general, a higher social norm resulted in performing more physical activity.Almost all participants experienced enough social support to perform the physical activity. Their social network did not counteract their intention to become (more) physical active. Two participants did not experience enough social support. These participants showed the lowest physical activity level. In general, participants enjoyed physical activity more when done with other people. Good guidance from a personal trainer or someone who is experienced is beneficial for the participants. Compliments from their surrounding are perceived as motivating. So is described: In most interviews, the weather is discussed as a facilitator/barrier. More than half of the participants said their physical activity depended on the weather. However, other facilitators or barriers were more prominent. Appendix ‘So for myself, I can leave it very easily, but if I let someone else down, I will find it more difficult’ (P15). Another participant said: ‘But if I have an appointment with Umh, a friend, then I force myself to go outside, to honour the deal’ (P3). Only a few participants did not experience enough social support. Some of the participants mentioned some reasons why they felt empowered to perform more physical activity after they encountered social support. One participant described that she felt upset when she saw her partner doing it better. However, she came out stronger after they talked about it and felt more supported. ‘But we do learn to talk about it. Umh, we explained to each other our struggles. And because of that, you can also embrace better what you already have’ (P2).All participants found it easier to become more active when they experienced enough social support  or when they felt committed to something. One participant described: ‘If you want to become active, find something that you like. Umh, because when you do not like it, your motivation is hard to find. And if you have something you really like, yes then you are also more motivated. You can keep doing it, otherwise, you will be tired of it after a week or a month’ (P12).Having fun during physical activity was mentioned, across all groups of physical activity levels. Some participants explored different physical activities before they found what they really liked. One participant explained: Because it helps me to see and do all kinds of fun things of course. Umh, yes, it helps me to be able to go somewhere else’ (P11). After people started a physical activity, they became more motivated to continue when they noticed some progress. ‘That you get better at something, because then, of course, it becomes more and more fun to do’ (P14).To become more active, it helped people to be outside or in a nice environment. Some physical activity helped them to explore their neighbourhood/new places. For example, this participant explained: ‘‘And then, I do it at the end of the day, I keep procrastinating... procrastinating... procrastinating...and eventually, at some point, the day is over and then I think yes… I will do it tomorrow’ (P1). One way to get physical activity in your daily routine is to have reminders. One participant had a smart solution to remind himself to perform some physical activity: ‘I also have a pull-up bar in my hall, so when I go to the toilet, I always see it. So that is a kind of a reminder of Oh yes, I still have to do something’ (P3). Reminders were an often-mentioned trick for participants to perform physical activity.One of the most frequently mentioned barriers to performing physical activity was being busy with other appointments followed by procrastination. On the other hand, participants found it easier to perform physical activity when it was part of their daily life. An example of how procrastinating resulted in not doing any physical activity anymore is as followed: ‘By writing a positive diary. So, you can write down: I have not put any pressure on myself by obsessively exercising or umh, by having to do that workout, no I have at least moved and that’s fine. And I took care of myself, I listened to my body’ (P16).Self-compassion is more mentioned among participants that were in ‘the active during both’ group. In addition, it was often mentioned as a wish, that it would help them to become more active in the other groups. An example of how self-compassion can work is described as followed: a mental breakdown’ (P7) is experienced, it is more difficult to do something active. When people are tired, low in energy, or did not sleep well it was also difficult to perform some active activities. Another frequently mentioned barrier was having negative thoughts. One of the participants describes: ‘I also get negative thoughts like “Oh I cannot do this at all” and “Oh this is not going well” or “I am not in shape” and “I will never get better at this”’ (P9). Another participant described how her thoughts are holding her back to perform physical activities ‘For me, it is mainly the way I approach it myself. Because I gave it such a negative connotation. Somewhere down the road, I made it an obligation for myself. So let me just say the mindset about it, that I would like to change for myself’ (P17).Mental complaints  and a lack of energy were the most frequently mentioned barriers next to the weather. One participant explained when ‘But, yes, I would like to do some exercises, but on the other hand, I am like, I do not want to do something wrong that can cause pain in my leg again’ (P5).Physical complaints or injuries often caused inactivity among the participants. Some physical conditions experienced were cardiac infarction, vertigo (dizziness) and hypermobility of the joints. Other people had an injury (in the past) or were discouraged to perform a physical activity because of their low aerobic fitness. People that (had) experienced an injury, expressed a fear of a new injury. This was another reason to be hesitant in performing physical activity. An example of how a participant described the fear of an injury: ‘https://osf.io/3puer/.About half of the participants set goals for their daily and/or moderate/vigorous physical activities. Some of the participants had a general idea of what they wanted to achieve but did not set clear goals for themselves. Across all groups, it was mentioned that when they wanted to achieve their goal, it was helpful to become more active. In general, people with clear goals, perform more physical activity. Five participants recommended setting goals for other people that want to become more physically active. An overview of mentioned goals can be found in Appendix This study provided new information about facilitators and barriers among people with moderate mental disorders to perform physical activity. First, most participants find physical activity important and experience a positive attitude towards it. However, not all of them have a sufficient level of physical activity and most expressed the intention to increase their physical activity level. The more confident people felt, the more physically active they were. A high social norm does not always have to be beneficial. However, almost everyone experienced enough positive social support, which was mentioned by all participants as a facilitator. Having fun was second-mentioned as a facilitator, with not having fun as a critical barrier. In addition, weather, performing the physical activity as part of a daily routine, self-compassion, and being in a nice environment were the most emphasized facilitators. Being busy, procrastinating, and having mental/physical complaints were the most mentioned barriers to becoming active. In general, these determinants are similar to the determinants among healthy people in previous studies  injury. This barrier is partly mentioned in other qualitative studies among people with mood- and/or anxiety-related disorders ; however, the current study did not test a full theory as it was meant to discover new determinants, facilitators and barriers among people with moderate mental disorders. The current study focused not only on moderate/vigorous physical activity but also on daily movements. During the interview, this distinction is not always clear in the answers of the participants. Some difficulties arose during the interpretation process because the two topics were intertwined in the interviews. Future research could divide the interview topics into daily movements and moderate/vigorous physical activity. Specific beliefs, facilitators, and barriers could then be investigated within the same person but across the two physical activity groups. Another recommendation for future research is to focus more on the background of the participants to find out how specific attitudes and beliefs have originated. This new information can help us understand how and why some people have a strong positive attitude towards physical activity. Future research could focus more on the distinction between people with a strong positive attitude and a negative/neutral attitude. At least, future research should conduct a quantitative study to confirm our results and to say something about generalizability.In general, people with mental disorders experience a positive attitude towards physical activity, and they consider it important. This is similar to healthy participants from previous research. However, people still encounter some difficulties to become (more) active and showed the intention to increase their physical activity level. People with mental disorders encounter specific facilitators and barriers, compared to healthy controls, such as the newfound facilitator of self-compassion: ‘self-understanding and self-kindness aimed at easing suffering during times of hardness’  intervention to increase physical activity among people with moderate mental disorders. Encourage people to find physical activities they enjoy. When they experience difficulties to being active alone, encourage them to find someone to commit to, also during times they feel low. Start a diary about the made progress and let people write down how they feel. Emphasize little steps and let them create reminders for themselves, so people can integrate physical activity into their daily/weekly life. When people experience negative thoughts or mental disorders, encourage them to be kind to themselves, let them listen to their bodies, and let them practice self-compassion. Let people look back at what they wrote down in their diary and soon they experience progress, which will motivate them again. A positive vicious cycle is round.


Since the emergence of COVID-19, issues have been raised regarding the approach used to engage with Culturally and Linguistically Diverse (CaLD) communities during this public health crisis. This study aimed to understand the factors impacting communication and engagement efforts during the COVID-19 pandemic from the perspective of crucial CaLD community stakeholders and opinion leaders.Forty-six semi-structured telephone interviews were undertaken with key stakeholders who have an active role (established before the pandemic) in delivering services and other social support to CaLD communities in Australia.Seven key themes emerged: (1) the digital divide and how to connect with people; (2) information voids being filled by international material; (3) Differentiating established with new and emerging communities’ needs; (4) speaking COVID-19; (5) ineffectiveness of direct translations of English language resources; (6) coordination is needed to avoid duplication and address gaps and (7) recognising the improvements in governments’ approach.Alliances must be set up that can be activated in the future to reduce issues around resource development, translation, and dissemination of messages to minimise gaps in the response. Financial assistance must be provided in a timely way to community organisations to support the development and dissemination of culturally appropriate communication materials.The online version contains supplementary material available at 10.1186/s12889-022-13680-1. Populations at risk of COVID-19 infection have been diverse and differ in COVID-19 literacy and social, behavioural, cultural and health practices. In non-pandemic times, people from Culturally and Linguistically Diverse (CaLD) backgrounds may be vulnerable to the factors that contribute to health inequity, including lower health literacy, cultural and language barriers, lower socioeconomic status, lack of provider cultural competence, lack of social support and a sense of disempowerment . During Previously it has been suggested that culture can also interplay with virus spread through behavioural and societal variances, including health-seeking behaviour and intergenerational cohabitation . In theoIn April 2020, letters were sent to federal, state and territory health ministers from 16 critical organisations, including the Ethnic Communities Council of Victoria, Settlement Services International, Migration Institute of Australia, and HOST International, which raised several key concerns about the Australian Governments’ COVID-19 responses. They spoke about a lack of consideration for CaLD communities, including access to appropriate and reliable in-language COVID-19 information and, most specifically, behaviour change advice and directives. Their call to action to the government was to make sure “that CaLD communities are not left behind in their access to and understanding of COVID-19 and are not made more vulnerable than other parts of the Australian community because they have become an afterthought in the rapid response to- curbing infections.” To support enhancements to Australia’s COVID-19 pandemic response, with a particular focus on communication and engagement with CaLD communities, this study aimed to understand the factors impacting pandemic response efforts from the perspective of key CaLD community stakeholders and opinion leaders.Semi-structured in-depth telephone interviews were undertaken with key stakeholders and opinion leaders, of approximately 30–40 min in duration, between January- April 2021. The collective term ‘Culturally and Linguistically Deeeeee (CALD)’ refers to “the non-Indigenous cultural and linguistic groups represented in the Australian population who identify as having cultural or linguistic connections with their place of birth, ancestry or ethnic origin, religion, preferred language or language spoken at home” . The HumParticipants included those who have an active role in delivering services via multicultural health and other support services via migrant resource centres, refugee health services, settlement services, community-based organisations, translation services and primary care settings. In addition, we sought to include people in senior leadership positions in multicultural health and diversity-related activities, whether through advocacy, policy/program development or research. This principally encompassed personnel such as those from government agencies, CaLD community peak bodies/Councils, and CEOs of community organisations.This study used a range of national-local-personal approaches to recruiting participants. Firstly, an online search of relevant websites was conducted to identify potential participants matching the eligibility criteria. Each potential participant was then contacted via email with an invitation letter. Secondly, interested participants were asked to recommend any colleagues who may be willing to participate directly. Lastly, emails were sent directly to known contacts of the research team working in the relevant sectors. An effort was made to recruit at least one person from Australia’s States and Territories to capture a broad range of views. However, we were unable to recruit any participants from Northern Territory. Participants were included in the study on receipt of informed verbal consent. This study did not collect any identifiable personal information from the participants.An interview guide was developed based on a scoping review of the literature and the observations from a research team member working within the multicultural sector. The remaining researchers reviewed the tool  to ensure that key areas of interest for the study were included. Open-ended questions focused on the following broad topics: perspectives towards the current communication approach being used by the government, factors affecting communication and engagement with CaLD communities, the communication roles and influences of different multicultural services, and suggested options that could be adopted to enhance communication and engagement with CaLD communities around the COVID-19 vaccine program. Additional items and modifications were added iteratively as interviewees raised new relevant issues unforeseen by the study team. All interviews were recorded using a digital recorder and fully transcribed with interviewee consent. Thematic analysis was undertaken using NVIVO 12, informed by a realist approach . The anaFifty-seven people were contacted to participate, of which 46 interviews were undertaken with key stakeholders and informants across Australia. The characteristics of the interviews are described in Additional file language-specific social support groups to citizenship classes, sewing classes, just social classes as well, and lot of information sharing, parenting classes. We had that kiddies’ playgroups and mothers’ groups” (Interview 1). Following the emergence of localised COVID-19 outbreaks in Australia, participants spoke of the “frantic” need to transfer to virtual or telephone mode to continue the delivery of routine services. This included conducting meetings via teleconferencing platforms to support engagement opportunities and to replace those face-to-face meetings that needed to be suspended. The virtual engagement approaches aimed to ensure that community members received relevant COVID-19 information, including physical distancing measures, lockdown requirements, testing recommendations, and the COVID-19 vaccination program.Before COVID-19, outreach activities with the community were undertaken mainly face to face via caseworkers visiting clients, walk-in appointments/consultations, or group meetings (i.e. with seniors or new mums). Social participation was encouraged: “They had taught them how to use some kind of video conferencing so that then they could have their meetings”). Whereas in other settings, telephone contact continued with clients  and community members: “for a lot of the older community, it’s very one-on-one. We implemented the phone checking service where we were identifying the most vulnerable and providing them support and information” (Interview 12). In one situation, a community organisation started up a Saturday night free call teleconference service to connect women “who can’t read or write in Somali, but want to know stuff about COVID.” (Interview 21).Not having access to a computer or the internet, having low digital or English literacy levels, and language barriers were all raised as barriers affecting the community. It was not just the community members who lacked the hardware (computers or modems) or internet access to switch online but also staff members from some community organisations. In these situations, many were heavily reliant on their mobile phones. To support those without the hardware, donated laptops and Wi-Fi dongles were used to ensure case workers and community members could continue to connect. Video conferencing sessions were given to help those in the community who were unsure about how to use Zoom, FaceTime, Viber, WhatsApp or other chat and conference platforms “The other thing was the absolute confusion…It’s complicated to understand full stop, but if you consider that most obviously, everyone in all our communities comes from somewhere else, and most of those places in the world have had a very different experience of COVID. I don’t think that in New South Wales, we were fast enough to provide the messaging to the community, and so we allowed that void to be filled” (Interview 33)Compounding this issue was some COVID-19 resources, as they included “technical jargon”, which may have been confusing for people with low literacy or health literacy levels, even if English was their first language. Government materials were not available across all languages, nor were they always available in simplified English that was “accessible” to communities.There are some communities that are missing the information. If we take the example of the South Sudanese community…. Dinka is one of the tribes among 64 other tribes. It means you provide information to one tribe; there are 63 missing. That’s what I mean by saying, yes, there’s some information there, but it doesn’t capture everybody. (Interview 1).“we can see the Department of Health information flashed in Arabic and Chinese, but no African languages were available”. (Interview 21). In these situations, it was stressed that community language radio and online information sessions  delivered in language were critical. Lastly, there were mixed feelings about Australia’s multicultural and multilingual broadcaster (SBS) role in disseminating information. Some participants described it as brilliant; others were more reserved in their comments and felt it failed to capture what was needed.Participants spoke about interpreting the information to “make it real” in some settings. For some communities, data was unavailable in their local language: ““My mother or auntie, there’s no connection to SBS as it used to be years ago. Why would they even go in and watch the Greek news if they can watch it directly from Greece? Why would I wait for the last night’s news if I can watch them live?” (Interview 11)“Stop wasting money on things like ethnic press and TV. Sure, they do a good job and are important to a degree. Still, theree is always going to be a gap that you’re not going to be able to plug unless the community takes ownership and gets them to do the communication themselves to the people they are close to”. (Interview 40)One suggestion that was put forward was to have community leaders talk in the language during the news programs on mainstream media channels or for messages to pop up. However, others felt this was still missing the mark.“I think “it’s the newly arrived communities with minimal infrastructure that are the most vulnerable. Particularly in small communities like the Rohingya, who have only had a written language since the ‘80 s, and hardly anybody can read those”. (Interview 16). However, not all participants agreed with this sentiment.There was not a consistent picture when it came to identifying which community groups should have support/resources directed to. Some participants suggested that newly emerging communities (migrant/refugee) would be most at risk of missing out on messages and support services. One key factor contributing to this was the focus on providing translated COVID-19 information to “high volume” community groups versus “high need” groups. Another issue identified was that established communities have ‘infrastructure’ in the form of community organisations, community leaders, in-language newspapers, radio stations etc. One of the first outbreaks I think in our region was in the meat works, and most of the employees at the meat works work from Karen and Burmese heritage. Many people in those communities don’t read or write in their own language either, so thanks to the local community leaders, we set up a testing site, and most people heard of it from word of mouth. That’s how, but we do have Karen information written, but we also had some videos made”. Having verbal messages was identified as being critical. In some suburbs, organisations resorted to door-knocking to encourage people to go and get tested.Participants also highlighted that Governments did not consider those individuals who come from cultural groups with oral traditions or who are illiterate in their language: “The really common accessibility issues were languages were ordered. You had to browse in English alphabetical order. Look, most people know their language’s name in English, but you also need to know the other language”. Participants noted that not all the COVID-19 resources available online were translated into every language.The ability to navigate websites was also emphasised as an issue for some community members. Especially at the beginning of the pandemic, it was not easy to locate relevant information on the government’s websites. While participants acknowledged improvements, challenges remained for those community members who did not read in English. Even if online information was translated, there was often the requirement to browse the website in English to find the relevant language: ““We’ve had GPs; we even had an orthopaedic surgeon present weekly COVID updates to audiences, getting the accurate advice, wash your hands, keep your distance, do all that, and talk about the specifics in the community.” (Interview 18)Issues around low levels of understanding about COVID-19  and increasing amounts of misinformation triggered some organisations to offer online community forums. These forums were provided for interpreters, case workers, and community leaders and often featured bilingual GPs and government officials to offer updated COVID-19 information and answer any questions. In some settings, these sessions were held weekly or fortnightly.“We established what we called the Greater Western Sydney Community Leaders Forum. What we did was we invited community leaders from across Western Sydney. We had Zoom meetings, initially weekly ones, and we started bringing in the police, for example, to talk about the fines and what was legal or not, and health practitioners to talk about the virus. Then we brought in some tax agents to talk about work, the job seeker and job keeper sort of stuff.” (Interview 11).Other forums were set up to provide updates to local community leaders so they could pass on relevant information to their communities: “We ran workshops called Speaking COVID. We’ve focused on engaging with the interpreters in workshops…. We did those bi-language group, and we had some content that talked about what does airborne transmission mean and what’s a droplet, what does isolation mean, and does quarantine mean, and all of the terms that became really common in that period and explained those in ways that the interpreters could understand so that they could, in turn, interpret them appropriately for the clients.” (Interview 16).Whilst resource kits were available from the government to support outreach efforts, criticisms were raised that the kits were just information. What was lacking during the early part of the pandemic were training sessions to support the adoption of the resource kit. As one participant indicated, there was a need to provide examples of what other organisations or community groups were doing. Lastly, participants also identified that there was a need to offer training forums to case and settlement workers, as well as translators/interpreters, to support their understanding about COVID-19: One story that someone told me is the true story of an older woman in a smaller community who contracted the virus. In that culture, when someone’s sick…you go and visit them”. (Interview 18). The problem is that the education resources did not account for these practices. Other participants spoke about the words/phrases that were in translated materials that were nonsensical or gave the wrong message: “when we hear the media or the government saying, ‘We’ve produced the written material, you have to be careful on what you’re saying because no one’s vetted the accuracy of that material. That’s where I’m suggesting that it seems on the surface that the right thing’s been done, but when you look at the content, it’s highly questionable” (Interview 13). As a solution, it was suggested that education resources be developed from scratch with the targeted communities, which are not only language-specific but also count for the nuances within the community. The videos should include local faces and phrases known in the community”.In other words, you end up with 20 slightly different documents. They’re not all the same, but that’s okay, as long as the basic information is the same, the way it’s presented is slightly different”. (Interview 17).“Understanding and acknowledging the different cultural beliefs about illness and COVID-19 was critical to developing resources. However, in many settings, participants spoke about the fact that COVID-19 education resources were often created in English and then translated. Potentially as an outcome, participants talked about mistrust and misunderstanding amongst community members, linked to the fact that resources were not tailored to their beliefs or practices: We paid our bilingual educators to make calls to people, the networks they had, give them targets, and say, “Try and call at least ten women that you can.” (Interview 43)“Beyond having resources developed in collaboration with the target community, there is still a need to have bicultural workers available to help with supporting community members’ understanding of the information. For example, it was recommended that people avoid ‘share-plates’. However, it is common practice for many Arabic-speaking and African communities to sit and eat communally, with everyone taking food from the main platter. Therefore, bicultural workers were critical in helping break down the messages and reassuring the community that they could still have dinner with their direct family members. These workers do not necessarily have a health background, but they can speak the language and read and write in English and their language. They are seen as having some influence and visibility within their community. In some settings, training was provided to the bilingual workers to become the ‘face’ of the COVID-19 communication strategy, working in partnership with the health officials.We hired eight bilingual workers in various language groups so that they can speak to callers to a particular language-specific phone number to ask for guidance on COVID-related matters. Not to be a substitute for the COVID helpline, but to be able actually to speak to someone in your language,”. (Interview 13)“They also enabled two-way feedback and the capacity to hear from the community members regarding any ongoing issues or factors impacting public health strategies such as testing. While participants spoke of the value of these workers, in reality, not all geographic areas had these workers available.What you ended up having was this website with collections of stuff in different languages often saying the same thing, but slightly different. It was a disaster” (Interview 33). Participants spoke about confusion amongst their community members when there were differing regulations across the different states/territories. They also cited confusion when organisations didn’t “sing from the same songbook” or when messages were not consistent: “the service providers might send them something, Department of Health sends them something, and then their workplace sends something else, so it creates a lot of misunderstanding, but it creates a lot of confusion for the young people” (Interview 4).The issue of duplication was raised in terms of the development of resources and videos for different community groups: “one-stop-shop where GPs and community members also could access accurate health information according to language that they could easily search up and share with other members of the community”. In putting for this suggestion, they acknowledge that a considerable amount of work was being done to develop resources but that they were not always stored in an easily accessible format. They were identifying the different needs of communities and the funding available, which needed to be promoted one state to introduce a community connector advisor, who was tasked with getting organisations to talk to each other. Other participants also endorsed the need for coordination at a state level, who felt that coordination of efforts could not be done at the district level: “Coordination is key… It’s essential to have functioning networks with good information-sharing and healthy relationships to avoid that”. (Interview 14).To reduce these issues, one participant suggested that it would be great to have a “In Queensland, we have quite strong regionalism, and people in the region are sometimes sick of being told what to do by Brisbane all the time. The decisions are from Brisbane in an urban area, and they don’t always understand what’s happening”. It was acknowledged that if bottom-up approaches like this are going to be done, health experts must also be involved to ensure the messages are accurate.However, duplication was not always framed as having a negative impact on pandemic efforts as in some instances, having multiple videos outlining the public health requirements or promoting the COVID-19 vaccine may be helpful as each community organisation will ‘add their own jargon” and will have a close relationship with the community they serve . As one participant stated: “15 min ahead of us in terms of the decisions and duration of the roll-out, in terms of the policy. A lot was happening, and it was swift. They just didn’t take their time, and maybe they didn’t have that time. (Interview 12). At a regional level, local government organisations undertook rapid consultations with community members to understand their perceptions of the pandemic and their concerns. Using this information, they could influence the local district response, including the visual and digital resources.The advantage of this was because the community came on board in terms of what should go in, how should it be said, we were able to address the immediate fears and concerns of communities. We were able to have their people as the front face so that we could get the messages across. (Interview 43).“Participants raised concerns that early in the pandemic, the Australian and state governments did not seem to have plans for multicultural communities. Issues were raised with governments, but there wasn’t the sense that organisations were ‘heard’. Participants acknowledged that the government was only “Two events were signalled as the triggers for the governments revising their approaches. The first event was the hard lockdown in nine public housing towers in inner Melbourne, Victoria. There were significant delays in preparing and distributing materials about the lockdown in community languages and an absence of interpreters. The second event was the issue regarding the translation of COVID-19 materials and the mix-up in languages, including one document with mixed Farsi and Arabic words. As one participant indicated, at that point: “the Department of Health said, “Well, okay, let’s get this done properly and listen.” Following those events, COVID-19 advisory groups focused on multicultural communities, bringing together academics, practitioners, GPs, and community members.they very clearly heard the message from communities, which is stopped doing it to us and start doing it with us”. Representatives from different community organisations spoke about meeting with federal ministers/policy advisors via Zoom meetings. While there appeared to be improvements, issues were still raised regarding the responsiveness of the different government teams, including the policy versus communication teams.My criticism of the Department is that the policy side of the policy team is switched on, and they’re with it; they’re listening to the advice we’re giving them. We’re on the same page. Whereas the communication team, we keep saying the same thing over and over and over again. In the meetings, they say, “Yes, that’s a good idea, and we’ll go away”, and we just keep seeing the same mistakes come up. We see things as fundamental as ensuring that English material is in plain simplified English before it goes to the translators. I think I’ve said that about 12 times. (Interview 40)This sense of a shift in the government’s approach from mid-2020 was a consistent message across all the interviews. As one participant suggested, “one community ended up getting some funding,… the women were keen to watch the news and find out what happened, but the news is all in English. They had someone who was taking the announcements… three or four days’ worth and putting it into one chunk of text and having that translated and then shooting that out via WhatsApp or WeChat or something, one of those platforms, to all of the members of the community group. (Interview 16). Lastly, criticisms were made of the funding that was directed towards consultants and creative agencies, as opposed to giving the money to the community to produce locally tailored content: “just give the money to the communities. They know the communities best, they know what the issues are. It’s targeted, they’re very local.” (Interview 40).In the initial phase, funding was made available however it was directed towards peak bodies instead of going directly to the community. It was on the peak bodies to organise the distribution of funds via multicultural COVID-19 community grants, which local organisations could apply for to support local activities. For example: “By undertaking interviews with stakeholders involved in providing support to people from CaLD backgrounds, we were able to gain a rich understanding of the critical challenges encountered around communication and the attempts being used to engage with community members regarding the COVID-19 public health measures and restrictions. Our study results echo the concerns raised by multicultural networks and consumer council reports published since the start of this pandemic . The remThroughout this pandemic, the issues of information/resource overload and duplication of efforts have been contrasted with issues regarding community members’ ability to access culturally tailored resources and in relevant modes of delivery. One possible strategy to reduce these issues in future events is to develop a management plan to support the response efforts focused on CaLD communities. A similar document is available to help the emergency response management and operations focused on Aboriginal and Torres Strait Islanders . It outlIn comparison, the need for a dedicated and tailored management plan for CaLD communities has not been historically outlined. Coming into this COVID-19 pandemic, Australia’s response was traditionally guided by the Australian Health Management Plan for Pandemic Influenza (AHMPPI) , which wWe have achieved a great amount collectively in an ever-changing environment with multiple players and complexities. This could not have been achieved without the partnership approach.” [At a state or district level, the value of having an interagency collective approach was outlined in a report focused on the network response that occurred in Queensland . The iniproach.” . HoweverThe need to support CaLD community leaders, faith leaders, and multilingual and settlement sector workers to be able to communicate about COVID-19 was a key message that came through all the interviews. These practitioners have been described as the “conduit between the Government and communities” based on their role in ensuring that messages are accessible, meaningful, and effective for communities [shared by phone calls, texts, and e-mails. Other participants have shared the information with caregiver support groups, book clubs, community associations, Sunday school classes, and colleagues” [The need to provide the latest information on COVID-19 and medical and community resources to community leaders was highlighted in an article by Panagis Galiatsatos and colleagues . The artleagues” .Beyond ensuring community leaders and other stakeholders can receive the latest guidance about the situation and ask questions, there is also the need to consider broader training opportunities during pandemics or other emergencies, as well as ways to expand the potential pool of practitioners rapidly in response to pandemics and health emergencies , 30. Pot‘Community ownership’ was a phrase that was repeatedly used by participants during the interviews, with emphasis placed on engaging communities in the development and testing of messages (and images) and audio/visual materials. The need for bottom-up communication approaches involving stakeholders and tailored materials has been repeatedly echoed in the published literature (and by our participants), as it enhances accessibility, usability, and inclusiveness , 31. A bLastly, while participants spoke about the close networks with community leaders and ambassadors, concerns were still raised about how actively governments  engage with these actors. Efforts must be taken to explore the feedback mechanisms being used and to ensure that feedback is being collected (and integrated into policy/revisions to strategies) from all of the different CaLD communities, as well as across urban, regional and remote areas. One suggestion is to establish WhatsApp groups with community ambassadors or community volunteers to collect questions, tips, and concerns. However, collecting this information is not enough; it must be discussed and shared across the response sectors.The lack of resources and funding to support local initiatives was raised as an issue by the participants. It is important to note that challenges around funding for the community sector were evident before the COVID-19 pandemic ; howeverIn planning for future events, there is a need to ensure that consideration of CaLD communities must be incorporated into Commonwealth and state and territory planning. In addressing the specific needs of CaLD communities, recognition must be given to the diversity within and between communities. A one size fits all approach is not likely to be effective, acknowledging that some communities can mobilise their resources and staffing . Our parThe study team acknowledges that CaLD communities are distinct yet heterogeneous groups with unique health delivery needs . EffortsDuring the COVID-19 pandemic, there have been issues around the poor quality, delays in the materials available to communities, and conflicting messages. There is an urgent need to capture these key lessons and use them to strengthen not only Australia’s pandemic response but that of other countries with diverse communities, to ensure that future responses are equitable, represented and appropriately resourced. Alliances must be set up that can be activated in the future to reduce issues around resource development, translation, and dissemination of messages to minimise gaps in the response. Financial assistance must be provided in a timely way to local organisations to support the development of culturally appropriate communication materials. Not all communities require translated materials, so it is essential that tailoring and targeted approaches are used to ensure those community members who may be more vulnerable in public health events are not left behind.Additional file 1. CORE-Q Consolidated Criteria for Reporting Qualitative Research.


Standardisation of knowledge has become a by-product of globalisation, and western-based models are often seen as the ultimate answer to expertise and development. In light of this, some professionals have debated the feasibility of employing cognitive behavioural therapy (CBT) with Muslim communities. Debates have focused on CBT’s secular roots and its compatibility with a world where Islam permeates most aspects of life. This article highlights some of the theoretical dilemmas of integration and suggests ways to bridge the existing gap between secular and Islamic literature and avoid alienating those individuals who might feel uncomfortable with secular CBT teachings. Contact, exchanges and reciprocal influences between different cultures are phenomena that date back to the origins of time, and indeed, history books are replete with narratives of encounters, clashes and movements between kingdoms and their inhabitants. However, whilst migrations—whether physical or cultural—are not a novel occurrence, the pace of the associated changes is. The advances in technology and transportation of last few decades have ensured that the opportunities for and the impact of these contacts have never been more immediate and far-reaching, creating a “global village” McLuhan, . As the Many complain of the devastating impact of globalisation on indigenous traditions, customs, languages and values , it tends to reinforce adverse power dynamics in which one party is seen as needing to be “modernised” according to preconceived standards. Marsella (2005) describes this form of globalisation as “hegemonic” and regards it as a legacy of colonialism. Whilst the nineteenth-century colonialist mentality prompted the unequivocal and often forceful replacement of traditional systems, hegemonic globalisation entails a much more subtle and less overtly intrusive alteration, often achieved through exporting education and health systems , evil eyes and “jinns”  in the West, and its short-term, protocol-led and highly manualised nature which greatly appeals to training institutions, some professionals have called for exporting this approach to working with Muslims  the possibility of some external influence on the person in terms of (…) unseen supernatural beings”. Ultimately, when modern social sciences separated from philosophy and established themselves as a scientific discipline, they emphasised the secularisation of knowledge. Social sciences embraced, instead, observation and experimentation at the expense of divine scriptures and metaphysical elements, whose roles in explaining behaviour were completely rejected , so we do not know; you don’t need that (a psychologist) because you are talking to friends and family say Weatherhead and Daiche’s , the “qalb” (heart), the “nafs” (self) and the “ruh” (spirit). The “aql” is believed to be the logical part of human beings, that part that is mostly concerned with rationality and logical thinking (comparable to CBT’s cognitions) whereas the “qalb” is believed to be that part of human beings where all emotions reside. It is noteworthy that Ghazali ; and one’s faculty of reason, endowed with knowledge and will, is the sultan’s vizier”. Just like the vizier manages the affairs on behalf of the sultan, who remains the highest authority, the “qalb” was believed to acquire a central role in maintaining equilibrium in and between all the elements of the psyche. This conceptualisation contrasts with CBT’s model of human nature that, instead, views thoughts in the driving seat.Whilst the role of the “e Haque, . Acknowli trans. , p.18 waqalb” (the emotions), is addressed in therapy, real change won’t happen as the “aql” alone is believed not to be sufficient to initiate long-lasting healing  to oneself, to significant others, to human beings in general, to other species, to nature, and to the cosmos  might impair judgments related to the pursue of the metaphysical and spiritual (ruh) against instinctual impulses (nafs). This, in turn, might impact on a person’s emotional core . On the contrary, a sound intellect, which works in unison with a healthy emotional regulatory system would not struggle to contain lower behavioural inclinations, knowing that its role is to transcend those to reach a spiritual connection with the divine. A hadith from Al Bukhari  confirms these interconnections: “there is an organ in the body, that if it’s pure, the whole body is pure and it is diseased, the whole body is diseased: the heart”.Regardless of the theoretical speculations about which Islamic component matches (if any) its western counterpart, these elements are believed to be intrinsically connected Ghazali, , so thatNotwithstanding the different emphasis between this position, which claims the heart to be the “command centre” Lodi,  and CBT,In addition to the similarities between the two models as described above, the supporters of an integration of CBT and Islamic principles argue that the scientific nature of CBT aligns well with the importance that Islam places on science and a scientific exploration  1991). Similarly, At-tabari  might be more consonant with the expectations of some Muslims coming from the Arab and South Asian cultures Haque, . In lineAllah is the best of Planners”  and that a believer ultimately has to understand and appreciate the divine plan, even though it might not be what the person had wished for .Whilst there seem to be several arguments in favour of the application of traditional CBT to Muslim communities, there are also many arguments against it. First of all, Islamic principles lay on ontological absolutism, which is in stark opposition to the constructive nature of CBT. Islam maintains that there is an absolute Truth and that “should” ought to exist Sheikh, . InsteadI did not create the Jinn and mankind except to worship me”—Holy Quran, Ad-Dhariyat 51:56). The associated goal can then be inherently different: self-determination for one versus rectification of Islamic psychological processing  map onto the first element of Ghazali’s ; “whoever puts their trust in Allah, he will be enough for them”  and “do not lose hope, nor be sad. You will surely be victorious if you are true believers . Rothman (dhikr” (remembrance of God), with “dua’s” (supplications) or with more helpful religious thoughts, a procedure in line with Seligman’s  and/or mindful “Tafakkur” (contemplation of God) , mindful “Rothman, . These severy morning a new arrival. A joy, a depression, a meanness, (…). Welcome and entertain them all!; the dark thought, the shame, the malice, meet them at the door laughing and invite them in”  metaphor of the “unwelcome party guest” Oliver,  and mindWhilst early in its development and far from claiming a universally accepted organic theoretical framework, incorporating Islamic principles into CBT seems a useful possibility. Islamically grounded interventions might not be suitable or appealing to everyone, including many Muslims who might prefer secular approaches. At the same time, it is vital to broaden the repertoire of available psychological and psychotherapeutic approaches and offer culturally sensitive frameworks as part of a commitment towards moving away from solely relying on western perspectives when practising and teaching psychology and psychotherapy. The traditional suspiciousness and reluctance that some individuals might experience concerning seeking treatment for mental health difficulties could then be chipped away by presenting an approach that might mirror the client’s belief system closer.there is no ailment that Allah has created, except that He also created its remedy” , suggesting that personal responsibility and commitment are key. Furthermore, it might be helpful for therapists to develop collaborative relationships with religious leaders. Due to the different idiom of distress in western and non-western cultures as previously discussed, working with religious leaders might, then, help healthcare professionals to develop explanatory models that better capture indigenous beliefs’ systems.People can be reminded that the Prophet Mohammed explicitly encouraged individuals to “heal themselves” .Given that several studies confirm the potential helpfulness of traditional interventions (Nortje et al., The present paper has both strengths and limitations. As a narrative review, it explores the state-of-the-art literature on the topic of integration of CBT and Islamic values in depth, and offers a bridge between the vast and disjointed array of articles on the subject. Indeed, one of the advantages of narrative reviews is that they present arguments at a theoretical level that empirical studies cannot address, often leading to novel conceptualisations and frameworks (Baumaister & Leary, As a result, further theoretical reflections and follow-up studies ought to take place before conclusions are drawn. These reflections should be driven by a bottom-up approach where the targeted population is recognised as the expert and consulted through qualitative studies.The impact of globalisation on the conceptualisation and treatment of psychological distress calls for a greater effort to integrate psychological and psychotherapeutic approaches in the respect of indigenous cultures. In light of this, the current paper engaged with the controversy of adapting the CBT approach to incorporate Islamic values. Given that each paradigm is rooted in contrasting ontological and epistemological positions and that acceptance of one model would indirectly influence the therapeutic stance Fatemi, , it seem


Gait speed is frequently the primary efficacy endpoint in clinical trials of interventions targeting mobility in people with multiple sclerosis (MS). However, it is unclear whether increased gait speed is a meaningful outcome for people living with MS. The purpose of this study was to identify the most important aspects of mobility for people with MS and physical therapists and to explore how patients and clinicians perceive whether physical therapy has been effective. Forty-six people with MS and 23 physical therapy clinicians participated in a focus group, one-on-one interview, or electronic survey. The focus group and interview data were transcribed and coded to identify themes. Free-text survey responses were also coded, and multiple-choice options were analyzed for frequency. Among people with MS, falls and difficulties getting out into the community were identified as highly important mobility limitations. Clinicians also identified falls and safety as a priority. Walking speed was infrequently described as a problem, and although gait speed is often measured by clinicians, improving gait speed is rarely a treatment goal. Despite their emphasis on safety, clinicians lacked certainty about how to objectively measure improvements in safety. People with MS evaluated physical therapy effectiveness based on the ease by which they can do things and acknowledged that “not getting worse” is a positive outcome. Clinicians evaluated effectiveness based on the amount of change in objective outcome measures and by patient and caregiver reports of improved function. These findings indicate that gait speed is not of major importance to people with MS or physical therapy clinicians. People with MS want to be able to walk further and without an assistive device, and they want to avoid falls. Clinicians want to maximize safety while improving functional ability. Clinicians and patients may differ in their expected outcomes from physical therapy. One of the most frequent symptoms of multiple sclerosis (MS) is difficulty walking. Mobility limitations affect more than 90% of people with MS , and of The most common intervention approaches for treating mobility limitations in people with MS are rehabilitation , exercise training, and dalfampridine (known as fampridine outside the United States). Gait speed is frequently the primary endpoint in studies to evaluate the efficacy of these interventions –13. DespThe purpose of this qualitative study was to identify the most important aspects of mobility for people living with MS as well as physical therapists who treat people with MS. A secondary focus was to explore how patients and clinicians perceive whether physical therapy has been effective.This qualitative study was completed in two stages. Firstly, we conducted a series of focus groups and one-on-one interviews separately for people with MS and for physical therapy clinicians with experience treating individuals with MS. The findings from the focus groups and interviews were then used to develop an electronic survey that could be distributed more broadly to patient and clinician stakeholders. Focus group and interview participants were recruited purposively through flyers distributed to professional groups and to local MS self-help groups. For the electronic survey, the invitation and link to access the survey was distributed via email to professional associates of the researchers and to the membership of the local chapter of the National MS Society. The associates of the researchers were also asked to share the survey invitation with their patients with MS and professional colleagues. The study was approved by the Institutional Review Board of the University of North Carolina at Chapel Hill. All participants provided informed consent to participate.Forty-six people with MS and 23 physical therapy clinicians participated. Of the 46 participants with MS, 4 participated in a focus group, 1 participated in a phone interview, and 41 responded to the electronic survey. Of the 23 physical therapists, 6 participated in a focus group, 1 participated in a phone interview, and 16 responded to the electronic survey. Initially, a greater number of focus groups was planned but lack of geographical proximity and mutual availability of interested participants restricted further focus groups from being conducted. Thus, as an alternative, individuals who had been unable to join a focus group were invited to complete the electronic survey or a one-on-one a phone interview. There are no rules governing the optimal sample size in focus group research; rather, the number of groups is determined by the objectives of the research and saturation of the data . TrianguThe focus groups were moderated by the first author, who is experienced in the focus group methodology , 16. An The surveys were developed using Qualtrics software . The responses were completely anonymous. After consenting to participate in the survey, participants were directed to a series of questions that generally followed the structure and questions of the focus groups and interviews. The question types included multiple-response options  and open-ended questions. The focus groups and interviews helped inform the response options, but survey participants were always provided with an option to write in their own response. Demographic information was requested at the end of the surveys to help describe the study samples.The focus groups and interviews were transcribed verbatim by a professional transcription service . The transcripts were then edited to remove any names and identifiable information about the participants. Focus group transcripts were further edited to add information about nonverbal behavior and group dynamics from the field notes taken during the discussions, as well as document the seating arrangement. Each transcript was read several times by each author independently, and potential themes were noted. The major ideas in response to each question, along with sample quotes, were then organized into a matrix to further assist in the identification of themes. An audit trail was also constructed in the data matrix to identify the origin and context of the data segments so that the researchers could retrace the data to its location in the transcript. The surveys were analyzed for frequency of response for multiple-choice options. Free-text answers were examined for themes, similar to the transcripts.The trustworthiness of the findings was maximized by several methodological strategies that enhance the dependability, credibility, transferability, and confirmability of the data . Specifin = 25) were currently using an assistive device to walk or mobilize ; 10 survey respondents did not provide a response to the assistive device question. The 23 physical therapists ranged in experience from less than 1 year to 40 years and represented a variety of practice settings, including acute care, inpatient and outpatient rehabilitation, home health, and school-based physical therapy. Seven therapists (30%) were certified neurologic clinical specialists by the American Board of Physical Therapy Specialties. The majority of participants in each cohort were female, which is consistent with the sex distribution among physical therapists in the United States [The 46 participants with MS mostly had relapsing-remitting MS, but individuals with primary or secondary progressive MS also participated. In addition, 3 of the survey respondents with MS reported having radiologically isolated syndrome. Disease duration ranged from 1 to 30 years and at least 65% .“I can't really go to the store… I can't take our dog on a walk unless I'm in the electric wheelchair because I can't walk that far without feeling like I'm actually falling.” (interview-MS).“Gardening is a problem. I mean, I feel like a lot of the things I used to do have really been, you know, I've really kind of had to give up a lot of those things.” (Interview-MS).Limitations in going out were sometimes related to difficulties with transportation:“I don't get out as much, like I'm driving my daughter's car more than getting on the bus. Because getting on the bus, I have to step up ‘cause some of these bus drivers won't put down the ramp for me to roll up .” (FG-MS).Others were concerned about being dependent on someone else to assist them when they go out, for example, “to push me in the portable wheelchair.” (Interview-MS).Slow walking speed was mentioned as a walking-related problem for people with MS, but mainly in the context of having to “take my time” (FG-MS) because of the time and energy required to walk or to avoid falling while walking. Indeed, it was clear that walking can be quite attention-demanding, “like babies when they start walking” (FG-MS), and that walking slowly is often a deliberate adaptive strategy to maintain safety or to conserve energy. More important than walking difficulties for some people with MS was not being able to get up from a fall:“I mean, my walking sucks, okay. But I get around. (Other participants nod in affirmation.) I use a rollator at home and this (scooter) I use for distances and energy conservation. But if I fall in my house, there are times I've dialled 9-1-1 and just said, ‘This is not an emergency, I just need someone to come and pick me up (off the floor).'” (FG-MS).n = 41) corroborated the importance of falls as a key mobility concern and that walking speed was not viewed as one of the most important walking difficulties. When identifying difficulties that limit walking, the top 5 selected survey responses were as follows: I fall or lose my balance , I have difficulty with stairs , I get very fatigued with walking , I drag my foot on the ground when I walk , and walking takes up so much energy . Walking slowly/unable to walk quickly  followed difficulties with knee buckling  and poor sensation or presence of tingling  were also common responses.The survey results from people with MS . Clinicians also reported that fatigue, dynamic balance, and weakness, especially in the lower extremity, including foot drop, were key problems. The theme of getting out into the community also arose in the discussions with clinicians:“Just not being able to walk in stores and things like that… I mean, they tell you they can't do what they'd like to do in the community.” (FG-PT).Regarding the importance of walking speed, the physical therapists said, “it depends on what they need to function” (FG-PT) as well as “the job that they're working and their responsibilities as an adult” (interview-PT) and whether it is “an applicable functional goal” (survey-PT). However, there was widespread agreement that “the first priority is to be able to walk safely” (FG-PT). One physical therapist commented that, “(The patient) may say, ‘I'm having a hard time with walking' or ‘I'm falling a lot,' but I've never heard someone say, ‘I can't walk quick enough.'” (FG-PT). Only 4 (25%) clinician survey respondents selected “slow gait speed” as a major problem for people with MS.It was recognized by the clinicians that being able to walk quickly was necessary “to be safe in the community” (interview-PT) such as “to cross a street” (Survey-PT) or “avoiding traffic” (survey-PT). Clinicians were also concerned about a patient's safety at faster walking speeds and whether “we are improving gait speed at the cost of better gait mechanics” (survey-PT).In line with the major themes from the people living with MS, clinicians also stated that not falling, “walking better” (FG-PT) or “ further… so they could, you know, get the groceries” (FG-PT) were more important to focus on than speed; but, still, “safety is number one” (FG-PT).n = 32, 78%), improve strength , with several participants emphasizing foot drop in particular . Related to walking, most people with MS wanted to improve the smoothness and quality of walking  and to be able to walk further/longer without needing a rest . Increasing walking speed was not a commonly stated goal of physical therapy for people with MS .When thinking about their most recent episode of physical therapy, people with MS described mostly functional tasks, such as sit to stand, as chief goals. Strengthening of the legs and getting “a good stretching program” (FG-MS) were also frequently desired outcomes. Indeed, several survey respondents specifically described stretching as one of the most effective parts of their physical therapy. Among survey respondents with MS, the most frequently reported goals of therapy were to improve balance .“My therapist paying attention and always doing what was best.” (survey-MS).“It was a waste of time with the last physical therapist I was working with, because they didn't listen to me… They didn't listen to me, so I didn't feel they were working on the things I needed.” (FG-MS).“But most of the time, I have to say that the physical therapists I've worked with it's the one-on-one for that 15 minutes or whatever it is. You have their undivided attention, and that makes all the different in the world. Don't tell me, ‘Here, go on the New Step for 10 minutes and I'll be back.' I don't want to hear that, you know. You need to be there and find out how I'm ticking.” (FG-MS).Consistent with this perspective that effective physical therapy involves direct attention from the physical therapist, a couple of survey respondents said that riding a stationary exercise bicycle was the least effective aspect of their physical therapy. Additionally, people with MS are unsatisfied and frustrated when given exercises “that do not work for me” (survey-MS), that are too difficult, or require machines that the person does not have access to without a gym membership.There was an admission by the focus group participants with MS that they are not always compliant with their home exercises, which was associated with “guilt, because I never do my routine at home” (FG-MS), whereas another participant suggested that noncompliance was related to lack of “incentive to do it when you feel like it's not budging at all” (interview-MS).It was evident that people with MS also value a therapist who has expertise in MS, commenting that those who are trained in MS “know not to get you to overdo it; they understand MS patients” (FG-MS), whereas, “you know if they are not trained in MS, they want to push, push you, push you and it's like, ‘No, that's not what you do with MS patients.'” (FG-MS). The clinician focus group corroborated this idea, with one therapist stating that, “I have people that are thrilled to have a therapist who has a little bit more appreciation for what MS can be” (FG-PT).Regarding intervention for mobility limitations in MS, the overwhelming theme to arise from the physical therapists was that treatment is a multidimensional approach that includes “a lot of stuff” (FG-PT) and is “as individualized as possible” (survey-PT). The therapists emphasized that it should include “functional activities… rather than giving someone just an exercise to do, make it something that's more important to their life” (FG-PT) or focus on “what's most pressing to them” (FG-PT).The most frequently reported activities for treatment of walking difficulties were lower extremity strengthening, gait training, and dynamic balance training “because  does impact walking so much” (FG-PT). Therapists also reported focusing on fatigue and spasticity management. Some therapists described using functional electrical stimulation and orthotic devices to help improve walking. The emphases on employing a variety of treatment activities and using a patient-centered approach were consistent across the focus group, interview, and surveys.n = 11, 69%), fatigue , usually assessed with the modified fatigue impact scale or the fatigue severity scale; and the 12-item MS walking scale . The timed 25-foot walk test was also reported to be commonly used among all participants, even though “I don't usually work on making them walk faster” (FG-PT), but “usually more just because I feel like I'm lacking in objective measures to say, ‘how is their walking quality'” (FG-PT). Other frequently mentioned outcome measures were the timed up and go test, the functional gait assessment, the dynamic gait index, the Berg balance scale, and the BESTest or the mini-BESTest.Therapists were also in general agreement about the assessment tools used to measure and evaluate walking limitations in MS, with a clear perception of a need to “find something functional and objective to measure” (FG-PT). Thus, the selection of the particular measures used was predominantly based on the patient-specific problems as opposed to routine selection or tests required by the facility. The top responses among survey respondents were the 6-minute walk test  I mean, I look, I… (PT2 interjects).PT2: It's a balance and… .PT6: …I do a lot a lot of questioning, yeah. Loss of balance and, um, I do a lot of questioning on, um, like their insight. Like asking them how they felt they did, during, you know, whatever the gait trial was that we did. Like were they unable to navigate obstacles? Were they steady or unsteady? Are they at risk for falling? Are they walking fast enough to get from point A to point B safely?PT2: Yeah, and balance confidence is linked with balance ability.  So balance, you know, so in that way, maybe looking at balance confidence.PT6: Yeah.PT5: Yeah, the ABC  scale is what I've used before. Just the subjective measure for balance confidence.PT4: Just whatever balance thing I, whatever balance test I did.PT5: Measurement (interjecting).PT4: I guess I only think really of falls when I think of safely walking, but maybe that's very narrow-minded.PT2: Yeah, I think the loss of balance and falls, how much assistance they need.PT4: Yeah.PT2: And those are things that you can measure, count.PT6: Yeah, their history of falls and I typically ask in the last three months or in the last six months, how many falls they have had.PT1: Yeah, and I use that too for goal setting. If someone's like, ‘I fall at least two times a week.' Then I might make a goal that they will not fall at all in the span of a week, or something like that.The verbal and nonverbal expressions suggested a relative lack of certainty about measurement of safety. As the discussion continued, the clinicians described the subjective nature of measuring safety during walking to include observations of “unsteadiness,” “loss of balance,” “frequent toe catching,” and “increased lateral sway.” They also described using “cut off scores” on balance measurement tools to determine fall risk as an indication of a patient's safety.In terms of knowing if physical therapy has been effective, participants with MS gauged effectiveness by whether “I can do a little bit more than I used to” (FG-MS) and “whether I feel like I can get around more easily and if I don't get tired out as much” (interview-MS). Among the focus group of people with MS, there was unanimous agreement that “not getting worse” was a positive outcome. Indeed, the focus group participants with MS acknowledged that “you're not going to suddenly get better,” and that “this is a disease you live with.” Another person with progressive MS commented that, “I don't have any great expectations at this point, but I would like to be able to keep at least doing what I can do” (interview-MS).n = 14, 34%) was the most frequently selected response option to indicate that physical therapy was effective. Other common responses included, I am more confident in my abilities , I am not as wobbly or unsteady when I walk , and I feel like I can do more ; the latter also being consistent with the focus group and interview findings. Importantly, “I can walk faster” was not a frequently reported indicator of therapeutic effectiveness among survey respondents with MS . Indeed, the “most important” to “least important” aspects of mobility as ranked by survey participants with MS were as follows:I do not want to fallI want to walk without an assistive deviceI want to be able to walk more smoothlyI want to be able to walk longer distancesI want to walk fasterI want to be able to talk or do other things while walkingSomething else is more important This finding was strongly corroborated by the survey responses in which, “I didn't get any worse during the therapy period” .“Well, of course, repeating the outcome measures and kind of using that as a guiding tool.” (interview-PT).“If measures improve.” (survey-PT).“Reassessment of outcome measures comparing at baseline vs re-evaluation.” (survey-PT).There was also agreement that patient self-report and, where applicable, family report is used to help determine if treatment had helped the patient. For example,“Report of family, patient's perspective.” (survey-PT).“But a lot of it, use patient reports of them being able to participate in different activities that they weren't able to do before. I've also found that family members and other caregivers, their input on how the person's performing their day-to-day activities, walking, how far they'll be able to walk, that subjective report from caregivers…” (interview-PT).“I think using some of those self-report measures is a great way to do that (know if a patient has benefited from therapy). Besides just asking, ‘Hey, how are you feeling?' from session to session, but when you're doing an actual assessment, to say, ‘Let's do the ABC scale again or the MS Fatigue Impact or the walking scale.'” (FG-PT).The idea that maintenance of functional level can be important also came up in the clinician focus group, with one therapist commenting:“And I think a challenge for patients that have MS is also just the progressive nature of the condition. And where they are along that progression because some people progress much more rapidly than others. So, a lot of times you're looking to see if you've made improvements, whereas other times it's a victory to have maintained where they were, when you first originally started working with them.” (FG-PT).The consensus on this idea was not as strong among the clinicians as it was among the focus group of people with MS. Further, it was clear that even though therapists recognize that patients with MS have a progressive disease, they like to give the patients activities or home exercises that make the person feel as though they have been “productive and successful” (FG-PT). Indeed, most survey respondents indicated that they were looking for patients to report “improved function.” None of the clinician survey respondents mentioned maintaining function as a demonstration of treatment efficacy. However, this may be because the questions directed them to think about a particular bout of physical therapy, rather than long-term management of patients.The purpose of this study was to identify the most important aspects of mobility for people with MS and physical therapy clinicians experienced in treating MS-related mobility impairments and to explore how patients and clinicians perceive whether physical therapy has been effective. The findings revealed that the most important priority for people living with MS was safety/avoiding falls. People with MS also regarded being able to participate in activities outside the home as highly important. Walking speed was not a high priority for people living with MS, with many participants acknowledging that slowness was a deliberate strategy for maintaining safe ambulation. Indeed, several other aspects of mobility were considered by patients with MS to be more important than walking speed, including not needing to rely on an assistive device, smoothness of walking quality, and endurance/distance.Safety was also the most important aspect of mobility expressed by clinicians. Although the clinicians described routinely measuring walking speed as part of their evaluation, the clinical decision-making process appeared to be driven by the need to document objective measures, as opposed to setting walking speed as a treatment goal. Walking speed assessments were also often used by clinicians to make inferences about safe and functional ambulation in the community. Indeed, gait speed is a well-recognized indicator of functional status and health ; thus, iInterestingly, although there is evidence that “fast” walking speed in people with MS can be improved following rehabilitation or exercise interventions in both relapsing-remitting –27 and pAlthough safety was the “number one” priority for clinicians, there was some uncertainty regarding practices to objectively measure improvements in safety. Rather, it appeared that clinicians relied on a subjective impression of safety informed by observations of stability or losses of balance during mobility-related activities, as well as consideration of patient-reported fall history. Clinicians described using standardized balance assessments with established associations with fall risk to objectively measure constructs related to patient safety. Indeed, given the focus of both patients and clinicians on the importance of avoiding falls, measures of dynamic balance and reactive postural control may be more meaningful than gait speed for evaluating therapeutic effectiveness of rehabilitation interventions for walking limitations. This is significant because a recent systematic review of outcome measures used in trials of gait rehabilitation in MS  found thRegarding how patients and clinicians evaluate treatment efficacy, there were some incongruencies between the two perspectives. In particular, many people living with MS reported that “not getting worse” is a successful outcome from an episode of physical therapy, whereas clinicians expected improvements in outcome measures exceeding minimal clinically important differences to demonstrate efficacy. However, clinicians also reported relying on patient and caregiver report of improved function. Interestingly, the systematic review of outcome measures used in trials of gait rehabilitation in MS  found thA limitation of this study was the limited number of focus groups that could be conducted due to complexities of participant availability and geographic location. However, the focus groups and one-on-one interviews informed the design of the survey, which provided valuable triangulation of the data. The questions in the focus groups, interviews, and surveys did not go into depth regarding the role of fatigue in walking difficulty in MS. Because fatigue can substantially limit mobility in MS , it may This qualitative study revealed that walking speed, despite its recognized functional significance in the clinical community and popular use in evaluating rehabilitation efficacy in clinical trials, is not of prime importance to people living with MS or to clinicians treating MS-related mobility impairments. Clinicians and patients were congruent in their prioritization of fall avoidance and safety but were somewhat incongruent in how they evaluate whether a bout of physical therapy has been effective. Given that patient perception of improvement is central to clinical significance, clinicians and researchers should consider incorporating assessments of dynamic postural control and fall risk when evaluating efficacy of interventions targeting mobility disability in MS.