Increased access to technology can promote independent living, stimulate cognitive functioning, relieve caregiver stress, improve telehealth access, increase overall well-being, and be used to share cultural resources such as Indigenous language applications. Many Indigenous older adults would like to learn more about technology and recognize the value of technology in supporting healthy ageing; however, as Morning Star Lodge has previously determined, accessibility and readiness were key factors in the use of this technology. Utilizing the guiding principles of the Model of Engaging Communities Collaboratively and the Ethical Engagement Training Module, Morning Star Lodge partnered with the Star Blanket Cree Nation to support the healthy lifestyle of six Indigenous older adults by increasing their access to and engagement with culturally safe technology solutions individual to their specific health and lifestyle needs. These co-researchers were provided with tablets, MiFis (mobile internet access), and learning workshops and were interviewed pre- and post-workshops to assess their comfort level with the device and information received. Additionally, these interviews assessed how the technology helped to address the health needs of the co-researchers. The findings demonstrated that the technology met the health needs of the older adults, particularly with the emergence of the COVID-19 pandemic and the need to stay connected to loved ones. The information gained through this work will support public health workers in responding to the needs of older Indigenous adults using technology to meet their health and well-being. There is also a significant need for pandemic preparedness work to be done with Indigenous communities and this work could inform this in part. Globally, access to technology and infrastructure, as well as awareness of what is available, can be limited. Barriers to access caused by infrastructure need to be addressed, especially in the context of COVID-19, which has ignited significant changes and restrictions in healthcare and physical distancing. With the emergence of the COVID-19 pandemic and the need to stay connected, access to culturally appropriate technology for remote Indigenous adults has become critical. Broadly, evidence suggests technology use among older adults in Canada increased due to the COVID-19 pandemic. But as Czaja observed, there is still the need to understand technology adoption and factors influencing technology uptake among subpopulations even if there is a general increase in technology use.Increased access to technology can promote independent living, stimulate cognitive functioning, relieve caregiver stress, increase overall well-being, and be used to share cultural resources such as Indigenous language applications. This understanding is significant for health leadership in Saskatchewan as the province is expanding virtual healthcare services to improve access to healthcare. Limited access to technology among older adults is a major policy concern in Canada. Particularly, for Indigenous older adults living in remote communities, access to culturally safe technology still remains a challenge.10 This study is therefore timely and relevant to health leadership in Saskatchewan as it highlights some of the deeper socio-cultural factors that influence technology use among Indigenous older adults within Star Blanket Cree Nation.Importantly, Czaja concluded, “... for the potential of technology to be realized for older adults, it is essential to understand trends in technology adoption and factors influencing technology uptake among older individuals.”12 Specifically, the researcher worked with six Indigenous older adults to identify technology needs through interviews and observation, where participants were provided with internet access and tablets . Educational workshops were offered to support the use of the new devices and the language apps. Prior to engaging co-researchers, the researcher compared and contrasted the Model of Engaging Communities Collaboratively (MECC) and the Ethical Engagement Training Module (EETM) to ensure ethical engagement principles of research for Indigenous peoples in Treaty 4, Saskatchewan.This research involved collaborating with older Indigenous adults to determine what they want and need from technology to both support a healthy lifestyle, while increasing access to and engagement of culturally safe technology solutions. Scholars have shown the need to assess the distinct technology needs of older adults before engaging them with different types of technologies.The research objectives of this work were to learn from Indigenous older adults about what they need, how competent they are/feel in using technology to meet these needs, and increase access to and engagement with technology specific to their overall well-being and healthcare. While the present climate of uncertainty weighs especially on Indigenous older adults about the safety of their health, the researcher aimed to increase their awareness of available resources and services that may help to alleviate any extra anxieties regarding their health. The research is also a pilot study of using the MECC and the EETM to support older Indigenous adults in addressing their health and well-being concerns and needs while also evaluating the processes of both these frameworks to further our understanding of working effectively and respectfully with Indigenous populations.The MECC and the EETM are models for engaging ethically and respectfully with Indigenous communities. The MECC was developed by Dr. McIlduff to inform the processes of implementing evidence-based practices with Indigenous populations in the Australian context. The EETM on the other hand was developed by Morning Star Lodge  in the Canadian context for engaging ethically and respectfully with Indigenous communities. Community engagement as used in this article means, building relationships with individuals and community members upon trust, cooperation, and mutual respect which extend beyond the life of a project.First, MECC and the EETM were compared and contrasted to inform the work with Indigenous older adults in Saskatchewan. This knowledge was utilized to engage a Community Research Advisory Committee, recruit co-researchers, conduct pre- and post-interviews, as well as implement educational workshops. Indigenous community-based research methods were essential to this work. Observationally, data pertaining to the co-researchers’ competence to use technology was also collected through the workshops and involvement in the community allowed the researcher to observe familial interaction using various technologies. Pre-interviews focused on building relationships, such as getting to know the co-researcher, their health needs and experience, as well as confidence or curiosity around technology. After pre-interviews were completed, tablets were pre-loaded with individualized health and well-being apps according to each co-researchers specified health and well-being concerns. These tablets, along with a MiFi device with unlimited data for six months, were delivered to each co-researcher. Given the timing of the delivery, at the height of the second wave of COVID-19, the researcher was not able to give in-person support to assist with technology familiarity. This added an intergenerational dynamic to the project as children or grandchildren of the co-researchers were recruited to support their family members with the initial use of the technology. The first two educational workshops were conducted using Zoom and the last four workshops were conducted in person. Often, the children and grandchildren of the co-researchers still chose to participate in supporting their family members for the in-person workshops. The first two workshops reviewed the functionality of the tablet, including general functionality, volume, camera, zoom, security, and walking them through what apps they had on their tablets. The following four workshops were in person and therefore were more in depth, in which the co-researchers learnt how to use some of the apps available, how to add additional apps they wanted on the tablet and some even set up social media accounts to keep in contact with family and community. Post-interviews focused on confidence changes with using technology, future technology learning, their health, and their experience with the research process. These were open ended questions giving co-researchers the opportunity to express their views on the technology. Each interview lasted about an hour. Within the interviews, quantitative data was collected verbally using a Likert scale see . The maiThis project received ethics approval from the Ethics Board at the University of Saskatchewan, Approval number 2292. Meaning the themes were co-deduced manually from the interview transcripts by the NAKPA panel. This data analysis approach aligns with the Community-Based Participatory Research methodology by directly involving the community in the analysis process. Hence, the data analysis was a collaborative process that involved the community. In this research, the panel consisted of researchers and Indigenous community members. The results were reviewed and approved by the community research assistant to ensure the results represented the co-researchers’ and community’s views. It is important to note that Indigenous community members were a part of the entire research process from its conception to the data analysis and knowledge mobilization. The quantitative data was also analyzed manually.The comparison of the similarities and differences amongst the guiding principles of the MECC and EETM was done with the support of the community research assistant to ensure cultural appropriateness of the comparison and further feedback. The qualitative results of the pre- and post-interviews were analyzed using an Indigenous data analysis method known as Nanâtawihowin Âcimowina Kika-Môsahkinikêhk Papiskîci-Itascikêwin Astâcikowin . NAKPA data analysis is a process where, “a panel of experts, community members, participants, Elders, Knowledge Keepers, and the researchers are gathered together to do the collective data analysis.”16 The EETM could benefit from more practical examples of how to attain ethical engagement similarly to what the MECC provides.For the sake of this paper, it was determined that both MECC and EETM had similar considerations, but also complemented one another. The EETM named Cultural Safety, Self Determination, and Data Sovereignty overtly; however, the more prescriptive/practical nature of the MECC embeds these imperative concepts into what is expected of researchers throughout the process as can be seen in The six co-researchers were between the ages of 55 and 81 . All but one of the co-researchers had multiple comorbidities. The one co-researcher who reported good health had significant concerns as a caregiver for other family members who had multiple comorbidities.“I think it went really good. I really enjoyed it” . Another said, “I thought it worked alright, lots to learn”(CR 4). A third co-researcher even identified the need for continued support after the research project formally ends. As she said, “That will be something, you know, like you coming out again and show us more and stuff, I really liked it, how it went, you did good you know” (CR 5).The results showed that combing the two engagement models to facilitate the study ensured the research was conducted ethically. The co-researchers were asked about how they thought the research was done or if they would change how it was done. One co-researcher stated, This satisfaction was also reflected in the quantitative survey  in whichAs stated earlier, the pre-interviews were to assess the technology needs of the co-researchers. This information informed the type of apps that were pre-loaded on the tablets. The major themes that emerged from the pre-interviews were: history, health access, health, impact of the pandemic, technology use, and confidence. For the sake of this paper, only representative quotes were chosen in an effort to briefly and adequately showcase what was shared.“[T]oday they’re all working and have their own jobs and have their own children to look after, they can’t be looking after us … Yeah, jobs and that take away people from families cause they have to work to survive … long ago they never had those, they never were they were self-efficient they lived off the land and lived off their own thing, today they have to live like they, they’re living in a society where they have to support themselves somehow and their families and even that having to work is taking away from being from family, their own kids” (CR 1). Additionally, a second co-researcher noted, “I lost my childhood, missed part of that circle, I was just busy looking after my siblings and family [in residential school]” (CR 4).It emerged that historical factors were some of the factors that influenced the co-researchers’ technology needs. Meaning the co-researchers’ technology competency, how they felt about using technology, and the type of apps they wanted pre-loaded were informed by these factors. Specifically, some co-researchers spoke about how colonialism and the residential schools disrupted traditional family structures and support systems, thereby affecting their current health circumstances and technology needs. These factors therefore influenced technology competency and informed how the technology would be used to stay connected to family and the community at large. As one co-researcher commented on her family, “Yeah, she lives right in the town here so it’s easy for her, for me if I needed homecare I would have a hard time out here, we have no funding whatsoever to hire homecare, people from out of our own community to help us” (CR 1). Another identified health access as a significant concern, particularly where aid/support was involved, “I have 3 other people helping now it used to be just me and I told them I was feeling my health” (CR 3). They also spoke of the importance of ancestral healing practices, “Praying I guess and spiritual, smudging trying to stay positive when things are going wrong” (CR 4).Another important theme that emerged in the pre-interviews was that health access played a significant role in how the co-researchers would use the technology. We found that the difficulties in accessing western healthcare system and the need for aid/support informed how the co-researchers would use the technology as well as the type of apps they wanted to meet their health needs. With most of the co-researchers being older adults, there was a strong need for social and healthcare from family members. Hence, they stated that although the technology would help them stay connected with their loved ones, having a family member living within the same community or physically present was also preferred. As one co-researcher stated when talking about her daughter, “I kind of think I’m getting arthritis ‘cause I’m having a lot of joint pain in my knees and it’s hard to go up and down the stairs a bunch” (CR 2). She went further to state that, “I notice the side where I have this bunion or whatever it’s called, it hurts my foot underneath like there’s a bone there” (CR 2).Another major theme that emerged from the pre-interviews was that individual co-researcher’s health concerns and the health concerns of loved ones or family would influence technology use and the type of apps they wanted on their tablets. Commenting on her current health concerns, a co-researcher explained, “Not a diabetic, but my youngest son is, he also has high blood pressure, I worry about him” (CR 4). She went further to explain that, “There’s a lot of respiratory problems in my family on my mother’s side—A lot of them had to be on oxygen and things like that” (CR 4). One co-researcher spoke of the experience of health changes, “My health being bad now, it’s hard to do those things I used to like” (CR 6).A second co-researcher also spoke of her family’s health as it affects her own life by stating she is “I’m not seeing family because of the pandemic, it’s very isolated times” (CR 5).Also, the pre-interviews showed the COVID-19 pandemic influenced the co-researchers use of the technology and the type of apps they wanted installed. With the emergence of the pandemic and the institution of social distancing regulations, the need to stay connected to loved ones and family was important for most co-researchers. This therefore informed how they would use the technology. Family plays a very important role within Indigenous communities, the isolation that came with the COVID-19 pandemic was therefore a health need that the co-researchers thought could be solved using the technology. As one co-researcher noted, “Sometimes we go on my husband’s phone, we do facetime.” She went on to state “I would like to learn more about zoom to attend community meetings” (CR 3).On co-researchers’ experience with technology and confidence in using the new technology, the pre-interviews showed their technology needs were influenced by language and culture, communication and staying connected and hesitancy and risk. Hence, communication apps and staying connected to the community were important to some of the co-researchers. As one co-researcher noted, “I actually took a few sessions of Cree on my phone, I enjoy learning about history, history of Indigenous peoples” (CR 5). Another co-researcher stated, “I use it to pray in the morning and pray in the night when it comes on my phone” (CR 2).Again, culture and language also came out as strong themes that influenced the co-researchers' technology needs. Some co-researchers talked about the need for Indigenous language apps and to reconnect with cultural teachings. Therefore they wanted the technology to help facilitate these cultural learning processes. A co-researcher, for example, commented, “Security is a concern with all the scammers out there” (CR 4). A second co-researcher also observed, “I’m just finding out about it [technology], I’m not really that good to tell you the truth” (CR 3). A third noted “Not many Elders are interested in these things—like technology” (CR 6).However, some co-researchers expressed concerns about the risk associated with technology use and the fact that they did not know much about the technology. Co-researchers spoke of the frequency of technology use, hesitancy in using technology and the risks associated with technology use. A co-researcher stated that, The major themes that emerged in the post-interviews were health, confidence, education, and the generational gap. For the sake of this paper, only representative quotes were chosen in an effort to briefly and adequately highlight what was shared.“My nephew, he has to go for a kidney transplant, he is trying to find a donor, they are testing, gonna get tested to donate to him. They say a live donor would be better” (CR 2). Another co-researcher observed, “I’m getting such short memory now, so things go in but don’t stay in … like you said, I might have to, you know, start writing stuff down in order to try and do stuff” (CR 4).As observed in the pre-interviews, when speaking about their health, the co-researchers included their family’s health as it also impacts the information they were seeking while using technology. Health influenced how the technology was used and the type of information the co-researchers used. As one co-researcher noted, “I’m comfortable with it, I just got to know a little bit more, I get frustrated” (CR 5). A second noted, “Yeah, I’m getting there [more confident] … when I use them” (CR 3). However, a third co-researcher admitted her confidence had increased but the rate at which new technologies and apps were being developed posed a threat to her learning about technology. By observing, “I’m not too well advanced in that, in the technology. Once I learn something then there’s something else new coming up. There’s something new every year, yeah like you know … I guess if I just you know, learn the basics and whatever I guess I’d be just fine with me” (CR 4).Following the workshops, while co-researchers still spoke to their hesitance, lack of confidence, and security concerns, their familiarity and use of technology had greatly increased. We found the educational workshops helped enhance the co-researchers’ confidence in using the new technology. One co-researcher stated, “Oh my goodness! I don’t wanna get too dependent on technology” (CR 5). Another co-researcher stated, “Sort of comfortable, I’m very careful about that. Yeah, I don’t go on-line like for Amazon or anything like that, I don’t purchase” (CR 4).We observed that although confidence in technology use improved, there was still some hesitancy on the use of technology among co-researchers. One co-researcher noted, “Kind of scary and then you … I’m listening to the news like every day, like what else can I do, but you know, listen and hear about you know scammers and whatever” (CR 4).She went further to state that “My e-mails are connected to both my cell and my personal computer” (CR 5). A second co-researcher went further to show how she has been able to use the tablets for on-line banking. She noted, “I do my on-line banking on my phone. I don’t do it on my personal computer. It’s more convenient on my phone” (CR 2).Further enquiries revealed some older adults within the community were victims of internet scams. Perhaps this explains some of the hesitancy around technology use among the co-researchers. Irrespective of this unfortunate experience, the post-interviews showed the co-researchers’ knowledge of the interconnectedness of many technologies grew significantly as they became more adventurous with the support of the workshops. As one co-researcher stated, “I probably will, you know, help me you know doing things on my tablet, I probably will get a different phone with those kinds of apps and whatever on them” (CR 4). Another spoke about the internet connectivity being slow. She stated, “It’s the wifi, I even bought an extra cable and even that is not connecting” (CR 5). Some of the co-researchers even added more apps to the technology. One co-researcher, for example, stated, “I don’t understand like Dropbox. Like how, like my files how to store them, I just store them wherever. I need to kind of look for them after” (CR 5).Again, others spoke openly of their new found confidence and understanding and trouble shooting. A co-researcher, for example, observed, “Actually, my doctor phones me when I can’t go in. So she set up a certain time that she would call between eleven and twelve and asked me all kinds of questions and stuff like that and yeah” (CR 6). She further observed, “He usually calls and checks up. He’s had his family doctor for over 20 years. So he’s really good with him. The doctor calls him, even on Saturday to see how he’s doing. I like that part about him” (CR 5).The post-interviews also showed some of the co-researchers used technology to access healthcare. Access to healthcare services remains a major challenge for older Indigenous adults living in remote communities. It was therefore important to find out that the technology was being used to access healthcare. Some of the co-researchers spoke of their (or their family’s) experience using telehealth. As one co-researcher stated, “So you know it’s I just watch and stuff like that and then I forget about it, eh, for a while. And then I go back and you know try and figure out stuff and things like that. So, I mean it comes to me eventually” (CR 4). Another co-researcher went further to talk about how technology could help with daily chores. As she noted, “I got a vacuum, robot vacuum cleaner. I don’t really know how to use the damn thing” (CR 3). Some co-researchers have even learnt to sync their accounts into a single account. Based on this a co-researcher commented, “All my devices are connected to my Bell account” (CR 5). We also found some of the co-researchers were willing to help their partners with the use of technology. One co-researcher spoke about her partner said, “So I don’t know what’s happening with his phone or if he needs a different phone, I always tell him he should get a bank, get your bank apps on your phone. But I don’t know if he’s able to do that” (CR 5). Additionally, they talked about which technology devices they preferred based on different functions. One co-researcher stated, “I would much rather use my computer, ‘cause it’s got the bigger screen. But yeah, if I have to, if I’m on the road, it’s really convenient with my cell phone ‘cause I can get Zoom and everything and my e-mails on my phone” (CR 6 ). When they spoke of their technology literacy, the ranges of what they could use had really expanded, “I don’t know anything on my phone except text and phone and play games and Facebook.”“I used to have games and then I deleted them, ‘cause I didn’t want to use up my gigabytes or whatever.”“The apps I do have right now, I like to get onto the iTunes - I have that and I have my banking app.”Another important theme that emerged from the post-interviews was around education. When co-researchers spoke of their own education around technology, they spoke of what they had already been learning and how they were sharing this knowledge, and what they would like to learn in the future. One co-researcher said, “If they [Elders] knew about it [technology], maybe they would, but I think we’re just kind of like in isolation right now. ”“I just don’t know how, my printer … I can’t get connected to my computer.”“And like, even now you know, like more people get, like this workshop.”“ We need to make this available for more Elders to come out. ”Many expressed interest in further learning around different technologies both for themselves and their fellow Elders, “And then when something comes up and stuff like that, then they say—oh you weren’t you know, notified—and stuff like that, like a lot of them, you know, don’t have access, like I said, you know we’re learning this tablet and that and Facebook and that, eh, and that I’m sure a lot of them have phones, you know, and they can get all this message and whatever if they had Facebook on their phones” (CR 3).A few of the co-researchers spoke of the generational gap created by technology, particularly around communication of current events occurring in their own communities. A co-researcher commenting on generational gap in technology use said, 18 Combining the EETM and MECC models ensured effective community engagement and collaboration in the research process. The strengths of both models ensured a continuous community involvement throughout the entire research process. Importantly, engaging the community in every stage of the research, including allowing the co-researchers to decide the type of apps to be loaded into the technology ensured the co-researchers were respected as equal partners in the research. Besides this, the community was also involved in the data analysis stage, reviewed and accepted the results before this article was submitted for publication. Again, this enhanced respect and trust which were very important for technology education during this research. Given the unfortunate experience of one of the co-researchers falling victim to internet scams, trust was very important in building the co-researchers’ confidence in using the technology. Also, the involvement of young family members in the technology education process helped build trust in the technology. The COVID-19 pandemic created an opportunity to engage young family members in teaching co-researchers to use the technology. Fortunately, most of the things taught by the researcher and the young family members were similar. Hence, further creating trust among the co-researchers in the technology and research process. Trust is therefore crucial in building older adults’ confidence in technology use and involving family members can help build this trust. This can be achieved through effective collaboration methods as shown by Community engagement plays a significant role in Indigenous research. The health of the co-researchers and their family members played a significant role in how they engaged with the technology. This was seen in the type of apps and information the co-researchers used. Most of these were centred around their health and the health of their family as well as loved ones. Tailoring technology to meet the specific health needs of older adults and their families can therefore enhance access and build confidence in technology use. Meaning it is also important to consider the families of older adults when engaging them in technology since family plays an important cultural role within Indigenous communities. The health and well-being of family members is as important as the co-researchers' own health and well-being. Additionally, it is important to note that Indigenous peoples view health as being holistic. Hence, the technology was also used to meet spiritual health needs including prayers. Basing technology education on a holistic concept of health is therefore important when engaging Indigenous older adults in technology use.When informed by Indigenous culture, technology can improve Indigenous older adults’ access to healthcare.21 As Choukou, Maddahi, Polyvyana, and Monnin observed, respect for Indigenous culture is key to Indigenous older adults’ acceptance of technology. Hence, incorporating Indigenous culture including Indigenous languages, songs, stories, ceremonies, and prayers improved the co-researchers' confidence in using the technology. Culture defined how the co-researchers used the technology and the type of apps and information they searched for. Specifically, some of the co-researchers reported how the technology helped them reconnect with their culture including using the technology for praying and learning their language.Again, culture is very important when engaging Indigenous older adults in technology use. This study also shows that involving family in technology education improves confidence in technology use among Indigenous older adults. Additionally, some of the co-researchers emphasized the need for Elders to lead technology education within their community. Unlike Western learning systems, learning within most Indigenous communities is integrated into the fabric of both the family and the community as a whole.22Centring technology education around Indigenous peoples' cultures and traditions improves access.While the co-researchers continued to speak of their low confidence in using technology, they also expressed many additional applications and ways they were using their devices which showed they were gaining confidence, potentially even more than they realized. A prime example was co-researchers speaking of gigabytes and e-mail access on phones which were not common knowledge for them previously. They also learnt about the differences between LTE and wifi which some already had set up in their homes, but were not utilizing on their devices. The co-researchers showed improved knowledge around health services and information which supported their health and well-being needs and those of their family members. They also showed interest in social media platforms to further address their concerns and the communication gap due to isolation that they were experiencing with events going on in their community and their families. Further, all the co-researchers wanted to continue on this learning journey to learn more about technology.Given the significant interest shown by the co-researchers and their motivation to share their new skills and this work with other older adults, this work could set a precedent for how other researchers can support Indigenous communities, nationally and globally to empower older adults in both bridging the generational communication gap often mentioned as a concern and addressing health access in this and future crises or pandemics. The audience/user groups who could benefit from the knowledge produced by this research include Indigenous older adults, Indigenous communities across Canada and globally, retirement homes/residences, homecare professionals, and other professionals/researchers working with these communities.Furthermore, user-needs research is foundational to technology uptake. This research was directly responsive to the user-needs which required flexibility and innovative solutions to fit the unique needs of this population. Limitations of this work include a small sample size; however, this small sample size also allowed for more individualized support and solutions for each co-researcher and more rich data.Also of note, while working with the tablets allowed the co-researchers to explore new technology and build confidence, it was also recognized that potentially a more effective way of building this confidence for a greater population would have been to utilize the technology that they already had been engaging with and build their confidence on these first before introducing a new technology. Given the individualized workshops, this certainly happened organically while the researchers were in their homes, but the money spent on the tablets could have been utilized to offer more workshops to more co-researchers.Given the need during the COVID-19 pandemic to continue to stay semi-isolated due to older Indigenous adults being susceptible to the virus, the information gained through this work has the capacity to support other researchers and public health workers to support Indigenous communities in Canada and globally in using technology to respond to older Indigenous adults’ health and well-being. There is also significant need for pandemic preparedness work to be done with Indigenous communities and this work could inform part of that preparedness, particularly for the older adult populations.The MECC processes and EETM principles have been shown here to be effective and culturally appropriate as seen through both qualitative and quantitative responses with Indigenous participants in Canada, furthering the importance of ensuring research and work with Indigenous peoples must take a more consultative, collaborative and community-led approach across all fields of research and programming.


Nursing students are required to acquire the necessary clinical knowledge and skills to provide safe and quality care. The method of providing training, particularly for final-year nursing students, is of utmost importance. An internship is a program during which students work in shifts similar to nurses employed in a hospital; however, the number of their shifts and patients is less than nurses; a nurse and the faculty supervise the care they provide, and they are paid a monthly salary. This study was conducted to explore nursing faculty, managers, new graduates, and students’ experiences of nursing internship program implementation.This descriptive qualitative study was conducted from November 2021 to March 2022. The participants were selected from among nursing managers, newly graduated nurses, nursing internship students , and faculty of Iran. Data were collected using in-depth semi-structured interviews. The qualitative content analysis approach was used for data analysis.Participants in this study included 17 nursing internship students, 12 nursing managers, three faculty members, ten nursing preceptors, and five newly graduated nurses from the internship program, 47 participants in total. After analyzing the data, five themes, including ‘facilitation of socialization process,’ ‘filling the gap between theory and practice,’ ‘improving self-confidence and independence,’ ‘an opportunity for clinical skill training,’ and ‘Achilles’ heel of the clinical setting,’ and nineteen subthemes were extracted from the participants’ experiences.Implementation of an internship program for final-year nursing students plays a role in preparing them for better professional performance, enhancing clinical skills, increasing self-confidence and independence, inspiring the nursing profession, strengthening professional commitment, and improving the chances of employment after graduation. In order to alleviate the identified challenges of the internship program, holding a briefing meeting with managers, supervisors, and faculty to determine working hours, performance standards, and amenities such as lunch, dinner, and resting place is efficient. Nursing students are required to acquire the necessary clinical knowledge and skills to provide safe and quality care –3; conseAn internship provides a worthwhile learning experience before entering the nursing profession and allows students to professionally apply the principles and theories learned in school. The internship program also has the potential to increase students’ self-confidence, critical thinking, knowledge, skills, and clinical competence and reduce their stress , 12. DurStudies show that novice nurses who have not experienced an internship program lack sufficient self-confidence and the ability to provide efficient and quality care in clinical settings upon entering the clinical environment . In AbdeDespite the benefits of the internship course, the program faces challenges such as inadequate faculty support, the faculty and hospital’s poor collaboration, the hospital’s unusual and improper expectations of students, the faculty’s insufficient academic and practical competence to supervise, and the faculty’s inadequate time allocated to students. Moreover, nurses have to work with students despite their heavy workload, inadequate staff, and the collaboration of a small number of or no faculty members. Under these circumstances, they are unable to effectively manage nursing students. In addition, students ought to be considered a vulnerable group since complete separation from the school and faculty is stressful for them, and there is a risk of exploiting students as free or cheap labor by hospitals .The internship program in Iran began for the first time at Isfahan University of Medical Sciences in 2018 and has continued to date. In this program, final-year nursing students fulfill their internship program in various hospital wards, including 20 shifts  per month, and are paid a monthly salary. At the time of patient assignment, the head nurses assign two patients to each student in the first week, three in the second, and four in the third and fourth weeks. Students are independently responsible for patients; however, they work under the nurse’s supervision and raise questions and problems. Besides, resident faculty visit students at least four times a month, evaluate their knowledge and skill, and provide feedback on their problems. Students ask professors about their problems during the visit sessions and share their problems with the ward and the entire course. It should be noted that before the start of the internship program, essential nursing concepts such as patient safety, nursing process, medication calculations, and nursing documentation are retaught to students.In order to improve, a new curriculum is required to be evaluated from stakeholders’ perspectives to identify benefits and gaps . QualitaThis descriptive qualitative study was conducted from November 2021 to March 2022. In this study type, the researcher provides a comprehensive summary of the phenomenon or related events in a common language but does not go into the deep phase of interpretation . These sThe participants were selected from among faculty, nursing managers, nursing internship students , and newly graduated nurses from six hospitals in Iran. The inclusion criteria for nursing internship students included at least three months of experience as an internship student in the clinical setting, Cardiac Care Unit(CCU), pediatric wards) and willingness to participate in the study.Inclusion criteria for faculty, newly graduated nurses, and nursing managers included at least one year of teaching and supervising experience of nursing internship students and willingness to participate in the study. They were excluded from the study if they refused to share their experiences. Participants were selected using a purposeful sampling method. Sampling was performed with maximum variation in terms of age, gender, and the number of years of work, teaching, and supervising experience.After coordinating with the educational manager of the school, contact numbers of the nursing internship student , faculty (at least one year of supervising experience), nursing managers of hospitals, and newly graduated nurses were obtained. We contacted participants, and If they were willing to participate in the study, the interview time and place were arranged at their convenience. Data were collected from November 2021 to March 2022 using in-depth semi-structured interviews. All interviews were conducted by the corresponding author (SF), who has Ph.D. in nursing and has published several qualitative articles. The interviews lasted for 30–45 min on average, and they all began with a general question to establish a close relationship with participants . Another student said in this regard: “We realized that we had to comply with a series of regulations. Someone called the head nurse, with whom we have to arrange shifts, supervises us. We have to be flexible. We learn to be accountable and understand who is responsible for the patient; what the work conditions are” (P3).This theme includes four subthemes: “role model nurses,” “awareness of and adherence to professional rules and regulations,” “gaining a professional identity,” and “awareness of different roles in nursing.” Participants’ experiences showed that students in the internship program chose nurses, especially those with high knowledge and clinical competence, as their role models. Students prepare for the transition to nursing as they provide professional care and learn about providing safe and quality care. One of the students stated: “We worked in shifts work like staff, we knew how to work in different shifts; what hospital conditions are; how a nurse should work” (P4).In addition, the participants were gratified that the internship program equipped them with the knowledge to provide high-quality nursing care to attain their patients’ trust. Nursing students experienced a transition to professional identity through gaining satisfaction with professional practice. One student said: “Now, I have learned everything, and I can introduce myself as a nurse to patients and attract their trust” (P19).Internship students are also introduced to nurse roles in different wards and prepare to take various nurse roles in the future. One of the faculty members stated: “In addition to caring for the patient, the student also teaches, gets acquainted with the role of the head nurse in the management course, learns to lead a care team, responds to family caregivers’ questions, and uses acquired theoretical and practical information to educate patients and families. These activities familiarize them with different roles they will take in the future” . Another nurse manager said: “The faculty’s supervision and responses to students’ and nurses’ questions about patient care resulted in the promoted quality of care provided by them” (P26). One of the nursing managers stated: “internship students’ presence, professors’ supervision, clinical rounds, and clarification of scientific ambiguities that occur at times can greatly help improve nurses’ knowledge” (P13).Nursing internship students, faculty, and administrators claimed that the internship course could integrate theoretical nursing into practice and help train skilled nurses. One of the students stated: “The professor supervises us and answers our questions. It helps us not to do clinical practice blindly” (P15). One of the head nurses said, “I have the least trouble working with Ms. F, who used to be our internship student;, I will not allow her to be transferred to other wards” (P1).The newly graduated nurses believed that the novice nurses who had worked as interns in a similar ward and had gained the necessary experience and skills to work in that ward were among the best nurses. One newly graduated nurse said: “The nursing internship students are much in demand due to the attendance of professors in the hospital and help to improve nursing care provided by nurses and students” (P2). In addition, internship nursing students gradually gained the confidence to provide direct patient care. One of the students said: “Before taking the internship course, I had a lot of information, but I wasn’t confident to practice them. I was stressed, but this course reduced my stress, and I gained confidence because the nurses accepted me into their team” (P3).This theme includes three subthemes: “Being approved by nurses,” “Providing direct patient care,” and “An internship student; as a member of the healthcare team.” Participants’ experiences showed that an internship student is considered an auxiliary force by nurses and is assigned tasks in the care team. One of the students said, “I handled the patient in the wards like a full-fledged staff. There was no one supervising me. The staff knew we faced problems only during the first and second months. They trusted us and assigned patient care to us. Another student said, “Care was provided through the case method, and we were assigned entire patient care” (P16). Another student said, “In the emergency department, there were patients of all kinds that we had never experienced in a previous training course. When I became an internship student, I learned about types of arrhythmias and strokes” (P10). In addition, participants’ experiences showed that the presence of internship nursing students in shifts and different wards and dealing with patients with complex problems significantly contributed to their proficiency and functional independence. One student said: “I fully learned what to do for a patient with ventricular tachycardia. In fact, I learned patient management well” (P6).This theme can be discussed in three subthemes: “Increasing the frequency of nursing procedures,” “Diverse nursing procedures in different shifts,” and “Exposure to a wide range of patients.” Participants’ experiences showed that although nursing students became knowledgeable about various nursing procedures during the first three years of their studies, they acquired the necessary clinical competence during the internship course due to the variety of procedures and the opportunity to perform them time and again. One of the students stated, “In the previous training course, I didn’t have much opportunity for IV insertion, but when I became an internship student, I performed multiple IV insertions and became proficient” . Another student said: “When a new patient was admitted to the ward, I was given responsibility. I had never encountered such a disease before, but the nurse expected me to do everything. My hands were shaking, but the nurse told me to do it at that moment to learn. I was under a lot of pressure” (P16). Routine-centeredness, no attention to patient-centered care, and inadequate student education reduce the quality of care.The participants’ experiences showed that despite the benefits of the internship program, it would be challenged if the clinical setting was not sufficiently prepared. The student’s presence in the ward and providing care supervised by a nurse carries the risk of inappropriate role modeling. In some cases, students performed what was considered by the nurse as the ward’s routine, which did not reflect evidence-based care. In addition, students often relied on routine care and endured a great deal of stress of being negatively scored by nurses. One student said: “I felt like I was stuck in the ward routine, and I wasn’t given important information about the ward and the care system. Although I learned how to do suctioning in nursing textbooks, it was done differently at the bedside. I did it as the nurse told me not to lose score” (P11). Inadequate rest, especially during the 12-hour night shift, can cause fatigue. Students’ drowsiness and fatigue can lead to errors and threats to patient safety.Participants acknowledged that since they were supervised by a nurse and had to seek help from a nurse in case of complex problems, they were compelled to participate in caring for the supervisor nurse’s patients. Consequently, students endured a heavy workload. According to the regulations of the internship program, a nursing student, similar to the ward nurses, has the right to use the nurses’ resting room and other amenities. However, such facilities were not available for nursing internships in some hospitals. One of the nursing managers said: “We were not allowed to enter the nursing station. They said that we couldn’t sit on the chairs or rest in the resting room. We worked like nurses. We had the right to use the facilities” , an internship program was conducted for senior nursing students, during which 3 h of theoretical and 18 h of practical training were held per week during one academic year. Students cared for patients for 15 to 20 days in each clinic under nurses’ supervision and discussed deficiencies with the clinic manager weekly. In this study, after the end of the course, students’ level of professional commitment increased . In a stParticipants’ experiences revealed that the internship program helped fill the theoretical and practical training gap. The faculty’s supervision and responses to students’ and nurses’ questions caused nurses to support and educate students about the necessary skills. Clinical knowledge and skills acquisition had distinguished nursing internship students; accordingly, supervisors were inclined to recruit students after graduation. The goal of education is learning, and every educator is gratified by achieving positive learning outcomes . AccordiMoreover, discussions about patient care plans improve students’ learning and increase their enthusiasm for the clinical setting . In EgypIncreasing students’ self-confidence was one of the significant features of the internship program. Students believed they had full responsibility for the patient, and nurses fully trusted them and considered them not students but nurses. In a study by Glynn et al. (2013), in which an internship program was conducted for graduate nurses, participants reported that their independence and self-confidence increased since they fulfilled activities independently. They also had the feeling of managing patients independently and appreciated the program implementation . In the Achilles heel of the clinical setting” was the main challenge of the internship program. The present study revealed that the internship students were conflicted in the hospital because the care measures they learned differed from what was performed by the nurses in the hospital and caused them confusion. For the preceptors to become good role models for the students, the participants acknowledged that the faculty should examine their scientific and clinical competency before selecting them. Furthermore, most of the clinical education was conducted by preceptors, and the internship students stated that they felt abandoned in the clinical environment due to separation from the faculty. To solve this challenge, holding nursing rounds in the presence of faculty and clinical nurses will be helpful since the nursing internship needs the faculty’s study and guidance to prepare for the nursing round. Additionally, increasing supervisory sessions by faculty can help students reduce feelings of abandonment.According to the findings of the present study, the “According to the participants’ experiences, abusing students to be involved in other patients’ care was among the problems of the internship program, and this finding was consistent with other studies . To avoiThis study used the purposive sampling method, which can limit the transferability of the results. However, researchers attempted to use maximum variation by considering the participants’ characteristics regarding age, gender, and different stakeholders including faculty, nursing manager, newly graduated nurses, nursing internship student, and educators’ work experience, and a proportional number of participants for qualitative studies were used.This qualitative study was conducted for the first time to evaluate the internship program from the perspective of different stakeholders . The results of the present study revealed that the implementation of an internship program for final-year nursing students played a role in preparing them for better professional performance, enhancing clinical skills, increasing self-confidence and independence, inspiring the nursing profession, strengthening professional commitment, and improving the chances of employment after graduation. In order to alleviate the identified challenges of the internship program, holding a briefing meeting with managers, supervisors, and faculty with the aim of determining working hours, performance standards, and amenities, such as lunch, dinner, and resting place, is efficient. Enactment of internship rules precludes professional regulations from being disregarded by hospitals, faculties, and students. It also prevents student abuse. Moreover, holding an introductory meeting with students will identify and introduce goals and expectations and help provide safe and quality care in the future.


Language supported group antenatal care (gANC) for Somali-born women was implemented in a Swedish public ANC clinic. The women were offered seven 60-min sessions, facilitated by midwives and starting with a presentation of a selected topic, with an additional 15-min individual appointment before or after. The aim of this study was to assess the feasibility for participants and midwives of implementing The Hooyo  gANC intervention, including implementation, mechanisms of impact and contextual factors.n = 9), complementary, in-depth and key-informant interviews  and questionnaire data .A process evaluation was performed, using The Medical Research Council (MRC) guidelines for evaluating complex interventions as a framework. A range of qualitative and quantitative data sources were used including observations , felt comfortable in the group (98%) and supported by the other women (79%), and they said that gANC suited them (79%). The intervention seemed to enhance knowledge and cultural understanding among midwives, thus contributing to more women-centred care. The intervention was not successful at involving partners in ANC.The Hooyo gANC intervention was acceptable to the Somali women and to midwives, but did not lead to greater participation by fathers-to-be. The main mechanisms of impact were more comprehensive ANC and enhanced mutual cultural understanding. The position of women was strengthened in the groups, and the way in which the midwives expanded their understanding of the participants and their narratives was promising. To be feasible at a large scale, gANC might require further adaptations and the “othering” of women in risk groups should be avoided.The study was registered in ClinicalTrials.gov (Identifier: NCT03879200). Carefully evaluated antenatal care (ANC) interventions are needed to address maternal and reproductive health inequalities for migrant women –4. SomalFew attempts have been made to develop and evaluate interventions for improving health outcomes for Somali-speaking and other migrant women during pregnancy and birth in Sweden, for example using mobile applications to improve communication and bi-lingual doulas , 24. AllStandard ANC in Sweden for uncomplicated pregnancies includes 8–9 individual midwife appointments, free of charge , with reGroup antenatal care (gANC) is an ANC-model which typically integrates pregnancy check-ups with group sessions for education and peer support in groups of pregnant women , 28. SliFrom the third ANC appointment around gwk 20, women were offered seven 60-min language-supported group sessions together with 6–8 other women + fathers-to-be or other partner, facilitated by midwives, starting with a presentation of a selected topic. Frequency and total number of appointments followed the Swedish national ANC recommendations, as did the topics that were covered  . Pregnanoverall ratings of care and emotional wellbeing measured by the Edinburgh Postnatal Depression Scale (EPDS) (Submitted). In summary, no differences in the overall ratings of antenatal care were identified, but women in gANC were happier with the information they received on different aspects of pregnancy, labour and birth.The Hooyo gANC intervention has been evaluated in a quasi-experimental study, using historical controls to assess impact, with the two primary outcomes being The study protocol describes initial assumptions and underpinning principles, including a logic model with hypothesised mechanisms of effect and desired outcomes . LanguagInclusion of partners was a desired outcome, based on findings from the FGDs with Somali parents  and on pTwo clinics were involved in the intervention development. The design and hypothesised mechanisms of impact differed slightly between the two. At one site we hypothesised that language-supported gANC would improve Swedish-Somali women´s experiences of ANC and emotional wellbeing, in groups with only Somali-born women. This intervention arm was implemented. At the other site, we hypothesised that gANC with women of diverse ethnic backgrounds including Swedish (“mixed groups”) would have additional positive impact on integration and increased mutual understanding across language and cultural barriers. This latter site withdrew prior to implementation however, for a range of reasons (see Results).This was the first time gANC was implemented in Sweden with the specific purpose of trying to improve ANC for a group of women with migrant background, so it was important to explore acceptability and feasibility of the intervention, both among pregnant women and care providers. The aim of this process evaluation was to explore aspects of providing and receiving language-supported gANC, from the perspective of both Somali-born women and midwives.The implementation process, including how successful the delivery of the intervention was and what was actually delivered including fidelity to what had been planned, the adaptations that were made and who were reached and not reached by the intervention.Mechanisms of impact, including participant responses to and interactions with the intervention, mediators and unexpected pathways and consequences. The Medical Research Council (MRC) framework for performing process evaluations of complex interventions developed by Moore et al.  was usedThe implementing clinic was public, with 10 midwives and one manager, situated in a mid-sized Swedish city . The catchment area is diverse including a large Somali community. Childbirth and parent education is integrated in the individual visits, and in addition, a 3-h evening seminar for prospective parents is offered, however, in Swedish only. In 2018, ANC enrolment in the catchment in average area was done in gwk 11 . The SweData collection for this process evaluation was nested in the different project phases of the main study. Informants were Somali-born women who attended gANC, the midwives and interpreters implementing the intervention, and research assistants who facilitated implementation. Qualitative and quantitative data were collected from multiple sources employing different measurement tools and activities: observations of sessions, complementary, in-depth and key-informant interviews, field notes, open-ended questions in questionnaires to participating women and midwives and logbooks, questionnaires and midwives’ brief evaluation form documenting each session. The MRC framework for performing process evaluations of complex interventions guided the development of interview guides and other data collection tools. Table n = 2) and by telephone (n = 4).A purposeful recruitment strategy was used for all interviews, and interview guides were developed for the different types of interviews. We applied a pragmatic approach to saturation of data, because of the large total amount of data sources. The research assistant contacted gANC participants for complementary interviews, based on her pre-understanding of the participants’ views of gANC that she gained from the main study questionnaires, as we wanted to interview participants with both positive and less positive experiences. The interview guide contained questions such as whether it was good with a Somali group or if a mixed group would have been better, if the partner had attended and reasons for not attending, if the participant made new friends through the group and if she would like to attend gANC again. The participant interviews aimed to provide more in depth understanding of a small, but diverse number of women’s views of Hooyo than could be gathered in the main study questionnaires. The complementary interviews were performed by MA together with a research assistant, in the home of the participant  (main study) and from the Swedish Ethical Review Authority [2019–01116] . Oral and written information about the study, its voluntary nature and confidentiality was provided in Swedish and Somali, and written consent was provided by all informants.n = 50 sessions) were arranged in a meeting room in the ANC clinic during an 18-month period. In total, 63 women were recruited to gANC and 52 took part in at least one session, which is described in Fig. Findings from both qualitative and quantitative data sources are presented under headings that mirror our initial assumptions, underlying principles and the MRC framework for performing process evaluations of complex interventions. In this study, seven series of gANC sessions . The mean number of sessions attended per woman was 3.8. When women were absent, another individual appointment was scheduled. Only four women attended all sessions.n = 9) were all female, of Swedish/Nordic ethnicity, above 46 years of age, and all with more than 5 years of experience as midwives.The midwives  were introduced in October 2017 . The cliDuring the design phase, the research team and the reference group discussed a number of design options. Table In the observed sessions, the topics appeared to be seen as relevant by women. During the planning phase, midwives had mentioned that non-pregnancy related problems, like concerns for other family members or housing, were frequently brought up in ANC. This was not observed in the group session.”Some women are very private, there are things you don´t discuss in a group. But to talk about circumcision and examinations during labour in the group, that was not a problem at all.” (Midwife interview 2).Midwives sometimes considered “violence”, “relationships” and “FGM/C” difficult to discuss in groups, but what was considered sensitive was not always what the midwives had expected.”We had one group where everybody got seated in a row, it really became like a school-bench, and then I tried to re-arrange, like, let’s move around so that we face each other, but it takes some time to get a hold of those things.” (Midwife interview 4).Despite an initial ambition to use a more informal pedagogy with a main emphasis on dialogue, both the observations and interviews revealed a tendency towards a more classroom-like situation:n = 11) and multiparous women (n = 52) were recruited, and at baseline, 24% of the women were grand multiparas (≥ 5 births). Women’s mean age was 31 years and the median length of stay in Sweden was seven years. Half (50.8%) the women had < 6 years of education, 22.2% had 7–9 years and 22.2% had > 10 years of education. The majority, 78.8%, were living with a partner.Both primiparous  was “well or fluent” in 65% of the women. When the midwives first informed women and asked about their interest in gANC, their impression was that women with fluency in Swedish were not interested. In the second recruitment step, when the research assistant provided more in-depth information, a frequently mentioned motive for declining participation was that gANC was too time-consuming. Other reasons suggested in follow-up interviews with some participants were that women may not have understood what gANC was, felt they were already sufficiently informed about pregnancy, labour and birth or preferred not to discuss private matters in groups, or a combination of these. No baseline data were collected for the women who declined participation.n = 25) of the female participants believed that it would have been valuable for fathers to participate in the group sessions. The research assistants were also approached by women who highlighted the importance of targeting men more directly. However, 42% (n = 18) said that male presence would have made them feel embarrassed. Other reasons for low male participation suggested by women were more practical, for example that evening sessions would be more feasible for some partners. Low male attendance was noticed and discussed during the course of implementation. The midwives reported that they did not push the agenda that partners should attend. This was also confirmed in the observations, where the absence of partners was not highlighted or addressed. Some midwives expressed the opinion that exclusive women’s groups could provide “a sheltered zone”, where women could be empowered through peer-support.“Actually, I was ambivalent to… I mean, I think there should be some sessions where men are actively invited, but then there is a need for this”sisterhood”, where women feel that now we are a group of women that sit and chat, and then we can talk freely about anything. I think both are needed.” (Midwife interview 4).The groups set their own rules, and some groups decided not to invite partners. In total, only four men attended any session. It is notable that partners seemed more likely to attend the individual appointments before or after the group session. Sometimes spouses waited in the waiting room during group sessions. In the post-intervention questionnaire, 58% (n = 6), had improved (n = 1) or was more difficult (n = 1) compared to standard care. However, half of the midwives (4/8) thought “caring for the emotional wellbeing of women” became more difficult in gANC.Prior to the intervention the reduced time with the “designated midwife” was a concern among the midwives, for fear that patient safety could be affected due to a loss of overall patient responsibility and control. Post-intervention, the midwives believed the possibility to identify pregnancy related risk factors remained the same in gANC  said they would have liked more private time with the midwife.Don´t worry, I will give you a private lesson.” (Observation 5).Negative features of gANC mentioned in midwife interviews were that “private time” with the midwife was important for this target group, and that it was difficult to capture individual issues in gANC. An illustrative example from a group observation was when a midwife told an anxious woman with a lot of questions: “n = 41; 91%) and 42 women (98%) felt comfortable in the group. Most participants  said they felt supported by the other women, and that gANC suited them . One woman said that the midwife was just providing information which she could easily find herself elsewhere (interview 5), and some believed gANC took too much time .The majority of women in the post-intervention questionnaire thought listening to other pregnant women during the sessions was valuable . Another first-time mother on the other hand had appreciated gANC, but would not like to attend again:“No. I know a lot now, I don´t need to attend again” .There were a range of views about attending gANC again for a future pregnancy. One primiparous woman wanted to attend gANC if she got pregnant again because From the women´s perspectives, positive features of gANC together with other Somali-born women included the possibility of getting pregnancy and childbirth information in Somali, and the opportunity to share experiences with other women who share a common language, especially if Swedish proficiency was inadequate.The midwives reported being “happy with the session” in 41/50 sessions. Positive features of gANC identified by the midwives was the opportunity for women to receive more information, to meet other parents-to-be and to share knowledge and advice with each other – and with the midwife. Yet only two midwives thought gANC increased work efficiency (2/8), four answered “no” (4/8) and two “to some extent” (2/8). Midwives believed gANC was time-consuming and they got frustrated when participants were absent.“It was OK [with the Somali group]. It…would have been better if it was a mix, which would have been better. I wanted to hear more from people who had given birth here, people with more experience from here, as I don´t have, I mean, I don´t have any such memory from the home country and I don´t have any experience from there, so it felt like I was, I don´t know, a bit excluded you can say” (Woman interview 5).In the complementary interviews with women, a preference for, or interest in, gANC with mixed ethnic groups was expressed, even though it was believed to be a situation of “win some, lose some”. Possible language barriers could be overcome. In mixed groups it might be harder to make new friends, but the perceived advantages of mixing might outweigh the downsides. Perceived benefits with mixed groups were to get the perspectives of others, to know how others think about pregnancy and childbirth. Pregnancy could provide an opportunity to meet women outside the Somali community—pregnancy providing a common shared experience. One participant said that she did not have so much in common with the others in the Somali group, who she felt shared previous experiences that she could not relate to:I who would want it to work, because that´s how we want our society [to be]…” (Midwife interview 3).“Yes, I have thought of that, and I think maybe it’s Five midwives wanted to continue with gANC – two with the current model and three in a modified form with fewer sessions – and three did not want to continue. When discussing alternative ANC models, some of the midwives expressed ambivalent feelings about language supported “Somali-groups” vs. mixed ethnicity groups. The midwives thought mixed groups could support integration and that the information provided to parents-to-be would become more equal. There was a concern that when tailoring information too much, there is a risk of losing valuable pieces of information, which can affect the quality. One midwife thought that the greater value placed on mixed groups was more in the eyes of society rather than of the participants.“..it was amazing how they listened and were attentive, and we could laugh about things that had been misunderstood, I mean, everybody was just very open, midwives and the pregnant women too” (Midwife interview 3).The observations revealed a generally relaxed, respectful and accepting atmosphere during the sessions. Groups differed, some were quieter while others were livelier. Dialogue and interaction were generally encouraged by the midwives. For example, participants vividly shared recipes and advice on nutritious food to support lactation and recovery after birth in one session. Differences in how midwives welcomed and introduced participants and themselves, offered refreshments and organized seating were noticed; seemingly simple things that could still influence comfort levels and in turn group dynamics. In one session, some participants sat with their jackets on and appeared uncertain, but subsequently they relaxed and joined in the dialogue (observation 1). Humor was used as a tool to create a relaxed, informal atmosphere and enhanced dialogue.”When you are in a group, you get more time, and if I forget to ask something, somebody else might remember to ask” A participant touched upon the issue of how the group format was supportive, and it also happened that participants asked questions on behalf of someone else in the group.n = 39; 91%) believed they got enough space in the groups to talk about what was important to them.Communication between midwives and participants, and with the interpreter, was assessed as mostly smooth in observations. The majority of women .From the midwives’ perspective, some, but not all, thought communication with participants improved, one strong reason being that the sense of mutual understanding increased:The midwives who were less positive about communication in gANC were concerned about discussing private matters in groups, and lack of control over what kind of information is delivered when more than one midwife is involved.n = 8; 19%) thought the interpreting was somewhat disruptive.Moreover, interpreting in gANC differed from that in standard care. The interpreter in gANC also helped to facilitate the sessions, for example by explaining things and making an effort to include quieter women. Most participants were happy with the interpreting and the role of the interpreter. A few .Midwives mostly felt that the gANC participants were happy to have gained more knowledge and information, and that the group format had improved women’s agency. One knowledge gap that was revealed was pelvic floor exercises, recognized by both participants and midwives. Other examples of areas where participants had gained new knowledge were anatomy and birth control.”There is a different power balance when you are invited, when I am invited, and it is not in my own comfort zone, but I reach out to the women instead. The groups have been like that.” (Midwife interview 2).The same midwife described a shift in power balance, similar to her experiences from engaging in outreach community work:”We screen all children for jaundice, yes, we do it all the time, but it seems we have not been able to tell the women what we are doing. They come, show their children, probably wondering what we are doing, but it is not clear to them what the purpose of the control is. Perhaps it is the same with Swedish speakers too, that they just submit to the routines, I don´t know. I see gANC as a way to get a good reputation, perhaps I can put it that way. Should I listen to my neighbor or to the health care provider? Then, if some have a positive experience of gANC, that can spread…” (Midwife interview 2).One midwife noted that to gain and sustain trust, becoming better at explaining was a key, and gANC could provide a good platform for this.“difficult to know if the patient has received adequate information” with gANC. Another commented:“It was easier with those in the group who were my own patients, then one could continue individually, if they had a need to ask more, afterwards…” The midwives were ambivalent about how person-centering was achieved in gANC. It became both easier and more difficult to provide person-centred care. The system with “designated midwives” was challenged with gANC, and the midwives struggled to merge the two models. One midwife said that it was On the other hand, women could wish to confide in a midwife who was not her designated midwife, and gANC could trigger issues that participants wanted to discuss privately later, and that might not have been revealed in standard ANC.”I am not so worried to let go of some control, because I am thinking that I have worked for a long time, so I know what things I need to include to feel they get the information they are supposed to get. It is ok that the group is buzzing…- That is when the interesting things happen.” .Experience and confidence might be required to enable midwives to let go of some of these feelings of loss of control:“Are you midwives?” (observation 3). She thought midwives worked at the delivery ward only, and the midwives had not introduced themselves adequately enough. Sometimes midwives overrated levels of health literacy and struggled to explain what were to them “self-evident” ideas, like the importance of having “good shoes” to prevent back pain.Sometimes it was clear that the midwives had not gained a sufficient understanding of the participants’ previous experiences and knowledge level in the sessions. For example, after having attended several sessions a woman asked “Which of these can be inserted?” The midwife realized that a central piece of the information had been missed and she adapted accordingly by fetching demonstrating materials (observation 6). Another example of new insights was the perceptions related to epidural analgesics:”Epidural for example. Some thought the side effects could be hair growth and back injuries. I thought it was more that they wanted to have a natural birth. I knew that there was also a fear about an injection in the back, but not that there were so many non-medical ideas about what could happen.” (Midwife interview 3).Both midwives and participants learned and developed new insights and skills through gANC. In one session, the midwife listed contraceptives on the white board. After quite some time, a participant asked “Yes, I have changed the way I provide information in private sessions after the gANC. One has picked up a lot, like, hey, this I have to discuss more…” (Midwife interview 3)The experiences from gANC may also have influenced how the midwives provided individual care:One initial assumption was that gANC would be less prejudice prone and reduce bias, because of the format and the changing power dynamics. Expressions of stereotypes were rarely observed in gANC.Prior to the intervention, the midwives expressed some concerns about certain cultural and religious norms, for example related to pregnant women fasting during Ramadan. In some sessions, a reluctance, hesitancy or uncertainty about discussing cultural norms relevant for maternal health was observed – “missed opportunities”. To exemplify, in one session, (observation 4) preparations for Eid al-fitr were discussed by participants. The midwives did not take the opportunity to follow up on this and ask questions about fasting or diet during pregnancy.Two research assistants were employed during different periods of the study, and a third research assistant worked short-term in the project. The recruitment and retaining of participants was challenging and time-consuming. The research assistants played an important role in community outreach work promoting the intervention, in disseminating information about the project in the local Somali community and served as a liaison between midwives, women attending gANC and the research team. The research assistants engaged with women at a community-based play group. They had regular contact with participants, sometimes phoning them before group sessions to confirm their attendance or reminding them to come, and they frequently served as informal interpreters for conversations between midwives and patients.Language-supported gANC was implemented in one clinic with overall fidelity to the design. The intervention was acceptable and feasible to participants, provided that it was voluntary and in combination with adequate individual time with the midwives. The majority of attending women said that gANC suited them, they felt comfortable and supported by the other women in the group, however, attendance was fairly low. gANC was also largely acceptable to midwives who noted that enhanced knowledge and cultural understanding had contributed to more women-centred care, but gANC might require further adaptations to be feasible on a larger scale and to be more time efficient. Many of the eligible women declined participation, which might indicate that gANC does not suit everyone, or also that new models of care take time to promote and become accepted. In addition, few women attended all sessions, and the reasons for being absent were not systematically collected, partly to respect the integrity of the participants, which was a limitation. Further, the intervention was unsuccessful in involving partners in ANC.A strength of this process evaluation was the participatory approach taken, from development of gANC to its implementation and evaluation, with the Somali-Swedish research assistants and the interpreter playing important roles. This evaluation reflects the perspectives of pregnant women, midwives and interpreters and is intended to give a holistic view of the possible mechanisms of effect of gANC.A more comprehensive ANC, with information and education alongside pregnancy controls, provided a good opportunity for women and midwives to get to know each other and strengthened the position of women through the group format. Language-supported gANC filled an existing knowledge gap and contributed to more equitable ANC for the participants, particularly as the childbirth and parent education provided as part of standard care was not an option for those with limited Swedish-proficiency. How social support in gANC can facilitate learning and more positive relationships with health care providers has been described previously in qualitative studies of gANC , 52. TheDespite our intentions to include fathers, few partners attended. Our qualitative study prior to the intervention showed that Somali-Swedish men were facing barriers to inclusion in ANC such as unclear expectations from the health care providers, and that they wished to be more involved . These cFrom the midwives’ perspective, perceived added values with gANC were more comprehensive ANC, providing a platform that could generate trust, which is central for compliance, person-centering and patient safety . This isPerson-centred care  was an uclinicians and on the systems in which they work [The midwives expanded their understanding of the participants through the dialogue encouraged in gANC, giving them new insights and a more nuanced picture of Somali-Swedish women, which in turn may help to reduce possible bias. In the US context it has been suggested that group antenatal care may impact on racial health inequities primarily through its impact on hey work . ConsequWe initially hypothesized that language-supported groups would strengthen and empower participants, and that “mixed groups” would strengthen integration. Unfortunately, it was not possible to compare the planned different intervention arms, as one study site withdrew. However, some of the women who attended the language-supported gANC said that they would have preferred mixed groups. Even though some benefits might be lost (like shared language), they suggested that there might be even more to gain from mixed groups. At the same time, single language groups seemed to strengthen and empower the participants. Ethnicity may become a demarcation line that differentiates people, and interventions targeting ethnic groups may inadvertently contribute to notions of otherness, despite good intentions, and regardless of whether ethnic groups are viewed by staff as more “exciting”, or alternatively as more “problematic” . TherefoOur intervention is in line with the framework for quality maternal and newborn care (QMNC) which highlights the need for preventive and supportive care that works to strengthen women’s capabilities in the context of respectful relationships, is tailored to their needs, focuses on promotion of normal reproductive processes, and in which first-line management of complications and accessible emergency treatment are provided when needed . HoweverIt would have been valuable to include the perspectives of fathers-to-be but that was not possible. Another limitation was a lack of data for exploring why women chose standard care rather than participating in gANC, and to find out more about why many women only attended a few sessions. Even though the intervention was only implemented in one site, the findings can still inform others who want to address health inequalities during pregnancy for migrant women by developing gANC or designing new models. Future gANC intervention studies should investigate the optimal number of group sessions. Perhaps fewer sessions would be of similar value, and not be considered as time-consuming by both participants and midwives.The Hooyo gANC intervention was largely acceptable to participants and midwives but did not engage fathers-to-be. The main mechanisms of impact were more comprehensive ANC and enhanced mutual cultural understanding. The position of women was strengthened in the groups, and the way in which the midwives expanded their understanding of the participants and their narratives was promising. To be feasible on a large scale, language-supported gANC might require further adaptations and the “othering” of women in risk groups should be avoided.