The concept of truth is at the core of science, journalism, law, and many other pillars of modern society. Yet, given the imprecision of natural language, deciding what information should count as true is no easy task, even with access to the ground truth. How do people decide whether a given claim of fact qualifies as true or false? Across two studies , participants saw claims of fact alongside the ground truth about those claims. Participants classified each claim as true or false. Although participants knew precisely how accurate the claims were, participants classified claims as false more often when they judged the information source to be intending to deceive (versus inform) their audience, and classified claims as true more often when they judged the information source to be intending to provide an approximate (versus precise) account. These results suggest that, even if people have access to the same set of facts, they might disagree about the truth of claims if they attribute discrepant intentions to information sources. Such findings may shed light on the robust and persistent disagreements over claims of fact that have arisen in the “post-truth era”. Although people employ the concept of truth daily when sifting through the deluge of information encountered in modern society, classifying something as true or false is no easy task. Natural language is vague and rife with approximations. People regularly contend with classifying claims as true or false in the context of numerical estimates , indefinite adjectives , generalizations , and omissions . Given these challenges, how do people decide whether to classify claims of fact as true or as false, even if they know exactly how accurate the claims are? Imagine, for example, a scientific paper is published that predicts a novel virus will infect 1.21% of the country’s population in the next month. A news headline reports, “Scientific paper predicts new virus will infect 1% of the nation’s population by next month.” Even if people knew the results of the original scientific paper, they might disagree about the veracity of this headline. Given the imprecision of natural language, what factors influence people’s decisions about whether a piece of information qualifies as true or false?One possibility is that people decide whether to classify claims as true by considering only the objective accuracy of the claims. Arguably, this is how matters of truth and falsity are often discussed in popular discourse—as if the labels “true” and “false” should correspond to the objective discrepancy between an alleged state of the world and the actual state of the world. If this were the case, people evaluating the example above should appeal only to the discrepancy of 0.21% between the report and the original scientific finding. We propose an alternative possibility, however: people might additionally consider features of the source of the claim—specifically, the source’s intentions—when deciding whether to classify a claim as true. If this were the case, people evaluating the example above might be swayed by whether they thought the news source intended to downplay the severity of the forthcoming contagion.4. A seminal paper by Grice5 proposed that communicators generally adhere to a Cooperative Principle, consisting of a constellation of norms (dubbed Gricean Maxims) that allow listeners to successfully infer the intended meaning of utterances. Interpreting others’ speech acts in light of their intentions allows forms of speech like sarcasm to be interpreted correctly. For example, if someone makes a crude remark, and an observer comments, “wow, he’s a real gentleman,” listeners do not interpret that statement literally because they infer the speaker’s intentions. Additionally, people form attitudes about everything from consumer goods to political views depending on the credibility people ascribe to relevant information sources7. One key way people assess credibility, and make other similar epistemic and moral judgments, is by inferring the intentions of others8. For example, even children 5–6 years of age appear to believe the testimony of an information source less if the source tried to be deceptive rather than informative in a previous task9. Moreover, people’s false statements have been shown to be considered more morally bad and more of a lie when the statements were intended to harm, rather than help, the target of the statement11. In short, people regularly infer and account for intent in order to interpret the meaning of others’ speech and evaluate the reliability of information sources.Decades of work on human social cognition has shown that people consider others’ intentions when evaluating their actions, including their speech actsBuilding on these findings, this paper tests whether attributions of intent affect what information people think qualifies as true. Specifically, do the intentions people attribute to information sources affect whether people classify claims as true or false—even when people know precisely how accurate or inaccurate those claims are?15, but, in brief, evidence suggests that people can believe false information for a whole host of reasons, including relying on familiarity and processing fluency as cues of truth16, seeking congruence with pre-existing worldviews18, relying on intuitive and non-deliberative thinking21, and using flawed cues of source credibility such as one’s perceived similarity with a source25. One high-level theoretical account argues that motivated reasoning is largely to blame for endorsement of misinformation and partisan disagreement over the veracity of claims. This view suggests that people often form beliefs in service of non-epistemic goals, such as aligning attitudes with political ingroup members29. Meanwhile, another dominant account argues that lack of critical reasoning is the primary culprit for the spread and influence of misinformation. This view contends that many people do not deliberate sufficiently on information they encounter before endorsing it30. Although these two high-level accounts continue to be debated, the misinformation literature has produced mountains of research describing when and why people are likely to believe a given piece of information is true.What information people believe to be true has received increased scrutiny and, arguably, taken on even greater importance in recent years during what some have dubbed the “post-truth era.” Building on decades of psychology research on belief formation, a burgeoning literature on misinformation has sought to identify the circumstances in which people buy into and share inaccurate information. Recent reviews cover this work in depthdiscern true versus false information. Rather, this paper seeks to understand what people think even qualifies as true versus false information. In other words, even when the truth is known, how do people decide whether to consider a claim to be true or false? Understanding what people think qualifies as true and false is neglected in the misinformation literature and broader psychology literature, but may be critical to making sense of and intervening in the post-truth era. For example, if situational factors such as perceived intentions of an information source affect what people consider to be true, it could be that some contemporary disagreements over claims of truth are not actually about the objective accuracy of a news report, political claim, or scientific finding, but about the intentions of the journalist, politician, or scientist. Additionally, it could suggest that getting people to “agree on the facts” may be insufficient for resolving disagreements over the truth, and that interventions should also focus on boosting trust in the intentions of society’s most important information sources. Moreover, it can shed light on how people react to intentionally misleading information, a particularly important topic given that information that is not completely false can still be misleading, and possibly even more convincing than complete falsehoods31.However, unlike most existing work on misinformation and belief formation, this paper does not assess how people To investigate if attributions of intent affect whether people think a claim qualifies as true or false, we ran a series of experiments in which participants were shown claims of fact alongside the ground truth relevant to those claims.  Participants were tasked with judging the intentions of the information sources and reporting whether they would consider each claim to be true or false in light of the ground truth. By providing participants with the ground truth (which deviates from most research in the misinformation and belief-formation literatures), we ensure that participants know the precise accuracy of each provided claim. Thus, participants’ truth classifications—that is, whether they classify statements as true or false—should reflect not how much they believe a given claim, but whether they think a given claim qualifies as true or false.Across all experiments, participants provided informed consent, protocols were approved by the Boston College Institutional Review Board, and procedures adhered to the guidelines and regulations of the Boston College Institutional Review Board.Study 1 tests if and how the intentions people attribute to information sources predict whether people classify claims from those sources as true or false. To do so, we leveraged a context that has spurred contention in the misinformation era: reports about politically charged scientific findings.https://luc.id/). 877 participants completed our study, 205 of whom were excluded, per our preregistered exclusion criteria, for not completing the primary dependent measures, failing the attention check, and/or completing the study in less than 50% of the median completion time. Our final sample size was 672 . See Supplementary Table We recruited a nationally representative sample of U.S. Republicans and Democrats via Lucid  report from a news outlet about that scientific finding . Supplying participants with the scientific finding on which the report was based ensured that all participants knew the ground truth of the topic the report detailed. Each report was crafted to be a logical consequence of the scientific finding, but to have a slant that supported the political agenda of either U.S. Republicans (as in the previous example) or U.S. Democrats. There were three Republican-slant stimuli and three Democrat-slant stimuli in total CNN, Huffpost, MSNBC, the New York Times, Fox News, Breitbart, the Sean Hannity Show, or the Wall Street Journal.For each stimulus, the report was either attributed to “a news outlet”  or attributed to one of eight real news outlets: After reading each stimulus, participants first completed an intent-to-mislead measure and a truth-classification measure. The intent-to-mislead measure asked, “To what degree do you think the news outlet was trying to purposefully mislead its audience about the original scientific finding?” . The truth-classification measure asked, “Assuming the original scientific finding is correct, would you consider the report from this news outlet to be true or false?” . These two questions were presented in random order for each stimulus.After the intent-to-mislead and truth-classification measures, participants completed the following five measures: (1) an accuracy measure asking, “Assuming the original scientific finding is correct, how accurate would you consider the report from the news outlet to be?” ; (2) a trust measure asking, “If this news outlet reported on a similar topic, how likely would you be to believe the report?” ; (3) an ethics-of-sharing measure asking, “How unethical do you think it would be for someone to share this news report on social media?” ; (4) a content-moderation measure asking, “If this news report were shared on social media, do you think the social media platform should take down the post?” ; and (5) a belief measure asking, “Do you believe the original scientific finding?” . After completing the above measures for each of the six stimuli, participants answered three questions about each of the eight news outlets to which the news reports were randomly attributed: (1) an outlet-familiarity measure asking, “Before taking this survey, had you heard of the following news outlets?” ; (2) an outlet-consumption measure asking, “About how often do you consume news from the following outlets?” ; and (3) an outlet political-leaning measure asking, “How politically conservative or politically liberal would you consider each of the following news outlets to be?” .We predicted participants would be more likely to classify a news report as false when they attributed greater intent-to-mislead to the news outlet.To test the relationship between intent-to-mislead judgments and truth classifications, we assessed the repeated-measures correlation between participants’ intent-to-mislead ratings and their truth classifications among the full sample, as preregistered.It is important to note that we also preregistered several other analyses, all of which are presented in the Supplementary Information. For these analyses, we expected that when the political leaning of the news outlet matched the political slant of the report, participants would attribute greater intent-to-mislead to the outlet and, in turn, be more likely to classify the report as false. Because of an error in the manipulation, the main-text analyses focus solely on the relationship between intent-to-mislead ratings and truth classifications. That said, preregistered analyses found the predicted effect of the manipulation on truth classifications among participants who passed the manipulation check . In other words, the more participants judged news outlets as intending to mislead, the more likely participants were to classify the outlets’ reports as false , which is reported in the Supplementary Information . Additionally, Study 2 directly manipulated deceptive intent by explicitly stating the intentions of the information source (which we will refer to as the “deceive-inform intent manipulation”). Study 2 also varied whether the numerical information provided by the information source was a rounded number or a non-rounded number (which we will refer to as the “specific-approximate report manipulation”). This manipulation was designed to lead participants to infer that the source was intending to provide either an approximate account or a specific account of the true state.33. Per our preregistered exclusion criteria, 91 participants were excluded for failing one or both attention checks, not completing all dependent measures, taking the study more than once, and/or completing the study in less than 50% of the median completion time. Our final sample size was 509 .600 U.S. participants were recruited on Amazon Mechanical Turk via the CloudResearch-Approved Participants ListAll participants read 24 stimuli in a randomized order. Each stimulus described a state of the world using a numerical value, an information source making an assertion about that state of the world, and a description of the intention of that information source. For example, one stimulus read, “A journalist learned that 463 people attended a local politician’s campaign rally. The journalist, trying to [accurately inform the public / inflate the politician's popularity], reported that [499 / 500] people attended the rally,” where the sections in brackets indicate the information that was manipulated.Each stimulus had a 2 (Inform Condition versus Deceive Condition) × 2 (Approximate Condition versus Specific Condition) structure. In the Inform Condition, the information source was said to be trying to accurately inform their audience , while in the Deceive Condition the information source was said to be trying to deceive their audience . Meanwhile, in the Approximate Condition the report was manipulated to be a rounded number , while in the Specific Condition the report was manipulated to be a non-rounded number that was closer to the ground truth than the approximate number .For each participant, 6 of the 24 stimuli were randomly selected to be in each of the four condition combinations. In contrast to Study 1, in which all of the reports participants classified were technically true given the supplied ground truth, all of the reports in Study 2 were technically false. All 24 stimuli are displayed in Supplementary Table information source] to be true or false?” . The trust measure asked, “How much would you trust other information provided by [information source]?” . The intent-to-deceive measure asked, “How much do you think [information source] was trying to deceive [audience]?” . The intent-to-approximate measure asked, “How much do you think [information source] was trying to report a rough approximation of [topic]?” . The portions in brackets indicate the type of stimulus-specific information that was piped into the question. Participants answered the truth-classification measure and the trust measure in a random order before answering the intent-to-deceive measure, followed by the intent-to-approximate measure.After each stimulus, participants responded to four measures. The truth-classification measure asked, “Would you consider the information reported by [We predicted that, across participants and stimuli, information sources’ reports would be more likely to be classified as true in the Inform Condition versus the Deceive Condition and in the Approximate Condition versus the Specific Condition.Due to space limitations, results for the two intent measures  are reported in the Supplementary Information, but, in brief, the manipulations successfully affected their corresponding measure of intent: there were higher intent-to-deceive ratings in the Deceive Condition versus the Inform Condition and higher intent-to-approximate ratings in the Approximate Condition versus the Specific Condition.As preregistered, to assess the effects of our manipulations on our primary dependent variable, we ran a generalized linear mixed effects model predicting truth classifications  as a function of the deceive-inform intent manipulation , the specific-approximate report manipulation , and the interaction between the manipulations. Participant-level and stimuli-level random intercepts as well as participant-level and stimuli-level random slopes for the deceive-inform intent manipulation, the specific-approximate report manipulation, and the interaction between the manipulations were included as random effects.b = 2.57 , SE = 0.21, z = 12.105, p < 0.001, such that reports were less likely to be classified as true in the Deceive Condition than in the Inform Condition, all else equal. There was also a significant effect of the specific-approximate report manipulation, b = 1.29 , SE = 0.21, z = 6.26, p < 0.001, such that reports were more likely to be classified as true in the Approximate Condition than in the Specific Condition, all else equal. Finally, there was a significant  interaction between the two manipulations, b = −0.73 , SE = 0.37, z = −1.98, p = 0.047, such that the effect of the deceive-inform intent manipulation on truth classifications was stronger in the Approximate Condition compared to the Specific Condition. See Fig. There was a significant effect of the deceive-inform intent manipulation, We also conducted four robustness checks that tested whether the effects of the manipulations on truth classifications held when assessing: (1) only the first stimulus participants responded to (preregistered); (2) only the responses from participants for whom the manipulations influenced intent ratings in the expected directions (preregistered); (3) only the responses from participants who classified at least one stimulus as true and at least one as false (not preregistered); and (4) the number of participants who showed the predicted condition differences across their 24 responses (not preregistered). All four robustness checks corroborated the main effects of both manipulations observed in the primary analysis. However, robustness checks 1 and 3 did not find the significant interaction effect observed in the primary analysis and robustness check 4 found that only 19.3% of participants showed the full pattern of responses suggested by the primary-analysis interaction effect. Details for the robustness checks can be found in the Supplementary Information.Study 2 tested 24 different stimuli in a within-subjects, repeated-measures design in which two features were manipulated: whether an information source was explicitly said to be trying to deceive or inform their audience and whether an information source reported a rounded or non-rounded number.As predicted, participants’ truth classifications corresponded to the effects of the manipulations on intent ratings. Participants were more likely to judge an information source’s report as false when the information source was said to be trying to deceive their audience (Deceive Condition versus Inform Condition) as well as when the information source reported a non-rounded, incorrect value (Specific Condition versus Approximate Condition). These findings were robust to several different formulations of the data (see Supplementary Information).Generally, the effects of each manipulation corroborate the findings from a between-subjects, single-stimulus version of this study (N = 744), which is reported in the supplement  rather than a precise account . Because participants in these studies always knew the ground truth, these results suggest that people do not only consider the objective accuracy of a claim when deciding whether the claim qualifies as true or false; rather, people additionally consider the information source’s intentions. In other words, our results suggest that the same exact claim might be considered true in one case and false in another, even when everyone involved knows precisely how accurate the claim is.34 and persuasion literature35, people might judge a source’s reliability as a function of the source’s intentions to help or harm  and the source’s ability to enact those intentions . The two manipulations in Study 2 arguably map well onto these two dimensions. The deceive-inform intent manipulation was designed to affect people’s perceptions of the source’s intentions to communicate accurate information. Meanwhile, the specific-approximate report manipulation might have affected people’s perceptions of the source’s ability to communicate accurate information. After all, when participants perceived the information source as trying to provide an exact account, they may have deemed the source as unable to communicate accurate information since that exact account was always wrong in our stimuli. Meanwhile, when participants perceived the information source as trying to provide an approximate account, they may have deemed the source as able to communicate accurate information since the approximate account reflected a reasonably rounded number in our stimuli. We hope future work tests this and other possible mechanisms directly.Why would attributions of intent affect what information people think qualifies as true? One possibility is that people use true–false labels not only to delineate fact from fiction, but also to signal the reliability of the information source. Labeling an information source’s claim as true or false not only signals to others the reliability of the claim in question, but also signals the reliability of the source. After all, a source whose claims are regularly called out for being false is unlikely to be considered a trustworthy source of information. Thus, when deciding whether a claim qualifies as true or false, people may account for the objective discrepancy between a claim and the ground truth as well as the perceived reliability of the source. As suggested by previous work in the person-perception literature36. In our work, it is unclear whether people would be more likely to judge an information source as intending to mislead if they considered the source to be biased versus untrustworthy. That said, the stimuli in Study 1 were designed to contain no complete falsehoods, hinting that the intent-to-mislead measure in Study 1 may have picked up perceptions of bias primarily. In Study 2, on the other hand, the numbers reported by the information source in the Specific-Deceive Condition may have been interpreted as lies since the source was said to be attempting deception and the numbers were patently incorrect. Yet, perceptions of bias were likely still present in Study 2 because the information source often provided information that was selfishly beneficial  and untrustworthiness , arguing that these perceptions can differentially affect how people react to claims from information sources15 or lack of critical reasoning14 are to blame for endorsement of misinformation. Both of these accounts focus on the role that discrepant beliefs about the true state of the world play in contemporary disagreements over the truth of claims of fact. Our work suggests that discrepant beliefs about the ground truth may not be necessary to produce these disagreements; discrepant attributions of intent may be sufficient. After all, in our studies, participants always knew the ground truth, ruling out discrepant beliefs about the ground truth as a likely explanation for our results. While our findings do not detract from the value of existing misinformation work, they reveal another avenue through which such disagreements can arise. This alternative avenue could suggest that interventions should focus on boosting trust in the intentions of important information sources, such as reputable journalistic, research, and governmental sources. On an optimistic note, our findings suggest that, by virtue of people’s tendency to label information from intentionally deceptive sources as false, people may be good watchdogs of intentionally misleading information. This could serve an important ecological niche in today’s information ecosystem given that claims that are not completely false can still be simultaneously misleading and convincing31.Regardless of the underlying psychological mechanisms at play, the fact that attributions of intent can affect what information people think qualifies as true—even when people know the ground truth—may shed light on disagreements in the post-truth era and contribute to the misinformation literature. As outlined in the introduction, the two dominant theoretical explanations in the misinformation literature suggest that either motivated reasoning37—one critical limitation of large language models is that they do not always produce accurate content38. One popular technical approach to aligning the output of large language models with the goals of its users is called reinforcement learning from human feedback. As its name implies, this approach relies on feedback about the output of the language model from human users to train a reinforcement learning model that, in turn, helps the language model produce content that better matches human preferences39. Indeed, Google DeepMind recently used a similar approach to train their model GopherCite to provide accurate information more often40. As large language models become more pervasive and influential , it is important to understand what lay people think qualifies as true since that same conceptualization of truth might be getting trained into these models through reinforcement learning from human feedback.Beyond this work’s relevance to the post-truth era, understanding what leads people to decide whether a piece of information qualifies as true or false is particularly important in light of recent large language models, such as ChatGPT and GPT-4. While these models have become immensely popular—ChatGPT is thought to be the fastest growing consumer app in historyIt is important to acknowledge that the studies in this paper had several limitations. First, although Studies 1, 2, S1, S2A, S2B, S2C, and S3 were preregistered, Study S4 was not preregistered because it was a small part of a large, exploratory study assessing how people think about truth along many different dimensions. Second, some of the preregistered analyses for Study 1 were not useful for testing the relationship between intent and truth because of an error in the manipulation (see Supplementary Information for more detail). Third, although the effect of the specific-approximate report manipulation was significant in Study 2 and Study S3, it was not significant in Studies S2A, S2B, or S2C, so the results for this manipulation should be interpreted cautiously (see Study 2 Discussion for more detail). Finally, it is possible that our use of within-subjects designs led to larger effects since participants had direct comparison points of other intentions that information sources might hold.41. First, all of our participants were English-speaking, U.S. adults, and only Study 1 explicitly sought out a nationally representative sample. The terms “true” and “false” may well be conceptualized and/or employed differently in other languages and cultures. Second, we would not expect the influence of intent on truth classifications to emerge for just any pairing of claim and fact. We specifically chose claims that occupied the gray area between completely inaccurate and precisely accurate. Although we found a relationship between intent and truth classifications for claims that are logically true (Study 1) and claims that are logically false (Study 2), we would not expect intent to matter when claims are interpreted as either perfectly matching or drastically departing from the ground truth.Additionally, there are at least two important constraints on the generality of our conclusions15 and decades of research on how people judge truth when uncertain about the accuracy of a claim12, there is little work directly probing what information people think qualifies as true even when they know the objective accuracy of that information. We hope this paper brings the field one step closer to understanding how people conceptualize truth—a concept core to science, journalism, law, and so many other pillars of modern society.Nevertheless, we hope that the experimental paradigm employed in this paper, in which participants are supplied the ground truth, offers one way to directly explore how people think about the concept of truth. While there is a burgeoning literature on how people navigate misinformationSupplementary Information.


Not being able to manage performance anxiety and subsequently experiencing a decline in performance have been called “choking under pressure”. High trait anxiety and fear of negative evaluation, as well as low self-efficacy or self-confidence, can put performers especially at risk of experiencing choking. This study, therefore, examined the effects of psychological choking interventions tailored to “choking-susceptible” performing artists individually in a coaching setting.We conducted a mixed-methods (QUANT + QUAL) collective case study with nine performing artists, who each received five individual coaching sessions. The tailored choking interventions comprised acclimatization training, goal setting, and pre-performance routines, including elements such as imagery, self-talk, and relaxation techniques. Before and after the 10-week intervention phase, they filled in questionnaires on trait performance anxiety, fear of negative evaluation, and self-efficacy, performed in front of a jury, and were interviewed about their experiences. Transcripts of interviews and coaching sessions were analyzed using thematic analysis. Heart rate measurements, weekly performance videos, and expert evaluations were also part of our comprehensive data.Quantitative data showed reductions in performance anxiety and fear of negative evaluation, and increases in self-efficacy and performance quality, from before to after the intervention phase. Most participants also had a lower heart rate when performing for the jury. Themes from qualitative analysis comprised managing nervousness and feeling more relaxed, becoming more self-confident, satisfaction with artistic and mental performance, feeling good and enjoying performing, and general positive effects.Tailoring psychological interventions may provide several benefits for choking-susceptible performing artists. Performing artists often have to perform in front of an audience, which may lead them to experience high pressure and anxiety, eventually harming their performance. Psychologists have called this “choking under pressure,” a phenomenon that refers to performing worse than expected despite high skills and motivation to perform well  similar to or based on PST interventions in sports psychology. These training programs consisted of different combinations of cognitive restructuring, behavioral exposure to performances, identification of strengths, goal-setting, imagery, practice strategies, arousal regulation, and relaxation, but were not specifically focused on high-pressure performance settings. Studies showed that PST interventions had a positive effect on music performance anxiety and performance quality in young musicians . In music, a case study was undertaken with a highly anxious violinist, who was guided toward mindfulness and acceptance of her unwanted anxiety symptoms through ACT , and to examine their experiences with the interventions using a collective, mixed-methods case study design.This collective case study is embedded in a theoretical approach of critical realism: by believing in a reality independent of our construal of it, and in the notion that all our construed knowledge about this reality is incomplete and interpretative, we adopt a combination of ontological realism with epistemological relativism Easton, . A colleM = 23.3, SD = 2.2), had on average 15.2 years (SD = 2.9) of experience in their respective performance domain, and practiced or trained their skills for an average of 26.1 h (SD = 13.8) per week. Participants were recruited from a renowned performing arts university in Austria. We selected them based on both qualitative and quantitative considerations. Musicians, dancers, and actors were invited via email to sign up via a link to an online questionnaire if they felt they were generally strongly affected by performance anxiety. Twenty-one performing arts students considered this to apply to them by accepting the invitation online. They gave informed consent according to the Declaration of Helsinki and filled in demographic as well as three psychological questionnaires for the subsequent quantitative identification of choking-susceptible participants. Ten participants were then purposively selected (see below). Due to COVID-19 and uncertainties about performance schedules at the time of selection, some of those originally chosen withdrew their participation. One musician did not wish to apply psychological interventions and thus received a different kind of coaching. Consequently, she was excluded from the analyses in this article. The final sample  included six musicians, two dancers, and one actress. They were 20–26 years old (The study consisted of four distinct phases: (1) selection, (2) pretest, (3) intervention, and (4) posttest . Materiaselection, all invited artists completed questionnaires on trait anxiety, FNE, and self-efficacy. Trait performance anxiety was measured with a short version of the Kenny Music Performance Anxiety Inventory  to 6 (strongly agree) was employed. The K-MPAI is widely used, and its reliability and validity have been supported by evidence from numerous studies  to 5 (extremely characteristic of me). Psychometric testing of the BFNE-II has shown acceptable psychometric properties  to 4 (exactly true), an example being “I can usually handle whatever comes my way”. Reliability and validity for this scale have been extensively established . Detailed information on their audition tasks can be found in M = 29.4, SD = 6.6).In the posttest was identical to the pretest, but preceded by the questionnaires from the selection phase a second time. It was required that participants perform the same audition excerpts as in the pretest. The semi-structured posttest interview included questions referring to each participant's interventions in addition to the questions also asked in the pretest. They closed with questions about other potential influences during the intervention time, what participants had learned during the study, and what they took away from the coaching. Posttest interviews lasted 29–63 min . After the interview, participants were paid and thanked.The bad) to 10 (excellent) by nine experts, who were renowned professionals, professors, and/or judges for auditions and competitions in the respective domains. They were instructed to do so in the same way they would for a professional audition procedure. Given the variety of domains, instruments, and genres, as well as the extensive amount of video material per participant, they only rated the respective participant for whose field they were indeed experts, so there was one expert rating per participant.Upon the completion of data collection, interviews and coaching sessions were transcribed verbatim using the transcription software f4transkript . The overall performance quality of all anonymized video recordings was evaluated individually on a scale from 1 , from the first author who is a psychologist and certified psychological coach. To ensure the personal relevance of the interventions, participants were encouraged to express their own goals for the whole intervention period as well as each coaching session. Interventions were then tailored to each participant's specific problems of performing under pressure by accommodating their own goals and requests during each session. Six participants wanted to increase their self-confidence, four asked for strategies for mental performance preparation and self-help, and two also wanted to enjoy performing and get immersed in the moment.During the 10-week Every session was somewhat unique, but in the following, we describe certain recurring elements. Some typical questions referred to the participant's hopes for ideal outcomes of the entire 10-week period (first session) as well as for each session at the beginning, how the participant had been doing the 2 weeks before (sessions 2–4 in particular), how the coach could support their concern(s), and which specific steps they would take in the following weeks (sessions 1–4). Session 5 was introduced as an opportunity to reflect on the past sessions, on aspects that had been helpful, and on how participants envisioned to continue in future . When participants had expressed a certain goal or need, they received psychoeducation about potentially matching psychological strategies. The chosen strategy was then tried out together, sometimes written down by the participant, or modified/adapted according to their experiences either during the session or in the field.The tailored choking interventions included PPRs, goal-setting, and acclimatization training see . To helpG) for each participant. To complement our qualitative and descriptive data, we used paired-sample t-tests, with a level of significance at p < 0.05 (one-tailed).Questionnaire data, quantitative expert evaluations, and HR measurements were analyzed using SPSS 27.0 . Questionnaire scores were computed by averaging the responses across respective items. In addition, we determined percentile ranks for each participant in relation to the norm. To analyze HR during pretest and posttest, we applied the formula from Pruessner et al.  to calcuWe analyzed the transcripts of interviews and coaching sessions using reflexive thematic analysis ; “I was so stressed before the stage” (Zoe). They described becoming anxious often because they felt like they had to prove their artistic ability and show everything they had prepared: “About 2 seconds before I went on stage, there was the thought ‘You're only allowed to show this once, you may never do it again, you now have to show everything you thought, and ideas, and just have fun now, because you can never repeat this, it's now the only and last time'. And your friends are watching and the jury is watching” (Lucy).Both trait performance anxiety and FNE appeared to significantly decline from pre- to post-intervention . One parstruggles due to performance circumstances, such as unexpected situations or adverse conditions. In particular, there was a feeling of not being able to communicate with the audience when face masks had to be worn during the performance. Other struggles that inhibited communication were caused by bad acoustics or having to play behind a wall in an audition. Participants further talked about being overwhelmed by the sudden increase in performances after lockdown and a subsequent lack of preparation and time pressure: “the problem was that I had had too little preparation. (…) It was just everything within a very short time. It was simply too much” (Vivi).The intensity of the anxiety experience was amplified by the fact that participants had not been on stage for months because of the COVID-19 pandemic. Their nervousness was, therefore, also elicited by feeling more relaxed and calm during performance after learning, and experimenting with, different strategies during the intervention period: “and then I actually could calm me down. And that was a really cool feeling” (Mia). Other participants similarly described managing their nervousness effectively. Lucy in particular was able to learn from her dissatisfaction with one performance, improving her anxiety management and performance during a subsequent audition:Notably, both quantitative and qualitative data indicated that participants learned to better manage their anxiety. They generally reported lower state anxiety before the posttest performance, with significantly lower values in both cognitive anxiety and somatic anxiety in the MRF-3 compared to the pre-test . HR simiI have now noticed what it is when I am too much. I have noticed what it is when I am too little (. …) ‘how do I achieve this balance?' And I somehow then managed that in the audition there and I was totally good, it was really fun.The effect of applying the interventions was also perceived as an absence of physical symptoms, such as shaking, palpitations, or being cold: “I didn't have so many palpitations, so I mean with me it is often like that, mainly due to excitement or stress, that I really, yeah, that it immediately manifests itself physically, but this time it did not” (Anne).Most participants exhibited a lower HR in the posttest, yet the HR measurement itself also led to discomfort: “what really bothered me is that the thing here [the chest belt] actually made me/ like I could feel my heartbeat all the time” (Mia); “this is kind of also stressful to see someone measuring your heart rate” (Zoe). Julia's HR even increased by 26% in the posttest. However, she evaluated this positively: “I arrived quite tired because it was a hard week (…) And I was actually rather glad that a bit of nervousness came, as one becomes more awake then”. This illustrates that heightened physiological arousal before a performance does not necessarily need to be debilitative. In the same vein, Julia said about her successful recital a few weeks before the posttest: “I was monstrously nervous, of course. But then it wasn't a problem.” Vivi even remarked that she needed a certain amount of nervousness for optimal performance: “the reason for some mistakes is that I was not alert enough (.…) The concentration is not quite there (.…) When I'm nervous, I am always a tad more precise”. Taken together, participants' performance anxiety decreased in the posttest, but they also acknowledged that they felt nervous in certain situations. This was sometimes facilitative, but often had to be regulated via an anxiety management strategy.Overall, participants appeared to show both significantly increased general self-efficacy after the intervention  and signconfidence in one's ability was expressed as trust that one can indeed play and perform, and having this trust allowed participants to let go more and not control too much: “I can play, because in that moment I could rely on it going well (.…) there I could listen relatively well. Yeah and that was very beautiful” (Julia). This confidence was extended to having strategies for managing anxiety and uncertainty: “and so generally I simply have a bit more confidence now that I do indeed play well in any case, but can also learn how to deal with my, yeah, nervousness” (Bianca); “that I can optimize my preparation (…), but also be ready to adjust” (Coco). Knowing such strategies gave participants a sense of security: “and there I was so certain and secure that nothing could faze me in that moment, nothing disturbed me” (Lucy); “I believe it just gives me like a general feeling of a bit of a greater security” (Tom).Our thematic analysis revealed that being more courageous, e.g., when improvising, taking risks on stage, or trying new things: “I was totally free (....) I knew nothing can happen now” (Lucy). Some also considered it courageous to show themselves on social media: “I already posted the videos from [prestigious performance venue] (...) I have never ever posted a video or a photo of myself on the stage before that. Never. (…) That's a big step” (Zoe). With their strengthened self-confidence, they noticed less concern about negative evaluation: “I'm actually not afraid of other musicians anymore” (Mia); “I didn't think much of like ‘how do I look?' and what people think” (Zoe). This is also underlined by the questionnaire results on reduced FNE described above.Having trust and security, participants also described themselves as stronger sense of artistic identity and pride. Being proud comprised all aspects of being an artist: “that I can indeed be proud of myself and that actually everything is alright the way it is, how I play and all” (Bianca); “I was really proud and I felt like ‘yes I was born to do this, like this is me, this is what I should do”' (Zoe). Especially after experiencing several lockdowns, being or becoming aware of one's artistic identity was quite powerful and meant to be fully connected to what one is doing: “it's like safe, it's kind of indestructible now, it's me and the violin” (Mia). Zoe elaborated that she was “embracing like who I am. And I was kind of lost, maybe because of lockdown (…) I'm a musician. (...) I'm like very proud of what I'm doing, what I'm going to do and I can see the future.”Finally, enhanced self-confidence became visible in expressions of a performance highlights occurred both during the intervention phase and in the posttest: “for me a highlight was now actually the intermediate exam” (Julia); “whoa, I found it fantastic today (laughs) (.…) and I was completely inside the character” (Lucy). Others mentioned that the performance went well, often despite adverse circumstances: “it was really crazy. But somehow it went well, like it's just, I didn't expect to” (Coco). Participants further expressed their satisfaction in describing how their own expectations were met by their positive performance experiences: “all what I had wished for, what I want to achieve with the monolog and after the training, exactly that I have accomplished today. (…) I'm one hundred percent satisfied” (Lucy); “so this was just pretty close to that ideal, what I just have there, or it was exactly that, how I actually wish it to be” (Tom).Performance quality appeared significantly higher in the posttest compared to pretest performances . The exprecognition of sub-par aspects. They gave different reasons for why they performed less than desired and also alluded to the importance of context:However, not all performances were completely satisfying, as indicated by participants' Today was a chaotic day for me. And like physically I don't feel so good (…) just internally focused on the music and on the steps and trying not to focus on the pain and on the audience and additional stress. (…) And I felt really in it. I mean it wasn't perfect, there was some little things that could have been better, I think. (Coco)Other aspects included intonation and technical issues, taking more time or preparing particular moments better and lacking artistic excellence: “it was not quite clean, that is of course a matter of practice, that the brilliance is a bit lower and it also does not sound so lively” (Julia). Participants justified sub-par performance with a lack of preparation or difficult circumstances or evaluated themselves worse when they were comparing the performance to previous, better ones. Going beyond artistic performance quality, participants also talked about satisfaction with progress in the psychological dimension of their performance: “and the performance like mentally, I am actually also really satisfied. I have actually also managed that well” (Bianca); “so it is now more, perhaps one can then let one's body (…), let one's skills just do, one does not worry so much anymore” (Anne).feedback from others, such as professors or members of the audience or jury. When participants were satisfied with their performance, positive feedback was perceived as encouraging or rewarding their effort: “when one gets praise from one's professors, also from non-accordionists, that/ and one sees, ‘ah yes, it was then somehow worth it'. Crazy often for months, I would run into a wall when playing from memory. But then it somehow did work out” (Julia). Discrepancy between the inner and outer perspective was perceived as interesting or illuminating: “that the self-evaluation after playing sometimes diverges quite substantially from what one would say if one had watched oneself from the audience's perspective” (Tom). Others' feedback was described as frustrating when it differed from one's self-evaluation in a negative, but also in a positive way, especially when not seen as constructive. In terms of the performance experience itself, one's own perception might actually be more important, as expressed by Vivi: “that is then actually horrible for me to play, when I myself do not [perceive] it as beautiful”.An important part of their performance evaluations concerned feeling good and enjoying performing, we extend the idea that the artists' own experience may be crucial. We identified a pattern of emphasizing one's feelings against technical or artistic evaluations of one's performance. In particular, Vivi stated: “I somehow find it more important how I'm doing (…) when I feel good, then of course the audience feels good, too”. On the one hand, feeling comfortable was explicitly related to a higher layer of experience: “I could listen relatively well to what I wanted to do and could divert a bit from this technical aspect (…) it is mainly that I now really had the feeling (…) that I can just make music” (Julia). On the other hand, feeling comfortable during the posttest was also described with different facets. Sometimes it was attributed to being more familiar with the situation: “I think I generally felt more comfortable (.…) also because I of course have already experienced the situation once, that naturally makes a difference” (Anne). Simultaneously to providing comfort, this familiarity also increased the pressure on some participants. Being aware of the comparability raised the expectation of performing substantially better than in the pretest: “I have put a bit more pressure on myself today, because I naturally, yeah, somehow just also wanted to show an improvement” (Bianca). Finally, when having to communicate dramatic emotions, feeling comfortable might even be counterproductive: “I was feeling very comfortable and I actually thought ‘Oh dear, how should I play this monolog now? I'm in way too good a mood”' (Lucy).With the theme Having fun was described as a particular way of enjoyment during the performance and related to a positive energy that was shared with one's ensemble or audience:At my concert it was truly like that, that I had really a lot of fun to play with the people (…) that also came like, as feedback from my fellow musicians, that they somehow also had fun and that it was a cool ambiance and energy. (Tom)Fun and enjoyment were mentioned as distinct features of the posttest and were connected to being in the moment:At the first one I was like kind of ‘okay let's sing it and let it be over. Let this moment to be over.' And today I was kind of more enjoying it. Like I could sing more, like I hold the last note. (Zoe)flow experiences, characterized by participants as being “simply completely in the zone” (Tom), “not thinking about doing it a certain way” (Coco), and “being rather than showing or doing” (Anne). For Lucy, this constituted her main goal for the coaching, and at the end, she reflected on its meaning:Ultimately, enjoying the performance and being in the moment was connected to For me, everything culminates in being in the moment. And through the exercises, I've accomplished that now, so I would say, I have/when I have managed to be in the moment, then I have indeed also achieved something in the other steps.general positive effects of the intervention that went beyond the effects outlined above. Enhanced motivation was explicitly mentioned as something participants took away from the coaching. For example, Zoe said:As a final theme, we identified I get a lot of motivation. Like, not like ‘okay let's get out of the bed and practice', not that. I mean I get motivation of singing again in shower, every moment of the day, and listening to music actually more, and enjoying it. Enjoying every noise that I'm hearing. So that was really nice. Thank you for that.Participants were mostly content when looking back at the coaching process and their initial goals, but sometimes they also changed the goals themselves, which opened up new perspectives: “not to look for perfection or stability in every area, that ‘now I'm prepared for everything', but also if I'm not prepared to something, that I can deal with it” (Coco). Using intervention strategies was described as effective and uplifting for how one talks to oneself, not just regarding performance, but also in everyday life: “I can deal better with agitation in general, or with the/ maybe also with thoughts or attitudes toward myself that are not helpful, but are in the way or rather hold back” (Anne). Indeed, being aware of one's ability to manage one's thoughts, feelings, and reactions, also through what was learned during the study, appeared as the main asset and take-home message:That I really feel like this, that I went from monochrome to full colors (.…) Like in almost every way when it comes to performing, like how my body reacts, how my mind is set up, how do I like interact with others, and this big calmness what is the current topic of mind, that's also coming, and that also changed my everyday. (Mia)In this study, we sought to illuminate the effects of tailored interventions on choking-susceptible performing artists' performance quality, performance anxiety, fear of negative evaluation (FNE), and self-efficacy with a mixed-methods approach. Amidst variation both between and within individuals, both qualitative and quantitative data indicate a positive impact. This includes higher performance quality according to experts as well as participants, enhanced self-efficacy, and lower performance anxiety and FNE in the posttest. Thematic analysis of interviews and coaching sessions revealed that this progress was not always characterized by linear improvement: instead, some experienced struggles with intense nervousness and subsequent performance decrements, but also performance highlights earlier in the intervention phase that made the posttest seem less remarkable in comparison. The positive effects of the intervention were perceived not only in relation to cognitive, emotional, and behavioral aspects of performance, but also extended to participants' everyday lives.Questionnaire and interview data appeared to show that participants had lower trait and state performance anxiety after the intervention period. During the intervention phase, however, some performances elicited strong anxiety. Participants were either able to manage their anxiety so that it did not negatively impact performance quality, or to learn from anxiety-provoking situations and thereby improve subsequent performances. Familiarity with the setting in the posttest created a more comfortable feeling, but at the same time also increased the pressure to perform even better than in the pretest. The relationship between perceived pressure of the situation and performance anxiety thus appears to be individual and context-dependent. Importantly, participants' interpretation of their anxiety symptoms, but also the controllability of these symptoms through psychological strategies, may be more important than their intensity.The relevance of interpretation and controllability has been pointed out in previous studies with actors  from PST and ACC programs delivered in group settings by performing arts educators without specialized psychological training Gill, . Future Because not all the originally selected artists were able to participate, and because the distribution in the population invited to participate was uneven between music, dance, and acting, the three domains were not equally represented. In addition, some participants did not meet all three quantitative selection criteria. Future studies may benefit from recruiting choking-susceptible participants from a larger pool of performing artists. That some of those originally chosen withdrew their participation was also due to the unique situation during recruitment: performances were finally possible again after over a year with several lockdowns. This situation should be considered when looking at the results: a certain enthusiasm, but also overexcitement about being on stage again may have been due to the contrast to previous restrictions.dz = 0.8, indicating that larger samples should be used in future studies that mainly focus on quantitative effects. In terms of performance quality, budget restrictions and the extensive amount of video material meant that each participant was only evaluated by one expert in their respective field. Future studies may include several raters per performance to ensure higher reliability of performance evaluations.Furthermore, the sample would be too small for a purely quantitative study. With the data of nine persons, we had 70% power to observe a large effect of There is recent evidence that repeated performance exposure can significantly reduce HR and anxiety-related non-artistic performance errors . Therefore, the causal effects of the interventions cannot always be implied. Future research might investigate possible underlying causes and mechanisms along with artists' abilities in applying psychological skills, and not just focus on the outcomes of an intervention.This study strengthens the bridges between different performing arts as well as between performing arts and sport psychology. Our data demonstrate that tailored interventions inspired by sport psychology can have a positive impact on choking-susceptible performing artists' anxiety, self-efficacy, performance quality, and even their everyday lives. In our view, the qualitative data particularly emphasize the importance of individual context. Whether an intervention can be considered beneficial also depends on the perspective taken: is it more relevant to improve the artist's or the audience's satisfaction with the artistic quality of the performance, or perhaps just artists' own emotional experiences while performing? Future research should thus be extended to the investigation of long-term effects and underlying mechanisms of tailored interventions, potentially with a stronger focus on how the interventions are being implemented and what role the relationship during coaching plays.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Institutional Review Board of the Department of Work, Economy, and Social Psychology, Faculty of Psychology, University of Vienna. The patients/participants provided their written informed consent to participate in this study.VL and PG conceptualized, designed, and conducted the study. VL implemented the interventions and wrote the first draft. SN-B conceptualized the qualitative analysis. PG and SN-B wrote sections of the manuscript. All authors contributed to data analyses and manuscript revision, read, and approved the submitted version.


Inadequate knowledge and skills and a lack of confidence to provide care have been identified as major unmet needs for carers of people with brain cancer. An online intervention was developed to address the unmet needs of carers of people with high-grade glioma.Ten carers evaluated the intervention through multiple methods. Acceptability and usability were measured through online data analytics , surveys, and interviews. Questionnaires measured potential impacts on distress (Distress Thermometer), depression, anxiety , carer competence , carer preparedness , unmet needs , usability and acceptability (USE).M = 76.3/100). Correlations indicated the potential to impact depression. Qualitative findings highlighted benefits of the intervention as a comprehensive reliable resource that could validate and normalize carer experiences. Interview findings guided further improvements .Results suggested the intervention had high levels of usability  and acceptability (The study indicated high acceptability and usability of an online intervention for carers of people with high-grade glioma. This exploratory study also provided preliminary indications of a potential to decrease depression. However, a more robust, potentially longitudinal, investigation is needed with a larger and broader sample. Informed by this study, the intervention has been amended and a randomized controlled trial will further evaluate the enhanced intervention. As a result of the tumor patients may experience physical symptoms such as weakness and motor dysfunction,8 Treatment frequently involves complex pharmacological regimens, requiring carers to administer and monitor these medications.9 Carers may also need to make ongoing and challenging medical decisions about the patients’ treatment and care.8 It is perhaps not surprising given these factors, that 40%10 to 52%11 of carers report anxiety and 72% report elevated stress levels.12These changes place a significant burden upon patients’ families who must take on challenging caregiving responsibilities, often with little prior understanding of how to provide physical care, manage behavioral changes, or adapt to their own and their relative’s changed roles.13 Among carers of brain tumor patients, a consistent need for additional, and more detailed, information has been found across studies.15 Carers frequently highlight being “unprepared” for their new carer role,16 and need information about how to manage physical, cognitive and personality changes,17 provide day-to-day care, and manage side-effects at home.7 Carers report needing help with accessing information about the benefits and side-effects of treatments,10 dealing with anxiety and stress, and coping with changes in their own social, work, and family life.18Inadequate knowledge and skills and a lack of confidence to provide care have been identified as major unmet needs for many cancer carers, and may intensify distress.Confidence to care, was developed by a multidisciplinary oncology team led by members of our team author and author (deidentified for review purposes) and has shown promise in initial trials.20 For instance, the randomized controlled trial (RCT) was effective in improving carer preparedness.21 To broaden the reach, and in view of a lack of online programs,22 the evidence-based Confidence to Care resources were transformed into an online format and adapted to form a stand-alone asynchronous online intervention (a website). The development of an online program was an extension of the more costly and geographically restricted nurse-led program. Although minimal, there is some evidence regarding online resources for adults living with brain cancer.22 While there are evidence-based interventions that have an online component, there appears to be little or no research demonstrating the effectiveness of stand-alone online programs for carers of people with brain tumors.22 This current stand-alone program is a web-based resource that can be accessed without barriers, at any time or place.A nurse-led tailored home-based education and support program for carers of patients with high-grade glioma (HGG), 22 promising results are emerging for online resources for carers of people living with dementia.23 Online resources have broader population reach and are less costly to implement.23 This pilot is the prelude to more rigorously examining the effectiveness of the online program in meeting carer support needs.While there appears to be little or no research demonstrating the effectiveness of stand-alone websites for carers of people with brain tumors,This online program now incorporates a range of other evidence-based resources, and is no longer nurse-led, but an online portal for carers to explore at their convenience. The objective of the online version is to increase access to evidence-based materials which carers can explore at their own pace within the convenience of their home. The aim of this study was to pilot the online intervention, specifically examining: Acceptability, usability, and how it met carer expectations; and any potential impacts on mood , unmet needs, carer preparedness and competence, and the caring experience in general.A single-group pilot study involving pre- and post-intervention questionnaires and an interview post-intervention was conducted.24 and the transactional model of coping, which considers the capability of the carer and the resources that they need to adapt to their situation.25 The online program focuses on building carers’ knowledge and skills to perform caregiving tasks, to enhance carers’ confidence and capacity to care for their family members and cope with their situation. The intervention content is divided into modules, to enable carers to proceed at their own pace, guided by self-assessment activities that suggest modules that may be of most help to the carer. The 6 modules include: Understanding HGG, Navigating the System, Changes to Expect, What else can I do?, People around you and When Things don’t go well. The modules consist of: Evidence-based information; links to resources, case examples and; an electronic notebook that allows participants to take notes as needed and personalize some of the information and activities.The online program, Caring for the Carer, was developed with the involvement of consumer representatives It is a 6-module, password-protected, online interactive psychoeducational program designed to prepare carers of people with HGG to undertake caregiving responsibilities. The intervention is guided by Bandura’s social cognitive theory, which proposes that a high degree of self-efficacy increases the likelihood that caregiving tasks will be successfully performed,Participants (18 years and above) were eligible if caring for an adult diagnosed with a high-grade (grade III or IV) glioma. Patients may have been diagnosed initially with a low-grade glioma (grade II) that progressed or transformed into HGG. Participants needed to be living with the person they were caring for and resident in Australia. Participants were also required to have internet access, an email address, and adequate English to be able to comprehensively review the online intervention. Carers were ineligible if the person with a brain tumor was less than 18 years old.The study was approved by the University of Queensland Human Research Ethics Committee (number 2018002631) and reciprocal approval was gained from Curtin University (HRE2019-0279). Recruitment of participants took place between September 2020 and February 2021. Online flyers, social media text and posts and, newsletter articles were distributed via various methods to invite participation. Potential participants were informed of the study via social networking sites  and requests to participate were disseminated via cancer and brain tumor support organizations’ email lists and consumer newsletters. Interested carers contacted the research team and underwent a screening telephone interview. Participant information and consent forms were emailed and written informed consent was gained. Consenting participants were emailed a pre-intervention questionnaire link.After completing the pre-intervention questionnaire, participants were emailed the link to the online intervention and provided a unique username and password. A follow-up phone call checked participants were able to access the online intervention. Google analytics tracked data usage during a 4-week timeframe. Participants were emailed after 2 weeks to check for any questions or concerns. Participants were emailed the post-intervention questionnaire link 4 weeks after login access was provided.https://www.qsrinternational.com/nvivo-qualitative-data-analysis-software/home) for data management and to facilitate qualitative analysis.Participants were also invited to participate in a semi-structured telephone interview. A researcher (author JC), under the supervision of author HH, an experienced qualitative researcher and Psychologist, conducted the interviews. All interviews were conducted by phone with people who had used the online program during the 4-week pre- and post-implementation period. The transcriptions were deidentified and names were replaced with pseudonyms. The interview transcripts were entered into NVivo12 27 assessed anxiety (7 items) and depression (7 items). Scores (ranging between 0 and 42) result in classifications of “possible” or “probable” mental health disturbances with calculation of a global score ≥ 15 indicating “emotional distress.”The 14-item Hospital Anxiety and Depression Scale (HADS),28 measured participants’ brain tumor-related unmet needs that had occurred over the previous month. It is measured on a 5-point Likert scale ranging from no need through to high need.An 11-item Supportive Care Needs Scale – Brain Tumor Specific instrument for carers (SCNS-P&C)29 a 4-item scale, assessed carers’ perceived adequacy in performing caring activities on a 4-point Likert scale .The Carer Competence Scale (CCS),30 an 8-item scale that measures carer readiness for the tasks and demands involved in a caregiving role. The CPS has good internal and external reliability and good construct validity.31Carer preparedness prior to viewing the website was measured using the Caregiving Preparedness Scale (CPS),Carer demographics, tumor type, and date of diagnosis information were also collected.To compare results pre- and post-intervention, the post-intervention questionnaire readministered the DT, CPS, CCS, HADS, and SCNS-BT. Additional measures post-intervention included: technology self-efficacy; intervention usability; and acceptability.32 assessed participant technology use competency. This scale has high internal reliability (α = 0.94)32 and has been administered in an Australian population. Scores range between 10 and 100, and measures self-efficacy in using technology alone and with the support of others.32The 10-item Modified Computer Self-Efficacy Scale33 assessed 4 domains of perceived usability of the online intervention: Usefulness; ease of use; ease of learning and satisfaction. The 30-item scale has been reported to have excellent internal reliability (α = 0.98), with good construct validity when compared with other usability scales.34The USE questionnaire35 As such, we developed a questionnaire based on Sekhon et al.’s (2017) theoretical framework of acceptability.35 Each item was scored on a 7-point Likert scale (strongly disagree to strongly agree), and scores were summed to create an index, which was transformed to a 0–100 scale for ease of interpretation.Despite the importance of assessing the acceptability of a health intervention, there remains a lack of definition and validated assessment in this regard.M = 30 minutes). Interviews were recorded and transcribed verbatim.The semi-structured interview sought to understand the acceptability, usability, and usefulness of the online intervention in greater depth. The phone interviews with individual users of Caring for the Carer ranged from 19 to 61 minutes (Engagement with the intervention (in the form of unique page views and time on each page) was assessed using Google Analytics. These raw data were later coded into thematic groups, as explained on P. 9 and in d = 0.2, d = 0.5, and d = 0.8 were interpreted as small, medium, and large effects, respectively.36 Statistical significance was assumed at P < .05.Where participants answered fewer than half the items on a scale, their scores were omitted. Mean imputation was not needed because the remaining participants answered all items. Due to the small sample size, survey data were analyzed descriptively. Continuous data were summarized using means and medians, depending on normality of the data. Categorical data were summarized using percentages. Bivariate statistics  were used to identify the relationship between variables. Cohen’s d was calculated to provide an approximate effect size for the change over time in variables measured both pre- and post-intervention. Effect sizes of 37 Each researcher compared and contrasted codes within and across each interview until first-level themes were drafted. One researcher  analyzed all interviews and the second researcher  analyzed 4 interviews. Once first-level themes were drafted, 3 rounds of peer debriefing were conducted with the researchers and author HH. These discussions lead to the final higher-level themes.Two researchers conducted a thematic analysis of the transcribed interviews as guided by Braun and Clark.Google analytics data for number of page views and average time on pages were collected for 257 unique URLs contained within the website. These data were coded in MS Excel into 9 categories, as per the coding scheme in Of 16 people who consented, 1 did not commence the study. Of the remaining 15 participants, only 12 people completed the post-intervention survey. Of these 12, one was excluded due to never logging onto the online intervention and another was excluded as the person they cared for went into a residential setting, which meant that the intervention potentially had less relevance in this type of caring. See The survey results suggest good acceptability, with at least 8 participants completing all items for all scales at each time point. The median times to complete the pre-intervention and post-intervention surveys were 9  and 17 (min.6 max 61.6) minutes, respectively. The average time between completion of the baseline and follow-up surveys was 38 (SD 11.9) days.38 at each time point with the exception of the CCS at follow-up, where a negative average covariance between items was observed at follow-up.All scales indicate acceptable reliability Mdiff = 1.3, SD = 2.4, P = .11), and HADS overall  and anxiety  and depression scales  decreased over time. Although Cohen’s d and statistical significance were calculated, as the sample size was small, results should be interpreted with caution. As such, these results are not included as part of the main manuscript but can be viewed in Mdiff = 1.2, SD = 0.7, P = .13). The mean carer competence score decreased slightly over time , indicating a decline in perceived competence to provide care. The median preparedness to care score increased over time, indicating an increase in preparedness to provide care .Descriptive statistics for the normally distributed  and not M = 6.7, SD = 0.4), with ease of use , usefulness  and satisfaction scores  generating means above 5 on a 7-point scale and indicating a positive rating of the program.34 Mean acceptability of the program was 76 (standard deviation 13.01) on a 0–100 scale, also suggesting the program was acceptable to participants.Scores on post-implementation only variables see  indicateGoogle analytics returned results on 257 separate URL pages. M = 55) years of age, were interviewed. All except one were spousal carers. Although there was only a small sample size, data saturation39 was reached with a steep decline in new codes toward the end of analysis and the peer debriefing meetings came to a consensus that the central themes for this pilot had been generated. The range of time caring for a person with a brain tumor ranged from 6 months to 6.5 years (mean= 2 years and 3 months). Participants were from Queensland (n = 4), Australian Capital Territory (n = 3), New South Wales (n = 2), Victoria (n = 1), and Western Australia (n = 1).Eleven  carers, aged 47 to 63  the intervention was relevant to their needs and comprehensive enough so that all such information could be located in the program, (2) their needs were satisfied overall, but with some desire for more in-depth information addressing the needs of more experienced carers, and (3) some improvements in the visual design was needed. The second theme highlighted perceived impacts of Caring for the Carer and was also comprised of 3 subthemes. That is, participants reported that: (1) the online intervention validated their caring efforts and provided validation that they were doing as much as they could even when they wished they could do more, (2) the intervention helped normalize their situation, especially as a result of being exposed to other carer experiences, and (3) the program prompted reflection upon their own carer journey and experiences.All 11 carers described satisfaction with the Caring for the Carer online intervention, stating that the intervention and its content were informative and relevant. Some participants conveyed satisfaction that the program was comprehensive with information “where everything was in one spot” [C6]. The participants reported (see examples below) that the online intervention was relevant to their caring needs and was a primary place to go for information.“It was extremely informative.” [C16]“I went through pretty much everything and I think all of it was excellent information.” [C9]The following quote shows the perception that the content is potentially relevant across carers.“As a carer there will become a time where I would argue all the carers would want to read it.” [C6].Although participants voiced satisfaction with the online intervention some, who had been caring for a longer time, expressed a desire for more in-depth content. They described how they found some of the information too basic and probably more suited for people closer to diagnosis. As described above, this study’s cohort had been caring for an average of 2 years and 3 months.For instance, one participant highlighted how useful and comforting having access to such a program would have been at the beginning of their caring journey but implies that it is less useful in their current situation years later.“I really felt that, if that had been around, at the beginning of my three years, it would have just saved me an enormous amount of time. In terms of me being obsessed, and confused and terrified and about, you know, the whole disease.” [C10].More overtly, the following 2 quotes demonstrate the desire for more in-depth information and reiterate the concept that they would have had more use for the information at the beginning of their caring journey.“I did think they were too shallow. I felt like they didn’t have the depth that I’d be wanting for my personal self. Having said that, if I was right at the beginning again, like twelve months ago. Then I probably would. I think they’d be valuable as a first step to look at but then I think as you start progressing through and you have more and more questions you come looking for more.” [C6].“Commonly, I found that as I went to each section, I would go, “I already know that”. I said this to you when we first started to go into this trial, because I’m two years into his disease, my perspective of what that website’s telling me is going to very different to someone who’s brand new into it. They might find all of this highly informative, knowledge and power-bringing to themselves, because it’s really putting them in a seat where they’re starting to understand more about the disease. You don’t get that information when you go in for a ten-minute clinical appointment with your oncology team.” [C15].Several participants highlighted the need to integrate more interactive elements and make the online intervention more visually appealing. Carers were aware that the online intervention was in its infancy and commented that it could be made more appealing through improvements in its visual design. They offered that it was “flat in its appearance” [C1] and needed more visual appeal through animations or more graphics.“…visual side of it, perhaps, but I know it’s early days so it’s hard to say, because some people more visual than others and …have different categories or something I’m not sure, yeah… like having more graphics, or that kind of thing.” [C9]“You know if this isn’t the end state product. That you’d say that if there’s severe enhancements, that it’s to evolve would, would be about the visualization, the user interaction, with it is quite, I’d call it flat in its appearance.” [C1]“I tend to go to look at sites that have more animations or more caring type tones about it… [more visual] But, still with the context of information being within. For example, I’ve got it open now, on the first main page for the website, it almost opens up like a news article to me. Whereas, other pages that I’ve gone to do look at things might have a picture of a family, or a picture of a peaceful scenery type thing, and it’ll talk about going to look for different things. I don’t think it’s warm and inviting, I think it’s actually quite – like, news-like…” [C15]When asked about its utility, participants described the impact of the online intervention on their thoughts and actions. The 3 subthemes generated were: Feelings of validation; normalization of carer experiences through learning about other carer experiences and: Reflection or increased awareness regarding their own situation.An important impact on carers using the online intervention was validation. That is, while the information may not have provided substantial new insights into their caring experiences (as per the finding that this cohort of carers were more experienced and searching for something more in-depth) it provided validation regarding what they were already doing as more experienced carers. Participants described how, in a situation of uncertainty and distress, the online intervention was reassuring as it often reinforced that they were doing well in their caring efforts. Statements alluding to self-doubt were accompanied by assertions that the online intervention validated that the way in which they were caring was probably the best they could do.“It was almost comforting. Almost, cause [sic] there is nothing that comforts me in this case.” [C5]“It allowed me to recalibrate [SIC], to tick the boxes in my own head that I was doing all I could…it was reassuring” [C6].“I think, it has a positive effect. Because, it has that timeout, to think oh you know okay … I can do this and you know like other people have been here and it’s ok. So that, I feel it’s, what’s the word, it’s a reinforcement of that you are on the right [track]. You are trying to do the right thing by your whoever it is, your loved one.” [C9].Through reading about other people’s caring experiences on the intervention, carers described how they felt reassured that they weren’t the only ones going through this caring experience. Participant responses indicated that Caring for the Carer, particularly exposure to other carer stories, could normalize a carer’s situation, experiences, and feelings. The intervention’s focus on caring for someone with a brain tumor could provide reassurance that the carer was not alone in their plight. For instance, C9 stated, “other people have been here and it’s ok.”“You realise that you’re not the only one who’s going through this. And that there’s support out there.” [C3].Carers mentioned how the online intervention “triggered” self-reflection, which they sometimes acted upon. Reading about other people’s experiences leads to reflection on their own situation and normalization. The online intervention, and subsequent reflection, prompted some carers to act. For instance, one carer who had read about the benefits of “laughter” even in the face of a distressing situation was prompted to seek out what made those around her laugh. Another participant relayed how they had shared some useful information with their adult children.“One of the tips was to find something that made you laugh and I haven’t come across that before. That’s the first time I’ve come across that and that sent me off on trying looking at bloopers and outtakes from movies. [I: Oh good it prompted you.] Yes, because it made me realize that it’s a long time since I had anything to laugh about… And having the tip to just find something that made me laugh. I actually asked my kids, who are grownup adults and I said come on guys, what used to make mum laugh?” [C3].23 Yet research is still lacking on the effectiveness of these online interventions,23 with little to no research on stand-alone web-based interventions for carers of someone with neuro-oncological disorders. This current research provided a pilot evaluation of an online program for carers of people with a brain tumor. Overall, the piloting of the online intervention, Caring for the Carers indicated that it was acceptable and usable. Combining survey and interview results, the pilot suggested the intervention was useful and had the potential to positively impact carers . However, randomization would be needed to demonstrate whether these changes occur over time or are a result of the intervention. Initial results indicate that the website has the potential to address the need for online information for carers of brain cancer patients as highlighted in Schaefer et al.’s (2021) systematic review.22Emerging research shows that online interventions have the potential to efficiently support carers of someone with dementia.32 results showed that the sample was fairly confident in using technology, which would also explain the ease of use results. In interviews, the carers described the intervention as relevant to their caring experiences, informative, and useful to have reliable information all in one spot. The importance of usability and acceptability of an online program for carer of people with cancer cannot be understated40 as it aims to address the unmet needs of this cohort.22 The moderate reduction in unmet needs, even in this small sample, supports further study to confirm the utility of the intervention.Survey results indicated that the intervention was easy to learn to use, acceptable and useful. The computer self-efficacyHowever, participants also expressed a desire for more in-depth information to meet the needs of carers who have been caring for a longer period of time. While noteworthy, such findings may also be an artifact of the current sample of carers being further along on the caring journey (average of 2 ¼ years) and highlights the need for further examination with a broader group of carers. This result and the Schaefer et al. (2021) review show that the usability of the pilot website needs amending to allow ease of navigation as a function of the cancer care continuum. This current study did, however, indicate that the content validated caring experiences for those further along the caring trajectory.The interviews also provided in-depth feedback regarding possible improvements to the intervention. For example, some carers suggested improvements to the layout and visual design, which have been incorporated into the next iteration of the intervention.41The quantitative results indicated a reduction in depression and a moderate reduction in distress and anxiety following the intervention, as well as an increase in perceived carer preparedness. However, considering the small sample size, such results are to be viewed with caution. An RCT would help to determine whether the intervention was the main contributor to these changes or whether change over time would have occurred without the intervention. Heinsch et al.’s (2021) systematic review found that significant clinical impact of similar interventions are a rarity and also calls for more RCTs.42 yet helplessness can be a common issue especially when faced with palliative conditions.44 The interview findings suggested that the self-doubt was countered by feelings of validation as a result of engaging with the intervention. Further examination of the role of self-doubt among carers is needed as well as the relationship between general self-confidence and confidence to care.The interview findings indicated the presence of self-doubt. Carer self-doubt pertained to fears that were not doing enough to care for the person with a brain tumor. Confidence and preparedness in carers can influence communication with health professionals and patient wellbeing,45 as it can have a marked effect on a person’s emotional response to a situation.46 Validation acknowledges the reality and potential distress of an issue such as caring for someone with cancer, and provides “permission” to feel; however, they feel.48 According to Linehan’s  conceptualization of validation, normalization is a component that allows a person to feel that their experience and emotions are “normal” and likely to be experienced by others in similar situations. The videos and case studies in the online intervention showed carers that there were others who had similar reactions to caring for someone with a brain tumor, thus validating and normalizing their experience.The interview findings underlined how the intervention could assist in validating the emotions associated with caring, and normalizing their situation. The importance of validation of one’s subjective experience and emotions has long been established49 It can involve an attempt to understand one’s reaction to an event and make sense of the resulting feelings.50 Research shows that adaptive reflection can assist with coping in a distressful situation, reducing negative emotions and increasing well-being.50 Consistent with the current study, existing research also demonstrates how reflection can promote well-being and prompt behavior changes in caregivers51 associated with an improved carer experience.52 Furthermore, as found in the current study, digital interventions have the potential to prompt and “guide” self-reflection so that it is adaptive and supports carers to “make sense” of their situation and potentially lead to adaptive coping behaviors.51Interview findings also suggested that the online intervention prompted self-reflection or reflection on their situation, which, in turn, often triggered a behavioral response. Reflection is a metacognitive process that involves unbiased self-observation of one’s own attitudes, thoughts, and behaviors to gain insight and increase personal effectiveness.The analytics data were coded for greater coherence and clarity. Google analytics showed that seeking information about HGG, carer well-being, and health and support systems were the most common activities. This supports the need for information that is easy to access, clear, and useful around these issues. The relatively high numbers for both time on page and page views related to website administration such as registration, navigation, and search are disappointing. We need to make the online intervention easily accessible and the registration and set-up process were too time-consuming. These processes, needed for data tracking, have been reviewed and simplified in the current version and will be completely removed after the final evaluation component project. We have also removed the notes feature, which necessitated much of the security and registration process in order to keep people’s notes private. Notes were difficult to include on many platforms, could have perceived privacy issues, was not well used and there are many other ways in which people may prefer to take and keep notes. Scores for stories about carers were also quite low. However, sections of these stories were also accessible throughout the intervention, where relevant, possibly superseding the need to review the whole story. Some interview participants also said they would prefer real people in the stories. Subsequently, we have created a series of videos of “real” carers speaking about a range of relevant topics and added these to the next iteration of the website.The main limitation of this pilot study was the small sample size. Sampling methods, focused on recruitment from cancer support groups, likely favored potential participants with higher levels of health literacy and those already seeking resources. However, triangulation of multiple methods makes the study more robust. Unfortunately, one item (“It makes the things I want to accomplish easier to get done”) from the usefulness domain of the 30-item USE questionnaire was not transposed to the online survey and therefore, never asked. The effect on scale reliability is probably minor as there were 7 remaining items measuring usefulness. Finally, although all carers appeared to have insight and provided detail with regard to their caring and the impact of the online intervention, it could not be verified that they were actually carers of someone with HGG. Furthermore, to reduce burden on the carers, we did not collect detailed data  on the person with HGG.The study indicated good acceptability and usability of an online intervention for carers of people with HGGs. A decrease in depression was found between pre- and post-implementation results. As such, an RCT would help to determine whether the intervention was the main contributor to decreased depression. This “one stop shop” was seen as useful and prompted carers to reflect on their own coping and caregiving. However, the carers who evaluated the online intervention provided feedback that they required more in-depth information especially as they were further along the trajectory of care. This highlighted the need for information to be tailored as a function of the care continuum. The online intervention has been amended in response to this study’s findings  and a follow-up RCT will further evaluate the enhanced intervention.Neuro-Oncology .Supplementary material is available online at npad032_suppl_Supplementary_MaterialClick here for additional data file.