With the aging population, family caregivers provide increasingly complex and intense care for older adults and persons with disabilities. There is growing interest in developing community-based services to support family caregivers. Caregiving occurs around the clock, and caregivers face challenges in accessing community-based services at convenient times owing to the demands of care. Web-based resources hold promise for accessible real-time support. CareNav (TM), a caregiver resource information system, is a web-based platform designed to support real-time universal caregiver assessment, a record of client encounters, development of a care plan, tailored information and resource content, access to web-based caregiver resources, the capacity to track service authorization and contracts, and secure communications. The assessment includes needs and health conditions of both the care recipient and caregiver; current resources; and priorities for support, information, and referral. In 2019, the California Department of Health Care Services funded the 11 nonprofit California Caregiver Resource Centers (CRCs) to expand and improve family caregiver services and enhance CRC information technology services. Deployment of a statewide information system offered a unique opportunity to examine structures and processes facilitating implementation, providing feedback to the sites as well as lessons learned for similar projects in the future.The aim of this paper was to describe the statewide implementation of the comprehensive CareNav system using the Consolidated Framework for Implementation Research as an organizing structure for synthesizing the evaluation.This mixed methods study used two major approaches to evaluate the implementation process: a survey of all staff who completed training (n=82) and in-depth qualitative interviews with 11 CRC teams and 3 key informants (n=35). We initially analyzed interview transcripts using qualitative descriptive methods and then identified subthemes and relationships among ideas, mapping the findings to the Consolidated Framework for Implementation Research.We present findings on the outer setting, inner setting, characteristics of the intervention, characteristics of the staff, and the implementation process. The critical elements for success were leadership, communication, harmonization of processes across sites, and motivation to serve clients in more accessible and convenient ways.These findings have implications for technology deployment in diverse community-based agencies that aspire to enhance web-based services. In the United States, approximately 20% of adults provide unpaid care to a family member or friend . Family Despite their vital role in optimizing function and health for older adults, caregivers are relatively invisible in health care. Caregivers provide valuable information about the person receiving care, yet rarely do health care professionals assess the capacity, readiness, or mental health of caregivers to provide care during routine health encounters ,5.In the absence of routine caregiver assessment and support in the clinical setting, there has been growing interest in developing community-based services to support family caregivers. Caregiving occurs around the clock, and caregivers face challenges in accessing community-based services at convenient times owing to the demands of care. Web-based resources hold promise for accessible real-time support, and targeted interventions have been developed for specific audiences such as caregivers for persons with cancer , dementiMost web-based supports emphasize one element such as psychoeducational offerings or stress management. Despite quality issues with many studies, the positive outcomes of targeted interventions have included improved self-efficacy, improved self-esteem, and less strain . MissingStudies on web-based caregiver support have demonstrated 3 tendencies. First, caregivers of persons with dementia are overrepresented because of the demanding nature of caregiving related to issues with memory, thinking, and behavior. Many studies on web-based support for dementia caregivers, such as iSupport , focus oSecond, the heterogeneity of web-based support types underlies varying results. Studies on web-based support for those caring for persons with cancer , posttraThird, the breadth and scope of caregiver support in the web-based modality affords subgroup-specific knowledge rather than exhaustive knowledge on implementation strengths and challenges. For example, in an implementation study of a video health technology intervention to improve self-care of caregivers of persons with heart failure, Hirschman et al  found adCareNav, a caregiver resource information system, is a web-based platform designed to support interactive universal caregiver assessment, a record of client encounters, development of a care plan, tailored information and resource content, access to web-based caregiver resources, capacity to track service authorization and contracts, and secure communications. The assessment includes both care recipient and caregiver needs and health conditions; current resources; and priorities for support, information, and referral. The assessment can be self-administered on the web or administered by a staff member over the phone or in-person. After assessment, a staff consultant meets with the caregiver to prioritize and develop a care plan that might include contracting services such as respite, referral to educational offerings or a support group, or vouchers for legal aid or counseling.The Family Caregiver Alliance (FCA), one of the 11 California Caregiver Resource Centers , pioneered CareNav with private funding and deployed this system across 3 CRCs that served as pilot sites. In 2019, the California Department of Health Care Services funded 11 nonprofit CRCs to expand and improve family caregiver services and enhance CRC information technology services, deploying CareNav as a common data set across the state over a 3-year period (2019-2022).The FCA led the implementation team for CareNav in partnership with the technology developer Quality Process (QP). The FCA contracted with the University of California Davis Family Caregiving Institute to conduct an evaluation of the implementation process as well as an analysis of the statewide data to determine program effectiveness and quality improvement opportunities. The implementation began in January 2020, and the system was fully deployed by September 2020.Implementation evaluation was guided by the health-focused CFIR ). The CFThis mixed methods study used two major approaches to evaluate the implementation process: in-depth interviews with key informants at the CRCs, and surveys of all staff who completed training. The in-depth interviews explored all aspects of the implementation process from multiple perspectives, while the surveys were used to characterize the readiness and self-efficacy of the staff implementing the system. This approach will enable the evaluation team to assess readiness and satisfaction over time using quantitative scores while developing a deeper understanding of the dynamics of change and appreciation of multiple perspectives afforded by qualitative interviews.The evaluation team conducted focus group interviews with teams of each CRC, and individual interviews with key informants from the implementation team. All current leaders and staff of the 11 CRCs were eligible to participate in this study. A focus group was established for each CRC to include all interested staff from the same site. The interviews elicited perspectives on implementation and training activities, including perceptions of benefits and concerns regarding CareNav. We used a semistructured interview guide for both focus groups and individual interviews asking about the implementation process, challenges and facilitators, anticipated system and client outcomes, and satisfaction with the process. Owing to the widespread implications of the COVID-19 pandemic on service delivery, we asked all participants about how the COVID-19 pandemic affected both the implementation process and experiences of their clients as caregivers. Interviews were conducted using Zoom, and audio was recorded with the consent of the participants and transcribed.The evaluation team designed a pretraining and posttraining readiness survey to determine readiness, preparation, and confidence regarding the implementation process and to identify self-efficacy and perceived benefits and concerns before and after training. We invited all staff to complete surveys before and immediately after a full day of formal training on CareNav.The pretraining readiness survey included 10 items rated on a 5-point scale, where 1 represents the most positive response. Cronbach α for the current sample was .83. The survey also assessed whether the participants are familiar with CareNav, know its purpose, and how to do an intake and assessment. Open-ended questions identified benefits and concerns about CareNav.The posttraining survey reassessed participants’ knowledge, preparedness for implementation, confidence, and knowing where to get help with CareNav. The posttraining survey also assessed whether the training met participants’ needs and their willingness to take actions that could support CareNav implementation, such as encouraging staff or coworkers to use CareNav and ensuring new staff members are educated on how to use CareNav.The transcribed interviews were imported into the Dedoose qualitative data analysis software. Qualitative descriptive methods were used to analyze the transcripts and open-ended responses to the surveys ,28. Two t tests for continuous variables and McNemar tests for dichotomous variables. Quantitative analyses were performed using the SPSS statistical package .Quantitative data were analyzed using descriptive statistics. To enable meaningful interpretation and visualization, the 10-item readiness scale was recoded to a 5-point scale in which a higher score represents better readiness. Pretraining and posttraining scores were compared using paired 2-tailed This study was determined to be exempt from ethics approval by the UC Davis institutional review board. We collected no identifying information about the participants in the survey and focus groups. Participants were informed about the purpose of the study and the voluntary nature of participation, providing assent by completing the survey or continuing with the recorded Zoom interview.In total, 86 staff members completed training, with 82 (95%) participants contributing pretraining data and 56 (65%) participants contributing posttraining data. The staff included CRC directors, family consultants who interact with caregiver clients and provide resources and support, and analysts who manage client and financial data. The surveys were anonymous, with no identifying data of the staff members. The results of readiness and self-efficacy are presented in subsequent sections within the CFIR model as characteristics of the staff.Between May and August 2020, we conducted 11 focus group interviews (ranging in size from 2 to 6 participants) and 5 focused individual interviews with key informants, totaling 35 participants. Participants represented all 11 sites and the implementation team and included all roles . To protect the privacy of the participants, we did not collect demographic data associated with these interviews.We mapped the findings of this evaluation to the following CFIR domains: outer setting, inner setting, characteristics of the intervention, staff characteristics, and implementation process. The specific findings related to these domains have been expanded upon in the subsequent sections.Interviews across CRC sites revealed site-level variability and heterogeneity in relationships and networking with external organizations as well as the diversity of client characteristics and needs . ImplemeSome CRCs exist as standalone organizations. More complex sites are embedded or hosted in larger health care systems with their own information technology platforms, which requires additional efforts to integrate CareNav and to be compliant with additional health system privacy and security policies. Moreover, the funding sources and constellations of services vary between sites and influence both documentation and administrative requirements. This challenged the transition from the existing local databases to the CareNav platform. For example:Because it’s a hospital it has security really well locked down. And so, the website that I need to access to see if the data is correct in their initial upload in our system is blocked. So, I’m working within my own organization to try to get that website unblocked.Geographic disparities are reflected in rural sites serving communities that lack the adequate technology structures and broadband connection necessary for reliable access to an internet platform. Clients are also diverse in their English proficiency and their capacity to use technology. Several participants mentioned low computer literacy and lack of technological and internet safety skills as barriers for older caregivers to use technology. Nonetheless, some of the staff reported being surprised by the amount of participation by clients whom they assumed would not ordinarily use technology. This observation was partially attributed to the consequences of the COVID-19 pandemic:But I think a lot of them are open to technology. I think this pandemic has forced that issue where a lot of family caregivers are using more technology now...And I'm surprised as to the ones that I thought wouldn't know how to use technology. The ones that before COVID there were a lot that I never, never thought that they could do it as a video with me. I never thought that because I just, you generalize people...because of age...a lot of them are facetiming family, they are video conferencing with their family care navigator...so we just have to start thinking differently as far as how we get them used to CareNav.The COVID-19 pandemic, which emerged simultaneously with the implementation kickoff, amplified the existing risks and threats to the well-being of caregivers. Family consultants reported higher levels of stress, more financial concerns, increased housing and food insecurity, job loss, and escalating costs of caregiving supplies (such as gloves and masks) among their clients. The strain was exacerbated by loss of support resources, including availability of adult day care, home help, in-person support groups, and a reluctance to consider assisted living or skilled nursing alternatives at this time as residential care facilities were widely reporting COVID-19 outbreaks and, in some cases, higher mortality rates for older persons. Many caregivers faced additional home demands, caring for multiple family members and children being schooled at home. The pandemic increased their sense of isolation, with family consultants reporting more symptoms of depression and anxiety among their clients. Finally, caregiver health was further compromised by the inability to quarantine when a family member was ill, thus increasing the exposure of the caregiver. Caregivers also expressed reluctance to access formal services owing to fear of contagion or not having the time to devote to their own health:We’ve seen kind of that increased risk, I think, across the board because a lot of our support systems are not available right now. [...] I think what most impacts caregivers, or can impact their health overall and wellbeing, is what level of support they have available to them.. Additional strain was placed on staff members who were already facing a learning curve to execute the new system, as well as dramatic changes in their workflow. Simultaneously, it accelerated the need for a web-based platform and rapidly demonstrated the usefulness and feasibility of the web-based environment . Interview participants highlighted how the pandemic demonstrated the benefits of CareNav:The pandemic created a particularly challenging climate for the implementation of a new major systemI think the Coronavirus kind of shows how helpful it is to have everything online. There really hasn’t been too much of a disruption to the services we’re able to provide our caregivers. I think that’s been a huge plus to be able to see how nicely it can transition when things do happen, that we’re still able to access what we need.The inner setting for CareNav implementation is the state-level CRC system and 11 individual CRCs .California launched a CRC system in 1984 with the enactment of the Comprehensive Act for Families and Caregivers of Brain-Impaired Adults, thereby establishing a network of support for caregivers. At present, the California Department of Health Care Services (DHCS) funds 11 CRCs that provide support to family caregivers affected by chronic health conditions, including Alzheimer disease and related dementias and other degenerative diseases.CRCs serve as a point of entry for services available to caregiving families, covering every county in California. While each center tailors its services to its geographic area, all CRCs have a core component of programs that provide uniform caregiver assessment and information, education, and support for caregivers. Individual CRCs also receive funds from county contracts, foundations, business partners, and donations to provide additional services. For over three decades, CRCs have supported caregivers in their regions, relying on staff intake interviews with caregivers and tailored referrals to relevant resources. With fluctuating funding, the programs became decentralized, and over the past decade, the 11 CRCs had been operating relatively independently. Funding to implement the statewide web-based platform provided an opportunity for new collaborations and connections.CRCs provide services across income categories, and the original enabling legislation included middle-income families who are often overlooked and for whom few services are targeted. CRCs are united by shared values emphasizing choice, collaboration, innovation, quality, participation, respect, and diversity.The implementation prompted culture change in three major ways: formalizing the system of CRCs across the state by uniting loosely affiliated sites, instituting standardized assessments, and changing to a new way of delivering services to clients virtually. The funding and subsequent process fostered a shared goal among CRC directors to serve the entire state and collaborate with one another to do so. Committing to a shared technology platform involved greater discussion and information exchange among the groups as well as the recognition that the whole is greater than the sum of the parts. A welcome culture change was the comradery and mutual aid that solidified over the initial year of implementation:I feel like just within the CRC system the genuine enthusiasm for the project. Just to embrace it, even with all this other kind of craziness [COVID-19 pandemic] going on in the world.In-depth interviews revealed a collective positive attitude with a willingness to change, staff dedication, continued learning, and patience to follow through the stages and steps of the process. All interview participants expressed enthusiasm for the adoption of CareNav and a belief in the positive potential of this change in their practices:I think it's been well received. We've been anticipating this for a long time. And have been very excited about it...We have some folks that were really excited and got right in there and started playing with it and working with it. Others I think are a little bit, you know, we're learning as we go.Participants expressed hesitation about changing to a technology platform but recognized that caregivers’ needs are changing in society and that the systems must evolve to meet the changing needs.The idea is to be innovative and for caregivers, because, as things continue our younger population is very used to being more self-directed and being online. So, it has potential for growth and change over time. We'll continue to do that with a lot of streamlining of systems.Communication was vital at all levels, from the implementation team to the sites, from the directors to their staff, and among sites. Communication involved developing a shared vision for the process and the outcomes, as well as coordinating the logistical aspects of the implementation. The process of preparing for technology deployment revealed workflow and processes that were not initially evident or taken for granted, and these had to be addressed as technology was applied to automate processes. Communication among the teams was vital to understanding work processes and establishing new ways of operating as needed.Communication and support from FCA and among CRC sites played a major role in successful implementation, particularly as sites faced delays or barriers and were able to benefit from lessons learned elsewhere:Something that's new is now we are communicating and reaching out to the other CRCs, which I believe hasn't happened in years. So it's really great that if we have a question or wondering, a different way of doing something in our program, I can just reach out and to anyone you know, in California and get their help and opinion.Both the implementation process and the shared platform facilitated deeper collaboration among sites and the ability to elevate local issues with colleagues across the state, enhancing the strength of recommendations to address caregiver needs more comprehensively.At the beginning of the implementation effort, 3 CRC sites, including FCA, were already using CareNav. The subsequent sites benefited from reliability and usability testing, as well as refinements and improvements that had been made during the initial, more limited deployment by FCA and QP.Leadership was an essential condition for success from the implementation team and at the CRC site level. Strong leadership, reassurance, and encouragement by managers, coupled with effective communication, established the overall vision, a shared understanding of the goal, the anticipated process and outcomes, and motivated staff across the sites to engage in implementation:I think there's been leadership behind this and a sense of vision...FCA is [a] very unique organization and that [sic] they are really sitting in this point where they're both policy wonks as well as clinical experts. And I think that this allows FCA to bring vision and be forward looking of where we're going. And I think that the other CRCs are benefiting from that.Focused interviews point to CareNav attributes that both facilitate and inhibit its implementation .A key factor for the intervention is its relative advantage over previous data collection tools and software used by CRC sites to gather and aggregate site-level data on the caregivers they served and the programs they administered. Using CareNav reduced paperwork, enabled easier documentation, more efficient and secure charting, and a more environment-friendly approach. Additional advantages included increased CRC capacity and round-the-clock accessibility for clients. Several participants emphasized how the design of CareNav supports the process of care:Now when a new person starts it’s...here’s the computer system that we use. This is the workflow, because I think it's really laid out nicely, the toolbar at the top of care journey. There’s a workflow that you follow. It’s just all right there in one place and as long as you have a secure connection, you can access it, so it’s going to save a lot of time. I think people are going to end up really happy that they have that information at their fingertips, and they don’t have to write it down on paper or search for it, laboriously, in their client file.Both clinicians and managers reported the advantages of CareNav for management functions. Standardization of the system across CRCs was perceived as allowing sites to collaborate for consultation, evaluation, and advocacy. Using a uniform tool supports administrative and management functions, including case data record-keeping as well as assessing the process and outcomes of the organization in real time:For a manager being able to pull up reports without it being having to dump it into Excel and then sort through all the different things that you don’t need. It looks like data collection is just going to be a lot simpler and easier...as a manager it’s easier to measure staff productivity on a system like that because you can go in their notes.The most frequently identified benefit and concern about CareNav implementation is related to the adaptability of CareNav to the outer-setting variability among sites and populations served. Sites varied along multiple dimensions including population served, geographic characteristics, funding sources, relationships with host organizations, and size. The ability of CareNav to provide remote access, particularly in rural areas, was perceived as a benefit even with the variability in geographic distribution of clients in several CRCs and the impact of the COVID-19 pandemic.Nonetheless, the digital divide (the issue of equitable access to technology and broadband connection) constitutes an ongoing barrier, particularly for rural, low-income, and non–English-speaking clients. Moreover, there are some caregivers in remote areas who value self-sufficiency and view government programs with suspicion, with reluctance to share information on the web regardless of access to broadband connection. Some communities in the catchment area do not have reliable broadband connections, and many clients may not be able to afford internet services or the associated technology. The platform is provided in English, limiting access to caregivers who do not speak English or have low literacy:But language for me is probably my biggest concern, because we do have a big, Spanish speaking population and Vietnamese. It’s a very significant group.Sites hosted within a larger health care and information system experienced difficulties associated with the lack of flexibility and data migration, adding complexity and increasing the time and effort demands for staff. For instance, double data entry was necessary for some CRCs to ensure timely and accurate data for fiscal reporting and reimbursement across various funding agencies.Confidentiality presents another level of complexity. While CareNav is a secure and private system, there is a learning curve for staff to understand the inherent privacy and security protection of the care team and clients. To assure a secure environment, written direct communication with clients changed with CareNav, requiring user authentication processes to maintain clients’ privacy:In the beginning, one of the issues that I was having, for example, when I was doing intake, if I sent emails, I was sending emails through CareNav. But people were not replying back and it turns out because it would send them a message into their actual email, but it would go to Spam....People just prefer for me to directly email them to their email.The threat of delay in funding and losing funding during the budget negotiations raised concerns about ongoing funding and support for CareNav. Several sites expressed frustration with the delays associated with state contracting and system readiness. Time-limited funding without a clear path to sustainability posed challenges for directors in their long-term planning.The pretraining survey was an early opportunity to evaluate CRC staff knowledge about CareNav, self-efficacy, and readiness for change . OverallAlmost 90% (73/82) of staff had seen or heard about CareNav before the training and almost all  believed that CareNav is designed to improve caregiver access to services. Before training, one-third  of the staff members reported understanding how to complete the intake and assessment in CareNav. The staff members also believed that CareNav would enable better structure and process of care including improved ability to record services  and providing tailored and accessible information for caregivers .The staff expressed a high level of self-efficacy to implement CareNav in terms of feeling prepared , confident , and capable .Regarding readiness for change, participants expressed a strong willingness to do new things  but believed that it would take time for everyone on the staff to become familiar with using CareNav .The elements of implementation included developing an overall project plan, engaging stakeholders, preparing technology for scaling, general training, and providing technical expertise and support at each CRC site .The implementation team consisting of staff from the FCA and QP developed a project management plan that addressed culture change, establishing site readiness, staff training, and technical implementation and support.Building on the demonstrated success and utility of CareNav in 3 sites, the implementation process involved planning for scaling the technology across 8 additional sites. As described in the inner and outer setting sections, the sites were diverse in several respects: the clients they served, the constellation of services and funding sources, and their relationship with a parent organization providing information technology. Early preparation involved assessing the requirements of each system for technology compatibility and interoperability, security, and compliance with applicable laws . The technology team engaged with each site in mapping the data processes, identifying data sources, and reporting requirements.The overall project plan involved determining major milestones along with the requisite resources and coordination to ensure progress. A major task of the technology team was to prepare the technology for scaling by harmonizing the data across the sites and mapping source data fields to the CareNav platform to assure standardization and data integrity. As the sites reviewed the CareNav software, they requested customization to fit their particular programs, funding requirements, and workflow, thus requiring site-specific revisions to the platform.The FCA team recognized the importance of engaging stakeholders throughout the process. They appreciated that scaling CareNav involved cultural change and made significant efforts to create a shared vision and commitment to engage in a new way. In a statewide kickoff meeting in January 2020, directors and staff of the CRCs came together to build relationships, develop a deeper understanding of CareNav and its deployment, and generate excitement regarding the effort. CRC sites shared best practices with one another and began to develop a stronger sense of collective resources and commitment to meet the needs of diverse caregivers across California.General training was accomplished through an initial in-person kickoff meeting followed by statewide webinars. The webinars were widely attended and offered topics to address overarching issues, such as managing change, using telehealth and technology-enabled assessment and supports, and using data for quality improvement.Technical and clinical support was provided by individual site-level trainings to prepare the staff for technology deployment, addressing site-specific workflow and learning needs. Starting in March 2020, these 2-day sessions included the opportunity for hands-on practice using CareNav, reviewing new work processes, creating Caregiver Action Plans and service authorizations, generating reports, and using the library of resources available within CareNav. The implementation team provided extensive individual coaching and problem solving to the sites as the implementation proceeded.Implementation, including all activities related to training, communication, and installation of CareNav at the 8 sites began in March 2020, and the last site was onboarded in late July 2020 . Both before and after training, the staff believed that the system would improve caregiver access to services. Given the high proportion endorsing this survey item in the pretraining and posttraining periods, this change was not statistically significant. Paired 2-tailed t test analysis showed significant improvement in feeling prepared to implement the CareNav score  and in knowing where to obtain help . A nearly significant decrease in the mean confidence score was found . It is likely that the training fostered a greater awareness of the system and recognition that it would take time to learn new ways of working and using technology.Comparing pretraining and posttraining readiness for implementation survey data shows significant increase in staff beliefs about their knowledge how to use CareNav, where to obtain help if needed and their preparedness. The proportion of staff who reported that they understood how to complete an intake and assessment in CareNav significantly increased from 27% before training to 97% after training  staff reported willingness to adapt current services or provide services using CareNav. All participants will ask for support if they have questions about how to use CareNav, and 55 participants (90%) will offer support to coworkers if they have questions; 52 (85%) participants will ensure new coworkers are educated on how to use CareNav, and 50 participants (82%) will encourage coworkers to use CareNav.Respondents found the training useful and helpful: 82% (n=50) rated the training as useful, 14% (n=9) were neutral, and 5% (n=3) did not find the training useful. In response to a question about whether the training met their needs, 76% (n=46) of the respondents agreed, 11% (n=7) were neutral, and 13% (n=8) did not feel that the training met their needs. Finally, almost 80% (n=48) felt that they had sufficient time to practice new skills.Focused interviews explored satisfaction with the system and implementation process. Overall, the interview participants expressed a high level of satisfaction with the implementation process, affirming the vision as important for the next phase of the work of the CRCs and embracing change as a positive force. Interview participants remarked on how easy it was to learn and use the new system and how readily they could see the benefits to their workflow and clients. Many expressed surprise at how well the process had gone despite the unforeseen challenges:I mean I think for rolling out a new platform of this magnitude, it’s gone amazingly well.It has been a pretty positive experience. So, I think it’s been easy for me to navigate and I think people who are used to doing everything online appreciate that from the system.Interview participants from the 2 sites that were the last to implement the program were less satisfied and more skeptical about the long-term benefits. Unlike other sites, these sites encountered system barriers including integration with the information system at the broader host organization and difficulty harmonizing their existing records with the new platform. Despite these frustrations and delays, the sites remained open-minded and were willing to move forward:I think it just further kind of reaffirms that our staff is flexible and we’ll just roll with it most of the time and yeah it’s frustrating and that sort of thing that we’re going to make the best of it, regardless of the situation and that’s just kind of our attitude about most things in general.The interview participants recognized that many of the features of the platform were even more relevant in the context of the pandemic and that physical distancing guidelines accelerated adoption by agencies and clients at an unexpected rate. Importantly, throughout the pandemic, CRCs continued to innovate and serve their clients who needed them more than ever:I think what we’ve all learned that we’ve been very surprised about is we have discovered, so many new opportunities because of the pandemic. And so, our repertoire of services or our availability is expanded. My staff continue to express great satisfaction with their relationships with their clients and, and they are now having satisfying phone conversations where they're having satisfying online support groups, we’re continuing to have our educational workshops and online and people are satisfied with that. So yes there are disappointments and frustrations, but at the same time we’ve discovered so many opportunities. And we’ve become empowered, and we are saying to the community, “We’re here. We’re open we didn't go anywhere, call us, we’re here for you” and so that was a nice surprise, and my staff, myself, the entire organization, we just feel more confident now of knowing how to work remotely, knowing how to use zoom, knowing how to use our new databases, we just feel like, we got it together. I always say to my team they’re rock stars they just impress me every day.The focused interviews also explored early outcomes of the implementation of the web-based platform, both at the system and client levels. Finally, the participants shared the lessons learned during the process.The most commonly reported benefits were improved access and convenience. This was particularly salient during the pandemic with staff working from home. Interview participants cited the benefits of having a single paperless location for client data, accessible by any staff member from any location. Family consultants also valued the ability to track services more completely:It’s allowed us to work remotely, it has allowed at the time of COVID to work safely as a group and still support our caregivers. We’ve been able to continue to offer services. We’ve continued to be able to document and work together.The directors valued the potential of the system to generate data to evaluate services, improve quality, guide program decisions, and provide evidence for advocacy. At the site level, directors anticipated using the data to guide strategic directions and identify service gaps. Statewide, they valued the potential to aggregate data to inform planning and policy. For example, data on caregivers can inform the implementation of the California Master Plan on Aging:The other big benefit eventually will be that we will have statewide information data that is consistent across all 11 Caregiver Resource Centers. And to me that's huge because it helps with government planning and policymaking as it relates to caregiving.A positive consequence of this initiative has been bringing the sites together, with a shared vision to serve caregivers across the entire state, learning from one another and sharing resources. Several directors shared a vision to collaborate in new ways, assuring that caregivers across the state had access to culturally and linguistically congruent resources. For example:Could we survey our sites to see who has family consultants in different languages? In our County we have a pretty sizable Korean population. We currently don’t have a Korean family consultant, but if another site did, could they serve them? And could we serve if they had a Vietnamese client? In other words, how do we leverage our statewide network around language barriers? I think there’s a potential opportunity to use the statewide network differently with this common platform.The greatest client benefit reported was having a platform that clients could access at their convenience, around the clock and from any location. In addition, the consultants found it beneficial that the platform enabled them to tailor resources for specific clients based on their assessment, which allowed for immediate delivery from the web-based library. Clients could also access information about authorized services, such as respite or counseling on the web. Several consultants voiced their advantage to clients with disabilities who find web-based navigation more accessible than other alternatives:I have clients with disabilities, for example, I had a few who were completely deaf and—we communicated through (CareNav) and through email. So, that was a wonderful tool for her because she said in the past it was really challenging to get services.The new platform provided an avenue for clients to connect during the COVID-19 pandemic and address social isolation in a way that had not been previously available:One of our staff members said, “my online Spanish support group are really having a hard time with the isolation and they so appreciate being together at least once a month, but they want to meet two times. Can I do my support group two times a month?” I said of course!patience. All the interview participants reported resilience and flexibility as they approached and engaged in the implementation process. Many affirmed the positive nature of the change and a commitment to ongoing learning associated with this platform enhancement. They expressed heightened appreciation for the importance of communication and collaboration within sites, across sites, and in the community. For those on the clinical and technical support teams, they recognized in even greater detail the variability and diversity across the sites:The most commonly stated lesson was Having to realize that people really think differently, and they learn at different speeds, and they communicate differently, both individuals and as organizations, and the variability in even their data or how they store their data and how they manage their programs. Yeah, I think there was just a little bit of variability everywhere.Our findings suggest 4 factors as essential underpinnings of successful implementation, with implications for future replication . First, Second, the interview participants stressed the key role of training and ongoing support to increase their self-efficacy using the technology platform. Ongoing training and support were suggested as effective strategies to attract and involve key stakeholders in implementing or using the innovation ,34. Our Third, CareNav represented culture change in two major ways: by bringing together decentralized sites and by introducing novel technology that provides customization, round-the-clock availability, and enhanced workflow for staff. In addition, CareNav reflects culture changes societally. In both surveys and interviews, participants expressed a high degree of willingness to change and an openness to new approaches to delivering and documenting interactions with caregivers. This willingness to adopt technology was a key factor in the rapid and successful deployment of the platform.Finally, the interview participants raised a critical issue of ongoing funding to support the CareNav initiative going forward. Over the last few decades, state funding for the CRC system has waxed and waned, along with the political will to support family caregivers. In the leanest years, CRCs functioned largely as independent entities, drawing on local funding and scaling back services accordingly. In the current phase of funding, state-level investment for CareNav was significant, covering the technology roll out across 11 sites and supporting the QP CareNav development team to provide ongoing technical support, system refinement, reporting capability, and building system elements that expand the functionality of the user interface of the portal through which caregivers can complete intake and assessment forms and access information around the clock. Without ongoing funds to support this vital work, the impact of this initial investment will be vastly diminished, and none of the stakeholders  will be able to capitalize on its full potential. Indeed, the long-term benefits of a uniform assessment, data collection, and reporting system are yet to fully materialize, with great potential to disseminate interventions to support family caregivers in the future.This study echoes the recent implementation literature underscoring the COVID-19 pandemic as an outer-setting construct inconclusively affecting implementation -37. In fAt the same time, CRC staff members themselves experienced added strain, juggling their own competing demands outside work, covering for one another owing to illness, coping with staff turnover, and pivoting to remote work from home to provide web-based family consultations to their clients. These factors may have either increased or decreased the willingness of the staff to use the CareNav platform to do their work in new ways, their readiness for change, and their perceived need to expand services. Moreover, the pandemic might have slowed the ability to integrate CareNav with other systems, specifically for sites hosted within a larger health care system who were themselves focusing on care delivery priorities. Similarly, the implementation of other web-based technologies encountered significant barriers, explained by time constraints and competing priorities associated with the COVID-19 pandemic . EffectiThis implementation evaluation also offers the knowledge needed to address gaps in prior research. A systematic review of internet-based supportive interventions for caregivers of patients with dementia recommended individual tailoring of supports for the success of digital interventions for caregivers . UnderlyStudies in the past have shown that web-based support can increase confidence, self-efficacy, and self-esteem and reduce depression and strain among caregivers ,23,42. TThis study was an evaluation of an implementation process in established CRCs across the state. There were trade-offs in data collection and reporting to protect the anonymity of participants who could otherwise be readily identified. Therefore, this study does not provide demographic characteristics of participants nor is it able to link findings to the specific roles of staff. However, the decision to permit anonymity facilitated broader participation and a more complete perspective on implementation, as evidenced by the high participation rate of staff in both the surveys and interviews. We applied the CFIR during the data analysis stages of the implementation and did not use the framework to its full potential in guiding implementation design. This study focused on the implementation process and its immediate impact on staff and clients, and did not examine changes in caregiver health and well-being.In this study, we applied the CFIR  to examiAs noted, the value of long-term care provided by family caregivers eclipses that provided by government funding . Caregivcaregiving that works [Among the 5 bold goals of California’s Master Plan on Aging for 2030 is at works . The Calat works . Future The next phase of implementation should involve developing a deeper understanding of the rich information available through CareNav, determining both site-specific and statewide reports that would be most helpful in evaluating adoption and dissemination of the programs into the community, effectiveness and gaps in service, quality of delivery, and the impact of the services and supports on caregiver outcomes. The data hold the power to drive individual and system changes. At the individual level, the assessment can be the basis for determining risk and matching services to caregiver needs. At the system level, the data can drive strategy for priority program development, funding, and advocacy. Future studies should evaluate the impact of the CRC system on caregiver health and well-being, as well as develop a deeper characterization of the trajectory of caregiving and how interventions can improve outcomes for caregivers and the persons in their care.A determined and committed group of leaders and staff dedicated to improving the lives of caregivers began a journey together. They are well on their way to actualizing a vision for the future of caregivers in California.


There are concerns that groundwater use for irrigation and for urban water supply is unsustainable in some parts of Bangladesh, particularly in the agriculturally productive northwest region. We use an integrated population – GDP – food – water model to examine water demand to 2100 in Bangladesh in development scenarios relevant to food and water security. The results indicate that irrigation water demand is projected to increase in coming decades, but later in the century it may decrease due to increasing crop yields and a falling population. The increased demand is greatest in the northwest region and, if unchecked, would increase concerns there about the unsustainable use of groundwater. The growth in demand is determined particularly by growth in crop yields, population growth and the fraction of food demand satisfied by imports. An extreme hot-dry climate change scenario has a lesser impact. This suggests that, in principle, Bangladesh can offset the impacts of climate change on irrigation water demand through its domestic policies. Urban water use currently also leads to concerns over unsustainable groundwater use. Our results suggest that urban water demand is likely to grow proportionately significantly more than irrigation water demand. Alternative sources for urban water are therefore urgently required. Developing nations also aim to increase economic development to tackle poverty, which will require an even greater use of resources, including water2. Groundwater use globally is particularly important, and its use may involve trade-offs amongst sustainable development goals, such as protecting groundwater on the one hand, and food security on the other3.Many developing nations face challenges with increasing population, growing demand for food and hence irrigation water, and unsustainable use of water. Climate change may exacerbate the challenges4. However, the national picture obscures local and seasonal water scarcity, which has led to the unsustainable use of groundwater for irrigation in parts of the northwest region13. Climate change may exacerbate the problems with sustainable use in the northwest14, as will population increase and the increase in demand for food15.At the national level, Bangladesh does not experience water scarcity, but does suffer from low water security due to extreme floods, poor water quality and transboundary water issues16. With the achievement of near self-sufficiency in rice, it may be preferable in future to limit the growth of rice production17, and instead grow crops which use less water, such as pulses and oilseeds18. However, grain self-sufficiency has declined in recent years19. Changing diets to consume less animal protein may also reduce the demand for water20, though in the case of Bangladesh (and many other countries) supplying the whole population with a recommended diet would increase water consumption21. Increases in crop yields will also affect future water demand15, as will the impact on local crop production of the quantity and type of food imports and exports.Other factors that will influence future irrigation water demand include the choice of crops, particularly a reduction in the future requirement for rice, a high-water using crop24 and quality25 of the resource. Population increase will again exacerbate the problems26. Urban water demand will also be affected by the rate of rural to urban migration.Urban water supply in Bangladesh’s biggest city, Dhaka, is also based on the unsustainable use of groundwater, with rapid depletion threatening both the quantity30. These plans include measures to sustain and increase overall agricultural production of the country due to rapid conversion of agricultural area for urban and industrial use in the central region32, to reduce Boro rice cultivation in the northwest region for sustainability of groundwater irrigation, to enhance the productivity of Transplanted Aus rice and dry season irrigated Boro rice to increase food security of the country, to expand surface irrigation in the southwest and northeast region, effectively addressing the overwhelming dependence on groundwater, and focusing on increasing the use of surface water. Similarly, the Dhaka Water Supply and Sewerage Authority aims to reduce the dependency on groundwater by increasing supply from the surface water sources33. Despite all these long-term and short-term plans, there are no comprehensive water security scenarios for the future considering the economic development, population growth, and climate change.In response to the problems and opportunities noted above, the Government of Bangladesh has developed a range of policy responses34, which includes the effects of: population growth; economic growth; the import and export of main food types; agricultural yield increases; changed regional cropping patterns; the impacts of climate change on rainfall and crop water demand; and the impacts of population growth and rural–urban migration on urban water demand. Some aspects of the model are similar to an earlier model for Pakistan35, but that model and the current model differ in several important ways (described later in the Methods section). In the model, population growth and economic growth are linked, and co-evolve in a way which matches the observed development in Bangladesh from 1975 to 2020, and the expected development in the future, based on a similar population – GDP model for Pakistan36. No study is known to us that examines this range of potential impacts on future irrigation and urban water demand.Our aim here is to examine development trajectories of irrigation and urban water demand to 2100 for Bangladesh under a range of assumptions about future development and climate change. We examine the demand trajectories for five regions of Bangladesh  and also matches with the Basin Development Plan 2100. While the model used here considers socio-economic effects, it is strictly not an economics model with supply – demand – price effects. We will comment on this in the methods section below and in the discussion section.The novel contribution in this paper is the range of effects considered under a single integrated analysis, in particular the integration of crop water demand (including climate change impacts) and urban water demand with socio-economic effects of population growth and GDP growth. We also consider projections to 2100, which is further ahead than most studies . Therefore, the model does not consider water supply. Based on the interactions with population, etc., described above, the model assesses the demand for water nationally, as well as regionally. While it may be preferable in many cases to study water use and demand within hydrological units such as a river basin, here we deal with demand only as it is managed nationally and regionally, hence our use of the regions shown in Fig. 34 including: population growth ; GDP growth; food availability, export and import; the areas, yield and production of seven main crop types in five regions of Bangladesh; crop water demand in the five regions; and urban water demand both overall and in Dhaka, the largest urban centre. The model also simulates future trends that compare with other projections34.The model can simulate reasonably well the historical (1975 to present) evolution of a wide range of features of BangladeshThe model outlined above does consider socio-economic effects, but is not an economics model with supply – demand – price effects. In particular, the imports and exports are not modelled as trade with an external (world) market; they are modelled simply to be deposited into, or withdrawn from an external pool. The effects of external trends and shocks such as the global food crisis of 2008 or the current crisis in Ukraine are large and largely unpredictable, and the response is as much political as it is purely economic. We think, therefore, that it is safer to model the consequences for the physical demand for water of effects resulting from changes to exports and imports, rather than attempting to model the economics of and responses to external trends and shocks.34 who give the sources of data and values for all parameters covering a wide range of inputs for GDP and population growth, food demand per capita, food imports, crop area and cropping intensity by region, crop water demand, and urban water demand, together with time series of rainfall and reference evapotranspiration. Many of the data, such as GDP and population, are at the national level, whereas data covering crop areas and yield are based on district level  scenario are described in detail by Kirby and Mainuddin35, but several are specific to the Bangladesh case: these include scenarios of rural to urban migration and urban water demand, food importation, and changed regional cropping patterns.We assessed projections under a base case  and with changes which might result from socio-economic effects , agricultural and water management , and climate change. We also assessed the impact on urban water demand of changes to population growth rates, GDP growth rates, and rural–urban migration rates. Some of these scenarios are similar to the earlier study in Pakistan34.The base case is a simulation of the development of population, GDP, food supply, and water demand in the absence of climate change or other changes. The climate for the base case is the historical climate time-series  from 1975 to 2020, repeated from 2021 onwards. The base case is identical to the example given in Kirby and Mainuddin41. The rate of population growth from 2020 onwards was changed in two scenarios, one of which resulted in a 14% larger population in 2100, and the other of which resulted in a 24% lower population. These scenarios are well within the UN Population Division’s probabilistic + /− 80% scenarios of a 32% smaller or a 35% larger population in 210042.The rate of population growth in the base case is that which simulates the population growth to 2100 of the median projection of the UNThe rate of urban population growth depends partly on the general rate of population growth and partly on rural to urban migration. In the base case, the urban population grows to 121 m by 2100. The rate of rural to urban migration was varied in two scenarios, in the first of which the urban population grows to 139 m and in the second it grows to 104 m.The rate of GDP growth from 2020 onwards was changed in two scenarios, such that annual GDP growth is 2% larger or 2% smaller. The first resulted in a 7% larger population in 2100, and the other in a 6% smaller population in 2100. The GDP change results in a population change, but because it also impacts factors such as food demand , these scenarios are not direct substitutes for population change scenarios.43. The rate of change of imports as a fraction of overall supply was changed in two scenarios, in the first of which the rate of imports grows faster to 2100, and in the second of which it grows slower with the import of some foods  ending in the later part of the century.Rice imports have fallen as a proportion of overall supply in the last few decades, although they have grown in absolute quantity; imports of some other food including wheat have grown both absolutely and as a proportion of supply19) was increased progressively from the current value to ten times that in 2100. In the second scenario, the amount of wheat per capita was increased progressively from the current value of about 17 kg/cap/year to three times that in 2100; the amount of rice was decreased by the same amount. The reduction in rice consumption was assumed to all come from a reduction in the Boro crop, because of the overlap of the wheat and Boro cultivation seasons.Dietary preferences were changed in two scenarios. In the first, the amount of maize per capita  rainfall and temperature projections from the most extreme scenario SSP5-8.5. We assessed the change in potential evapotranspiration from the change in maximum and minimum temperatures using the Hargreaves Equation.44. We combined the driest and hottest  to form an extreme hot-dry scenario, and the wettest and least hot  to form a warm-wet scenario. The changed climate values in the scenarios are summarised in Table Climate change projections of the 6th Assessment Report of The Intergovernmental Panel on Climate Change can be obtained for individual countries or river basins from the IPCC WG1 Interactive Atlas at 34. Here we focus on the time-series of irrigation and urban water demand as indicators of water security, and on the population and GDP per capita (as an index) in 2100. We examine the total volume of demand projected in each of the five regions.The integrated model results in the output of many variables, each as a time series from 1960–2100. These include population, GDP, food demand, food imports, areas of crops (for each of seven crop groups in five regions), and demand for water41. The GDP  and GDP per capita (GDP as an index divided by population) in the base case are shown in Table The total and urban population from 1975 to 2100 in the base case is shown in Fig. The water demand for irrigation in the base case  is shown in terms of total volume of demand in Fig. The population, GDP  and GDP per capita (GDP as an index divided by population) in the scenarios at 2100 are shown in Table Figure The projected urban water demand in the scenarios is shown in Fig. 34.In the base case, many features of the simulation  compare reasonably well to the historical values for the period 1975–2020The results show that the volume of irrigation water demand in Bangladesh is likely to increase in a business-as-usual scenario, due to population increase and increased consumption, offset somewhat by increased crop yields. The increase is concentrated mainly in the northwest, which has experienced greater increases in crop area in recent decades than have other regions. In the northwest, the increasing demand could exacerbate falling groundwater levels. The southwest is also projected to experience increasing irrigation water demand, though this is projected to peak there around 2060, and thereafter decline slightly. In a business-as-usual scenario, the irrigation water demand in other regions is not projected to increase much beyond present levels, and indeed could soon start to decrease.49. Yields in current rice farming systems are about 50% below the potential yield50, and 20 to 30% below those that can be achieved with better practice58. Continuing large increases in rice yield are regarded as achievable59. With improved varieties and practices in the future, the assumed yield increases therefore appear plausible. On the other hand, future rice and wheat yield increases may be limited (or even reversed) by climate change60. However, the impacts of climate change on yield may be offset by practices such as changed rice transplanting dates64. To account for these various effects, our scenarios include a scenario with limited growth in yields above current yields, a middle  and a high yield growth scenario.Several factors could raise or lower the projected irrigation water demand from the business-as-usual case. The demand projections are affected more by the crop yield increase assumptions than by other assumptions used here. Most studies of yield increases in Bangladesh, including those mentioned in what follows, refer to rice and/or wheat only. Rice and wheat yields have increased substantially in recent decades65, inasmuch as different socio-economic pathways (which include widely differing population growth trajectories) lead to different climate change outcomes.Faster or slower population growth than that projected in the UN Population Division median projection has the next greatest impact on demand projections, after the crop yield assumptions. As noted in the methods section, the assumed population growth scenarios are well within the UN Population Division’s + /− 80% probabilistic scenarios , and are therefore not extreme assumptions. While we have treated population growth and climate change as independent at the country level, population growth and climate change are linked at the global level43. While some authors discuss policies for achieving food self-sufficiency50, Bangladesh does not have a comparative advantage in growing wheat, and should import wheat while focussing production on rice, maize and potatoes66. Our scenarios of changing the fractions of crop requirements that are imported covers the possibilities of both greater and lesser self-sufficiency in the future. The impact on demand projections of changing the fraction of food imported in our scenarios is similar to that of the changed population growth scenarios. As noted in the methods section, our model does not simulate the economics of imports and exports, but treats them simply as a deposit into, or withdrawal from, an external pool. We think that this limitation is appropriate for our analysis.Bangladesh in recent decades has approached self-sufficiency in food production, but nevertheless imports about 10–15% of its rice, wheat and maize67. However, our results suggest that the direct effects of most extreme hot-dry projection in the most extreme IPCC SSP5-8.5 scenario results in a smaller impact on water demand for irrigation than the scenarios noted above. A wetter scenario barely differs from the projected demand without climate change. This is not to say that climate change is unimportant; indirect effects will likely include changes to crop yields which, as shown above, do have a large impact on the results.Bangladesh is considered to be particularly vulnerable to climate related disasters and to climate change68. A continuation of this trend, with a corresponding lowering of rice consumption, would decrease irrigation water demand. Increasing the proportion of wheat in a rice-based diet leads to better health and also lowers greenhouse gas emissions69. This factor in our scenarios has a similar magnitude of impact to that of an extreme hot-dry climate change, but in the opposite direction. On the other hand, a scenario with an increase in maize cropping for meat production had only a minor effect on the volume of irrigation water demand.Food preferences shifted from 1961 to 2013 to double the proportion of wheat in the diet35), reinforcing the implication that Bangladesh is likely to be able to manage the impact of climate change on water demand.It may be noted from the above that several factors that are (in principle) within Bangladesh’s control  have a greater impact than the most extreme hot-dry climate change scenario. This implies that, although climate change is projected to impact Bangladesh greatly, it is likely to be within Bangladesh’s capacity to manage the impact on water demand for irrigation. Although we have not modelled the scenarios in combination, the impact of factors within Bangladesh’s control would be greater if factors acted together  are, in much of Bangladesh, no greater than the areas currently under crops. This results partly from an increase in yields, and partly from an increase in the average number of crops grown each year on a piece of land, projected from the historical trends. Despite problems with salinity and limited water supply for irrigation, with appropriate management there is also great potential to expand cropping in the coastal zone77 and elsewhere78, including under conditions of climate change70 and sea level rise potentially leading to greater flooding77. In addition, there are trials with increased cropping intensity of four crops per year79, while agricultural land could be used more optimally by increasing the area under pulses, oilseeds and spices, and to limit the area under potatoes18. Whether these factors are enough to offset the declining area of arable land will depend on the impacts of Bangladesh government policies to limit the conversion of agricultural land to other uses. Currently, there is no policy to protect agricultural lands for conversion to urban and industrial use. However, there are increasing concerns at the policy level about the protection of agricultural lands to sustain crop production and food security, and a bill has been tabled in the Bangladesh Parliament for the proper use and protection of agricultural land .Across Bangladesh as a whole, the area available for cropping is declining at about 1% per year as arable land is converted to other uses25. Groundwater depletion may also be a problem in other large cities such as Chittagong80. Urban water demand is projected to increase to approximately double the current level. The projected increase is impacted by overall population growth  and by rural–urban migration. The latter impact could see urban water demand continue to grow after the overall population of Bangladesh has ceased to increase. The projected growth in urban water demand is a greater proportionate increase than that of irrigation water demand. If groundwater continues to be a major source of water for large urban centres, it therefore seems likely that the concerns over the unsustainability of use will grow more acute in the urban case than in the irrigation supply case.While irrigation is the greatest user of water, particularly groundwater, groundwater pumping for urban water supply  is nevertheless a concern. The use of groundwater to supply Dhaka already causes concerns over regional impacts of contaminant migration and potential contamination of deep aquifersWe conclude that, consistent with the findings of many studies in the literature, pressure on water use in Bangladesh is likely to increase in coming decades. In particular, irrigation water demand in a business-as-usual scenario in the northwest is likely to increase for much of the coming century, potentially exacerbating concerns about sustainable use of groundwater. However, several policy options could reduce this pressure in the northwest, including policies that shift future growth in irrigated cropping to the southwest, shift crops away from rice (particularly Boro rice) perhaps due to a change in food preferences, and limit population growth (perhaps in concert with increased GDP growth).Urban water demand is also projected to grow, to about double the current level. In the case of Dhaka in particular, this would place great pressure on groundwater supplies unless alternative sources are developed.


Artificial intelligence (AI) for use in health care and social services is rapidly developing, but this has significant ethical, legal, and social implications. Theoretical and conceptual research in AI ethics needs to be complemented with empirical research to understand the values and judgments of members of the public, who will be the ultimate recipients of AI-enabled services.The aim of the Australian Values and Attitudes on AI (AVA-AI) study was to assess and compare Australians’ general and particular judgments regarding the use of AI, compare Australians’ judgments regarding different health care and social service applications of AI, and determine the attributes of health care and social service AI systems that Australians consider most important.We conducted a survey of the Australian population using an innovative sampling and weighting methodology involving 2 sample components: one from an omnibus survey using a sample selected using scientific probability sampling methods and one from a nonprobability-sampled web-based panel. The web-based panel sample was calibrated to the omnibus survey sample using behavioral, lifestyle, and sociodemographic variables. Univariate and bivariate analyses were performed.We included weighted responses from 1950 Australians in the web-based panel along with a further 2498 responses from the omnibus survey for a subset of questions. Both weighted samples were sociodemographically well spread. An estimated 60% of Australians support the development of AI in general but, in specific health care scenarios, this diminishes to between 27% and 43% and, for social service scenarios, between 31% and 39%. Although all ethical and social dimensions of AI presented were rated as important, accuracy was consistently the most important and reducing costs the least important. Speed was also consistently lower in importance. In total, 4 in 5 Australians valued continued human contact and discretion in service provision more than any speed, accuracy, or convenience that AI systems might provide.The ethical and social dimensions of AI systems matter to Australians. Most think AI systems should augment rather than replace humans in the provision of both health care and social services. Although expressing broad support for AI, people made finely tuned judgments about the acceptability of particular AI applications with different potential benefits and downsides. Further qualitative research is needed to understand the reasons underpinning these judgments. The participation of ethicists, social scientists, and the public can help guide AI development and implementation, particularly in sensitive and value-laden domains such as health care and social services. Artificial intelligence (AI) and automation are accelerating in many fields driven by an increase in the availability of massive linked data sets, cloud computing, more powerful processors, and the development of new types of algorithms, particularly in the field of machine learning. In this paper, AI will be broadly conceptualized, consistent with the Australian Council of Learned Academies definition, as “a collection of interrelated technologies used to solve problems and perform tasks that, when humans do them, requires thinking” . These tA growing body of literature acknowledges the complex ethical, legal, and social implications (ELSI) of AI deployment ,7,8. In For the first case, health care AI, research on ELSI has been rapidly expanding since 2019. In a 2020 review, Morley et al  highlighautomate inequality. Similar concerns have been raised in Australia in relation to the Online Compliance Intervention known as robodebt. The scheme automated the calculation of welfare debts based on an income-averaging algorithm. The legality of the algorithm was successfully challenged before a domestic court in 2019, culminating in an Aus $1.8 billion (US $1.25 billion) class action lawsuit against the Australian government and prompting significant public and scholarly criticism of the scheme  and C02 [machine triage]) and 2 social service scenarios (D01 [automation of unemployment benefit decision-making] and D02 [chatbot advice about carer payments]). We asked respondents to rate the importance of different attributes of the AI system in each one, where the attributes reflected a key ethical, legal, or social dimension of the AI or its use. For health care scenarios, these attributes included responsibility for decision-making as this is central to medicolegal frameworks and professional autonomy. For welfare scenarios, they included personal tailoring as this is a key promise of automation and machine decision-making in welfare contexts.extremely important to 5 for not at all important; thus, lower scores indicate more importance. All means were <3, the midpoint of the scale; t tests against a mean of 3 were statistically significant with P<.001, indicating that more of the distribution of responses was in the extremely or very important categories. The attributes in As shown in The AVA-AI study has created one of the first large, robust data sets reflecting public views on the potential use of AI in health care and social services, with particular attention to the ELSI of those technologies. Future studies will provide a greater breakdown of the variation in responses among different population subgroups. This analysis focused on answering 3 key questions: how judgments in general compare with judgments in particular, how judgments about use in health care compare with judgments about use in social services, and whether judgments differ when ELSI differ.all support and all oppose categories only, we have done the same. Both the AVA-AI study and the Monash survey suggest more positive general views in Australia than in the United States, although the results of the AVA-AI study are less positive than those of the Monash survey. Speculative reasons for this difference could include more prominent public discourse regarding harms from AI deployment in the US context  or, more tentatively, that, in the 2 years between the surveys  and have downsides . On the basis of our findings, we hypothesize that members of the general public may remain broadly unaware of the potential downsides of AI in use and that some of these downsides  matter more to them than others . We did not test the level of awareness of ELSI problems with AI—this is a potential direction for future research. Participants’ more negative judgments in the case-specific questions also empirically reinforce what has already been argued in the literature: that the ELSI of AI applications need to be considered in the context of detailed cases.As a minority of AVA-AI study respondents began the survey with negative general views on AI and >60% expressed support, any negative judgments expressed seem likely to be a response to the details of the scenarios presented rather than reflect prejudice against or fear of AI in general. When asked about specific scenarios for AI use, respondents were consistently more negative—the reduction in support between the general question and all 6 specific scenarios was statistically significant, and support expressed in the specific scenarios dropped between 17 and 33 percentage points. The simple opening the application of artificial intelligence to social, humanitarian and environmental challenges. The areas that received the most support—>75% of respondents—were health and medicine, whereas the areas that received the least support  included equality and inclusion and public and social sector management.Respondents had slightly stronger, more diverse, and more negative views on using AI in health care as opposed to in social services. This may be because they themselves have more direct experience of using health care or consider health care more relevant to them; alternatively, respondents may consider health care to be a higher-stakes service for which they are less tolerant of social or ethical wrongs or harms. Again, respondents in the AVA-AI study were less strongly supportive than respondents in the Monash survey, expressing 27% to 43% support for health care scenarios and 31% to 39% support for social service scenarios. In the Monash survey, respondents were asked to rate their support or opposition to The differing responses to the 2 surveys may arise from the framing of the questions. The Monash questions were framed optimistically and presented no downsides; the AVA-AI questions presented both benefits and downsides or burdens. In health care, we held effectiveness and health benefits against requirements to share data, nonexplainability, and clinical deskilling. In social services, we held the accuracy and consistency of predictions and decisions against the potential for overtargeting, poor contestability, and nonexplainability. The differences in responses between the 2 surveys may show that the ethical and social risks of AI matter to people and will make a difference in their evaluations.The respondents clearly made judgments about the ELSI of AI. Although all ELSI were considered important, this was by degree. Respondents made quite finely graded judgments that intuitively aligned with the characteristics of the scenarios, suggesting both that they took the questions seriously and that different attributes will be differently important in different cases. For example, speed was more important in triage, where time is critical, than in diagnosis. Explanation was more important in automating unemployment benefits than in an information chatbot, which would be consistent with the view that people deserve to know why they do or do not receive payments. Human contact, personal tailoring, and speed were more important for the chatbot than for the benefits system, possibly reflecting that chatbot interactions are short and information-heavy and that people want a human to talk to if the automated system fails.accuracy in different contexts is not straightforward). The lower importance given to cost reduction may reflect a general rejection of instrumental decision-making in policy and of cost-based arguments in public services. Contextual factors include Australia’s publicly funded health care system being popular and entrenched [Two things were consistent: accuracy was always the most highly valued, and reducing costs was always the least highly valued across health care and social services. The lack of any significant difference in the importance of accuracy across scenarios suggests that this is an entry-level requirement for the use of AI . This suggests the importance of pursuing an augmentation rather than a replacement role for AI in both health care and social services. For all of these findings, further qualitative research is needed to better understand the reasons underpinning people’s judgments.When asked to make an on-balance judgment about the To the best of the authors’ knowledge, this study is one of the largest and most robust surveys of public attitudes toward health care and welfare AI to date. The methodological approach taken allowed for the collection of detailed information on attitudes for a substantial sample using a relatively low-cost web-based panel while compensating for the potential biases in the creation of such a panel. Although the results suggest that respondents were able to engage with the details of the questions, the relatively low level of knowledge of AI in the community and the speculative nature of the questions mean that people’s responses to a direct experience of AI may differ from their responses in this survey. A strength of our design was the use of questions that were deliberately structured to present both the potential benefits and the potential burdens or harms of AI while attempting to maintain neutral sentiment and avoid normative valence in the language used. The survey was conducted before the onset of the COVID-19 pandemic, which initiated the rapid digitization of many health care and social services; it is possible that responses would be different if the survey were repeated today.Australians support the idea of AI in a general sense, but their support diminishes when considering the details of particular scenarios and the potential harms or burdens that may accompany any promised benefits. Respondents consistently rated the accuracy of performance as the most important attribute in an AI system, but only 1 in 5 valued the speed, accuracy, and convenience of AI systems more than continued human contact and discretion in service provision. Overall, this study suggests that the ethical and social dimensions of AI systems matter to Australians and that Australians want AI systems to augment rather than replace humans in the provision of both health care and social services and to reflect human values. Meaningful engagement and participation of ethicists, social scientists, and the public can highlight what harms and wrongs are most important to avoid in all stages of the development and implementation of AI, including in sensitive and value-laden domains such as health care and social services.