Without it, nothing can succeed.”A little over a century later, in 1967, President Lyndon Baines Johnson formed the National Advisory Commission on Civil Disorder, headed by Illinois Governor Otto Kerner, Jr. to search for and identify the root causes of the riots that erupted in over 150 cities across the United States during the summer of 1967. When it issued its report the Kerner Commission cited institutional racism, police brutality, and lack of employment opportunity as the causes of the 1967 uprisings. Forty-nine years later, the conclusions cited by the Kerner Commission are still relevant. Institutional and structural racism still perpetuate barriers to employment. Police brutality along with myriad inequities in opportunity for health, housing, education, transportation, and most of the social determinants of wellbeing still persist today. These barriers remain despite significant efforts to close these opportunity gaps and despite the Civil Rights legislative and judicial victories of that era.http://healourcommunities.org) work launched by the W.K. Kellogg Foundation (WKKF) is a national truth and reconciliation process for the United States of America, its territories, and the sovereign nations of indigenous people within its borders. The TRHT, while informed by the well-recognized truth and reconciliation commission (TRC) model, is a unique process designed to reflect, embrace, and address the unprecedented diversity and unparalleled racialized history of the United States. Lincoln knew the primacy of the public “sentiment” in 1858. The Kerner Commission emphasized its importance again in 1968. Its final report, which still stands as the country's most thorough public research on racism put it this way:2The need is not so much for the government to design new programs as it is for the nation to generate new will. Private enterprise, labor unions, churches, foundations, universities, and all our urban institutions must deepen their involvement in the life of the city and their commitment to its renewal and welfare.The Truth, Racial Healing, and Transformation :The Merriam-Webster Dictionary defines public sentiment as follows: “An attitude, thought, or judgment colored or prompted by feeling or emotion.” The Cambridge English Dictionary introduces the word “idea” into its definition of sentiment. “A thought, opinion, or idea based on a feeling about a situation; a way of thinking.” It is the latter, the way of thinking, that has the most relevance to TRHT.Dog Whistle Politics: How Coded Racial Appeals Have Reinvented Racism and Wrecked the Middle Class uncovered the solid connection between anti-government sentiment and America's racialized politics, both past and present.4 The book provides a platform for a deeper consideration of how economic, legal, and social policy debates can mask deep-seated, but easily manipulated racial biases. The 2016 presidential election did not use coded racist messages but was more overt and directly inflammatory and divisive, seemingly intentionally leveraging racial anxieties and fears to mobilize voters. The election outcome ushered in documented increases in hate crimes, child bullying, and immigrant intimidation along with white nationalist discourse, deemed unacceptable in recent decades.Public sentiment in the 21st century is influenced and assessed in ways that were unimaginable in the 19th and 20th centuries. Information technology capabilities, polling methodologies, communications, media, particularly social media and global influences combine today to create an overwhelmingly dynamic landscape of public opinion. Even so, the issue of racism is no less salient today than it was when Lincoln and Douglas debated, or when President Johnson created the Kerner Commission. Add to the crowded public opinion/sentiment landscape the recent deliberative and participatory democracy movement that has been gaining momentum since the 1990s. People across America in their local communities are engaging on issues of concern and using their muscle to influence policies. As exciting as these citizen engagement developments are, they are not designed to consider conscious or unconscious racial biases. During the early 1990s, I served as the director of the Innovations in American Government Awards Program at Harvard's John F. Kennedy School of Government. Our review teams were always impressed by the emerging participatory governance models such as citizen-based budgeting and deliberative democracy initiatives. Engaging diverse groups of citizens in decision-making and thoughtful deliberation on critical issues seemed to be a good strategy for pushing back against the then (as now) rising tide of anti-government sentiment. Berkeley Professor Ian Haney Lopez's 2015 groundbreaking book Lincoln's talk about the power of public sentiment in 1858 and the Kerner commission's call for the public will to engage in urban issues were, I believe, thinly veiled calls for changing hearts and minds about race and racism. The promise of democracy in America cannot be fully realized without responding to this call. WKKF and, to date, over 50 other foundations agree that it is now time for communities throughout America to begin this deliberative racial healing work. We are supporting TRHT coalition efforts locally and nationally that are explicitly and transparently focused on eliminating the very notion, belief, and false ideology of a human value hierarchy based on physical characteristics—racism.The goal of the TRHT is to change the way the people in America think about issues of racism by exposing and addressing the fallacy of the dominant belief and subsequent societal systems of racial hierarchy. Belief in a hierarchical taxonomy or classification system for the human family was formalized by Swedish botanist Linnaeus in the 1700s. He was building on a then centuries-old Doctrine of Discovery in the Papal Bull issued by Pope Alexander VI on May 4, 1493, which became the basis for all land acquisition by non-indigenous people in the New World. Linnaeus codified a biological system of superiority and inferiority for diverse humans from different geographic locations into “races.” These racial groups also had varying physical characteristics. Behavioral and character traits were assigned to these groups which became the basis of so-called scientific racism. It was used to justify and rationalize violations of humanity for centuries. Although now discredited by science, the legacy of this widely held and deeply embedded belief in racial hierarchy still lives today. It still resides in all of the normalizing, socializing, and standardizing systems and institutions of today. From education to art, to media and religion, to politics and finance, the legacy of racial hierarchy—as a core societal construct—still exists. Public sentiment today in America is still largely shaped by racism.5 Researcher Dolores Acevedo Garcia calls this double jeopardy, emphasizing the cumulative harms associated with concentrated poverty and racially segregated communities.6 While changing demographics create an imperative for eliminating racism on the one hand, fear of increasing diversity has fueled greater resistance on the other.Population demographics create an urgency for ridding our society of the burden of racism. According to the U.S. Census data, most of the children born in America today are children of color. The majority of these children are growing up in low-income or impoverished families and communities.I have had the privilege of working for the WKKF for the last decade and as vice president for program strategy guiding multiple program areas, including designing and leading the foundation's racial equity and racial healing funding approach. Will Keith Kellogg created the foundation over 80 years ago giving it one simple mandate: the money was to be used to improve the lives of vulnerable children. When the WKKF board members faced the demographic realities of vulnerable children in 2007, they were easily convinced that just dealing with the consequences of racism would no longer suffice. Board members realized that persistent health disparities such as infant mortality, widening wealth divides, and seemingly intractable educational achievement gaps are actually the consequences of structured racism. The foundation's leadership made a bold commitment to becoming the most effective anti-racist organization that promotes racial equity. Although board members, staff, and the CEO have changed during the last decade, WKKF's firm commitment to racial healing and racial equity has remained intact.7In a society where frank discussions about race and racism are all too rare, the Foundation openly advocates for putting racism behind us and acknowledging the damage it has caused. This advocacy enables opportunities for healing and progress, bringing hope for future generations.The unanimous decision by the board to support the TRHT is further affirmation of its abiding commitment.8 Their analysis of recent survey data reveals that opinions about how increasing racial diversity will affect American society had more impact on support for the Republican presidential candidate in the 2016 campaign when compared to support for Republican candidates in the previous two presidential elections. They conclude that the winning presidential candidate successfully leveraged existing resentment toward African Americans in combination with emerging fears of increased racial diversity in America to literally reshape the presidential electorate. Finally, McElwee and McDaniel assert that racial and identity attitudes have further displaced class as the central battleground of American politics.Researchers Sean McElwee of Demos and Jason McDaniel of San Francisco State University explain how racial resentment played a larger role in the 2016 presidential election than the popularly touted economic concerns.9 So, we have the tension between two expanding pools of public sentiment. One is clinging to the mythology of a hierarchy of human value (racism). The other, an increasing segment of the majority population  wants to eradicate racism and create equity.This, ironically, comes at a time when polling data showed that for the first time in our national history, whites and people of color were moving toward greater consensus about the need to effectively address race relations in this country. In a national poll conducted in 2015, 53%of whites said that more changes are needed to give blacks equal rights with whites, up from just 39%a year earlier.After reviewing the literature on the 44 TRC's around the world, a core guiding principle emerged for creating a successful TRHT for America. It would have to be multisectoral. It's noteworthy to remember that it was also a multisectoral approach that was called for by the Kerner Commission in 1968, but never realized. While in the early months of our work on TRHT, we reached out to and received calls from over 100 diverse organizations that expressed the desire to get involved and help in this unprecedented effort—public, private, nonprofit, faith, academic and research, media, grassroots, advocacy, civil and human rights, and judicial organizations reflect this multisectoral emphasis.We had already learned from almost a decade of funding the racial equity and racial healing work that the approach had to be racially and ethnically expansive in nature. By focusing on uprooting the absurd belief in racial hierarchy itself, it became quite natural to address the multiple effects and harm caused to many, if not all, population groups. Creating a broad, expansive, and inclusive coalition engaging Native and indigenous groups, Asian American, Pacific Islander, immigrant groups, Latino and Hispanic, African American, Arab American, and European or white Americans is a second core principle of the TRHT work.The Narrative Change Design Team examined how to create a more complete and accurate narrative that will help people understand how racial hierarchy has been embedded in our society from the beginning. The team was committed to utilizing all available vehicles to ensure that a more complete and accurate narrative emerges.The Racial Healing and Relationship Building Design Team focused on ways all of us can heal from the wounds of the past and build mutually respectful relationships across racial and ethnic lines, relationships that honor and value each person's humanity. The team also explored ways to inform public policies so that they better reflect our common humanity.The Separation Design Team examined and found ways to address segregation, colonization, and concentrated poverty in neighborhoods.The Law Design Team reviewed discriminatory civil, criminal, and public policies and recommended solutions that will produce a more just application of law.The Economy Design Team studied structured inequality and barriers to economic opportunities and developed solutions that will create a more equitable society.One of the first steps we asked ourselves was how the belief in a hierarchy of human value became foundational in the United States and how it has been sustained for centuries. We knew that the national narrative was key to embedding and sustaining the belief—and so we were clear that we needed to work on narrative change. There's been an absence of acknowledgement of the harm that has and continues to come from the belief, resulting in the absence of a concerted effort to heal from it—and so we knew that we needed to do work on racial healing. We also saw that the belief has been embedded in our systems—in the ways communities are kept separate from one another, in the laws  and in the economy. We set up five design teams to think about how to develop TRHT around these five areas: narrative change, racial healing, separation, the law, and the economy:Participants in the design teams worked collaboratively between June and November 2016 to co-design the TRHT approach. The design teams were extremely busy people spread throughout the country working collaboratively, so we needed to develop a creative approach for interaction. Each team of 30–40 people had at least one face-to-face meeting and continued to work through virtual meetings and through an online community.Unlike many approaches to social change that start from the problem, what's been missing has been a clear vision of a redesigned society that is no longer built on the premise of a hierarchy of human value. Each team discussed and wrestled with how to transform our country by answering the following questions:Question 1: What will the country look and feel like when we jettisoned the belief in a hierarchy of human value and the narratives that reinforce that belief?Question 2: Where are we now and how did we get here?Question 3: What are the key leverage points for jettisoning the belief in a hierarchy of human value?Question 4: Who must be involved in order to make the deep and lasting changes we need to make?Question 5: What are the key initial activities that need to happen in order to heal from and transform the narrative?Here are examples of answers to Question 1 from two of the design teams .Narrative Change: To achieve “TRHT,” we need strong and accessible narratives that advance the values of fairness, compassion, inclusion, and justice. We need narratives that not only effectively challenge racial hierarchies and discrimination based on white hegemony, but that also encourage new ways to coexist in multiracial communities as a nation. We envision stories being told that are complete and accurate in their portrayals of people of color, who have been overwhelmingly misrepresented, objectified, and stereotyped in U.S. media and cultural institutions since before the nation's founding. As a result, the nation's history and identity have set and reinforced the ideology of false ideology of racial year after year for five centuries, often by making invisible the profound role racial exploitation has played in establishing the nation we now live in.Changing such long-held ideas won't be easy, but those of us committed to a nation in which we tell complex truths rather than simple lies must take on this work. If we successfully pursue the following analysis and recommendations, we will create a culture populated with diverse positive images of ourselves and each other in our full humanity and potential in all media and cultural settings. Such settings would include literature, museum exhibits, parks, places of worship, schools, magazines, newspapers, music, art, theater, television shows, movies, radio programs, games, and social media. The narrative will foster empathy and connections that allow us to see ourselves in each other and thereby help to eliminate the emotional separation between communities. Americans would overwhelmingly have a full, complex understanding of each other. The infrastructure needed to create and distribute new narratives will be strong, with people of color having plenty of access to the means of production and distribution. Financing for story making and storytelling will be widely available—not controlled by a select few. This would lead to a country living up to its creed, finally realizing its own ideal of freedom.Racial Healing: We imagine an America where all people are seen through the lens of our common humanity and we see ourselves in one another. This new society is characterized by love, interconnectedness, mutual respect, accountability, empathy, honoring nature, and care for the environment. In this society, healing and justice flow from authentic relationships.Our children and grandchildren feel safe and secure in who they are and proud of their heritage and culture. They are able to look within themselves and to their communities to find their identity; they recognize and value the differences inherent in all of us, while celebrating the common threads that bind us together.10Schools are well funded and recognize that all children have a sacred gift and purpose; they offer early education in the child's own language. Libraries and museums reflect the rich heritage and stories of every group, told from the perspective of each group. Memorials serve as a reminder of suffering but also the effort and strength that emerged from it. We no longer carry the pain, fear, and shame of history, for we have discovered how to look at our past with courage and honesty. Places of worship celebrate diversity and work actively to cultivate equitable empowering life in their communities. Parks and public spaces are accessible to all. Our financial system focuses on supporting the health and welfare of communities. In responding to those who do us harm, our justice system reflects a focus on restorative rather than punitive justice. In jettisoning the belief in a hierarchy of human value based on race, we have also eliminated a hierarchy based on class, gender, age, religion, sexual orientation, and ability. In achieving this vision, we have truly achieved transformation.https://youtu.be/xwtnanuRrrc), bringing together people who had been involved in the Design Teams, WKKF grantees, and those who were interested in implementing TRHT in their communities. This was an expansive group of over 570 people from across the United States Native American, Alaska Native, Native Hawaiian, Asian American Pacific Islander, Latino, African American, Arab American, and White from multiple sectors  to fully engage for four full days in racial healing, sharing the incredible results of the national design team process and planning a way forward.In December, 2016, we convened a national summit in Carlsbad, California , tens of thousands of people in communities and organizations across this country stood together for love on the inaugural National Day of Racial Healing in America. The states of Michigan and Georgia, along with 15 localities issued proclamations to recognize January 17 as the National Day of Racial Healing. For this first annual National Day of Racial Healing, we reached 1,527,228 people on Facebook and had 48,700 impressions on Twitter. The National Day of Racial Healing in 2018 will be on January 16, 2018, the day after the Martin Luther King Day Celebration.In the Spring of 2017, the WKKF announced funding for the first 14 places implementing the TRHT. In each community, the core group of participants includes philanthropic representatives; elected officials; faith community representatives; grassroots activists; healing practitioners; young leaders; community media/narrative change agents ; people focused on housing, segregation, and colonization locally; people who work with civil or criminal law or public policy and people who work with changing the local economy.TRHT participating communities are using the same design process, answering the same key questions but tailoring the recommendations to the needs of their local communities. They are organizing local TRHT coalitions to heal racial wounds of the past, while addressing barriers to success for all people, especially children and people of color. The community-based effort is working with people of all races, ethnicities, and national origins to bring together public officials, community, and civic leaders, churches, schools, foundations, and organizations to implement a TRHT process that engages the community in telling the authentic stories and history of that place, helping people heal the racial divides that keep them apart, and addressing the structural challenges related to segregation and colonization, the law and the economy.Through the TRHT, participants are developing new skills and capacities at individual, organizational, and community levels to identify biases, behaviors, and institutional practices that perpetuate racial discrimination and divisions, so they can truly begin to transform public sentiments and take actions that lead to new policies and structures in their communities.In April 2017 in Chicago, 200 people gathered at the Chicago Theological Seminary for a day of racial healing, in which people from all walks of life shared their perspective on racism that they have encountered or even projected onto others. These healing circles are critical to building trust that allows diverse audiences to have genuine conversations about racism and differences, and move forward to address its consequences in their communities.The work in the 14 places includes comprehensive research of the region's racial past, and an acknowledgement of that history whether it includes lynching or abolitionists. One coalition's participants vow to explore their personal narratives about others; challenge perceptions about race, race relations and racial equity; end personal roles in perpetuating racial division; elevate views of all individuals; and move forward on a path of justice, dignity, and humanity.These communities are boldly moving beyond dealing with the consequences of racism, which has been the focus of most social justice and advocacy efforts since the 1960s. Now, we are addressing the core fundamental belief itself, the racial hierarchy that fuels racism and the notion that the color of one's skin should dictate their station in life.The overriding purpose of the TRHT is to improve our capacity as communities and as a country to see ourselves in each other, so that we can shape a more equitable future with opportunities for every child to thrive.TRHT Implementation Guidebook at www.racialequityresourceguide.org/guides-workshops/trht-implementation-guidebook.11If you share this vision and want to become more involved in the TRHT process, you can do so as an individual, as part of an organization or as a community. More detailed guidance is available for engaging at any of these levels in the comprehensive You may want to implement some or all of the TRHT framework within your organization—at least taking on narrative change and racial healing—and participate in the annual National Day of Racial Healing.Chicago and Alaska are two of many local U.S. communities that began implementing the TRHT framework in their jurisdictions in the summer of 2017. Each has created a broad multisector coalition that represents diverse racial, ethnic, religious, generational, class, and identity groups. They understand that through engaging and experiencing all their diverse stories and narratives, healing insights are gleaned; and a path toward affirming their shared, common humanity emerges. With funding from WKKF and many other local foundations, all participating communities are now part of an expanding national network of communities, organizations, and individuals working to heal America's unnecessary racial divides. They are all holding themselves accountable for building trust across racial lines, while recognizing and changing limiting and biasing narratives. They have agreed to measure their progress in making sustainable changes that overcome negative consequences of colonization, forced segregation, and concentrated poverty. They are boldly working to transform legal and economic systemic inequities by facing historic and contemporary truths about the role of racism, while finding ways to work together for redress. They are proclaiming a new narrative and creating a new reality that refutes the false ideology of a hierarchy of human value, replacing it with affirmation of our equal humanity and sacred interconnected reality. They are not naive nor are they bitter. They are acknowledging and facing the deep, longstanding racial divisions and biased sentiments in their communities, sectors, organizations, and in their own hearts. But they know these divides are needless and harmful. TRHT participants are leveraging this knowledge to begin the healing journey for the sake of our children, ourselves, and our democracy.


Background: Informal caregivers are individuals who provide care for ill, frail, or otherwise dependent family members, siblings, or friends. Due to the caregiving demands, informal caregivers are known to experience negative mental health symptoms, such as stress or anxiety. Interventions based on Internet-based Cognitive Behavioral Therapy (ICBT) principles have been previously found to be effective for different populations and could also be considered as a plausible support option for informal caregivers. However, findings regarding effectiveness alone might not be sufficient for informing about the overall feasibility of the intervention.Objective: The aim of this process evaluation study was to evaluate the feasibility of a previously developed ICBT intervention for informal caregivers in Lithuania. More specifically, we evaluated the suitability of the intervention in relation to its content and delivery mode.Methods: Two studies were conducted. Study 1 consisted of participant evaluations of an 8-week, 8-module long therapist supported ICBT intervention. Evaluations for the Study 1 were retrieved from previously unused data, obtained from pilot testing of the intervention in which 63 informal caregivers took part. The evaluations contained of qualitative data (participant comments), as well as quantitative data . The Study 2 was an online stakeholder focus-group discussion conducted via Zoom. Eight stakeholders took part in the discussion, among whom there were social workers, medical professionals as well as individuals with caregiving experience themselves. Data were analyzed using descriptive statistics, thematic analysis, and data coding.Results: Results of the Study 1 showed that most of the pilot randomized controlled trial participants evaluated content and format of the intervention positively. These results were complemented by the findings in the Study 2, in which stakeholders evaluated the intervention as suitable and promising. In addition, stakeholders made certain suggestions for improving the intervention's usability for the informal caregivers. This included improving the instructions, providing with more guidance, and considering personalization options.Conclusion: The process evaluation helped to evaluate the feasibility of the ICBT intervention for informal caregivers in Lithuania from the two perspectives: users and stakeholders. Our findings suggest that the intervention is suitable for the target population. Informal caregivers are individuals who provide care for family members, siblings, or close acquaintances who due to the chronic illness, frailty, or other reasons are not able to live fully independently. Informal caregiver involvement varies greatly from helping with general hygiene, medication intake, and up to 24 h per day support . BecauseThere are examples of internet interventions for informal caregivers. The focus has been on psychoeducation , informaDue to its effectiveness in treating various psychiatric and somatic conditions  internetVarious frameworks exist for guiding the development, evaluation, and implementation of the internet interventions. The Medical Research Council (MRC) framework for complex interventions  –21 is a When should a process evaluation be done? To start with, it could be useful following the development on an intervention, as the obtained knowledge could then be applied for investigating quality, feasibility, and prospects for implementation. At the same time, process evaluations could be conducted in other phases of development. For example, it could be useful after pilot testing of efficacy, to either help in interpreting the results or, to provide with additional evidence . MoreoveIn this paper, we present the results of a process evaluation of an ICBT intervention for reducing informal caregiver burden. We recently conducted a pilot randomized controlled trial (RCT)  and a quThe main objective of the present paper was to conduct a process evaluation study for examining feasibility of the ICBT intervention for reducing informal caregiver burden. More specifically, we focused on evaluating delivery, content, and suitability for the target population. For this purpose, two research studies were conducted and will further be presented separately. The findings in this study will hopefully guide further development and implementation of the intervention.This process evaluation study was performed following the efficacy and intervention acceptability studies. The study design was driven by recommendations provided by Moore et al. . To meetThe intervention was developed in three main steps: (1) concept development and considerations, (2) selection of the content, (3) revision of the content by a Lithuanian research group of clinical psychologists for cultural appropriateness and relevance.The idea to develop a guided internet-delivered self-help intervention for informal caregivers in Lithuania was initiated in association with an EU-project (ENTWINE) and was a collaboration between Linköping University in Sweden, Vilnius University in Lithuania, and the University of Groningen in the Netherlands. Few most important aspects were agreed upon on this stage. Firstly, the Iterapy online treatment platform  was chosThe intervention was named ‘Slaugau artima’ which translated from Lithuanian language means I take care of my close one. In the Lithuanian context this was decided to be the closest as well as culturally understandable approximation of the English term informal caregivers.A CBT approach was chosen as theoretical framework. This decision was prompted by accumulating evidence in support of ICBT for adults experiencing psychiatric and somatic conditions . FollowiThe selected content was put together for each of the topics and then translated into Lithuanian language by Lithuanian speaking research group members. Initial checks for the comprehensiveness and appropriateness of the content for the target population were then conducted. Since the intervention targeted Lithuanian informal caregivers, much attention was dedicated for making the content culturally appropriate. From the initial stage throughout the development of the intervention, adjustments of intervention content to local cultural context were discussed in the Swedish and Lithuanian research teams. Also, a small convenience sample of stakeholders from the researchers' network were consulted when necessary.In the first stage of the revisions, a Lithuanian fluent student assistant reviewed the content of the intervention for its suitability and comprehensiveness. Certain observations were noted regarding the use of language, case examples and the structure of the content which were communicated to the research team so that changes could be made where appropriate. Following this, several discussions in the research group, including experienced clinical psychologists and researchers from Lithuania, took place. Once again, the content was revised and adapted when needed. The intervention was finalized when there were no further revisions to be made regarding the content, cultural appropriateness, and the use of language. In Study 1 we retrieved previously unused intervention evaluation data obtained from the participants during the pilot RCT study . ParticiA total of 63 informal caregivers were included in the pilot RCT. Most of the participants were female (90%) with an average age of 52 years (SD = 8.4). Participants displayed high burden  as measured by the Caregiver Burden Inventory . A complData retrieved from the pilot RCT participants consisted of module evaluation questions as well as an additional question about the content that participants were provided at the start of each module. Module evaluation questions consisted of four questions and one open box answer . For thiThe pilot RCT study was conducted between October 2019 and March 2020. Participants in the study were able to choose to evaluate each of the eight modules as well as to share their experiences of applying the knowledge at the start of the each of the new modules. Answering intervention evaluation questions was on a voluntary basis and took only a few minutes.Quantitative data were analyzed using IBM SPSS Statistics (version 25). Descriptive statistics were used for summarizing quantitative responses. The qualitative data were coded after reading all the text responses provided by the participants . First, Participant responses to multiple choice module evaluation questions are summarized in n = 176) or participant reflections (n = 147). Latter comments were not coded further, as it represented individual's personal experiences and thoughts. Content specific comments were divided into three main categories: Content/format positive (72.2%), Content/format hesitant (20.4%) and Content/format negative (7.4%). Short definitions and examples of participant comments illustrating each of the categories and sub-categories are presented in A summary of the results is presented in Comments in the first, Content/format positive category represented aspects of the intervention that the participants appreciated. These comments were further sub-categorized into five smaller groups. The two biggest ones were Learning about thoughts (31.5%) and Overall applicability (23.6%). Comments in the Learning about thoughts sub-category indicated participants to benefit from the knowledge about their own thought patterns. Also, to benefit from information about how to interpret their thoughts and how the negative automatic thoughts could be changed into the less-negative alternative ones. Consequently, participants comments in the Overall applicability sub-category indicated participants to be generally able to select and apply the provided information. Also, these comments indicated participants to find the content as well as the format of the intervention overall acceptable and suitable. The remaining three sub-categories in the Content/format positive category were Being able to relax (13.4%), Dedicating time for own needs (12.6%) and other (18.9%). Firstly, the comments in the first two sub-categories indicated participants to benefit from the relaxation techniques as well as the parts of the content, that encouraged to focus on own needs. By some, intervention itself was perceived as a means of distraction from daily routine and an opportunity to spend the time for one-self. In turn, the comments in the sub-category other were either in relation to learning to problem solve (5.5%), improving quality of communication with the close ones (5.5%), or ability to share own thoughts and experiences with the therapist (7.9%). That is, to very specific components of the intervention, namely, the problem solving and communication skill related content as well as the function allowing to communicate with the therapist.The remaining two categories were the Content/format hesitant (20.4%) and Content/format negative (7.4%). It could be summarized, that the main difference between these two categories was that participant comments in the latter category expressed more direct dislike or lack of approval as opposed to hesitancy or reluctancy toward engaging with the intervention. To start with, comments in the Content/format hesitant category reflected participant reservations about either the content and format of the intervention or own abilities in applying the intervention's materials. That is, some of the comments expressed participant doubts regarding content's applicability to their own situation, with some of the topics or exercises being perceived as less relevant for individual caregivers. In addition, some participants expressed uncertainty or doubts about how some of the exercises should be conducted or, were not certain if they are able to conduct such exercises correctly. Also, there were comments that indicated some participants to experience difficulty in translating the knowledge from the intervention into the daily life situations. In turn, as indicated by the categories title, comments in the last category, Content/format negative, represented participant negative attitude toward intervention's format or applicability of the content. Most of the comments in this category could be summarized to illustrate participant critique toward the content or exercises as being not suited for their needs or circumstances. In addition, comments in this category also indicated some of the caregivers to be longing for more intensive contact with the therapists. Lastly, some comments indicated participants to be burdened with the fact that the intervention required time to engage with.Study two was set up as a stakeholder discussion. Informed consent was obtained from all participants. Ethics approval for this study was not required according to the national ethical regulations for research, as it was not a clinical trial, participants were not requested to share any sensitive information and no obvious risks could be identified. Participation in the focus group discussion was completely voluntary and no monetary compensation was offered.We defined stakeholders as individuals who were connected to the informal caregiving either via personal experiences or professional capacity . As a coThe discussion guide included the meeting's agenda, several broadly phrased questions, and several question probes. The discussion part was structured to cover three main aspects in relation to the intervention: (1) information provided in the public pages of the intervention, (2) format and the content of the intervention and (3) the communication function between the participants and the therapists. Some of the questions posed to the participants were: What is your first impression after viewing this? What are your thoughts after seeing this? and Now that you have seen it, what is your opinion about the structure of the content?In preparation for the discussion, the main author of the paper (IB) and a student assistant familiar with the intervention pilot tested the procedure using the discussion guide. The stakeholder focus group discussion took place in November 2020 online, via Zoom and was recorded following consent from all participants. IB chaired the discussion and the student assistant took the notes. The discussion started with a general introduction. Before recording, participants were once again asked for verbal consent. All three parts of the intervention relevant for the discussion  were introduced and discussed separately. Following the focus group discussion, participants were provided with a short summary of the main discussion points. Participants were also encouraged to contact the researchers with suggestions or corrections regarding the discussion's summary.Data analysis was performed using inductive reflexive Thematic Analysis (TA) , 33 condICBT intervention's potential and considerations and four sub-themes were generated. The sub-themes are: (1) feasible and needed, (2) need to clarify instructions and manage expectations, (3) need to provide with guidance after the intervention has ended, and (4) similar challenges, but need of flexibility. The first sub-theme (Feasible and needed) illustrates benefits of the current ICBT intervention. The remaining three present several suggestions that could be implemented for maximizing intervention's benefits for the caregivers. Illustration of the themes and sub-themes is presented in the The focus group discussion lasted for 1 h and 42 min. Following data analysis, one main theme titled Discussion regarding the intervention's content was accompanied by the view, that informal caregivers, despite their unique circumstances, are often faced with similar psychological challenges. As described in the first sub-theme Feasible and needed, stakeholders overall expressed a positive attitude toward the intervention. More specifically, the intervention's format, selection of themes and ability to contact the therapists were appreciated. On the other hand, stakeholders emphasized that despite being faced with similar demands, each informal caregiver has a unique set of personal characteristics, has different caregiving experience, and is faced with unique challenges. Hence, the main overarching idea behind the remaining of the three sub-themes is that current version of the intervention could be developed further to offer valuable support for many, despite their different circumstances. That is, by providing options for personalization and by offering clearer instructions as well as options for the continuity of the support.Stakeholders reflected on how much psychological support is needed as well as the lack of resources for informal caregivers in Lithuania. The intervention was seen as an accessible and suitable support option that could bridge this existing gap. In addition, stakeholders appreciated that the intervention covered a range of different topics relevant for informal caregivers. Also, that the intervention was seen as well-structured.One can see that a lot of work has been put into this; a lot of materials, systemised; included (information) is really useful and needed. (Ida)One other outlined aspect was the communication between the informal caregivers and therapists. Stakeholders positively reflected on the fact that informal caregivers were able to communicate with their assigned therapist throughout the duration of the intervention. This function was also found to be useful for encouraging caregivers to engage with the materials. Also, such function was deemed important for allowing them to share their personal experiences and challenges. Lastly, the fact that the intervention is delivered online was also perceived positively. This finding is especially valuable considering the ongoing COVID-19 pandemic at the time of data collection and the reduction in availability of face-to-face support.At this moment, such support is more relevant than live support. (Ann)In addition to recommending including options for personalization stakeholders reflected upon certain aspects that could improve prior expectations and the ease of using the intervention. To start with, two main aspects were outlined by the stakeholders regarding prospective user expectation management: time involvement and relationship with the therapist. Stakeholders emphasized the importance of informing informal caregivers about how much time would be required for engaging with the intervention. This was mentioned because caregivers often have a limited amount of time to spare. Including at least an approximate estimation of time could prepare them for scheduling the time around their duties. In addition, it was suggested that more information should be provided regarding the frequency of communication with the therapist. That is, how soon the participant will receive a response, how frequently communication will take place and what format it will take.The more there is clarity, the easier everything is, the less questions arise. (Ann)In terms of the ease of using the intervention, two main points were outlined. First, stakeholders suggested that more quick access options should be included in the intervention. That is, to provide certain shortcuts and a clear sequencing for accessing different topics and exercises. This was not only to make it more user friendly, but to also to save time for the caregivers. Second, stakeholders discussed including additional guidelines about using the intervention and especially, the technical parts of it, such as logging in, since not all the informal caregivers might be equally confident or affinitive in using online interventions.some instructions would help at least a bit for some. (Rose)…This subtheme reflects the need for continuation of support. Stakeholders discussed the importance of providing participants with different information sources about where one could reach out for support once the intervention had finished. For this, several suggestions were made. For example, to provide a list of helplines that offer mental health support, to provide with links to literature, useful web resources and possibly even online support communities. Such information regarding further support was stressed as an additional and essential tool for informal caregivers in allowing them to maintain their well-being and further apply the knowledge gained throughout the course of the intervention.So not to leave (them) (…) in the hands of the fate, so that they could further reach out somewhere else in the future. (Ida)Even though stakeholders described the topics of the intervention as useful, it was also commonly agreed upon that to reach and benefit informal caregivers in their differing circumstances, certain personalization options could be implemented. For example, to give participants an opportunity to choose the topics they want to start with instead of providing everyone with the same sequence of the topics.My idea was that (…) a person could switch things around based on what theme is the most relevant for him at the moment. (Lily)Other aspects that were mentioned were to include a wider range of selection options for either listening to information, or viewing it, since majority of the intervention's content is currently provided in text. Lastly, the opportunity for tailoring the communication with the therapist function was also discussed. Stakeholders suggested that due to individual differences, some of the participants might benefit for an opportunity to call or reach the therapist in other ways in addition or instead of currently implemented messaging function.hybrid way is good (…) meaning that it is possible to mix-it up, really. (Iris)…In this paper we aimed to conduct a process evaluation investigating the feasibility of ICBT intervention for informal caregivers in Lithuania. More specifically, we have aimed to evaluate the intervention by examining its delivery, content, and suitability for the target population. Two studies were conducted. In Study 1 we have analyzed evaluation data obtained from the informal caregivers who took part in a pilot RCT study for efficacy of the intervention . Study 2Content/format positive category. Learning about thoughts  and Overall applicability were the two largest sub-categories in this group. This is in accordance with the Feasible and needed theme generated following focus group discussion in Study 2. Stakeholders found the intervention useful due to its clear structure and coverage of a range of topics. Clear structure, comprehensiveness and helpfulness of the content was previously outlined as beneficial in other ICBT studies . It could be stated that the stakeholders were more expressive about the benefits of such support. As it is evident from our previous qualitative work in evaluating the acceptability of the ICBT intervention, not all informal caregivers appreciated the therapist support equally .The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Immigrant populations experience diverse barriers to access healthcare services in the host countries. Among them, undocumented immigrants have more restricted legal access conditions and higher risk of having poorer health. Likewise, women are more likely to seek healthcare and face gender-based factors that hinder their access.This thesis analysed the access of undocumented immigrants and immigrant women to public healthcare services in the Basque Country (Spain).The thesis contained three sub-studies, carried out with qualitative and quantitative methods. For the quantitative approach, the trend in the number of consultations in a free clinic for undocumented immigrants was analysed before and after the launch of a new law, using a negative binomial regression analysis . For the qualitative approach, qualitative content analysis was applied to 25 in-depth interviews with 14 immigrant women and 11 free clinic healthcare professionals.No clear relationship was found between the application of more restrictive legal conditions for immigrants to access public healthcare services and the trend of attendance of undocumented immigrants to a free clinic. Access of undocumented immigrants and immigrant women to healthcare services was subject to barriers dependent on their characteristics, health system functioning, legal requirements and a stereotyped and poor social consideration of immigrants, shared by professionals at the health centres. Meanwhile, provision of legal information and support by individual professionals, social organizations and personal networks represented main facilitators for accessing.For the access of undocumented immigrants and immigrant women, structural and individual barriers based on their social vulnerability were found. Among others, gender-based violence reduced women’s possibility to access healthcare services and being undocumented led to restricted access entitlement and to fear rejection at health centres. Therefore, besides ensuring immigrants’ legal entitlement, there is need of promoting rights-based attention to get more inclusive health systems. Does the health system respect immigrants’ right to health? Analysing immigrant women’s healthcare access in the Basque Country’ [The doctoral thesis entitled ‘Country’  was a reIn recent years, the number of immigrants in the European Union (EU) has consistently increased . In SpaiStudies regarding access of immigrants to healthcare services in Spain have concluded that they utilize them to a lesser extent than natives. In general, the immigrant population used less specialised, primary, and mental healthcare services in comparison to natives, even if they used the emergency services more . Among tIn the European context, undocumented immigrants, which are the non-nationals who enter or stay in a country without the appropriate legal documentation , have a In Spain, access to the National Health System, which include all regional health systems, is ruled by the centralised state legislation and it is known for offering broad services to all immigrants, being close to the universal healthcare access . In addiIn 2012, using the economic crisis as justification, the Spanish Government enacted a law that dramatically reduced access to healthcare services for undocumented immigrants to the National Health System. Consequently, in 2013, the regional Basque Government, the region where data were collected, launched the Basque Decree 114/2012 to reduce the negative impact of the new Spanish law on immigrants’ access. Even then, the conditions for all immigrants to access healthcare services in the regional health system became more restrictive. It was during this period that the studies were conducted. In July 2018, due to a government change, the access conditions from before 2012 were restored in the whole National Health System, including the Basque Country.For providing attention to those excluded from public health systems, who are mainly undocumented immigrants, in some countries free clinics exist, which are usually run by non-governmental organisations (NGOs) ,16,23–25Access to healthcare acts as an important health determinant  and is cThe first framework, Watters’ multi-level model of access, integrates the levels for a comprehensive examination of access to healthcare services for immigrants and populations in situation of vulnerability. The framework was used as a research roadmap, allowing the exploration of different levels of access, namely 1) entitlement, 2) access, and 3) appropriateness . HoweverLevesque’s framework allows the researcher to address and contextualize the experiences of access from the perspective of care-users . It consThe right to health approach is centred on the concept of entitlement and it was useful to understand and explore the roles and responsibilities of the different social actors on its fulfillment ,30. UndeThe main objective of this thesis was to analyse the access of immigrant women and undocumented immigrants to public healthcare services in the Basque Country. Based on the hypothesis that for undocumented immigrants, more difficulty in accessing public health systems means more use of the available free clinics, the first specific objective was stablished: 1) To assess the impact of the implementation of more restrictive conditions for accessing public healthcare services for immigrants on the number of consultations of undocumented immigrants at a primary healthcare free clinic. In addition, in order to get a more complete perspective of the barriers that hinder the access to healthcare services for immigrant women and undocumented immigrants in our setting, exploratory specific objectives were stablished: 2) To determine the perception of healthcare professionals working in free clinics on the barriers and facilitators of access to healthcare services by immigrant women and undocumented immigrants in the Basque Country and 3) To analyse Sub-Saharan African immigrant women’s perceptions and experiences of access to appropriate healthcare services in the Basque Country.Three individual studies formed this doctoral thesis. The methodological approach used for responding to the first objective was quantitative (Part I), while a qualitative approach was used for achieving the second and third objectives (Part II) . The useIn 2013, the new Basque Decree 114/2012 established more restrictive conditions for accessing public healthcare services for immigrants, which mainly affected the undocumented ones. Based on the hypothesis that more difficulty in accessing public healthcare services led to more use of the available free clinics, a segmented time series approach was used to analyse the trends on the number of consultations of undocumented immigrants in a primary healthcare free clinic, before and after the law launch.The application of the Basque Decree 114/2012 in January 2013 was considered the intervention point, so the intervention phase was defined as the first quarter of 2013. Therefore, the pre-intervention phase was settled from January 2007 to December 2012 and the post-intervention phase from January 2013 to June 2017.First, the number of consultations was counted manually from registration forms completed during the health consultations, extracted into an Excel spreadsheet on a quarterly basis and exported to Stata 13.0 software for analysis. Frequencies for total and new patient consultations, country of origin and diagnosis for men and women were collected from the free clinic database for descriptive analysis .Table 3.The data on the number of consultations were adjusted for Biscay province’s unemployment rate, percentage of registered immigrant population and seasonality. Unemployment rate was used to capture the possible influence of the financial crisis on the number of immigrants attending the free clinic. The percentage of registered immigrant population aimed to capture the variability in the amount of immigrants in the province. Finally, the seasonality captured the summer holiday period (third quarter of each year), when the number of consultation days clearly decreased every year.Data were represented as the following equation:where Y represented the outcome variable ; ß0 was the baseline level of the outcome at the beginning of the period; ß1 estimated the structural trend in the outcome before the intervention; ß2 estimated the immediate impact of the intervention through the change in level of the outcome and ß3 reflected the change in the trend of the outcome after the intervention.Negative binomial regression analysis was applied to the data, obtaining rate ratios (RR) and the 95% confidence intervals (95% CI), stratified by sex.For exploring the perceptions and experiences on immigrant women’s and undocumented immigrants’ access to healthcare services, in-depth interviews were conducted with healthcare professionals and immigrant women. Clearance from the university ethical committee was obtained before contacting any participant, who gave oral and written consent before starting the interviews.These participants were purposively selected for having a deep knowledge of the immigrants’ social and healthcare situation, due to their experience of providing healthcare to undocumented immigrants and immigrant women who are not legally entitled to public healthcare services.For data collection, the responsible persons of the four free clinics of the Basque Country were contacted. The study was presented to them so they could offer to the healthcare professionals the possibility to participate. The ones who agreed to take part contacted the researcher in order to receive further information and to fix a date and an adequate place for the interview. Data collection took place between September and December 2015. Eleven interviews with healthcare professionals were carried out.A semi-structured interview guide was used to conduct the interviews. After collecting some socio-demographic data from each informant , questioData were analysed using qualitative content analysis. Graneheim and Lundman’s approach was used to develop the analysis as they propose . First, Based on the results of the previous study, which identified black African immigrant women as the most vulnerable in accessing public healthcare services, 14 immigrant women from eight Sub-Saharan African countries were interviewed. All of them were living in the Basque Country and had used the public healthcare services at least one time by the moment of the interview. Some socio-demographic data were collected from each participant . The recThe interviews were conducted from June 2016 to October 2017. A semi-structured guide was used, which contained questions regarding the knowledge of the legal norms, the influence of the language, and being undocumented in the access to healthcare services. Other relevant emerging issues were also discussed during subsequent interviews, like the influence of being black or of the racism of the professionals at the health centres in their access. Interviews lasted between 25 and 70 minutes. Nine interviews were conducted in Spanish, one in English, three in French and one in Swahili and French. On three occasions, based on the preference of the participants, translators provided by them were used.The interviews held in English and Spanish were transcribed verbatim, while the interviews conducted in French were translated into Spanish for analysis. All transcripts were reviewed for accuracy and entered into Open Code 4.03 Qualitative Data Analysis  softwareThe main results of the thesis for achieving the specified objectives were the following:From January 2007 to June 2017, a total of 9,272 health consultations were attended in the primary healthcare free clinic, 76.94% for men and 23.06% for women. 49.58% of the women and 40.03% of the men attended the clinic for the first time .The total number of consultations for men in the whole period was 7,134, almost 4 times that of women, which was 2,138. The baseline level of the number of consultations for men was 193.23 at the beginning of the whole period, while it was 44.92 for women. During the pre-intervention phase, while a non-significant increase of 2% in the trend of consultations was observed among men from one quarter to the next  there was a significant trend decrease of 2% in consultations for women during the same period . The level of the number of consultations decreased significantly by 40% for men and increased 187% for women per quarter just after the intervention. Finally, the trend of consultations experienced a non-significant increase of 1% per quarter in the post-intervention phase  for men and a statistically non-significant decrease of 1% per quarter in the attendance trend for women   Figure Figure 1Tell me who you are so I can tell you how you access, related to the influence of the personal characteristics of the immigrants on the access; 2) Once they get the consultation, everything is fine. The problem is with administrative staff, explained the importance of the attitude of the staff at the health centres; 3) An inflexible and passive health system represented the impact of the functioning of the health system and the last category 4) If you do not fulfil the requirements, you are just out. The law is the law was related to the effect of health policies in their access.After analysing the discourse of healthcare professionals working at free clinics about the access of immigrant women and undocumented immigrants to public healthcare services, four categories were developed: 1) Latin women have no problem to access. Africans no way! First, no one is going to listen to them when they speak English or Nigerian … so they will not even pass the counter to reach the healthcare consultation (Nurse)Participants considered that women’s approachability and ability to identify healthcare services depended on their origin. Latin-American women in contrast to Africans, besides sharing the language with natives, were considered to have better knowledge on their rights and the functioning on the health system, thus better access.Immigrant, but also native women, were considered to be less able to seek care when they were victims of gender-based violence. First, because perpetrators could directly deny their attending healthcare services. Second, because the women themselves could hesitate contacting with healthcare professionals in order to hide their situation of violence.Attention to immigrants is different than to locals. The staff at the health centres have a huge workload and they are used to always following the same routine. The routine change can create tension so they behave differently with immigrants (Physician)Participants described administrative professionals as the main barrier for immigrants’ access due to the poorer attention they provide to immigrants and their lack of knowledge of immigrants’ access rights. In contrast, healthcare professionals’ attention to immigrants was considered more adequate, even if in general, all professionals’ willingness to attend to and fulfil immigrants’ needs was considered weak.Undocumented immigrants are left out of the health system. But there are some other vulnerable groups, like women working in prostitution or victims of human trafficking, which should be reached in a more direct manner, because they do not attend the consultations themselves even if they need it (Nurse)Participants described that information about access to healthcare was not widespread in the community but confined within the health centres. Consequently, it was difficult for populations in situations of vulnerability to be able to seek care that responded to their needs.When receiving healthcare, the scarcity of personnel and short consultation times with each patient were considered to reduce the ability of immigrant women to become involved in decision-making with regards to their own health and treatment.When they get there, they are asked for the council registration or for money. If they don’t have them, they directly leave without been attended (Physician)All the participants described the legal conditions as the main barrier for immigrants to access the public healthcare services, amplified with their lack of knowledge of their rights. Some participants identified that the legal access conditions, bound to council registration, are difficult to fulfil for immigrants, especially for undocumented ones.Moreover, participants considered that undocumented immigrants fear approaching healthcare centres for the potential legal consequences of being identified as undocumented in a public institution, such as being deported.As facilitating factors, being in contact with social organizations and having a broad personal network were considered a source of information and support for accessing healthcare services. Likewise, finding sensitized professionals with immigrants’ social vulnerability was considered a key facilitator for improving access of this group, including those who are not legally entitled.Fear of entering a health system perceived as not friendly for immigrants; Being attended on professionals’ own communication terms and Is mistreatment based on racism or merely on bad luck?, which were, respectively, related to access conditions, communications with professionals and racism were developed.Immigrant women from Sub-Saharan Africa were identified by healthcare professionals working at the free clinics as facing the largest barriers to access the public healthcare services. That directed the focus of the last study on this specific group. After analysing the interviews with Sub-Saharan African immigrant women, the three categories Participants reported that lack of knowledge on the laws regulating access for immigrants, which were considered difficult to accomplish, made them refrain from trying to access healthcare. In contrast, having the healthcare card was considered key for making rights go into effect, despite other barriers.Imagine: I was very sick, but they were not attending me. The man there  told me: “Sorry, we can’t do anything”. He also told me that I could pay and access, but I told him: “To pay? I have no money, no aid, I have nothing”. It was difficult. So I left (Arjana)Undocumented immigrants were considered to avoid seeking care for fearing being reported to state immigration institutions or incurring debt with a public institution, which could result in their deportation. Therefore, being asked to pay for a healthcare consultation, acted as a discouraging factor in continuing asking for healthcare.However, attending NGOs to get proper information, reaching health centres accompanied by someone or finding sensitive professionals acted as facilitating factors for access.Language was experienced as one of the most important barriers by the participants. Lack of communication with administrative staff led to more difficulties on meeting a healthcare professional. Likewise, lack of communication with healthcare professionals hindered their possibility to be diagnosed, being offered a proper treatment or it led to mistakes in the medical treatment.Ahhh … is very difficult, because a lot of people there  they don’t speak English. The only thing is to say … slowly … and then I try to understand. I use my phone to translate. Look, it is like … I don’t need to attend you. They tell me: “You are in the Basque Country; you need to speak in Spanish” (Jessy)In addition, those who do not speak the local language perceived that the lack of communication put them in a disadvantaged position, reinforced by a poor consideration about immigrants of certain staff at health centres.To overcome these situations, staff and immigrants developed strategies to communicate, including the use of translators.Participants perceived that the administrative staff at the health centres behaved differently with them than with natives. Even if healthcare professionals’ vocation was considered incompatible with being racist, some situations of differentiated treatment and mistreatment were also reported. For example, some cases on which a stereotype of immigrants influenced the diagnoses were presented.All those labels that the history has accumulated on us influence the way we are attended. A social rejection image follows us wherever we go and hinders our access to the health system (Elizabeth)Participants working at social organizations connected the poorer attention given to immigrants and black people in the health system with colonial domination of high-income countries. Likewise, they pointed out that usually the staff at the health centres considered immigrants undeserving to receive healthcare.In contrast, while some participants connected of the differentiated treatment they received with a systemic tendency of racism, others based it on more individual factors, like individual professionals’ bad day or lack of patience.The discussion section aims to compare the main findings of the quantitative and qualitative studies with the literature, under a common frame of the three conceptual frameworks. Although results are divided following the Watters’ multi-level model of access, there are close connections as well as overlapping areas between the different aspects of access that each of the levels entail.The results of the studies indicate that there is a considerable number of barriers and some facilitators in the access of immigrant women and undocumented immigrants to public healthcare services in the Basque Country. Main barriers at entitlement level included lack of entitlement, lack of knowledge on the rights to access healthcare services and difficulties for fulfilling the legal access conditions. At access level, factors such as lack of information, lack of an effective communication with staff at the health centres and fear to be rejected or billed discouraged immigrants from approaching the health centres, especially those in situations of vulnerability, like undocumented immigrants or women exposed to gender-based violence. At appropriateness level, staff’s lack of cross-cultural knowledge and lack of willingness to attend immigrants and racism represented great barriers on the compliance of the health needs of immigrants. For counteracting these barriers, facilitators such as being informed, accompanied or having support by individual professionals, social organizations, free clinics and personal networks were highlighted.Considering the right to health approach, states’ core obligation is taking appropriate measures to provide healthcare to vulnerable members of society ,30. HoweSpain, before the law change in 2012 and nowadays, after the new law launched in July 2018, is among the EU countries offering broader services to immigrants . HoweverIn addition, the law change generated confusion for both patients and professionals in relation to the entitlement of immigrants to healthcare ,15. ProfHowever, very different trends of attendance of undocumented immigrant men and women were observed over a 10 year period in the same free clinic, as men represented 76.94% of total consultations. Due to the lack of the above-mentioned key demographic information, demographic reasons which could explain these trends could also not be contrasted. Moreover, nor did the proportion of documented registered immigrants shed light on the reasons for the excess number of consultations of men, as from 2006 to 2019, the proportion of sexes in the council register was close to 50% each [As in the literature, in the thesis the lack of legal entitlement was widely considered a crucial barrier for immigrants to access healthcare services ,36. HoweRelated to access to healthcare, defined as the opportunity to reach and obtain appropriate healthcare services in situations of perceived need for care , it was Except for some gender-based conditions, the barriers which were related to immigrant women could also explain the difficulties of accessing healthcare services of immigrant men, such as the above-mentioned lack of entitlement or the influence of being undocumented. In the case of immigrant women, their autonomy and ability to reach healthcare were considered more limited for those forced into prostitution or experiencing other forms of gender-based violence ,40. TherThe language barrier was extensively described in the literature as in our studies as one of the main barriers for access ,37,38,41Being undocumented was extensively considered as a great barrier for keeping good health and accessing healthcare services ,16,38. FPopulations in situations of vulnerability tend to attend social-based resources and free clinics, where besides providing information and/or healthcare, they do advocacy work for their inclusion in the public health system. That is why free clinics and social organizations were presented as key resources on the promotion of the health and healthcare access of populations in situations of vulnerability ,15,25. HConsidering that receiving appropriate care is also part of adequate access, in our results, the negative social consideration of immigrants and black people was considered to also played a role in access to healthcare services of Sub-Saharan African participants, as they perceived having received differentiated treatment in comparison to native people, so having felt discriminated against by professionals in the health centres . StructuIn contrast to discriminatory practices, the right to health approach and healthcare professionals’ ethical guidelines promulgate the necessity of attending all patients equally, not discriminating against any person in the provision of healthcare.The studies contained certain methodological strengths and weaknesses that require mention. The used quantitative method, interrupted time series design, since it makes account for pre-intervention trends, is considered as a good method for assessing an intervention impact. However, further than the new policy implementation, other factors not taken into consideration in the study could also help explaining the results. Even if data from the public health system on the number of immigrants attended could have given a reliable picture and a more specific answer to the objective, unfortunately it was not publicly available.The qualitative methods used allowed closer contact with the participants and captured essential characteristics of the topic, based on participants’ experience. In addition, the study design was flexible, as the focus of one study was based on the results of the previous one. All participants were purposely selected based on their knowledge and experience on the researched topic. Therefore, it was considered that their discourses could also represent the discourse of those who are in similar position. In addition, the study area and the recruitment process were widely explained in the thesis, letting the reader consider if the results could be transferred to their setting.Related to credibility, as the author was at first not familiar with the study topic, she approached it with an open viewpoint that allowed considering the topic from a broader perspective than the experiential. However, the absence of familiarity with the study topic also posed some challenges, such as the possibility of failing to fully comprehend participants’ experiences or reflecting them properly.The main limitation of the qualitative study considering the perception of the healthcare professionals was that even if the focus and the general aim of the study was put on the access of immigrant women, many of the participants’ answers included both immigrant men and women, even if they considered women as more vulnerable. Therefore, to better capture the influence of the gender-based factors when accessing healthcare services, the second qualitative study was only focused on women.Access to the Basque public health system for undocumented immigrants and immigrant women is subject to individual and systemic factors that may act as barriers or facilitators at different levels of access, namely entitlement, access, and appropriateness. For documented immigrants, the barriers for women and men were found to be similar, except for those women experiencing different forms of gender-based violence. Moreover, undocumented immigrants’ vulnerability led to fearing approaching health centres, so to encourage attendance at free clinics, which were considered to play a crucial role on providing healthcare attention and on doing advocacy on immigrants´ access.Further than ensuring the legal entitlement of immigrants to healthcare, there is a need to provide them rights-based and culturally appropriate attention. In this regard, the use of cultural mediators, reinforcing non-discrimination values and the creation of more approachable and multilingual information sources are key aspects to improve all immigrants’ access and to get health systems that are organized for considering the needs of a culturally, linguistically, and socially diverse population.


Collaboration among disciplines is becoming a standard practice in Architecture, Engineering, and Construction (AEC) industry. However, limited studies have addressed the involvement of interdisciplinarity into architectural undergraduate curricula. The study seeks to expand the literature on this topic, namely by offering an alternative model for teaching an Interdisciplinary Design Course (IDC), mainly in architectural engineering departments, with the participation of engineering departments. The authors hypothesize that by the adoption of the IDC, architecture students would have a better understanding of the nature of AEC interdisciplinary design knowledge. The study aims to highlight the value of the IDC and to test the hypothesis. A qualitative research methodology has been adopted, including the design of an experiment and then the application of a case study comprising four instructors and 24 students from four departments in the Faculty of Engineering, Cairo University. Students’ design process, teamwork attitude, and own experiences on the IDC have been recorded using direct observation, interviews, and surveys. Data have been analyzed using descriptive statistics to identify the effectiveness and challenges of the experiment, in addition to the comparison with the traditional design studio. The results have shown the students’ satisfaction with collaboration with their peers from other disciplines, as it boosted their understanding of the integrated design process and increased their knowledge about each other’s discipline. In addition, architecture students commended the IDC much more than the traditional design studio.The online version contains supplementary material available at 10.1186/s44147-021-00010-2. The real practice of Architecture, Engineering, and Construction (AEC) is based on collaboration among disciplines . The desThe term “Interdisciplinary” is an adjective that describes the interaction that occurs among two or more disciplines. Such interaction is broader than “multi-disciplinary” teamwork or collaboration, which are considered as one-discipline-based terms . AccordiIn essence, building an interdisciplinary course combining architecture and engineering is a challenge due to the pedagogical differences between the two pillars: architecture and engineering . To overVarious attempts at interdisciplinary approaches in design education were made since the late 1980s . Two sigHowever, limited attempts have addressed the pedagogical challenges to undergraduate interdisciplinary courses . A part A recent study has adopted an experimental course of an AEC interdisciplinary design . After sThe present study attempts to further expand the literature on interdisciplinary design education, offering an alternative model for collaborative teaching, mainly in the architecture department, and with the involvement of related engineering departments, i.e., structural, electrical, and mechanical engineering departments. The authors hypothesize that architecture students working on an interdisciplinary project would understand the nature of AEC interdisciplinary design knowledge, better than if working on a traditional project-based design studio.The objective of this paper is to highlight the value of interdisciplinary design studio employed as an elective course in the architecture department, in addition to test the hypothesis, through a designed case study of instructors and senior students from different departments. It is worth mentioning that the meant interdisciplinary design course is that by which students from different disciplines participate in the design, get critiqued, and graded by an interdisciplinary team of academicians and experts. It is different from the traditional mono-discipline courses that provide a background about other disciplines’ knowledge and that are restricted to only architecture instructors and students.The study adopts a qualitative research methodology. To start with, the study has synthesized a pedagogical framework for constructing an Interdisciplinary Design Course (IDC), based on the literature, and aiming to find the best practices of teaching IDCs. Based on the framework, an experiment has been designed and then implemented with a case study of 24 fourth-year students from four different departments. Students’ design processes and teamwork attitudes have been recorded using direct observation and interviews during the experiment. In addition, students’ own experiences have been registered using a post-experiment survey, which has been sent to the students after the last day of the experiment. Data have been analyzed using descriptive statistics, directly to identify the effectiveness and encountered challenges of the experiment. Results have been compared to the Traditional Design Studio (TDS) to test the hypothesis.The study has selected five papers that documented experiments of teaching interdisciplinary design, aiming to figure out the best practices for constructing such experiments, e.g., course durations, learning objectives, and project selection criteria. Table Each program should create a set of learning objectives as to represent its own ideologies and circumstances, yet meeting the criteria of an accreditation organization . GuthrieUsually, interdisciplinary courses are being run at the latest academic year or senior level, which is the culmination of architectural education . MoreoveThe experiment of the interdisciplinary design was carried out in the academic year 2019–2020 as an elective course, for 24 fourth-year students from four different departments in the Faculty of Engineering, Cairo University, namely (1) Architectural Engineering (ARCH), (2) Structural Engineering (STR), (3) Electrical Power Engineering (ELEC), and (4) Mechanical Power Engineering (MECH). Coordination with the last three departments started 2 months before the semester’s beginning. Instructors were informed by the authors of the experiment’s idea. They were then requested to assign at least four volunteer students from their departments to join the experiment. Instructors were requested also to participate in supervision. At that time, the faculty was not applying interdisciplinary courses or programs, which made a considerable challenge in the preparation of the experiment, since neither instructors nor institution was ready with proper experiences and facilities.However, the selection procedures of ARCH students were easier. After publishing a video to architecture students explaining the idea and encouraging them to volunteer, an online survey was conducted, targeting those who were interested in joining the course. The survey contained questions regarding the academic performance level, the desire extent to join the course, and the level of mastering Revit software. Out of 29 respondents from 140 architecture students studying in the 4th year, 12 architecture students were chosen, taking into consideration (1) the highest desire to join the course, the highest level of mastering Revit software, and the variety of the academic performance level. The chosen students were then divided into four teams, three students in each. By the end of the introduction lecture at the first week, all students were requested to get to know each other, so the architecture teams can choose their partners from the other disciplines . The experiment was run as a competition among the four teams. The students were to meet on campus 2 h a week, according to the proposed schedule.In the semester prior to the experiment, ARCH students had been through a traditional project-based studio that provided a background about other disciplines’ knowledge. The pilot project’s specifications were designed to be close to that of the project assigned in the previous semester, including design duration and project size and typology, so the comparison between traditional and the IDC could be more reliable. In addition, the specifications were designed in which to ensure equal challenges among students from different disciplines. The design challenges and their respective disciplines are presented in Table Although the chosen project was not supported by a real client, specifications were based on real circumstances. The pilot project was a cinema complex intended to be built as a part of a larger complex compound . The project land was owned by one of the investment companies, in a prestigious setting on 26 of July route, in El-Sheikh Zayed City. The ILOs and assessment criteria of the project were set as what previously mentioned in Table During the experiment, semi-structured interviews were conducted with a teammate in each team. The questions were regarding productivity, interaction among members, and communication efficiency, which collectively indicated the level of teamwork efficiency. It could be concluded from the discussions that ARCH students were much more interactive with each other, while less interactive with the other disciplines. In addition, all teams expressed the dominant role of ARCH at the first stages of design, one team even stated that the role of the other disciplines was almost ignored at the schematic design phase. Meeting manners were also different among the teams. Two teams were conducting meetings with the participation of all disciplines, which was expected. They claimed that productivity gets higher in the multi-disciplinary meeting rather than while working separately. However, the ARCH members of another team were working either solo or in pairs with each discipline member when needed. The members of the fourth team were not working in parallel, they were rather exchanging the same working Revit file and developing it consecutively. Communication modalities were almost the same for all teams, which were direct conversations and personal laptops. Other than physical meetings on campus, the students contacted online via WhatsApp as extra meeting hours spent working on the project.At the last weeks, students prepared the presentation of their projects, beginning with clarifying the project’s concept, functional zoning, and form generation, followed by technical drawings of all disciplines. The detailed tasks and output format are illustrated in Table After the experiment was finished, an online questionnaire was sent to the students from the four disciplines  claimed that they had a clear picture of the nature of other disciplines’ tasks. However, four ARCH students (18%) complained about the lack of communication with the other disciplines, attributing the reason to the other disciplines’ unawareness of architectural work. ARCH students described their experiences regarding working with other disciplines as in Table Figure Negative feedback regarding course schedule and course administration was received from most of the students. First, 11 students (50%) complained about the lack of adaptability to the exceptional circumstances, indicating the period of closure due to the COVID-19 pandemic. Six students (27%) stated that the administration should have had more strictness with the instructors, since the instructional following up was weak or, according to some students, was almost absent. Three students (14%) mentioned that this caused poor technical knowledge. Not only the instructors who were said to lack commitment, but three students (14%) also complained about the unseriousness of their teammates. In addition, complaints were reported regarding the graduation project (GP)’s effect on students’ performance, which was clearly stated by three students (14%).On the other hand, there was positive feedback from seven students (32%) who showed their satisfaction with designing a semi-real project as it is considered a practical training under the academic supervision. In addition, some students commended that the experiment was being run as a competition, which gave them much encouragement.The students were asked if using BIM software helps in the collaborative design. Figure Eleven students (50%) have reported that they have gained more understanding of BIM technology or mastering Revit software through the experiment. For example, Student 4 claimed that the discussion with the colleagues from all disciplines had helped grasping how to deal with the software. He stated: “for example, in the clash detection task, the understanding the other disciplines’ delicate needs created specific problems and sub-tasks, which helped deep searching and finding the best software techniques to solve them.” However, all MECH and ELEC students  stated that they faced barriers while using software to design. Thus, one can observe the significant variance in feedback between ARCH and students from other disciplines. This can be explained because of the previous experience of ARCH students in using such software.The results of the experiment have shown that the hypothesis is likely true. ARCH students manifested a satisfying understanding of other disciplines’ knowledge as well as the integrated design process itself. In addition, they thought that such understanding would be attained by the IDC, much better than by the TDS. However, ARCH students played a dominant role more than expected. They were much more interactive with themselves, while less interactive with their colleagues from the other disciplines.It is clearly noticed from the students’ feedback that providing prior knowledge required for the IDC is highly recommended. For example, they recommended early provision of BIM software tutorials before starting the experiment. In addition, students reported that the opportunity of applying the IDC should be expanded by mainly allowing more dedicated time. Specifically, they suggest (1) increasing meetings hours on campus; (2) reducing the size of the pilot project, in which less time is required in earlier stages of design; (3) applying the IDC to be a part of the GP, which would cause no busyness due to the GP; and (4) offering the IDC as a compulsory rather than an elective course.Other suggestions were relevant to the improvement of the quality of interdisciplinary design. For example, some students preferred that only top students should be chosen. They also suggested that communication should be done with graduated students and professionals besides the instructors in order to gain more design experience.The study has clarified the shortcoming of the existing literature on AEC interdisciplinary design education. In response, it has offered an alternative model of interdisciplinary design studio employed as an elective course in architectural and other engineering departments. The study has adopted a qualitative research methodology to highlight the value of interdisciplinary design studio and to test the hypothesis. An experiment has been designed and then applied with a designed case study. Using observation, interviews, and surveys, data have been gathered and then analyzed to identify the experiment’s effectiveness, challenges, and students’ own experiences, in comparison with the traditional design studio.The results of the experiment have shown that the hypothesis is satisfactory. All students expressed considerable satisfaction with the IDC. They claimed that the collaboration has raised the awareness of each other’s knowledge and the understanding of the integrated design process. However, they have reported negative feedback regarding the course schedule and course administration. ARCH students were better at delivering their knowledge than were other disciplines. They were more aware of other disciplines’ work and had more understanding of BIM and Revit software. In addition, the IDC has been proved by all ARCH students to be more valuable than the TDS in the understanding of the integrated design process and mastering BIM software.The chosen programs that documented experiments of teaching interdisciplinary design are limited to the same country (USA), having similar university settings. Studying a variety of programs for universities from different environments and cultures would be more convincing. In addition, the introduced methods for the application of the IDC in the design studio are preliminary and suggested, carried out on a small sample. A bigger sample could offer more reliable results. Other researchers are encouraged to test the proposed framework and research methods further or to introduce other methods to highlight the value of interdisciplinary design studio in architecture or other engineering departments.The paper fulfills the existing need to study how collaborative teaching can be adopted to teach AEC interdisciplinary design as an elective course in architectural and other related engineering departments, i.e., structural, electrical, and mechanical engineering departments. The paper’s contribution will have a wide-range impact. It can guide the educators in architectural and engineering programs, locally or internationally, in establishing new curricula and developing existing ones.Additional file 1. Post-experiment survey.