The burden of depression and anxiety is on the rise globally. Mindfulness-Based Programs (MBPs) are a particular group of psychosocial programs targeting depression and anxiety. There is growing research and practice interest in MBPs internationally, and they are becoming more commonly implemented in a number of countries’ healthcare services.To systematically map the existing provision of MBPs in the Swedish healthcare sector, in order to understand facilitators and barriers to uptake, and so inform future implementation efforts.We assessed the experiences of MBP implementation among relevant stakeholders in Swedish healthcare settings through an online survey. The survey was designed to gather data on (1) the evidence-base of practice being implemented; (2) the context in which implementation was taking place and (3) the process of facilitation. Respondents were identified through snowball sampling of key stakeholders.In total, 129 individuals from 20 of the 21 healthcare regions in Sweden responded to the survey. Our findings showed that there is variation in the types of MBP models being implemented, and that the delivery structure of evidence-based programs were often being modified for implementation. We found some divergence from international guidance on good practice standards for the training of MBP teachers within Swedish implementation processes. The main service context for implementation is primary care; the most important facilitating factors for successful MBP implementation were the presence of a championing individual and support from leadership. The most influential hindering factors for implementation were lack of time, and lack of funding.To support integrity and fidelity of MBP implementation in Sweden, a strategic plan and good practice guidelines seem necessary. Also, an evidence-based stepped care model for implementation may work to ensure intervention fidelity in cases where time and funding constraints permit. In Sweden, Common Mental Disorders (CMDs), including depression and anxiety, account for approximately 90% of all sick leave due to mental illness.5 Adults with depression and generalized anxiety are mainly treated with antidepressant medication and psychosocial interventions. This paper focuses on the implementation of one particular group of evidenced based psychosocial interventions targeting CMDs – Mindfulness-Based Programs (MBPs).Worldwide, the burden of mental disorders is on the rise, and depression has become a leading cause of disability. By 2017, 264 million people were affected with either chronic depression or major depressive disorder. In the last decades, the number of scientific studies on MBPs has increased exponentially, and their use has spread in clinical practice as well as in society at large. Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT) are the two most common programs offered in clinical settings, and the ones that have been most extensively researched. According to a recent meta-analysis, MBPs have the strongest evidence for managing depression. Mindfulness-Based Cognitive Therapy significantly reduces the risk of relapse in recurrent major depressive disorder, being most effective for participants with three or more previous episodes and at least as effective as maintenance antidepressant medication.12 Consistent with these findings, another meta-analysis concludes that MBCT and MBSR are effective for a variety of psychological problems, especially for reducing anxiety, depression, and stress. However, in parallel with increasing research evidence of the benefits of MBPs, reports of potential harm from mindfulness practice have recently emerged. A recent meta-analysis of adverse events during and after meditation – including mindfulness – concluded that such events are not uncommon and may occur even in individuals without previous mental health problems. A recent conceptual paper recommended that research should more specifically address factors that may contribute to the risk of adverse events from MBPs, including program-, participant- and teacher-related factors.Mindfulness has been described as ‘the awareness that arises from paying attention, on purpose, in the present moment and non-judgmentally’.17 A review of the literature on implementation of MBPs internationally reveals that this research area has not yet been extensively addressed. Indeed, a mapping published in 2015 of the MBP evidence offered a framework for understanding the strengths and vulnerabilities of the current research on MBSR and MBCT. Seven recommendations were made to ensure that the forward trajectory of MBP research developments is strong – two of these relate to the importance of future research engaging with questions related to the practical implementation of MBPs. One of these recommendations focused on the question of clinician as well as quality and integrity of the delivery of MBPs. The second recommendation related to the risk of developing ‘orphan innovations’, which may contribute to the loss of intervention effectiveness that often occurs in real-world clinical settings, due to various reasons. There are some studies on the implementation of MBPs in schools,19 and a smaller number on the implementation of MBPs in healthcare systems.2022 This paper reports on a study investigating the MBP implementation challenge in the Swedish healthcare system.There is growing interest in MBPs globally, and they are becoming more commonly implemented in a number of countries’ healthcare services.The ASPIRE study on the implementation of MBPs’ in the UK health service is the most thorough investigation of the factors influencing implementation to date. The findings point to four factors for successful implementation, including (1) careful adaptation of MBCT services to ensure it fits within the local context, by integrating it with existing care pathways, organizational structures and service priorities; (2) drawing on a diversity of evidence to support the drive to implement ; (3) the presence of MBCT implementers, or so-called ‘champions’, who have key leadership or influential roles within the relevant context for implementation, and (4) ‘pivot points’ along the implementation pathway that provided windows of challenge or opportunity . However, even if a psychosocial intervention has a vast evidence-base and is recommended in national treatment guidelines, its value in reality is determined by how widely available it is in the health service. Even in the United Kingdom, where it has been national policy since 2004 to embed MBCT in health service delivery, there is a high variability in the access to MBPs. In the Swedish context, there is a lack of systematized knowledge regarding the provision of MBPs – including the types of programs being provided, the level of training among MBP teachers, and the extent to which programs are available. Also, Swedish guidelines for mental health promotion in the workplace point out that there is a lack of systematized certification procedures and competence criteria for the selection and assessment of MBP teachers in Sweden. Therefore, a systematic approach to investigating the process of MBP implementation in Sweden may inform and optimize the delivery approach going forward.Recently, MBCT and MBSR have been included in the depression treatment guidelines of the Swedish National Board of Health and Welfare. This framework is utilized in health service research and practice to guide implementation, with a focus on understanding the complexities of the transition from evidence to practice. Translation from evidence to practice is generally not a straight-forward process. Practice often lags behind what is known to be evidence-based best practice. In the PARIHS framework, successful implementation is represented as an interaction between (1) the nature and the type of evidence being implemented; (2) the qualities of the context in which it is being implemented and (3) the process of facilitation. The PARIHS framework utilizes a broad perspective on evidence, including rigorous qualitative and quantitative research, practice-based clinical evidence, and patient experiences and preferences. The term context in the framework refers to the setting within which evidence is transferred into practice. Important aspects in this process include culture, leadership and the continuous evaluation of the process of implementation. Finally, the term facilitation focuses on the process of facilitating evidence into practice. This can, for example, occur through the activities of a key stakeholder with the right knowledge and skills to help others in the process of implementation. Altogether, the framework can be used to map factors that are important in enabling successful implementation before, during and after the efforts.The present study is based on the implementation framework ‘Promoting Action on Research Implementation in Health Services’ (PARIHS).The present study has also been informed by the ASPIRE study (see above), which also utilized the PARIHS framework to develop an explanation for MBCT implementation in the UK health service. The aim of the present study is to systematically map the existing provision of MBPs in the Swedish healthcare sector, informed both by the PARIHS framework and the ASPIRE study. Our aim is that the resulting understanding will inform the next steps in the implementation journey both in Sweden and internationally. This was designed to gather data on (1) the evidence-base of practice being implemented; (2) the context in which the implementation was taking place and (3) the process of facilitation. We utilized the survey previously used in the UK study as a base for the present survey, added some modifications to that survey based on findings from the ASPIRE project, and included some more specific questions regarding facilitating and hindering factors for implementation in the Swedish context. The structured web survey consisted of questions with closed answer options as well as open questions allowing participants to elaborate their responses . The survey scoped existing provision and focused on perceptions about MBPs, ascertained views about embedding MBPs into service delivery, including models of teacher training, facilitators, barriers, costs and benefits. Respondents were identified through snowball sampling with key stakeholders. We aimed to include stakeholders from the following groups, in order to provide a broad and nuanced view of MBP implementation: MBP teachers, primary and mental healthcare service managers, commissioners, referrers, regional and county coordinators, and MBP teacher trainers.We assessed experiences of MBP implementation among relevant stakeholders in Swedish healthcare settings. An online survey, based on the PARIHS framework had previously been developed and used in the UK.: Center for Mindfulness Sweden, providing teacher training in MBSR, and Mindfulnesscenter, providing teacher training in an MBP that is a modified version of MBSR, called the Here & Now program. The survey was disseminated though the networks of both of these centers.The survey was e-mailed out to respondents during autumn 2019. We aimed to include commissioners, managers, referrers and service coordinators at regional and county levels as respondents in the study. However, it was challenging to obtain survey responses from other stakeholders than MBP providers and teacher trainers (those who could be regarded as ‘champions’ of MBP provision), despite attempts to reach them via targeted e-mails. Presumably, busy working schedules and time priorities render those more specifically interested in advancing MBP provision more likely to respond to the survey, and others less likely to do so. Therefore, the study findings do not reflect the views of the broader range of stakeholders that we aimed for, but rather mainly of MBP providers and teacher trainers. There are two main providers of MBP teacher training in SwedenOur aim was to include participants from all 21 regions in Sweden, in order to gain a broad geographical perspective on MBP implementation in the country. Within each area, we aimed to begin with a stakeholder who had knowledge of MBP service delivery across their region, and then to snowball out to stakeholders who were involved in the delivery of MBP services, commissioning of the service, use the service or referral to the service. The study had ethical approval from the Swedish Ethical Review Board, approval number 2019-02952.The software used for analysis was IBM SPSS version 26. Descriptive statistics were used to describe the frequencies of the baseline variable categories among the participants as well as other survey responses.evidence being implemented; (2) the qualities of the context in which it is being implemented; and (3) the process of facilitation. For context, prior to presenting the results we summarize the training routes available for MBP teachers in Sweden – see Supplemental Material.1. The evidence-base of practiceThe findings from this survey provide a perspective from MBP teachers and teacher trainers on if and how MBPs are being delivered across Sweden, including the factors that have facilitated and/or hindered its implementation both at the level of commissioning and service delivery. In total, 129 individuals from 20 of the 21 geographical regions in Sweden responded to the survey. The following section reporting the results of the survey is structured by the PARIHS framework: (1) the nature and the type of  and an ongoing commitment to develop its evidence base; whilst, many others were implementing programs that were variations and modifications of the original programs which do not have empirical support.We found that there was broad variation in the types of MBP models that were being implemented see  and 2. SSupplemental Material), information regarding the number of weekly meetings, the weekly meeting length and the assigned home practice is given in 2. The context of implementationThere was a lot of divergence from international norms of good practice in MBP provision. The most common minimum criteria for MBP providers that were required by the work settings was that they have a professional license to practice, and have taken the ‘Here & Now’ stage 1 training. These minimum criteria were in place in 28.7% of the cases (n = 37). The second most commonly implemented minimum criterion in place was having a license to practice as well as a full MBSR or MBCT teacher training . Other work settings had other forms of minimum criterion, or none at all. As regards the level of fidelity to the form of the manualized MBP programs that were implemented  indicated that MBPs had not been implemented in their workplace. The rest of the respondents indicated that MBPs were actively being implemented, but with some variation. The most common response  was that MBPs had been implemented with success, and with good support from the organizational leadership. The rest of those who responded reported that MBPs had been implemented, but with some difficulty: either the MBP did not play a significant role in the workplace and was not supported by leadership ; or implementation was supported by the organization, but funding was an issue or difficulty .3. The process of facilitationThe patient groups that MBPs were being offered to were as follows: Anxiety ; stress ; mild depression ; prevention of depression relapse ; pain  and ‘other’, including trauma, tinnitus, fatigue, burnout, fear of childbirth, sleeping problems, ADHD, and bipolar disorder .Important areas of facilitating and hindering factors to implementation were illustrated through the survey responses as follows. Among the respondents, the majority  thought that there was either no support or not very much support from leadership in their organization for the implementation of MBPs. Among those who agreed to the statement that leadership was supportive of implementation, 38.0% (n = 49) somewhat agreed, and 8.5% (n = 11) agreed fully. The majority of participants expressed that there were no opportunities , or very little opportunities  for professional development and supervision for MBP providers, while others indicated that such opportunities were provided either in part  or fully . The majority of participants were allowed to use their working hours for MBP provision and preparation ; while some indicated that they could not fit this work within their working hours . Administrative support was obtained by the majority, where 39.5% agreed in part and 15.5% agreed fully; while some also indicated that they did not receive administrative support for MBP implementation . Finally, respondents were asked to tick boxes to indicate which facilitating and hindering factors for implementation were relevant for their setting – the results from the responses are summarized in evidence, context and facilitation.Here, we examine the survey findings within the structure of the PARIHS framework:  and a commitment to developing the evidence going forward.The findings revealed that there was broad variation in the types of programs being implemented, and that the level of fidelity to evidence-base programs such as MBSR and MBCT was frequently low, with modifications such as the length and number of sessions and the amount of home practice being assigned. Although the programs that were being implemented draw on the wider evidence for MBPs, the specific adapted programs do not have research support. The exception to this is the Here & Now program which is a Swedish adaptation of MBSR that has preliminary evidence, These factors were all issues that the Swedish implementers were facing. Implementers are navigating the tension between delivering evidenced-based interventions with high fidelity within organizational settings that are often not able or willing to release the level of resources needed for gold standard delivery vs reducing the ‘dose’ of the intervention and therefore, the resource demand to overcome organizational barriers.Ensuring a good ‘fit’ between the program and the delivery context was a key recommendation from the UK ASPIRE research. This process involves the alignment between the intervention and context, including efforts to make the intervention fit with existing local service strategies, priorities, pathways, resources and the ethos or culture of the service. Also, a good fit requires recognition of national and service performance targets and alignment with managers’ and service users’ needs and interests. A stepped care model for implementing mindfulness might involve a number of tiers depending on symptom severity.One helpful way of approaching the challenge of the tension of the benefits of high fidelity/high resource interventions vs lower dose/lower resource interventions is a ‘stepped care’ implementation model. However, to date there is not enough evidence to guide the implementation of MBP in stepped care formats, rolling admissions or shorter sessions. In the Swedish context, there appears to be a lack of provision of the full evidence-based programs MBSR and MBCT as recommended in the national guidelines. Also, from the results of this survey, it is unclear whether the modifications of the programs have been conducted in response to patient needs, or whether such modifications are instead guided by situational and contextual factors unrelated to patient needs.Indeed, from our findings, it appears that the beginnings of a stepped care approach are being implemented, with many shortened and adapted versions of evidence-based programs being in place. Also, other researchers have suggested additional ways in which MBPs could be modified to fit context, including open or rolling admission groups where both newcomers and prior attendees can attend any treatment session, or by shortening treatment sessions.). These guidelines include attendance at silent mindfulness meditation retreats as part of the teacher training – something that is not included in for example the Here & Now stage 1 training, which we found to be most broadly implemented. Our finding here again mirrors those from the ASPIRE study, where teacher training levels could vary from simply reading the MBCT manual, to having completed full training pathways. Indeed, Crane and Kuyken have based on their findings in the UK, detailed some key aspects to ensuring the quality of professional MBP training, and these include (a) the content, method and process of MBP teacher development and training; (b) good practice standards and (c) the definition of skills needed to teach mindfulness groups. These aspects seem not to be systematically in place in the clinical settings in Sweden that were studied through the present survey. However, good practice guidelines are in place in the UK, for instance, and they could provide a basis to delineate more clearly what would be best practices for the Swedish context.From our findings, it appears clear that training of MBP teachers overall is not in line with international guidelines for good practice established by a consensus of trainers working globally . This pattern is somewhat different from the one described by Crane and Kuyken in the UK, of MBP implementation, due to primary care being an accessible gateway into the healthcare system. Additional services where implementation was taking place ranged from hearing care, maternal health care, youth care centers and pain and rehabilitation clinics. The implementation of MBPs for some of these patient groups is not fully in line with what is recommended in the national guidelines or supported by research evidence for MBPs. Therefore, our findings indicate that the implementation of MBPs in Sweden may in some places be rushing ahead of the evidence – in similar ways that have been discussed in international research.Mindfulness-Based Programs were being implemented in a broad range of services beyond psychiatry and primary health care from depression and anxiety as suggested by the national guidelines. The main service of implementation was primary care, and this is indeed in line with suggestions made by Demarzo et al the main facilitating factor for MBP implementation indicated by our survey participants was the presence of a championing individual. The ASPIRE findings elucidate that some particular characteristics of these champion individuals are particularly important. These include status within the organizational hierarchies as well as social skills, and they were often self-designated individuals who ‘championed’ grass-roots implementation. Our findings in the present study do not provide detail about the particular characteristics of these championing individuals that are deemed important in the Swedish settings. This would be a useful line of inquiry for the future. The second most important facilitating factor indicated by our participants was support from leadership. In terms of hindering factors for implementation, lack of time was indicated most frequently, followed by lack of funding.In line with the ASPIRE findings,A strength of this study was that it spanned all but one region in Sweden, thus providing a relatively good geographical representation of the whole country. Also, the respondents worked in various forms of healthcare services, thus providing a broad picture of the various implementation settings. A clear limitation, however, is that the survey responses came mainly from MBP providers, that is, so-called ‘champions’. In order to gain a clearer and fuller picture of the facilitating and hindering factors for implementation, the view of service managers, coordinators and referrers is also needed. We did aim to survey these groups of respondents but did not receive any responses despite e-mail reminders. Presumably, busy working schedules and time priorities render those more specifically interested in advancing MBP provision more likely to respond to the survey, and others less likely to do so.As of yet, in Sweden, MBP strategy appears to be in place only at the national level in the form of guidelines. Our study did not show evidence of the existence of more regional or local strategies, as the actual implementation appears patchy and versatile. Our findings indicate that MBPs are being implemented in various healthcare contexts and modified in various ways, which raises questions about intervention fidelity and integrity. Also, future research that addresses the question of ‘dose-response’, for example, for patients with less severe symptoms, as shorter or less intensive forms of MBPs may be more suitable for broad implementation in a number of settings. Since time and funding are indicated as main hindrances for implementation, the development of evidence-based stepped care models may ensure high quality implementation for those patients who would most benefit from MBPs, while patients with less severe symptoms could benefit from ‘lighter touch’ programs. In summary, taking the long view and setting good practice guidelines for MBPs seems to be pivotal for good quality implementation of MBPs in Swedish healthcare settings.Click here for additional data file.Supplemental Material, sj-pdf-1-gam-10.1177_21649561211049154 for The Implementation of Mindfulness-Based Programs in the Swedish Healthcare System – A Survey Study of Service Providers by Maria Niemi, Rebecca Crane, Jermo Sinselmeijer and Susanne Andermo in Global Advances in Health and Medicine


Care personalization is key to the well-being of people with dementia according to person-centered care. With the development of the internet of things, a large quantity of personal data can be collected securely and reliably, which has the potential to facilitate care personalization for people with dementia. Yet, there are limited assistive technologies developed for this purpose, and the user acceptance of assistive technologies is low in nursing homes. Therefore, through a data-enabled design approach, a digital platform was developed for helping the care team in a nursing home to personalize dementia care, specifically in the management of behavioral and psychological dementia symptoms.This study aimed to evaluate the digital platform in a real-life context with potential users from the following two aspects: (1) to explore if the digital platform could help with generating insights on the current state of each person with dementia and (2) to gather feedback on the digital platform from the care team.The digital platform was deployed in the nursing home for 7 weeks and the data collected were visualized and presented to the care team via the digital platform. The visualizations were analyzed by the researchers for pattern detection. Meanwhile, the care team was asked to examine the visualizations and were interviewed for the following: (1) if any insights and actions were generated from the examination, (2) the usefulness of the digital platform, and (3) the improvements they would like to see.The data collected on the digital platform demonstrated its potential for pattern detection. Insights were generated by the care team and categorized into “client level,” “ward level,” and “team level.” The corresponding actions taken by the care team were classified into “investigation” and “implementation.” User acceptance varied across the care team, and three aspects of improvement for the digital platform were identified.By evaluating the digital platform, this study gained insights on applying data-enabled design for personalizing dementia care; besides, it offers future researchers some recommendations on how to integrate assistive technologies in the nursing home context. Dementia has physical, psychological, and social impacts on affected people, their caregivers, and their families, and it is an economic burden to the society at large . The “peOver 80% of people with dementia will develop BPSD during the course of their disease , and 90%Over the years, low-cost sensors, wearables, electronic health records, and artificial intelligence have been deployed in the health care setting to collect and analyze data about an individual in terms of his/her physical condition, living environment, lifestyle choices, etc . ResearcPrevious attempts have explored the application of data-driven assistive technologies in the field of cancer care , physiotIn our prior work, we involved the care team from a Dutch nursing home and developed a digital platform for personalizing BPSD management via a data-enabled design approach. Data-enabled design is about using quantitative data from sensors and qualitative data from users in the field as creative design material to inspire and inform the design process . These dWe positioned this digital platform as an assistive technology to facilitate the care team in personalizing BPSD management. Studies from the perspectives of care research ,29, anthThis study aimed to (1) explore if the data visualizations of the digital platform could help with generating insights into the current state of each person with dementia and (2) gather feedback on the digital platform from a care team after deployment in a nursing home for a longer period of time. In this way, it builds on our preceding work by investigating the interplay of the digital platform and the care team in a longer time frame to explore the opportunities and challenges for personalizing BPSD care with assistive technologies in a real-life context among potential users.In our prior study, an Indoor Positioning System (IPS) was deployed in one of the nursing home sites of Zorggroep Elde Maasduinen in the Netherlands to collect continuous location data from the residents and the professional caregivers (hereafter the caregivers). Zorggroep Elde Maasduinen is a large-scale organization for the care of older adults in the south of the Netherlands , with muThe Oleander was selected to be the development site of the digital platform since it offers a typical case of BPSD management in an institutional setting. The IPS was hence deployed in the Oleander with the consent of all the legal representatives of all the residents and all care team members. Contextual information concerning the culture of the nursing home, the ward ambiance of the Oleander, and the working structure of the care team is provided in The study protocol was approved by the Human Research Ethics Committee of Delft University of Technology and the Board of Directors of Zorggroep Elde Maasduinen . Meanwhile, qualitative data about each resident  were collected to contextualize the location data. How might the digital platform help with personalized BPSD management is illustrated with a few envisioned scenarios in In this study, a longitudinal design was employed. As demonstrated in the previous section, evaluating the digital platform for BPSD management in the Oleander constituted a macro case study. Within the macro case study were nested micro case studies, and each micro case study was about one person with dementia. The sampling strategy of this study was a combination of typical case sampling and criterion sampling. Regarding typical case sampling, a broad consensus about what is typical was achieved via a discussion involving the research team and care team. All 10 residents in the Oleander were identified as exhibiting typical BPSD. Within these residents, the legal representatives of eight residents with dementia signed the consent form. Three residents showed signs of dislike toward the tags, and they were excluded from the study. Two participants dropped out later because of signs of dislike toward the tags. Thus, three participants completed the study, resulting in three micro case studies. The three people with dementia were two females and one male. Moreover, one had vascular dementia, one had Lewy body dementia, and one had Alzheimer disease. Based on the information from the care team, all three people with dementia were in the later stages of dementia, as supported by their Mini-Mental State Examination scores. Basic information about these three people with dementia can be found in Specifically, in week 1, an introduction was given to the participants, and the IPS was tested for its functionality. In weeks 2 to 8, the residents and caregivers wore tags for collecting their location data in the ward in everyday life. The caregivers wrote daily reports and gave a color code on the perceived stress levels of the people with dementia . For minimizing the workload of the care team, these tasks were designed to be as close as possible to the working routine of the care team. As for the daily report, it was part of the working routine of the care team. The daily report usually recorded when and where the person with dementia got stressed, what did he/she do, and what did the caregiver do to reduce his/her stress. Once a report was written, caregivers could select a category for the report to be uploaded to the system . These reports were shared with other members of the care team, which could sometimes result in additional remarks and editing. The stress rating was done with the Crisis Development model (Crisisontwikkelingsmodel in Dutch) , which iIn week 9, both quantitative and qualitative data were visualized on the digital platform. Since this study spans a longer period of time, new types of visualizations were created on the digital platform for conveying the large amount of collected data effectively. Once the visualizations were done, a notification was sent to the caregivers to start the data examination. This is because the user scenario adopted was as follows: “the responsible caregiver examines the visualizations and discusses his/her findings with other team members in a care plan meeting” (refined based on a previous study ). Hence,The categories of data collected and their collection times in this study are summarized in Three analyses were performed to fulfill the research goals outlined above. The first analysis examined the availability and utility of the data collected by the digital platform. The second analysis investigated what types of insights and actions, if any, could be generated by the care team via using the digital platform. The third analysis studied the perceived usefulness and desired improvements regarding the digital platform.Concerning the transferability of this study, we followed the strategies by Polit and Beck , which rThe aim of this analysis was to determine whether the digital platform could collect adequate data for the intended purpose of identifying behavioral patterns. With “adequate,” we implied the amount of data that could enable behavioral patterns to be revealed via visual inspection. Visual inspection, sometimes referred to as visual analysis, is the most widely used and recommended method for interpreting single-subject data ,39. ThisThe researchers examined the data availability by checking the proportion of the study period for which data were available for each person with dementia. Visual inspection was then applied to identify whether behavioral patterns could be revealed for each person with dementia. If behavioral patterns were found, these findings would be validated with the care team. Three types of visualizations were created in the end, namely, tile plots , includes (1) day structure according to care plan, (2) moments of unrest, (3) unusual movement trajectory, (4) behavior change over time, (5) physical activity over time, and (6) effect of medication. The second theme, ward level, includes (7) interaction with caregivers, (8) interaction with other people with dementia, and (9) dining environment. The third theme, team level, includes (10) more detailed reports, (11) tag usage, (12) behaviors of caregivers, and (13) workflow. These themes and subthemes of insights are presented in Except for the manager, the rest of the care team participants wanted to take some actions based on the insights they uncovered. Their intended actions were grouped into six subthemes that are under two themes. The first theme, investigation, includes (1) discuss causes behind insights, (2) monitor day structure, and (3) evaluate changes in care plan. The second theme, implementation, includes (4) change in care plan, (5) work practice, and (6) prediction. These themes and subthemes of actions are presented in The feedback of the care team participants on the usefulness of the digital platform for their work was categorized according to their professions. Their feedback is summarized in The care team participants formulated 23 key areas for developing the digital platform further. These were grouped into 10 subthemes that are under three themes. The first theme, data collection, includes (1) more types of data, (2) define whose data to collect, and (3) reliability of stress rating. The second theme, data visualization, includes (4) personalized parameters, (5) filter data by time, and (6) less clicking. Finally, the third theme, data examination, includes (7) reduce the examination time, (8) who should examine the data, (9) develop an examination workflow, and (10) automatic notifications. These themes and subthemes of areas of improvement are presented in By evaluating the digital platform in a real-life context with potential users for 7 weeks, this study gained insights on applying data-enabled design for personalizing dementia care in a nursing home. The results demonstrated the potential for the data visualizations in the digital platform to reveal behavioral patterns despite the missing data. In addition, we identified three main types of insights generated from data analysis, two main types of corresponding actions, the perceived usefulness of the digital platform, and three areas for its improvement.The results showed that integrating the digital platform into the nursing home environment might offer an opportunity for the care team to uncover the behavior patterns of the residents and personalize care plans accordingly.A study on adapting mobile and wearable technology to support and monitor rehabilitation for people with dementia in the home environment has discussed that the monitoring approach could replace traditional methods for behavior analysis  with four advantages . The finThe workload of the care team members might decrease in the long term as they gain experience with managing the tags and examining the visualizations. Meanwhile, the future development of the digital platform should focus on autonomizing some tasks for the care team. Moreover, BPSD management contributes to a high percentage of caring workload , and theThe three main types of insights generated after data analysis were at the client level, ward level, and team level. Even though the initial aim of introducing the digital platform was to collect data that are unique to each individual, the care team generated insights that were not limited to the clients. This is because the context in which a person with dementia lives is also an important part to consider when personalizing dementia care, which reveals the importance of context in personalized dementia care. We recommend that future researchers and developers pay attention to this.Although the types of insights and the types of actions were categorized in the Results section, they were interrelated in various ways. A tentative overview of the interrelations among them is shown in Zooming out from the “types of insights” in These types of insights and actions together with their interactions could also be applied in evaluating assistive technologies in other contexts of personalizing dementia care in nursing homes. We hence encourage future researchers and developers to use The people with dementia, caregivers, doctor, psychologist, dietitian, and manager were among the key stakeholders for the digital platform. Previous studies have found that caregivers’ acceptance of assistive technologies is vital for successful integration and usage of these technologies in nursing homes . We woulTo manage the competing needs stemming from different stakeholders, we recommend future studies to apply a multicriteria analysis to prioritize the stakeholders involved . For exaWe postulate that the three main areas of improvement identified for the digital platform, namely, data collection, data visualization, and data examination, are interconnected to each other. Their tentative connections are shown in Through the evaluation of the digital platform, we also learned about the value of data-enabled design in personalizing BPSD management. First, we experimented with the frequency and duration of collecting different types of data to explore the qualities and limitations of data as design material, as suggested by Bogers and van Kollenburg (who coined data-enabled design) . In thisIn addition, we adapted data-enabled design in several aspects to fit it in the dementia care context. First, even though one of our key stakeholder groups, people with dementia, was not involved in the data examination and interview sessions owing to cognitive impairments, we paid attention to their nonverbal behaviors when introducing the tags to them. Residents who showed signs of dislike toward the tags were excluded from the study, although their family members had signed the consent forms. We then included “design the tags to be more dementia friendly” on the to-do list. We found that more relevant design directions could be generated by combining data-enabled design with close observations of people with dementia (a way of co-designing with people having dementia ). In conSecond, the data-enabled design approach was initially developed for designers to gain rich insights for their design projects. As stated by Bogers and van Kollenburg, “the aim of this approach is to, together with end-users, unravel the relevance, potential, and pitfalls of data in a specific context to design concepts that resonate” . In our Finally, if one would like to apply data-enabled design in the dementia care context, an evaluation of the designed product  in the longer term is important. Both The main limitation of this study was that all the interviews were conducted in a one-to-one format. This is because finding a time slot suitable for all the participants was difficult given the fast pace and high uncertainty of the working environment in the nursing home. A potential shortcoming of this format is the lack of discussions within the care team, which might have stimulated more ideas during the interviews. The benefit of this format is that each participant can express his/her own views and interpretations without being influenced by other participants. The strengths of this study were that the digital platform was deployed in a real-life context and a wide range of stakeholders with different professional backgrounds was involved. Previous research has found that the use of different professionals’ perspectives is valuable in developing assistive technologies for people with dementia -53.For future work, the digital platform could be improved based on the feedback from the care team. For instance, regarding reducing the data examination time, the manual process of data visualization is planned to be automated by algorithms. In addition, further algorithms could be developed for pattern analysis  and for making predictions. The results of the algorithmic analysis could then be presented in the form of push notifications, with which relevant visualizations will be provided.Moreover, it would be interesting to investigate if combining different types of visualizations could generate more insights. Although all three types of visualizations were sent to the care team at the same time, all participants discussed the visuals one by one, which indicates that combining visualizations might not have been explored during the data examination process. It could be that there was no explicit instruction for exploring visuals in a combined way, or all participants did not see added value when combining these visuals; therefore, these explorations were not mentioned in the interviews.In this study, we presented an in-depth investigation with a care team that was insightful in understanding the value of the digital platform and the application of data-enabled design in developing assistive technologies for personalizing BPSD care. We, therefore, suggest researchers and developers consider this case study approach in the development of future assistive technologies for personalizing dementia care.This study was carried out during the lockdown period in the Netherlands because of the COVID-19 pandemic. At the beginning of the project, the research team  went to the nursing home to introduce and discuss the study both at the management level and at the ward level. The principal researcher (GW) then spent a few months developing the digital platform with the care team. When the nursing home shut down because of COVID-19, the principal researcher stayed in touch with the care team via email, Skype, and Zoom. In this way, the research team collected all the data without going to the nursing home and conducted the interviews online with the care team. In hindsight, this digital platform has the potential to help care team members and researchers gain insights about each person with dementia remotely, which might be valuable in case of the current pandemic and future pandemics. In addition, the family members of people with dementia could benefit by using the digital platform to stay updated about the situation of their loved ones in the nursing homes remotely, which could decrease the already high communication workload of the care team during a pandemic.By evaluating the digital platform developed, this study gained insights on applying data-enabled design for personalizing dementia care, specifically in BPSD management. The collected data demonstrated potential use for pattern detection. The types of insights and actions generated from using the digital platform were identified and found to be interconnected. The perceived usefulness of the digital platform was found to vary across the care team, and we uncovered three aspects of improvement for the digital platform. These findings could guide future researchers and developers in investigating similar assistive technologies for personalizing dementia care in nursing homes and beyond.


The prevalence of mobbing among nurses in various countries is around 17–20%. Some researchers have attempted to explain the success or failure of adaptation to the work environment and teamwork and to buffer the effects of psychological harassment in the workplace by incorporating emotional intelligence into the mobbing context. As its main objectives, this quantitative, observational, cross-sectional study analyzed the relationship between emotional intelligence and mobbing as perceived by nurses and sought to establish the mediating roles of other variables involved, such as social support and sensitivity to anxiety. The final sample consisted of 1357 Spanish, self-selected nurses aged 22–58 from multiple healthcare institutions. The questionnaires  were implemented on a web platform, which enabled the participants to complete them online. Descriptive analyses and mediation models were estimated. Personal characteristics related to high sensitivity to anxiety and low emotional intelligence implied greater presence of mobbing at work. This mobbing may be buffered if the person perceives enough support from family, friends or significant others. Our results recommend reinforcing the social support network of nursing personnel to improve the work climate and training them in emotional intelligence in university and on-the-job programs. Mobbing refers to the phenomenon by which one or several persons in the workplace exert extreme psychological harassment toward another or others by destroying their communication networks and their professional reputation and impairing their physical or psychological health so that they quit their jobs . Thus, mIn Spain, the latest Cisneros report stated that over 34% of nursing personnel had experienced psychological mobbing in the workplace . HoweverIn view of the above, a change in how a representative percentage of these healthcare professionals relate to each other would be indispensable. It is also urgent to improve interpersonal relations and provide a common space in the workplace for them to meet to contribute to the positive development of the organization and its members, more so because their work deals basically with improving the health of others, for which good psychological adjustment is an indispensable requirement ,11,12,13Mobbing may be attributed to a variety of causes. The most accepted explanatory models of mobbing at work by Leymann , HirigoyEmotional intelligence may be defined as a set of personal and interpersonal emotional skills which influence one’s capacity to cope with environmental demands and pressures . The valSimilarly, according to Leymann , and in Thus, keeping in mind our research objectives, the hypotheses of this study were:Hypothesis 1 (H1):Different profiles can be identified based on emotional intelligence component scores, with differences in social support, sensitivity to anxiety and perceived mobbing.Hypothesis 2 (H2):An emotional profile with scores below the mean is positively related to perceived psychological harassment.Hypothesis 3 (H3):Perceived social support acts as a mediator (protective effect) in the relationship between the emotional profile and perceived mobbing.Hypothesis 4 (H4):Sensitivity to anxiety acts as a mediator (risk effect) in the relationship between the emotional profile and perceived mobbing.Hypothesis 5 (H5):Social support reduces the harmful effect of sensitivity to anxiety on the relationship between the emotional profile and perceived mobbing.n = 1357 nurses aged 22–58 , the majority being women . At the time of data collection, 23.1% were working under a permanent contract, 72.2% (n = 980) temporary, and the remaining 4.7% (n = 64) were unemployed.The original sample consisted of 1377 Spanish, self-selected nurses. Twenty questionnaires were discarded due to incongruent or random answers to the control items included. Thus, the final sample was An ad hoc questionnaire was prepared to collect sample sociodemographic data  and information on their current employment status.The Perceived Psychological Harassment Questionnaire (CAPP)  evaluateThe Brief Emotional Intelligence Inventory (EQ-i-20M)  is an adThe Brief Perceived Social Support Questionnaire (CASPE)  consistsThe Spanish version of the Anxiety Sensitivity Index-3 (ASI-3)  by SandíSpanish healthcare centers and scientific societies distributed the survey among their members in their bulletins by email, social networking sites, etc. The questionnaire was implemented on a web platform, which enabled the participants to complete them online during the last quarter of 2019. A series of control questions were included to be able to identify random or incongruent answers, and these cases were discarded from the study sample. The survey was also distributed on social networks , thereby acquiring access to nurses who were not working at the time of data collection.Before data were collected, participants were guaranteed compliance with the standards of information, confidentiality and ethics in data processing. Participation was voluntary, and, on the first page, before starting to answer the questionnaire, relevant information on the study and its purpose was provided. The participants gave their informed consent by marking a box designated for the purpose, which then allowed them to continue with the questionnaire. The Bioethics Committee approved the study (Ref: UALBIO2019/031).The study design was quantitative, observational and cross-sectional. First, to identify the relationships between the study variables  and perceived mobbing, the Pearson’s correlation coefficient was calculated in addition to the corresponding descriptive statistics.t test for independent samples, with a significance level of 0.05, and the Cohen’s d  and 3 , the data suggest that Path 1  was the most important.Then, the analysis of indirect effects was carried out using bootstrapping. Even though the effect of emotional intelligence was statistically significant through Paths 2  and , while the difference between indirect effects was not statistically significant .To estimate the importance of each of the paths, contrast or comparison tests of the mediators were applied. The results found that there were statistically significant differences in the contrasts of the indirect effects [IndThis study found significant associations between the components of emotional intelligence and perceived social support. The higher the score on the interpersonal, mood and adaptability components was, the higher the perceived social support available to nursing personnel, with a large effect size in all the correlations. Data compatible with these were found by Montes-Berges and Augusto  and, morIn the relationship between emotional intelligence and sensitivity to anxiety, the stress management component correlated significantly negatively with the global sensitivity to anxiety score and, in particular, with the cognitive anxiety score, with a large effect size. The findings of other researchers have related higher tolerance and stress management to lower perceived anxiety, where emotional intelligence usually exerts a mediator role between sensitivity to anxiety and manifestation of stress or anxiety symptoms ,34. KillAnother of the objectives of this study was to explore the different emotional intelligence profiles in nursing. The cluster analysis found two profiles based on the emotional intelligence components, which were related to perception of psychological harassment in the workplace and to sensitivity to anxiety.The first group (38.7% of the sample) comprised nurses with high scores in the intrapersonal, interpersonal, stress management, adaptability and general mood components of emotional intelligence. The second, larger (61.3%) group was made up of nurses with low scores in these emotional intelligence components. The contrast tests between the two groups of nurses and psychological mobbing or sensitivity to anxiety showed that the first group of nurses, with higher scores in emotional intelligence, also scored lower in perception of psychological harassment and perceived fear/anxiety than the second group. High scores in emotional intelligence were associated with low scores in mobbing and sensitivity to anxiety. In this vein, some authors have suggested that improvement in emotional competence could reduce mobbing , perhapsThis study also met its objective of developing a mediation model for mobbing in nursing, considering the existence of a significant relationship between emotional intelligence profiles and psychological harassment in the workplace, which included the role of the sensitivity to anxiety and perceived social support psychological variables. Our results showed that perceived social support and sensitivity to anxiety were mediators in this relationship between the variables in the healthcare context, although perceived social support acquired more importance. Thus, perceived social support acted as a buffer in the relationship between emotional intelligence and mobbing. Several of the studies reviewed also found a role of social support in mobbing ,47 in suThis study went one step further, showing the mediator role of social support in a concrete model and demonstrating its relationship with mobbing. Social support is, then, once more, very important in the relationship established between nurses’ emotional intelligence and mobbing, mediating and strengthening its effect.Some limitations should be kept in mind. Firstly, the sample was made up of a majority of women, and, although this is a reflection of the professional profile, the results may not be generalizable to both sexes. Self-report measures were used in the evaluation of both social support and mobbing ,55,58, wA future line of research will be to study how much is explained by personal variables, such as the role of positive and negative affect, tolerance to frustration and stress coping mechanisms, as well as continuing with the study of preventive strategies and characteristics that strengthen the organization to avoid circumstances associated with mobbing and its high psychological and economic costs. Finally, not forgetting the organizational side, we propose meeting spaces, which would favor work relations, training programs for acquiring emotional intelligence competencies, among many other activities in the organization to promote social support and staff relations. It would also be of interest to check whether the mediation model proposed can be applied to other groups where there is a high prevalence of mobbing, such as among workers in large companies.The results of this study have implications for professional practice, leading to both prevention of mobbing in the workplace and intervention when it occurs. Our results advise reinforcing the social support network of nursing personnel to improve the work climate, with the organizational and personal measures that this involves, and reinforcing the emotional intelligence of nurses through university and on-the-job programs . We agreThese findings have important implications for understanding psychological harassment in the workplace. Keeping in mind the severe psychosocial consequences of mobbing at work, these data underline the urgent need to contribute to the positive development of the organization and its members by improving interpersonal relations and providing a place for staff to interact.High sensitivity to anxiety and low emotional intelligence are associated with a greater presence of mobbing at work. Mobbing can be buffered if the person perceives sufficient support from family, friends or significant others. Therefore, contributing to social support as a protective factor and reducing sensitivity to anxiety as a possible risk factor are the two main lines of intervention derived from this study. We also suggest continuing with the study of the role of positive affect and satisfaction in the workplace as possible mediators in the relationship between emotional intelligence and mobbing.


Obsidian, originating from the Rocky Mountains and the West, was an exotic exchange commodity in Eastern North America that was often deposited in elaborate caches and burials associated with Middle Woodland era Hopewell and later complexes. In earlier times, obsidian is found only rarely. In this paper we report two obsidian flakes recovered from a now submerged paleolandscape beneath Lake Huron that are conclusively attributed to the Wagontire obsidian source in central Oregon; a distance of more than 4,000 km. These specimens, dating to ~ 9,000 BP, represent the earliest and most distant reported occurrence of obsidian in eastern North America. Obsidian, or volcanic glass, is a prized raw material for knappers, both ancient and modern, with its lustrous appearance, predictable flaking, and resulting razor-sharp edges. As such, it was used and traded widely throughout much of human history. Since obsidian has unique, identifiable chemical signatures, it has also played an important role in the documentation and analysis of ancient exchange networks in places as diverse as the Arctic, the Eastern Mediterranean, Southeast Asia, and Mexico –6.Within the continental United States and Canadian provinces, the principle sources of obsidian are found in the Pacific Northwest, as far east as South Dakota; and in the Southwest, particularly in Arizona and New Mexico –9. WhileGiven this established pattern of spatial and chronological distribution, the discovery of two obsidian flakes attributable to ~ 9000 yrs BP from the bottom of Lake Huron is unprecedented. The fact that both specimens are unambiguously derived from the Wagontire source in central Oregon, a distance of ~4,000 km, is extraordinary. These specimens represent the oldest and farthest east confirmed occurrence of western obsidian in the continental United States. In this report we document the context of the find, describe the specimens, and present the detailed compositional data that allows the specimens to be linked to their central Oregon source.Over the past 18,000 years water levels in the North American Great Lakes have fluctuated significantly. These dynamic water levels, coupled with isostatic rebound since the last ice age, exposed and then submerged vast areas of land . At the The obsidian artifacts were recovered from sample DA-1 comprised of 3 litres of sediment that was hand excavated at a depth of 105’ ft (32 m) in an area between two identified hunting structures, TV-1 and V-Cluster . RadiocaTwo small flakes were recovered from sample DA-1  and 3. BThe second specimen (laboratory number 105–2) is a small, very thin, translucent flake on a material visually similar to the larger specimen. The morphology is consistent with light percussion flaking on a biface. The flake has a ventral and dorsal face, but no platform. It is likely that this flake detached along with another flake during bifacial refurbishment.The small size and technological character of the obsidian flakes suggest they represent a fairly delicate biface refurbishment episode. The flakes do not display obvious evidence of use as tools themselves. Given their spatial association, raw material, and technological character, it is likely that these two flakes are from the same bifacial tool and were produced as a byproduct of a single resharpening event.Field Museum and analyzed using a Bruker TRAcER III-SD portable XRF apparatus, and the identification of obsidian was confirmed. The North American geological database at the Field Museum was not robust enough to identify the obsidian source for the specimens so the samples were transferred to the Northwest Research Obsidian Studies Laboratory. There the samples were analyzed with another XFR, confirmed again as obsidian with a likely source area of Central Oregon.Lithic materials recovered from the Lake Huron archaeological sites are typically fashioned on chert cobbles collected from local glacial deposits . The twoUniversity of Missouri Research Reactor center (MURR) where analysis was conducted using only short irradiation NAA. This method allowed comparison with the laboratory’s global database of sources and focused on an additional set of elements not accessible to XRF. More specific information on the materials and methods of underwater sample recovery and processing as well as NAA procedures can be found in Given the remarkable distance between the find spot and the apparent source as well as the limitations of XRF analysis, the samples were further analyzed with a complementary method, neutron activation analysis (NAA). As the Lake Huron samples were small and potentially unique, the excavators were unwilling to undertake destructive analysis. As such the samples were transferred to the Northwest Research Obsidian Studies Laboratory are presented in The results of analysis using energy dispersive x-ray fluorescence (EDXRF) at the The NAA results were compared to the entire database of sources at MURR, including almost every known source worldwide. The only possible match was Wagontire. As such, the identification of both artifacts as obsidian was independently confirmed by three laboratories and two methods, while the specific sourcing of the artifacts to Central Oregon was confirmed by laboratories using both high definition XRF and NAA, and the specific source, Wagontire, was determined by NAA and comprehensive comparison to global obsidian sources.The Lake Huron finds represent both the earliest and most easterly occurrence of western obsidian in the continental United States that have been recovered from a secure archaeological context. It is worth noting in this regard that this is the first documented archaeological context for Wagontire obsidian outside the state of Oregon. It is likely these artifacts were deposited as the result of a single event of biface refurbishment, suggesting a high level of curation. Yet, while clearly exotic, it is noteworthy that they are attributable to a relatively routine activity in a kill area and do not occur as part of any special or ritual context. The extreme distance between source and find location raises renewed questions concerning the scale of mobility and social connectedness during the Pleistocene-Holocene transition.While it is notoriously difficult to parse out the specific means for the long-distance movement of goods among mobile foraging populations , it seems probable that these specimens arrived in the Great Lakes through multiple hands, rather than through any direct access to the central Oregon obsidian source.The artifacts reported therefore likely reflect the existence of continent-wide social networks that extended west-to-east across the recently deglaciated landscapes of North America at the end of the Pleistocene. In other geographic areas, e.g. Alaska, it has been noted that recently deglaciated landscapes are productive new lands which were often exploited by small, highly mobile bands utilizing a miniaturized lithic technology with micro-blades –31. WhilGiven the evidence at hand, we cannot determine whether the obsidian came to the Great Lakes as a chance event or was part of a more frequent and regular occurrence. While the finds likely reflect the existence of an extensive network of contacts along recently deglaciated landscapes at the end of the Pleistocene, it is impossible to know whether the Lake Huron peoples actually knew where the exotic stone came from. What we can say with confidence is that there is no plausible natural process that can account for the presence of the obsidian flakes in this location.The Lake Huron finds fit within the broader, global context of obsidian movement generally, and the long-distance movement of raw materials in Late Pleistocene North America more specifically. The Lake Huron specimens date to the Late Pleistocene/Early Holocene in North America, a time of Paleoindian occupation–an archaeological culture which is known for the long-distance movement of high-quality tool stone ,38,45. WOverall, the recovery of these specimens from beneath Lake Huron is significant, as it represents a secure archaeological context and underscores the remarkable potential of underwater investigations. It is likely that additional research underwater, as well as targeted research on land, will further elucidate the character of Terminal Pleistocene/Early Holocene exchange networks. Regardless of the flakes’ use and the frequency of these interactions, the materials themselves represent trans-continental connections spanning from the West Coast to the Great Lakes. These specimens provide greater resolution, as well as greater complexity, to an important and poorly understood time period in the North American past.S1 Table(DOCX)Click here for additional data file.S1 Text(DOCX)Click here for additional data file.


The most common chronic disease affecting children in Canada is dental caries. The objective of this study was to explore, identify, and address the strengths and barriers related to oral health services with an independent Indigenous community in Saskatchewan.Community-based participatory research used interviews with Elders, health care providers, teachers, and parents/guardians of elementary school-aged children. The research focused on the development of genuine partnerships with the community. During data collection, the findings/results were returned to the community to establish direction, build success, and establish next steps. Thematic analysis was undertaken with the community. Descriptive statistics were analyzed using SPSS.The most commonly identified themes included: community resilience; the need for resource development and process to improve oral health literacy and skills; and how access to care barriers dually affected and related to personal and community cost, time, and human resources.The research process involved the co-creation of tools to identify strengths within the community and drive opportunities for change; subsequently generating solutions to the practical problems and potentially transform the health system accessed by the community. Although dental caries is common in Canadian children today, there is evidence that it was not always as prevalent in Indigenous communities –4. ArcheOral health impacts general health and quality of life and there is increasing evidence of a direct link between oral and systemic disease(s) . Early cThe Canadian Academy of Health Sciences’ (CAHS) Report  on the iThe Federal Government funds health transfers to the provinces and territories via the Canada Health Act. For the most part, oral health falls outside of the Canada Health Act; consequently, there is considerable variation in services, continuity of programming and portability of benefits from one province or territory to another . ServiceThis study explored the perceptions of Indigenous community members on the impact of oral health on children in Canada. This included the current practices in implementing health promotion, prevention, and treatment to improve the oral health status of children in an Indigenous community. The study also examined the barriers that parents and the community perceived exist to accessing basic health promotion, prevention, and treatment of oral health resources in children. Based on the services currently available, further implementation of programs that address oral health in meaningful ways were also explored with the community members.The Community: Thunderchild First Nation is an independent Cree First Nation in Saskatchewan, Canada and is located approximately 113 km northwest of North Battleford, SK . This FiThe researchers, along with the Thunderchild Advisory Board, formalized the proposal and the Application for Behavioural Ethics Review. Once the content was agreed upon, the proposal was submitted to the University of Saskatchewan’s Behavioural Research Ethics Board for consideration and approval. It was approved on August 22, 2017 (Beh 17-305).Community leaders helped to identify and invite participants that met the inclusion criteria to participate in the research project . The ThuDescriptive statistics were analyzed using the Statistical Package for the Social Sciences (SPSS v17) to provide a profile of those that participated in the research project. Each participant was given an opportunity to review the written copy and modify the content following the interview. The interviews were transcribed, and an inductive, thematic analysis undertaken with the community . The datTwenty-eight community members participated in the survey. The majority of participants were female 23/28; 82%) between 40 and 59 years of age 14/28; 50%)  said that Cree was their first language and 50% (14/28) of participants responding to the survey said that English was their first language. An additional 21% (6/28) said that they spoke Cree and/or English as their first language Table .Table 3FOver half of the participants were employed  Table .Table 4ESeventy nine percent (22/28) of the participants said that children lived in the household. Thirty six percent (10/28) of the children were < than 5 years of age and 43% (12/28) were > than 5 years of age. Eighteen percent of participants said that there were older adults or Elders living in the household. Almost half, 53% (15/28) of participants reported that they lived in homes with four or fewer people, and 11 of these 15 (39%) participants lived in homes with only 1-2 people Tables . Almost Twenty one percent (6/28) said that they also accessed dental benefits through Social Assistance Table . The majThe participants had very good knowledge about the impact of healthy baby teeth and children’s teeth to the overall health of children  and described healthy teeth, in general, as having good hygiene and self-care , healthy nutrition , or reflecting on the health of teeth  or appearance of teeth . Almost all participants agreed that the health of teeth effect the way children talk, their hearing, their self-confidence and self-esteem, their appearance  and or the pain they experience.Participants described both nutrition choices and dental hygiene as reasons why children may develop cavities and decay in baby teeth . Historically, some participants described that children’s teeth were healthier . Traditional practices to keep children’s teeth healthy included, more traditional soothers  hide to help with teething and ‘Indian soup’ broth and… red willow, grinded, wrapped in broad cloth. Babies suck on it to help teething and strengthen teeth). Brushing teeth was identified as important to keep children’s teeth healthy; however, the frequency of how often children have their teeth brush varied . A lack of understanding was identified related to: how long children needed to be supervised when brushing teeth; when dental assessments should be performed; and the role of fluoridation in preventive care. Often the parents viewed the first contact with dentists or therapists as traumatic or painful.▪ having a dental clinic within the community .▪ quality of care provided at the dental clinic, and▪ incentives offered at the dental clinic and by the program  were also identified.The strengths identified included:The existing barriers/roadblocks preventing families in the community from receiving care and information about child oral health included: transportation; knowledge of services available; types of information available (inclusive of communication channels used); language; parents’ and community’s lack of interest; and income . Access and affordability of nutritious food and dental care supplies were also highlighted as preventing parents or caregivers from providing good care for their children’s teeth . Several participants mentioned the challenges in the community to access healthy food , as well as the high cost of food .The participants shared several thoughts on how to help parents and caregivers take care of young children’s teeth. As stated above, many participants spoke about the importance of access to dental care supplies, education materials to increase awareness and help to address barriers, such as affordability of healthy nutritional foods and dental care services . Some participants also shared the importance of health workers and programs in the community . The significant role of family and early interventions was also highlighted .In summary, the ideas included: incentives ; information about the role of parents/caregivers in teaching and ensuring proper care for their children’s teeth ; and increasing access to information .Community needs discussed related to oral health care services and prevention programming included transportation, incentives , and a focus on prevention programs located at the school . The community expressed a need to expand incentive programs that are offered in schools to include parents and offer free dental supplies and transportation. A need was also shared for an additional dentist or an increase to the range of services the dental therapist provided so community members do not have to travel off reserve .Considering these findings, recommendations for improving the oral health of children would also include sharing information about preventive practices related to bottle feeding which was identified as the most frequent form of feeding . Encouraging age-appropriate methods of cleaning teeth as well as when children should have their first dental visit were also recommended. The dentist or dental therapist were the most frequently mentioned people to best provide information on how to take care of children’s teeth. In addition, the nurse, community health representative, health care provider, teacher and parents were also mentioned.Understanding the context of the community is central in developing partnerships and ongoing relationships. Incorporating cultural teachings were significant to the research relationship and research processes. Following proper protocol is critical in authentic engagement.When entering the research process with communities, it is vital to understand that their time is limited. Community members often fill numerous roles within the community, and research projects are usually in addition to their ongoing workload. Researchers need to be aware of this when timelines are established. When communities experience celebrations or a death, the research processes stop to observe the cultural protocol.Trust is developed by following the principles of TCPS 2 and respecting cultural practices identified which have been broadly discussed in this manuscript . DevelopThe participants identified strengths/supports, barriers/roadblocks and solutions to oral health issues in their community. The participants in Thunderchild First Nation have good knowledge about the impact of good oral health on speech, self-confidence, nutrition, and prevention of oral pain. The participants were aware of the preventative strategies such as limiting the use of bottles in duration and contents. There was recognition of the need to emphasize tooth brushing and how to access dental supplies. They also appreciated the attempts by the Community Administrators to have more support for dental services close to the local community including those of a dental therapist. Health Canada has supported the use of dental therapists in communities since the 1970’s . A revieIn this study, the participants identified the difficulty in applying good preventive strategies such as limiting or not using bottles with pressures in crowded homes to quiet and comfort fussing children. There was no discussion of alternative strategies to deal with this circumstance. The participants also noted that the challenge that transportation brings also affects healthy food choices and access to dental services. Holve et al.  identifiSuggestions by the participants included that the focus of education should be on prevention that would enhance oral health outcomes in children along with access to dental supplies and reminders of oral health strategies. Community outreach programs focusing on prenatal nutrition have been shown to improve caregivers’ knowledge of ECC and its effects , 40. In This research focused on pediatric oral health and was strength-based. Parental experiences with oral health care were not included so the history of oral care in individual families could not be used to help inform the results/findings. Hiring and training community Research Assistants, as well as conducting interviews in person to obtain the survey results, were time and resource intensive, but essential for the outcomes in this research.Given the nature of the work, the methods and processes can be transferred but the results/findings are not generalizable.Community-based research and integrated knowledge translation fosters processes that co-create knowledge. This community identified specific knowledge translation processes, including the need for public service announcements in English and Cree over the community radio station and developing key targeted meaningful messages. Similar techniques have been used in Northern Ontario with Indigenous communities consisting of bi-annual media campaigns, pamphlets, and posters in public areas promoting oral health .When working with the community, it would be helpful to link oral health to overall health and wellness, informing youth and parents of resources, and communicating to all levels of the community.In summary, an approach that invites the community to participate is paramount, as well as timing and teamwork. A book (in progress), translated into Plains Cree, is being co-created with the community to incorporate strengths/supports and highlight the barriers/roadblocks that need to be addressed to improve the oral health of children.This research was one of the first to explore oral health requisites with an independent Indigenous community. The study specifically explored the strengths/supports and barriers/roadblocks related to the availability, accessibility, accommodation, affordability, and acceptability of oral health care services. In addition, it also included the beliefs and health behaviours related to oral health and the impact that oral health has on the overall well-being of an individual. Developing authentic community engagement is critical to better understand, identify strengths/supports and barriers/roadblocks to oral health care services, and subsequently to establish new resources with Indigenous communities. Engaging individuals, families, community leaders, health care practitioners, educators, and policy makers will aid in the co-creation of a framework to be used in and with the community. The knowledge gleaned by this interdisciplinary, community–based participatory research team has the potential to build capacity with individuals, communities, provinces, and at the national level. Community-based participatory research used in this project established processes to ensure that any change in and with the community is sustainable and has the potential to prevent dental caries among young children. The research processes increased skills and capacities of the research team and the community resulting in sustainable relationships and research results/findings that will inform clinical practice guidelines (CPGs), policy and future research in this vital area of health and well-being.