This study used a retrospective mixed methods observational design, involving secondary analysis of routinely collected call handler logs from a national dementia helpline. A deductive framework approach was used to qualitatively examine the extent to which call handlers’ responses reflected predefined TI principles, alongside descriptive quantitative analysis of caller characteristics, call timing, reasons for contact, and theme frequency.

Reporting followed the Standards for Reporting Qualitative Research guideline [39], with items applied where relevant to secondary analysis of routinely collected service data. Items relating to participant recruitment, data saturation, and interview techniques were not applicable due to the retrospective evaluation design using anonymized call handler logs.

No participants were actively recruited; instead, we used a purposeful sampling approach and focused on call logs collected between April 2020 and April 2021, a period when global COVID-19 restrictions were in place and demand for helpline support was markedly elevated. During this time, the Alzheimer Scotland helpline received 7357 calls, compared with an annual average of approximately 2000 calls. To select the study sample, Alzheimer Scotland applied a random number generation procedure to assign a random value to each unique call identifier and then retained the 200 logs with the lowest values. All identifiers were removed by Alzheimer Scotland prior to transferring the anonymized dataset to the research team. The research team had no contact with callers and no role in data generation or record selection.

Calls to the helpline are not audio recorded. Call logs completed by call handlers capture key caller concerns, callers’ emotions, and call handler response. Anonymized data capturing the call handler response were extracted for analysis in this retrospective study.

Ethics approval was obtained from the University of the West of Scotland Health and Life Sciences Academic Integrity and Ethics Committee (application reference 17641) for the secondary analysis of personal data. Organizational consent was granted by Alzheimer Scotland. The study involved analysis of deidentified, routinely collected call log records and did not involve direct contact with callers or helpline staff. As such, the project was classified as secondary use of personal data, and individual informed consent was not required. Prior to transfer, Alzheimer Scotland removed all direct and indirect identifiers and provided an anonymized dataset to the research team via secure transfer; data were then stored on secure servers at the University of the West of Scotland in compliance with institutional data governance and General Data Protection Regulation. The helpline does not record audio; only call handler summaries were available for analysis. No participants were recruited or compensated for this study. The manuscript and supplementary materials contain no identifiable images or media, and there is no risk of visual identification.

The helpline is staffed by volunteer call handlers who complete a 4‑day induction program focused on call handling skills and dementia information, followed by approximately 2 days of refresher training each year. Training includes awareness‑level TI content (eg, recognizing possible adversity or trauma and responding with empathy and validation) but did not include formal TI practice competency training during the study period. Call logs are used for documentation and operational follow‑up (eg, onward referral); we did not have access to a formal TI competency audit, and calls were not recorded, precluding verification against audio.

Retrospective document analysis [38] with framework analysis was used to organize and interpret the narrative summaries recorded by call handlers. An a priori framework matrix was used to chart the data according to the 5 TI principles of collaboration, empowerment, safety, choice, and trust. Quantitative methods analyzed demographic data from call logs on a range of caller characteristics (time of call, who is calling, diagnosis, and reason for call) and theme frequency. We report counts and percentages only. No inferential statistics were conducted due to small subgroup sizes, nonindependence of multiple themes per call log, and the subjective nature of theme coding.

Framework analysis, guided by TI principles, was the conceptual framework for data analysis. The analysis was structured around the 5 TI principles defined by NHS Education for Scotland (NES) [40], which are explicitly aligned with the “Concept of Trauma and Guidance for a Trauma‑Informed Approach” of the US Substance Abuse and Mental Health Services Administrations [5]. These principles and their operational definitions were selected because they provide guidance that is directly appropriate to UK health and social care settings and well suited to the analysis of helpline interactions. The 5 principles applied were safety (ensuring physical and emotional safety with attempts to prevent retraumatization), trust (transparency, task clarity, and respecting interpersonal boundaries), choice (individual has meaningful choice, control, or voice in decision-making, with clear and appropriate message about rights), collaboration (recognizing the value of the caller experience, enabling decision-making, and providing knowledge to support the individual overcome challenges), and empowerment (sharing power, build capacity, and prioritize voice in decision-making with validation and affirmation of concerns).

Framework analysis is widely used as an effective analytic approach in multidisciplinary contexts and described as a pragmatic and rigorous data analysis technique [41]. A 5-stage process described by Ritchie and Spencer [42,43] (familiarization, identifying theme, indexing, charting and summarizing, and interpretation or mapping) was conducted by 3 members of the research team, with calibration checks performed by a fourth team member. In line with the recommendations on intercoder reliability in qualitative research [44], a sample of 10% (20/200) of call logs was reviewed by all members of the project team, with a very high level of agreement achieved (196/200, 98%). Call logs were divided between 3 reviewers for analysis, and the fourth team member reviewed a further sample from each group; a very high level of agreement was reported (198/200, 99%). Given the exploratory nature of this pilot, we report percentage agreement rather than κ and acknowledge its limitations. A thematic analysis was conducted using the framework analysis approach, enabling a structured and systematic examination of patterns across the dataset:

The systematic approach to coding the data supported the analysis of theme frequency. Theme frequency refers to how often each theme occurs across the dataset (reported as a percentage).

These data were analyzed using SPSS (version 25; IBM Corp) [45] to report demographic characteristics. Descriptive statistics report the frequency of each type of caller (eg, carer and person with dementia), time, reasons for the call, and occurrence of the TI themes. Independent samples 2-tailed t tests were initially considered to explore differences in theme frequency across caller subgroups; however, assumptions of normality and independence could not be verified given the sample size and nonindependent coding structure (multiple themes per call log). Consequently, inferential statistics were deemed inappropriate, and results are presented descriptively (counts and percentages) to avoid overstating findings.

The quantitative results provide data on caller characteristics, including the reason for call, caller identity, time of the call, and diagnosis. Differences in the frequency of themes in call handlers’ responses depending on the “time of call” and “caller identity” were also analyzed.

This pilot exploratory study of call handler summaries from the United Kingdom’s only 24‑hour dementia helpline suggests that responses frequently reflected TI principles, particularly collaboration and empowerment, with safety more evident during out‑of‑hours calls. Illustrative excerpts indicate empathetic listening, validation, shared problem‑solving, and signposting consistent with TI principles. Given the retrospective nature of the data and bias associated with this type of call logs, findings should be interpreted cautiously and considered hypothesis‑generating.

Because call logs rather than recorded calls were analyzed, the study reflects call handler interpretations rather than verbatim interactions. While our deductive framework ensured alignment with the study aim, it may have constrained identification of inductive themes. Therefore, we emphasize description over explanation and avoid claims about effectiveness.

The prominence of collaboration and empowerment aligns with the helpline’s role as a gateway to support and information, while the higher frequency of safety‑oriented responses during evening and early hours is consistent with greater perceived vulnerability and limited access to routine services at those times. These patterns warrant prospective confirmation using richer data sources.

Reliable, accessible information for carers and people with dementia remains a major gap across the diagnostic pathway [46]. The helpline helped address this need by providing timely information and signposting, with “information on caring” and “difficulty accessing services” among the most common reasons for contact. In fragmented care systems that often fail to meet complex needs [46], carers frequently become what Brodaty and Donkin [17] term the “invisible second patient,” facing multiple inequalities and psychological distress without adequate skills or support.

Consistent with prior evidence on the high stress of dementia caregiving, “emotional support” was the most common reason for contacting the helpline, followed by “carer stress.” Responses reflected multiple TI principles, suggesting awareness of potential distress during exchanges [47]. Notably, 22% (45/200) of callers sought help without a confirmed diagnosis, indicating the helpline may serve as an early point of contact for individuals concerned about their own symptoms or those of a loved one [27].

A strength of this study was the use of a predefined TI framework to guide analysis, which provided a systematic structure aligned with the aim. The stepwise approach to framework analysis and team‑based coding enhanced consistency and transparency, while interrater reliability checks increased confidence in coding validity.

However, several limitations must be acknowledged. First, the analysis relied on call handler summaries rather than recorded calls, introducing subjectivity and interpretive bias, as no audio verification was possible. The level of detail in call logs varied, which may reflect differences in call length or documentation practices. Volunteer call handlers had awareness-level TI training, but no formal competency audit was conducted, and retrospective document analysis carries inherent bias related to the original purpose of the logs. Findings also reflect a unique pandemic period and may not generalize beyond this context. Quantitative outputs were descriptive only, as inferential testing was not undertaken due to unmet assumptions. Finally, the impact of frequent exposure to distressed callers on call handlers was not assessed; future research should explore this using a TI lens.

This pilot exploratory study highlights the potential value of embedding TI principles within helpline services for people affected by dementia. Services may consider structured TI training, routine reflective supervision, and feasible quality assurance measures such as periodic recording (with consent) and documentation audits to support fidelity and staff well-being. Future research should triangulate call logs with recorded calls and caller‑reported outcomes, use validated coding protocols, and examine the impact of empathic engagement on call handlers. Prospective studies using richer data sources and robust designs are needed to confirm these preliminary findings and inform best practice in TI helpline provision.

This pilot exploratory study examined call handler responses from the United Kingdom’s only 24‑hour dementia helpline to assess the extent to which TI principles were reflected in practice. Findings suggest that, despite only brief awareness‑level training, call handlers demonstrated approaches consistent with TI principles, including collaboration, empowerment, and safety.

To advance international aspirations for TI care, helpline services for dementia and other life‑altering conditions should consider embedding structured TI training, reflective supervision, and safeguards to minimize the risk of trauma for both callers and volunteers. This is particularly important as volunteers may experience cumulative exposure to distressing information.

Although limited by reliance on call logs and the unique pandemic context, this study provides preliminary evidence that TI principles can be operationalized within helpline interactions. Future research should confirm these findings using recorded calls, caller‑reported outcomes, and robust evaluation designs to inform best practice for TI helpline provision.