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Background In recent years, narrative practice has been applied in clinical settings to address the relational and psychological concerns that occur in tandem with physical illness. It is an emerging strategy to treat patients as individuals with their own stories, rather than purely based on symptoms. Objective To synthesize the experience of patients with cancer using narrative practice. Methods Following a systematic search strategy, a literature search was conducted to identify qualitative studies on the experience of patients with cancer using narrative practice. Nine databases were searched up to April 2018, which included six English databases and three Chinese databases. A meta‐synthesis was conducted to synthesize the findings of the included studies. Main Results Seven studies out of 2894 studies were included in this review. Patients with cancer had different preferences on narrative practices. In terms of the impacts of narrative practice on patients with cancer, six themes were identified, which included ‘(a) reducing the gap between patients and clinicians; (b) healing effect; (c) social connection; (d) facilitating self‐reflection, self‐recognition and self‐realization; (e) risk of negative impacts; and (f) Patients' preference on different approaches of narrative practice’. Conclusions Patients with cancer experienced positive effects regarding narrative practice. Although some patients may experience negative effects, narrative practice is a humanized way to provide care for patients with cancer in the clinical settings.

2nd International Behcet Uz Children's Congress -- MAR 04-07, 2020 -- Izmir, TURKEY Background. We aimed to investigate the effectiveness of ketogenic diet (KD) in children with various types of refractory epilepsy. Methods. A total of 91 children (49 females) aged 3 to 193 months (median, 52 months) with drug resistant epilepsy who received KD treatment for at least 12 months were enrolled in the study. Seizure frequency, adherence to diet, reason for discontinuation of KD, and adverse effects were recorded. Response was defined as >= 50% improvement in seizure frequency compared to baseline. We also searched for influences of different variables on the outcome. Results. Intent-to-treat analysis revealed an improvement in seizure frequency for >= 50% in 73.6%, 80.2%, 75.8%, 73.6%, and 70.3% of patients at month-1,-3,-6,-9, and month-12, respectively. Overall, 32 (35.2%) patients remained seizure-free at month-12. There was no significant differences between responders and non responders in terms of age at onset of epilepsy, age at onset of KD, gender, or etiology. Mild hyperlipidemia was associated with a higher response rate. At the last follow-up (median: 20 months), 38 (41.8%) patients were still maintained on KD. While 15.4% of patients completed the diet with a success in seizure control, remainder discontinued KD due to lack of efficacy (23.1%), non-adharence to diet (11%), intercurrent infection (4.4%), adverse effects (3.3%), and death (1.1%). Conclusion. Ketogenic diet treatment appears to be effective in about two-thirds of children with various types of drug-resistant epilepsy, including one-third remaining seizure free. Mild hyperlipidemia seems to be associated with a higher response rate. Discontinuation of KD is mostly due to lack of efficacy or nonadherence, and rarely side effects.

This article presents the results of a study based on a group of participants’ interactions with an experimental sound installation at the National Science and Media Museum in Bradford, UK. The installation used audio augmented reality to attach virtual sound sources to a vintage radio receiver from the museum’s collection, with a view to understanding the potentials of this technology for promoting exploration and engagement within museums and galleries. We employ a practice-based design ethnography, including a thematic analysis of our participants’ interactions with spatialised interactive audio, and present an identified sequence of interactional phases. We discuss how audio augmented artefacts can communicate and engage visitors beyond their traditional confines of line-of-sight, and how visitors can be drawn to engage further, beyond the realm of their original encounter. Finally, we provide evidence of how contextualised and embodied interactions, along with authentic audio reproduction, evoked personal memories associated with our museum artefact, and how this can promote interest in the acquisition of declarative knowledge. Additionally, through the adoption of a functional and theoretical aura-based model, we present ways in which this could be achieved, and, overall, we demonstrate a material object’s potential role as an interface for engaging users with, and contextualising, immaterial digital audio archival content.

Background - Primary hypothyroidism is a common endocrine disorder, more so in an increasing UK ageing population. There is no qualitative research examining the older patient perspective of symptoms, treatment and self‐management of hypothyroidism.\ud \ud Objective - In this study we explored the experience of hypothyroidism in older people and examined how this may influence their understanding and acceptance of diagnosis, treatment with Levothyroxine and the monitoring process.\ud \ud Design - We conducted semi‐structured interviews with 18 participants aged between 80 and 93 years. Interview transcripts were analysed using a thematic approach.\ud \ud Results - The themes involved older individuals’ knowledge about symptoms, confidence in diagnosis and understanding of clinical management regimen to understand hypothyroidism. Interpretation of the themes was informed by the Health Belief Model.\ud \ud Conclusion - Our findings can help to inform the development of interventions by treating clinicians and support staff to engage older patients in the long‐term management of this chronic condition.

Background Patient engagement is a worldwide trend in health care. Patient portals have the potential to increase patients’ knowledge about their health and care and therefore enhance patient engagement. Portal users’ experiences are needed to determine if these portals work appropriately and if there are barriers to achieving the aims that were set before their implementation. Objective The aim of this study is to analyze pharmacy customers’ experiences of the Finnish nationwide patient portal My Kanta in terms of benefits, problems, and potential improvements. Methods A questionnaire survey was conducted among pharmacy customers in the spring of 2019. The questionnaires (N=2866) were distributed from 18 community pharmacies across mainland Finland to customers aged ≥18 years who were purchasing prescription medicines for themselves or their children aged

Background An increase in the number of people presenting to emergency departments (EDs) is contributing to ED overcrowding. In the early stages of the COVID-19 pandemic, there was a significant reduction in the number of ED presentations in Australia, creating an opportunity to learn from patients’ experiences of alternative management options. Objective The aim of this study is to report on the use and experience of health services by Australian adults experiencing a health issue during the COVID-19 pandemic for which they would have presented at an ED prior to the pandemic. Methods An online survey was conducted in May 2020. Reported health issues were categorized using an existing classification system. Data collected included demographics, care pathways, levels of concern at times of health issue and survey completion, and patient-reported experiences with care. Results A total of 1289 eligible respondents completed the survey. Almost 25% (309/1289) of respondents avoided an ED presentation, of which 58% (179/309) used an alternative form of health care and 42% (130/309) self-managed. Respondents making face-to-face or telehealth appointments with their general practitioner (GP) reported high levels of ED avoidance (135/286, 47%) and mostly positive experiences of care provided by GPs. A high proportion of those who self-managed reported high levels of concern at the time of completing the survey (42/130, 32%). Conclusions Telehealth consultations with GPs may be a more promotable alternative to the ED beyond the COVID-19 pandemic, providing easier access to a doctor with access to patients’ medical histories than an appointment for a face-to-face consultation. GP telehealth consultations may also address barriers to accessing health care for those with potentially the greatest need. The reported use and positive experiences with GP telehealth appointments should inform further research on their appropriateness as an alternative to the ED.

BACKGROUND: A dominant context for pregnant women in the Western world is medical technologies such as ultrasound and screening. It has been argued that such technologies may result in tentative pregnancies, which may be particularly prominent in the first trimester. However, little is known about how women experience early pregnancy.OBJECTIVE: To explore the everyday experiences and expectations of first trimester pregnant women in a medicalized context of comprehensive and routine prenatal screening.DESIGN: Qualitative, semi-structured interviews analysed using thematic analysis.SETTING: Between May 2015 and January 2016, participants were recruited from two general practices and one obstetric ultrasound unit in Aarhus, Denmark.PARTICIPANTS: Twenty, first trimester pregnant women (15 primiparae, five multiparae) aged 21-39 years.RESULTS: Early pregnancy is often kept secret in the first trimester due to a higher risk of miscarriage. However, the pregnancy is very real in the lives of the pregnant women who make it meaningful through practices of information seeking, listening to the body and anticipating the different milestones in pregnancy. First trimester screening represents one such milestone that is expected to mark a new and more certain phase in the pregnancy. A majority expects to terminate following a prenatal diagnosis, but this does not seem to influence their engagement with the pregnancy.CONCLUSIONS: The pregnant women use medical technologies to mark a milestone in pregnancy but do not expect all concerns to disappear upon a normal screening result. The majority of women acknowledge that pregnancy involves simultaneous feelings of happiness and worry.

Background A growing body of evidence is suggesting a significant association between the COVID-19 pandemic and population-level mental health. Study findings suggest that individuals with a lifetime history of disordered eating behavior may be negatively affected by COVID-19–related anxiety, and prevention measures may disrupt daily functioning and limit access to treatment. However, data describing the influence of the COVID-19 pandemic on disordered eating behaviors are limited, and most findings focus on individuals in treatment settings. Objective The aim of this study is to characterize the experiences of Reddit users worldwide who post in eating disorder (ED)–related discussion forums describing the influence of the COVID-19 pandemic on their overall mental health and disordered eating behavior. Methods Data were collected from popular subreddits acknowledging EDs as their primary discussion topic. Unique discussion posts dated from January 1 to May 31, 2020 that referenced the COVID-19 pandemic were extracted and evaluated using inductive, thematic data analysis. Results Six primary themes were identified: change in ED symptoms, change in exercise routine, impact of quarantine on daily life, emotional well-being, help-seeking behavior, and associated risks and health outcomes. The majority of users reported that the COVID-19 pandemic and associated public health prevention measures negatively impacted their psychiatric health and contributed to increased disordered eating behaviors. Feelings of isolation, frustration, and anxiety were common. Many individuals used Reddit forums to share personal experiences, seek advice, and offer shared accountability. Conclusions Reddit discussion forums have provided a therapeutic community for individuals to share experiences and provide support for peers with ED during a period of increased psychiatric distress. Future research is needed to assess the impact of the COVID-19 pandemic on disordered eating behavior and to evaluate the role of social media discussion forums in mental health treatment, especially during periods of limited treatment access.

Background: This study recorded the functional health literacy levels of people with musculoskeletal (MSK) conditions from harder to reach groups and explored their experiences in engaging with health care professionals to self-manage their MSK condition. Methods: We recruited participants, identified by key health and social care contacts as likely to have lower health literacy levels, and used semi-structured interviews to collect data. Thematic analysis was used to identify the main key themes arising from the transcribed interviews. Results: Eighteen participants were identified and recruited from harder to reach community populations, 10 were scored as having inadequate functional health literacy on the Short Form Rapid Estimate of Adult Literacy Measure. Three themes were identified in relation to participants’ experiences of MSK self-management approaches: engaging with health care services; interpreting the health care providers’ message; and facilitating participation in MSK self-management. Conclusions: Our findings indicate that people with a MSK condition, from harder to reach groups, experience multi-morbidity, find health care systems complicated and hear from health care professionals that their MSK condition cannot be cured. People interpreted that a lack of cure meant that nothing could be done to help their MSK pain. Engaging with self-management strategies was not seen as a priority for our participants. Strategies to simplify health communication, more time to process health information and supportive social networks helped our participants to understand and manage their MSK health on a day-to-day basis. Implications for RehabilitationMSK conditions are long term and prevalent in the UK with substantial impact on people’s daily life.Currently self-management strategies for MSK conditions are poorly communicated and many patients believe that nothing can be done to help their MSK pain.Good clinician communication that supports self-management is needed so that key messages can be effectively understood and used by patients with a range of literacy skills.Health services need to be even more accessible to help all individuals from a range of backgrounds better self-manage their MSK conditions.

Introduction Advanced Practice Nurse (APN) is a fairly new role in the Swedish health care system. Aim To describe patients' experiences of health care provided by an APN in primary health care. Methods An inductive, descriptive qualitative approach with qualitative open‐ended interviews was chosen to obtain descriptions from 10 participants regarding their experiences of health care provided by an APN. The data were collected during the spring 2012, and a qualitative approach was used for analyze. Results The APNs had knowledge and skills to provide safe and secure individual and holistic health care with high quality, and a respectful and flexible approach. The APNs conveyed trust and safety and provided health care that satisfied the patients' needs of accessibility and appropriateness in level of care. Conclusion The APNs way of providing health care and promoting health seems beneficial in many ways for the patients. The individual and holistic approach that characterizes the health care provided by the APNs is a key aspect in the prevailing change of health care practice. The transfer of care and the increasing number of older adults, often with a variety of complex health problems, call for development of the new role in this context., SUMMARY STATEMENT What is already known about this topic? Advanced Practice Nurse is an established role worldwide but is fairly new in Sweden.Patients express a high level of satisfaction with the health care provided by an APN in various settings worldwide. What this paper adds? APNs provide safe and secure individual and holistic health care with high quality.APNs have knowledge and skills that they carry out with a respectful and flexible approach.APNs convey trust and provide health care that satisfies the patients' needs of accessibility and appropriateness in level of care. The implications of this paper: The transfer of care from hospital to home and the increasing number of older adults, often with complex health problems, call for development of the new role in various contexts in Sweden.The individual and holistic approach that characterize APNs needs to be reflected upon in practice, education, and health care policies as key in the prevailing change of health care practice.

Background Data regarding the acceptability, feasibility, and quality of telehealth among adolescents and young adults (AYA) and their parents and caregivers (caregivers) are lacking. Objective The aim of this study was to assess the noninferiority of telehealth versus in-person visits by comparing acceptability with respect to efficiency, effectiveness, equity, patient-centeredness, and confidentiality. Methods Cross-sectional web-based surveys were sent to caregivers and AYA following video visits within an Adolescent Medicine subspecialty clinic in May-July 2020. Proportions of AYA and caregivers who rated telehealth as noninferior were compared using chi-squared tests. Feasibility was assessed via items measuring technical difficulties. Deductive thematic analysis using the Institute of Medicine dimensions of health care quality was used to code open-ended question responses. Results Survey response rates were 20.5% (55/268) for AYA and 21.8% (123/563) for caregivers. The majority of the respondents were White cisgender females. Most AYA and caregivers rated telehealth as noninferior to in-person visits with respect to confidentiality, communication, medication management, and mental health care. A higher proportion of AYA compared to caregivers found telehealth inferior with respect to confidentiality (11/51, 22% vs 3/118, 2.5%, P Conclusions Telehealth was highly acceptable among AYA and caregivers. Future optimization should include improving privacy, ameliorating technical difficulties, and standardizing at-home methods of obtaining patient data to assure patient safety.

Background Neutralizing monoclonal antibody (MAB) therapies may benefit patients with mild to moderate COVID-19 at high risk for progressing to severe COVID-19 or hospitalization. Studies documenting approaches to deliver MAB infusions and demonstrating their efficacy are lacking. Objective We describe our experience and the outcomes of almost 3000 patients who received MAB infusion therapy at Northwell Health, a large integrated health care system in New York. Methods This is a descriptive study of adult patients who received MAB therapy between November 20, 2020, to January 31, 2021, and a retrospective cohort survival analysis comparing patients who received MAB therapy prior to admission versus those who did not. A multivariable Cox model with inverse probability weighting according to the propensity score including covariates (sociodemographic, comorbidities, and presenting vital signs) was used. The primary outcome was in-hospital mortality; additional evaluations included emergency department use and hospitalization within 28 days of a positive COVID-19 test for patients who received MAB therapy. Results During the study period, 2818 adult patients received MAB infusion. Following therapy and within 28 days of a COVID-19 test, 123 (4.4%) patients presented to the emergency department and were released, and 145 (5.1%) patients were hospitalized. These 145 patients were compared with 200 controls who were eligible for but did not receive MAB therapy and were hospitalized. In the MAB group, 16 (11%) patients met the primary outcome of in-hospital mortality, versus 21 (10.5%) in the control group. In an unadjusted Cox model, the hazard ratio (HR) for time to in-hospital mortality for the MAB group was 1.38 (95% CI 0.696-2.719). Models adjusting for demographics (HR 1.1, 95% CI 0.53-2.23), demographics and Charlson Comorbidity Index (HR 1.22, 95% CI 0.573-2.59), and with inverse probability weighting according to propensity scores (HR 1.19, 95% CI 0.619-2.29) did not demonstrate significance. The hospitalization rate was 4.4% for patients who received MAB therapy within 0 to 4 days, 5% within 5 to 7 days, and 6.1% in ≥8 days of symptom onset (P=.15). Conclusions Establishing the capability to provide neutralizing MAB infusion therapy requires substantial planning and coordination. Although this therapy may be an important treatment option for early mild to moderate COVID-19 in patients who are at high risk, further investigations are needed to define the optimal timing of MAB treatment to reduce hospitalization and mortality.

This paper, analyzing interviews with men that donate their semen in Denmark, explores what it means to be a sperm donor. Breaking with the assumption that men have a specific and clearly identifiable motivation to become sperm donors, this paper leaves the confinement of such an accountable actor model implied in asking for men's motivations to donate semen. Instead, the author describes the experiences of sperm donors to show how the moral, organizational, and biomedical-technological context of sperm donation in Denmark makes for enactments of moral selves as well as specific embodiments of masculinity. Instead of looking for motivations that can be accounted for, the author engages with the question of how donating semen affords men the experience of moral and gendered selves This paper, analyzing interviews with men that donate their semen in Denmark, explores what it means to be a sperm donor. Breaking with the assumption that men have a specific and clearly identifiable motivation to become sperm donors, this paper leaves the confinement of such an accountable actor model implied in asking for men's motivations to donate semen. Instead, the author describes the experiences of sperm donors to show how the moral, organizational, and biomedical-technological context of sperm donation in Denmark makes for enactments of moral selves as well as specific embodiments of masculinity. Instead of looking for motivations that can be accounted for, the author engages with the question of how donating semen affords men the experience of moral and gendered selves

Background The diverse Asian American population has been impacted by the COVID-19 pandemic, but due to limited data and other factors, disparities experienced by this population are hidden. Objective This study aims to describe the Asian American community’s experiences during the COVID-19 pandemic, focusing on the Greater San Francisco Bay Area, California, and to better inform a Federally Qualified Health Center’s (FQHC) health care services and response to challenges faced by the community. Methods We conducted a cross-sectional survey between May 20 and June 23, 2020, using a multipronged recruitment approach, including word-of-mouth, FQHC patient appointments, and social media posts. The survey was self-administered online or administered over the phone by FQHC staff in English, Cantonese, Mandarin, and Vietnamese. Survey question topics included COVID-19 testing and preventative behaviors, economic impacts of COVID-19, experience with perceived mistreatment due to their race/ethnicity, and mental health challenges. Results Among 1297 Asian American respondents, only 3.1% (39/1273) had previously been tested for COVID-19, and 46.6% (392/841) stated that they could not find a place to get tested. In addition, about two-thirds of respondents (477/707) reported feeling stressed, and 22.6% (160/707) reported feeling depressed. Furthermore, 5.6% (72/1275) of respondents reported being treated unfairly because of their race/ethnicity. Among respondents who experienced economic impacts from COVID-19, 32.2% (246/763) had lost their regular jobs and 22.5% (172/763) had reduced hours or reduced income. Additionally, 70.1% (890/1269) of respondents shared that they avoid leaving their home to go to public places (eg, grocery stores, church, and school). Conclusions We found that Asian Americans had lower levels of COVID-19 testing and limited access to testing, a high prevalence of mental health issues and economic impacts, and a high prevalence of risk-avoidant behaviors (eg, not leaving the house) in the early months of the COVID-19 pandemic. These findings provide preliminary insights into the impact of the COVID-19 pandemic on Asian American communities served by an FQHC and underscore the longstanding need for culturally and linguistically appropriate approaches to providing mental health, outreach, and education services. These findings led to the establishment of the first Asian multilingual and multicultural COVID-19 testing sites in the local area where the study was conducted, and laid the groundwork for subsequent COVID-19 programs, specifically contact tracing and vaccination programs.

Background Digital development has caused rehabilitation services and rehabilitees to become increasingly interested in using technology as a part of rehabilitation. This study was based on a previously published study that categorized 4 groups of patients with cardiac disease based on different experiences and attitudes toward technology (e-usage groups): feeling outsider, being uninterested, reflecting benefit, and enthusiastic using. Objective This study identifies differences in the biopsychosocial profiles of patients with cardiac disease in e-usage groups and deepen the understanding of these profiles in cardiac rehabilitation. Methods Focus group interviews and measurements were conducted with 39 patients with coronary heart disease, and the mean age was 54.8 (SD 9.4, range 34-77) years. Quantitative data were gathered during a 12-month rehabilitation period. First, we used analysis of variance and Tukey honestly significant difference test, a t test, or nonparametric tests—Mann–Whitney and Kruskal–Wallis tests—to compare the 4 e-usage groups—feeling outsider, being uninterested, reflecting benefit, and enthusiastic using—in biopsychosocial variables. Second, we compared the results of the 4 e-groups in terms of recommended and reference values. This analysis contained 13 variables related to biomedical, psychological, and social functioning. Finally, we formed biopsychosocial profiles based on the integration of the findings by constant comparative analysis phases through classic grounded theory. Results The biomedical variables were larger for waistline (mean difference [MD] 14.2; 95% CI 1.0-27.5; P=.03) and lower for physical fitness (MD −0.72; 95% CI −1.4 to −0.06; P=.03) in the being uninterested group than in the enthusiastic using group. The feeling outsider group had lower physical fitness (MD −55.8; 95% CI −110.7 to −0.92; P=.047) than the enthusiastic using group. For psychosocial variables, such as the degree of self-determination in exercise (MD −7.3; 95% CI −13.5 to −1.1; P=.02), the being uninterested group had lower values than the enthusiastic using group. Social variables such as performing guided tasks in the program (P=.03) and communicating via messages (P=.03) were lower in the feeling outsider group than in the enthusiastic using group. The feeling outsider and being uninterested groups had high-risk lifestyle behaviors, and adherence to the web-based program was low. In contrast, members of the being uninterested group were interested in tracking their physical activity. The reflecting benefit and enthusiastic using groups had low-risk lifestyle behavior and good adherence to web-based interventions; however, the enthusiastic using group had low self-efficacy in exercise. These profiles showed how individuals reflected their lifestyle risk factors differently. We renamed the 4 groups as building self-awareness, increasing engagement, maintaining a healthy lifestyle balance, and strengthening self-confidence. Conclusions The results facilitate more effective and meaningful personalization guidance and inform the remote rehabilitation. Professionals can tailor individual web-based lifestyle risk interventions using these biopsychosocial profiles.

Background There has been a recent spate of mobile health (mHealth) app use for immunizations and other public health concerns in low- and middle-income countries. However, recent evidence has largely focused on app development or before-and-after effects on awareness or service coverage. There is little evidence on the factors that facilitate adoption of mHealth programs, which is critical to effectively embed digital technology into mainstream health systems. Objective This study aimed to provide the qualitative experiences of frontline health staff and district managers while engaging with real-time digital technology to improve the coverage of routine childhood immunization in an underserved rural district in Pakistan. Methods An Android-based app was iteratively developed and used for a 2-year period in 11 union councils of the Tando Muhammad Khan district, an underserved rural district with poor immunization coverage in Pakistan. We used iterative methods to examine the (1) acceptability and operability of the app, (2) validity of the collected data, and (3) use of the collected data. In addition, we collected the barriers and enablers for uptake of the mHealth app. Each of these topics was further explored related to changes in work as well as the enabling factors for and barriers to app use. In-depth interviews were conducted with the 26 vaccinators posted in the 11 union councils and 7 purposively selected key informants (government district managers) involved with the Expanded Program for Immunization. Findings were triangulated in line with the three broad research areas. Results Digital immunization tracking was considered acceptable by vaccinators and district managers. Real-time immunization data were used to monitor vaccination volume, track children with incomplete vaccinations, develop outreach visit plans, correct existing microplans, and disburse a fuel allowance for outreach sessions. The validity of the app data was perceived to be superior to that of data from manual records. Ease of operability, satisfaction with data, personal recognition, links to field support, and a sense of empowerment served as powerful enablers. Taking twice the time to complete both manual and digital entries and outdated phones over time were considered constraints. An unintended knock-on effect was improved coordination and strengthening of Expanded Program for Immunization review platforms across district stakeholders through digitalized data. Conclusions Embedding digital technology into mainstream health systems relies on use by both end users and district stakeholders. Ease of operability, satisfaction with data reliability, personal recognition, links to field support, and empowerment are powerful enablers, whereas improved coordination as a result of easy, transparent data access can be an important by-product of digitalization. Findings are relevant not only for wide-scale implementation of immunization tracking apps in Pakistan but also for informing the use of digital technology for results-based delivery by frontline health workers.

Inhibiting learned behaviours when they become unproductive and searching for an alternative solution to solve a familiar but different problem are two indicators of flexibility in problem solving. A wide range of animals show these tendencies spontaneously, but what kind of search process is at play behind their problem-solving success? Here, we investigated how Eastern grey squirrels, Sciurus carolinensis, solved a modified mechanical problem that required them to abandon their preferred and learned solution and search for alternative solutions to retrieve out-of-reach food rewards. Squirrels could solve the problem by engaging in either an exhaustive search (i.e., using trial-and-error to access the reward) or a ‘backup’ solution search (i.e., recalling a previously successful but non-preferred solution). We found that all squirrels successfully solved the modified problem on their first trial and showed solving durations comparable to their last experience of using their preferred solution. Their success and high efficiency could be explained by their high level of inhibitory control as the squirrels did not persistently emit the learned and preferred, but now ineffective, pushing behaviour. Although the squirrels had minimal experience in using the alternative (non-preferred) successful solution, they used it directly or after one or two failed attempts to achieve success. Thus, the squirrels were using the ‘backup’ solution search process. Such a process is likely a form of generalisation which involves retrieving related information of an experienced problem and applying previous successful experience during problem solving. Overall, our results provide information regarding the search process underlying the flexibility observable in problem-solving success. Electronic supplementary material The online version of this article (10.1007/s10071-019-01261-6) contains supplementary material, which is available to authorized users.

Background The pandemic of SARS-CoV-2, which causes COVID-19, has caused disruptions in ongoing clinical trials and is expected to accelerate interest in conducting research studies remotely. Objective A quasi-experimental, mixed methods approach was used to examine the rates of visit completion as well as the opinions and experiences of participants enrolled in an ongoing clinical trial of smoking cessation who were required to change from in-person clinic visits to remote visits using video or telephone conferencing due to the COVID-19 pandemic. Methods For quantitative comparisons, we used a quasi-experimental design, comparing a cohort of participants followed during the pandemic (n=23, COVID-19 cohort) to a comparable cohort of participants followed over a similar time period in the calendar years 2018 and 2019 (n=51, pre–COVID-19 cohort) to examine the rates of completion of scheduled visits and biospecimen collection. For the qualitative component, interviews were conducted with participants who experienced the transition from in-person to remote visits. Results Participants in the COVID-19 cohort completed an average of 83.6% of remote clinic visits (95% CI 73.1%-91.2%), which was not significantly different than the in-person completion rate of 89.8% in the pre–COVID-19 cohort. Participants in the COVID-19 cohort returned an average of 93.2% (95% CI 83.5%-98.1%) of saliva specimens for remote clinic visits completed, which was not significantly different than the in-person saliva specimen completion rate of 100% in the pre–COVID-19 cohort. Two broad themes emerged from the qualitative data: (1) the benefits of remote visits and (2) the challenges of remote counseling compared to in-person counseling. Despite limited experience with telehealth prior to this transition, most participants expressed a willingness to engage in remote visits in the future. Conclusions Even in the context of a rapid transition from in-person to remote visits necessitated by the COVID-19 pandemic, rates of visit completion and return of biospecimens remained high. Participants were generally accepting of the transition. Further research is needed to identify the optimal mix of in-person and remote visits beyond the pandemic context and to better understand how these changes may impact study outcomes. Trial Registration ClinicalTrials.gov NCT03262662; https://clinicaltrials.gov/ct2/show/study/NCT03262662

Background Using serious games for learning in operations management is well established. However, especially for logistics skills in health care operations, there is little work on the design of game mechanics for learning engagement and the achievement of the desired learning goals. Objective This contribution presents a serious game design representing patient flow characteristics, systemic resource configurations, and the roles of the players based on a real Swedish emergency ward. The game was tested in a set of game-based learning practices in the modalities of a physical board game and an online multiplayer serious game that implemented the same game structure. Methods First, survey scores were collected using the Game Experience Questionnaire Core and Social Presence Modules to evaluate the experience and acceptance of the proposed design to gamify real processes in emergency care. Second, lag sequential analysis was applied to analyze the impact of the game mechanics on learning behavior transitions. Lastly, regression analysis was used to understand whether learning engagement attributes could potentially serve as significant predicting variables for logistical performance in a simulated learning environment. Results A total of 36 students from courses in engineering and management at KTH Royal Institute of Technology participated in both game-based learning practices during the autumn and spring semesters of 2019 and 2020. For the Core Module, significant differences were found for the scores for negative affect and tension compared with the rest of the module. For the Social Presence Module, significant differences were found in the scores for the psychological involvement – negative feelings dimension compared with the rest of the module. During the process of content generation, the participant had access to circulating management resources and could edit profiles. The standard regression analysis output yielded a ΔR2 of 0.796 (F14,31=2725.49, P Conclusions The high scores of positive affect and immersion compared to the low scores of negative feelings demonstrated the motivating and cognitive involvement impact of the game. The proposed game mechanics have visible effects on significant correlation parameters between the majority of scoring features and changes in learning engagement attributes. Therefore, we conclude that for enhancing learning in logistical aspects of health care, serious games that are steered by well-designed scoring mechanisms can be used.

Background The COVID-19 pandemic has impacted the lives of expectant parents and parents of young babies, with disruptions in health care provision and loss of social support. Objective This study investigated the impact of the COVID-19 pandemic and its associated lockdown on this population through the lens of users of the UK National Health Service–approved pregnancy and parenting smartphone app, Baby Buddy. The study aims were threefold: to gain insights into the attitudes and experiences of expectant and recent parents (with babies under 24 weeks of age) during the COVID-19 pandemic; to investigate whether Baby Buddy is meeting users’ needs during this time; and to identify ways to revise the content of Baby Buddy to better support its users now and in future. Methods A mixed methods study design combining a web-based survey with semistructured telephone interviews among Baby Buddy users in the United Kingdom was applied. Data were collected from April 15 to mid-June 2020, corresponding to weeks 4-13 of the lockdown in the United Kingdom. Results A total of 436 expectant (n=244, 56.0%) and recent (n=192, 44.0%) parents responded to the web-based survey, of which 79.1% (n=345) were aged 25-39 years and 17.2% (n=75) spoke English as their second language. Of the 436 respondents, 88.5% (386/436) reported increased levels of anxiety around pregnancy, birth, and being a new parent, and 58.0% (253/436) were concerned about their emotional and mental health. Of the 244 pregnant respondents, 43.4% (n=106) were concerned about their physical health. Telephone interviews with 13 pregnant women and 19 recent parents revealed similarly increased levels of anxiety due to reduced health care provision and loss of support from friends and family. Although a minority of respondents identified some positive outcomes of lockdown, such as family bonding, many telephone interviewees reported feeling isolated, disregarded, and overwhelmed. Recent parents were particularly anxious about the impact of the lockdown on their baby’s development and socialization. Many interviewees were also concerned about their physical health as a consequence of both limited access to face-to-face medical appointments and their own poorer dietary and physical activity behaviors. Across both samples, 97.0% (423/436) of respondents reported that Baby Buddy was currently helping them, with many commenting that its role was even more important given the lack of face-to-face support from health care and parenting organizations. Greater speed in updating digital content to reflect changes due to the pandemic was suggested. Conclusions The COVID-19 pandemic has created heightened anxiety and stress among expectant parents and those with a young baby, and for many, lockdown has had an adverse impact on their physical and mental well-being. With reductions in health care and social support, expectant and new parents are increasingly relying on web-based resources. As a free, evidence-based app, Baby Buddy is well positioned to meet this need. The app could support its users even more by actively directing them to the wealth of existing content relevant to their concerns and by adding content to give users the knowledge and confidence to meet new challenges.

Background Swallowing difficulties (ie, dysphagia) are common among older adults, with a 13% to 54% prevalence. Adequate interventions to improve the swallowing function of older adults would reduce morbidity and enhance health-related quality of life outcomes. Mobile health (mHealth) apps may help alleviate dysphagia symptoms by providing programs that maximize the intensity and frequency of training without requiring high costs or regular clinic visits. Objective The aim of this pilot study was to assess the usability of swallowing training apps by quantitatively and qualitatively evaluating older adults’ self-reported data, taking into consideration their educational levels and exposure to mobile technology. We conducted surveys and brief interviews while the participants used a swallowing intervention app we developed. We subsequently identified and resolved individual-specific usability issues to improve future implementation of the app protocol for older persons with swallowing difficulties. Methods A total of 11 participants (10 women, 91%; mean age 75.7 years, SD 3.93) from two district-run senior welfare centers took part in this study. The participants were divided into a high-potential group and a low-potential group based on their total number of years of education and smart device usage. To investigate the usability of the app twice (ie, in the second week of the intervention and the postintervention stage), we used mixed methods consisting of both quantitative approaches, namely the System Usability Scale (SUS) and modified Computer Self-Efficacy Scale (mCSES) surveys, and qualitative approaches (ie, interviews). Results The quantitative results of the SUS and mCSES surveys revealed that the high-potential group was more inclined to adopt and learn new technology than the low-potential group. Specifically, within the high-potential group, a Wilcoxon signed-rank test indicated that the postintervention mCSES scores (median 65.50) were significantly higher than those in the second week of intervention (median 54.00; z=–2.023, P=.04). Additionally, the usability scores in the low-potential group were within the “marginal acceptability” range even after completion of an 8-week intervention program. Qualitative analyses via semi-structured interviews yielded promising outcomes regarding app acceptability, training program utilization, emotional responses, and learning experience. Conclusions To the best of the authors’ knowledge, this usability and feasibility study is the first report of a swallowing training app designed to improve the swallowing function of older adults. Future research should consider several issues, such as user characteristics, pretraining education, and the intensity and innate characteristics of the intervention program.

Introduction: The liver is the most common site of colorectal metastases (colorectal liver metastases – CLM). Surgical treatment in combination with oncological therapy is the only potentially curative method. Unfortunately, only 10–25% of patients are suitable for surgery. Traditionally, open liver resection (OLR) is usually performed. However, laparoscopic liver resection (LLR) has become popular worldwide in the last two decades. Aim: To evaluate the effectiveness and benefits of radiofrequency minor LLR of CLM in comparison with OLR. Material and methods: The indication for surgery was CLM and the possibility to perform minor laparoscopic or OLR not exceeding two hepatic segments according to Couinaud’s classification. Results: Sixty-six minor liver resections for CLM were performed. Twenty-five (37.9%) patients underwent a laparoscopic approach and 41 (62.1%) patients underwent OLR. The mean operative time was 166.4 min for LLR and 166.8 min for OLR. Average blood loss was 132.3 ±218.0 ml during LLR and 149.5 ±277.5 ml during OLR. Length of hospital stay was 8.4 ±2.0 days for LLR and 10.5 ±5.8 days for OLR. All resections were R0. There was no case of mortality. Postoperative complications were recognized in 9 (13.6%) patients: 8 in the group of OLR patients and 1 in the LLR group. The median survival time for LLR was 70.5 months and for OLR 61.9 months. The 5-year overall survival rate was higher for LLR vs. OLR – 82.1% vs. 69.8%. The average length of disease-free interval after LLR was greater (52.2 months) in comparison with OLR (49.4%). The 5-year disease-free interval was 63.2% for LLR and 58% for OLR. Conclusions: Outcomes and oncological radicality of minor laparoscopic liver resections of CLM are comparable to outcomes of OLR. Web of Science 10 2 212 205

Routine clinical practice data often differ from clinical trials. This study describes real-world treatment patterns and effectiveness among patients with metastatic colorectal cancer (mCRC) receiving ziv-aflibercept in non-academic, community oncology practices in the USA. De-identified electronic medical records from Vector Oncology and Altos Solutions databases were analysed. We identified 218 patients diagnosed with mCRC who had received prior oxaliplatin therapy and initiated ziv-aflibercept as part of second-line or later-line therapy. Overall survival (OS) and progression-free survival (PFS) were estimated using Kaplan–Meier analysis. Mean age was 62.8 years at ziv-aflibercept initiation. Most patients (91.7%) received bevacizumab before ziv-aflibercept, 95.4% initiated ziv-aflibercept with FOLFIRI or another irinotecan-based regimen, and 59.6% had received prior irinotecan. Overall, 24.8% of patients initiated ziv-aflibercept in second line, 31.7% in third line, 21.6% in fourth line and 22.0% in later lines of therapy. Mean duration of ziv-aflibercept treatment was 5.3 months. For patients initiating ziv-aflibercept in second-, third- and fourth-line therapy, median OS was 11.9 (95% confidence interval 5.1–16.2), 11.1 (6.9–16.7) and 8.1 (5.2–11.4) months, respectively, and median PFS was 4.4 (2.8–6.5), 4.3 (2.9–6.3) and 3.4 (2.2–5.2) months, respectively. Common adverse events (AEs) (any grade) included gastrointestinal disorders (64.7%) and asthenia/fatigue (63.3%). In routine clinical practice, ziv-aflibercept was frequently initiated in third line or later lines of therapy. Although patients receiving ziv-aflibercept were more heavily pretreated and potentially less robust compared with the VELOUR trial, median OS for patients receiving second-line ziv-aflibercept was comparable. AE rates were similar to or lower than the VELOUR trial.

Item does not contain fulltext Clinical workplaces offer postgraduate trainees a wealth of opportunities to learn from experience. To promote deliberate and meaningful learning self-regulated learning skills are foundational. We explored trainees' learning activities related to patient encounters to better understand what aspects of self-regulated learning contribute to trainees' development, and to explore supervisor's role herein. We conducted a qualitative non-participant observational study in seven general practices. During two days we observed trainee's patient encounters, daily debriefing sessions and educational meetings between trainee and supervisor and interviewed them separately afterwards. Data collection and analysis were iterative and inspired by a phenomenological approach. To organise data we used networks, time-ordered matrices and codebooks. Self-regulated learning supported trainees to increasingly perform independently. They engaged in self-regulated learning before, during and after encounters. Trainees' activities depended on the type of medical problem presented and on patient, trainee and supervisor characteristics. Trainees used their sense of confidence to decide if they could manage the encounter alone or if they should consult their supervisor. They deliberately used feedback on their performance and engaged in reflection. Supervisors appeared vital in trainees' learning by reassuring trainees, discussing experience, knowledge and professional issues, identifying possible unawareness of incompetence, assessing performance and securing patient safety. Self-confidence, reflection and feedback, and support from the supervisor are important aspects of self-regulated learning in practice. The results reflect how self-regulated learning and self-entrustment promote trainees' increased participation in the workplace. Securing organized moments of interaction with supervisors is beneficial to trainees' self-regulated learning.

Aims and objectives To present a discussion on newcomer adaptation as a lens through which to understand how nursing students adapt to clinical practice and raise awareness of strategies that can be used to enhance their learning experiences. Background Socialisation is an important factor that facilitates students’ learning in the clinical setting. Therefore, it is beneficial to examine organisational socialisation literature, particularly that pertaining to newcomer adaptation. Design This is a critical review of organisational socialisation literature. Methods Seminal literature and more recent research in the field of organisational socialisation and newcomer adaptation were accessed. In addition, nursing and allied health literature examining students’ socialisation and the clinical learning environment was retrieved. Conclusions It is revealed in this article that to create an appropriate clinical learning environment, an understanding of socialisation tactics could be beneficial. Role modelling is deemed crucial to successful newcomer adaptation. Peer support is necessary but must be advocated with caution as it can have a negative impact when students form a ‘parallel community’. Students with some knowledge of the workplace tend to adapt more easily. Likewise, students’ disposition and, in particular, their confidence can also enhance the socialisation process. Relevance to clinical practice Both the organisation and the student can impact on how successfully the nursing student ‘fits in’. Understanding this through the lens of newcomer adaptation means that strategies can be put in place to facilitate this process.

Background: It is generally assumed that incoming students in medical education programs will be better equipped for the “digital age” given their younger age and an educational upbringing in which technology was seemingly omnipresent. In particular, many assume that today's medical students are more likely to hold positive attitudes and increased comfortability with technology and possess greater information technology (IT) skills. Objective: The purpose of this study was to compare responses of incoming veterinary medical students to a series of IT-related questions contained in a common questionnaire over the course of a 10-year period (2005-2015) to discern whether students’ attitudes have improved and uses and comfortability with technology have increased as anticipated. Methods: A survey measuring attitudes and preferences, computing experience, and technology ownership was administered each year for the past 10 years to incoming veterinary medical students at a large veterinary school in the United States. Students' responses to survey items were compared at 3 data points (2005, 2010, and 2015). Results: Today's incoming veterinary medical students tend to indicate the same desire to improve skills using spreadsheets and web page design as incoming students from 10 years ago. It seems that despite technological advances and increased exposure to such applications and skills, there remains a challenge for students to “keep up” with the ever evolving technology. Moreover, although students continue to report they are very comfortable with using a computer (and related devices), many use their computers as typewriters or word processors, as opposed to a means for performing more advanced computing functions. Conclusions: In general, today's medical students are not expert computer users as many assume. Despite an upbringing in a digitized world, many students still lack many basic computing skills.

Background: Web-based programs for smoking prevention are being increasingly used with some success among adolescents. However, little is known about the mechanisms that link the experience of such programs to intended nicotine or tobacco control outcomes. Objective: Based on the experiential learning theory and extended elaboration likelihood model, this study aimed to evaluate the impact of a Web-based intervention, A Smoking Prevention Interactive Experience (ASPIRE), on adolescents’ intention to smoke, while considering the experience of interactivity and entertainment as predictors of reduced intention to smoke, under a transitional user experience model. Methods: A total of 101 adolescents were recruited from after-school programs, provided consent, screened, and randomized in a single-blinded format to 1 of 2 conditions: the full ASPIRE program as the experimental condition (n=50) or an online , text-based version of ASPIRE as the control condition (n=51). Data were collected at baseline and immediate follow-up. Repeated-measures mixed-effects models and path analyses were conducted. Results: A total of 82 participants completed the study and were included in the analysis. Participants in the experimental condition were more likely to show a decrease in their intention to smoke than those in the control condition (beta=−0.18, P=.008). Perceived interactivity (beta=−0.27, P=.004) and entertainment (beta=−0.20, P=.04) were each associated with a decrease in intention to smoke independently. Results of path analyses indicated that perceived interactivity and perceived entertainment mediated the relationship between ASPIRE use and emotional involvement. Furthermore, perceived presence mediated the relationship between perceived interactivity and emotional involvement. There was a direct relationship between perceived entertainment and emotional involvement. Emotional involvement predicted a decrease in intention to smoke (beta=−0.16, P=.04). Conclusions: Adolescents’ experience of interactivity and entertainment contributed to the expected outcome of lower intention to smoke. Also, emphasis needs to be placed on the emotional experience during Web-based interventions in order to maximize reductions in smoking intentions. Going beyond mere evaluation of the effectiveness of a Web-based smoking prevention program, this study contributes to the understanding of adolescents’ psychological experience and its effect on their intention to smoke. With the results of this study, researchers can work to (1) enhance the experience of interactivity and entertainment and (2) amplify concepts of media effects (eg, presence and emotional involvement) in order to better reach health behavior outcomes. Trial Registration: Clinicaltrials.gov NCT02469779; https://clinicaltrials.gov/ct2/show/NCT02469779 (Archived by WebCite at http://www.webcitation.org/6nxyZVOf0) [J Med Internet Res 2017;19(2):e44]

To assess the accuracy of (semi-)automatic measurements of left ventricular (LV) functional parameters in cardiac dual-source computed tomography (DSCT) compared to manually adjusted measurements in three different workstations. Forty patients, who underwent cardiac DSCT, were included (31 men, mean age 58 +/- A 14 years). Multiphase reconstructions were made with ten series at every 10% of the RR-interval. LV function analysis was performed on three different, commercially available workstations. On all three workstations, end-systolic volume (ESV), end-diastolic volume (EDV), LV ejection fraction (LVEF) and myocardial mass (MM) were calculated as automatically as possible. With the same DSCT datasets, LV functional parameters were also calculated with as many manual adjustments as needed for accurate assessment for all three software tools. For both semi-automatic as well as manual methods, time needed for evaluation was recorded. Paired t-tests were employed to calculate differences in LV functional parameters. Repeated measurements were performed to determine intra-observer and inter-observer variability. (Semi-)automatic measurements revealed a good correlation with manually adjusted measurements for Vitrea (LVEF r = 0.93, EDV r = 0.94, ESV r = 0.98 and MM r = 0.94) and Aquarius (LVEF r = 0.96, EDV r = 0.94, ESV r = 0.98 and MM r = 0.96). Also, good correlation was obtained for Circulation, except for LVEF (LVEF r = 0.45, EDV r = 0.93, ESV r = 0.92 and MM r = 0.86). However, statistically significant differences were found between (semi-)automatically and manually adjusted measurements for LVEF (P

We retrospectively analysed 90 patients who underwent “ en bloc” resection and modular endoprosthesis reconstruction in the lower limbs between 1987– 2003. After proximal femur resection, reconstruction was performed with a modular endoprosthesis by Howmedica (KFTR, designed by Kotz) and modular revision endoprosthesis by W. Link or Lima-Lto (Revision system, designed by Wagner). The knee joint was reconstructed with a modular endoprosthesis (Howmedica, KFTR designed by Kotz) after distal femur or proximal tibia resection. Malignant bone tumours were present in 58 patients (64.5%), benign tumours in 16 (17.8%), metastases in 8 (8.9%), tumour-like lesions in 4 (4.4 %) and non-tumour-related destruction of the femur in 4 patients (4.4%). High-grade tumours were found in the majority of malignant bone tumours (70.7%). Treatment complications, which occurred in 26 patients, were: local recurrence of the tumour, deep infection, acetabular destruction following hemiarthroplasty, recurrent dislocations of endoprosthesis, periprosthetic fracture and hardware problems. In total, 23 patients (25.6%) died due to tumours. Endoprostheses should be considered as a treatment of choice for bone tumours in the hip and knee joint region. Advances in limb salvage surgery are, and will long continue to be, a great challenge for orthopaedic oncologists of the 21st century.

To assess the long-term results and health-related quality of life in patients undergoing surgery for oesophageal achalasia.Thirty-nine patients with achalasia (25 males, mean age 42+/-13 years) underwent open-Heller myotomy and Dor fundoplication by the same surgeon. Long-term results were assessed by imaging, endoscopy, manometry, pH-metry, and Short Form 36 and Nottingham Health Profile questionnaires whenever applicable. Six patients were at radiological stage I, 20 were at stage II, 2 at stage III and 11 at stage IV. Dysphagia and regurgitation were scored according to the four-grade classification (1=no symptoms; 4=persistent symptoms). Pulmonary symptoms were present in six patients. Lower oesophageal pressure was 30+/-34 mmHg. Six patients had undergone previous pneumatodilation.No procedure related mortality was recorded. Mean follow-up was 107+/-30 months (54-177). Preoperative to 5-year postoperative mean decrement in lower oesophageal sphincter pressure was 12.3+/-8.3 mmHg (P0.001) in oesophageal width was 11.5+/-7.1 mm (P0.001) in dysphagia 1.8+/-0.8 (P0.001) and regurgitation 1.4+/-0.7 (P0.001) Four patients presented relapse dysphagia and two of those were re-operated upon. Three patients developed acid reflux, which was satisfactorily treated with proton-pump inhibitors. Preoperative to 4-year postoperative quality of life scores were available for 20 patients. Questionnaires showed a significant improvement (P0.001) especially in all psychosocial domains, which were correlated with postoperative dysphagia score and lower oesophageal sphincter pressure.Heller myotomy and Dor fundoplication is a safe and effective procedure that improves symptoms, functional status and especially psychosocial aspect of quality of life in the long term in oesophageal achalasia.

Letter concerning a position in horticulture and botany at Utah Agricultural College, copies given to J. C. Blair, J. L. Snyder, and L. H. Bailey.

Interactions between humans and smart products (i.e. digital components integrated in physical Internet of Things devices) are becoming more complex and less visible. Yet designers lack tools to capture these interactions and incorporate them into their design. In this paper we present the Human-Computer-Context Interaction (HCCI) tool that helps the designer to consider the different interactions of the user early in the conceptualisation phase, in order to eventually improve the user experience for smart products. This tool introduces 5 relevant interaction levels to be considered, when defining the context-of-use. In this paper we assess the use of the tool by means of a design challenge with a total of 34 industrial design students, given the task to design a smart kitchen concept. The tool was evaluated by a mixed method approach. Results show that the tool was evaluated as useful and usable during the early concept phase of the design of smart products. Unsupported concepts typically envisioned a single user interacting with one object through explicit interactions. Hence, tool-supported designs were more holistic and better captured interactions with other objects, users, content and services. From this we conclude that the tool can help to detect possible pitfalls of design selections. The tool is aimed to be used in a new product development process by HCI researchers, designers, and developers and is technology independent. Based on observations and participant feedback, we reflect on the strengths and limitations of this tool.

PurposeThis paper considers the potential of social media for developing public services. The paper approaches social media as a context that can provide information that might otherwise be unattainable. The focus of analysis is on a special hard-to-reach group of marginalized youths who appear to have isolated themselves from society.Design/methodology/approachThe authors answer the question: How can the experiences of socially withdrawn youth as shared on social media be used to enrich the knowledge base relating to the initiation phase of co-creation of public services? The data retrieved from the Finnish discussion forum are analyzed using the combination of unsupervised machine learning and discourse analysis.FindingsThe paper contributes by outlining a method that can be applied to identify expertise-by-experience from digital stories shared by marginalized youths. To overcome the challenges of making socially withdrawn youths real contributors to the co-creation of public services, this paper suggests several theoretical and managerial implications.Originality/valueCo-creation assumes an interactive and dynamic relationship where value is created at the nexus of interaction. However, the evidence base for successful co-creation, particularly with digital technology, is limited. This paper fills the gap by providing findings from a case study that investigated how social media discussions can be a stimulus to enrich the knowledge base of the co-creation of public services.

Purpose Refugee entrepreneurship is increasing because of the increased influx of refugees around the globe. This leaves us with the question that how refugees integrate economically in the host country in the presence of all social, emotional and economic constraints. Existing literature suggests looking into the role of social capital to address refugee economic integration, particularly in developing nations. To acknowledge this call, this paper aims to explore the impact of family social capital on the economic integration process. Particularly, this study has investigated the Afghan refugee entrepreneurial activities and the integration process of Afghan refugees in economic and social spaces in Pakistan. Design/methodology/approach The study is rooted in 18 in-depth interviews with five participants that run small businesses in the city of Rawalpindi in Pakistan. Findings The findings revealed Afghan refugee entrepreneurs, develop a different type of family social capital i.e. horizontal and vertical social capital. Afterward, when the acculturation pace up across refugees’ generations then they accumulate bridging social capital gradually. The process of economic integration happens in different stages as also shown in the existing literature. Based on (Berry, 2003; Evansluong et al., 2019; Khulman, 1991) economic integration process this paper has discussed three main stages (entry in labor market, gradual integration and gradual sub-merging in host society) of Afghan refugee economic integration in Pakistan and further this study has shown how different steps are arranged within these stages to smoothen the integration process. Research limitations/implications With this research, this paper calls for a more nuanced approach to address the challenges that are faced by refugees during their economic integration. Future research on Afghan economic and social integration can contribute to a better understanding of refugee settlement, well-being and self-sufficient status in host countries. One of the limitations of the study is the focus on male participants because female Afghan refugees do not work mostly because of strong patriarchal structures observed in refugee Afghan groups. Practical implications Most Afghan entrepreneurs consider them as Pakistani and do not want to repatriate to Afghanistan. This provides an opportunity for Pakistani policymakers to provide regulations and opportunities to Afghan entrepreneurs who want to stay in Pakistan and contribute to their family well-being and economic income generation and employment in Pakistan. Social implications The role of the family acts as a means to refugee entrepreneurs’ integration in the host country. Strong migration networks and dense family configurations are a source of pride, responsibility, resilience and self-esteem for Afghan refugees to start and expand their businesses. Originality/value This study provides the opportunity to explore the under-researched role of family social capital in the migrant and refugee entrepreneurship literature.

During COVID-19, many renowned galleries and art fairs used Virtual Reality (VR) exhibitions for art information dissemination and online displays. To avoid the risks of offline viewing of exhibitions, users can access a web-based VR exhibition platform for remote appreciation of artworks, gaining a rich art experience and thus contributing to physical and mental health. The reasons affecting users’ continued usage intentions are not clear enough in the existing studies of VR exhibitions. Therefore, further studies are needed. This paper explores the relationship between users’ escapist experience, aesthetic experience, presence, emotional responses, and continued usage intention through a survey of VR exhibition users. The survey data were collected from 543 users who had experienced the VR exhibition through an online survey website. The study results show that users’ continued usage intentions are influenced by escapist experience and aesthetic experience. Presence plays a mediating role in the influence of escapist experiences and aesthetic experiences on continued usage intention. Emotional responses play a moderating role in the impact of user experience on continued usage intention. This paper provides a theoretical reference for the study of the impact mechanism of continued usage intention of VR exhibitions from the perspective of mental health. In addition, this study enables VR exhibition platforms to better understand the emotional state of users during art experiences to create and share healthy aesthetic information that can contribute to the management and enhancement of mental health. At the same time, it provides valuable and innovative guidance solutions for the future development of VR exhibitions.

Glazkova Iryna. The issue of polycultural competence formation in Ukraine and Chine. Journal of Education, Health and Sport. 2021;11(1):238-245. eISSN 2391-8306. DOI http://dx.doi.org/10.12775/JEHS.2021.11.1.023 https://apcz.umk.pl/czasopisma/index.php/JEHS/article/view/JEHS.2021.11.1.023 https://zenodo.org/record/4637751 The journal has had 5 points in Ministry of Science and Higher Education parametric evaluation. § 8. 2) and § 12. 1. 2) 22.02.2019. © The Authors 2021; This article is published with open access at Licensee Open Journal Systems of Nicolaus Copernicus University in Torun, Poland Open Access. This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author (s) and source are credited. This is an open access article licensed under the terms of the Creative Commons Attribution Non commercial license Share alike. (http://creativecommons.org/licenses/by-nc-sa/4.0/) which permits unrestricted, non commercial use, distribution and reproduction in any medium, provided the work is properly cited. The authors declare that there is no conflict of interests regarding the publication of this paper. Received: 25.12.2020. Revised: 14.12.2020. Accepted: 29.01.2021. THE ISSUE OF POLYCULTURAL COMPETENCE FORMATION IN UKRAINE AND CHINE Iryna Glazkova Berdyansk State Pedagogical University, Ukraine Dean of the Department of Philology and Social Communications, Doctor of pedagogical sciences, Professor Abstract The article deals with the search of the effective ways of the students’ polycultural competence formation process at Chinese and Ukrainian universities. The analysis of Ukrainian and Chinese scientists’ view scientific papers, give us possibility to state that polycultural competence is an integrative personal formation that includes the knowledge, skills, traits and values of a person. Polycultural competence facilitates one’s ability to interact effectively with representatives of other cultures on the basis of mutual respect, understanding and tolerance as well as the willingness to continue and to develop the diversity of cultural self-expressions in the context of a globalized society. The author proves that the basis of the polycultural competence formation is a foreign language. The effectiveness of such method as: reading, direct method, method of analogy and purposeful and practical methods in the process of polycultural competence formation while teaching foreign languages in higher education institutions in Ukraine and Chine are described. Keywords: polycultural competence; a university; China; a student; experience.

S’il est indéniable que certaines expositions non critiques renforcent des récits nostalgiques du passé, cet article cherche à démontrer l’existence d’expositions critiques et à expliciter leurs ressorts. On analyse la façon dont la production de formes d’expérience affective et non rationnelle visant à induire un plus grand engagement de la part des visiteurs est utilisée pour faciliter une réflexion plus critique sur le rapport entre le passé et le présent. Les exemples, tirés des pratiques curatoriales en Australie, à propos soit des histoires du contact colonial, soit des histoires de migration, permettent de montrer comment des formes explicites d’engagement avec les sens dans les expositions contemporaines mènent non seulement à une nouvelle compréhension du rôle pédagogique des musées, mais également à de nouvelles formes de pratiques pédagogiques. While the existence of uncritical exhibition practices that support nostalgic narratives about the past cannot be denied, this paper is focused on demonstrating both the existence of critical exhibitions and on explaining how they work. In particular, this paper looks at the ways in which the production of affective, non-rational forms of experience aimed at inducing a heightened level of engagement on the part of visitors is being used to facilitate a more critical reflection on the relationship between past and present. My examples, drawn from curatorial practices in Australia dealing either with contact histories or histories of migration, will be used to explore how explicit forms of engagement with the senses in contemporary exhibition practices gesture toward not only a new understanding of the pedagogical role of museums but also to new forms of pedagogical practice. Si bien no cabe duda que ciertas exposiciones no críticas, refuerzan los relatos nostálgicos sobre el pasado, este estudio busca demostrar la existencia de exposiciones críticas y explicar sus propósitos. El presente artículo analiza la manera en que, mediante formas de experiencia afectiva y no racional, éstas buscan provocar una mayor vinculación con los visitantes y facilitar una reflexión más crítica sobre la relación entre el pasado y el presente. Los ejemplos, extraídos de la práctica curatorial en Australia, sean estos sobre historias del contacto colonial o de historias de la migración, muestran cómo las exposiciones contemporáneas que involucran explícitamente a los sentidos, se encaminan no solamente hacia una nueva comprensión del papel pedagógico de los museos, sino que también hacia nuevas formas de prácticas pedagógicas.

This paper explores how personal experience acquires the status of knowledge and/or evidence in contemporary healthcare contexts that emphasise being both patient-centred and evidence-based. Drawing on a comparative analysis of three case studies – self-help and mutual aid groups; online patient activism; and patient feedback in healthcare service delivery – we foreground: a) the role that different technologies and temporalities play in how experience is turned (or fails to be turned) into knowledge or evidence; b) the role that experts-of-experience, in addition to the more frequently referenced experts-by-experience, play in mediating how, when and why experience is turned into an epistemic resource; and finally, c) how the need to be ‘evidence-based’ remains a persistent, yet at times productive, challenge to how patient and user experiences are incorporated in contemporary healthcare policy and practice. Throughout the paper, we argue that it is necessary to look at both democratic and epistemic imperatives for including patient and service users in healthcare services and policymaking based on their experience.

This paper analyzes the relationship between community gallery spaces as (a) places for pursuing leisure and (b) a means of health promotion through connectedness. We argue that art experience in the community space is an interesting and particular form of leisure which links individuals with communities, cultures and histories. We provide a philosophical reflection on the ways that leisure and health intersect using the experience of art through community galleries as a case example. The community gallery experience as leisure raises interesting questions about the nature of leisure and the role that community spaces and resources can play in connecting individuals to the world in ways that promote their well-being. This paper is not a detailed empirical analysis, but rather a broad survey of the theoretical relationship between art, leisure and health with the aim of motivating a research agenda Refereed/Peer-reviewed

BackgroundResearch tools to evaluate institutions or interventions in the field of mental health have rarely been constructed by researchers with personal experience of using the mental health system (“experiential expertise”). This paper presents a preliminary tool that has been developed within a participatory-collaborative process evaluation as part of a controlled, multi-center, prospective cohort study (PsychCare) to evaluate psychiatric flexible and integrative treatment, FIT for short, models in Germany.MethodThe collaborative research team consisting of researchers with and without experiential expertise developed 12 experiential program components of FIT models by an iterative research process based on the Grounded Theory Methodology. These components were transformed into a preliminary research tool that was evaluated by a participatory expert panel, and during a pilot and validation study, the latter using a random sample of 327 users from 14 mental health departments. Internal consistency of the tool was tested using Cronbach's alpha. Construct validity was evaluated using a Principal Components Analysis (PCA) and a Jonckheere Terpstra test in relation to different implementation levels of the FIT model. Concurrent validity was tested against a German version of the Client Satisfaction Questionnaire (ZUF-8) using correlation analysis and a linear regression model.ResultsThe evaluation of the expert panel reduced 29 initial items to 16 that were further reduced to 11 items during the pilot study, resulting into a research tool (Needs and Experiences in Psychiatric Treatment—NEPT) that demonstrated good internal consistency (Cronbach's alpha of 0.89). PCA yielded a 1-component structure, which accounted for 49% of the total variance supporting the unidimensional structure of the tool. The total NEPT score increased alongside the increasing implementation of the FIT model (p < 0.05). There was evidence (p < 0.001) for convergent validity assessed against the ZUF-8 as criterion measure.ConclusionsThe NEPT tool seems to be promising for further development to assess the experiences with and fulfillment of needs of psychiatric care models from the perspective of users. This paper demonstrates that it is possible to use a participatory-collaborative approach within the methodologically rigorous confines of a prospective, controlled research design.

Due to the COVID-19 pandemic, university closures were commonplace worldwide from March 2020, meaning that lecturers and students had to adapt to emergency remote teaching with little or no notice. In this paper, we report upon the results of an online survey undertaken with university mathematics lecturers during May–June 2020. There were 257 respondents from 29 countries who gave their reactions to emergency remote teaching due to the COVID-19 pandemic. Here, we focus upon lecturers’ perceptions of how their students coped with this style of teaching, considering any particular difficulties they reported to their lecturers, their attendance at online teaching sessions, and their engagement in a general way. Lecturers reported students struggling with both hardware and software issues, particularly in relation to fast, reliable broadband. Childcare issues also emerged as a challenge for students during this timeframe, as well as students’ personal circumstances in terms of living situations and financial stability. Overall, lecturers reported lower levels of engagement with online learning compared to in-person lectures, which occurred prior to the pandemic. However, four-fifths of respondents were still in regular contact with their students during this time. Many of the studies exploring the impact of COVID-19 on the teaching and learning of mathematics in higher education are small-scale, sometimes single-module studies. Restrictions differed greatly between countries, and indeed between regions, meaning that the results of any regional study cannot be generalised to a more international experience. In addition, the experience of students studying mathematics as their degree programme differed from those who undertook only one mathematics module as part of a science, engineering, or business degree. This paper provides a more global insight into the student experience during the COVID-19 pandemic. By focusing on lecturers, rather than asking students directly, the experiences of those students who may not have engaged with such a study have been included; oftentimes, these students were those who struggled the most with this new format of learning.

This dissertation provides evidence about the relationship between the characteristics of different corporate managers or insiders and financial reporting quality, based on agency theory and upper echelon theory. The first paper examines the influence of CEOs' international experience on earnings management. We measure international experience using three categories: international experience of either study or work, only study, and both study and work. Three commonly used proxies capture earnings management: discretionary accruals, meet or beat earnings forecast, unconditional conservatism. OLS models test a sample of China's listed firms from 2010 to 2014. A propensity score matching method is used to generate a matched sample with balanced covariate means to address endogeneity problems. The empirical results show no significant relationship between CEOs' international experience and earnings management, suggesting that the gain in human capital has a weak effect on inhibition of earnings management in China's listed firms. When looking at subcategories, CEOs with international study and work experience do have a significant restraining effect on absolute discretionary accruals. Furthermore, only CEOs with international study experience are related to less conditional conservatism. Meet or beat analyst earnings forecasts demonstrate no relationship with experience among three dependent variables. The second research explores how the board secretary in China's listed firms affects management and analyst earnings forecast properties. I measure the characteristics of the board secretary using the stock-based incentives, tenure and financial expertise; forecast properties using accrual-based earnings management, accuracy, likelihood and frequency of management forecast, and disclosure transparency score. The empirical analysis is based on a sample of the listed firms from 2012 to 2016 in Shenzhen Stock Exchange. Evidence supports the general idea that the characteristics of board secretary are associated with disclosure quality. Tenure is positively related to forecasts related to financial figures, that is, to less upward discretionary accruals and more management forecast accuracy. Longer tenure inhibits the likelihood and frequency of earnings forecast preannouncements. The Shenzhen Stock Exchange transparency score indicates that the disclosure quality is improved with the board secretary who experiences longer employment. In contrast to tenure, stock-based incentives display opposite coefficients in almost all regressions. Larger stock-based incentives are associated with upward accrual-based earnings management while increased likelihood and number of earnings preannouncement issuances. The results suggest that stock performance motivates the board secretary to engage in upward earnings management and frequent preannouncement issuances to intervene in information disclosure. The influences of financial working experience on disclosure quality are limited to earnings forecast preannouncements. The results indicate that a board secretary who used to work in the finance industry has less tendency in issuing preannouncements and that the number of issuances decreases with such experience. The effect of financial work experience resembles that of tenure, suggesting that expertise, representing a better understanding of the firm's financial status and familiarity with the financial market, increase the reluctance of issuing earnings forecast preannouncements. Further instrumental variable approach and propensity score matching methods confirm that the baseline results do not suffer from severe endogeneity problems. The third paper focuses on the pledging of shares by non-state enterprises (NSOEs) using two empirical analyses: first on the shares pledged by controlling shareholders and then on a regulation shock. Based on a sample of China's NSOEs from 2011 to 2018, tests on the first type employs a fixed-effect model. Evidence shows that the occurrence of share pledging by controlling shareholders is associated with more management forecast issuances and fewer management forecasts biases, while no significant effect on analyst forecast accuracy and relative optimism. The effort to improve management forecast quality suggests that the firm stabilises stock price and avoids margin call risk. In addition, the net value of pledged shares and the ratio of pledged to total tradable shares are positively associated with analyst forecast bias and relative optimism of managers to analysts. The results indicate the information asymmetry between the two sides, suggesting that share pledging is so intricate to add noise to analyst forecast. The second part investigates a regulation shock in share pledging. The regulation came into effect in the middle of 2013, allowing securities companies to make share pledging business as pledges. Based on a difference-in-difference model, empirical evidence demonstrates an improvement in analyst forecasts accuracy, indicating that analysts might benefit from extra cross-department private information about the financial or operational status of the listed firms with share pledging. While on the contrary, management forecasts display relatively more optimism than analysts, showing that the firm attempts to use optimistic reports to influence outsiders., Diese Dissertation liefert Belege über die Beziehung zwischen den Eigenschaften verschiedener Unternehmensmanager oder Insider und der Qualität der Finanzberichterstattung, basierend auf der Agency- und der Upper-Echelons-Theorie. Die erste Studie untersucht den Einfluss der internationalen Erfahrung von CEOs auf das Ertragsmanagement. Wir messen Auslandserfahrung anhand von drei Kategorien: Auslandserfahrung durch Studium oder Arbeit, nur durch Studium und durch sowohl Studium als auch Arbeit. Drei häufig verwendete Messgrößen erfassen das Ertragsmanagement: diskretionäre Periodenabgrenzungen, die Erfüllung oder das Übertreffen der Gewinnprognose der Analysten und unbedingt vorsichtige Bilanzierung. Die empirischen Ergebnisse zeigen keinen signifikanten Zusammenhang zwischen der internationalen Erfahrung von CEOs und dem Ertragsmanagement, was darauf hindeutet, dass der Gewinn an Humankapital einen schwachen Effekt auf die Hemmung des Ertragsmanagements in Chinas börsennotierten Unternehmen hat. Betrachtet man die Unterkategorien, so haben CEOs mit internationaler Studien- und Berufserfahrung einen deutlich dämpfenden Effekt auf die absoluten Ermessensrückstellungen. Darüber hinaus senken nur CEOs mit internationaler Studienerfahrung die vorsichtige Bilanzierung. Die Erfüllung oder das Übertreffen der Gewinnprognosen von Analysten zeigen keinen Zusammenhang mit irgendeiner Erfahrung gemessen durch die drei abhängigen Variablen. Die zweite Studie untersucht, wie der Vorstandssekretär in Chinas börsennotierten Unternehmen die Gewinnprognosen des Managements und der Analysten beeinflusst. Die Eigenschaften des Vorstandssekretärs werden anhand von aktienbasierten Anreizen, Betriebszugehörigkeit und Finanzexpertise gemessen; die Eigenschaften der Prognosen mithilfe von periodengerechtes Ertragsmanagement, Qualität, Wahrscheinlichkeit sowie Häufigkeit der Managementprognosen und einem Maßstab zur Offenlegungstransparenz. Die empirische Analyse basiert auf einer Stichprobe der von 2012 bis 2016 an der Shenzhen Stock Exchange notierten Unternehmen. Die empirischen Belege stützen die allgemeine Vorstellung, dass die Eigenschaften des Vorstandssekretärs mit der Offenlegungsqualität verbunden sind. Die Betriebszugehörigkeit steht in positivem Zusammenhang mit Prognosen in Bezug auf Finanzkennzahlen, d. h. mit weniger positiven diskretionären Periodenabgrenzungen und einer höheren Genauigkeit der Managementprognosen. Eine längere Betriebszugehörigkeit hemmt die Wahrscheinlichkeit und Häufigkeit der Vorankündigungen von Gewinnprognosen. Der Maßstab zur Offenlegungstransparenz der Shenzhen Stock Exchange zeigt, dass die Offenlegungsqualität mit dem Vorstandssekretär verbessert wird, der länger beschäftigt ist. Im Gegensatz zur Betriebszugehörigkeit weisen aktienbasierte Anreize in fast allen Regressionen entgegengesetzte Koeffizienten auf. Größere aktienbasierte Anreize sind mit einem aufwärtsgerichteten Ertragsmanagement verbunden, während die Wahrscheinlichkeit und Anzahl der Veröffentlichung von Gewinnvorankündigungen erhöht wird. Die Ergebnisse deuten darauf hin, dass die Wertentwicklung der Aktie den Vorstandssekretär dazu motiviert, sich an einem Ertragsmanagement nach oben zu beteiligen und häufig Vorankündigungen herauszugeben, um in die Offenlegung von Informationen einzugreifen. Die Einflüsse der Finanzarbeitserfahrung auf die Offenlegungsqualität beschränken sich auf die Vorankündigungen von Gewinnprognosen. Die Ergebnisse zeigen, dass ein Vorstandssekretär, der früher in der Finanzbranche gearbeitet hat, weniger dazu neigt, Vorankündigungen herauszugeben und dass die Anzahl der Veröffentlichungen mit dieser Erfahrung abnimmt. Die Wirkung von Berufserfahrung im Finanzbereich ähnelt der von Betriebszugehörigkeit, was darauf hindeutet, dass Fachwissen, welches ein besseres Verständnis der Finanzlage des Unternehmens und Vertrautheit mit dem Finanzmarkt darstellt, die Zurückhaltung bei der Veröffentlichung von Vorankündigungen für Gewinnprognosen erhöht. Weitere Instrumentalvariablenansätze und Propensity-Score-Matching-Methoden bestätigen, dass die Hauptergebnisse nicht unter schwerwiegenden Endogenitätsproblemen leiden. Die dritte Arbeit konzentriert sich auf die Verpfändung von Aktien durch nichtstaatliche Unternehmen mithilfe von zwei empirischen Analysen: zuerst werden die von kontrollierenden Aktionären verpfändeten Aktien untersucht und anschließend ein Regulierungsschock. Die erste Analyse basiert auf einer Stichprobe von Chinas nichtstaatliche Unternehmen von 2011 bis 2018 und verwendet ein Modell mit fixen Effekten. Die Untersuchungen zeigen, dass das Auftreten von Aktienverpfändungen durch Mehrheitsaktionäre mit mehr Veröffentlichungen und weniger Verzerrungen von Managementprognosen verbunden ist, während es keinen signifikanten Einfluss auf die Genauigkeit der Analystenprognosen und den relativen Optimismus hat. Die Bemühungen, die Qualität der Managementprognosen zu verbessern, deuten darauf hin, dass das Unternehmen den Aktienkurs stabilisiert und das Margin-Call-Risiko vermeidet. Darüber hinaus sind der Nettowert der verpfändeten Aktien und das Verhältnis der verpfändeten Aktien zu den gesamten handelbaren Aktien positiv mit der Verzerrung der Analystenprognosen und dem relativen Optimismus der Manager gegenüber den Analysten verbunden. Die Ergebnisse zeigen die Informationsasymmetrie zwischen den beiden Seiten, was darauf hindeutet, dass die Verpfändung von Aktien so kompliziert ist, dass sie die Analystenprognosen verfälscht. Der zweite Teil untersucht einen Regulierungsschock bei der Verpfändung von Aktien. Mitte 2013 trat die Verordnung in Kraft, die es Wertpapierfirmen ermöglicht, Aktienverpfändungsgeschäfte als Verpfändung zu tätigen. Basierend auf einem Differenz-von-Differenzen-Modell zeigen empirische Belege eine Verbesserung der Genauigkeit der Analystenprognosen, was darauf hindeutet, dass Analysten von zusätzlichen abteilungsübergreifenden, privaten Informationen über den finanziellen oder operativen Status der börsennotierten Unternehmen mit Aktienverpfändung profitieren könnten. Währenddessen zeigen Managementprognosen relativ mehr Optimismus als Analysten, was zeigt, dass das Unternehmen versucht, optimistische Berichte zu verwenden, um Außenstehende zu beeinflussen.

This paper is a discussion paper and it seeks to re-consider the Freudian psychoanalytic concept of interpretation within the relational approach to psychoanalysis. As such, it aims to argue the Freudian approach to interpretation is rejected because it is not relational but involves only the analyst as interpreter of the patient’s experience. Instead, within the relational approach, it is suggested that if interpretation, as a process of making meaning of experiences, is re-considered as the outcome of the intersubjective relationship in which the process of making-meaning is essentially a co-creational process of the patient’s experience of the analyst in the here-and-now, interpretation can potentially be an agent of change. The clinical implication is that interpretation must be the construction of the patient’s meaning of his experience but within the relational context. A clinical verbatim transcript is documented as it illustrates this relational process in interpretation.

Despite the current surge of interest in loneliness, its health consequences, and possible remedies, the concept itself remains poorly understood. This paper seeks to contribute to a more fully worked out account of what loneliness consists in. It does this by stressing that loneliness always has an experiential component and by introducing a simple psychological structure to analyze the experience. On this basis, it suggests that we can distinguish between three ways of thinking about the phenomenal dimension of loneliness. There are objectivist views that seek to understand loneliness by a description of its intentional object, subjectivist views that consider its holistic relation to other aspects of the sufferer’s psyche, and embodied and enacted views that focus on the relation between the lonely person’s mental life and her social environment. The aim is not to adjudicate between these views or to suggest that they are mutually exclusive. Rather, this paper recommends a pluralistic framework on which all three approaches have something to contribute to a fuller understanding of the condition and may be of use in devising measures aimed at improving sufferers’ health.

The article analyses the negotiations between European Union and countries of the Western Balkans and attempts to identify where the major problems are likely to be. The main obstacles in the process of European integration of the countries from Balkan region are analyzed. Also, the paper focuses on the key priorities that Western Balkan countries have to accomplish in order to reach the domestic readiness for their process of European integration. An important goal of the article is to identify some important conclusions for the European road map of the Republic of Moldova from experience of the presented states.

In postmodern society the importance of traditional religious organisations and practices have declined. As a result, spirituality tends to be sought outside of institutionalised religion. Tourism is seen as one avenue for such spiritual fulfilment. Tourism research commonly frames tourism as a sacred journey and has pointed out that like modern-day pilgrims, tourists seek spirituality through travel. Of course, not all tourist travel is motivated by a search for spirituality, and yet many tourists still describe their travel experiences as spiritual. Therefore, in addition to understanding motivations of travel, the tourist experience is also an important element of making tourism a sacred journey. Is spiritual motivation a necessary prerequisite for a tourist to have a spiritual experience? What other site-specific elements might enable spiritual experiences of tourists, even if they are not motivated by a search for spirituality? Such questions have not been sufficiently explored. The aim of this paper is to investigate the relationship between visitor motivation and spiritual experience at an influential religious sacred site in rural Japan; the Shingon Esoteric Buddhism headquarters in the town of Koyasan in Wakayama Prefecture. Since becoming registered as a UNESCO World Heritage Site in 2004, Koyasan has rapidly become an internationally renowned spiritual tourism destination. This paper presents the result of a questionnaire survey of both religious tourists and tourists to Koyasan. The findings indicate spiritual motivation is not a prerequisite for spiritual experience and shows how tourists’ spiritual experiences are affected by the atmosphere of place, people and activities that comprise the temple stay setting in Koyasan.

Purpose The purpose of this paper is to see how children aged 7–11 years can become the actors of tomorrow’s hypermarket experience by providing a review of past research on children as retail consumers, with a specific reference to their customer experience. Design/methodology/approach The literature review will be organised by presenting a “child hypermarket customer experience” model. Finally, a conceptual and methodological critique of past research will be presented followed by the revised model and conclusions. Findings The literature review finds six independent variables presented in the model: customer satisfaction, in-store conflicts, buying intention, purchase basket value, loyalty and average time spent in store measure a positive hypermarket shopping experience for children. There are then six types of mediators presented in the updated model: type of product, product offering, pocket money amount, environment, technology (games, tablets) and experiential marketing that mediate the impact of these independent variables on children as the actors of tomorrow’s hypermarket experience. Research limitations/implications This paper is conceptual in nature. Future research should empirically validate the conceptual model developed in the paper for children 7–11 years of age. Practical implications The conceptual discussion shows that hypermarket managers can use technology such as games and tablets not only to reduce the conflicts between parents and children in hypermarkets but also positively impact on the average time spent in the store. Further, the discussion shows that hypermarket managers can offer children the experience they expect with the use of specific experiential stimuli adapted to children in “children’s aisles” such as toys, children’s clothing, children’s hi-tech and children’s books. They can also theme the experience for children using memorabilia and the engagement of senses. Managerial research should empirically validate this for children 7–11 years of age. Originality/value This is the first study that conceptually creates a model of children as the actors of tomorrow’s hypermarket experience. This is something that empirically researched will enhance the understanding of young consumers’ behaviour in the retail process in this advanced age of retailing.

Purpose The purpose of this paper is to consider the role that technology may play in the future of experiential tourism. This viewpoint paper begins to question future developments in technological mediation and how these may challenge the author’ view of experiences and their construction in a period of immense and rapid technological development. Design/methodology/approach This is a short viewpoint paper driven by theoretical perspectives in the existing academic literature and the author’s personal stance on the future of experiential tourism. Findings This paper suggests that while there is considerable research into the role and application of technology within tourism, there is a lack of future-orientated debate. The views expressed within the paper argue that three potential directions exist for the future of technological mediation in experiential tourism: mass acceptance and customisation; experiential convergence or “rewinding the clock”, each with significant implications for the management of technological mediation in experiential tourism. Originality/value The paper provides an initial insight into future directions of the tourism industry in a period of immense technological development. Based on existing theoretical perspectives, these viewpoints indicate three potential routes for the industry and act as a catalyst for further dialogue within tourism scholarship.

Limited research has considered social learning tools and preferences of the Generation Z learner from a higher educational perspective. This research is based on the educational theories of constructivism and social learning, in attempt to reflect on social learning tools employed in a third year Urban and Regional Planning module at the North-West University (South Africa). The empirical investigation was based on the reflections from Generation Z learners who were introduced to a range of social media tools. The paper aimed to investigate if social learning tools can positively impact the learner experience in the contemporary classroom based on longitudinal data. It identified the preferences of the Generation Z learners in terms of social media tools, and the trends thereof, during a 10-year period (2011–2020). Finally, the paper drew on the perspective of the educator, in reflecting on the challenges, but also scope, to include social learning tools as part of higher education teaching-learning.

The following paper deals with reflecting on two different community-engaged-learning experiences, offered through Western University, that I had the privilege of completing during my final year. The first experience was working for Centre Marembo, an NGO in Kigali, Rwanda that specializes in the rehabilitation and education of abused girls. The second was assisting in writing a compilation of biographical stories for Single Women in Motherhood, a local London organization that aims to help single mothers succeed. Throughout the paper, there is a strong focus on the concept of service-learning, experienced both abroad and here in Canada, and the different expectations for such a concept at various placements. In addition, it will overview adjusting one’s expectations for volunteering and how I, in particular, came to have a strong appreciation for both the lessons learned working abroad and at home.