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Progression of geographic atrophy varies significantly based on individual and lesion characteristics. Much research has strived to understand prognostic indicators of lesion progression over time, yet integrating findings to date may pose a challenge to clinicians. This review strives to synthesize current knowledge on genetic, behavioral, structural, and functional factors that influence geographic atrophy across the lifetime. Further, it highlights how vision-related quality of life allows for a more holistic appraisal of the impact of geographic atrophy on everyday functioning. The ultimate aim of this paper is to aid clinicians in counseling patients on medical management as well as providing accurate disease prognostication tailored to the individual patient., (© 2024. The Author(s), under exclusive licence to The Royal College of Ophthalmologists.)

Objective: The primary goal of this study was to determine how structural and functional parameters influence the vision-related quality of life (VRQoL) in patients suffering from geographic atrophy (GA) secondary to age-related macular degeneration., Design: This study was designed as a prospective, noninterventional, natural-history study (Directional Spread in Geographic-Atrophy study, NCT02051998)., Subjects: The research involved 82 patients with bilateral GA., Methods: The study examined parameters including GA location as assessed by the ETDRS grid, best-corrected visual acuity, low-luminance visual acuity (LLVA), reading acuity, and speed. These parameters were then correlated with VRQoL, which was gauged using the National Eye Institute Visual Function Questionnaire 25. The analysis method employed was the least absolute shrinkage and selection operator with linear mixed-effects models., Main Outcome Measures: The central parameters measured in this study encompassed GA area, VRQoL scores associated with different GA subfields, and the significance of LLVA for foveal-sparing patients., Results: On average, patients showed a total GA area of 2.9 ± 1.2 mm 2 in the better eye (BE) and 3.1 ± 1.3 mm 2 in the worse eye. The most significant associations with VRQoL scores for distance and near activities were observed in the inner lower and inner left subfields of the BE, respectively. For patients with foveal-sparing GA, the LLVA of the BE stood out as the most influential variable across all VRQoL scales., Conclusions: The study's findings point toward the pivotal role of GA location, especially the inner lower and inner left subfields of the BE, in relation to VRQoL in GA patients. The LLVA's importance becomes even more pronounced for foveal-sparing patients. These observations highlight the need for health care professionals to better understand the association between lesion location and patient-reported outcomes. This is critical for informing treatment decisions and refining the planning of interventional trials., Financial Disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article., (Copyright © 2024 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Objective: Cardiac inherited diseases can have considerable psychosocial effects, including lifestyle limitations, anxiety and depression. Most research to date on patient experiences of CID has been conducted with people from Western cultures, yet culture can shape patient views and experiences of health. The aim of this research was to explore the experiences and perspectives of Māori and Pasifika living with a cardiac inherited disease (CID)., Methods and Measures: Semi-structured interviews were conducted with 14 Māori and 14 Pasifika patients living with a cardiac inherited disease and seven of their family members, using Talanoa and Kaupapa Māori methodologies. Themes from the interviews were identified using interpretative phenomenological analysis., Results: Three common themes were identified as important in shaping participants' perceptions and experiences of CID: (1) difficulty in understanding the disease as separate from symptoms, (2) considering ancestors and future generations and (3) the role of spirituality and religion., Conclusion: This study highlights a gap between indigenous patients' understanding of CID and the western biomedical approach. Patients' understanding and treatment behaviours depend on symptoms, familial ties and spirituality. The findings support the need for transparency and culturally appropriate practices in healthcare. Considering these aspects may help to reduce health inequities for these populations.

Background: Loneliness is a significant issue in older adults and can increase the risk of morbidity and mortality., Objective: To present the development of ElliQ, a proactive, AI-driven social robot with multiple social and health coaching functions specifically designed to address loneliness and support older people., Development/implementation: ElliQ, a consumer robot with a friendly appearance, uses voice, sounds, light, and buttons through a touch screen to facilitate conversation, music, video calls, well-being assessments, stress reduction, cognitive games, and health reminders. The robot was deployed by 15 government agencies in the USA. Initial experience suggests it is not only highly engaging for older people but may be able to improve their quality of life and reduce loneliness. In addition, the development of a weekly report that patients can share with their clinicians to allow better integration into routine care is described., Conclusion: This paper describes the development and real-world implementation of this product innovation and discusses challenges encountered and future directions., Competing Interests: DS is the CEO and co-founder of Intuition Robotics, which developed ElliQ. GI and GC are employees of Intuition Robotics. KL is a former employee of Soul Machines Ltd (an AI company that makes digital humans), and EB is a consultant to Soul Machines Ltd. EB, PMD, and SB are co-developers of the COBOT scale. EB, KL, SB, MC and PMD have no financial relationship with Intuition Robotics. PMD has received grants, advisory fees and/ or stock from other biotechnology companies for unrelated projects and serves on the boards of health systems and advocacy groups., (© The Author(s) 2024.)

Background: Evidence suggests that countries with higher Covid-19 infection rates experienced poorer mental health. This study examined whether hair cortisol reduced over time in New Zealand, a country that managed to eliminate the virus in the first year of the pandemic due to an initial strict lockdown., Methods: A longitudinal cohort study assessed self-reported stress, anxiety and depression and collected hair samples that were analyzed for cortisol, across two waves in 2020. The sample consisted of 44 adults who each returned two 3 cm hair samples and completed self-reports. Hair cortisol was assessed per centimetre., Results: Hair cortisol reduced over time (F (5, 99.126) = 10.15, p < .001, partial eta squared = 0.19), as did anxiety and depression. Higher hair cortisol was significantly associated with more negative life events reported at wave two (r = 0.30 segment 1, r = 0.34 segment 2, p < .05), but not anxiety or depression., Conclusions: Strict virus control measures may not only reduce infection rates, but also reduce psychological distress, and hair cortisol over time., Competing Interests: TC is part-funded by the 10.13039/501100000272National Institute for Health Research (10.13039/501100000272NIHR) Biomedical Research Centre at 10.13039/100009362South London and Maudsley NHS Foundation Trust, King's College London. She has grants from Guy's St Thomas Charity Grants, 10.13039/501100000272NIHR and 10.13039/100014013UKRI for post COVID syndromes. She has received travel expenses, accommodation costs, and honorarium for several lectures in Europe and has received travel expenses and accommodation costs for attending American Thoracic Society Conference. She was on the Expert Advisory Panel for Covid-19 Rapid Guidelines., (© 2024 The Authors.)

People who consume tobacco are at greater risk of developing severe COVID-19. Unfortunately, the COVID-19 pandemic reduced the accessibility of tobacco cessation services as a result of necessary social restrictions. Innovations were urgently needed to support tobacco cessation during the pandemic. Virtual humans are artificially intelligent computer agents with a realistic, humanlike appearance. Virtual humans could be a scalable and engaging way to deliver tobacco cessation information and support. Florence, a virtual human health worker, was developed in collaboration with the World Health Organization to remotely support people toward tobacco cessation during the COVID-19 pandemic. Florence delivers evidence-based information, assists with making quit plans, and directs people to World Health Organization-recommended cessation services in their country. In this viewpoint, we describe the process of developing Florence. The development was influenced by a formative evaluation of data from 115 early users of Florence from 49 countries. In general, Florence was positively perceived; however, changes were requested to aspects of her design and content. In addition, areas for new content were identified (eg, for nonsmoker support persons). Virtual health workers could expand the reach of evidence-based tobacco cessation information and personalized support. However, as they are a new innovation in tobacco cessation, their efficacy, feasibility, and acceptability in this application needs to be evaluated, including in diverse populations., (©Kate Loveys, Erica Lloyd, Mark Sagar, Elizabeth Broadbent. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 05.12.2023.)

Drinking water treatment residuals (DWTRs), solid by-products of drinking water treatment, are dominated by calcium (Ca), iron (Fe), or aluminum (Al), depending on the coagulant used. DWTRs are often landfilled, but current research is exploring options for beneficial reuse. Previous studies have shown that Al- and Fe-rich materials have potential to reduce the mobility of per- and polyfluoroalkyl substances (PFAS). Here, we investigated how amending biosolids with 5% wt/wt DWTRs affected plant bioavailable PFAS in two different simulated scenarios: (1) agricultural scenario with Solanum lycopersicum (tomato) grown in soil amended with an agronomically relevant rate of DWTR-amended biosolids (0.9% w/w, resulting in 0.045% w/w DWTR in the biosolids-amended soil) and (2) mine reclamation scenario examining PFAS uptake by Lolium perenne (perennial ryegrass) grown in soil that received DWTR-amended biosolids amendment at a rate consistent with the mine remediation (13% w/w, resulting in 0.65% w/w DWTR in the biosolids-amended soil). Amending biosolids with Ca-DWTR significantly reduced perfluorobutanoic acid (PFBA) uptake in ryegrass and perfluorohexanoic acid uptake in tomatoes, possibly due to DWTR-induced pH elevation, while Fe-DWTR amendment reduced PFBA bioaccumulation in ryegrass. The Al-DWTR did not induce a significant reduction in accumulated PFAS compared to controls. Although the reasons for this finding are unclear, the relatively low PFAS concentrations in the biosolids and relatively high Al content in the biosolids and soil may be partially responsible., (© 2023 The Authors. Journal of Environmental Quality © 2023 American Society of Agronomy, Crop Science Society of America, and Soil Science Society of America.)

Objective: Virtual humans are likely to enhance the delivery of health care over the next decade. Virtual humans are artificially intelligent computer agents with hyperrealistic, autonomously animated embodiments based on affective computing techniques. Virtual humans could be programmed to screen for health conditions, triage patients, and deliver health interventions, with appropriate facial expressions and body gestures, functioning as a supplement to human care. This article provides a perspective on the implications of virtual humans for behavioral and psychosomatic medicine, and health psychology., Methods: A narrative review was conducted to integrate observations and findings from research on virtual humans from 91 articles in this multidisciplinary area., Results: Virtual humans can be used for multimodal behavior analysis of patients, individualized tailoring of interventions, and detection of changes of psychological and behavioral measures over time. Virtual humans can also pair the scalability of a website with the interactivity and relational skills of a human tele-therapist. Research is beginning to show the acceptability, feasibility, and preliminary effectiveness of virtual humans in a range of populations. Virtual humans can be easily tailored in terms of their appearance, voice, and language, and may be adapted to fit the characteristics of a patient population or hard-to-reach groups. If co-designed with these communities, virtual humans may help to promote health care engagement and improve outcomes., Conclusions: Virtual humans can engage and motivate patients, and deliver personalized psychological and behavioral health care. This article provides an overview of the potential impact of virtual humans on psychosomatic medicine and discusses ethical implications., (Copyright © 2023 by the American Psychosomatic Society.)

Background: Chronic gastroduodenal disorders including, chronic nausea and vomiting syndrome, gastroparesis, and functional dyspepsia, are challenging to diagnose and manage. The diagnostic and treatment pathways for these disorders are complex, costly and overlap substantially; however, experiences of this pathway have not been thoroughly investigated. This study therefore aimed to explore clinician and patient perspectives on the current clinical pathway., Methods: Semi-structured interviews were conducted between June 2020 and June 2022 with 11 patients with chronic nausea and vomiting syndrome alone (based on Rome IV criteria) and nine gastroenterologists who treat these conditions. Interviews were recorded, transcribed, and thematically analyzed using a reflexive, iterative, inductive approach. Five key patient themes were identified: (1) the impacts of their chronic gastroduodenal symptoms, (2) the complexity of the clinical journey, (3) their interactions with healthcare providers, (4) the need for advocacy, and (5) their experience of treatments. Five key clinician themes were also identified: (1) these conditions were seen as clinically complex, (2) there is an uncertain and variable clinical pathway, (3) the nuance of investigations, (4) these conditions were difficult to therapeutically manage, and (5) there are barriers to developing a therapeutic relationship., Conclusion: Findings indicate that both patients and clinicians are dissatisfied with the current clinical care pathways for nausea and vomiting syndromes. Recommendations included the development of more clinically relevant and discriminant tests, standardization of the diagnostic journey, and the adoption of a multidisciplinary approach to diagnosis and treatment., Competing Interests: GO’G and AG hold grants and intellectual property in the field of gastrointestinal electrophysiology and are Directors in Alimetry Ltd. GO’G is a Director in The Insides Company and CK is a medical advisor for The Insides Company. GS, ML, SC, CA, and CD are members of Alimetry Ltd. The remaining author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Sebaratnam, Law, Broadbent, Gharibans, Andrews, Daker, O’Grady, Calder and Keane.)

Companion robots with AI may usher a new science of social connectedness that requires the development of ethical frameworks.

Background: Virtual humans (VHs), teletherapy, and self-guided e-manuals may increase the accessibility of psychological interventions. However, there is limited research on how these technologies compare in terms of their feasibility and acceptability in delivering stress management interventions., Objective: We conducted a preliminary comparison of the feasibility and acceptability of a VH, teletherapy, and an e-manual at delivering 1 module of cognitive behavioral stress management (CBSM) to evaluate the feasibility of the trial methodology in preparation for a future randomized controlled trial (RCT)., Methods: A pilot RCT was conducted with a parallel, mixed design. A community sample of distressed adult women were randomly allocated to receive 1 session of CBSM involving training in cognitive and behavioral techniques by a VH, teletherapy, or an e-manual plus homework over 2 weeks. Data were collected on the feasibility of the intervention technologies (technical support and homework access), trial methods (recruitment methods, questionnaire completion, and methodological difficulty observations), intervention acceptability (intervention completion, self-report ratings, therapist rapport, and trust), and acceptability of the trial methods (self-report ratings and observations). Qualitative data in the form of written responses to open-ended questions were collected to enrich and clarify the findings on intervention acceptability., Results: Overall, 38 participants' data were analyzed. A VH (n=12), teletherapy (n=12), and an e-manual (n=14) were found to be feasible and acceptable for delivering 1 session of CBSM to distressed adult women based on the overall quantitative and qualitative findings. Technical difficulties were minimal and did not affect intervention completion, and no significant differences were found between the conditions (P=.31). The methodology was feasible, although improvements were identified for a future trial. All conditions achieved good satisfaction and perceived engagement ratings, and no significant group differences were found (P>.40). Participants had similar willingness to recommend each technology (P=.64). There was a nonsignificant trend toward participants feeling more open to using the VH and e-manual from home than teletherapy (P=.10). Rapport (P<.001) and trust (P=.048) were greater with the human teletherapist than with the VH. The qualitative findings enriched the quantitative results by revealing the unique strengths and limitations of each technology that may have influenced acceptability., Conclusions: A VH, teletherapy, and a self-guided e-manual were found to be feasible and acceptable methods of delivering 1 session of a stress management intervention to a community sample of adult women. The technologies were found to have unique strengths and limitations that may affect which works best for whom and in what circumstances. Future research should test additional CBSM modules for delivery by these technologies and conduct a larger RCT to compare their feasibility, acceptability, and effectiveness when delivering a longer home-based stress management program., Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12620000859987; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380114&isReview=true., (©Kate Loveys, Michael Antoni, Liesje Donkin, Mark Sagar, Elizabeth Broadbent. Originally published in JMIR Formative Research (https://formative.jmir.org), 09.02.2023.)

Background: Research suggests that psychological factors may influence vulnerability to SARS-CoV-2 infection, although the mechanisms are unclear., Purpose: We examined whether the hypothalamic-pituitary-adrenal axis may be a possible mechanism, by measuring the relationship between indices of psychological distress and cortisone in hair (hairE) in a UK cohort during the COVID-19 pandemic., Methods: Participants (N = 827) provided two 3 cm hair samples over a 6-month period between April-September 2020. Samples reflected hairE in the 3 months prior to the collection date., Results: HairE in the first samples (T1: commenced April 2020) did not differ significantly from pre-pandemic population norms. However, hairE in the second samples (T2: commenced July 2020) were significantly higher than T1 and pre-pandemic population norms, with a 23% increase between T1 and T2. Linear regressions, controlling for age and gender, demonstrated that at both timepoints, hairE levels were greatest in people with a history of mental health difficulties. In addition, stress reported at T1 predicted greater hairE at T2 and a greater change in hairE between T1 and T2., Conclusions: These findings demonstrate that during the COVID-19 pandemic hairE was substantially elevated across a large community cohort, with greatest levels in those with a history of mental health difficulties and greatest changes in those reporting greatest levels of stress early in the pandemic. Further research is required with verified SARS-CoV-2 outcomes to determine whether the HPA axis is among the mechanisms by which a history of mental health difficulties and stress influence SARS-CoV-2 outcomes., Competing Interests: Conflict of interest AM is the director of Cortigenix (www.cortigenix.com). Cortigenix provided guidance on remote self-collection of hair samples by participants., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Emerging research on positive and adverse childhood experiences (PCEs and ACEs) indicates that both may be important to adult health, but little is understood about the pathways through which childhood experiences affect adult health., Objective: The aims of this study were to 1) examine how shame may mediate the relationship between childhood experiences and health, and 2) whether PCEs moderated the relationship between ACEs, shame, and adult health., Participants and Setting: The sample consisted of 206 low-income adults ages 18-55 who were living in a community in the Intermountain West., Methods: Participants were recruited at a local food bank and community center where various services for low-income residents were offered. Each participant completed a 15-20-minute survey. The data were analyzed using a structural equation modeling (SEM) framework., Results: Shame mediated the relationship between both ACEs and PCEs with depression in the expected direction. Among participants with low-to-moderate PCEs, ACEs were directly associated with shame and tobacco usage. Among participants with high PCEs, ACEs were not associated with shame, depression, nor stress, and the relationship between ACEs and tobacco usage was attenuated., Conclusion: Shame may be an important pathway through which childhood experiences affect adult health. Additionally, promoting high levels of PCEs may mitigate the negative effects of early adversity on adult health., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Adverse and advantageous childhood experiences (ACEs and counter-ACEs) during adolescence are understudied. This study examined how childhood experiences affect youth tobacco/alcohol use. Participants included 489 U.S. adolescents (baseline 10-13 years; 51% female) from the first five waves of the Flourishing Families Project. Results of the cross-lagged model showed ACEs were predictive of early tobacco use only. Counter-ACEs in wave two and wave three predicted, respectively, decreased tobacco and decreased alcohol use in the following wave. Counter-ACEs were also correlated with reduced alcohol and tobacco use in later waves. These findings indicate the salience of counter-ACEs over ACEs in persistent and late adolescent substance use, though ACEs may be important to consider to prevent very early initiation of tobacco.

Objective: To investigate the effects of expressive writing and its timing (pre or post wounding) on re-epithelialisation and leucocyte subsets within healing tissue. We previously showed expressive writing pre-wounding improved re-epithelialisation. Here we investigate cellular processes in the wound., Methods: In a 2(writing content) x 2(writing timing) randomized trial, 122 participants were randomized to perform either expressive or control writing, before or after a 4 mm punch biopsy wound. On day 14 post-wounding, participants had a 5 mm punch biopsy of the initial wound. Seven of 16 primary registered outcomes were analysed, including re-epithelialisation from two photographs of the 4 mm biopsy (previously reported). This paper reports immunohistochemistry analysis of five primary outcomes - Langerhans cells, immune cell activation (HLA and CD3+), and macrophages (CD68 and MPO) - in the 5 mm biopsies in a random sample of 96 participants., Results: Participants who performed either writing task pre-wounding had greater Langerhans cell infiltration, than those who wrote post-wounding (F (1,85)  = 7.86, p = .006, η p 2  = 0.08). Those who performed expressive writing also had greater Langerhans cell infiltration than those who performed control writing (F (1,85)  = 4.00, p = .049, η p 2  = 0.04). There were no significant group or interaction effects on immune cell activation or macrophages. Healed wounds on day 10 had lower levels of macrophages (z = -1.96, p = .050), and CD3+ cells (z = -1.99, p = .046) than non-healed wounds., Conclusion: Langerhans cells in the healing skin are affected by the timing and topic of writing. More research is needed to further explore timing and corroborate these results., Clinical Trials Registration: Registered at https://www.anzctr.org.au/ (Trial ID: ACTRN12614000971639)., Competing Interests: Declaration of Competing Interest The authors have no competing interests to report., (Copyright © 2022 Elsevier Inc. All rights reserved.)

PFASs are highly persistent in the environment and the potential exists for terrestrial biota to accumulate PFAS, which may result in exposure of higher trophic level organisms to these compounds through consumption. However, trophic transfer of proteinophilic compounds such as PFAS has not been extensively studied and the degree to which plant-accumulated PFAS will be transferred to herbivorous consumers is unclear. Here, we exposed Solanum lycopersicum (tomato) plants to a suite of 7 different PFAS, including 4 carboxylic acids (PFOA, PFHxA, PFHpA and PFDA) and 3 sulfonates (PFBS, PFHxS and PFOS). Exposed leaf tissues were subsequently fed to Manduca sexta (tobacco hornworm) caterpillars. Biomagnification factors (BMFs) were all below 1 and patterns of uptake and elimination were similar between the different PFAS. However, PFOS bioaccumulated in the hornworms to a much higher concentration, with approximately 5-fold higher BMFs and assimilation efficiencies (AEs) than other PFAS tested. AE and BMF, as well as PFAS uptake by the plants, were positively correlated with PFAS carbon chain length for both sulfonates and carboxylic acids, providing evidence that longer chain PFAS may be more efficiently accumulated (or less efficiently eliminated) than shorter-chain PFAS in some contexts., (Copyright © 2022. Published by Elsevier Ltd.)

Aims: This study investigated differences in illness perceptions and self-care behaviours between Māori and New Zealand (NZ) Europeans with type 2 diabetes mellitus (T2DM), and how these perceptions were related to clinical outcomes., Methods: Participants were 85 Māori and 85 NZ European adults, recruited from outpatient clinics, who completed a cross-sectional questionnaire on illness perceptions and self-care behaviours. Clinical data, including HbA1c, retinopathy, neuropathy and nephropathy, were collected from medical records., Results: Compared to NZ Europeans, Māori had higher HbA1c, lower adherence to medication and a healthy diet, and were more likely to smoke. Māori reported greater perceived consequences of diabetes on their lives, and more severe symptoms than NZ Europeans did. Māori were more likely to attribute T2DM to food and drink, whereas NZ Europeans were more likely to attribute T2DM to weight. Perceiving that treatment could help control diabetes was associated with lower HbA1c and higher medication adherence in Māori and NZ Europeans independently., Conclusions: Māori experienced and perceived worse T2DM outcomes than NZ Europeans did. Research is needed to develop and test clinical interventions to address these inequities and improve outcomes, possibly by asking patients about their perceptions, providing tailored and culturally appropriate education, and discussing patients' concerns., Competing Interests: Nil., (© PMA.)

Cardiac Inherited diseases (CID) and minority ethnic status are both associated with anxiety and depression. This study aimed to investigate differences in patient experiences of CID between ethnic groups in New Zealand (NZ) in order to inform psychosocial interventions and promote health equity. A cross-sectional survey was administered to a NZ CID database. One-hundred and fifty-two (152) NZ Europeans, 19 Māori, and two Pasifika participated. Māori and Pasifika peoples reported significantly greater symptom perceptions, shorter timeline perceptions, higher perceived risk of severe symptoms, and were less likely to attribute the cause of their CID to hereditary factors than NZ Europeans. Māori and Pasifika also reported more anxiety and distress, although both groups reported beneficial medication perceptions and high medication adherence. Differences could not be attributed to clinical or other demographic variables. The use of screening tools and development of culturally appropriate interventions may help reduce both distress and health inequities., (Copyright © 2022 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Background: Visualizations of illness and treatment processes are promising interventions for changing unhelpful perceptions and improving health outcomes. However, these are yet to be tested in patients with type 2 diabetes mellitus (T2DM)., Objective: This study assesses the cross-cultural acceptability and potential effectiveness of a brief visual animation of T2DM at changing unhelpful illness and treatment perceptions and self-efficacy among patients and family members in 2 countries, New Zealand and Saudi Arabia. Health care professionals' views on visualization are also explored., Methods: A total of 52 participants (n=39, 75% patients and family members and n=13, 25% health care professionals) were shown a 7-minute T2DM visual animation. Patients and family members completed a questionnaire on illness and treatment perceptions and self-efficacy before and immediately after the intervention and completed semistructured interviews. Health care professionals completed written open-ended questions. Means and 95% CIs are reported to estimate potential effectiveness. Inductive thematic analysis was conducted on qualitative data., Results: All participants rated the visual animation as acceptable and engaging. Four main themes were identified: animation-related factors, impact of the animation, animation as an effective format for delivering information, and management-related factors. Effect sizes (ranged from 0.10 to 0.56) suggested potential effectiveness for changing illness and treatment perceptions and self-efficacy among patients and family members., Conclusions: Visualizations are acceptable and may improve the perceptions of patients' with diabetes in a short time frame. This brief visual animation has the potential to improve current T2DM education. A subsequent randomized controlled trial to investigate the effects on illness and treatment perceptions, adherence, glycemic control, and unplanned hospital admission is being prepared., (©Mohsen Alyami, Anna Serlachius, Mikaela Law, Rinki Murphy, Turky H Almigbal, Mataroria Lyndon, Mohammed A Batais, Rawabi K Algaw, Elizabeth Broadbent. Originally published in JMIR Formative Research (https://formative.jmir.org), 09.08.2022.)

Background: Functional gastroduodenal disorders include functional dyspepsia, chronic nausea and vomiting syndromes, and gastroparesis. These disorders are common, but their overlapping symptomatology poses challenges to diagnosis, research, and therapy. This study aimed to introduce and validate a standardized patient symptom-logging system and App to aid in the accurate reporting of gastroduodenal symptoms for clinical and research applications., Methods: The system was implemented in an iOS App including pictographic symptom illustrations, and two validation studies were conducted. To assess convergent and concurrent validity, a diverse cohort with chronic gastroduodenal symptoms undertook App-based symptom logging for 4 h after a test meal. Individual and total post-prandial symptom scores were averaged and correlated against two previously validated instruments: PAGI-SYM (for convergent validity) and PAGI-QOL (for concurrent validity). To assess face and content validity, semi-structured qualitative interviews were conducted with patients., Key Results: App-based symptom reporting demonstrated robust convergent validity with PAGI-SYM measures of nausea (r S  =0.68), early satiation (r S  =0.55), bloating (r S  =0.48), heartburn (r S  =0.47), upper gut pain (r S  =0.40), and excessive fullness (r S  =0.40); all p < 0.001 (n = 79). The total App-reported Gastric Symptom Burden Score correlated positively with PAGI-SYM (r S  =0.56; convergent validity; p < 0.001), and negatively with PAGI-QOL (r S  = -0.34; concurrent validity; p = 0.002). Interviews demonstrated that the pictograms had adequate face and content validity., Conclusions and Inferences: The continuous patient symptom-logging App demonstrated robust convergent, concurrent, face, and content validity when used within a 4-h post-prandial test protocol. The App will enable standardized symptom reporting and is anticipated to provide utility in both research and clinical practice., (© 2022 The Authors. Neurogastroenterology & Motility published by John Wiley & Sons Ltd.)

Background: Cross-sectional research demonstrates associations between illness perceptions and glycemic control in people with type 2 diabetes (T2D). Prospective studies are limited and show mixed findings. This study aimed to investigate (1) whether baseline illness perceptions predicted glycemic control (HbA1c levels) at 6-12-month follow-up and (2) possible differences in baseline illness perceptions between individuals who completed at least one HbA1c blood test during the 12-month follow-up and those who did not., Methods: A total of 115 individuals with T2D were recruited from an outpatient clinic. Demographic and clinical information and illness perceptions were assessed at baseline. HbA1c was assessed at baseline and 12 months later from clinical records. Hierarchical multiple linear regression examined associations between baseline illness perceptions and HbA1c levels at 6-12-month follow-up, controlling for age, sex, education, types of diabetes medication, and baseline HbA1c., Results: Univariate analysis showed perceived weight management effectiveness at baseline was associated with lower HbA1c at follow-up (rho = -.25, p = .04, n = 67). Adjusted multiple regression showed that HbA1c at baseline was the only significant predictor of HbA1c at 6-12-month follow-up (β = 0.51, p < .001). There were no significant differences in baseline illness perceptions between individuals who completed HbA1c blood tests during follow-up (n = 78) and those who did not (n = 34), p > .05., Conclusion: Illness perceptions at baseline did not predict longitudinal HbA1c in adjusted analyses, nor completion of HbA1c tests. Results may be due to temporal variability in HbA1c and barriers to accessing blood tests., (© 2021. International Society of Behavioral Medicine.)

An aging global population and preference for aging-in-place pose the opportunity for home-based robots to assist older adults with their daily routines. However, there is limited research into the experiences of older adults using robots in their own homes. In this descriptive qualitative feasibility study, older self-supporting and community-dwelling adults with various age-related health needs used Bomy, a dailycare robot in their homes for up to one week. The study explored the usefulness of the robot and participants' perceptions and experiences of using it. Bomy reminded them of daily activities and delivered cognitive stimulation games. Semi-structured in-person interviews were conducted, and data were analyzed thematically. Findings revealed an acceptance toward robots and the value of assistive dailycare robots. Participants perceived Bomy as a companion and made suggestions for improvement, including resolving technical issues associated with long-term use. Future functions should be personalizable, to accommodate each user's health needs and could also include smoke detection and reading aloud functions. Dailycare robots show promising potential in elderly care, especially in providing reminders for medication, health and wellbeing. This study highlights the importance of co-design and testing robotics in the environments for which they have been developed. Widespread implementation of Bomy might be feasible in the future, with some further adjustments.

Emotions are multimodal processes that play a crucial role in our everyday lives. Recognizing emotions is becoming more critical in a wide range of application domains such as healthcare, education, human-computer interaction, Virtual Reality, intelligent agents, entertainment, and more. Facial macro-expressions or intense facial expressions are the most common modalities in recognizing emotional states. However, since facial expressions can be voluntarily controlled, they may not accurately represent emotional states. Earlier studies have shown that facial micro-expressions are more reliable than facial macro-expressions for revealing emotions. They are subtle, involuntary movements responding to external stimuli that cannot be controlled. This paper proposes using facial micro-expressions combined with brain and physiological signals to more reliably detect underlying emotions. We describe our models for measuring arousal and valence levels from a combination of facial micro-expressions, Electroencephalography (EEG) signals, galvanic skin responses (GSR), and Photoplethysmography (PPG) signals. We then evaluate our model using the DEAP dataset and our own dataset based on a subject-independent approach. Lastly, we discuss our results, the limitations of our work, and how these limitations could be overcome. We also discuss future directions for using facial micro-expressions and physiological signals in emotion recognition., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Saffaryazdi, Wasim, Dileep, Nia, Nanayakkara, Broadbent and Billinghurst.)

Demographics and media discourse impact vaccine hesitancy. We explored the New Zealand public's perceptions of COVID-19 vaccines and associated media portrayal, and determined predictive factors associated with willingness to receive vaccines. A community cohort (N = 340) completed online surveys. A logistic regression explored whether characteristics predict willingness to receive the vaccine. Textual data were analysed thematically. Willingness to receive the vaccine was high (90%). Having a postgraduate degree (p =.026), trying to receive an influenza vaccine (p <.001) and fewer concerns (p <.001) predicted willingness. Health keyworkers (p <.001) were less willing. Participants wanted the vaccine for protection and returning to normality. Reasons against receiving vaccines regarded safety, efficacy, and an unclear roll-out plan. The media was reported to generally provide good/positive coverage, but also engage in unbalanced reporting and spreading misinformation. Education strategies should include collaborations between media and scientists and focus on distributing easy-to-access information. Health keyworkers should be reassured of testing/safety., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: Previous research has shown that psychological factors, such as stress and social support, are associated with greater susceptibility to viral respiratory illnesses and more severe symptoms. During the COVID-19 pandemic there has been a well-documented deterioration in psychological well-being and increased social isolation. This raises questions as to whether those experiencing psychological adversity during the pandemic are more at risk of contracting and/or experiencing COVID-19 symptoms., Purpose: To examine the relationship between psychological factors and the risk of COVID-19 self-reported infection and the symptomatic experience of SARS-CoV-2 (indicated by the number and severity of symptoms)., Methods: As part of a longitudinal prospective observational cohort study, 1,087 adults completed validated measures of psychological well-being during April 2020 and self-reported incidence of COVID-19 infection and symptom experience across the pandemic through to December 2020. Regression models were used to explore these relationships controlling for demographic and occupational factors., Results: Greater psychological distress during the early phase of the pandemic was significantly associated with subsequent self-reported SARS-CoV-2 infection as well as the experience of a greater number and more severe symptoms., Conclusions: COVID-19 infection and symptoms may be more common among those experiencing elevated psychological distress. Further research to elucidate the mechanisms underlying these associations is needed., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Society of Behavioral Medicine.)

Objective: Stress can play a role in the onset and exacerbation of psoriasis. Psychological interventions to reduce stress have been shown to improve psychological and psoriasis-related outcomes. This pilot randomised study investigated the feasibility of a brief interaction with a Paro robot to reduce stress and improve skin parameters, after a stressor, in patients with psoriasis., Methods: Around 25 patients with psoriasis participated in a laboratory stress task, before being randomised to either interact with a Paro robot or sit quietly (control condition) for 30 min. Raman spectroscopy and trans-epidermal water loss were measured at baseline, after the stressor and after the intervention as indexes of acute skin changes. Psychological variables, including self-reported stress and affect, were also measured at the three time-points., Results: No statistically significant differences between the two conditions were found for any of the outcomes measured. However, effect sizes suggest significance could be possible with a larger sample size. Changes in the psychological and Raman spectroscopy outcomes across the experimental session were found, indicating the feasibility of the procedures., Conclusion: This pilot study showed that a brief interaction with a Paro robot was a feasible intervention for patients with psoriasis, but future trials should broaden the inclusion criteria to try to increase recruitment rates. Studying people who are highly stressed, depressed or who are stress-responders may increase the power of the intervention to show effects using a longer-term intervention., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Law, Jarrett, Nieuwoudt, Holtkamp, Giglio and Broadbent.)

Objectives: Stunting remains a prevalent issue in Tanzania. The consequences of stunting include reduced height, greater susceptibility to disease, and diminished cognitive ability throughout the lifespan. Lack of psychosocial stimulation is associated with increased stunting, particularly in terms of its cognitive impact. The Addressing Stunting in Tanzania Early (ASTUTE) program was a large social and behavior change communication (SBCC) intervention that aimed to reduce childhood stunting in the region by targeting early childhood development (ECD) behaviors. The purpose of this study is to report on the extent to which exposure to ASTUTE might be related to ECD behaviors. Methods: ASTUTE disseminated program messages via a mass media campaign and interpersonal communication (IPC). Logistic regression models were used to explore the relationship between exposure to TV, radio, IPC messages, and key ECD behaviors of female primary caregivers and male heads of household. Results: Among primary caregivers, IPC was positively associated with all ECD behaviors measured. Radio was associated with all behaviors except drawing with their child. TV was associated with all behaviors except playing with their child. Among heads of household, only the radio was positively associated with the ECD behaviors measured. Conclusions for practice: Findings indicate that SBCC interventions that include mass media and IPC components may be effective at promoting parental engagement in ECD behaviors. Significance: We know that ECD is important for a child's development. We know that parents play a critical role in promoting ECD behaviors. We are still exploring ways to influence parents so that they are more involved in ECD behaviors. The results presented here provide evidence for successful mass media and IPC efforts to improve parents' ECD behaviors. We hope this study will add more evidence for large interventions such as these to the literature, and we are very hopeful that governments and large international NGOs will prioritize SBCC approaches in the future, especially in locations where face-to-face interventions may be challenging.

Contact tracing for infectious diseases can be partially automated using mobile applications. However, the success of these tools is dependent on significant uptake and frequent use by the public. This study explored the barriers and facilitators to the New Zealand (NZ) general public's use of the COVID-19 contact NZ COVID Tracer app. Adults (≥18 years, N = 373) in NZ. Qualitative and quantitative data were gathered from a nation-wide online survey. App use and frequency of use were presented as descriptive statistics. Qualitative data were analyzed thematically. 31% reported using the app frequently, 24% used it sometimes, 21% had installed but not used it, and 24% had not installed it. Barriers to use include technical issues, privacy and security concerns, forgetfulness and a lack of support from businesses. The perceived risk of contracting COVID-19, government recommendations and communications, and the importance of contact tracing facilitated use. Technical, user, business, and government factors influenced the public's use of a COVID-19 contact tracing app. The development of apps requiring minimal user effort and initial user testing may improve uptake. Enabling environments and better risk communication may improve uptake of similar community-driven contact tracing apps during future pandemics.

Artificial intelligence (AI)-enhanced interventions show promise for improving the delivery of long-term care (LTC) services for older people. However, the research field is developmental and has yet to be systematically synthesised. This systematic review aimed to synthesise the literature on the acceptability and effectiveness of AI-enhanced interventions for older people receiving LTC services. We conducted a systematic search that identified 2720 records from Embase, Ovid, Global Health, PsycINFO, and Web of Science. 31 articles were included in the review that evaluated AI-enhanced social robots (n=22), environmental sensors (n=6), and wearable sensors (n=5) with older people receiving LTC services across 15 controlled and 14 non-controlled trials in high-income countries. Risk of bias was evaluated using the RoB 2, RoB 2 CRT, and ROBINS-I tools. Overall, AI-enhanced interventions were found to be somewhat acceptable to users with mixed evidence for their effectiveness across different health outcomes. The included studies were found to have high risk of bias which reduced confidence in the results. AI-enhanced interventions are promising innovations that could reshape the landscape of LTC globally. However, more trials are required to support their widespread implementation. Pathways are needed to support more high-quality trials, including in low-income and middle-income countries., Competing Interests: Soul Machines (a New Zealand-based AI company) supported KL with a PhD stipend at the time of the research and currently employs her as a Postdoctoral Research Associate (but not at the time the research was conducted); Soul Machines also contracts EB for consultancy work. Soul Machines had no say in the conduct of the study, its interpretation, and its conclusions. All other authors declare no competing interests. The views expressed in this paper are those of the authors and do not necessarily reflect the views of WHO., (© 2022 World Health Organization.)

Background: The COVID-19 pandemic has had profound consequences for population mental health. However, it is less clear for whom these effects are sustained., Aims: To investigate the prevalence, incidence, prognosis and risk factors for symptoms of depression and anxiety in a UK cohort over three distinct periods in the pandemic in 2020., Method: An online survey was completed by a UK community cohort at three points (n = 3097 at baseline, n = 878 completed all surveys): April (baseline), July to September (time point 2) and November to December (time point 3). Participants completed validated measures of depression and anxiety on each occasion, and we prospectively explored the role of sociodemographic and psychological factors (loneliness, positive mood and perceived risk of and worry about COVID-19) as risk factors., Results: Depression (Patient Health Questionnaire-9 means: baseline, 7.69; time point 2, 5.53; time point 3, 6.06) and anxiety scores (Generalised Anxiety Disorder-7 means: baseline, 6.59; time point 2, 4.60; time point 3, 4.98) were considerably greater than pre-pandemic population norms at all time points. Women reported greater depression and anxiety symptoms than men. Younger age, history of mental health disorder, more COVID-19-related negative life events, greater loneliness and lower positive mood at baseline were all significant predictors of poorer mental health at time point 3., Conclusions: The negative impact of the COVID-19 pandemic on mental health has persisted to some degree. Younger people and individuals with prior mental health disorders are at greatest risk. Easing of restrictions and resumption of social interaction could mitigate the risk factors of loneliness and positive mood.

Mercury emissions from artisanal and small-scale gold mining throughout the Global South exceed coal combustion as the largest global source of mercury. We examined mercury deposition and storage in an area of the Peruvian Amazon heavily impacted by artisanal gold mining. Intact forests in the Peruvian Amazon near gold mining receive extremely high inputs of mercury and experience elevated total mercury and methylmercury in the atmosphere, canopy foliage, and soils. Here we show for the first time that an intact forest canopy near artisanal gold mining intercepts large amounts of particulate and gaseous mercury, at a rate proportional with total leaf area. We document substantial mercury accumulation in soils, biomass, and resident songbirds in some of the Amazon's most protected and biodiverse areas, raising important questions about how mercury pollution may constrain modern and future conservation efforts in these tropical ecosystems., (© 2022. The Author(s).)

Purpose: This research aimed to evaluate medication software for a healthcare robot. Study I compared two software versions (RoboGen and RoboGen2) for system usability, speed and accuracy of medication entry; Study II evaluated system usability and community pharmacists' views of RoboGen2. Methods: Study I had a within-subjects experimental design and recruited 40 Health Sciences students to enter different, comparable sets of prescriptions into the two systems, in randomized order, within a limit of 15 min. Screen activity was recorded to observe prescription errors. Study II had a cross-sectional observational design and recruited 20 community pharmacists using convenience sampling. Pharmacists entered three prescriptions using RoboGen2. Participants in both studies completed the System Usability Scale (SUS) following each task. Study I participants completed a questionnaire on system preference, and Study II participants a semi-structured interview. Results: Study I participants preferred Robogen2 ( p < 0.001) due to its sleek and modern layout, good flow, ease of use, and intuitive design. SUS scores [ t (40) = -3.40, p = 0.002] and speed of medication entry favored Robogen2 ( t = 3.65, p < 0.001). No significance was found in accuracy ( t = 1.12, p = 0.27). In study 2, pharmacists rated the usability of RoboGen2 below average. Themes from interviews were navigation and streamlining the system, ease of use, and integration with pharmacy software systems. Conclusion: Adding safety features and better aesthetics can improve the usability and safety of a medication prescription system. Streamlining workflow and pre-populating data can increase speed of prescription entry without compromising patient safety. However, a better approach is integration with pre-existing pharmacy systems to reduce workload while incorporating safety features built into existing dispensing systems., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Martini, Broadbent, Koo, Lam, Verches, Zeng, Montgomery-Walsh and Sutherland.)

Background: Loneliness is a growing public health problem that has been exacerbated in vulnerable groups during the COVID-19 pandemic. Social support interventions have been shown to reduce loneliness, including when delivered through technology. Digital humans are a new type of computer agent that show promise as supportive peers in health care. For digital humans to be effective and engaging support persons, it is important that they develop closeness with people. Closeness can be increased by emotional expressiveness, particularly in female relationships. However, it is unknown whether emotional expressiveness improves relationships with digital humans and affects physiological responses., Objective: The aim of this study is to investigate whether emotional expression by a digital human can affect psychological and physiological outcomes and whether the effects are moderated by the user's gender., Methods: A community sample of 198 adults (101 women, 95 men, and 2 gender-diverse individuals) was block-randomized by gender to complete a 15-minute self-disclosure conversation with a female digital human in 1 of 6 conditions. In these conditions, the digital human varied in modality richness and emotional expression on the face and in the voice (emotional, neutral, or no face; emotional or neutral voice). Perceived loneliness, closeness, social support, caring perceptions, and stress were measured after each interaction. Heart rate, skin temperature, and electrodermal activity were assessed during each interaction. 3-way factorial analyses of variance with post hoc tests were conducted., Results: Emotional expression in the voice was associated with greater perceptions of caring and physiological arousal during the interaction, and unexpectedly, with lower feelings of support. User gender moderated the effect of emotional expressiveness on several outcomes. For women, an emotional voice was associated with increased closeness, social support, and caring perceptions, whereas for men, a neutral voice increased these outcomes. For women, interacting with a neutral face was associated with lower loneliness and subjective stress compared with no face. Interacting with no face (ie, a voice-only black screen) resulted in lower loneliness and subjective stress for men, compared with a neutral or emotional face. No significant results were found for heart rate or skin temperature. However, average electrodermal activity was significantly higher for men while interacting with an emotional voice., Conclusions: Emotional expressiveness in a female digital human has different effects on loneliness, social, and physiological outcomes for men and women. The results inform the design of digital human support persons and have theoretical implications. Further research is needed to evaluate how more pronounced emotional facial expressions in a digital human might affect the results., Trial Registration: Australia New Zealand Clinical Trials Registry (ANZCTR) ACTRN12621000865819; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=381816&isReview., (©Kate Loveys, Mark Sagar, Xueyuan Zhang, Gregory Fricchione, Elizabeth Broadbent. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 25.11.2021.)

Background: Loneliness is a growing public health issue that has been exacerbated in vulnerable groups during the COVID-19 pandemic. Computer agents are capable of delivering psychological therapies through the internet; however, there is limited research on their acceptability to date., Objective: The objectives of this study were to evaluate (1) the feasibility and acceptability of a remote loneliness and stress intervention with digital human delivery to at-risk adults and (2) the feasibility of the study methods in preparation for a randomized controlled trial., Methods: A parallel randomized pilot trial with a mixed design was conducted. Participants were adults aged 18 to 69 years with an underlying medical condition or aged 70 years or older with a Mini-Mental State Examination score of >24 (ie, at greater risk of developing severe COVID-19). Participants took part from their place of residence (independent living retirement village, 20; community dwelling, 7; nursing home, 3). Participants were randomly allocated to the intervention or waitlist control group that received the intervention 1 week later. The intervention involved completing cognitive behavioral and positive psychology exercises with a digital human facilitator on a website for at least 15 minutes per day over 1 week. The exercises targeted loneliness, stress, and psychological well-being. Feasibility was evaluated using dropout rates and behavioral observation data. Acceptability was evaluated from behavioral engagement data, the Friendship Questionnaire (adapted), self-report items, and qualitative questions. Psychological measures were administered to evaluate the feasibility of the trial methods and included the UCLA Loneliness Scale, the 4-item Perceived Stress Scale, a 1-item COVID-19 distress measure, the Flourishing Scale, and the Scale of Positive and Negative Experiences., Results: The study recruited 30 participants (15 per group). Participants were 22 older adults and 8 younger adults with a health condition. Six participants dropped out of the study. Thus, the data of 24 participants were analyzed (intervention group, 12; waitlist group, 12). The digital human intervention and trial methods were generally found to be feasible and acceptable in younger and older adults living independently, based on intervention completion, and behavioral, qualitative, and some self-report data. The intervention and trial methods were less feasible to nursing home residents who required caregiver assistance. Acceptability could be improved with additional content, tailoring to the population, and changes to the digital human's design., Conclusions: Digital humans are a promising and novel technological solution for providing at-risk adults with access to remote psychological support during the COVID-19 pandemic. Research should further examine design techniques to improve their acceptability in this application and investigate intervention effectiveness in a randomized controlled trial., Trial Registration: Australia New Zealand Clinical Trials Registry ACTRN12620000786998; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380113., (©Kate Loveys, Mark Sagar, Isabella Pickering, Elizabeth Broadbent. Originally published in JMIR Mental Health (https://mental.jmir.org), 08.11.2021.)

Objective: Little is known about the psychological experiences of individuals being investigated for cardiac inherited diseases (CID). This study aimed to assess the prevalence, trajectory and associated variables of anxiety and depression in this population., Design: This was a longitudinal study with 116 individuals being investigated for a CID; 85 (73%) completed follow-up., Main Outcome Measures: Questionnaires were administered at the first appointment, post-disclosure of genetic results, and six-months later. Questionnaires measured demographic and psychological variables. The NZCID Registry provided clinical and genetic information., Results: Thirty-seven (43%) individuals reported clinical and subclinical levels of anxiety and/or depression at least once. Anxiety and depression at follow up were associated with anxiety (p < .001) and depression ( p < .001) at baseline. Elevated anxiety and depression scores at any point were also associated with more reporting of somatic symptoms ( p < .001), poorer social support ( p < .01) and greater intolerance for uncertainty ( p < .001). There were five different trajectories of anxiety and depression: stable-low, stable-high, increasing, decreasing and fluctuating., Conclusion: A significant minority of individuals being investigated for a CID experience anxiety and depression. Ongoing screening for anxiety, depression, social support and somatic symptoms could help identify those individuals.

Objective: To review the existing evidence on the effects of viewing visual artworks on stress outcomes and outline any gaps in the research., Design: A scoping review was conducted based on the Joanna Briggs Institute methodology for scoping reviews and using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. Two independent reviewers performed the screening and data extraction., Data Sources: Medline, Embase, APA PsycINFO, Cochrane CENTRAL, Scopus, Google Scholar, Google, ProQuest Theses and Dissertations Database, APA PsycExtra and Opengrey.eu were searched in May 2020., Eligibility Criteria: Studies were included if they investigated the effects of viewing at least one visual artwork on at least one stress outcome measure. Studies involving active engagement with art, review papers or qualitative studies were excluded. There were no limits in terms of year of publication, contexts or population types; however, only studies published in the English language were considered., Data Extraction and Synthesis: Information extracted from manuscripts included: study methodologies, population and setting characteristics, details of the artwork interventions and key findings., Results: 14 primary studies were identified, with heterogeneous study designs, methodologies and artwork interventions. Many studies lacked important methodological details and only four studies were randomised controlled trials. 13 of the 14 studies on self-reported stress reported reductions after viewing artworks, and all of the four studies that examined systolic blood pressure reported reductions. Fewer studies examined heart rate, heart rate variability, cortisol, respiration or other physiological outcomes., Conclusions: There is promising evidence for effects of viewing artwork on reducing stress. Moderating factors may include setting, individual characteristics, artwork content and viewing instructions. More robust research, using more standardised methods and randomised controlled trial designs, is needed., Registration Details: A protocol for this review is registered with the Open Science Framework (osf.io/gq5d8)., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Aim: Loneliness is a common problem in older adults and contributes to poor health. This scoping review aimed to synthesize and report evidence on the effectiveness of interventions using social robots or computer agents to reduce loneliness in older adults and to explore intervention strategies., Methods: The review adhered to the Arksey and O'Malley process for conducting scoping reviews. The SCOPUS, PUBMED, Web of Science, EMBASE, CINAHL, PsycINFO, ACM Digital Library and IEEE Xplore databases were searched in November, 2020. A two-step selection process identified eligible research. Information was extracted from papers and entered into an Excel coding sheet and summarised. Quality assessments were conducted using the Mixed Methods Appraisal Tool., Results: Twenty-nine studies were included, of which most were of moderate to high quality. Eighteen were observational and 11 were experimental. Twenty-four used robots, four used computer agents and one study used both. The majority of results showed that robots or computer agents positively impacted at least one loneliness outcome measure. Some unintended negative consequences on social outcomes were reported, such as sadness when the robot was removed. Overall, the interventions helped to combat loneliness by acting as a direct companion (69%), a catalyst for social interaction (41%), facilitating remote communication with others (10%) and reminding users of upcoming social engagements (3%)., Conclusion: Evidence to date suggests that robots can help combat loneliness in older adults, but there is insufficient research on computer agents. Common strategies for reducing loneliness include direct companionship and enabling social interactions. Future research could investigate other strategies used in human interventions (eg, addressing maladaptive social cognition and improving social skills), and the effects of design features on efficacy. It is recommended that more robust experimental and mixed methods research be conducted, using a combination of validated self-report, observational, and interview measures of loneliness., Competing Interests: Elizabeth Broadbent authored/co-authored five studies included in the review. However, Elizabeth did not conduct the quality assessments, so potential conflicts of interest were mitigated. Soul Machines Ltd (a company that makes digital humans) employs Kate Loveys as an intern and contracts Elizabeth Broadbent as a consultant. The authors report no other conflicts of interest in this work., (© 2021 Gasteiger et al.)

Objectives: The COVID-19 pandemic has caused unprecedented disruption to daily life. This study investigated depression, anxiety and stress in New Zealand (NZ) during the first 10 weeks of the COVID-19 pandemic, and associated psychological and behavioural factors. It also compares the results with a similar cross-sectional study in the UK., Design: Cross-sectional study., Setting: NZ community cohort., Participants: N=681 adults (≥18 years) in NZ. The cohort was predominantly female (89%) with a mean age of 42 years (range 18-87). Most (74%) identified as NZ European and almost half (46%) were keyworkers. Most were non-smokers (95%) and 20% identified themselves as having clinical risk factors which would put them at increased or greatest risk of COVID-19., Main Outcome Measures: Depression, anxiety, stress, positive mood and engagement in health behaviours (smoking, exercise, alcohol consumption)., Results: Depression and anxiety significantly exceeded population norms (p<0.0001). Being younger (p<0.0001) and most at risk of COVID-19 (p<0.05) were associated with greater depression, anxiety and stress. Greater positive mood, lower loneliness and greater exercise were protective factors for all outcomes (p<0.0001). Smoking (p=0.037) and alcohol consumption (p<0.05) were associated with increased anxiety. Pet ownership was associated with lower depression (p=0.006) and anxiety (p=0.008). When adjusting for age and gender differences, anxiety (p = 0.002) and stress (p = 0.007) were significantly lower in NZ than in the UK. The NZ sample reported lower perceived risk (p<0.0001) and worry about COVID-19 (p<0.0001) than the UK sample., Conclusions: The NZ population had higher depression and anxiety compared with population norms. Younger people and those most at risk of COVID-19 reported poorer mental health. Interventions should promote frequent exercise, and reduce loneliness and unhealthy behaviours., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Peri-operative hypothermia is associated with significant morbidity, yet limitations exist regarding non-invasive temperature assessment in the post-anaesthesia care unit (PACU). In this prospective study of 100 patients, we aimed to determine the reliability of two commonly used temperature measurement devices, forehead temporal artery temperature and tympanic measurement, in addition to an indwelling urinary catheter with temperature probe, in comparison with the final nasopharyngeal core temperature at the end of surgery. Agreement of forehead measurement with nasopharyngeal temperature showed a mean bias (±95% limits of agreement) of 0.15 °C (±1.4 °C), with a steep slope of the relationship on the Bland-Altman plot of -0.8, indicating a tendency to normalise patient temperature readings to 36.4 °C. Only 54% of hypothermic cases were correctly detected by the forehead measurement device. Agreement of tympanic measurement with nasopharyngeal core temperature measurement was marginally improved with a mean bias of 0.13 °C (95% limits of agreement ±1.15 °C). In contrast, agreement of bladder temperature with nasopharyngeal temperature showed a mean (SD) bias of 0.19 (0.28) °C (95% limits of agreement ±0.54 °C), with a relatively flat line of best fit. We demonstrated that two commonly used temperature measurement devices, forehead temporal artery temperature and tympanic measurement, compared with nasopharyngeal core temperature, were imprecise and unreliable following major surgery. However, the indwelling catheter with temperature sensor was precise and acceptable for continuous core temperature measurement in the PACU., (© 2020 Association of Anaesthetists.)

Aims: This systematic review sought to synthesize the evidence regarding the effectiveness of illness perception interventions compared with control conditions at changing illness perceptions and improving glycaemic control in individuals with type 2 diabetes., Methods: Seven electronic databases were searched between October 2018 and May 2020. Randomized controlled trials that tested interventions informed by the Common-Sense Model in adults with type 2 diabetes, and measured illness perceptions and glycaemic control at pre- and post-intervention were included. The Cochrane risk of bias tool was used to assess risk of bias., Results: A total of 4095 articles were identified, of which nine randomized control trials (2561 participants) across 12 publications were included in this review. Findings showed that all the illness perception domains were modified in at least one trial, with the exception of cyclical timeline perceptions. Coherence, personal control, treatment control and chronic timeline perceptions were the most frequently modified perceptions. Glycaemic control demonstrated an improvement in the intervention group compared to the control group at 3 and 6 months post-intervention in two trials. Risk of bias assessment showed high risk of bias especially for the blinding of participants and the personnel domain., Conclusions: There is limited evidence that interventions informed by the Common-Sense Model can improve glycaemic control in individuals with type 2 diabetes through changing inaccurate illness perceptions. Recommendations for future research are to tailor intervention content based on baseline perceptions, measure the emotional and causal domains, and involve family members in the intervention. (PROSPERO registration: CRD42019114532)., (© 2020 Diabetes UK.)

Objectives: The number of people testing positive for Severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) in the UK, particularly among young adults, is increasing. We report here on the mental health of young adults and related psychological and behavioural responses to the pandemic and consider the role of these factors in fuelling the increase in coronavirus disease 2019 (COVID-19) in this group., Methods: An online survey was completed during the first six weeks of the first UK-wide lockdown by 3097 respondents, including data for 364 respondents aged 18-24 years. The survey included measures of mental health and indices capturing related psychological and behavioural responses to the pandemic., Results: The mental health of 18- to 24-years-olds in the first 6 weeks of lockdown was significantly poorer than that of older respondents and previously published norms: with 84% reporting symptoms of depression and 72% reporting symptoms of anxiety. Young adults also reported significantly greater loneliness and reduced positive mood, both of which were also associated with greater mental health difficulties., Conclusions: We contend that the combination of mental health, social and economic considerations may have contributed to the rise of COVID-19 infections in young adults, and ascribing blame to this group will not aid our efforts to regain control of the disease., (Copyright © 2020 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

Families strongly influence the health of communities and individuals across the life course, but no validated measure of family health exists. The absence of such a measure has limited the examination of family health trends and the intersection of family health with individual and community health. The purpose of this study was to examine the reliability and validity of the Family Health Scale (FHS), creating a multi-factor long-form and a uniform short-form. The primary sample included 1,050 adults recruited from a national quota sample Qualtrics panel. Mplus version 7 was used to analyze the data using a structural equation modeling framework. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) confirmed a 32-item, 4-factor long-form scale. The four factors included (1) family social and emotional health processes; (2) family healthy lifestyle; (3) family health resources; and (4) family external social supports. A 10-item short-form of the FHS was also validated in the initial sample and a second sample of 401 adults. Both the long-form and short-form FHS correlated in the expected direction with validated measures of family functioning and healthy lifestyle. A preliminary assessment of clinical cutoffs in the short-form were correlated with depression risk. The FHS offers the potential to assess family health trends and to develop accessible, de-identified databases on the well-being of families. Important next steps include validating the scale among multiple family members and collecting longitudinal data., (Copyright © 2020 Crandall, Weiss-Laxer, Broadbent, Holmes, Magnusson, Okano, Berge, Barnes, Hanson, Jones and Novilla.)

Objective: Environmental enrichment (EE) can reduce stress, alter immunity, and speed wound healing in animals. However, it is not known whether these effects translate to humans. This study aimed to investigate whether sensory EE could improve wound healing after a stressor in humans., Methods: A total of 105 participants underwent a tape-stripping procedure and were then stressed using a laboratory stress paradigm. After this, they were randomized to interact for 30 minutes with one of two possible sensory EE interventions (music as auditory enrichment or a Paro robot as multisensory enrichment) or to a control condition. Skin barrier recovery was measured using transepidermal water loss at baseline, after the stressor, and after the intervention. Stress was measured using self-report, heart rate, blood pressure, and salivary stress-related biological measures. Enjoyment during the intervention was measured by self-report as a possible mediator., Results: The Paro condition had significantly improved skin barrier recovery (mean [M] = 44%, standard error [SE] = 1.92) compared with the control condition (M = 37% SE = 2.01, F(2,88) = 3.25, p = .043), both with and without controlling for covariates. The music condition did not significantly differ from the other conditions (M = 42%, SE = 1.95, p values > .05). Both objective and subjective stress measures did not significantly differ between conditions. Mediational analysis showed that enjoyment levels during the intervention period significantly mediated the relationship between condition and skin barrier recovery (z = 2.00, p = .046)., Conclusions: Paro, or other companion robots, may be an effective form of enrichment to improve skin barrier recovery in humans after a laboratory stressor, and this effect may be due to enjoyment. Further research with patient groups is required to investigate whether Paro can help heal clinical wounds., Trial Registration: ACTRN12618000953235, registered at https://anzctr.org.au.

Public health programming efforts have traditionally focused on either an individualistic or population approach, neglecting the family as a setting for or partner in health promotion efforts. Due to the multi-faceted influence of families on individual health, family-focused, and family-friendly public health interventions are important to making lasting changes for individual and community health. The purpose of this study was to examine the degree to which health promotion programs in a state in the US Intermountain West involve and support families across four family impact principles: family engagement, family stability, family responsibility, and family diversity. A survey was completed by 67 health promotion administrators and practitioners from 12 out of 13 county health departments with additional responses from public health practitioners at the State Health Department. The results of the survey indicated that health promotion efforts were best at supporting family responsibility and a diverse group of families but were weaker in family engagement and family stability. Applying a more family-centered and family-focused approach to health promotion efforts can be achieved by employing interdisciplinary efforts and by taking advantage of tools like the Public Health Family Impact Checklist to intentionally engage and support families in programs and interventions., (Copyright © 2020 Novilla, Broadbent, Glade and Crandall.)

Background: Research indicates that adverse childhood experiences (ACEs) can lead to poorer adult health, but less is known how advantageous childhood experiences (counter-ACEs) may neutralize the negative effects of ACEs, particularly in young adulthood., Purpose: We examined the independent contributions of Adverse Childhood Experiences (ACEs) and Advantageous Childhood Experiences (counter-ACEs) that occur during adolescence on five young adult health indicators: depression, anxiety, risky sexual behaviors, substance abuse, and positive body image., Participants and Setting: The sample included 489 adolescents from a large northwestern city in the United States who were 10-13 years at baseline (51 % female)., Methods: Flourishing Families Project survey data were used for this secondary analysis using structural equation modeling. Adolescents and their parents completed an annual survey. ACEs and counter-ACEs were measured over the first five years of the study. The five health indicators were measured in wave 10 when participants were 20-23 years old., Results: Participants had on average 2.7 ACEs and 8.2 counter-ACEs. When both ACEs and counter-ACEs were included in the model, ACEs were not predictive of any of the health indicators and counter-ACEs were predictive of less risky sex (-.12, p < .05), substance abuse (-.12, p < .05), depression (-.11, p < .05), and a more positive body image (.15, p < .01). Higher ratios of counter-ACEs to ACEs had a particularly strong effect on improved young adult health., Conclusions: Counter-ACEs that occur in adolescence may diminish the negative effects of ACEs on young adult health and independently contribute to better health., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Objectives: Previous pandemics have resulted in significant consequences for mental health. Here, we report the mental health sequelae of the COVID-19 pandemic in a UK cohort and examine modifiable and non-modifiable explanatory factors associated with mental health outcomes. We focus on the first wave of data collection, which examined short-term consequences for mental health, as reported during the first 4-6 weeks of social distancing measures being introduced., Design: Cross-sectional online survey., Setting: Community cohort study., Participants: N=3097 adults aged ≥18 years were recruited through a mainstream and social media campaign between 3 April 2020 and 30 April 2020. The cohort was predominantly female (n=2618); mean age 44 years; 10% (n=296) from minority ethnic groups; 50% (n=1559) described themselves as key workers and 20% (n=649) identified as having clinical risk factors putting them at increased risk of COVID-19., Main Outcome Measures: Depression, anxiety and stress scores., Results: Mean scores for depression ([Formula: see text] =7.69, SD=6.0), stress ([Formula: see text] =6.48, SD=3.3) and anxiety ([Formula: see text] = 6.48, SD=3.3) significantly exceeded population norms (all p<0.0001). Analysis of non-modifiable factors hypothesised to be associated with mental health outcomes indicated that being younger, female and in a recognised COVID-19 risk group were associated with increased stress, anxiety and depression, with the final multivariable models accounting for 7%-14% of variance. When adding modifiable factors, significant independent effects emerged for positive mood, perceived loneliness and worry about getting COVID-19 for all outcomes, with the final multivariable models accounting for 54%-57% of total variance., Conclusions: Increased psychological morbidity was evident in this UK sample and found to be more common in younger people, women and in individuals who identified as being in recognised COVID-19 risk groups. Public health and mental health interventions able to ameliorate perceptions of risk of COVID-19, worry about COVID-19 loneliness and boost positive mood may be effective., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To investigate the associations between illness perceptions, God locus of health control (GLHC) beliefs, and self-care behaviours in Saudi patients with type 2 diabetes (T2D). Design: A cross-sectional study was conducted with 115 adults with T2D in a Saudi Arabian diabetes clinic. Illness perceptions, GLHC beliefs, and self-care behaviours were assessed using the Arabic versions of the Brief Illness Perception Questionnaire, God Locus of Health Control, and Summary of Diabetes Self-Care Activities. Logistic and linear regressions were conducted. Results: Greater perceptions of personal control (OR = 2.07, p =  .045) and diet effectiveness (OR =   2.73, p =  .037) were associated with higher odds of adhering to general diet. Greater perceptions of diet effectiveness ( β  = 0.27, p  = .034) and better understanding of T2D ( β  = 0.54, p  < .001) were significant independent predictors of fruit and vegetables intake and exercise respectively. Patients with lower GLHC beliefs (OR =  4.40, p =  .004) had higher odds of adhering to foot care than those with higher GLHC beliefs. Illness perceptions and GLHC beliefs did not predict adherence to a low-fat diet, self-monitoring of blood glucose, or not smoking. Conclusion: Greater perceptions of personal control, coherence, diet effectiveness, and lower GLHC beliefs were associated with higher adherence to self-care behaviours in Saudi patients with T2D. Interventions designed to promote self-care behaviours in Saudi patients with T2D could focus on addressing these perceptions., Competing Interests: No potential conflict of interest was reported by the author(s)., (© 2020 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

Digital humans show promise for use in healthcare as virtual therapists to deliver psychotherapy or companions for social support. For digital humans to be effective and engaging in these roles, it is important they can build close relationships with people. Emotional expressiveness can improve social closeness in human relationships, especially for females. However, it is unknown whether multimodal emotional expression improves relationships with digital humans. Participants were 185 adults aged 18 years or older with English fluency. Participants were block-randomized by gender to complete the Relationship Closeness Induction Task with one of six versions of a digital human. The digital humans varied in modality richness (face, no face) and emotional expression (emotional voice, neutral voice; emotional face, neutral face). Participants' language was analysed for emotional content using Linguistic Inquiry and Word Count software. A series of three-way ANOVA and ANCOVA were conducted to evaluate the effect of digital human face type, voice type, and participant gender on emotional content in participant language. A digital human with no face was associated with more first-person singular pronoun use than a neutral face and an emotional face digital human. A digital human with no face and a neutral voice received more general negative emotion language than a digital human with no face and an emotional voice. Findings suggest the presence of a face and emotion in the voice may improve emotional responses to digital humans. Results provide evidence for aspects of the theoretical framework of embodied agent-patient communication.