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Health technology assessments (HTAs) are used as a policy tool to appraise the clinical value, or cost effectiveness, of new medicines to inform reimbursement decisions in health care. As HTA organisations have been established in different countries, it has become clear that the outcomes of medicine appraisals can vary from country to country, even though the same scientific evidence in the form of randomised controlled trials is available. The extant literature explains such variations with reference to institutional variables and administrative rules. However, little research has been conducted to advance the theoretical understanding of how variations in HTA outcomes might be explained. This paper compares cases of HTA in England and Germany using insights from Kuhn (1962, The Structure of Scientific Revolutions, 2nd edn. Chicago: The University of Chicago Press) and Hall (1993, Policy paradigms, social learning, and the state: the case of economic policymaking in Britain. Comparative Politics 25, 275-296) to demonstrate how policy paradigms can explain the outcomes of HTA processes. The paper finds that HTA outcomes are influenced by a combination of logical issues that require reasoning within a paradigm, and institutional and political issues that speak to the interaction between ideational and interest-based variables. It sets out an approach that advances the theoretical explanation of divergent HTA outcomes, and offers an analytical basis on which to assess current and future policy changes in HTA. [ABSTRACT FROM AUTHOR]

The effective collection and management of personal data of rapidly migrating populations is important for ensuring adequate healthcare and monitoring of a displaced peoples' health status. With developments in ICT data sharing capabilities, electronic personal health records (ePHRs) are increasingly replacing less transportable paper records. ePHRs offer further advantages of improving accuracy and completeness of information and seem tailored for rapidly displaced and mobile populations. Various emerging initiatives in Europe are seeking to develop migrant-centric ePHR responses. This paper highlights their importance and benefits, but also identifies a number of significant ethical, legal and social issues (ELSI) and challenges to their design and implementation, regarding (1) the kind of information that should be stored, (2) who should have access to information, and (3) potential misuse of information. These challenges need to be urgently addressed to make possible the beneficial use of ePHRs for vulnerable migrants in Europe. [ABSTRACT FROM AUTHOR]

In the 1980s debate intensified over whether there was a protective effect of high-density lipoprotein cholesterol (HDL-C) or an adverse effect of triglycerides on coronary heart disease (CHD) risk. In a 1991 paper reprinted in the IJE we suggested that the high degree of correlation between the two, together with plausible levels of measurement error, made it unlikely that conventional epidemiological approaches could contribute to causal understanding. The consensus that HDL-C was protective, popularly reified in the notion of 'good cholesterol', strengthened over subsequent years. Reviewing the biostatistical and epidemiological literature from before and after 1991 we suggest that within the observational epidemiology pantheon only Mendelian randomization studies-that began to appear at the same time as the initial negative randomized controlled trials-made a meaningful contribution. It is sobering to realize that many issues that appear suitable targets for epidemiological investigation are simply refractory to conventional approaches. The discipline should surely revisit this and other high-profile cases of consequential epidemiological failure-such as that with respect to vitamin E supplementation and CHD risk-rather than pass them over in silence. [ABSTRACT FROM AUTHOR]

Purpose: In a randomised controlled trial, patients were offered financial incentives to improve their adherence to anti-psychotic maintenance medication. Compared to a control group without the incentives, they had an improved adherence and also better subjective quality of life (SQOL) after 1 year. This paper explores the question as to whether this improvement in SQOL was associated with the amount of money received or with the improved adherence itself.Method: A secondary analysis was performed using data of the experimental group in the trial. Adherence was assessed as the percentage of all prescribed long-acting anti-psychotic injections that were taken by the patient. In regression models, we tested whether changes in medication adherence and/or the amount of incentives received over the 12-month period was associated with SQOL, as rated on the DIALOG scale.Results: Adherence changed from 68.49 % at baseline to 88.23 % (mean difference in adherence = 19.59 %, SD = 17.52 %). The total amount of incentives received within the 1-year study period varied between £75 and £735, depending on the treatment cycle and the number of long-acting injections taken. Improvement in adherence was found to be a significant predictor of better subjective quality of life (β = 0.014, 95 % CI 0.003-0.025, p = 0.014), whilst the amount of incentives received was not (β = 0.0002, 95 % CI -0.002 to 0.002, p = 0.818).Conclusion: Improved medication adherence is associated with a more favourable SQOL. This underlines the clinical relevance of improved adherence in response to financial incentives in this patient group. [ABSTRACT FROM AUTHOR]

Background: Electronic formats of patient-reported outcome (PRO) measures are now routinely used in clinical research studies. When changing from a validated paper and pen to electronic administration it is necessary to establish their equivalence. This study reports on the value of Rasch analysis in this process.Methods: Three groups of US pulmonary hypertension (PH) patients participated. The first completed an electronic version of the CAMPHOR Activity Limitation scale (e-sample) and this was compared with two pen and paper administrated samples (pp1 and pp2). The three databases were combined and analysed for fit to the Rasch model. Equivalence was evaluated by differential item functioning (DIF) analyses.Results: The three datasets were matched randomly in terms of sample size (n = 147). Mean age (years) and percentage of male respondents were as follows: e-sample (51.7, 16.0 %); pp1 (50.0, 14.0 %); pp2 (55.5, 40.4 %). The combined dataset achieved fit to the Rasch model. Two items showed evidence of borderline DIF. Further analyses showed the inclusion of these items had little impact on Rasch estimates indicating the DIF identified was unimportant.Conclusions: Differences between the performance of the electronic and pen and paper administrations of the CAMPHOR Activity Limitation scale were minor. The results were successful in showing how the Rasch model can be used to determine the equivalence of alternative formats of PRO measures. [ABSTRACT FROM AUTHOR]

Introduction: The PROMIS Smoking Initiative has developed six item banks for assessment related to cigarette smoking among adult smokers (Nicotine Dependence, Coping Expectancies, Emotional and Sensory Expectancies, Health Expectancies, Psychosocial Expectancies, and Social Motivations). This article evaluates the psychometric performance of the banks when administered via short form (SF), computer adaptive test (CAT), and by mode of administration (computer vs. paper-and-pencil).Methods: Data are from two sources: an internet sample (N = 491) of daily and nondaily smokers who completed both SFs and CATs via the web and a community sample (N = 369) that completed either paper-and-pencil or computer administration of the SFs at two time points. First a CAT version of the PROMIS Smoking Assessment Toolkit was evaluated by comparing item administration rates and scores to the SF administration. Next, we considered the effect of computer versus paper-and-pencil administration on scoring and test-retest reliability.Results: Across the domains approximately 5.4 to 10.3 items were administered on average for the CAT. SF and CAT item response theory-scores were correlated from 0.82 to 0.92 across the domains. Cronbach's alpha for the four- to eight-item SFs among daily smokers ranged from .80 to .91 and .82 to .91 for paper-and-pencil and computer administrations, respectively. Test-retest reliability of the SFs ranged from 0.79 to 0.89 across mode of administration.Conclusions: Results indicate that the SF and CAT and computer and paper-and-pencil administrations provide highly comparable scores for daily and nondaily smokers, but preference for SF or CAT administration may vary by smoking domain. [ABSTRACT FROM AUTHOR]

Background: Health systems guidance (HSG) are systematically developed statements that assist with decisions about options for addressing health systems challenges, including related changes in health systems arrangements. However, the development, appraisal, and reporting of HSG poses unique conceptual and methodological challenges related to the varied types of evidence that are relevant, the complexity of health systems, and the pre-eminence of contextual factors. To address this gap, we are conducting a program of research that aims to create a tool to support the appraisal of HSG and further enhance HSG development and reporting. The focus of this paper was to conduct a knowledge synthesis of the published and grey literatures to determine quality criteria (concepts) relevant for this process.Methods: We applied a critical interpretive synthesis (CIS) approach to knowledge synthesis that enabled an iterative, flexible, and dynamic analysis of diverse bodies of literature in order to generate a candidate list of concepts that will constitute the foundational components of the HSG tool. Using our review questions as compasses, we were able to guide the search strategy to look for papers based on their potential relevance to HSG appraisal, development, and reporting. The search strategy included various electronic databases and sources, subject-specific journals, conference abstracts, research reports, book chapters, unpublished data, dissertations, and policy documents. Screening the papers and data extraction was completed independently and in duplicate, and a narrative approach to data synthesis was executed.Results: We identified 43 papers that met eligibility criteria. No existing review was found on this topic, and no HSG appraisal tool was identified. Over one third of the authors implicitly or explicitly identified the need for a high-quality tool aimed to systematically evaluate HSG and contribute to its development/reporting. We identified 30 concepts that may be relevant to the appraisal of HSG and were able to cluster them into three meaningful domains: process principles, content, and context principles.Conclusions: Our study showed the role that the quality criteria play in the development, appraisal, and reporting of HSG and demonstrated the link and resonance within and between the various concepts in the three domains. [ABSTRACT FROM AUTHOR]

Background: Current guidelines do not clearly outline when assent should be attained from paediatric research participants, nor do they detail the necessary elements of the assent process. This stems from the fact that the fundamental justification behind the concept of assent is misunderstood. In this paper, we critically assess three widespread ethical arguments used for assent: children's rights, the best interests of the child, and respect for a child's developing autonomy. We then outline a newly-developed two-fold justification for the assent process: respect for the parent's pedagogical role in teaching their child to become an autonomous being and respect for the child's moral worth.Discussion: We argue that the ethical grounding for the involvement of young children in medical decision-making does not stem from children's rights, the principle of best interests, or respect for developing autonomy. An alternative strategy is to examine the original motivation to engage with the child. In paediatric settings there are two obligations on the researcher: an obligation to the parents who are responsible for determining when and under what circumstances the child develops his capacity for autonomy and reasoning, and an obligation to the child himself. There is an important distinction between respecting a decision and encouraging a decision. This paper illustrates that the process of assent is an important way in which respect for the child as an individual can be demonstrated, however, the value lies not in the child's response but the fact that his views were solicited in the first place. This paper demonstrates that the common justifications for the process of assent are incomplete. Assent should be understood as playing a pedagogical role for the child, helping to teach him how specific decisions are made and therefore helping him to become a better decision-maker. How the researcher engages with the child supports his obligation to the child's parents, yet why the researcher engages with the child stems from the child's moral worth. Treating a child as having moral worth need not mean doing what they say but it may mean listening, considering, engaging or involving them in the decision. [ABSTRACT FROM AUTHOR]

Background: A storyline in a grounded theory study plays two important roles: an analytical tool and a research product. Using more than one language in a study affects the research, including the dissemination of its findings. Very little literature discusses how to develop and disseminate a storyline. Aim: This paper offers insight into the crafting of a storyline to disseminate a grounded theory study describing how people in Indonesia with diabetes learn about their disease. Discussion: This paper explains how the researchers developed the storyline. The authors then address considerations in the storyline's development and explain how they disseminated it, as well as the factors that influenced that dissemination. Conclusion: Disseminating findings through a storyline written in the local language ensures that the target audience all have access to a study's outcomes through an easily readable publication. Implication for practice: Sharing a storyline helps to disseminate the outcomes of a grounded theory study. It informs the wider community of new knowledge and enables it to review, understand and apply the outcomes of research. [ABSTRACT FROM AUTHOR]

Hypertension (HT) is associated with cardiovascular events and increased mortality, and identification of persons at risk in due time is therefore important. Finding a biomarker to identify those at risk will enable early preventive treatment, and high-sensitivity cardiac troponin (hs-cTn) seems to be a highly relevant candidate. To gather the existing knowledge on the association between hs-cTn and future HT, a systematic literature review was conducted following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) reporting guidelines and using the PICOS system. Medline was searched until August 2018. Of 45 extracted papers, eleven papers were eligible for the study. None were randomized controlled trials. Three studies assessed hs-cTnI, eight studies assessed hs-cTnT. All studies found statistically significant associations between hs-cTn concentrations and future HT, but the studies included different types of blood pressure (diastolic, systolic, diurnal). Due to differences in troponin assay construction and test capability, a direct comparison of test performance in terms of specificity, sensitivity and predictive values was not possible, and a specific hs-cTn cutoff value for HT prediction could therefore not be defined. Furthermore, a number of conditions known to affect troponin concentrations (e.g. gender, renal function, and co-morbidities) were not sufficiently studied. All retrieved studies found significant associations between hs-cTn concentrations and future HT; although the findings are promising, the studies were too heterogeneous, and many conditions affecting troponin concentrations needs investigation at these low concentrations before hs-cTn can be considered a useful HT predictor. [ABSTRACT FROM AUTHOR]

Background: The PACE Steps to Success programme is a complex educational and development intervention to improve palliative care in nursing homes. Little research has investigated processes in the cross-cultural adaptation and implementation of interventions in palliative care across countries, taking account of differences in health and social care systems, legal and regulatory policies, and cultural norms. This paper describes a framework for the cross-cultural development and support necessary to implement such an intervention, taking the PACE Steps to Success programme as an exemplar.Methods: The PACE Steps to Success programme was implemented as part of the PACE cluster randomised control trial in seven European countries. A three stage approach was used, a) preparation of resources; b) training in the intervention using a train-the-trainers model; and c) cascading support throughout the implementation. All stages were underpinned by cross-cultural adaptation, including recognising legal and cultural norms, sensitivities and languages. This paper draws upon collated evidence from minutes of international meetings, evaluations of training delivered, interviews with those delivering the intervention in nursing homes and providing and/or receiving support.Results: Seventy eight nursing homes participated in the trial, with half randomized to receive the intervention, 3638 nurses/care assistants were identified at baseline. In each country, 1-3 trainers were selected (total n = 16) to deliver the intervention. A framework was used to guide the cross-cultural adaptation and implementation. Adaptation of three English training resources for different groups of staff consisted of simplification of content, identification of validated implementation tools, a review in 2 nursing homes in each country, and translation into local languages. The same training was provided to all country trainers who cascaded it into intervention nursing homes in local languages, and facilitated it via in-house PACE coordinators. Support was cascaded from country trainers to staff implementing the intervention.Conclusions: There is little guidance on how to adapt complex interventions developed in one country and language to international contexts. This framework for cross-cultural adaptation and implementation of a complex educational and development intervention may be useful to others seeking to transfer quality improvement initiatives in other contexts. [ABSTRACT FROM AUTHOR]

Background: Patients who survive critical illness have well-defined physical, cognitive, emotional, and familial problems. However, the impact of these problems on survivors' ability to return to work and other financial outcomes is less clear.Objectives: To determine the financial and employment consequences of an intensive care stay, we performed a systematic review and meta-analysis.Data Sources: We searched the MEDLINE, Embase, and CINAHL databases (1970-2018). All publication types except narrative reviews, case reports, case-control studies, and editorials were included. Included studies assessed financial outcomes in patients admitted to critical care and their caregivers.Data Extraction: Two reviewers independently applied eligibility criteria, assessed quality, and extracted data. The primary outcome reported was return to employment among those previously employed. We also examined financial stress and the impact financial outcomes had on quality of life and psychosocial health.Data Synthesis: Of 5,765 eligible abstracts, 51 studies were included, which provided data on 858 caregivers/family members and 7,267 patients. Forty-two papers reported patient outcomes, and 11 papers described caregivers/family members. Two papers included data from both patients and caregivers/family members. Return to employment was the most commonly reported financial outcome for critical care survivors. The pooled estimates for return to employment among those who were employed before critical illness were 33% (95% confidence interval [CI], 21-48%), 55% (95% CI, 45-64%), and 56% (95% CI, 45-66%) at 3, 6, and 12 months, respectively. Across the studies included in this review, there was a positive association with psychosocial health if patients returned to employment. This included improved health-related quality of life and fewer depressive symptoms. Regarding caregivers/family members, six studies reported changes in employment such as reduced hours and lost earnings.Conclusions: After critical illness, many patients who were previously employed do not return to work, even one year later. This new job loss is associated with worse health-related quality of life among survivors and worse psychological function among survivors and caregivers/family members. More interventional research is required to understand how best to support employability after critical illness.Registered with PROSPERO (CRD42018102360). [ABSTRACT FROM AUTHOR]

A classification scheme for periodontal and peri-implant diseases and conditions is necessary for clinicians to properly diagnose and treat patients as well as for scientists to investigate etiology, pathogenesis, natural history, and treatment of the diseases and conditions. This paper summarizes the proceedings of the World Workshop on the Classification of Periodontal and Peri-implant Diseases and Conditions. The workshop was co-sponsored by the American Academy of Periodontology (AAP) and the European Federation of Periodontology (EFP) and included expert participants from all over the world. Planning for the conference, which was held in Chicago on November 9 to 11, 2017, began in early 2015. An organizing committee from the AAP and EFP commissioned 19 review papers and four consensus reports covering relevant areas in periodontology and implant dentistry. The authors were charged with updating the 1999 classification of periodontal diseases and conditions and developing a similar scheme for peri-implant diseases and conditions. Reviewers and workgroups were also asked to establish pertinent case definitions and to provide diagnostic criteria to aid clinicians in the use of the new classification. All findings and recommendations of the workshop were agreed to by consensus. This introductory paper presents an overview for the new classification of periodontal and peri-implant diseases and conditions, along with a condensed scheme for each of four workgroup sections, but readers are directed to the pertinent consensus reports and review papers for a thorough discussion of the rationale, criteria, and interpretation of the proposed classification. Changes to the 1999 classification are highlighted and discussed. Although the intent of the workshop was to base classification on the strongest available scientific evidence, lower level evidence and expert opinion were inevitably used whenever sufficient research data were unavailable. The scope of this workshop was to align and update the classification scheme to the current understanding of periodontal and peri-implant diseases and conditions. This introductory overview presents the schematic tables for the new classification of periodontal and peri-implant diseases and conditions and briefly highlights changes made to the 1999 classification. It cannot present the wealth of information included in the reviews, case definition papers, and consensus reports that has guided the development of the new classification, and reference to the consensus and case definition papers is necessary to provide a thorough understanding of its use for either case management or scientific investigation. Therefore, it is strongly recommended that the reader use this overview as an introduction to these subjects. Accessing this publication online will allow the reader to use the links in this overview and the tables to view the source papers (Table 1). [ABSTRACT FROM AUTHOR]

The aim of this study was to investigate the accuracy and reliability of interpreting occlusal markings made by articulating paper on complete dentures intraorally. Clinical teachers at a training hospital interpreted occlusal markings intended for adjustment. Their scores were compared to a control score to determine accuracy. For reliability determination, the observations were repeated. Only between 20% and 30% of observations were found to be both accurate and reliable. Unless the procedure can be standardized, this technique shouldn't be considered appropriate prosthodontics protocol for balancing the occlusion of complete dentures. [ABSTRACT FROM AUTHOR]

Background: MiRNA is a class of non-coding single-stranded RNA molecules with a length of approximately 22 nucleotides encoded by endogenous genes, which can regulate the expression of other genes. Therefore, it is very important to predict the associations between miRNA and disease. Predecessors developed a new prediction method of drug-disease association, and it achieved good results.Methods: In this paper, we introduced the method of LAGCN to identify potential miRNA-disease associations. First, we integrate three associations into a heterogeneous network, such as the known miRNA-disease association, miRNA-miRNA similarities and disease-disease similarities, next we apply graph convolution network to learn the embedding of miRNA and disease. We use an attention mechanism to combine embedding from multiple convolution layers. Unobserved miRNA-disease associations are scored based on integrated embedding.Results: After fivefold cross-validations, the value of AUC is reached 0.9091, which is higher than other prediction methods and baseline methods.Conclusions: In this paper, we introduced the method of LAGCN to identify potential miRNA-disease associations. LAGCN has achieved good performance in predicting miRNA-disease associations, and it is superior to other association prediction methods and baseline methods. [ABSTRACT FROM AUTHOR]

Background: There is an increasing demand for mental health support in primary care, especially for young people. To improve mental health support for young people in general practice, the needs of young people must be considered.Aim: To explore the experiences of young people (aged 12-25 years) on receiving mental health care in primary care and identify the needs of young people who present with mental health concerns.Design and Setting: A systematic review and narrative synthesis.Method: This was a systematic review and narrative synthesis. Six databases were searched for literature relating to young people's experiences of receiving mental health care in primary care. Additional handsearching and manual internet searching were conducted. Narrative synthesis was employed.Results: Five papers and a further two reports from manual internet searching were found, resulting in the inclusion of 1823 young people from four different countries (UK, US, Ireland, and Canada) for synthesis. The synthesis generated four themes: the centrality of a trusting relationship; showing empathy and taking concerns seriously; being given time to talk; and barriers to accessing mental health support in primary care.Conclusion: Young people need a trusting relationship to discuss sensitive issues. To enable high-quality and effective mental health consultations with young people and the development of trust, GPs require unhurried consultations and the ability to maintain continuity of care. [ABSTRACT FROM AUTHOR]

Aim: This study aimed to explore nurses' views and experiences regarding remaining silent. Background: Silence is a barrier for organizational improvement and can occur for many reasons; it cannot be simply defined as the opposite of speaking out. Method: An exploratory qualitative design was used for this study. Data were collected using semi‐structured interviews in 2016 with 24 nurses who were recruited by using a snowball sampling method. Results: Three themes emerged as a result of the thematic analysis: fear, silence climate and disengagement. The first theme contained three subthemes: avoidance of being seen as a troublemaker, financial loss and reluctance to reveal lack of ability or knowledge. The results indicated that nurses remained silent when they felt unsupported or psychologically unsafe in their work environment. Conclusion: Encouraging nurses to express their opinions is essential for creating a psychologically safe nursing work environment and an organizational climate that supports open communication. Because the majority of healthcare professionals are nurses, they can act as role models and change agents for other nurses if they are encouraged to share their ideas and opinions without fear of retribution. Summary statement: What is already known about this topic? Silence negatively affects work environment and causes job dissatisfaction.Silence is a threat to the development of new ideas and prevents nurses from raising concerns about critical issues. What this paper adds? Nurses remain silent when they fear losing their jobs, showing weakness or being labelled as a troublemaker.Nurses' work environment affects their decision to speak up.If nurses do not receive any support or see any change, they tend not to speak up. The implications of this paper: Hospital managers should support a work environment that encourages open communication and productive feedback systems.Silence can be prevented by creating a psychologically safe environment in which no one is judged for their opinion. [ABSTRACT FROM AUTHOR]

Purpose: To systematically review the literature comparing marginal bone loss (MBL) and pink esthetic scores of implants with convergent or concave transmucosal profiles vs divergent or parallel profiles.Materials and Methods: A PICO question was defined, and an electronic search was carried out in the MEDLINE/PubMed and Cochrane Oral Health Group databases. Studies documenting type of transmucosal profile (either tissue-level profiles or abutments) and soft and/or hard tissue outcomes of implants were considered eligible. Studies were selected on the basis of the inclusion criteria and quality assessments. A meta-analysis with subgroup analyses was performed.Results: Five papers fulfilled the inclusion criteria, and four were eligible for meta-analysis. Significantly less MBL was found in concave/convergent groups, with a mean difference of 0.772 (95% confidence interval [CI]: 0.450 to 1.095; P < .001). In the subgroup analyses for platform-switching and platform-matching connections, a significant effect in favor of concave/convergent was detected, with a standardized difference in means of 1.135 (95% CI: 0.688 to 1.583, P < .001) when platform switching was considered. No significant effects were found for platform-matching connections.Conclusion: Within the limitations of this review, it is suggested that concave/convergent implant transmucosal profiles result in less MBL. No statistically significant results were obtained for soft tissue-related outcomes or for the platform-matching connection subgroup. [ABSTRACT FROM AUTHOR]

Background: Game‐based learning can frame problem‐solving as a sense‐making experience with domain‐specific tasks for school students. However, multiple challenges arise when trying to support learners in such a complex, problem‐oriented learning environment. Objectives and Methods: With an architecture‐themed mathematics learning game, we conducted two mixed‐method studies to explore the impact and design of game‐based mathematical experience on the math problem‐solving performance of middle school students. Results and Conclusions: The study findings suggested a positive impact of game‐based math experience on math problem‐solving for middle school students. Problematization‐oriented game‐based math tasks with structuring features enhanced students' reasoning with problems and channelled it to doing mathematics. Takeaways: The current research findings support the initiative to frame learning as a sense‐making experience with domain‐specific tasks and inform the design of game‐based mathematical experience and learning support. Lay Description: What is already known about this topic: Realistic mathematical practices frame learning as a sense‐making experience.Challenges arise when involving learners in realistic mathematical experiences driven by domain‐specific tasks. What this paper adds: Game‐based simulation of math tasks framed learning as sense‐making experience.Game‐based math experiencing promoted math contextual problem‐solving performance.Structuring features enhanced problematized experiencing with math tasks. Implications for practice and/or policy: Teachers can integrate and facilitate game‐based math experiencing in class.Efforts should be made to make game‐based math tasks meaningful for students. [ABSTRACT FROM AUTHOR]

Background: Online collaboration tools have been identified as potentially effective means for enhancing student learning, motivation, and engagement in science education. However, their effectiveness in improving science education outcomes among middle school students remains uncertain. Objectives: The study aimed to investigate the impact of online collaboration tools on science education outcomes among middle school students, focusing on learning achievement, engagement, and motivation. Methods: A quasi‐experimental design with a pretest‐posttest control group was used in this study. A total of 60 eighth‐grade middle school students were involved in the study, with both the experimental and control groups comprising 30 students each. The experimental group incorporated the use of digital collaboration platforms, including Asana, Slack, and Team Viewer, as instrumental components of group project execution and discussion in their science lessons. Conversely, the control group adhered to the current educational approach in Turkey, characterized by the employment of an inquiry‐based learning strategy in their science instruction. Data was collected over eight weeks using a science achievement test, engagement scale, and science motivation scale. Results: The experimental group demonstrated significantly higher post‐test scores compared to the control group, suggesting that online collaboration tools positively impacted science education outcomes. Additionally, survey data indicated high levels of engagement and motivation among the experimental group students when using the online collaboration tools. Conclusions: The findings support the notion that online collaboration tools can effectively enhance learning, motivation, and engagement in science education among middle school students. These results have significant implications for educators, educational institutions, policymakers, and curriculum developers. Further research is needed to examine the potential of these tools in various educational contexts and with different student populations. This will help broaden the understanding of how online collaboration tools can be integrated into diverse learning environments, potentially benefiting a larger number of students and further improving science education outcomes. Lay Description: What is already known about this topic: Technology's role, particularly online collaboration tools, in enriching science education is undebatable (Donkin & Rasmussen, 2021; Rahmawati et al., 2022). Such tools have been theorized to bolster student learning outcomes, motivation, and engagement (Donnelly et al., 2013; Ekici, 2017; Khazanchi & Khazanchi, 2019). Yet, the empirical evidence validating their efficacy in science educational settings remains sparse. What this paper adds: This research delves into the influence of online collaboration tools on science learning outcomes among middle school learners. Data indicates that employing these digital tools substantially elevates student performance, as gauged by a science achievement test. Furthermore, students navigating through these online collaborative platforms recorded elevated levels of both engagement and motivation. The primary effectiveness of online collaboration tools stems from their ability to foster specific behaviours, such as increased communication frequency and structured task management, which can amplify learning and group collaboration through their facilitated structured interactions. Implications for practice and/or policy: This study's conclusions offer pivotal insights for educators, academic institutions, policy framers, and curriculum architects. Online collaborative platforms exhibit promise in amplifying student outcomes and engagement within the realm of science education. It is imperative to broaden this research scope to discern the tools' potential across varied educational environments and diverse student demographics. There is a compelling case for stakeholders, especially educators and policymakers, to contemplate incorporating these online tools into science pedagogy, aiming to magnify student learning experiences and engagement levels. [ABSTRACT FROM AUTHOR]

Drowning diagnosis is a complicated process in the autopsy, even with the assistance of autopsy imaging and the on-site information from where the body was found. Previous studies have developed well-performed deep learning (DL) models for drowning diagnosis. However, the validity of the DL models was not assessed, raising doubts about whether the learned features accurately represented the medical findings observed by human experts. In this paper, we assessed the medical validity of DL models that had achieved high classification performance for drowning diagnosis. This retrospective study included autopsy cases aged 8–91 years who underwent postmortem computed tomography between 2012 and 2021 (153 drowning and 160 non-drowning cases). We first trained three deep learning models from a previous work and generated saliency maps that highlight important features in the input. To assess the validity of models, pixel-level annotations were created by four radiological technologists and further quantitatively compared with the saliency maps. All the three models demonstrated high classification performance with areas under the receiver operating characteristic curves of 0.94, 0.97, and 0.98, respectively. On the other hand, the assessment results revealed unexpected inconsistency between annotations and models' saliency maps. In fact, each model had, respectively, around 30%, 40%, and 80% of irrelevant areas in the saliency maps, suggesting the predictions of the DL models might be unreliable. The result alerts us in the careful assessment of DL tools, even those with high classification performance. [ABSTRACT FROM AUTHOR]

Introduction: Extended periods of bed rest and mechanical ventilation (MV) have devastating effects on the body. Background: Early mobility (EM) for patients in respiratory failure is safe and feasible, and an interprofessional team is recommended. Using simulation to train EM skills improves student confidence. The purpose of this study was to enable health care student collaboration as an interprofessional team in providing safe management and monitoring during an EM simulation for a patient requiring MV. Methods: Nursing (n = 33), respiratory (n = 7), occupational (n = 24), and physical therapist students (n = 55) participated in an EM interprofessional education (IPE) simulation experience. A mixed-methods analytic approach was used with pre/post quantitative analysis of the Student Perceptions of Interprofessional Clinical Education--Revised, Version 2 instrument and qualitative analysis of students' guided reflection papers. Results: Pre/post surveys completion rate was 39.5% (n = 47). The Student Perceptions of Interprofessional Clinical Education--Revised, Version 2 instrument indicated a significant improvement (P = .037) in students' perceptions of interprofessional collaborative practice. Qualitative data showed a positive response to the EM simulation IPE. Themes reflected all 4 Interprofessional Education Collaborative competencies. Discussion: This study demonstrated improved perception of interprofessional collaborative practice and better understanding of the Interprofessional Education Collaborative competencies. Conclusion: Students collaborated in the simulation-based IPE to provide EM for a patient requiring MV and reported perceived benefits of the experience. [ABSTRACT FROM AUTHOR]

With the growing use of artificial intelligence, search engine providers are increasingly pushing advertisers to use automated bidding strategies based on machine learning. Such automated decision‐making systems leave advertisers in the dark about the data being used and how they can influence the outcome of the decision‐making process. Previous literature on artificial intelligence lacks an understanding of the dangers related to artificially intelligent systems and their lack of transparency. In response, our paper addresses the inherent risks of the automated optimization of advertisers' bidding strategies in search engine advertising. The selected empirical case of a service company therefore demonstrates how data availability can trigger a long‐term decline in advertising performance and how search engine advertising performance metrics develop before and after an event of data scarcity. Based on data collected for 525 days, difference‐in‐differences analysis shows that the algorithmic approach has a considerable and lasting negative impact on advertising performance. Furthermore, the empirical case indicates that self‐regulated learning can initialize a downward spiral that gradually impairs advertising performance. Thus, the aim of this study is to increase awareness regarding automated decision‐making dangers in search engine advertising and help advertisers take preventive measures to reduce the risks of algorithm missteps. [ABSTRACT FROM AUTHOR]

This paper explores teenage girls' responses to general advice, and formal prevention messages, designed to reduce sexting-related risk and prevent harm. We conducted workshops with seven groups of girls (28 in total), aged 16–17 years, in a New Zealand city. Each group participated in a series of three workshop sessions. Drawing on a Freirean 'problem-posing' approach, we designed the workshops as spaces in which girls were invited to observe and critically discuss norms related to sharing nudes as well as harm prevention messages. Girls noticed the problematic gender and sexual politics that shape abstinence-based models that target girls (implicitly) to not send nudes, but which leave boys who distribute or otherwise misuse them out of the picture. Participants navigated a careful path between attending to risk and protection on the one hand, and endorsing their right to freedom of expression on the other. We argue for a subtle, but significant, shift away from a focus on sexting safety to a focus on the prevention of image-based sexual coercion, harassment and abuse. This reframing would help to direct prevention efforts to the gendered drivers and dynamics of harm perpetration, and the ways in which they are problematically socially ignored or condoned. [ABSTRACT FROM AUTHOR]

Background: Person‐centred services are inherently related to patients/caregivers' needs. However, the extent to which dysphagia services within Singapore meet consumer needs is largely unknown. Involving patients/caregivers in service evaluation/redesign deepens the understanding of consumer needs. This process also increases the success of implementing service enhancements through relevant and meaningful change. Aim: This study aimed to identify aspects of dysphagia services, within acute and subacute settings in Singapore, perceived as highly important and easy to change by patients/caregivers. Methods & Procedures: Using concept mapping methodology, 5 patients and 11 caregivers reflected on their experiences of receiving dysphagia care and proposed 59 unique suggestions to improve dysphagia services within Singapore. Then, each individual sorted the suggestions into groups based on similarity and rated each statement for its perceived importance and changeability for service enhancement. Data were analysed using multidimensional scaling, hierarchical cluster analysis, and bivariate analysis to generate clusters of conceptually similar suggestions and a prioritised list of suggestions for service enhancement. Results: Twelve clusters were identified, with most rated as more important than changeable for service improvement. Participants prioritised 23 (39%) of the suggestions as highly important and easy to change, and these focused on ensuring effective communication among consumers and healthcare team, enhancing patients and carers' access to support at home, increasing patients and carers' access to educational resources, and improving service quality and access through technology. Conclusion: These findings provide future directions on how to develop and implement dysphagia services in Singapore to better meet the needs of patients/caregivers. WHAT THIS PAPER ADDS: What is already known on this subject: Little is known about patients and caregivers' experiences and expectations of receiving dysphagia services in Singapore. Consulting them in service review and improvement deepens understanding of their needs and increases the success of implementing meaningful service enhancements. What this study adds to existing knowledge: This study shows that patients and caregivers in Singapore identified a wide range of dysphagia service issues and prioritised a list of suggestions for service improvement. They prioritised four key areas for service optimisation: ensuring effective communication among consumers and healthcare team, enhancing patients and carers' access to support at home, increasing patients and carers' access to educational resources, and improving service quality and access through technology. What are the clinical implications of this work?: This research highlights the importance of considering the consumers' perspectives in service review and redesign. Patients and caregivers in Singapore identified four prioritised areas for service enhancements. These findings provide future directions on how to develop and implement dysphagia services in Singapore to better meet the needs of patients and caregivers. [ABSTRACT FROM AUTHOR]

Introduction: Pre-discharge home assessments by occupational therapists facilitate safe and timely discharge from hospital and are associated with better health outcomes. Digital technology offers the potential to reduce duplication of documentation and improve communication and sharing of home assessment findings. Objective: This quality improvement project evaluated time-cost; clinician satisfaction and confidence; and acceptability of the use of a digital approach to home assessments. Methods: A prospective, cross-sectional design was used to compare usual practice with the digital approach across two sub-acute wards in a large metropolitan hospital in Queensland, Australia. Time to document and conduct home assessments as well as clinician satisfaction and confidence were compared using descriptive statistics. Clinician perspectives about the home assessment approaches were collected through a survey and analyzed using content analysis. Results: Home assessment and documentation time were significantly lower for the home assessments conducted using the digital approach compared with usual practice assessments. Clinician satisfaction with using digital technology was higher. Conclusions: The introduction of this simple technology reduced clinicians' time to conduct home assessments and document home assessment reports. The project was well received by occupational therapy clinicians. http://links.lww.com/IJEBH/A187 [ABSTRACT FROM AUTHOR]

INTRODUCTION In recent years, e-cigarettes as an emerging tobacco product have been favored by college students. Our study aims to explore the factors affecting the use of e-cigarettes among college students and to put forward feasible suggestions for effectively controlling the use of e-cigarettes among college students. METHODS The participating students were from three undergraduate and three specialized colleges in Guangdong Province, surveyed from January to March 2022. The Fuzzy-set Qualitative Comparative Analysis (fsQCA) method was used to analyze the influence mechanism and path of five antecedents: self-efficacy, social environment, cognition, sales environment, and negative outcome expectation, on the use of e-cigarettes. The fsQCA used in this study is a novel research methodology that combines the strengths of qualitative and quantitative analyses, through which we can determine which conditions are essential to the outcomes that lead to e-cigarette use among college students, and which combinations of conditions are more important than others. RESULTS The interaction of self-efficacy, social environment, cognition, sales environment, and negative outcome expectation, affected college students' use of e-cigarettes. Through the fsQCA method, it was found that self-efficacy alone constitutes a necessary condition for college students not to use e-cigarettes. There are four possible pathways for college students not to use e-cigarettes, with higher self-efficacy, correct cognition, and a healthy social environment influencing the most important combination of conditions for college students to use e-cigarettes. CONCLUSIONS The use of e-cigarettes by students in Guangdong Province is the result of the synergistic effect of multiple factors. Tobacco control action suggestions focus on improving students' self-efficacy and paying attention to the combination of different factors to achieve more effective tobacco control. [ABSTRACT FROM AUTHOR]

There were 9.7 million Native Americans (American Indian, Alaska Native-AI/AN- these acronyms will be used interchangeably with Native Americans throughout the paper) in 2019 comprising 2.9% of the U.S. population. Native American populations have disproportionately higher rates of mental illnesses compared to other racial groups in the U.S. Mental health is a significant public health concern for this population, impacting different areas of their lives including employment. Additionally, Native Americans continue to experience significant disparities in access to Vocational Rehabilitation (VR) services and have poor employment outcomes. However, little is known about the relationships among demographic factors, vocational rehabilitation services, and employment outcomes of Native Americans with mental illness. Consequently, the current study examined how demographic factors and VR services are related to successful employment outcomes for Native American VR clients with mental illnesses using data from the Rehabilitation Services Administration (RSA) program year (2019) Case Service Report (9–11). Both descriptive analysis and data mining approaches were used to answer the research questions. Chi-square Automatic Interaction Detector (CHAID) analysis was used to determine which of the VR services could best predict the successful employment outcome of Native Americans with mental illness. The findings of the data mining approach revealed that among all the vocational rehabilitation services, job placement assistance was the strongest predictor of successful employment among Native American clients with mental illnesses. The second most important service predicting successful employment for those who received job placement assistance was shown to be maintenance. Implications for rehabilitation counselors and future research are discussed. [ABSTRACT FROM AUTHOR]

Background: Education is, after gaming, the second largest sector embracing augmented reality (AR) at an accelerated pace, yet studies on AR's potential as an efficient learning environment had mixed results. Objectives: This study's primary objective is to test students' interaction with graphical 3D elements in AR and its impact on information retention. The second objective is to compare information retention from AR engagement with information retention from exposure to identical 3D content delivered via instructional video. Finally, the third objective explores students' perceptions of AR as a learning environment. Methods: Sixty‐five college students participated in a two‐arm experiment followed by semi‐structured interviews. Results and Conclusion: AR can efficiently deliver a meaningful learning experience and promotes information retention. Nevertheless, AR's interactive features and novelty may distract learners while they engage with the virtual environment. Objective data obtained through eye tracking and video monitoring showed similar levels of engagement with a 3D model for both environments. While both AR and video groups showed significant knowledge gain from pre to post‐intervention, the video format was overall significantly more effective than AR in increasing topic‐related information retention. However, participants preferred the AR learning environment significantly more than the video. Takeaways: Although effective, AR is still a distracting instructional environment. Designing learning experiences tailored explicitly for AR environments requires additional research to ensure its successful deployment as a learning tool. Lay Description: What is already known about this topic: Education is the second‐fastest growing sector to adopt and experiment with augmented reality (AR).Hardware and software tools to create AR environments have reached the consumer level.The advantage of immersing learners in dedicated virtual environments seems obvious.Research has had mixed results in validating AR as a proper learning environment. What this paper adds: AR is a viable environment which supports information retention.For many students, the medium's novelty promotes engagement with the content.Students prefer AR to video lectures, but it may distract them from learning.Regarding information retention, video lectures do better than AR. The implications of study findings for practitioners: Learning experiences in AR should be reserved for some specific topics and designed purposedly.Progressive exposure of learners to AR environments may produce habituation and decrease distraction. [ABSTRACT FROM AUTHOR]

Background: Tele‐collaborative projects serve as invaluable platforms for students from diverse countries to engage in cross‐cultural communication and exchange cultural knowledge. These projects offer immense benefits in terms of fostering intercultural competence among participants. However, one challenge arises when participants engage in spoken communication rather than written. Those who may not share a common first language often rely on a lingua franca such as English for intercultural communication. In such spoken exchanges, varying levels of language proficiency can lead to communication errors that hinder the intercultural learning process and impede the development of intercultural competence in their fellow participants. Objectives: In the present trial study, our primary objective was to tackle the language‐related challenge associated with spoken communication head‐on. Our focus centred on addressing the discrepancies arising in spoken communication, and we aimed to mitigate these discrepancies by utilizing speech‐enabled corrective feedback technology. Methods: In a tele‐collaborative project involving 28 graduate students from the People's Republic of China and Republic of Kazakhstan, the participants engaged in spoken communication and cultural exchange in English via the internet. Given the emphasis on spoken communication and the recognition that English was not their first language, we implemented a speech‐enabled corrective feedback (SECF) technology to ensure effective communication in terms of pronunciation, grammar, and word choice. The SECF technology detected and provided instant feedback on any speech mistakes, enabling participants to make corrections accordingly. The main aim of our study was to explore the potential benefits of integrating SECF technology into a tele‐collaborative project for the development of participants' intercultural competence. Additionally, we sought to gather insights into the students' perceptions of the SECF support. Results and Conclusions: The results of our study revealed significant improvements in the participants' intercultural competence across dimensions such as knowledge, skills, attitude, and awareness. Furthermore, the participants expressed positive perceptions of the SECF technology. Drawing from our findings, we offer valuable implications and recommendations for educators and researchers in the field, enhancing their understanding of the role of SECF technology in supporting intercultural competence development in tele‐collaborative settings. Lay Description: What is currently known about the subject matter: Tele‐collaborative projects are widely utilized to enhance intercultural competence.Low language proficiency of participants often poses a significant challenge in tele‐collaborative projects. What this paper adds: The present study addressed the language barrier by incorporating speech‐enabled corrective feedback (SECF) technology to support our tele‐collaborative project.The study explored how our tele‐collaborative project, supported by SECF, facilitated the development of intercultural competence. The implications of study findings for practitioners: Scholars and practitioners should consider implementing SECF technology to address language‐related barriers in tele‐collaborative projects.Guidelines based on our study can be utilized to design tele‐collaborative projects with SECF support.Training on technology and constant support needs to be provided to participants. [ABSTRACT FROM AUTHOR]

Background: Students who are blind are integrated into public schools in many countries, yet are often excluded from full participation in science since most learning materials are visual. To create a compensatory route, an existing model‐based inquiry‐learning environment was adapted by means of sonification (addition of non‐speech sounds that represent dynamic information). The learning environment uses agent‐based models and a complex systems approach to teach the Kinetic Molecular Theory (KMT) and Gas Laws. The models are accompanied by a workbook consisting of text (printed or auditory) and images (printed or tactile). Objectives: The current research examined whether such perceptual compensation creates a comparable learning environment for learners who are blind compared with learners who are sighted using the original learning environment. The aim of the study is to expand knowledge about how the auditory channel may compensate the visual channel among individuals who are blind. Methods: Conceptual learning in science and reasoning about complex systems were assessed using pre‐ and post‐questionnaires. To explore learners' learning progression throughout the unit, four progression analysis 'windows' were selected. These were groups of adjacent or nearly adjacent items in the workbook that permitted a glimpse of learners' progression. Results: The sonified environment not only supported the learning of learners who are blind compared with the learning of learners who are sighted using visual material, but even furthered their learning with respect to diffusion, one of the more challenging concepts in KMT. It seems the types of sonified representations used in this study increased listeners' sensitivity to the micro‐level interactions in a way less accessible in visual representations. Takeaways: Sonified environments can be provide learners who are blind with equitable participation by compensating and complementing the visual channel. Sonification can have implications for students who are blind as well as students who are sighted. Lay Description: What is already known: Sonification is the use of non‐speech sounds to represent dynamic information. Sonification can potentialy be used to allow equitable participation for students who are blind. What this paper adds: To test this, the study compared the outcomes of learners who are blind who used a sonified learning environment (L2C) to that of learners who are sighted who used a visual environment. Implications for practice: Learners who are blind showed equal or better learning outcomes using the sonified models compared with the learners who are sighted using the visual models. There are major implications for integrating students who are blind in public school classrooms. [ABSTRACT FROM AUTHOR]

Objective: In recent years, the academic medicine community has produced numerous statements and calls to action condemning racism. Though health equity work examining health disparities has expanded, few studies specifically name racism as an operational construct. As emergency departments serve a high proportion of patients with social and economic disadvantage rooted in structural racism, it is critically important that racism be a focus of our academic discourse. This study examines the frequency at which four prominent emergency medicine journals, Annals of Emergency Medicine, Academic Emergency Medicine, the American Journal of Emergency Medicine, and the Western Journal of Emergency Medicine, publish on health disparities and racism. Methods: This is a descriptive analysis measuring the frequency of publications on health disparities and racism in U.S.‐based emergency medicine journals from 2014 to 2021. The search strategies for the concepts of "racism" and "health disparities" used a combination of MeSH and keywords. These search strategies were developed based on prior literature and the MEDLINE/PubMed Health Disparities and Minority Health Search Strategy. Articles identified through the PubMed search were then reviewed by two authors for final inclusion. Results: Since 2014, a total of 6248 articles were published by the four emergency medicine journals over the 8‐year study period. Of those, 82 research papers that focused on health disparities were identified and only 16 that focused on racism. Most emergency medicine publications on racism and health disparities were in 2021. Conclusions: Our findings suggest that the national discourse on racism and calls to action within emergency medicine were followed by an increase in publications on health disparities and racism. Continued investigation is needed to evaluate these trends moving forward. [ABSTRACT FROM AUTHOR]

Introduction: To increase the likelihood of research responding to societal needs, intermediary structures such as Science Shops are being created. Science Shops respond to research needs identified and prioritized through participatory processes involving civil society. However, these are not mainstream structures, and most research needs addressed by the scientific community are not defined by a diversity of stakeholders (including citizens) but are mostly prioritized by researchers and funders. Literature shows this often leads to bias between the research topics investigated and the research needs of other relevant stakeholders. This study analyses how 14 Science Shops contribute to decreasing bias in health research agenda setting. Methodology: We compare the research priorities identified through participatory processes by the Science Shops, which participated in the European Union‐funded project InSPIRES (2017–2021), to the available research addressed in the literature (identified in Web of Science), which we use as a proxy for current research priorities. Results: Science Shop projects contributed to decreasing the existing bias in health research agenda setting: (1) between drug and nondrug treatments and (2) between clinical trials of treatments for illnesses affecting high‐income versus middle‐ and low‐income countries, which leads to a lack of local strategies for high disease burdens in nonhigh‐income regions. Conclusion: This study provides the first evidence of Science Shops' effectiveness in addressing current biases in health research agenda setting. We conclude they could play a key role in shaping local, national and international research policies. [ABSTRACT FROM AUTHOR]

Objective: To identify differences in the muscle mechanical properties of the pelvic floor (PF) and lumbar paravertebral (LP) muscles between young nulliparous and uni/multiparous women. Secondarily, specific behaviors, depending on the presence or absence or urinary incontinence (UI), were also researched. Design: Case–control study. Setting: Higher education institution. Participants: One hundred young women participated, divided into two groups depending on whether they had vaginal birth (nulliparous or uni/multiparous). Each group included women with and without UI. Main measures: A muscle mechanical properties (tone, stiffness, decrement—inverse of elasticity—, and viscoelastic properties: relaxation and creep) assessment of the PF and LP muscles were performed with a hand-held tonometer. Results: Tone and stiffness of both sides of the PF presented group by UI interaction (p < 0.05), with uni/multiparous women with UI showing higher tone and stiffness compared to multiparous women without UI. In LP muscles, uni/multiparous women showed greater tone and stiffness on the right and left sides [−2.57 Hz (95% confidence interval −4.42,−0.72) and −79.74 N/m (−143.52,−15.97); −2.20 Hz (−3.82,−0.58) and −81.30 N/m (−140.66-,21.95), respectively], as well as a decrease in viscoelastic properties compared to nulliparous women [relaxation: 2.88 ms (0.31,5.44); creep: 0.15 (0.01,0.30); relaxation: 2.69 ms (0.13,5.25); creep: 0.14 (0,0.28), respectively]. Conclusions: Vaginal birth and UI have a differential influence on the muscle mechanical properties of the PF and LP muscles. The determination of muscle mechanical properties by externally applied hand-held tonometry improves the knowledge of the lumbopelvic status, with applicability in clinical and research fields. [ABSTRACT FROM AUTHOR]

Background: As adequate support, virtual reality (VR) has been increasingly introduced into the classroom to help students learn a new language. However, empirical studies exploring the educational potential of using 360° spherical video‐based virtual reality (SVVR) in high‐school Chinese language classrooms are still lacking. Objectives: A mind mapping‐based SVVR learning system is proposed for international high‐school students' Chinese courses and examines its effects on improving Chinese learning achievements and perceptions among Grade 10 students who learn Chinese as a foreign language. Methods: This study adopted a quasi‐experiment design. Participants (N = 66) were assigned to one of three conditions: mind mapping‐based SVVR (MMBSVVR), conventional SVVR (CSVVR), or traditional lecturing (TL). Our mixed‐method approach employed pre‐and post‐tests to measure Chinese learning achievements, questionnaires to measure Chinese learning motivation, problem‐solving ability, and self‐efficacy, and semi‐structured interviews to further explore students' feelings and attitudes about Chinese courses in corresponding learning environments. Results and Conclusions: The results showed that the MMBSVVR classroom significantly improved high students' Chinese learning achievements in Chinese vocabulary and making sentence, problem‐solving ability, and self‐efficacy. Moreover, SVVR stimulates students' learning interest and class participation, and mind mapping provides students with a clear guide to arrange the knowledge. These findings help interpret the relationships between MMBSVVR and learning achievements, Chinese learning motivation, problem‐solving ability, and self‐efficacy in an international high school Chinese courses, thus providing insight on integrating MMBSVVR into existing classrooms. Lay Description: What is Already Known about this Topic: By creating fully immersive 3D environments, 360° spherical video‐based virtual reality (SVVR) in promoting language learning has been confirmed by many scholars with a focus on English language learning.Mind mapping effectively enables second language learners to review and retain new words in the target language meaningfully. Also, it can create a more vivid learning atmosphere through images and graphics and promote learners' memory and learning motivation. What This Paper Adds: A mind mapping‐based SVVR learning system has been developed with the support of the constructivism theory.A mind mapping‐based SVVR learning system is proposed to facilitate international students' Chinese learning performance in Chinese vocabulary acquisition and sentence construction.In addition to promoting international students' learning outcomes, the proposed approach indicated promising results in learning motivation, problem‐solving ability, and self‐efficacy. Implications for Practice and/or Policy: This study provides an evidence base for further research through the utilization of VR learning environments in Chinese language classrooms.This study advocates introducing SVVR technology in the Chinese learning classrooms to increase the learning context for international students. It is also worth encouraging scholars to design VR learning systems with different learning strategies.Due to the cognitive requirements of the Chinese language learning process, it is necessary to introduce mind maps in the SVVR learning system to assist students in constructing knowledge and combining prior and new knowledge to generate long‐term memory. [ABSTRACT FROM AUTHOR]

Sensory sensitivities in children are found not only across a range of childhood disorders, but also within the general population. The current exploratory study examines the reliability and validity of a novel parent-report measure which assesses sensory-sensitivities in both typically developing and non-typically developing children. This 42-item Parent-completed Glasgow Sensory Questionnaire (GSQ-P) has been adapted by us from an existing adult tool (Glasgow Sensory Questionnaire), and measures children's hyper-sensitivities (sensory overload leading to avoidance-behaviours) and hypo-sensitivities (sensory dampening leading to seeking-behaviours) across seven different sense domains (visual, auditory, gustatory, olfactory, tactile, vestibular, proprioception). We validated this novel measure on the parents of 601 English children 6–11 years. Both the long version (42-items GSQ-P) and an additional reduced version (24-item rGSQ-P) significantly associated with children's anxiety, behavioural difficulties, and ability to empathise. As expected, sensory sensitivities were invariant across age and gender, but non-typically developing children had significantly elevated scores compared to typically developing peers (in both GSQ-P and rGSQ-P). We also provide insight into the structure of sensory sensitivities in children, showing for the first time that hyper sensitivities cluster by sense (e.g., tactile questions cluster together; visual questions cluster together) whilst hypo sensitivities cluster by behaviour (e.g., a cluster of seeking-behaviours irrespective of sense; a cluster of sensory dampening irrespective of sense). We offer both instruments (GSQ-P and rGSQ-P) as free reliable measures for better understanding children's sensitivities, for use in different circumstances depending on focus. Highlights: The paper explores two new parent-report sensory sensitivity questionnaires adapted from the adult Glasgow Sensory Questionnaire. Sensory sensitivity scores were invariant across age groups (6–10 years) and between girls and boys. Anxiety, internalising behaviours and poorer empathy were associated more closely with hyper-sensitivity, whereas externalising behaviours were associated more with hypo-sensitivity. Hyper-sensitivity items clustered together within sense modalities, whereas hypo-sensitivity items tendered to cluster by behavioural manifestation. [ABSTRACT FROM AUTHOR]

This paper explores the perception of "relatives" during the rehabilitation of young adults with severe acquired brain injury (SABI). This longitudinal qualitative study followed eight young adults with a SABI from hospital discharge to a year and a half after discharge. The design encompassed professional records, interviews, and surveys, including a name generator list completed by the young adults and focus group interviews with both their families and professionals. We apply a sociological theoretical framework concerning friendship, and we employ social network analysis (SNA) methodology to capture, visualise, and analyse the young adults' significant social relations. Social relations engaged as relatives during rehabilitation are to a large extent determined by the perceptions of professionals and the parents of the young adult. These perceptions contain a limited number of social relations, with priority given to biological and juridical ties. This might reflect the reduced social support available for the young adult, who initially had a much larger social network. The authors suggest a professional rethinking of who "relatives" are as well as considering these social ties as dynamic. Rehabilitation professionals must be aware of and pay attention to differing perceptions that exist as to who qualifies as significant social relations in order to reconsider the practical implementation of relative involvement. The perception of who relatives are during the rehabilitation process should be reconsidered and extended to include who the young adult perceive as significant social relations. Relatives are not a fixed entity and should be considered dynamically throughout the rehabilitation process. Social relations of the young adult must to a larger extent be considered during rehabilitation to prevent social isolation in the long run. [ABSTRACT FROM AUTHOR]

Background: The use of patient-reported outcome measures (PROM) and patient-reported experience measures (PREM) provide health providers with valuable feedback on how to improve clinical care and patient outcomes. This paper describes a qualitative study that was conducted to learn about factors influencing the well-being of people living with HIV (PLHIV) in Finland. The findings will be used to develop themes for HIV-specific PROM and PREM questions. Methods: PROMs and PREMs were developed by the Finnish Institute for Health (THL) as a part of a project to develop a national quality-of-care registry for HIV. The study aimed to identify issues and concerns among people living with HIV (PLHIV) that influence their well-being (PROMs) and their experiences in the healthcare system (PREMs). The data were collected through face-to-face in-depth interviews and focus group discussions based on open-ended and semi-structured questions. The data were analyzed using thematic analysis. Results: The assessment identified the following PROMs of concern: psychological well-being, concerns about stigma, physical health, social well-being, sexual well-being, medication uptake, managing other medications with antiretrovirals (ARVs), and growing old. The assessment identified the following PREMs: helping patients understand their own health status, proving an opportunity for patients to discuss physical health, psychological and sexual well-being, supporting the uptake of ARVs, assisting patients with medication use, showing compassion towards patients, and empowering patients against stigma. Conclusion: These findings of the study can be used to develop domain-specific PROM and PREM questions for the national HIV quality care register. [ABSTRACT FROM AUTHOR]

Background: Mobile‐assisted language learning (MALL) has long been advocated to promote students' language study outcomes. However, little is known about how using instant messaging applications (an example of MALL) affect student motivation, language anxiety, and actual achievement. Objectives: To help close this gap, we have conducted a quasi‐experimental study, in which we have used self‐determination theory to test a mediational process model, in an effort to understand the psychological mechanisms that underlie the effect of instant messaging applications on student outcomes. Methods: Two groups of Saudi undergraduate students (N = 447) were recruited to participate in the study. Participants under the experimental condition were invited to engage in language‐related tasks with their teacher outside of class through the WhatsApp application, whereas participants under the control condition received standard teaching. We applied partial least square structural equation modelling (PLS‐SEM) to test our model. Results and Conclusions: The results of the PLS‐SEM showed that the total effects of using instant messaging applications on autonomous motivation and L2 achievement were significant but that language anxiety was influenced only indirectly and negatively through language achievement. Also, the PLS‐SEM showed that our results have strong predcitive power indicating support for external validity. Implications: Our results show that instant messaging applications can be used to facilitate interest and achievement and to decrease anxiety. Furthermore, we are contributing to L2 methodological literature by using applications of PLS‐SEM in experimental designs that can help researchers and practitioners of motivational processes. Lay Description: What is already known about this topic: Using WhatsApp and more broadly instant messaging applications are conceived to be motivating in language teaching contextStudies indicate students are inclined toward using these applications in language learningResearch shows that using WhatsApp is easy to apply for language teaching purposes What this paper adds: The study examined the effect of using WhatsApp on language learners' motivation, achievement, and language anxietyA pre‐ and post‐test approach with experimental and control condition has been used to evaluate the effect more accuratelyThe study employs Self‐determination Theory as a theoretical framework for testing a motivational process modelResults show that using WhatsApp predicted the outcomes directly and indirectly Implications for practice and/or policy: WhatsApp can significantly encourage university students to better learning of the language skills especially in times where face‐to‐face communication is limitedWhatsApp is conditioned by the guidance of instructors, their ongoing formative and summative assessmentWhatsApp appears to allow students enjoy their learning process due to the opportunities for collaborative work and constant exchange of content [ABSTRACT FROM AUTHOR]

Accessible Summary: What is known on the subject?: Having a mental illness may undermine men's self‐image as a father while having children may facilitate their recovery.Many fathers who experience mental health issues experience stigma and are reluctant to seek support in their parental role.Most studies in this field focus on fathers from Western countries. What does the paper add to existing knowledge?: Similar to Western fathers, Chinese fathers reported both negative parenting (parenting disengagement, harsh parenting and inconsistent discipline) and positive father–child interactions when ill.Unlike their Western counterparts, Chinese fathers relied on extended family support in their parenting role, though this support was problematic at times. What are the implications for practice?: This research helps mental health nurses understand the experiences of Chinese fathers with mental illness.Findings suggest that specific cultural adaptions to family‐focused interventions are needed for the Chinese context including considering extended family members (e.g. grandparents). Introduction: Parenting roles are important for those with a mental illness. While research on mothers is well established there is scant focus on fathers with mental illness, especially in non‐Anglophone countries. Aim: To better understand the parenting and family experiences of fathers, who have a mental illness, from the People's Republic of China. Method: Qualitative semi‐structured interviews were conducted with nine Chinese fathers with mental illness, using Interpretative Phenomenological Analysis. Results: Seven superordinate themes were identified: (i) mental illness undermines idealized images of fatherhood; (ii) parenting in the context of mental illness; (iii) concerns about the negative impact of their illness on children; (iv) children as a burden and a source of hope; (v) stigma; (vi) relying on family support; and (vii) unmet professional and peer support needs. Discussion: Chinese fathers held a gendered image of fatherhood, and experienced self‐stigma for not living up to their ideal sense of fatherhood, which resulted in a reluctance to seek support. This study adds to the existing literature by focusing on Chinese fathers. Although many of their experiences are similar to fathers from Western countries, some differences were found, notably around a reliance on extended family support. Implications for practice: Nurses and other mental health professionals need to adopt a family‐focused, culturally informed approach to supporting Chinese fathers with mental illness and their families. [ABSTRACT FROM AUTHOR]

Objective: Developing an ontology can help collecting and sharing information in traditional medicine including Persian medicine in a well-defined format. The present study aimed to develop an ontology for gastric dystemperament in the Persian medicine.Methods: This was a mixed-methods study conducted in 2019. The first stage was related to providing an ontology requirements specification document. In the second stage, important terms, concepts, and their relationships were identified via literature review and expert panels. Then, the results derived from the second stage were refined and validated using the Delphi method in three rounds. Finally, in the fourth stage, the ontology was evaluated in terms of consistency and coherence.Results: In this study, 241 concepts related to different types of gastric dystemperament, diagnostic criteria, and treatments in the Persian medicine were identified through literature review and expert panels, and 12 new concepts were suggested during the Delphi study. In total, after performing three rounds of the Delphi study, 233 concepts were identified. Finally, an ontology was developed with 71 classes, and the results of the evaluation study revealed that the ontology was consistent and coherent.Conclusion: In this study, an ontology was created for gastric dystemperament in the Persian medicine. This ontology can be used for designing future systems, such as case-based reasoning and expert systems. Moreover, the use of other evaluation methods is suggested to construct a more complete and precise ontology. [ABSTRACT FROM AUTHOR]

Aims: To explore the factors related to hospital‐to‐home transitional self‐monitoring blood glucose behaviour among patients with diabetes‐related foot ulcer. Background: The 30‐day readmission rate of patients with diabetes‐related foot ulcer can be reduced when good glycaemic control is achieved. The practice of self‐monitoring blood glucose promotes optimal glycaemic control. Design A comparative descriptive study. Methods: In this study, 200 participants, who had been hospitalized due to diabetes‐related foot ulcer, were recruited from August 2017 to July 2018. Before participants were discharged from the hospital, psychosocial factors (family support, threat belief, self‐efficacy and knowledge) and pre‐hospitalization self‐monitoring blood glucose behaviour were collected using a structured questionnaire. Then, after discharge, self‐monitoring blood glucose behaviour delivery was collected again. Results: Five variables explained 47% of the variance in the delivery of self‐monitoring of blood glucose at home. The delivery of hospital‐to‐home transitional self‐monitoring blood glucose behaviour was more likely for individuals with higher pre‐discharge self‐efficacy, higher post‐discharge self‐efficacy, more attention to pre‐hospitalization glycaemic status and post‐discharge insulin usage and those without an insensitive foot. Conclusion: Self‐monitoring blood‐glucose behaviour should be promoted among post‐discharge patients with diabetes‐related foot ulcer. The modifiable factors identified in this study can be integrated into the discharge plan. Summary statement: What is already known about this topic? Patients with diabetes‐related foot ulcer have higher 30‐day readmission rates than the general inpatient population. Such readmissions can be prevented when good glycaemic control is achieved.As a centrepiece of diabetes self‐management, self‐monitoring blood glucose practice promotes optimal glycaemic control.Although there have been several survey studies of self‐monitoring blood glucose practice among patients with diabetes, to our knowledge, no study has used longitudinal data to explore the self‐monitoring of blood glucose behaviour. In addition, no study has explored hospital‐to‐home transitional self‐monitoring of blood glucose among patients with diabetes. What this paper adds? After participants were discharged from the hospital, approximately one‐fourth did not perform self‐monitoring of blood glucose at home.The delivery of hospital‐to‐home transitional self‐monitoring blood glucose practice was more likely for individuals with higher pre‐discharge self‐efficacy, higher post‐discharge self‐efficacy, more attention to pre‐hospitalization glycaemic status and post‐discharge insulin usage as well as for those without an insensitive foot.Self‐efficacy of self‐monitoring of blood glucose is the most powerful predictor of hospital‐to‐home transitional self‐monitoring blood‐glucose practice. The implications of this paper: For patients with less attention paid to their glycaemic status previously and with impaired foot sensation, an intensive discharge plan should be provided to promote their self‐monitoring blood‐glucose practice.To promote self‐monitoring blood‐glucose practice, strategies to improve self‐efficacy related to self‐monitoring of blood glucose should be integrated into the discharge plan and subsequent follow‐up. [ABSTRACT FROM AUTHOR]

Background: Traditional approaches to identify missing mechanisms are usually based on the hypothesis test and confronted with both theoretical and practical challenges. It has been proved that the Bayesian network is powerful in integrating, analyzing and visualizing information, and some previous researches have verified the promising features of Bayesian network to deal with the aforementioned challenges in missing mechanism identification. Based on the above reasons, this paper explores the application of Bayesian network to the identification of missing mechanisms for the first time, and proposes a new method, the Bayesian network-based missing mechanism identification (BN-MMI) method, to identify missing mechanism in medical research.Methods: The procedure of BN-MMI method consists three easy-to-implement steps: estimating the missing data structure by the Bayesian network; assessing the credibility of the estimated missing data structure; and identifying the missing mechanism from the estimated missing data structure. The BN-MMI method is verified by simulation research and empirical research.Results: The simulation study verified the validity, consistency and robustness of BN-MMI method, and indicated its outperformance in contrast to the traditional logistic regression method. In addition, the empirical study illustrated the applicability of BN-MMI method in the real world by an example of medical record data.Conclusions: It was confirmed that the BN-MMI method itself, together with human knowledge and expertise, could identify the missing mechanisms according to the probabilistic dependence/independence relations among variables of interest. At the same time, our research shed light upon the potential application of BN-MMI method to a broader range of missing data issues in medical studies. [ABSTRACT FROM AUTHOR]

Background: Rigorously designed longitudinal studies can inform how best to reduce the widening health gap between Indigenous and non-Indigenous children.Methods: A systematic review was performed to identify and present the breadth and depth of longitudinal studies reporting the health and well-being of Indigenous children (aged 0-18 years) globally. Databases were searched up to 23 June 2020. Study characteristics were mapped according to domains of the life course model of health. Risk of bias was assessed using the National Institutes of Health (NIH) Study Quality Assessment Tools. Reported level of Indigenous involvement was also appraised; PROSPERO registration CRD42018089950.Results: From 5545 citations, 380 eligible papers were included for analysis, representing 210 individual studies. Of these, 41% were located in Australia (n = 88), 22.8% in the USA (n = 42), 11.9% in Canada (n = 25) and 10.9% in New Zealand (n = 23). Research tended to focus on either health outcomes (50.9%) or health-risk exposures (43.8%); 55% of studies were graded as 'good' quality; and 89% of studies made at least one reference to the involvement of Indigenous peoples over the course of their research.Conclusions: We identified gaps in the longitudinal assessment of cultural factors influencing Indigenous child health at the macrosocial level, including connection to culture and country, intergenerational trauma, and racism or discrimination. Future longitudinal research needs to be conducted with strong Indigenous leadership and participation including holistic concepts of health. This is critical if we are to better understand the systematic factors driving health inequities experienced by Indigenous children globally. [ABSTRACT FROM AUTHOR]

The purpose of this pilot study was to compare embedded audio feedback (EAF), which faculty provided using the iPad® application iAnnotate® PDF to insert audio comments and written feedback (WF), inserted electronically on student papers in a series of writing assignments. Goals included determining whether EAF provides more useful guidance to students than WF and whether EAF promotes connectedness among students and faculty. An additional goal was to ascertain the efficiency and acceptance of EAF as a grading tool by nursing faculty. The pilot study was a quasi-experimental, cross-over, posttest-only design. The project was completed in an Informatics in Health Care course. Faculty alternated the two feedback methods on four papers written by each student. Results of surveys and focus groups revealed that students and faculty had mixed feelings about this technology. Student preferences were equally divided between EAF and WF, with 35% for each, and 28% were undecided. [J Nurs Educ. 2015; 54(1):41-44.] [ABSTRACT FROM AUTHOR]

The article summarizes the lessons learned from the case studies on innovations in paper health register systems in Ethiopia, Ghana, South Africa and Ghana, which include recommendations for aligning standard registers designed by global organizations with local health needs.

Background: Individual-based models (IBMs) are useful to simulate events subject to stochasticity and/or heterogeneity, and have become well established to model the potential (re)emergence of pathogens (e.g., pandemic influenza, bioterrorism). Individual heterogeneity at the host and pathogen level is increasingly documented to influence transmission of endemic diseases and it is well understood that the final stages of elimination strategies for vaccine-preventable childhood diseases (e.g., polio, measles) are subject to stochasticity. Even so it appears IBMs for both these phenomena are not well established. We review a decade of IBM publications aiming to obtain insights in their advantages, pitfalls and rationale for use and to make recommendations facilitating knowledge transfer within and across disciplines.Methods: We systematically identified publications in Web of Science and PubMed from 2006-2015 based on title/abstract/keywords screening (and full-text if necessary) to retrieve topics, modeling purposes and general specifications. We extracted detailed modeling features from papers on established vaccine-preventable childhood diseases based on full-text screening.Results: We identified 698 papers, which applied an IBM for infectious disease transmission, and listed these in a reference database, describing their general characteristics. The diversity of disease-topics and overall publication frequency have increased over time (38 to 115 annual publications from 2006 to 2015). The inclusion of intervention strategies (8 to 52) and economic consequences (1 to 20) are increasing, to the detriment of purely theoretical explorations. Unfortunately, terminology used to describe IBMs is inconsistent and ambiguous. We retrieved 24 studies on a vaccine-preventable childhood disease (covering 7 different diseases), with publication frequency increasing from the first such study published in 2008. IBMs have been useful to explore heterogeneous between- and within-host interactions, but combined applications are still sparse. The amount of missing information on model characteristics and study design is remarkable.Conclusions: IBMs are suited to combine heterogeneous within- and between-host interactions, which offers many opportunities, especially to analyze targeted interventions for endemic infections. We advocate the exchange of (open-source) platforms and stress the need for consistent "branding". Using (existing) conventions and reporting protocols would stimulate cross-fertilization between research groups and fields, and ultimately policy making in decades to come. [ABSTRACT FROM AUTHOR]

Background: Self-interviews, where the respondent rather than the interviewer enters answers to questions, have been proposed as a way to reduce social desirability bias associated with interviewer-led interviews. Computer-assisted self-interviews (CASI) are commonly proposed since the computer programme can guide respondents; however they require both language and computer literacy. We evaluated the feasibility and acceptability of using electronic methods to administer quantitative sexual behaviour questionnaires in the Somkhele demographic surveillance area (DSA) in rural KwaZulu-Natal, South Africa.Methods: We conducted a four-arm randomized trial of paper-and-pen-interview, computer-assisted personal-interview (CAPI), CASI and audio-CASI with an age-sex-urbanicity stratified sample of 504 adults resident in the DSA in 2015. We compared respondents' answers to their responses to the same questions in previous surveillance rounds. We also conducted 48 cognitive interviews, dual-coding responses using the Framework approach.Results: Three hundred forty (67%) individuals were interviewed and covariates and participation rates were balanced across arms. CASI and audio-CASI were significantly slower than interviewer-led interviews. Item non-response rates were higher in self-interview arms. In single-paper meta-analysis, self-interviewed individuals reported more socially undesirable sexual behaviours. Cognitive interviews found high acceptance of both self-interviews and the use of electronic methods, with some concerns that self-interview methods required more participant effort and literacy.Conclusions: Electronic data collection methods, including self-interview methods, proved feasible and acceptable for completing quantitative sexual behaviour questionnaires in a poor, rural South African setting. However, each method had both benefits and costs, and the choice of method should be based on context-specific criteria. [ABSTRACT FROM AUTHOR]

Background: Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA) is common with a prevalence of 6% of all patients fulfilling the diagnosis of myocardial infarction. MINOCA should be considered a working diagnosis. Cardiac Magnetic Resonance (CMR) imaging has recently been suggested to be of great value to determine the cause behind MINOCA. The objectives of this paper are to describe the rationale behind the second Stockholm Myocardial Infarction with Normal Coronaries (SMINC-2) study and to discuss the protocol for investigation of MINOCA patients in the light of the recently published position paper from the European Society of Cardiology.Methods: The SMINC-2 study is an open non-randomised study using historical controls for comparison. The primary aim is to prove that MINOCA patients investigated with the latest CMR imaging technique can achieve a diagnosis in 70% of all cases entirely by imaging. By including 150 patients we will have >80% chance to prove that the diagnostic accuracy can be improved by 20 absolute % with a p-value of less than 0.05 when compared with CMR imaging in the SMINC-1 study. Furthermore, in addition to invasive coronary angiography, coronary arteries are evaluated by computed tomography angiography to investigate coronary causes and questionnaires are used to describe Quality-of-Life (QoL). By January 1st 2017, 75 patients have been included.Discussion: Whether CMR imaging can provide a diagnosis to an adequate proportion of MINOCA patients is unknown. Well-defined inclusion and exclusion criteria will be used to compare a MINOCA cohort from the population with an appropriate control group. Positive results are likely to influence future guidelines of the management of MINOCA. Furthermore, the study will give mechanistic insights into MINOCA in particular in patients with "true" myocardial infarction and describe QoL in this vulnerable group of patients.Trial Registration: Clinical Trials NCT02318498 . [ABSTRACT FROM AUTHOR]

Objective: To determine the effects on weight loss of three abbreviated behavioral weight loss interventions with and without coaching and mobile technology.Methods: A randomized controlled efficacy study of three 6-month weight loss treatments was conducted in 96 adults with obesity: 1) self-guided (SELF), 2) standard (STND), or 3) technology-supported (TECH). STND and TECH received eight in-person group treatment sessions. SELF and STND used paper diaries to self-monitor diet, activity, and weight; TECH used a smartphone application with social networking features and wireless accelerometer.Results: Weight loss was greater for TECH and STND than SELF at 6 months (-5.7 kg [95% confidence interval: -7.2 to -4.1] vs. -2.7 kg [95% confidence interval: -5.1 to -0.3], P < 0.05) but not 12 months. TECH and STND did not differ except that more STND (59%) than TECH (34%) achieved ≥ 5% weight loss at 6 months (P < 0.05). Self-monitoring adherence was greater in TECH than STND (P < 0.001), greater in both interventions than SELF (P < 0.001), and covaried with weight loss (r(84) = 0.36-0.51, P < 0.001).Conclusions: Abbreviated behavioral counseling can produce clinically meaningful weight loss regardless of whether self-monitoring is performed on paper or smartphone, but long-term superiority over standard of care self-guided treatment is challenging to maintain. [ABSTRACT FROM AUTHOR]