Journal articles on the topic 'Emotional Design, Healthcare Design for Children, Affective Evaluation Methods, Emotional Design Process'

Abstract Playing computer games is a predominantly emotional than rational process. Video games with affect-based adaptation measure player’s behavior signals and recognize player’s emotional states in order to adapt specific game features in a dynamic manner and to improve player’s engagement, immersion, excitement, and challenge. The present review deals with models for the presentation of emotions, techniques for measuring behavioral signals, emotion recognition and adaptation mechanisms applied in video games with affective feedback including methods for their assessment and validation. Studies using self-reports, observational methods and psychophysiological measurements of both autonomic and central nervous systems including processing and interpretation of signals are systematically reviewed with regard to their results concerning emotional adaptation in games. Next, the article provides a comparative analysis of affect-based adaptation methods and techniques applied in 14 adaptive video games developed in last ten years. Based on this comparison, we summarized future directions in research, design and evaluation of video games with affective adaption.

Abstract: The COVID-19 pandemic situation that occurred over a long period of time had quite an impact on student learning methods. These emerging learning innovations greatly impact the involvement of students, especially elementary school children. This study aims to identify the relationship between engagement strategies and student's involvement in a hybrid-based English class at SDIT AT-Taqwa Surabaya. This research is a descriptive qualitative study. Data were collected through a process of observation and questionnaires that focused on the types of engagement strategies used, as well as the responses shown by grade 1A and 1B students at SDIT AT-Taqwa Surabaya. The results show that the students' engagement strategies used by grade one English teachers at SDIT AT-Taqwa are varied. These strategies are socio-affective, design, and organization engagement. Teachers strongly emphasize the use of socio-affective engagement strategies, especially in order to increase students' emotional involvement. The teacher understands that to create an active, collaborative and conducive hybrid class, the teacher must build a sense of comfort among the students in the classroom. In other words, the teachers realize that emotional involvement is the foundation in triggering cognitive and behavioral engagement. It can be stated that the hybrid-based English classes at SDIT AT-Taqwa are being conducted successfully and wisely in a very balanced online and offline approach using the available resources.

Background Out of school hours care (OSHC) services provide a unique opportunity to deliver early intervention programs to enhance primary school–aged children’s social, emotional, physical, and cognitive well-being; however, such programs are currently lacking. Objective This study aims to address the lack of well-being programs for children accessing OSHC services in the research literature by using participatory design (PD) to collaboratively develop and test an OSHC well-being program—the connect, promote, and protect program (CP3). Methods The study employed methods of PD, user (acceptance) testing, and iterative knowledge translation to develop a novel well-being program framework—CP3—with key stakeholders (eg, children, OSHC staff, volunteers, families, clinicians, educators, and researchers). Thematic techniques were used to interpret and translate the qualitative information obtained during the research and design cycles. Results The co-design process generated the CP3 model, which comprises a group-based mentoring approach to facilitate enhanced activities in OSHC settings. Activities are underpinned by 4 key principles of program delivery: build well-being and resilience, broaden horizons, inspire and engage, and connect communities. Conclusions To our knowledge, the CP3 program is the first co-designed well-being program developed specifically for OSHC services. This co-design process is key to ensuring local community needs—particularly those of young people accessing OSHC—are met and that these individuals are meaningfully and actively involved in all stages of the research and design process, from conception to implementation, evaluation, and continuous improvement.

Background Smartphone apps could support patients and caregivers in disease self-management. However, as patients’ experiences and needs might not always align with clinical judgments, the eliciting and engaging of perspectives of all stakeholders in the smartphone app design process is of paramount importance. Objective The aims of this study are to better understand the needs of and challenges facing caregivers and health care professionals (HCPs) who care for children with atopic dermatitis (AD) and to explore the desirable features and content of a smartphone app that would support AD self-management. Methods This study adopted a qualitative participatory co-design methodology involving 3 focus group discussions: workshop one focused on caregivers; workshop two engaged with HCPs; and in the last workshop, caregivers and digital health experts were asked to design the wireframe prototype. The participants completed a sociodemographic questionnaire, a technology acceptance questionnaire, and a workshop evaluation form. Results Twelve caregivers participated in the first workshop, and 10 HCPs participated in the second workshop. Eight caregivers and 4 digital health experts attended the third workshop. Three superordinate themes that reflected caregivers’ and HCPs’ challenges and needs were identified: empowerment by education, confusion over treatment, and emotional impact. Workshop participants also raised a series of suggestions on the features and contents of the AD self-management app, which informed the last co-design workshop, and described their needs and challenges. In the last workshop, the participants developed a wireframe prototype of the app following the identified requirements and recommendations. Conclusions The co-design approach was found to be a successful way of engaging with the participants, as it allowed them to express their creativity and helped us to articulate the root of the clinical problems. The co-design workshop was successful in creating and generating new ideas and solutions for smartphone app development.

Background: Globally, many infants and children are diagnosed with illnesses that impose limitations on their well-being and life course trajectory. Children’s care becomes the central focus of family life. Inadequate support for parents is detrimental to their well-being and management of their child’s care and support needs. Methods: The second phase of this evaluation study followed a quasi-experimental crossover design to test a theory-based psychosocial intervention, the Keeping Hope Possible Toolkit. Fifty-nine participants were randomly assigned to one of two sequence groups, with measures of hope, feelings of control, distress, and uncertainty completed pre- and post-intervention, and at a three-month follow-up. Qualitative interviews sought to assess participant experiences with the intervention, along with acceptability and feasibility. Results: Significant influence on parental distress was found, and the qualitative findings reveal benefits of the intervention for parental wellbeing. The intervention effectively offered practical and emotional support to diverse family caregivers. Conclusions: The evidence-informed KHP intervention can be used by healthcare providers to intervene with family caregivers to support their dynamic emotions including hope, need to live in the moment and remember self, and social preferences. In doing so, parents’ critical caregiving activities can be sustained and their child’s health and wellbeing optimized.

Aim To assess the effects of virtual reality (VR) on the depressive state of patients with stroke admitted to neuro-rehabilitation units. Design: Systematic review and meta-analysis protocol. Methods Randomized Controlled Trials (RCTs) focusing on the effects of virtual reality on depressive state as a primary outcome will be included. Grey literature and the following databases will be consulted: PubMed, Cinahl, PsycInfo, Scopus, Embase, Cochrane Library and Web of Science. The recently revised Cochrane risk of bias tool will be used to assess the quality of included studies. Data will be extracted and meta-analyses will be performed within the specific condition of the emotional state of stroke patients admitted to neurorehabilitation units. Meta-regression and subgroup analyses will be used to identify effective modes and patterns of therapy delivery. The approach of assessment, development and evaluation of recommendations will be applied to reach a convincing conclusion. Discussion An accurate, transparent and standardized review process is expected to provide recommendations on the use of VR technology in the healthcare of stroke patients. Impact Emotional difficulties are common after stroke and have an impact on rehabilitation outcome. VR seems to have an important role in the treatment and depression in neurological patients, as it is able to improve levels of well-being, coping strategies and social relationships. The systematic review may contribute to a more convincing and specific conclusion compared to existing studies of this type. Trial registration Systematic review registration: CRD42022303968.

Abstract Background In view of the new era of teaching reform, the teaching mode of colleges and universities has changed the concept of education and innovative talent training mode, it is emphasized that “curriculum is the core element of talent training, and the quality of curriculum directly determines the quality of students.” talent training has different levels of teaching reform and curriculum practice. In response to this demand, colleges and universities have also carried out different degrees of teaching reform and curriculum practice research. Especially in the design curriculum of environmental design specialty, it is very necessary to explore the teaching reform of “X-Y theory” based on emotional regulation. Research Objects and Methods In order to overcome the shortcomings of this course in knowledge dimension, scalability, design thinking development and regional industry, this course is based on McGregor's “X-Y theory”, that is, psychological behavior motivation. According to the principle of street design, the basic theory and experimental test of street microclimate environment, guide students to carry out the simulation design practice of street landscape design. Each stage of the design practice process starts from the students' emotional “sensory multi-channel”, through the students' good sensory channel to obtain and remember matching information, and test the students' sensitivity and understanding of knowledge points. The second knowledge integration test is conducted through online sharing evaluation and offline simulated defense courses, so that students can promote each other and gradually improve in their autonomous learning experience. Use students' painting materials to establish a course case base. In order to verify the influence of the teaching reform exploration of the design course X-Y theory of environmental design specialty on emotion regulation, this study measured the junior middle school students in a school in a northern city, half male and half female, aged between 13 and 16 years (average age is 14.96 ± 0.85 years). According to the scores of “cognitive reappraisal” and “expression inhibition” strategies, the subjects were divided into high and low groups, and those with significant differences in the scores of the two strategies were selected as the subjects of the experimental group. According to the scores of “cognitive reappraisal” and “expression inhibition”, 50% of the middle group was used as the subjects of the control group. Finally, there were 100 effective subjects, including 50 in the positive emotion group and 50 in the negative emotion group. Using emotion inducing materials, negative emotion inducing materials are a 10 minutes film clip of “Tangshan earthquake”. The film describes the story that when the earthquake occurred, the family was buried underground, and the mother struggled to make the decision that two children can only save one child in order to save her children. The positive emotion inducing material selects a 6-minute film clip of “people in the middle of nowhere”, which tells a series of funny things that happen when two men live in a small hotel together. Neutral emotion inducing material selects a scenic film as the film material of educational film. Results Through online theoretical lectures, preliminary research, surveying and mapping research, microclimate measurement, practical design exercises and expert simulation debate, students deepen their understanding and understanding of the physical characteristics of street space and the actual construction of engineering technology through repeated matching and intentional matching strategies, so as to realize the balanced development of students' psychological function in all aspects. The results of repeated measurement analysis of variance showed that after watching the negative emotion induced film, the scores of negative emotion words (sadness, pain, fear, etc.) were significantly higher than the pre-test scores, and the scores of positive emotion words (happiness, interest) were significantly lower. This shows that the negative emotion inducing film clips effectively induce the subjects' negative emotion, and the selection of negative emotion inducing materials is reasonable. After watching the positive emotion induced film, the scores of positive emotion words (happiness and interest) were significantly higher than the pre-test scores, and the scores of negative emotion words (surprise and fear) decreased significantly, and there was no difference between the negative emotions (anger, disgust, sadness, contempt, embarrassment and pain) caused by the two videos. This shows that the positive emotion inducing film can effectively induce the subjects' positive emotion, and the selection of positive emotion experimental materials is reasonable. The level of optimism has a significant inhibitory and influence on the level of self depression, at the level of 0.01. Conclusion This course aims to meet students' different needs and stimulate students' autonomous learning potential through four different application experience modes: integration, integration, creation and enjoyment. From the curriculum feedback in the past three years, the intentional mismatch strategy selection of students' behavior path can be extended to allow students to experience and evaluate problem conflicts by evaluating courses, such as mapping, studying and testing real cases. This teaching method can effectively promote the depth and breadth of the teaching mode reform of architectural background design course, and is conducive to the formation of more practical teaching effect in the course. Acknowledgements Supported by a project grant from The Second Batch of New Engineering Research and Practice Project of the Ministry of Education (Project No. B-TMJZSLHY20202152).

Introduction: Anxiety disorders (AD) share features of both anxiety and fear linked to stress response. The hypothalamic-pituitary-adrenal (HPA) axis is considered the core biological pathway of the stress system and it is known that an inappropriate response to environmental stimuli may be related to individual genetic vulnerability in HPA-linked genes. Despite the biological plausibility of a relationship between the HPA axis and AD, few studies have investigated associations between genetic polymorphisms linked to the HPA axis and this complex disorder. Objective: To investigate whether AD are associated with genetic polymorphisms in HPA-linked genes in adolescents. Methods: Our study consisted of a cross-sectional evaluation of a community sample comprising a total of 228 adolescents (131 cases of AD). We extracted DNA from saliva and genotyped polymorphisms in HPA-linked genes (FKBP5: rs3800373, rs9296158, rs1360780, rs9470080 and rs4713916; NR3C1: rs6198; CRHR1: rs878886; and SERPINA6: rs746530) with real time polymerase chain reaction (PCR). The instruments used to diagnose and assess the severity of AD were the Schedule for Affective Disorder and Schizophrenia for School-Age Children - Present and Lifetime (K-SADS-PL) and the Screen for Child and Anxiety related Emotional Disorders (SCARED). Results: We failed to detect any associations between AD and genetic polymorphisms in HPA-linked genes (p > 0.05). Conclusion: To our knowledge, this is the first study evaluating these specific polymorphisms in relation to AD in adolescents, which encourages us to design further research on the subject.

Purpose – The purpose of this paper is to present the Early Childhood-Socio-Emotional and Behavior Regulation Intervention Specialist (EC-SEBRIS) Certificate Program model integrating knowledge and practice. Coursework, videotaping, on-site coaching, and the reflective process facilitate the application of knowledge through the integration of theory and practice supporting young children and families. It is designed to help teachers and early childhood professionals to internalize the skills and competencies needed to address challenging behaviors in their classrooms or at homes so that they can meet the critical social-emotional and behavioral needs of children. Design/methodology/approach – The paper will provide: research-based information to establish the need for such training programs; the rational to the conceptual framework of the EC-SEBRIS Certificate Program; the depiction of the wraparound training model, which uses triple coaching and mentoring methods: reflective supervision, videotaping, and on-site coaching for teachers; and a preliminary evaluation of the program, and future plans. Findings – The EC-SEBRIS Certificate Program is at its early implementation stage. The author have graduated four cohorts, for a total of 113, early childhood professionals who have been hired to enhance the behavioral health services provided to young children and families. Overall, results suggest that the students’ knowledge base and confidence improved from time 1 to time 2 for each of the knowledge-based courses. Research limitations/implications – This is a conceptual paper. Practical implications – The program bridges the early childhood education (ECE) and early childhood mental health fields, and recognizes the important role that early care and education professionals play in the socio-emotional development of young children. Coursework, videotaping, on-site coaching, and the reflective process facilitate the application of knowledge through the integration of theory and practice in the field supporting young children and families. Social implications – Challenging behaviors are one of the issues all early childhood educators have to deal within their classrooms. The model, as presented in the manuscript, can be implemented in other higher education institutions to enhance the skill sets of professionals who need to respond to this critical need and support healthy development of young children. Originality/value – This is an original model emphasizing the importance of training early childhood educators to support emotion and behavior regulation in young children. The paper presents a cutting edge teaching model which integrates knowledge, practice, and reflective practice. This training model focuses on the ECE workforce as the front line to the provision of early childhood mental health support.

Background Most cancer treatments today take place in outpatient clinics; however, it might be necessary for some patients to be admitted to hospital departments due to severe side effects or complications. In such situations, support from family and social relations can be crucial for the patients’ emotional well-being. Many young adolescents and children whose parents have cancer describe how they are not seen, heard, or listened to as the worried relatives they are. Within the intensive care unit, it has been recommended that early supportive interventions are tailored to include children of the intensive care patient; a similar approach might be relevant in the oncological setting. To our knowledge, no studies have explored how to involve young relatives who are visiting their parent at an oncological department. Recently, a framework for developing theory-driven, evidence-based serious games for health has been suggested. Such a process would include stakeholders from various disciplines, who only work toward one specific solution. However, it is possible that bringing together different disciplines, such as design, art, and health care, would allow a broader perspective, resulting in improved solutions. Objective This study aims to develop tools to enhance the social interaction between a parent with cancer and their child when the child visits the parent in the hospital. Methods In total, 4 groups of design students within the Visual Design program were tasked with developing games addressing the objective of strengthening relations in situ during treatment. To support their work, the applied methods included professional lectures, user studies, and visual communication (phase I); interviews with the relevant clinicians at the hospital (phase II), co-creative workshops with feedback (phase III), and evaluation sessions with selected populations (phase IV). The activities in the 4 phases were predefined. This modified user design had the child (aged 4-18 years) of a parent with cancer as its primary user. Results Overall, 4 different games were designed based on the same information. All games had the ability to make adults with cancer and their children interact on a common electronic platform with a joint goal. However, the interaction, theme, and graphical expression differed between the games, suggesting that this is a wide and fertile field to explore. Conclusions Playing a game can be an efficient way to create social interaction between a parent with cancer and a child or an adolescent, potentially improving the difficult social and psychological relations between them. The study showed that the development of serious games can be highly dependent on the designers involved and the processes used. This must be considered when a hospital aims to develop multiple games for different purposes.

Abstract BACKGROUND: Children born preterm (<37 weeks) with cerebral palsy (CP) have long-term complex medical needs that require transitions between multiple healthcare services, necessitating parental support. The experiences of parents undergoing early transitions from the neonatal intensive care unit (NICU) to neonatal follow-up clinics (NFUC) to home are well-documented. Our prior research conducted found parents described positive transitions as: access to information, feeling involved in care and witnessing improvement in their child’s health outcomes post-transition. Negative experiences entail: unanticipated differences between healthcare services, feeling separated from their child and having inadequate information. Unfortunately, the next transition from children with CP born preterm (<37 weeks) to developmental/rehabilitation services (DRS) is grossly under-studied and knowledge from well-studied healthcare transitions has yet to be applied to this population. OBJECTIVES: To identify and describe the experience and needs of parents of children with CP born preterm, as they transition from NFUC to DRS. Additionally, to make recommendations building upon characteristics of supportive/positive transition experiences to meet the emotional, informational, and instrumental needs of parents during transition to DRS. DESIGN/METHODS: A descriptive qualitative study was conducted recruiting English-speaking parents of children born preterm with CP that required NICU hospitalization, and DRS post CP diagnosis. Purposeful and maximum variation strategies were used to recruit a sample of 15 parents. To ensure rigor, sampling continued until data saturation was reached. Interviews were audio-recorded, transcribed verbatim, coded using NVivo 10 software and underwent thematic analysis. Data collection and analyses were performed concurrently, with themes from early interviews incorporated, collapsed and used to inform later interviews. RESULTS: A majority of participants were mothers, whose child had received DRS for the past one to 12 years. Preliminary themes iterated by parents’ transition experiences included: Poor communication of diagnosis caused anxiety surrounding transition of care; a lack of timely access to appropriate care and resources negatively affected parents’ experiences; continuity and consistency of healthcare providers improved families’ perception of accessibility to care; and social support was desired throughout the transition period. CONCLUSION: The transition between NFUC and DRS for families with CP is significant, but lacks best practice research to advise care. Preliminary recommendations derived from data reveal the need to better support families earlier on in the transition process, beginning at the NFUC. Further research is required to identify best practices to strengthen communication, family involvement, continuity of care, and timely access to informational supports for parents.

The idea of edutainment began to become the interest of early childhood educators to make the learning process more holistic, including knowledge about how the brain works, memory, motivation, self-image, emotions, learning styles, and other learning strategies. This study aims to analyse and compare the effect of edutainment and group learning on the socio-emotional development of early childhood. This research method uses a quasi-experimental design with data collection techniques derived from the results of the pre-test and post-test on 20 children. The results of this study indicate that there are differences in the influence of edutainment learning with the control group on the social-emotional development of early childhood. Although both groups affect the socio-emotional development, edutainment learning has a better effect than the control group. 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Abstract Background Child maltreatment is common with a reported prevalence of 32.1%. Physical abuse (PA), sexual abuse (SA), and exposure to intimate partner violence (IPV) are reported by 26%, 10%, and 7.9% of Canadian adults, respectively. While many child maltreatment cases require health evaluation, there is little data on the medical assessment of these cases. The Canadian Incidence Study of Reported Child Abuse and Neglect (CIS-2008) reviewed child welfare cases but not data on their medical aspects, despite 5% of substantiated PA cases being sufficiently severe to require need for medical assessment. There is no published data describing the type, breadth, or outcomes of cases seen in the Canadian healthcare system. Objectives 1 - To describe 10 years of institutional data of children and youth seen for concerns of maltreatment. 2- To use this information to provide recommendations for resource allocation and highlight need for services. Design/Methods Secondary data was analyzed using descriptive statistics from a preexisting quality improvement database where information was collected from the CHEO Child and Youth Protection Review Committee (CYP RC) over 10 years (April 2009-April 2019). The project was approved by the CHEO REB. Results There were a total of 2651 cases reviewed at the CYP RC. Fifty-seven percent (n=1658) of child maltreatment cases were substantiated. The most common types of substantiated child maltreatment were caregiver capacity 29% (n=481), emotional abuse 19% (n=321), PA 18% (n=304), neglect 16% (n=259), SA 14% (n=227), sexual assault with CYP concerns 2% (n=36), and abandonment 2% (n=30). For PA, soft tissue injuries (e.g., bruising) and fractures were the most common injuries seen in medical evaluations for maltreatment. The most frequently ordered tests are skeletal survey, coagulation screening blood work, and CT head. In SA, most cases of substantiated sexual abuse cases were intra-familial (75%). Most physical examinations in SA cases were normal (83%). Forty one percent (1100/2651) of cases were alerted in the medical record for child protection purposes. Conclusion Our findings expand our knowledge of the different types of child maltreatment by linking child welfare and medical assessment information. In cases identified and/or assessed by hospital staff for child maltreatment, 54% were substantiated by child welfare and 41% were “alerted” in the electronic medical record (EMR). The most common type of child maltreatment was “concern for caregiver capacity” which highlights the need for parental education and supports.

Abstract BACKGROUND Genetic testing is often pursued in children with medical complexity (CMC), in an attempt to establish a unifying diagnosis, understand pathogenicity and disease progression, guide care and inform reproductive planning. CMC are defined by at least one chronic condition, technology dependence, multiple subspecialist involvement, and high healthcare utilization. Despite multiple efforts to confirm clinical suspicion of an underlying genetic condition, many remain undiagnosed. Whole genome sequencing (WGS) is becoming increasingly available as an informative diagnostic tool. The application of genomic technology to this population has the potential to increase the proportion of CMC for whom diagnoses are established, in an effort to reduce time and emotional burden of the diagnostic process, and reduce health care system costs. OBJECTIVES The main purpose of this study was to optimize the clinical implementation of state-of-the-art genome diagnostics for CMC, in terms of diagnostic yield. DESIGN/METHODS We conducted a prospective study using patients followed by the Complex Care program at a large urban tertiary care center. Research ethics board approval was obtained. Of 435 patients screened, 114 were eligible for inclusion as an underlying genetic condition was clinically suspected but not established to date by conventional genetic testing. To date, 21 participants were evaluated through a clinical genetic assessment, previous genetic testing review and peripheral blood-derived DNA sequence. A laboratory team identified candidate genetic variants associated with patients’ clinical symptoms, as well as other paediatric medically actionable variants. When found, these variants were validated as clinically significant by comparing the child’s DNA to his parents’. WGS diagnostic yield was then determined by calculating the proportion of cases for which a genetic diagnosis was established. RESULTS Of the 21 patients recruited, nine WGS analysis were completed thus far. Among these, four participants were diagnosed with established diseases, two of which were considered as novel diseases. One case was identified with a possible diagnosis, however, the interpretation of this clinical phenotype remains of unknown significance. The other four patients of the study remained undiagnosed. Given these preliminary results, the diagnostic yield of WGS was predicted at 44% in CMC. This can be compared to a previous study performed at our center in which the diagnostic rate for chromosomal microarray alone was reported to be 8% and microarray plus targeted gene sequencing 13%. CONCLUSION This study has shown WGS to be feasible and achieve a higher diagnostic yield in our complex care population. As detection rates improve and laboratory costs decrease overtime, WGS will undoubtedly become a more informative diagnostic tool, particularly in this population. Optimizing the application of this increasingly sophisticated genomic technology warrants further consideration.

Background The children of parents with severe personality difficulties have greater risk of significant mental health problems. Existing care is poorly co-ordinated, with limited effectiveness. A specialised parenting intervention may improve child and parenting outcomes, reduce family morbidity and lower the service costs. Objectives To develop a specialised parenting intervention for parents affected by severe personality difficulties who have children with mental health problems and to conduct a feasibility trial. Design A pragmatic, mixed-methods design to develop and pilot a specialised parenting intervention, Helping Families Programme-Modified, and to conduct a randomised feasibility trial with process evaluation. Initial cost-effectiveness was assessed using UK NHS/Personal Social Services and societal perspectives, generating quality-adjusted life-years. Researchers collecting quantitative data were masked to participant allocation. Setting Two NHS mental health trusts and concomitant children’s social care services. Participants Parents who met the following criteria: (1) the primary caregiver of the index child, (2) aged 18–65 years, (3) have severe personality difficulties, (4) proficient in English and (5) capable of providing informed consent. Index children who met the following criteria: (1) aged 3–11 years, (2) living with index parent and (3) have significant emotional/behavioural difficulties. Exclusion criteria were (1) having coexisting psychosis, (2) participating in another parenting intervention, (3) receiving inpatient care, (4) having insufficient language/cognitive abilities, (5) having child developmental disorder, (6) care proceedings and (7) index child not residing with index parent. Intervention The Helping Families Programme-Modified – a 16-session intervention using structured, goal-orientated strategies and collaborative therapeutic methods to improve parenting, and child and parent functioning. Usual care – standard care augmented by a single psychoeducational session. Main outcome measures Trial feasibility – rates of recruitment, eligibility, allocation, retention, data completion and experience. Intervention acceptability – rates of acceptance, completion, alliance (Working Alliance Inventory-Short Revised) and experience. Outcomes – child (assessed via Concerns About My Child, Eyberg Child Behaviour Inventory, Child Behaviour Checklist-Internalising Scale), parenting (assessed via the Arnold-O’Leary Parenting Scale, Kansas Parental Satisfaction Scale), parent (assessed via the Symptom Checklist-27), and health economics (assessed via the Client Service Receipt Inventory, EuroQol-5 Dimensions). Results The findings broadly supported trial feasibility using non-diagnostic screening criteria. Parents were mainly referred from one site (75.0%). Site and participant factors delayed recruitment. An estimate of eligible parents was not obtained. Of the 86 parents referred, 60 (69.7%) completed screening and 48 of these (80.0%) were recruited. Participants experienced significant disadvantage and multiple morbidity. The Helping Families Programme-Modified uptake (87.5%) was higher than usual-care uptake (62.5%). Trial retention (66.7%, 95% confidence interval 51.6% to 79.6%) exceeded the a priori rate. Process findings highlighted the impact of random allocation and the negative effects on retention. The Helping Families Programme-Modified was acceptable, with duration of delivery longer than planned, whereas the usual-care condition was less acceptable. At initial follow-up, effects on child and parenting outcomes were detected across both arms, with a potential outcome advantage for the Helping Families Programme-Modified (effect size range 0.0–1.3). For parental quality-adjusted life-years, the Helping Families Programme-Modified dominated usual care, and child quality-adjusted life-years resulted in higher costs and more quality-adjusted life-years. At second follow-up, the Helping Families Programme-Modified was associated with higher costs and more quality-adjusted life-years than usual care. For child quality-adjusted life-years, when controlled for baseline EuroQol-5 Dimensions, three-level version, usual care dominated the Helping Families Programme-Modified. No serious adverse events were reported. Conclusion The Helping Families Programme-Modified is an acceptable specialised parenting intervention. Trial methods using non-diagnostic criteria were largely supported. For future work, a definitive efficacy trial should consider site selection, recruitment methods, intervention efficiency and revised comparator condition. Trial registration Current Controlled Trials ISRCTN14573230. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 14. See the NIHR Journals Library website for further project information.

Abstract STUDY QUESTION What are the views, experiences and healthcare needs of infertile women from a minority ethnic or religious background living in Wales? SUMMARY ANSWER Women from ethnic and religious minority backgrounds consider that their communities have highly pronatalistic attitudes and stigmatize infertility, and express the need for more infertility education (for themselves and their communities), as well as more socio-culturally and interpersonally sensitive fertility care. WHAT IS ALREADY KNOWN Some people from minority ethnic or religious groups perceive pressure to conceive from their communities, experience social costs when they are unable to have children and stressful interactions with the fertility healthcare system while attempting to conceive. STUDY DESIGN, SIZE, DURATION This study was based on a one-day drawing workshop to collect visual (artwork produced by participants) and textual (all conversations and discussions during the workshop) data about the participants’ views and experiences of infertility and their fertility care needs. PARTICIPANTS/MATERIALS, SETTING, METHODS Participants were nine adult women with a minority ethnic or religious status living in Wales, UK, who were experiencing or had experienced infertility in the past. The workshop comprised five activities: (i) small and large group discussion of infertility-related drawings, (ii) lide-based lecture consisting of an introduction to the basics of drawing objects and people and (iii) thoughts and feelings, (iv) free drawing session and (v) group sharing. Audio recordings of the workshop were transcribed verbatim. Textual data was analysed with thematic analysis. Risk for bias was addressed via individual coding by two authors followed by joint presentation and discussion of results with the research team and participants. MAIN RESULTS AND THE ROLE OF CHANCE Forty-one themes were identified and grouped into eight distinct higher order themes. These themes described the emotional, relational and social burden of infertility experienced by women, which they perceived to result from their communities’ highly pronatalistic attitudes and stigmatization of infertility. Themes also captured women’s adaptive coping strategies and critical attitude towards pronatalist ideologies. Lastly, themes captured their overall positive evaluation of their fertility health care, their desire for more infertility education (for themselves and their communities) and for culturally competent and interpersonally sensitive care. LIMITATIONS, REASONS FOR CAUTION Our participants were a small, non-random sample recruited in collaboration with a local charity, which may mean that all participants were well integrated in their communities. Analysis focused on capturing commonalities in participants’ experiences and this may sometimes result in homogenising diverse experiences. WIDER IMPLICATIONS OF THE FINDINGS More education about the infertility experiences of minority ethnic and religious groups at the community and healthcare delivery level may translate into lessened negative attitudes towards infertility and more culturally competent care, which can be beneficial for women. STUDY FUNDING/COMPETING INTEREST(S) This research was funded by Welsh Crucible. The authors have no conflict of interests to declare.

Purpose Beaches are icons of summer tourism and a strong motivating factor for the arrival of tourists in the sun and sea tourism destinations. Spending time on the beach is one of the most popular forms of tourism leisure worldwide. Beaches serve both as recreational areas of coastal cities, and valuable ecosystems that provide natural and protective functions. The Croatian coast is relatively rich in this valuable tourism resource, but the management of beaches as a tourist product has not reached significant progress. This dissertation aims to contribute to the sustainable management of beaches as a tourism product and recognises the possibility of involving all stakeholders in this process by studying socio-demographic factors, preferences, satisfaction, and future behavioural intentions of beach visitors. This knowledge can make an important contribution to the beach management process because it can be used to make more informed management decisions. Which characteristics of a particular beach need to be improved, what facilities should be introduced or discontinued, beach managers can find out through social science research methods that can encourage participation of all stakeholders, increase visitor satisfaction and destination competitiveness, and thus lay the groundwork for more sustainable development of beaches as tourism products. The purpose of this doctoral dissertation is to develop a cognitive-affective-conative model of beach visitor satisfaction. This dissertation developed, validated, and tested an empirical model of beach visitor satisfaction by combining the sustainable development framework, international coastal zone management protocols, and national legislation with theories of satisfaction, quality, and consumer behaviour. The empirical model includes measures of beach visitor satisfaction levels with natural beach features, beach facilities, overall beach experience, emotional experience and their future behavioural intention. Methodology The study follows a mixed method design, employing both quantitative and qualitative research methods. The structural equation modelling (PLS-SEM) method was used for the purpose of testing the links between model constructs. Kruskal Wallis and MannWhitney U tests were used in analyses of socio-demographic variable influences of beach visitors. Data was collected through a semi-structured questionnaire on three separate beach locations in the Primorsko – goranska county littoral during the summer of 2021, with the paper assisted personal interview (PAPI) technique. A 5-point Likert scale was used in attribute level satisfaction and importance performance measurements. Qualitative methods include investigation by an unstructured inquiry of importance, concerning beach attributes not mentioned in the structured part of the questionnaire, as an opening of an unstructured interview with the beach visitor. Findings of the qualitative analysis have shown that beach visitors also value cultural factors and place high importance on beach sediment quality. Findings The findings of the descriptive statistical analyses concerning socio-demographic characteristics of beach visitors indicate that on average, women (59.4%) visit the beach more than men (40.6%). The most frequent age group of beach visitors is in between 45- 54 years old (25.7%), followed by visitors in between 15-24 (21%) years old. Regarding education levels, on average most visitors have finished high school (54.6%) followed by visitors with university level education (43.5%). Foreign tourists make up most of beach visitors (60.2%) while domestic tourists are second most represented (20.7%), followed by local residents (17.2%) and season residents (1.9%). Concerning the habits of beach visitors, they are most likely to visit the beach as a family with children (31.3%), as a couple (26.8%) or with friends (26.3%). Beach visitors will most likely use a car to get to the beach (77.7%), go on foot (12.5%) or use public transport (8.8%). Concerning the time they spend on the beach, most visitors stay in between 3-5 hours long (39.5%), followed by stays in between 1-3 hours long (38.2%) and stays over 5 hours long (21.2%). The descriptive statistical analyses of structural model independent variable constructs for the whole sample of all three beaches, indicates that regarding beach natural characteristics, beach visitors are most satisfied with beach scenery = 4.57, cleanliness of the sea = 4.47 and texture of beach sediment = 4.06. Beach visitors are somewhat satisfied with the opportunities to observe maritime species = 3.42. The least levels of beach visitor satisfaction are with available shade on the beaches = 2.82. Concerning beach visitor satisfaction with beach facilities, all average values of individual attributes are below 4, which indicates that beach visitors are on average more satisfied with the natural beach attributes than facilities available at the beaches. In the overall sample, beach visitors are satisfied the least with lifeguard and/or medical service = 2.90, accessibility to the beach and sea for persons with disabilities = 2.97, rental service of water sport and recreation equipment = 3.12, parking space availability = 3.12, shower availability = 3.13, toilet cleanliness = 3.15 and toilet availability = 3.24. Beach visitors are satisfied the most with bar and restaurant service on the beaches = 3.99, clearly designated safe swimming areas in the sea = 3.88, litter bin availability = 3.88 and with areas for sport, recreation, and children play on the beaches = 3.81. Concerning the descriptive analyses of beach visitor emotional experiences, measured on the Destination Emotion Scale (DES), on average beach visitors feel joy = 4.21 the most, followed by the emotion of love = 3.84 and positive surprise = 3.69. Beach visitor satisfaction with the overall experience at the beaches is on average relatively high = 4.29, as are the intention of revisit = 4.49, and the intention of recommending the beach = 4.35 The results of the bivariate statistical analysis show significant statistical differences in overall experience satisfaction regarding visitor type, while no differences were found by age or gender. Domestic tourists are least satisfied on average, while season residents are satisfied the most. The results partially support hypothesis H1. Significant statistical differences were found in the construct of intention of recommendation by gender and age. Women have a higher intention to recommend the beach than men. Age groups of 15-24 years of age tend to recommend the beach the least, while age groups of 45-54 and 55-64 have the highest levels of recommendation intention. These results partially support hypothesis H2, as no differences were found by beach visitor type. Women also have a higher intention of revisit the beach then men, while local residents and season residents have significantly higher intention of revisit than tourists, partially supporting hypothesis H3, as no differences by age were found. Lastly, the results of multivariate statistical analysis show that satisfaction with natural beach characteristics affects satisfaction with the overall experience at the beach (β=0.529, p<.01), intention to revisit (β=0.37, p<.01) and intention to recommend (β=0.497, p<.01). Thus, confirming hypothesis H4, H5 and H6. Satisfaction with beach facilities affects the overall experience satisfaction with the beach (β=0.189, p<.01), the intention to revisit (β=0.146, p<.01) and the intention to recommend the beach (β=0.106, p<.01) confirming hypotheses H7, H8 and H9. Concerning the impact of beach visitor emotions on the overall beach experience, the results show that joy (β=0.437, p<.01), love (β=0.203, p<.01) and positive surprise (β=0.105, p<.05) have a significant impact. Confirming in this way hypothesis H10. The impact of emotions on revisit intention is also statistically significant for joy (β=0.442, p<.01) and love (β=0.266, p<.01), while positive surprise is not related to revisit intention (β=0.061, p=0.271). By this, hypothesis H11 is partially confirmed. Concerning the effect of emotions on recommendation intention, both joy (β=0.445, p<.01) and love (β=0.27, p<.01) affect recommendation intention, while the relationship with positive surprise is not statistically significant (β=0.047, p=0.333). The results confirm partially hypothesis H12. Satisfaction with overall beach experience is significantly related to the intention of revisit (β=0.585, p<.01) and with the intention of recommendation (β=0.597, p<.01) confirming hypothesis H13 and H14 respectively. Mediation analysis results indicate that emotions partially mediate the relationship between satisfaction with natural beach characteristics and overall experience at the beach, while complete mediation of emotions is established between satisfaction with beach facilities and overall experience satisfaction. Finally, confirming hypothesis H15 and H16 respectively.

Abstract Background Apathy in patients with epilepsy is associated with a wide range of consequences that reduce the patient’s ability to perform social functions and participate in self-care and rehabilitation programs. Therefore, apathy is one of the important diagnoses of the healthcare team in the process of caring for epileptic patients and its dimensions need to be examined and recognized. Therefore, appropriate instruments with the sociocultural milieu of each community should be provided to health care providers. The aim of the present study was to design and measure epilepsy–related apathy scale (E-RAS) in adults with epilepsy. Methods This study of sequential exploratory mixed methods design was conducted in Iran from April 2019 to December 2019. In the Item generation stage, two inductive (face-to-face and semi-structured interviews with 17 adult epileptic patients) and deductive (literature review) were used. In item reduction, integration of qualitative and literature reviews and scale evaluation were accomplished. For Scale Evaluation, face, content, construct [exploratory factor analysis (EFA) (n = 360) and confirmatory factor analysis (CFA) (n = 200)], convergent and divergent Validity and reliability (internal consistency and stability) were investigated. Results The results of EFA showed that E-RAS has four factors, namely, motivation; self-regulatory; cognition and emotional-effective. These four latent factors accounted for a total of 48.351% of the total variance in the E-RAS construct. The results of CFA showed that the 4-factor model of E-RAS has the highest fit with the data. The results of convergent and divergent validity showed that the values of composite reliability (CR) and average variance extracted (AVE) for the four factors were greater than 0.7 and 0.5, respectively, and the value of AVE for each factor was greater than CR. The Cronbach’s alpha coefficient for the whole scale was obtained 0.815. The results of the test-retest showed that there was a significant agreement between the test and retest scores (P < 0.001). Conclusion E-RAS is a multidimensional construct consisting of 24 items, and has acceptable validity and reliability for the study of epilepsy-related apathy in adult epileptic patients.

Due to an increasing number of children under the age of three attending early childhood education and care (ECEC), there is an increasing need for high-quality care settings. In addition to primary caregivers, ECEC teachers are important socializers of children’s emotional development and may become children’s attachment figures. Early preventive interventions bear the potential to reduce the risk for later maladaptive development in the social-emotional domain. The first objective of the present article is to introduce the Papilio-U3 program, a universal preventive intervention program to foster positive and sensitive teacher-child interactions, to foster children’s early social-emotional competence and secure child-teacher attachment relationships in ECEC, and to prevent children’s emotional and behavioral problems. Furthermore, we report the design and first results of the formative evaluation derived from the pilot evaluation study. The program was developed according to the Intervention Mapping Approach, and the present article describes the planning process comprising a needs assessment and description of the intervention context, the derivation of the logic model of change, a detailed account of the program design, production, implementation, and an overview of the program evaluation study (multi-centric, randomized-controlled trial). The total sample of the evaluation study comprised 125 teachers (age M= 34.0, SD = 10.1, 98.4 % female) from 55 ECEC centers. For the formative evaluation, teachers of the intervention group (n = 61) reported on training content, methods, material, organizational conditions, and potential challenges in the course of program implementation. Finally,we provide directions to revise the program and to guide future implementation of preventive intervention programs in the ECEC context.

Abstract Background Healthy habits are essential for preschoolers to have a healthy lifestyle. The promotion of these healthy habits from a holistic approach by preschool teachers guarantees a better quality of life and a healthier society. Using cocreation, we designed training for healthy habit promotion for preschool teachers (all@once). Then, we implemented the training and evaluated its impact on classroom teaching strategies. Methods This study presents the all@once training design and its implementation and evaluation during 2019. The cocreation process involved 8 parents, 9 preschool teachers and 9 health professionals (selected by a nonprobabilistic sampling system according to quotas) to design training from a holistic perspective. To evaluate the all@once impact in classroom practice, a pilot study was undertaken in four public schools in Barcelona (Spain). All@once was implemented with 16 volunteer teachers selected by convenience sampling and 328 children. A mixed methods approach was chosen to collect data based on direct nonparticipating naturalist systematic observations in June and October 2019. After qualitative data categorization, changes in health routines and actions at school were assessed by either contingency table analysis of frequency distributions or nonparametric comparisons of two related samples. Results The cocreation process provided training organized into online capsules with a holistic view of health in four main dimensions (nutrition, hygiene, physical activity and emotional health). Of these dimensions, the emotional health dimension comprised half of the training content. Pilot testing of the impact of all@once on classroom health-related activities evidenced an increase in the likelihood of observing fruit consumption by children, healthy habit promotion and hand washing. The most significant all@once-induced changes that we observed were related to teaching strategies concerning the emotional health dimension of the training. Conclusions This pilot study provides evidence of cocreation being a productive way to design training for preschool teachers regarding inclusive education in integral health. This approach collects the needs of the school community, provides training with a holistic concept of health and effectively impacts classroom routines and family health habits in the short term.

Background: The law and literature about children’s consent generally assume that patients aged under-18 cannot consent until around 12 years, and cannot refuse recommended surgery. Children deemed pre-competent do not have automatic rights to information or to protection from unwanted interventions. However, the observed practitioners tend to inform young children s, respect their consent or refusal, and help them to “want” to have the surgery. Refusal of heart transplantation by 6-year-olds is accepted. Research question: What are possible reasons to explain the differences between theories and practices about the ages when children begin to be informed about elective heart surgery, and when their consent or refusal begins to be respected? Research design, participants and context: Research methods included reviews of related healthcare, law and ethics literature; observations and conversations with staff and families in two London hospitals; audio-recorded semi-structured interviews with a purposive sample of 45 healthcare professionals and related experts; interviews and a survey with parents and children aged 6- to 15-years having elective surgery (not reported in this paper); meetings with an interdisciplinary advisory group; thematic analysis of qualitative data and co-authorship of papers with participants. Ethical considerations: Approval was granted by four research ethics committees/authorities. All interviewees gave their informed written consent. Findings: Interviewees explained their views and experiences about children’s ages of competence to understand and consent or refuse, analysed by their differing emphases on informed, signified or voluntary consent. Discussion: Differing views about children’s competence to understand and consent are associated with emphases on consent as an intellectual, practical and/or emotional process. Conclusion: Greater respect for children’s practical signified, emotional voluntary and intellectual informed consent can increase respectful understanding of children’s consent. Nurses play a vital part in children's practitioner-patient relationships and physical care and therefore in all three elements of consent.

The early childhood education system nowadays requires the use of authentic assessment in schools. Authentic assessment is an integrative method of assessing the learning process, reflective to the real-world situations, using varieties methods and holistic criteria to assess the cognitive, affective, and skills in early childhood. Social development occurs dominantly after physical, cognitive, and language developments. Based on the minimal developmental standard, many early-childhood children show substandard development in environment adaptation ability, self-managing ability, responsibility, ability to follow rules, sharing, respecting others, cooperation, toleration, and emotional expression. This study aims to identify the influence of cooperative learning through authentic assessment-based jigsaw in the social development of early childhood. This study uses a pre-test post-test design on 50 subjects aged 5-6 years old. The experiment was carried out in 4 stage with 4 learning sub-themes. Data collected with a 1-4 scale observation instrument to get quantitative data and analyzed using t-Test. Results from data analysis concluded that cooperative learning through authentic assessment-based jigsaw has a positive influence on social development in early childhood. We recommend the implementation of this method to optimize social development in early childhood.

Abstract Background Families with minor children affected by parental cancer are at risk of considerable emotional and organizational stress that can severely burden all family members. So far, there has been a lack of comprehensive support services for affected families. The aim of this project is to implement and evaluate a complex psychosocial intervention for these families by providing advice, information, and care on an emotional, psycho-social, and communicative level during and after the cancer experience and across healthcare sectors. Methods Family-SCOUT is a project supported by the German Innovation Fund (https://innovationsfonds.g-ba.de/). The evaluation is based on a mixed-methods quasi-experimental design with the intervention and control groups. A standardized postal survey at three measurement points (T0: study enrollment; T1: 3 months of follow-up; T2: 9 months of follow-up), secondary data from the participating health insurance funds, and semi-structured qualitative interviews are used for summative and formative evaluation. The study aim is to include n=560 families. Data will be analyzed according to the intention-to-treat principle. The primary analysis is the comparison of the Hospital Anxiety and Depression Scale (HADS) response rates (minimal important difference (MID) ≥ 1.6 in at least one of the two parents) at T2 between the intervention and control group using Fisher’s exact test. The conduct of the study as well as the development and implementation of the intervention will be accompanied by comprehensive study monitoring following the principles of an effectiveness-implementation hybrid study. Discussion The results will allow to test the effectiveness and efficiency of the intervention for the target group. The first experience with the implementation of the intervention in model regions will be available. The evaluation results will serve as the basis to assess the need of including the intervention in the catalog of services of the statutory health insurance funds in Germany. Trial registration ClinicalTrials.gov, NCT04186923. Retrospectively registered on 4 December 2019.

Abstract Aim To synthesise and analyse the existing literature regarding parent satisfaction with sustained home visiting care for mothers and children. Background Sustained home visiting is a service delivery mechanism of both prevention and intervention, in which people receive structured support services within their home environment over an extended period of months or years. For the purposes of this paper, sustained home visiting refers to in-home nursing support to address health inequities for mothers and young children. Sustained home visiting programs have been found to support improved health, wellbeing, and developmental outcomes for children and families. However, there is limited knowledge with regards to the level of parent satisfaction with care provided at home, and the factors and elements of care parents perceive to be critical to their satisfaction. It is important for healthcare practitioners to understand what practices and process parents consider to be a priority in securing their ongoing engagement. Design Integrative review. Data sources PubMed/Medline, CINAHL, Embase, and PsycINFO. Methods A multi-step approach was used to search and retrieve peer-reviewed studies from the databases. Study selection, data extraction, data synthesis and critical appraisal were undertaken by two independent researchers. Results A total of 13 studies met the inclusion criteria, including nine quantitative and four qualitative studies. The review found that parents provided with home visiting interventions had higher levels of satisfaction with care than those who received routine or facility-based care. Service dose was a factor associated with parent satisfaction, however, the direction of impact on parent satisfaction was mixed. Other elements of care parents perceived as important to service satisfaction included the nurse-client relationship, being treated with respect, empowerment, and emotional support. Conclusion While it is critically important that home visiting practitioners provide evidence-based care and interventions, it is equally important that services are delivered in the context of positive and empowering relationships. Further research is recommended to understand the care process and mechanisms that enhance parent satisfaction and positive experiences, providing optimal quality of care.

Background: As the South African government re-engineers primary healthcare (PHC), the need for additional information on stakeholders involved in the process has emerged. Of these are community health workers (CHWs), who have been identified as central to PHC success.Objectives: To profile the current CHWs within KwaDabeka and Clermont in KwaZulu-Natal, to describe their roles and to explore the barriers and enablers influencing their service delivery.Method: A convergent mixed methods design was employed with a sample of CHWs with the use of a survey (n = 53) and two focus groups (n = 10) and semi-structured interviews with four ward councillors (n = 4). Data were analysed statistically and thematically.Results: The profile of CHWs reflected only women with a mixed age range and a majority of 59% who had not completed formal schooling. General work experience as a CHW varied. There were diverse opinions expressed towards the CHW role which related to their job title and identity, supervision, remuneration, growth pathways and psychological and emotional issues. Whilst the National Community Health Worker Profile Framework was established for the CHW programme, there are several factors lacking in the current CHW programme such as a formal growth pathway or formal training to align the CHWs with the National Qualifications Framework.Conclusion: The study findings are essential for the monitoring and evaluation as well as development and refinement of policies that will assist in ensuring adequate rollout of PHC with CHWs.

Abstract Background Systems integration to promote the mental health of Aboriginal and Torres Strait Islander children works towards developing a spectrum of effective, community-based services and supports. These services and supports are organised into a coordinated network, build meaningful partnerships with families and address their cultural and linguistic needs, to help children to function better at home, in school, in the community, and throughout life. This study is conducted in partnership with primary healthcare (PHC) and other services in three diverse Indigenous Australian communities. It entails conceptualising, co-designing, implementing, and evaluating the effectiveness of systems integration to promote the mental health and wellbeing of Indigenous school-aged children (4–17 years). This paper outlines a protocol for implementing such complex community-driven research. Methods/design Using continuous quality improvement processes, community co-designed strategies for improved systems integration will be informed by narratives from yarning circles with Indigenous children and service providers, and quantitative data from surveys of service providers and audits of PHC client records and intersectoral systems. Agreed strategies to improve the integration of community-based services and supports will be modelled using microsimulation software, with a preferred model implemented in each community. The evaluation will investigate changes in the: 1) availability of services that are community-driven, youth-informed and culturally competent; 2) extent of collaborative service networks; 3) identification by PHC services of children’s social and emotional wellbeing concerns; and 4) ratio of children receiving services to identified need. Costs and benefits of improvements to systems integration will also be calculated. Discussion The study will provide evidence-informed, community-driven, and tested models that can be used for implementing systems integration to promote the mental health and wellbeing of Indigenous children. It will identify the situational enablers and barriers that impact systems integration and determine the extent to which systems integration improves service availability, systems and child outcomes. Evidence for the cost effectiveness of systems-level integration will contribute to national mental health policy reform.

Abstract Background Child mental health problems are a major public health concern associated with poor mental and physical health later in development. The study evaluates a new community-based intervention to promote sensitive parenting and reduce enduring mental health problems and unhealthy weight among vulnerable infants aged 9-24 months. Methods We use a step-wedge cluster randomized controlled trial design conducted within a home visiting program offered by community health nurses to infant families in Denmark. Sixteen municipalities are randomly allocated to implement the intervention starting at three successive time points from May 1, 2022 to January 1, 2023. A total of 900-1000 families will be included. A standardized program, Psykisk Udvikling og Funktion (PUF), is used to identify infants with major problems of eating, sleep, emotional or behavioral regulation or developmental problems. The intervention builds on the Video-Feedback Intervention to Promote Positive Parenting (VIPP) program, adapted to the PUF-context and named the VIPP-PUF. Children will be followed up at ages 18 and 24 months. Primary outcome measure is the Strengths and Difficulties Questionnaire (SDQ) at child age 24 months. The other outcome measures include body mass index z-scores, the Ages and Stages Questionnaire Social-Emotional (ASQ:SE2); the Child Behavior Checklist (CBCL 1½ -5); Eating behavior Questionnaires; the Being a Mother-questionnaire (BaM13); the Parental Stress Scale (PSS); and the WHO-5 well-being index (WHO-5). Data on child and family factors are obtained from National registries and the Child Health Database. Quantitative measures are applied to examine the effectiveness of the VIPP-PUF intervention and the implementation process. Qualitative measures include interviews with CHNs, parents and municipality stakeholders to explore factors that may influence the adherence and effectiveness of the intervention. Discussion The study examines a service-setting based intervention building on the promotion of sensitive parenting to vulnerable infants. We use a mixed methods approach to evaluate the intervention, taking into account the influences of COVID-19 pandemic running since March 2020. Overall, the study has potential to add to the knowledge on the possibilities of prevention within the municipality child health care to reduce the risk of mental health problems and unhealthy weight in early childhood. Trial registration www.ClinicalTrials.gov; IDNCT04601779; Protocol ID 95-110-21307. Registered 25 June 2021.

Abstract Background Up to 20% of UK children experience socio-emotional difficulties which can have serious implications for themselves, their families and society. Stark socioeconomic and ethnic inequalities in children’s well-being exist. Supporting parents to develop effective parenting skills is an important preventive strategy in reducing inequalities. Parenting interventions have been developed, which aim to reduce the severity and impact of these difficulties. However, most parenting interventions in the UK focus on early childhood (0–10 years) and often fail to engage families from ethnic minority groups and those living in poverty. Strengthening Families, Strengthening Communities (SFSC) is a parenting programme designed by the Race Equality Foundation, which aims to address this gap. Evidence from preliminary studies is encouraging, but no randomised controlled trials have been undertaken so far. Methods/design The TOGETHER study is a multi-centre, waiting list controlled, randomised trial, which aims to test the effectiveness of SFSC in families with children aged 3–18 across seven urban areas in England with ethnically and socially diverse populations. The primary outcome is parental mental well-being (assessed by the Warwick-Edinburgh Mental Well-Being Scale). Secondary outcomes include child socio-emotional well-being, parenting practices, family relationships, self-efficacy, quality of life, and community engagement. Outcomes are assessed at baseline, post intervention, three- and six-months post intervention. Cost effectiveness will be estimated using a cost-utility analysis and cost-consequences analysis. The study is conducted in two stages. Stage 1 comprised a 6-month internal pilot to determine the feasibility of the trial. A set of progression criteria were developed to determine whether the stage 2 main trial should proceed. An embedded process evaluation will assess the fidelity and acceptability of the intervention. Discussion In this paper we provide details of the study protocol for this trial. We also describe challenges to implementing the protocol and how these were addressed. Once completed, if beneficial effects on both parental and child outcomes are found, the impact, both immediate and longer term, are potentially significant. As the intervention focuses on supporting families living in poverty and those from minority ethnic communities, the intervention should also ultimately have a beneficial impact on reducing health inequalities. Trial registration Prospectively registered Randomised Controlled Trial ISRCTN15194500.

Abstract Background Schools are ideally placed to provide children and adolescents with multiple opportunities to be or learn to be physically active. However, key reviews have reported that interventions to date have largely failed to have any long-term impact on overall physical activity levels. In this position paper, greater attention to key issues is needed to realise the full potential of schools and ideal physical activity for health promotion setting. Methods This study draws on multi-author expertise to develop a position paper to advance opinion on school-based programmes. Collaborative conceptual thinking was established through various tools such as literature review, evidence synthesis and online and in person meetings. Results/Discussion The adoption of a systems approach is valuable for understanding the complexities of the school setting and to support the implementation of whole-of-school initiatives. Furthermore, we contend that the full range of physical, cognitive, emotional and social benefits that physical activity provides should be considered, rather than a narrow focus solely on physical activity levels. Interdisciplinary research questions are most useful in exploring and evaluating whole-of-school approaches. Informed by process, impact and outcome evaluation and implementation science, both qualitative and quantitative research methodologies and a move beyond traditional research design are needed to advance our knowledge of what works, for whom and in what context. Case studies from several European countries will be presented to illustrate examples of systems approaches in action. This includes examples at multiple levels firstly, a national approach including a Physical Education curriculum reformation (Portugal), a regional approach such as a county council partnership with a University to support physical activity promotion (France) and a local approach at the school level i.e. a whole-of-school physical activity programme (Spain and Ireland). Conclusion From authors expertise and reflection, this paper makes recommendations on the nature of the evidence required to bridge the implementation gap, sustain and scale-up innovative approaches to whole-of-school programmes.

Story spreads out through time the behaviors or bodies – the shapes – a self has been or will be, each replacing the one before. Hence a story has before and after, gain and loss. It goes somewhere…Moreover, shape or body is crucial, not incidental, to story. It carries story; it makes story visible; in a sense it is story. Shape (or visible body) is in space what story is in time. (Bynum, quoted in Garland Thomson, 113-114) Drawing on Goffman’s classic work on stigma, research documenting the existence of discrimination and bias against individuals classified as obese goes back five decades. Since Cahnman published “The Stigma of Obesity” in 1968, other researchers have well documented systematic and growing discrimination against fat people (cf. Puhl and Brownell; Puhl and Heuer; Puhl and Heuer; Fikkan and Rothblum). While weight-based stereotyping has a long history (Chang and Christakis; McPhail; Schwartz), contemporary forms of anti-fat stigma and discrimination must be understood within a social and economic context of neoliberal healthism. By neoliberal healthism (see Crawford; Crawford; Metzel and Kirkland), I refer to the set of discourses that suggest that humans are rational, self-determining actors who independently make their own best choices and are thus responsible for their life chances and health outcomes. In such a context, good health becomes associated with proper selfhood, and there are material and social consequences for those who either unwell or perceived to be unwell. While the greatest impacts of size-based discrimination are structural in nature, the interpersonal impacts are also significant. Because obesity is commonly represented (at least partially) as a matter of behavioral choices in public health, medicine, and media, to “remain fat” is to invite commentary from others that one is lacking in personal responsibility. Guthman suggests that this lack of empathy “also stems from the growing perception that obesity presents a social cost, made all the more tenable when the perception of health responsibility has been reversed from a welfare model” (1126). Because weight loss is commonly held to be a reasonable and feasible goal and yet is nearly impossible to maintain in practice (Kassierer and Angell; Mann et al.; Puhl and Heuer), fat people are “in effect, asked to do the impossible and then socially punished for failing” (Greenhalgh, 474). In this article, I explore how weight-based stigma shaped the decisions of bariatric patients to undergo weight loss surgery. In doing so, I underline the work that emotion does in circulating anti-fat stigma and in creating categories of subjects along lines of health and responsibility. As well, I highlight how fat bodies are lived and negotiated in space and place. I then explore ways in which participants take up notions of time, specifically in regard to risk, in discussing what brought them to the decision to have bariatric surgery. I conclude by arguing that it is a dynamic interaction between the material, social, emotional, discursive, and the temporal that produces not only fat embodiment, but fat subjectivity “failed”, and serves as an impetus for seeking bariatric surgery. Methods This article is based on 30 semi-structured interviews with American bariatric patients. At the time of the interview, individuals were between six months and 12 years out from surgery. After obtaining Intuitional Review Board approval, recruitment occurred through a snowball sample. All interviews were audio-taped with permission and verbatim interview transcripts were analyzed by means of a thematic analysis using Dedoose (www.dedoose.com). All names given in this article are pseudonyms. This work is part of a larger project that includes two additional interviews with bariatric surgeons as well as participant-observation research. Findings Navigating Anti-Fat Stigma In discussing what it was like to be fat, all but one of the individuals I interviewed discussed experiencing substantive size-based stigma and discrimination. Whether through overt comments, indirect remarks, dirty looks, open gawking, or being ignored and unrecognized, participants felt hurt, angry, and shamed by friends, family, coworkers, medical providers, and strangers on the street because of the size of their bodies. Several recalled being bullied and even physically assaulted by peers as children. Many described the experience of being fat or very fat as one of simultaneous hypervisibility and invisibility. One young woman, Kaia, said: “I absolutely was not treated like a person … . I was just like this object to people. Just this big, you know, thing. That’s how people treated me.” Nearly all of my participants described being told repeatedly by others, including medical professionals, that their inability to lose weight was effectively a failure of the will. They found these comments to be particularly hurtful because, in fact, they had spent years, even decades, trying to lose weight only to gain the weight back plus more. Some providers and family members seemed to take up the idea that shame could be a motivating force in weight loss. However, as research by Lewis et al.; Puhl and Huerer; and Schafer and Ferraro has demonstrated, the effect this had was the opposite of what was intended. Specifically, a number of the individuals I spoke with delayed care and avoided health-facilitating behaviors, like exercising, because of the discrimination they had experienced. Instead, they turned to health-harming practices, like crash dieting. Moreover, the internalization of shame and blame served to lower a sense of self-worth for many participants. And despite having a strong sense that something outside of personal behavior explained their escalating body weights, they deeply internalized messages about responsibility and self-control. Danielle, for instance, remarked: “Why could the one thing I want the most be so impossible for me to maintain?” It is important to highlight the work that emotion does in circulating such experiences of anti-fat stigma and discrimination. As Fraser et al have argued in their discussion on fat and emotion, the social, the emotional, and the corporeal cannot be separated. Drawing on Ahmed, they argue that strong emotions are neither interior psychological states that work between individuals nor societal states that impact individuals. Rather, emotions are constitutive of subjects and collectivities, (Ahmed; Fraser et al.). Negative emotions in particular, such as hate and fear, produce categories of people, by defining them as a common threat and, in the process, they also create categories of people who are deemed legitimate and those who are not. Thus following Fraser et al, it is possible to see that anti-fat hatred did more than just negatively impact the individuals I spoke with. Rather, it worked to produce, differentiate, and drive home categories of people along lines of health, weight, risk, responsibility, and worth. In this next section, I examine the ways in which anti-fat discrimination works at the interface of not only the discursive and the emotive, but the material as well. Big Bodies, Small Spaces When they discussed their previous lives as very fat people, all of the participants made reference to a social and built environment mismatch, or in Garland Thomson’s terms, a “misfit”. A misfit occurs “when the environment does not sustain the shape and function of the body that enters it” (594). Whereas the built environment offers a fit for the majority of bodies, Garland Thomson continues, it also creates misfits for minority forms of embodiment. While Garland Thomson’s analysis is particular to disability, I argue that it extends to fat embodiment as well. In discussing what it was like to navigate the world as fat, participants described both the physical and emotional pain entailed in living in bodies that did not fit and frequently discussed the ways in which leaving the house was always a potential, anxiety-filled problem. Whereas all of the participants I interviewed discussed such misfitting, it was notable that participants in the Greater New York City area (70% of the sample) spoke about this topic at length. Specifically, they made frequent and explicit mentions of the particular interface between their fat bodies and the Metropolitan Transit Authority (MTA), and the tightly packed spaces of the city itself. Greater New York City area participants frequently spoke of the shame and physical discomfort in having to stand on public transportation for fear that they would be openly disparaged for “taking up too much room.” Some mentioned that transit seats were made of molded plastic, indicating by design the amount of space a body should occupy. Because they knew they would require more space than what was allotted, these participants only took seats after calculating how crowded the subway or train car was and how crowded it would likely become. Notably, the decision to not take a seat was one that was made at a cost for some of the larger individuals who experienced joint pain. Many participants stated that the densely populated nature of New York City made navigating daily life very challenging. In Talia’s words, “More people, more obstacles, less space.” Participants described always having to be on guard, looking for the next obstacle. As Candice put it: “I would walk in some place and say, ‘Will I be able to fit? Will I be able to manoeuvre around these people and not bump into them?’ I was always self-conscious.” Although participants often found creative solutions to navigating the hostile environment of both the MTA and the city at large, they also identified an increasing sense of isolation that resulted from the physical discomfort and embarrassment of not fitting in. For instance, Talia rarely joined her partner and their friends on outings to movies or the theater because the seats were too tight. Similarly, Decenia would make excuses to her husband in order to avoid social situations outside of the home: “I’d say to my husband, ‘I don’t feel well, you go.’ But you know what? It was because I was afraid not to fit, you know?” The anticipatory scrutinizing described by these participants, and the anxieties it produced, echoes Kirkland’s contention that fat individuals use the technique of ‘scanning’ in order to navigate and manage hostile social and built environments. Scanning, she states, involves both literally rapidly looking over situations and places to determine accessibility, as well as a learned assessment and observation technique that allows fat people to anticipate how they will be received in new situations and new places. For my participants, worries about not fitting were more than just internal calculation. Rather, others made all too clear that fat bodies are not welcome. Nina recalled nasty looks she received from other subway riders when she attempted to sit down. Decenia described an experience on a crowded commuter train in which the woman next to her openly expressed annoyance and disgust that their thighs were touching. Talia recalled being aggressively handed a weight loss brochure by a fellow passenger. When asked to contrast their experiences living in New York City with having travelled or lived elsewhere, participants almost universally described the New York as a more difficult place to live for fat people. However, the experiences of three of the Latinas that I interviewed troubled this narrative. Katrina felt that the harassment she received in her country of origin, the Dominican Republic, was far worse than what she now experienced in the New York Metropolitan Area. Although Decenia detailed painful experiences of anti-fat stigma in New York City, she nevertheless described her life as relatively “easy” compared to what it was like in her home country of Brazil. And Denisa contrasted her neighbourhood of East Harlem with other parts of Manhattan: “In Harlem it's different. Everybody is really fat or plump – so you feel a bit more comfortable. Not everybody, but there's a mix. Downtown – there's no mix.” Collectively, their stories serve as a reminder (see Franko et al.; Grabe and Hyde) to be suspicious of over determined accounts that “Latino culture” is (or people of colour communities in general are), more accepting of larger bodies and more resistant to weight-based stigma and discrimination. Their comments also reflect arguments made by Colls, Grosz, and Garland Thomson, who have all pointed to the contingent nature between space and bodies. Colls argue that sizing is both a material and an emotional process – what size we take ourselves to be shifts in different physical and emotional contexts. Grosz suggests that there is a “mutually constitutive relationship between bodies and cities” – one that, I would add, is raced, classed, and gendered. Garland Thomson has described the relationship between bodies and space/place as “a dynamic encounter between world and flesh.” These encounters, she states, are always contingent and situated: “When the spatial and temporal context shifts, so does the fit, and with it meanings and consequences” (592). In this sense, fat is materialized differently in different contexts and in different scales – nation, state, city, neighbourhood – and the materialization of fatness is always entangled with raced, classed, and gendered social and political-economic relations. Nevertheless, it is possible to draw some structural commonalities between divergent parts of the Greater New York City Metropolitan Area. Specifically, a dense population, cramped physical spaces, inaccessible transportation and transportation funding cuts, social norms of fast paced life, and elite, raced, classed, and gendered norms of status and beauty work to materialize fatness in such a way that a ‘misfit’ is often the result for fat people who live and/or work in this area. And importantly, misfitting, as Garland Thomson argues, has consequences: it literally “casts out” when the “shape and function of … bodies comes into conflict with the shape and stuff of the built world” (594). This casting out produces some bodies as irrelevant to social and economic life, resulting in segregation and isolation. To misfit, she argues, is to be denied full citizenship. Responsibilising the Present Garland Thomson, discussing Bynum’s statement that “shape carries story”, argues the following: “the idea that shape carries story suggests … that material bodies are not only in the spaces of the world but that they are entwined with temporality as well” (596). In this section, I discuss how participants described their decisions to get weight loss surgery by making references to the need take responsibility for health now, in the present, in order to avoid further and future morbidity and mortality. Following Adams et al., I look at how the fat body is lived in a state of constant anticipation – “thinking and living toward the future” (246). All of the participants I spoke with described long histories of weight cycling. While many managed to lose weight, none were able to maintain this weight loss in the long term – a reality consistent with the medical fact that dieting does not produce durable results (Kassirer and Angell; Mann et al.; Puhl and Heuer). They experienced this inability as not only distressing, but terrifying, as they repeatedly regained the lost weight plus more. When participants discussed their decisions to have surgery, they highlighted concerns about weight related comorbidities and mobility limitations in their explanations. Consistent then with Boero, Lopez, and Wadden et al., the participants I spoke with did not seek out surgery in hopes of finding a permanent way to become thin, but rather a permanent way to become healthy and normal. Concerns about what is considered to be normative health, more than simply concerns about what is held to be an appropriate appearance, motivated their decisions. Significantly, for these participants the decision to have bariatric surgery was based on concerns about future morbidity (and mortality) at least as much, if not more so, than on concerns about a current state of ill health and impairment. Some individuals I spoke with were unquestionably suffering from multiple chronic and even life threatening illnesses and feared they would prematurely die from these conditions. Other participants, however, made the decision to have bariatric surgery despite the fact that they had no comorbidities whatsoever. Motivating their decisions was the fear that they would eventually develop them. Importantly, medial providers explicitly and repeatedly told all of these participants that lest they take drastic and immediate action, they would die. For example: Faith’s reproductive endocrinologist said: “you’re going to have diabetes by the time you’re 30; you’re going to have a stroke by the time you’re 40. And I can only hope that you can recover enough from your stroke that you’ll be able to take care of your family.” Several female participants were warned that without losing weight, they would either never become pregnant or they would die in childbirth. By contrast, participants stated that their bariatric surgeons were the first providers they had encountered to both assert that obesity was a medical condition outside of their control and to offer them a solution. Within an atmosphere in which obesity is held to be largely or entirely the result of behavioural choices, the bariatric profession thus positions itself as unique by offering both understanding and what it claims to be a durable treatment. Importantly, it would be a mistake to conclude that some bariatric patients needed surgery while others choose it for the wrong reasons. Regardless of their states of health at the time they made the decision to have surgery, the concerns that drove these patients to seek out these procedures were experienced as very real. Whether or not these concerns would have materialized as actual health conditions is unknown. Furthermore, bariatric patients should not be seen as having been duped or suffering from ‘false consciousness.’ Rather, they operate within a particular set of social, cultural, and political-economic conditions that suggest that good citizenship requires risk avoidance and personal health management. As these individuals experienced, there are material and social consequences for ‘failing’ to obtain normative conceptualizations of health. This set of conditions helps to produce a bariatric patient population that includes both those who were contending with serious health concerns and those who feared they would develop them. All bariatric patients operate within this set of conditions (as do medical providers) and make decisions regarding health (current, future, or both) by using the resources available to them. In her work on the temporalities of dieting, Coleman argues that rather than seeing dieting as a linear and progressive event, we might think of it instead a process that brings the future into the present as potential. Adams et al suggest concerns about potential futures, particularly in regard to health, are a defining characteristic of our time. They state: “The present is governed, at almost every scale, as if the future is what matters most. Anticipatory modes enable the production of possible futures that are lived and felt as inevitable in the present, rendering hope and fear as important political vectors” (249). The ability to act in the present based on potential future risks, they argue, has become a moral imperative and a marker of proper of citizenship. Importantly, however, our work to secure the ‘best possible future’ is never fully assured, as risks are constantly changing. The future is thus always uncertain. Acting responsibly in the present therefore requires “alertness and vigilance as normative affective states” (254). Importantly, these anticipations are not diagnostic, but productive. As Adams et al state, “the future arrives already formed in the present, as if the emergency has already happened…a ‘sense’ of the simultaneous uncertainty and inevitability of the future, usually manifest in entanglements of fear and hope” (250). It is in this light, then, that we might see the decision to have bariatric surgery. For these participants, their future weight-related morbidity and mortality had already arrived in the present and thus they felt they needed to act responsibly now, by undergoing what they had been told was the only durable medical intervention for obesity. The emotions of hope, fear, anxiety and I would suggest, hatred, were key in making these decisions. Conclusion Medical, public health, and media discourses frame obesity as an epidemic that threatens to bring untold financial disaster and escalating rates of morbidity and mortality upon the nation state and the world at large. As Fraser et al argue, strong emotions (such hatred, fear, anxiety, and hope), are at the centre of these discourses; they construct, circulate, and proliferate them. Moreover, they create categories of people who are deemed legitimate and categories of others who are not. In this context, the participants I spoke with were caught between a desire to have fatness understood as a medical condition needing intervention; the anti-fat attitudes of others, including providers, which held that obesity was a failure of the will and nothing more; their own internalization of these messages of personal responsibility for proper behavioural choices, and, the biologically intractable nature of fatness wherein dieting not only fails to reduce weight in the vast majority of cases but results, in the long term, in increased weight gain (Kassirer and Angell; Mann et al.; Puhl and Heuer). Widespread anxiety and embarrassment over and fear and hatred of fatness was something that the individuals I interviewed experienced directly and which signalled to them that they were less than human. Their desire for weight loss, therefore was partially a desire to become ‘normal.’ In Butler’s term, it was the desire for a ‘liveable life. ’A liveable life, for these participants, included a desire for a seamless fit with the built environment. The individuals I spoke with were never more ashamed of their fatness than when they experienced a ‘misfit’, in Garland Thomson’s terms, between their bodies and the material world. Moreover, feelings of shame over this disjuncture worked in tandem with a deeply felt, pressing sense that something must be done in the present to secure a better health future. The belief that bariatric surgery might finally provide a durable answer to obesity served as a strong motivating factor in their decisions to undergo bariatric surgery. By taking drastic action to lose weight, participants hoped to contest stigmatizing beliefs that their fat bodies reflected pathological interiors. Moreover, they sought to demonstrate responsibility and thus secure proper subjectivities and citizenship. In this sense, concerns, anxieties, and fears about health cannot be disentangled from the experience of anti-fat stigma and discrimination. Again, anti-fat bias, for these participants, was more than discursive: it operated through the circulation of emotion and was experienced in a very material sense. The decision to have weight loss surgery can thus be seen as occurring at the interface of emotion, flesh, space, place, and time, and in ways that are fundamentally shaped by the broader social context of neoliberal healthism. AcknowledgmentI am grateful to the anonymous reviewers of this article for their helpful feedback on earlier version. References Adams, Vincanne, Michelle Murphy, and Adele E. Clarke. “Anticipation: Technoscience, Life, Affect, Temporality.” Subjectivity 28.1 (2009): 246-265. 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