The focus groups were analyzed through content analysis.Juices and chips were the most salient snacks, with availability and flavor as reasons for their consumption. Children found images on labels appealing, which created a desire for the food, although could be deceptive. Snacks perceived as healthy were encouraged by parents, and children could more easily convince them to buy snacks with health claims. Colors and brands were important to catch children's attention and make the snack recognizable. Television commercials and mascots reinforced marketing strategies on labels.Our results point to the need for public health strategies to deal with the obesity epidemic through creating and implementing specific legislation to regulate food labels to discourage the consumption of unhealthy snacks and prohibit food marketing targeted at children. Although 75.3% of participants affirmed that the school offered meals, 48.0% of participants never or rarely ate them. Additionally, the consumption of foods from school canteens and informal selling points in the schools' surroundings were reported by 48.8 and 48.7%, respectively. Foods and drinks most available in canteens were baked goods, fruit juices, and sodas. In informal selling points, they were sodas, crisps, and deep-fried goods  that incorporated a free lists exercise. FG is a research technique that produces data through interaction. The free lists exercise aimed to complement information produced from FG discussions by eliciting the most relevant food and drink snacks for children in the school context. Materials and methods are reported below, following the Standards for Reporting Qualitative Research (SRQR)  and the A total of 69 participants provided data that were used in this study. Participants were recruited by convenience, through a Brazilian research firm, from a database of potential participants. Participants were approached by email, and the inclusion criteria were as follows: (1) ages between 7 and 12 years, (2) living in urban regions of São Paulo municipality, and (3) agreeing to participate and having parental consent. The exclusion criterion was having parents working in the health sector and/or in the food or tobacco industries. Nobody refused to participate in the study, and no participants dropped out. None of the authors had any interaction with the participants prior to or during the FGs. Participants had no information about the researchers or the FG moderator. Nine FGs were conducted during the day, between 1 and 8 August 2019, in a research facility in São Paulo, Brazil.The FGs were stratified by age range (7–9 and 10–12 years) and socioeconomic status (SES) (A+B1 and B2+C). Stratification was justified as follows: (1) children in the same FG are recommended not to be more than 2 years apart in age  and (2) Procedures involving research study participants were approved by the Research Ethics Committee of the Public Health School at the São Paulo University (protocol no. 3.441.247). Written informed consent was obtained from all participants' caretakers, and verbal assent was obtained from all participants before the focus groups.We used data triangulation of FG and free lists to assess food and drink items mostly consumed at school by the participants. The listing activity and the FG guide were pretested with a group of children aged 7–9 years, B2+C SES. These data were not included in the final sample. In our study, foods and drinks considered “desired snacks to eat at school” were expected to be relatively similar across participants, as: (1) children's eating practices are highly influenced by their peers , (2) claAll free lists and FGs were conducted in Portuguese, by a female, trained moderator who graduated in social sciences and who specialized in data collection with children. At the time of the study, the moderator was employed by the Brazilian research firm responsible for recruiting the participants, having vast experience in conducting FGs. Also participating in FGs were one note-taker and one to three observers behind a one-way mirror who were also taking notes.For the free lists exercise, at the beginning of FGs, after an ice-breaker question (“What shows or cartoons do you like to watch?”), we asked participants to individually write a list of desired snacks to eat at school. Children were given 5 min to make a list as complete as possible. During the time taken to complete the task, the moderator ensured that the children were not communicating with each other or seeing each other's lists. The literature on free lists suggests that about 30 participants are needed to provide a representative sample , and thiAfter the lists were completed and collected (approximately 10 min), the moderator started the FG discussion. Based on the foods and drinks presented in the free lists, the interview guide approached: (1) snacks (foods and drinks) consumed at school, (2) reasons for and frequency of consuming them, and (3) opinions and perceptions about the food and beverage packages. The average FG duration was 1 h and 5 min. The audio was recorded and transcribed verbatim. Transcripts were read by PdMS, and data saturation was considered reached after eight FGs, meaning that no relevant new information was identified in the last FG .Food lists were analyzed for the most salient foods and drinks using the data analyses software Free-List Analysis under Microsoft Excel (FLAME v1.1). First, the foods and drinks listed were grouped into 12 broad food categories by two researchers (PdMS and NK). In the analysis, triangulation of free lists and FG was used to inform free list categories based on children's own food classification during FG discussions. As not all children described foods' characteristics with the same specificity, grouping foods served to unify similar foods. For instance, one child wrote “natural juice” and the other “juice,” hindering UPF classification. In cases in which the food or drink's process level was not clear, triangulation of data allowed consulting FG discussions to assess more detailed information about the item. Also, categories did not distinguish between similar snacks with different food flavors and brands .S = [(L – Rj + 1)/L]/N, where L is the length of each list, Rj is the rank of item J in the list, and N is the number of lists in the sample : e sample . Thus, te sample .The FG discussions were analyzed using content analysis, as described by Bernard, Wütlich, and Ryan . We usedA total of 69 children composed the nine FGs. More details about the participants' age range, SES, gender, and type of school are presented in Food groups identified through free lists were juices, chips, fruits and vegetables, cakes, sodas, bread, milk and yogurt, cookies and crackers, candies and chocolates, fast foods, and water and coconut water. The 30 codes produced through the content analysis were classified into 10 themes, five concerning ultra-processed snacks consumed at school—highlighting what was most consumed, why (reasons for eating them) and how/when (based on rules associated with them); four about their packages and labels—concerning their design, marketing strategies, and participants' perceptions about them; and one about other media that reinforce labels' information—more specifically, about television commercials. The coding tree is presented in most liked snacks to eat at school  and reasons to eat it at school . How often children took a certain food or beverage to school was explained by food rules. Further details are described below.Subthemes about UPF included The main foods and beverages mentioned in the FGs reflected the most salient foods in the free lists exercise , which aJuice was the most mentioned food/drink in free lists and had the most coded segments. It was sometimes referred to as “packaged juice.” The main reason for drinking it at school was the flavor, followed by being considered healthy and giving energy. Other reasons were related to being refreshing. Its relevance in the context of school meals is reinforced by being the only food/drink most cited as “always eaten/drunk.” It was the second most accessible food/drink by some children in school, following sodas. However, unlike soda, juice was often served at school meals—“At my school, they give us juice” .Chips were the second most mentioned food/drink, mainly liked by children because of their flavor. Other reasons for taking it to school were being crunchy and giving energy/satiating. They were consumed at school sometimes, either brought from home or bought at the canteen. All other foods/drinks were also mainly consumed at school because of their flavors, except breads, which were consumed for giving energy/satiating. Cake and soda were the only foods/drinks to which being healthy was not a reason for eating/drinking them at school.All food rules mentioned by children were related to eating healthy foods. Almost all rules were taught and set by their mothers, often being related to having specific days to eat what was considered “unhealthy”—“Friday is ‘cheat day', we call it that” . Other contributors to perpetuating food rules were doctors—“I went to the pediatrician and she told me that I can't eat it [cookies and crackers] all the time otherwise I will have high blood pressure, this type of stuff, so I only eat it on weekends or Fridays” —and schools—“In my school we can't bring chips from Monday to Wednesday” .The foods/drinks most often linked with food rules were juice and soda. While sodas were unhealthy for having “a lot of sugar,” juices were “free” for children to drink—“My mom lets me take juice to school every day” . In this case, the social rule was reinforced by peers where—“Almost everyone takes juice to school” .product brands, design elements on the label , marketing elements on the label , and perceptions about the label .Subthemes about UPF packages and labels included Coke® [soda brand]… but not every day” —or were used to indicate preference—“I really like Natural One® [juice brand], it is made from the fruit. It says so in the bottle” . Alongside the brand names, children were well informed about other aspects of the product—“Mini Oreo® [cookie brand] has a new package and new flavors” , being mentioned when images on the labels were described. The most cited image among brands were characters—“Toddy® [chocolate milk brand] has a little cow” , followed by colors—“The [label] color that everyone knows is Coke® [soda brand]” .Product brands were frequently cited, especially cookies and crackers brands (24.29%), followed by sodas (17.14%) and chips (15.71%). Brands commonly replaced the food's name—“[I take to school] a bag of chips, a Minions®” and personalities—“There is a soccer player saying that it's good. The package changes, but the player remains” .Overall, the most cited design element on the labels was related to color, followed by characters. Colors were mainly mentioned for being eye-catching—“The red is very flashy, strong color…” , but children also recognized that they reinforced information about the product—“Sometimes the color distinguishes the flavor” . Characters were mainly products' mascots—“A farmer with a yellow round face. He's the corn” . They also included famous cartoons—“I like the ones with the Yakult® [fermented milk drink brand] with the Sponge Bob®” , and promotions—“Ruffles® [chips brand] has a promotion that they take you on a trip” . Packages and label formats, and the words on them, were much less mentioned. The expiration date and ingredients were also mentioned by the children.Marketing elements on the label depicted products' characteristics like foods' flavors, but also included ingredients—“[the chips] are made with actual potatoes” . Information about ingredients also made the product very appealing—“The cookies packaging shows the chocolate drops… makes you drool” . However, information was not always accurate—“Cookies… there is one with a nice photo on the package, but when you open it, it's like half a dozen of chocolate drops” . Another main cited marketing element were surprise and collectible giveaways—“[this bag of chips] comes with a surprise, a sticker. You can collect the stickers, my cousin does” , games—“Sometimes I see it [puzzle] and I solve it before drinking the juice. I solve the puzzles in the ones [food packages] I know that have it, as Doritos® [chips brand], all those colors… I wanted to eat it right away” . The second most mentioned perception was related to the label's qualities, in which children classified food labels, as eye-catching and appetizing, but, for some, “usually deceptive” . Finally, during the conversation about the information on food labels, children mentioned another media that reinforced the information presented on food labels, “television commercials”—“There are TV commercials with the mascot” .Most perceptions around packages and labels concerned feelings toward the food, which included it being flavorful and the desire to buy or eat it—“There is a picture that makes your mouth water… makes you want to eat it” . One child mentioned craving the food very badly—“I got anxious because I saw the package and it had many Our study focused on children's most salient and desirable snacks to be eaten at school, unveiling the centrality of UPF, with the most frequently reported being juices and chips. The main reason for choosing a food/drink for a snack was flavor , followed by giving energy/satiating and being healthy . Health concerns were taught by the adults, with children perceiving that they could rely on health claims to convince parents to allow them to buy/eat ultra-processed snacks. Different food characteristics were perceived by children to be promoted on food labels, influencing them to desire the product. Persuasive information about the products was transmitted by images, or even just by the product's brand, and was reinforced by other media, such as TV commercials.in natura/minimally processed foods among our participants' school snacks. This observation highlights the importance of schools' food environment to children's food choices, as has been described by a systematic review conducted by Driessen et al.   .Our results add to the current understanding of children's food package perception by revealing the importance given to food brands by them and illustrating a high presence of brands from transnational companies in their discourses. We argue that current food packages not only promote products' hedonic and healthy attributes but also create and perpetuate an image related to a brand, including through brand-specific characters  that proAdditional strategies that reinforce the ones on food packages, such as TV commercials, were cited by our participants and resonate with Mehta et al.'s  study tho163/2014 of the Brazilian Council for Children and Adolescents Rights  provides an interpretation of the CDC and the examples of abusive marketing, including the use of child characters, cartoons, promotions with awards or collectibles, excess of colors, etc  in foods with excessive amounts of critical nutrients together with the implementation of these warnings in all kinds of advertisements in Peru , the proHealth professionals and educators have a crucial role in promoting critical thinking about food marketing strategies. Actions targeted to children should focus on increasing children's advertising knowledge and help them engage critically with commercial messages in ways that are developmentally appropriate. Parents should be educated about food marketing along with the negative effects of high exposure to food marketing on children's food choices. Research on the area demands more engagement directly with young people to learn about the development of critical thinking across childhood .Our study has some limitations. First, our results cannot be generalized to Brazil; however, we highlighted the heterogeneity of our sample in terms of SES and age, aimed to capture a diversity of children's views. Second, although not all food/drink snacks mentioned by children during FGs and the free lists were classified as UPF , we wereOur study shows that Brazilian children preferred ultra-processed snacks at school, choosing them mainly because of their taste. Other valued foods' attributes were their ability to provide energy and healthiness, with the last being learned from parents/health professionals and explored as a marketing strategy on UPF packages. Marketing strategies used in foods and beverages targeted at children were mentioned by our participants, pointing to the efficiency of such elements in catching their attention and promoting snacks' hedonic and nutritional characteristics. In this scenario, there is an urge for public health measures to deal with the obesity epidemic by creating and implementing specific legislation to regulate packages and labels to discourage the consumption of unhealthy snacks, as well as to prohibit food marketing targeted at children, considering their lack of discernment and experience to understand commercial messages and to regulate the availability of unhealthy snacks in the school food environment, that is supposed to be safe for children.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Ethics Committee of the Public Health School from the São Paulo University. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.PS, FL, and LM performed the content analysis. NK performed the free list analysis. PS wrote the first draft of the manuscript. FL, AM, LM, and NK wrote sections of the manuscript. All authors contributed to conception, design of the study, revision, read, and approved the submitted version.Funding for this study was provided by UNICEF Brazil (BRZ/PCA/2017-2021/IDEC) and the São Paulo Research Foundation – FAPESP (Grants 2017/05651-0 and 2019/22278-7).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Due to the adverse effects of teachers’ burnout on their professional performance, remarkable attention has been devoted to this mental state and its negative predictors. In this regard, multiple empirical research has been carried out to assess the effects of grit and self-efficacy as negative predictors of teacher burnout. Yet, no empirical or review study has delved into the impact of these variables at the same time. The current study attempts to fill this gap by delineating the impact of English as a Foreign Language (EFL) teachers’ grit and self-efficacy on their burnout. The significant role of grit and self-efficacy in curbing EFL teachers’ burnout was illustrated using theoretical and empirical evidence. The pedagogical implications are also offered. As Maslnal life . Finallynal life . Put simnal life .As put forward by Grit generally refers to “one’s passion and perseverance for long term goals” , p. 1089Another emotional factor that may negatively predict teacher burnout is self-efficacy, which generally pertains to “beliefs in one’s capabilities to organize and execute the courses of action required to produce given attainments” , p. 4. IGiven the significant role of grit and self-efficacy in mitigating the causes of teacher burnout , severalThe concept of “grit” refers to “stamina one has for sticking with long-term, life goals despite difficulties, failures, or adversities” , p. 320.magnitude,” “generality,” and “strength.” Magnitude, as the first dimension, pertains to the degree of performance an individual teacher feels he or she is capable of achieving. The second dimension, generality, refers to how far improvements in self-efficacy beliefs may be extended to other behaviors and contexts. Strength, as the last dimension, refers to the firmness of an individual teacher’s belief that he or she is able to perform a particular activity (The term “self-efficacy” pertains to a person’s positive evaluation of his or her own personal capabilities . Put simactivity .Burnout has been broadly defined as “a psychological syndrome that develops in response to chronic emotional and interpersonal job stressors” , p. 931.To elucidate the role of self-efficacy beliefs in curbing burnout among EFL teachers, To date, a plethora of research has been done on the impact of EFL teachers’ self-efficacy on their burnout e.g., . For insSo far, the concepts of teacher grit, teacher self-efficacy, and teacher burnout were clearly described. Moreover, the dimensions and components of these variables were outlined. Furthermore, the role of grit and self-efficacy in reducing EFL teachers’ burnout was elucidated using theoretical and empirical evidence. Relying on the available evidence, one can logically conclude that both grit and self-efficacy can negatively predict EFL teachers’ burnout. Put simply, grittier and self-efficacious teachers are less likely to experience burnout during their professional life. This outcome seems insightful and instructive for all English language teachers in any EFL context. Given the importance of self-efficacy beliefs in curbing teacher burnout, EFL teachers should have faith in their professional abilities in order to energetically pursue their vocation. The finding of this review appears to be enlightening for teacher educators as well. As the outcomes of this review study revealed, teachers with strong desire and perseverance can handle the job-related stressors, which is the main cause of burnout. Accordingly, teacher educators need to teach their trainees how to persevere against the pressures, challenges, and problems of teaching profession.The author confirms being the sole contributor of this work and has approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


As an indispensable part of contemporary medical services, Internet-based medical platforms can provide patients with a full range of multi-disciplinary and multi-modal treatment services. Along with the emergence of many healthcare influencers and the increasing connection between online and offline consultations, the operation of individual physicians and their teams on Internet-based medical platforms has started to attract a lot of attention. The purpose of this paper is to, based on an Internet platform, study how the information on physicians’ homepages influences patients’ consultation behavior, so as to provide suggestions for the construction of physicians’ personal websites. We distinguish variables into strong- and weak-ties types, dependent on whether deep social interactions between physicians and patients have happened. If there exist further social interactions, we define the variable as the “strong ties” type, otherwise, “weak ties”. The patients’ consultation behavior will be expressed as the volume of online consultation, i.e., the number of patients. We obtained the strong and weak ties information of each physician based on EWM (entropy weight method), so as to establish a regression model with explained variable, i.e., the number of patients, and three explanatory variables, i.e., the strong and weak ties information, and their interaction term. The estimation results verified our hypotheses and proved to be robust. It showed that both strong and weak ties information can positively influence patients’ consultation behavior, and the influence of weak ties information is greater. Regarding the positive influence of strong and weak ties, we found a trade off effect between them. Based on the results, we finalize with some suggestions on how to improve a physician’s online medical consultation volume. Online healthcare consultation has become an essential part of healthcare system. Online medical platforms provide patients with a channel that allows them to make an appointment, learn about a physician, understand their severity of illness, and ask for advice on the Internet without having to leave home ,2,3.Researchers focus on different kinds of information in the online health community to investigate how factors impact patients’ consultation behavior. The Information of physicians contains the self-disclosed information, online image, etc. ,2,4,5. IThe current physician–patient relationship in China is experiencing dilemmas, which are partly due to the information asymmetry ,8,9 betwThe online medical platform and patients can essentially be regarded as an internet product and its users. So, the social relationship of this platform itself can objectively affect user behavior. The impact of online social relationship strength on user behavior is also an important research topic. Current research on social interaction suggests that people’s social relationships are related to the strength of their ties, which are defined as weak and strong ties. Weak ties between people are more important in the process of information dissemination than strong ties ,26,27. TOn the other hand, patient behavior can also exert an influence on physicians. Whether or not patients choose to ask for a consultation is also used as an indicator to measure physician services, which will further motivate physicians to improve the quality of their services . TherefoIn order to research the influence of physicians’ information on patients’ consultation behavior, we use physicians’ data from Online Medical Platform A, a well-known Chinese online medical platform. The data are classified into strong and weak ties information based on the social ties perspective, so as to investigate the impact of physician–patient interaction intensity on patients’ consultation behavior. We will explore the role of online medical information on patient behavior from a new perspective and will further improve the research about how online social relationship strength information influences user behavior in the online medical field. Furthermore, the results, to some extent, can provide the support of theoretical suggestions to solve physician–patient conflicts caused by the information gap between physicians and patients in the Internet medical field.(1)How do strong and weak ties information affect patients’ consultation behavior through the online medical platform?(2)Which has more influence on patients’ consultation behavior? Strong ties information or weak ties information?(3)Do strong and weak ties exert a trade-off effect on each other’s influence on patients’ consultation behavior? For example, does the enhancement of weak ties information reduce the positive effect of strong ties information on the patients’ consultation behavior?(4)The influence of non-social ties information, i.e., some nature of the physician himself, on the patients’ consultation behavior.Our study will explore the answers to the following questions:We used Python to crawl 52,645 physicians’ homepages on 18 January 2022 and 25 January 2022 from the well-known Chinese Online Medical Platform A for model building and robustness test. From the perspective of horizontal physicians’ homepages, each datum contains numerical and textual information that users can see when they visit physicians’ homepages. From the platform perspective, the 52,645 data we crawled account for 22% of the total number of registered physicians, which is a very large sample. Such a rich and large volume of data will help us to more fully explore the information behind the data and explore the impact of physicians’ homepage information on patients’ consultation behavior.NCP)”, “Number of comments after consultation (NCC)”, “Number of thank-you letters (NTL)”, “Number of gifts (NOG)”, and “Number of online patients (NOP)” to form strong ties. The variables such as “Comprehensive recommendation score (CRS)”, “Number of articles on Health subscription (NAH)”, and “Number of articles reads (NAR)” are used to form weak ties. These variables will be processed later to form three independent variables: WeakTies, StrongTies, and the interaction term WeakStrongTies, which will be the real independent variables needed for the models.We select “Number of checked patients ”, “Number of comments after consultation (NCC)”, “Number of thank-you letters (NTL)”, “Number of gifts (NOG)”, and “Number of followers (NOF)”, generated by the in-depth interaction between the physician and the patient to form the “strong ties” behavior indicator. Thus, the following hypotheses are proposed:In online medical platforms, patients and physicians will have close interactions, including but not limited to offline consultation, evaluation of physician’s service, following physicians, expressing gratitude through thank-you letters and gifts, and so on. Therefore, this paper selects the patient-generated information data, i.e., “Number of checked patients (Hypothesis 1.Strong ties have a positive effect on the patients’ consultation behavior .NAR). Although some of these data, such as the comprehensive recommendation score rated by Online Medical Platform A, are jointly calculated by the algorithm based on some patient-generated information and system-generated information on the physician’s homepage. However, in general, this part of the data is mostly determined by the system, and the interaction between patients and physicians cannot exert too much influence on it. So, we use the explicit website data, i.e., “Comprehensive recommendation score (CRS)”, “Number of articles on Health subscription (NAH)”, and “Number of articles reads (NAR)”, to form “weak ties” behavior indicators. Thus, the following hypotheses are proposed:System-generated information exists on the physician’s homepage, such as the number of reads of articles published on the physician’s website health subscription Strong Ties Model:In the process of constructing the strong and weak ties model, considering that the information performance of the original variables is fairly objective, we did not choose the subjective weighting method. Instead, we chose the objective weighting entropy method to assign weights to the original indicators and complete the classification calculation based on the coefficients, so as to build the required strong and weak ties model:(2)Weak Ties Model:(3)Interaction Term of Weak Ties and Strong Ties:(4)Strong Ties Model:We used Python to calculate the entropy method assignment coefficients and bring them into the Formulas (1) and (2), respectively, to obtain the following models:(5)Weak Ties Model:iStrongTies, iWeakTies, and iStrongWeakTies. We used these three as partial independent variables and participated in the construction of the regression model.Finally, we obtained the data of three variables, op-dummy*” are the dummy variables generated by the variable “outpatient”, which represents the highest level of outpatient consultation type that a physician can provide offline. As shown in op_dummy1” represents the number of physicians whose highest level of outpatient consultation type is “VIP5-VIP outpatient”.We construct models 1–5 separately using ordinary least squares (OLS) regression.Since the number of consultations on online medical platforms represents the attractiveness of physicians to patients, we constructed five models to test how two types of information, weak ties and strong ties information, impact patients’ consultation behavior. Model 1, which is our baseline model, is configured as follows:i = 1, 2, …, 5 presents physicians’ id numbers. The dependent variable “iPatients” is the total number of patients who have consulted physicians. Variable “iStrongTies” is generated by Equation (1), and variable “iWeakTies” is generated by Equation (2).In this model, dummy variable to join the model:Considering that some confounding factors may have an influence on the relationship between social ties information and patients’ consultation behavior, we chose physicians’ title information as a dummy variable in model 3:The level of physicians’ education title may influence the decision of patients’ consultation behavior, so we added the education title as a dummy variable in Model 4:Information of outpatient, which is the highest level of outpatient consultation type that a physician can provide offline, may also influence the decision on patients’ consultation behavior, so we used outpatient information as another To explore the nature of the interaction between the influences of education title and strong ties, we introduced six interaction terms on the basis of Model 4:WeakTies and StrongTies are positive and significant, and the coefficients for StrongWeakTies are negative and significant. Therefore, hypotheses 1–3 are accepted. In addition, the coefficients for weak ties are on average 9.8 times stronger than the coefficients for strong ties.The results are shown in WeakTies has a positive and significant coefficient, suggesting that weak ties information positively affects patients’ consultation behavior StrongTies also has a positive and significant coefficient, suggesting that strong ties information positively affects patients’ consultation behavior StrongWeakTies is negative and significant WeakTies and StrongTies are between , the value is smaller after multiplication, and the coefficient is greater in the regression. This result shows that in the online medical platform, the enhancement of weak ties information will reduce the positive effect of strong ties on the impact of physicians’ online consultations and vice versa.It can be perceived that in Model 1, WeakTies, StrongTies, and StrongWeakTies are consistent with those of Model 1. Model 2 adds the title dummy variable. The coefficients for StrongWeakTies are negative and significant In Model 2, the results for dummy variable of education title to Model 2, the results for WeakTies, StrongTies, and StrongWeakTies are still consistent with those of Model 1 and Model 2, Model 3 adds the dummy variable, i.e., the highest level of outpatient consultation type that a physician can provide offline, to Model 3, and the results for WeakTies, StrongTies, and StrongWeakTies are still consistent with those of Model 1 dummy are all positive and significant dummy. It means that outpatient type information has a positive impact on patients’ consultation behavior and is more important than physicians’ education title.Model 4 adds the StrongTies to Model 4 with the cross-product term of dummy variable education title, and the positivity and significance of the main coefficients such as WeakTies, StrongTies, etc., remained unchanged StrongTies had significant and negative coefficients with the two categories of teaching assistants and lecturers StrongTies negatively adjusted for the role of education title when the education titles were teaching assistants and lecturers [Model 5 added ecturers .dummy variables of title, education title, and outpatient type step by step. In addition, we add the cross term in Model 5. We also test AIC, and BIC. AIC performs smaller from 173,591.7 to 172,810.8 in Models 1 to 5. BIC becomes smaller from 173,626.3 to 173,016.3 in Model 1 to 4 but becomes bigger in Model 5 . Considering these three tests, we think Model 5 performs the best, which indicates that education title information is useful to patients’ consultation behavior.In Models 2 to 4, we add the We adopted the method of replacing samples for robustness testing and selected 52,645 homepage information of the same group of physicians on 25 January 2022 to construct the same model for validation.dummy of associate researcher performs significant, which is the same as other education title and does not affect the conclusion of the original variable analysis.As shown in the Through the above experiments, we can see that both strong and weak ties information has a positive effect on patients’ decision of whether to choose the physician for consultation . The infWeakTies” is always bigger than the coefficient of “StrongTies”.Furthermore, we found that weak ties information is, on average, 9.8 times more influential than strong ties information in comparison to the influence on patients’ consultation behavior. Therefore, we can conclude that strong ties information does not have a strong positive relationship with patients’ physician consultation behavior. Instead, weak ties information has a greater positive impact on patients’ consultation behavior. That is, it is not the case that the stronger the interaction between the physician and the patient, the greater the positive effect of the generated information on the patient’s choice of the physician for consultation. In other words, the more intuitive information, that is, weak tie information, displayed on the physician’s homepage without deep interaction between the physician and the patient, the stronger the positive effect on patients’ consultation behavior. This also validates the findings of Granovetter (1973) , whose sOn the other hand, this also shows that it is necessary for physicians to take some actions, such as proactively generating objective data, adding more expertise, etc., to maintain their homepage, so as to facilitate patients to understand their state of disease and judge the physician’s professionalism. For example, patients can obtain a deeper understanding of a physician’s knowledge of a certain disease from articles published on Health subscription, which is more effective than the information about the physician’s interaction with the patient.We also found that even though both strong and weak ties information have a positive effect on patients’ consultation behavior, the enhancement of one side’s information will reduce the positive effect of the other side’s information on the consultation service. Strong ties information can certainly show the physician’s high quality consultation service and patient’s recognition, but combined with the conclusion that weak ties information is on average 9.8 times more influential than strong ties information, we suggest that physicians need to pay more attention to the role of weak ties information. Strong ties information is more concerned with the good results brought by the quality of consultation service, while weak ties information should be regarded as the focus of personal brand maintenance, so as to increase the number of consultations most efficiently.dummy variables, we found that information such as title, education title, and outpatient type can impact the choice of patients slightly. In addition, the outpatient type and title information are more important than the education title. They all have positive impacts on patients’ consultation behavior.However, in the exploration of dummy variables we included in the model were all considered to show the objective professionalism of physicians. We explore the influence of title, education title, and the highest level of offline outpatient types on patients’ consultation behavior, but the exploration of other information about physicians is insufficient. Third, we may consider the effect of physicians’ group performance in the future [In this paper, we innovatively study the patients’ consultation behavior from the perspective of social ties and explore the influence of strong and weak ties information on it. However, our study still has certain limitations. First, our data sources are limited, and we only crawled the data of Online Medical Platform A, a well-known Chinese online healthcare platform. However, there are important differences across the different media , and bige future .In summary, our research provides support for further exploration of the role of strong and weak ties information on users in the online healthcare field. Future research could further explore how strong and weak ties affect other patient behaviors. It could also further mine textual information to explore the impact of online social text information on patient behavior.The following conclusions and suggestions can be drawn from this paper:Both strong and weak ties have a positive effect on patients’ consultation behavior. However, the enhancement of informativeness on one side will reduce the positive effect of information on the other side on the patients’ consultation behavior.In comparison of the impact on the patients’ consultation behavior, weak ties information was on average 9.8 times more influential than strong ties information. Weak ties variables have a more positive effect on patients’ consultation decision.Based on the first and second conclusions, this paper suggests that physicians should pay more attention to improving the quality of weak ties information, to efficiently attract more patients and increase the number of consultations.Information such as the physician ‘s title, education level and the highest type of outpatient physicians can offer offline, which can represent the physician ‘s professional competence, can have a positive impact on patients’ physician consultation decision. The patients’ consultation behavior can reflect patients’ recognition of the physician. Therefore, this paper suggests that physicians should strive to improve their professional competence and obtain a high professional title and to increase patients’ recognition and trust.


Voice-hearing in clinical and nonclinical groups has previously been compared using standardized assessments of psychotic experiences. Findings from several studies suggest that nonclinical voice-hearing is distinguished by reduced distress and increased control. However, symptom-rating scales developed for clinical populations may be limited in their ability to elucidate subtle aspects of nonclinical voices. Moreover, such experiences often occur within specific contexts and belief systems, such as spiritualism. We investigated similarities and differences in the phenomenology of clinical voice-hearing and nonclinical voice-hearer (NCVH).N = 26) and psychosis patients (N = 40). The nonclinical group was recruited from spiritualist communities. We used content analysis and inductive thematic analysis to create a coding frame which was used across both spiritual and patient groups to compare phenomenological features of voice-hearing.We conducted a comparative interdisciplinary study which administered a semi-structured interview to NCVH individuals (The findings were consistent with previous results regarding distress and control. Additionally, in the NCVH group, multiple modalities were often integrated into 1 entity, and there were high levels of associated visual imagery, and subtle differences in the location of voices relating to perceptual boundaries. Most NCVHs reported voices before encountering spiritualism, suggesting that their onset was not solely due to deliberate practice.Nonclinical spiritual voice-hearing has important similarities and differences to voices in psychosis. Future research should aim to understand how spiritual voice-hearers cultivate and control voice-hearing after its onset, which may inform interventions for people with psychosis with distressing voices. Previous studies comparing the phenomenological, cognitive, and neural characteristics of voice-hearing in psychosis patients and nonclinical voice-hearers (NCVHs) have used a combination of standardized scales and clinical interviews for assessing hallucinations. Daalman et al5 used the Psychotic Symptoms Rating Scale (PSYRATS) and Auditory Hallucination Rating Scale (AHRS) with 111 NCVHs, reporting that nonclinical voice-hearing was more controllable, less frequent, and less negative. Peters et al6 showed that individuals in the general population with persistent psychotic-like experiences often experienced hallucinations across more perceptual modalities than individuals with psychosis, a finding observed elsewhere.7 Using the number of different semi-structured and self-report questionnaires with a group of self-reported “clairaudient” psychics, Powers et al8 reported NCVHs having higher levels of control over voices .Alongside featuring in schizophrenia10 Thus, alternative and interdisciplinary approaches are needed to evaluate the phenomenology of voice-hearing properly.11While such findings are important, tools developed for clinical assessment may miss more nuanced aspects of these voice-hearing experiences. The phenomenology of voice-hearing can be highly varied and multimodal: semi-structured and open-ended interviews with psychosis patients have shown the complexity and variation of voice-hearing across individuals, in aspects such as personification, agency, and perceived location.8 such research often involves people with high levels of spiritual and paranormal belief. Sommer et al12 reported that 58% of the participating NCVHs believed their voices came from “benevolent spirits.” Ninety-one percent of healthy individuals with psychotic experiences in Peters et al6 classed themselves as “spiritual” . Assessing such groups using clinical tools may identify apparently comparable levels of hallucination, but may not sufficiently consider the roles of context, belief, and expectation specific to each community.13 For example, a recent online open-ended survey with Christians reporting hearing the voice of God noted key differences from voices in psychosis, including personal significance, positive emotions, and occurrence in the context of prayer.14A case in point is the intersection of spiritual and paranormal experiences with NCVH. Although few studies have sought to recruit people with clairaudient experiences explicitly,12; however, it is often unclear whether voice-hearing developed before (perhaps leading to) spiritual beliefs, or whether spiritual beliefs emerged first, with people actively cultivating their voice-hearing experiences. As well as being sharply distinguished from voices in psychosis (unlikely to be purposely developed), this issue may be of relevance to neurocognitive models of voice-hearing that foreground expectations and beliefs.16 One study regarding spiritual beliefs and voice-hearing17 indicated that voice-hearing experiences preceded spiritual beliefs. Although qualitative analysis of mediumistic experiences has emphasized the importance of anomalous childhood experiences,18 within-sample variability suggests a more complex relationship between beliefs and voice-hearing. Some participants report voice-hearing starting only when they actively engaged with relevant spiritual practices,17 consistent with other research emphasizing the practice (“kindling”) of such experiences.19Important questions remain concerning the development of voice-hearing in such groups. Research with NCVHs has frequently reported an earlier age of onset than in psychosis10 We aimed to explore similarities and differences with voices in psychosis that may be missed by standardized scales. While the study was primarily descriptive , based on previous research, we expected spiritual voices to be less negative, more controllable, and more likely to occur across multiple modalities than voices in psychosis. We also aimed to provide data on the cultivation of voices over time, the nature of the messages communicated by the voices, and the levels of personification and social agency associated with them.Here, we investigated nonclinical voice-hearing experiences in individuals with spiritualist and related beliefs . Within the United Kingdom, spiritualists typically believe in the possibility of communicating with the dead, often receiving messages they believe should be passed on to other people and working as professional mediums to do so. While there is large variability in specific beliefs surrounding spiritualism, one core tenet is that such experiences should be cultivated and controlled. We used an open-ended, semi-structured interview with spiritualist voice-hearers, developed by an interdisciplinary team for use in both clinical and nonclinical populations. Interviews were coded and directly compared to an extant patient dataset.N = 26, 19 female) were recruited from spiritualist communities across the United Kingdom, via newsletters, social media advertisements, and word-of-mouth. Participants were mostly over 50 (M [SD] = 58.23 [11.07] years), although ages ranged from 30 to 73 years. Participants were screened via telephone and were invited to take part if they were aged 18–75 years, fluent English speakers, and reported voices occurring at least once a month that did not solely take place within a spiritualist church . Participants were not eligible to take part if they reported a psychiatric or neurological diagnosis, contacting any mental health services in relation to voice experiences, alcohol or drug abuse within the last 3 months, or severe distress in relation to voices, assessed during telephone screening.Spiritual NCVH , with an age range of 16–61 years. Procedures were approved by the relevant university ethics committee.The spiritualist group was compared to 40 psychosis patients  recruited from Early Intervention in Psychosis (EIP) services, who completed the same interview procedure as part of a prior study.10 for further information), and administered by one of 2 interviewers trained in clinical and phenomenological interviewing. Questions were purposely broad (“Please could you describe the voice or voice-like experiences you have been having?”), moving to more specific themes as the interview progressed.Participants completed a semi-structured interview, comprising 8 open-ended questions about voices, with each followed by prompts to elicit further details if needed see . The int20The PSYRATS was included as a standardized assessment of voice frequency, duration, location, loudness, distress, controllability, and disruption to life, for comparability with previous research. It contains 11 questions with each item scored between 0 and 4.21). Interviews were recorded and professionally transcribed.After consenting, participants undertook the phenomenology interview, followed by the PSYRATS. Sessions took place in participants’ homes or in a quiet university setting, and typically lasted 60–90 min (range 24–111 min). Participants also completed a questionnaire pack and were invited to take part in cognitive testing and neuroimaging . A number of additional codes were developed specifically for the spiritual group . Disagreements were resolved via discussion, and the remainder of the interviews were coded separately. Interrater reliability was satisfactory . The same procedure was used for the patient interviews.10 We report descriptive statistics across groups for each code, and log ORs for rate differences between groups, inferring a difference when 95% CIs of log ORs do not cross 0.Similarly to previous work,rame see  was devegustatory  and tactile. While there was no group difference in rates of olfactory or visual hallucinations, every spiritual participant reported visual imagery, often referring to seeing things in the “mind’s eye.” The spiritual group was also more likely to report multimodal voices—experiences in different modalities attributed to the same entity as the voice (regardless of simultaneity).The spiritual group was more likely to report experiences in modalities other than auditory, including thought-like voices , although the majority also described auditory voices  often occurred in psychosis, whereas these were relatively infrequent in this spiritual group.Spiritual voice-hearers also reported more Box 1I’m getting told information… to relay to the people who are in the church, so the congregation, if you will… and how I get that is I “hear,” and I use the word in inverted commas because it’s not like I’m hearing you, it’s kind of like thoughts or impressions…you know there’s a gentleman here, he’s taller than yourself, [I can] describe his hair, you know, black hair with a parting and like, his clothes, because they show you how they look… they might adjust their attire…So you can see all that, and then you can say, oh hasn’t he got a deep voice, you know … that’s how it works for me. To me it’s real. But I can understand why you’re asking the question, because if it’s real and they’re standing there, why can’t you see them, yeah?’ and then suddenly I just got a, just an image of a baby and you know just in my head, just an image of a baby, and then just a feeling So the next thing that normally comes in will be … either who they were or I’ll hear them say their name, and so I may hear the name, for instance, you’ll get a person who’ll say, “it’s OK, I’m Margaret.” OK, who are you? “Well I’m gran.” At the same time as a picture coming in, as she’s showing what she looked like. Then I’d be asking, well OK, give me more details about yourself, things like age, what did you pass from … And the funny thing is, the voice that you get back very much mimics the personality of who they were. volitional experiences, as well as being more likely to report the ability to influence their voices. Crucially, when discussing development of voices, the spiritual voice-hearers were more likely to describe a change in influence over voices, which tended to reflect the development of increased control .The spiritual group reported more trol see . This waBox 2I think the first time I ever heard a voice was when I was about eighteen, and I thought I heard somebody calling my name, well I was positive I heard somebody calling my name. And I was the only person in the house at the time. And it sounded like it was coming from outside the house. So I went to the front door, nobody there, went to the back door, walked all the way round the house, nothing, came back in and thought, oh that was weird, wasn’t a radio on, there wasn’t TV on, there was nothing, and I heard it again, calling my name, Laura, Laura, [said with urgency]. And I had to go round the house again, outside, opening all the doors, and I thought, well that’s bizarre, dismiss it, ignore it. So that was the first time it ever happened, I didn’t know anything about spirit or anything like that. I think for me, when I very first started, the only thing that would happen was I’d get my name shouted when I was at work, you know, when there was nobody around… and I think for me sort of I almost questioned if it was real… you know there’s no one else heard it… I think in terms of feelings when I first started having experiences, like I said, I didn’t really have many clairaudient experiences, but I sort of had this feeling of presences… And I think initially I was almost a little bit concerned. And sort of thinking, is there something wrong, you know and being honest, was I mental, was there some sort of illness happening? What I do is I kind of take my consciousness out and allow the spirit world to come in basically…However, sometimes I may not even consciously be thinking about anything and certain words will come into my head. For example if I have, like for example, the other day there I wanted to ask spirit a question and I asked them the question and for the last three days I’ve been getting the same answer… How I do it is I have a little mantra I go through, which is, and I just basically say to the spirit world that I am ready to work… There was things happening when I was younger that I didn’t understand at the time, which, once I started learning about it, started to make more sense […] I deliberately developed it, well I’m saying deliberately, I kinda got drawn to it, I was brought up as a Catholic, and I got to… typically get to teenage years and you start questioning things. And I found that the Catholic faith created more questions than answers, and I started looking around for something else. And by the time I think I first went, I would have been about … nineteen, twenty, when I started going to spiritualist churches positive content, elicited positive emotions, and correspondingly were less likely to report abusive or violent, commanding, or commenting voices that elicited negative emotions. Instead, their voices were more likely to impart knowledge they were not aware of, speak in a simple structure, and be recognizable as the voices of persons from the voice-hearer’s real life. As part of the coding, the interviews were coded for “levels of agency” 22 for auditory verbal hallucination. The spiritual group was more likely to report both externally individuated voices  and internally individuated voices . All spiritual participants reported at least some internally individuated voices, typically due to their beliefs that (often unrecognizable) spirits would speak in order to pass a message to another person. In our psychosis interviews,10 we observed that some patients described highly personified voices (complex personification), exhibiting their own intentions, emotions, and personality characteristics. This rate was similar in the spiritual group, suggesting that the groups are not distinguished by varying degrees of personification.The spiritual group was more likely to report voices that contained supernatural, with all participants in that group describing belief in a supernatural explanation. That said, a substantial number also described potential biophysical explanations or described the experiences “running in the family,” at a similar rate to the patient group. The spiritual group was less likely to offer stress as an explanation than the patients.Unsurprisingly, the most common narrative applied to voices in the spiritual group was around the sleep; and describe suicidal ideation. A majority of the spiritual group suggested that their voices were an important part of their identity, with social aspects of their spiritual beliefs playing an important role.The spiritual group was also less likely to say that their voices caused a negative impact on relationships with others; mention disrupted We also developed a group of codes applicable only to the spiritual group. These indicated that most of the spiritual group reported that their first voice experiences were spontaneous (88.5%) and tended to precede their beliefs in spiritualism (69.2%). Most engaged in ongoing cultivation of the voices (96.2%) and viewed voice-hearing/clairaudience as a learnable skill (76.9%). Finally, most were highly convinced of their spiritual beliefs (80.8%), and most used their voice-hearing as part of a profession  (88.5%).We conducted phenomenological interviews with a group of NCVHs reporting spiritual voices. Despite much overlap in the voice-hearing experience, group differences included variation in control, multimodality, and valence, as well as nuanced differences in descriptions of location.7 with NCVHs, the spiritual voice-hearers were more likely to report experiences occurring across sensory modalities, being more likely to describe tactile or gustatory experiences, as well as visual imagery associated with voices. A novel finding was that voices themselves were more likely to be multisensory, compared to psychosis: not only did spiritual voice-hearers report experiences co-occurring across modalities, but they were also more likely to attribute them to the same entity . Our analysis of interviews also distinguished between experiences such as visual hallucinations and visual imagery. All participants in the spiritual group reported visual imagery in association with voice-hearing, with rates of visual hallucinations comparable to the psychosis group. This highlights an important consideration relating to understanding the experiences of different voice-hearing groups: the language used to describe voices—often shaped by clinicians (in psychosis patients) or peers —can have large effects on interpretations by researchers.23–25 Many spiritual participants reported visual imagery in their “mind’s eye” that they distinguished from typical visual imagery by its spontaneity and/or alien quality, but which was easily distinguished from external visual perception.Consistent with the previous studies26 It is unclear whether high rates of visual hallucinations reported in other nonclinical voice-hearing studies may include such reports of imagery. Furthermore, detailed phenomenological research would be needed to understand whether the difference between such experiences is quantitative  or qualitative.This might raise the worry that spiritual voice-hearers are generally having an experience more akin to imagery than something resembling “true” hallucination, but the majority of spiritual voice-hearers in our study did report some experience of externalized, vivid perceptions which they held to be really occurring. Moreover, voice-hearing in psychosis is often described with “thought-like” qualities  and is often located inside the head. Traditional categorization into “true” and “pseudo” hallucinations is nowadays thought to be of questionable clinical relevance.27–29 control or influence over voices seems to differentiate clinical and nonclinical groups. Methods by which control was exerted over the experience varied widely between participants, with some describing a process of “tuning in”  and others describing a more elaborate process of influencing the voice via dialogue. A key distinction here is between volitional control , and influence over voices (through other strategies such as engagement or distraction), referred to elsewhere as direct and indirect control.27 The spiritual group reported substantially higher levels of control and influence compared to patients. Consistent with previous research demonstrating that control may increase over time,30 nearly 3 quarters of the group reported a change in their ability to influence the voices over time—compared to 12.5% of psychosis patients—suggesting that this ability is not always present from the onset of voice-hearing in nonclinical populations and instead can be actively developed; 88.5% of our spiritual group described their voices starting spontaneously, with 69.2% reporting that this was before they had contact with spiritualism itself. Thus, while most of the group (96.2%) reported ongoing cultivation of the voices, and often reported developing influence over time, it seems that spiritual practices mostly do not elicit the actual initial onset of the voices, instead playing a role in honing the experience. This is consistent with previous qualitative analysis suggesting that mediums, and people of Christian faith who report hearing the voice of God,14 often discuss nonspiritual anomalous experiences in childhood18 which, as adults, are only later interpreted as spiritual in nature. The high prevalence of reported ongoing cultivation of voices, typically within a spiritualist community setting, may support the suggestion that culture has a role to play in shaping how voices are experienced and reported by different groups,31 possibly affecting reports of multimodality, control, vividness, and distress, and also suggesting that how voices are interpreted and reacted to in early psychosis could predict future functioning. NCVHs in other studies have also reported earlier ages of onset compared to psychosis patients, and childhood experiences such as imaginary companions are increasingly recognized as sharing some underlying cognitive markers.32 While others have argued for the importance of spiritual practice, expectation, and belief in the occurrence of voices or hallucination-like experiences,19 our data suggest that although the spiritual practices and beliefs reported by this group may play a role in developing control over and influencing the experience, possibly across sensory modalities, for most, they may be less important in initial onset.As reported in previous studies,33 our data show that this does not necessarily inform negative content of experiences. One possibility is that spiritual practices may alleviate or control negative affective elements of the experience: for example, many spiritual mediums report that they interpret many voices as containing a message meant for other people, which could reduce negative impact and mean that voices are seen as inherently helpful.It is noteworthy that, despite the rarity of negative or abusive voices in this group, 42.3% of the spiritual group reported some form of traumatic event around the point of initial voice onset. These experiences were often nonviolent events , but also included parental verbal or physical abuse. While it is well established that people with psychosis report heightened rates of adverse childhood experiences,Whether initially experienced, or latterly interpreted, as comforting/positive, it is noteworthy that a majority of the spiritual group understood voices as important to their sense of identity. The salience of “voice-hearer” as an identity has been forged in opposition to the “psy” disciplines by those who may otherwise have been labeled “schizophrenic.” It will be important in the future to investigate the relationship between comforting/controllable voices and personal identity as well as whether mental health treatments can avoid the interpellation of patient identities while retaining therapeutic gains. It is also worth mentioning that, for a minority of participants, voices only occurred after contact with (and presumably as a result of) spiritual practices. An important question for future research is to understand differences between the spontaneous and nonspontaneous onset of voices.27 the spiritual group’s ability to exert control over voices may have much to tell us about coping strategies that could be employed by people experiencing distressing voices; for example, the spiritual voice-hearers described using techniques similar to meditation, mindfulness, or voice-dialogue to control or influence voices. However, because the spiritual voice-hearer group reported a higher rate of positive and helpful voices, their experiences may be more amenable to the development of control or influence — that is, positive voices could be constructively engaged with, which may not be the case with more distressing experiences. An alternative position to the aforementioned potential role of cultural differences is that differences in cognition could at least partially underlie differences in control between the groups. A separate study21 investigating cognition in this sample suggested that ability to intentionally inhibit intrusive memories may be higher in the spiritual group than in voice-hearing psychosis patients, raising the possibility that inhibitory ability could underlie control over voices.As noted by others,boundary voices—that is, voices located at thresholds such as doors or through walls—compared to the patient group. In psychosis patients, boundary voices seem to be linked to descriptions of uncertainty or anxiety regarding who is speaking; in contrast, the spiritual group, while often not initially knowing the source of a voice, are used to engaging with and interpreting their voices  and, as discussed, typically develop control and influence over their experiences. It may be that increased engagement with the voices leads to clearer and more certain reports of both the source and location of the voice; alternatively, the “boundary” location of the voice may play a part in the associated distress of some patients , meaning that such experiences are less likely to be nondistressing and thus deemed “nonclinical.”The issue of location  has also been discussed in previous research, with mixed findings. Our interviews suggested that the spiritual voice-hearers were no more likely to describe internally located voices. However, one novel finding was that the spiritual group was less likely to describe 34 which may include different psychosocial and spiritual explanations between ethnic groups.There were a number of limitations to the present study. Firstly, although the sample is not small within qualitative research, our design precludes strong statistical inferences, particularly regarding equivalence between groups. Secondly, the spiritualist and patient groups differed on a number of demographic attributes, including education, gender, and age. The 2 groups were recruited in separate studies; we aimed to treat previously published patient data as a reference point, rather than a matched control group. It seems unlikely that key differences between the groups  could be explained by such group differences. Where differences relating to demographic attributes may exist, they are likely to interact with group status and voice phenomenology in ways that would not be possible to untangle here. Finally, the spiritualist voice-hearer group predominantly represented beliefs and traditions endorsed by spiritualist churches in the United Kingdom , and the sample was of a primarily white British demographic. Furthermore, research should attempt to increase the diversity of both clinical and nonclinical groups recruited into nonclinical voice-hearing research, including investigating spiritual experiences in younger adults or adolescents. It is notable that ethnic minority groups show higher rates of diagnosed psychotic disorders in the United Kingdom and the United States, and recent research with Black psychosis service-users has suggested that interventions should take into account personal beliefs regarding mental health,In summary, using a mixed-methods approach we compared voice phenomenology in a nonclinical, spiritual voice-hearer group to a group of voice-hearing psychosis patients. As well as supporting previous findings regarding low levels of distress and increased control and multimodality in nonclinical groups, we also provided novel evidence of other more subtle differences, including a lower likelihood of experiencing voices coming from perceptual boundaries, and increased integration of modalities into one entity. The majority of participants in the spiritual group reported unusual sensory experiences before encountering spiritualism, suggesting that, while spiritual practices may shape, influence, or increase the frequency of such experiences, they are not typically involved in the initial onset. The mixed-methods approach employed here revealed novel differences between voice phenomenology reported by different groups that might have been missed by standardized clinical assessments . Our replication of previous findings  using a different methodological approach can increase our confidence in their veracity. Future research should aim to understand more about strategies used to control voices, which could inform interventions for those in distress.sbac054_suppl_Supplementary_MaterialClick here for additional data file.


The experimental intervention included the utilization of a smartphone app designed specifically for improving older adult well-being and mindfulness levels. Participants completed semi-structured interviews evaluating participants’ treatment experience and technology-acceptance at recruitment  and post-intervention . Through thematic analysis, four themes were identified from verbatim responses of both interviews: Utility of technology for health, Impressions of technology, Mindful-benefits of smartphone application usage, and Smartphone application usage as a means to improve interpersonal relationships. Participants showed a positive experience of the app intervention. Qualitative analysis underlined the main Mindfulness-benefits reported by participants and the potentially crucial role of “Langerian” mindfulness in the relationship between older adults and health technology.The global population is aging while modern healthcare systems are responding with limited success to the growing care demands of the senior population. Capitalizing on recent technological advancements, new ways to improve older adults’ quality of life have recently been implemented. The current study investigated, from a qualitative point of view, the utility of a mindfulness-based smartphone application for older adults. A description of the older adults’ experience with the smartphone application designed to enhance well-being and mindfulness will be presented. Participants’general beliefs about the benefits of technology for personal well-being will also be discussed. 68 older adults were recruited from different education centers for seniors. Participants were randomly assigned to two groups: a) a treatment group, which received the smartphone application intervention ( The world population is aging while modern healthcare systems are responding with limited success to the growing care demands of the senior population with chronic conditions, creating long-term economic consequences , an intuitive, user-friendly, visual programming environment that allows laypeople to build fully functional apps for smartphones and tablets. The blocks-based tool facilitates the creation of complex, high-impact apps in significantly less time than traditional programming environments. Our team carefully developed the App to obtain the most intuitive design, specifically created for older adults. For example, few colors were chosen, with each one identifying a specific button throughout the entire App’s environment  explanatory videos presenting theoretical, scientific and practical principles on which mindfulness practice have been developed, with a particular focus on the possible benefits obtainable through a mindful approach to daily life events; b) pre-recorded audio files giving pieces of information on mindful aging and mindfulness practice; and c) brief texts explaining mindfulness and mindfulness-related general exercises. The first block of seven exercises was specifically designed to empower and stimulate users’decision-making process, as well as awareness. The exercises prompted older adult users to focus on their cognitive process and to reflect on their own choices, in order to promote self-awarenessFigs.  and 3.FiThe second block of seven exercises focused on the development of lateral thinking, challenging users with creative riddles, logical tests, or behavioral challenges for daily situations (i.e. brushing teeth with the left hand). Within the first seven exercises, users were cognitively stimulated by the different puzzling tasks, ensuring adherence to the study protocol due to the combination of highly ludic engagement experience with accessible positive reinforcements coming from the tasks’ solutions. A different approach was required by the remaining tasks, stimulating creativity, and out of the box mind-sets, with clear references to everyday situations Fig. .Fig. 4.MWithin the context of a larger study  > 18. The MMSE is a common psychometric instrument used to assess individual cognitive performance in clinical practice . Regarding educational level, 6% had an elementary degree, 25% had a middle school degree, 53% had a high school degree, and 16% had a master’s degree. At the time of the study, 89% of the sample were employed, and only 11% had retired. Approximately half of the sample (55%) were living with a partner, 32% were living alone, and 13% were living with a relative or a friend. Most of the sample had previous experience with smartphone Apps (80%), and only 20% of the entire sample had no previous experience of any kind with smartphone Apps.The final sample was mainly female , and b) a waitlist control group (n = 34) which had to wait until the end of the trial before receiving the App.After providing informed consent, participants were randomly assigned to two groups: a) a treatment group, which received the new smartphone application intervention , while the second was conducted after the end of treatment . The semi-structured interviews allowed participants to express themselves freely while enabling the interviewer to follow a logical focus. Participants were interviewed by two researchers (F.V.R. & B.C.). Interviews lasted between 30 min and an hour. All interviews were recorded and transcribed.Verbatim responses from both interviews were analyzed using thematic analysis, in line with Braun and Clarke’s  guidelinParticipants’ verbatim responses were read and re-read by the researchers  in order to better familiarize themselves with the full material. Initial codes were then produced to systematically identify key features of the data. After all data were coded and collated, different codes were sorted into potential themes. In this phase, the relationship between codes, themes, and subthemes was first examined, and a preliminary sense of the significance of individual themes was developed , while 20% of participants indicated that they were unsure of technology’s utility in healthcare (category 3). In contrast, only 12% of participants did not agree that technology was useful for health (category 2).Participant 13: Yes, [technology is] useful for keeping your mind exercised and challenged…it’s like going to a gym, where you can do something to get in shape…to keep your mind in good shape and healthy...to improve your situation.Participant 4: Technology could be useful for improving memory and could be very useful [for health] in general.Additionally, many participants predicted that technology’s usefulness for health would improve in the future;Participant 6: Technology could be useful [for health], but in the near future. For example, in robotic systems for the elderly population.Participant responses revealed a general perception that technology for healthcare might be useful in the future, but that they did not currently believe it was aiding their health.Accounts of technology’s utility as a health tool predominantly focused on how technology could be useful in elderly populations, for example in the improvement of cognitive functioning and medical interventions.At baseline, participant impressions of technology could be grouped into five categories, ranging from positive (1) to negative (5): “Technology as useful”, “Technology as an interesting element”, “Technology as something valid, if not over-used”, “Technology as addictive”, and “Technology as scary”.Participant 12: Technology is progress, it's an activity, it's indispensable for humanity.Participant 20: [Technology is] really useful for your daily life.Other participants thought technology was something interesting, although not completely clear;Participant 11: Technology is quite interesting, even if I feel like I am not getting it completely, but it’s fascinating.Participant 29: [Technology is] something that has always interested me. SometimesI try to understand it more…However, despite a generally positive view towards technology, many participants mentioned their perceptions of technology’s potentially addictive qualities, as well as its possibility to be used for negative or frivolous reasons;Participant 15: Technology is a good thing unless you become addicted to it.Participant 24: It's useful, but I don't think it's ok to use it for social media… people spend too much time on those things, instead of actually talking to real people… strangers can use social media to trick you, or to try to steal things from you…In contrast, some participants were strongly against technology and thought that it was frightening and responsible for stealing human jobs;Participant 28: Technology steals works from humans. It is a negative thing.Participant 10: Technology is dangerous. I don’t like it because I can’t control it completely, and it’s scary not to have control over something like that.After using the application, four categories were identified regarding experimental group response to whether their impressions of technology had improved:“Yes”,“Yes, but only slightly as their original impression was positive”,“No, because their opinion was already positive”, and “No”.Most participants thought technology was useful. In particular, they highlighted its value as a beneficial tool to improve daily life;Participants most frequently stated that their impressions of technology improved after using the app, with 34% in category 1, and 24% in category 2. Approximately one-third of participants (31%) reported no improvement because their opinion was already positive, and 11% did not report any improvement.“Yes”,“No, due to prior curiosity about technology use before using the app”, and  “No”,Participants were also asked whether they were more curious about technology after using the app for fourteen days. Based on responses, three categories were established:In general, participants were curious about technology; with 46% stating they were more curious after using the application (category 1), and 45% stating that they were curious prior to using the app (category 2). The remaining 9% of the sample (category 3) stated that they continued to be incurious about technology.“Increased flexibility of perspective-taking and lateral thinking”,“Improved cognitive ability”, and “No benefits”.Participants in the experimental group were generally positive about using the application and the majority (86.3%) indicated that they acquired some type of benefit as a result of the mindful components featured within the App. Mindful-benefits of application usage fell into three sub-categories: Participant 4: It was a great experience and now I'm able to consider alternative solutions to daily problems. The game tasks were easy to follow, and thanks to them I was willing to try those things I was learning even outside of the App.Additionally, they found that using the app helped them to consider things from unconventional or more mindful viewpoints and enabled them to evolve their personal perspectives;Participant 7: It helped me to focus on many things from an unconventional point of view.Participant 17: The advantage of using the application was that I gained awareness of the fact that I'm pretty limited in my way of thinking, but now I have a broader point of view.Participants in Category 2 (27%) emphasized that one of the main benefits of using the app was that it produced a deeper way of thinking:Participant 8: Using your brain more. Thinking about stuff in a deeper way. I have tried to use the mindful information, and they somehow work, they really do.Participant 13: It made me think deeper.The Mindfulness features of the Apps seem to have been appreciated by most participants, and despite the short period of use, were potentially able to affect participants’ mind-sets. Benefits highlighted by the interviews seem in line with the general outcomes reported in the relevant literature describing mindfulness integration and acceptability in older adult samples (Bercovitz and Pagnini Participants in category 1 (65%) expressed enthusiasm regarding the ability of the mindful app to change the way they thought about and approached basic tasks of daily life;Amongst the remaining 8% who did not find the application to be beneficial, the most commonly cited reasons were that they found the exercises to be too easy and that the application included information they were already familiar with.Participant 16: Yes, I talked a lot about my experience with other people. I think it takes time to gain trust in new situations, but the application has helped me a lot.Participant 4: Yes, I feel empowered and more open to outside experience.As such, it appears that some participants may view this application as a useful tool to build and improve relationships.Given that loneliness is a common affliction in the older adult population, this analysis investigated whether application usage improved experimental group participants’ ability to connect with others in their social networks and/or strengthened their pre-existing interpersonal relationships. The mindfulness social component featured within the App was designed to encourage participants’ social interactions and social involvement. Additionally, one of the main theoretical goals of mindfulness practice is to increase feelings of empathy and compassion, resultantly improving individuals’ interpersonal skills , the experience with this specific e-health application had small effects on participants’ interpersonal relationships. Still, those few individuals who experienced some kind of improvement in their relationships highlighted the application’s ability to help them with their social interaction. It is not clear whether this effect could be directly attributed to any specific features of the app or rather to the experience of the experimentation itself, but this application shows potential as an empowering tool to build and improve relationships for some older individuals.The sample size could potentially be one limitation of the present study, as well as the short duration of the App’s utilization. Further longitudinal studies may be better able to investigate long- term effects. Most participants had high academic achievement and previous experiences using smartphone applications, potentially creating a bias in the present study.Results from this study appear to show a positive experience of the App intervention for most participants. This qualitative analysis emphasizes the potential role of Langerian mindfulness when exploring the relationship between older adults and health technology. The mindfulness component of the current smartphone App may improve results in terms of older adults’ openness and acceptance of health technology in their daily living.Qualitative findings from this study highlight the great potential for positive outcomes in older adults via better integration between technology and psychology. The App appears to be clinically useful at promoting older adults’ psychological well-being. Future studies are needed in order to better understand the generational gap between older adults’ psychological needs, Gerontechnology, and clinical practice.


In the published article, there was an error regarding the affiliations for Elif Sengun. As well as having affiliation 1, she should also be affiliated with “Department of Pharmacology, Institute of Graduate Studies in Health Sciences, Istanbul University, Istanbul, Türkiye.”The authors apologize for this error and state that this does not change the scientific conclusions of the article in any way. The original article has been updated.