Living in times of increasing complexity is hard; it becomes even harder with the realisation of diminishing control. How do we adapt our governance to this complexity to ensure peaceful cohabitation of the established and emergent order regimes? This paper contends that it is important to embrace complexity in full, conceptually and practically, by shifting from ‘the global’ to ‘the local’, to understand the pressure of transformational change and to prepare the ground for the emergence of more resilient and cooperative orders. We apply this complexity-thinking, using a 3P analysis, to Central Eurasia, presently a battleground of three competing order-making regimes—the EU, China and Russia. We argue that for more resilient and cooperative orders to emerge, it is essential to understand and enable ‘the local’ and embrace the region in is diversity, to facilitate a more joined-up and bottom-up governance in managing the complexity of a changing world. To live ace Beck  and the ace Beck —may evenace Beck . However‘Taking back control’ in times of complexity (and crisis) seems to be a popular action these days taken by a range of governments around the world, in an effort to secure their authority and disconnect from global challenges to nurture national survival in isolation. Its long-term benefits, however, are uncertain and highly controversial, as the COVID-19 pandemic has vividly demonstrated.The other option is to ‘go global’ and expand existing hegemonic orders, which are often seemingly legitimised on the grounds of their historical longevity, and claims to normative ‘universality’ and inter-cultural affinity Smith . The prenot to disconnect (as the first option implies), rather—to understand change and its effect on ‘the person’ locally, and connect it back to ‘the global’ by enabling collective resilience and facilitating cooperative orders, as was posited by the European Union’s (EU) Global Security Strategy (EUGS) in 2016. For this to happen, the foundations of how the world is governed today must be rethought, both in theory and practice. As Kavalski argues, one ought to make complexity-thinking an integral part of International Relations (IR)—Complex IR (CIR), which is the conceptual premise of this article—to advocate for a new ‘vision of politics that emphasises responsibility’ and ‘immanent self-ordering’  are possible across Central Eurasia. To this end, we will examine the three actors’ power projections, normative promises and practices to demonstrate how currently disjointed and disconnected their visions and actions are in relation to the region, and vis-à-vis each other. This may suggest that even before any resources could be committed and infrastructures built, power strategies ought to engage with the ‘local’ and each other, to embrace complexity more fully in the development of more sustainable orders.This article will deploy a ‘three-P’ 3P)—power, principles and practice—framework, developed by Flockhart  as betteP—power, The article will proceed by first, briefly introducing the 3P framework and then applying it to each chosen actor vis-à-vis the Central Eurasian region. It will conclude with further discussion of the ‘missing elements’ in today’s global strife to develop more adaptive governance strategies for managing complexity, especially with the rise of local visions across Central Eurasia.relational nature of complexity  there, it is essential that first, we introduce the fifth IR debate, or ‘Complex International Relations’ Kavalski  as our crelational turn, as ‘relationalism represents an attempt to recast social ontology in a way that rejects essentialist notions of social units’  complexity of Central Eurasia, and the degree of relationality between the ordering initiatives of the EU, China and Russia vis-à-vis the region, and each other.7It is worth noting that the 3P elements in this analytical framework are inherently interlinked, and should not be studied in isolation. At the same time, each focuses on a specific question, to make the inquiry distinct analytically: the first is about how modus operandi there has progressed from standard Partnership and Cooperation Agreements (PCAs) of the mid-1990s to more advanced and differentiated forms of cooperation—the Association Agreements (AAs)—since 2014 under the European Neighbourhood Policy (ENP). The latter can now provide some hitherto unthinkable sectoral opt-outs as is in the case of Armenia’s Comprehensive and Enhanced Partnership Agreement (CEPA) and ongoing tailored negotiations with Azerbaijan and Belarus.reflective thinking vis-à-vis the region. On the other hand, however, judging by a varied (and largely tepid) regional response  to its immediate neighbourhood. This resulted in the adoption of so-called ‘deliberative governance’, associating with the recognition of partners’ interests at the negotiation table, developing a dual track engagement with multiple stakeholders, and less interference in the implementation process. The EU also included regular consultations with policy stakeholders, and yet, the response was almost similar to that of the previous years in terms of reciprocation, with the exception of Ukraine, which unexpectedly became a battleground of openly contested ordering initiatives between the EU and Russia. The subsequent annexation of Crimea and the ongoing crisis in Ukraine serve as a reminder of still largely mono-logical actions by the power actors failing to understand the underwriting complexity of the wider region.9To improve its credibility, the EU went through a series of further iterations. Initially, governance actions included further regionalisation (2007/8), and differentiation to seek consultation and partnership with different-level stakeholders via a ‘more for more approach’ (2011). This new EU approach could be described as adaptive governance’, is important for testing the EU’s ability to be a reflective (and effective) order-making actor in Central Eurasia. On the one hand, the EU’s intention, at least in rhetoric, is to decentre from its own agenda, to the level of partner states and local communities, to better understand their needs, and enable them to seek their own solutions to development problems. This should, in theory, enable individuals to grow their strength and capacity to better manage change via local transformation, and where necessary, with the external support (and not intervention) of the EU—just as Kavalski  policy and action plan with that of the EUGS 2016, with resilience taking a centre stage. It is argued elsewhereKavalski  imaginedOn the other hand, there are already some warning signs to show that ‘business as usual’ continues, especially when it comes to instrumentalising ‘local ownership’ for the purpose of legitimising the EU’s own agenda in managing external insecurities , thus once again suggesting anchoring new partnerships in the EU-based vision of order.However, lately the EU seems to have begun opening up to other norms, at least rhetorically. As the EUGS stated, ‘we will not strive to export our model, but rather seek reciprocal inspiration from different regional experiences’ EUGS , p. 32. Putting reflectivity to practice proves much harder. Having pioneered the people-to-people dimension in all its ENP sectoral policies as early as the 2000s, the EU still struggles to make its ‘hearts and minds’ appeal more tangible  is the EU continuing struggle to maintain the trialogue between the EU, Russia and Ukraine, to seek crisis resolution in the region. This is manifest, for example, by the recent negotiations regarding the post-2020 arrangements for the transit of Russian gas to Europe via Ukraine, impeded by EU insistence on adopting its own regulatory framework.14China, too, is grappling with the unravelling VUCA-world, but seemingly in a more adept way, even in the times of the global pandemic. In 2013, the Chinese Communist Party articulated its new external strategy of embracing complexity as ‘One Belt One Road’ or the BRI for external use, which embraces both the Silk Road Economic Belt and the 21st-century Maritime Silk Road Yang .By 2015, the BRI policy framework consolidated into the ‘Vision and Actions’, with the State Council’s authorisation, and the Leading Group was established to ‘build a global community of shared future’ , p. 9. WThe BRI in a sense is China’s response to the increasing uncertainty, fragmentation and diminishing control over both the internal and external environment. As Jinny Yan, China’s Chief Economist for the BRI, insisted, it is designed to be a non-hierarchical and bottom-up engagement with all-level stakeholders, to develop their resilience and connectedness in the face of future challenges,promote the connectivity of Asian, European and African continents, and their adjacent seas, establish and strengthen partnerships among the countries along the BRI, set all-dimensional, multi-tiered and composite connectivity networks, and realise diversified, independent and sustainable development in these countries.It rests on five principles of peaceful co-existence, in line with the principles of the UN Charter (Ibid), and sets to pursue five specific cooperation priorities to ‘boost [multilateral] cooperation platforms’ for ‘increasing mutual understanding, reaching consensus and deepening cooperation’ .According to the BRI founding document  better policy coordination; (2) development of infrastructural connectivity; (3) promotion of unimpeded trade; (4) enhancement of financial integration for better access to investment and resources; and (5) people-to-people bonds. In 2019 priorities were extended to include (6) industrial cooperation for China’s investment in BRI countries. The key ‘cooperation mechanisms’ initially prioritised bilateral links (through joint committees) with the BRI governments (very similar to the EU governance of pre-2011) and mobilise existing multilateral mechanisms, such as Shanghai Cooperation Organisation, ASEAN Plus China (10+ 1), Asia–Pacific Economic Cooperation, and others . These mechanisms were supposed to ‘support local authorities & general public of BRI countries to explore their historical and cultural heritage’, thus specifically underscoring the salience of bottom-up governance and cooperative initiatives (Ibid p. 10).Having celebrated 5 years since inception, the BRI has enjoyed enormous progress in terms of its expansion and development of international cooperation, seeing some tangible results along the way. By the end of March 2019, Chinese government signed 173 cooperation agreements, with 125 countries and 29 international organisations, having expanded through Asia to Europe and Africa, and also procured new partnerships in Latin America and the South Pacific ?‘The people-to-people’ dimension, while being under-invested, has nevertheless seen some interesting results. Initially, for example, the intention to win ‘hearts and minds’ of the populations, in Central Eurasia, was intended via school cooperation and student exchange (a strong EU measure). China put aside funds to invest up to 10,000 scholarships per year for BRI countries and provide financial support for Chinese cultural events. This commitment, as the 2019 review reports, has exceeded manifolds. Investment was granted to support diverse forms of cultural exchange, including Chinese and local festivals, bazaars and art fairs. In 2017 alone, about 40,000 scholarships were issued to students from the BRI countries, to study in China, which is about 66% of all students receiving such scholarships  sense of ‘good life’, ambitions and needs. This is what has been causing disquiet and resistance and in some cases even outright rejection Cavanna , p. 4.20The two powers at least talk to each other, through the established EU–China platform , the Alexander Gorchakov Public Diplomacy Fund, Friendship Society etc.  use of power where rhetoric often contradicts practice. For example, while reiterating voluntary membership—‘we are not going to hurry up or nudge anyone. A state must only join on its sovereign decision … [and] long-term national interests’ , it has also proved reluctant to learn from the norms, traditions and aspirations of its neighbours on the regional level, which implies that facilitation of cooperative orders with its participation is highly unlikely.In summary, while Russia may be a Similarly, to the EU, Russia’s reflectivity has also proved difficult to translate into practice, with the latter being clearly affected by the established, deeply rooted relations with its neighbourhood. Beside the cases of Armenia and Belarus vis-à-vis the EAEU, there are many other examples to illustrate this argument. Notably, due to Russia’s pressure, much of the EAEU code of practice has been made advantageous for Russia, thus causing concerns and grievances among EAEU member states.The EAEU will join the dialogue with the EU. Apart from bringing direct economic benefits, EAEU accession will also help countries integrate into Europe sooner and from a stronger position. In addition, a partnership between the EAEU and the EU that is economically consistent and balanced, will prompt changes in the geo-political and geo-economic setup of the continent as a whole with a guaranteed global effect.In practice, however, over the past decade not only the two regional orders failed to establish a dialogue with one another, and vis-à-vis the region; they drifted further apart to what is now seen as ‘principally incompatible’ orders (Suslov Concerning the facilitation of cooperative orders, Russia in rhetoric has been one of its most vocal proponents. As Putin argued in 2011:s Suslov . Russia complexity associated with uncertainty, unpredictability and crisis (Kavalski This article started from the observation that Kavalski  is becomreflective of their policies premised on regional response, and tried to adjust to the emergent environment accordingly. They became more adept at differentiating their governance to regional needs, and with time, more engaged with developing horizontal people-to-people relations, each using different approaches and instruments. At the conceptual and rhetorical levels, the EU’s approach has proved most comprehensive, taking its governance, post-EUGS to a seemingly new ‘decentred’ level of engagement with ‘the local’ via ‘resilience’. China initially prioritised bilateral relations with governments and is only now coming to realise that it must foster a bottom-up engagement, for BRI 2.0 to succeed. Russia, in turn, has been using both hard and soft means of power, especially its cultural affinity through language and media presence, to manage the growing complexity of the region more efficiently. And yet, each power, while reflective, still centred their governing strategies on their own vision of development priorities for this multifaceted region, and their own understanding of peoples’ needs, thus proving un-relational to the region’s complexity, and vis-à-vis each other’s initiatives.As was shown above, all three powers targeting Central Eurasia have been mindful of complexity and adapting their governing strategies towards this multivocal region accordingly. Notably, the EU, Russia and China, to various extent, have been All three powers have also introduced and projected elaborate ideational structures, connecting their principles, norms and values with the narratives of ‘the good life’, pertinent to each particular order. As demonstrated by the analysis, despite the rhetoric of a multi-order world and respect for different civilisations, these ideational structures remained strictly self-centred, presenting their own principles as universal for achieving better living across the region. Learning from the norms of others and developing a shared response to complexity proved particularly difficult for the EU and Russia.cooperative way, to prioritise capacity-building bottom up and inside out. One of the possible explanations is, as Bossuyt and Bolgova (Putting reflective power projections and principles to practice, to make respective governing strategies more adaptable and responsive to change, has appeared to be the most problematic. While each power emphasised the rhetoric of cooperation and local ownership, none succeeded in properly connecting with local communities, in a  Bolgova , p. 242


Pre-exposure prophylaxis (PrEP) for HIV is instrumental in the prevention of HIV for HIV-uninfected persons, by drastically reducing the risk of acquisition in the case of high-risk exposures. Despite its demonstrated efficacy, it remained under-prescribed in France until 2018. The principal aim of this study was to understand the motivations of Men who have Sex with Men (MSM) who started using PrEP in Montpellier, France.A phenomenological study was undertaken, using semi-structured interviews with twelve participants attending the University Hospital of Montpellier for PrEP. Interviews were analysed by means of triangulation up to the point of theoretical saturation, using a semio-pragmatic method.Fear of HIV infection, personalised regular follow-up, and the wish to take care of one’s health were the primary motivational factors. PrEP allows for a better sexual life restoring a sense of freedom despite the risks of STI, deemed manageable by PrEPers. PrEP does not modify long-term risk-taking behaviours but helps them better live their own sexuality and guides them towards a responsible approach to sexuality. Unclear information on PrEP, delivered by their family doctor, public campaigns or the media, leads to misrepresentations or negative social representation, including within the MSM community, which may delay its implementation.Fear of HIV infection and the benefits of regular medical follow-up to take care of one’s health were motivational factors of importance for the use of PrEP by MSM in this study. PrEP transforms all existential dimensions of their lived experience, improving sexual identity and happiness. There is a need to improve professional awareness of the effectiveness of PrEP and to develop a patient centered approach, to disseminate information more widely to the general public and among MSM to reduce stigmatisation. In 2018, approximately 37.9 million people were living with Human Immunodeficiency Virus (HIV) globally  and it became a chronic illness’ E12; ‘we are not in the same era, there is a different state of mind’ E12; ‘anyway, it’s less dangerous’ E6.Interviewees highlighted a decrease in protective behaviors (particularly condom use): ‘for me, I still have the image of skeletal people with Kaposi marks, that I’ve seen my whole life’ E2.For older interviewees, having had their first sexual experiences before the era of effective antiretroviral combinations, anxiety persisted regarding the possible transmission of the virus. This fear was embodied in their lived experience: ‘The first image that I had of homosexuality was linked to death’ E7.This era prior to antiretroviral combinations was experienced as traumatic for some participants and affected their current sexual behaviour considerably: ‘I still have this image of a terrible illness, that mustn’t be caught at any cost […] I’d really prefer to have a cancer than to catch this disease because, there it is, there’s everything behind it, everything that surrounds the thing…’ E4.Finally, the stigmatised perception of HIV remained present: ‘On the tv news. After going out, in some places, I saw that there were small leaflets, but for a long time I didn’t look at them anymore because it was always about the same thing’ E6; ‘social networks first’ E8.Most of the interviewees had first heard about PrEP from the televised media or through social networks: ‘I didn’t have enough information, and that made me fearful, and I believed more that it was a treatment against AIDS’ E2) or not feeling concerned .Those who discovered PrEP via a prevention campaign said that they did not feel concerned by the content of a prevention campaign about PrEP and had not understood the message (‘my GP spoke to me about post-exposure prophylaxis (PEP) and therefore it was very vague’ E1), or indeed even feeling judged ‘when I spoke to her about PrEP, she didn’t know. And when I explained to her what it was, she had a prejudiced reaction that shocked me.’ E4.Others tried to inform themselves through their family doctor, without more clear understanding (people I met who were on PrEP’ E8), through the Grinder meeting app , or through information sites such as AIDES or sida-info service.Almost all of those interviewed said they found clearer responses to their questions through social media  as well as in the MSM community .The first representations of PrEP, coming from the media, were rather negative as well as those coming from the general population  or of being a carrier of disease by their potential partners .The primary motivation of almost all of those interviewed was the protection PrEP offers against HIV and of the anxiety of being infected by HIV : ‘no, it didn’t lead to any particular change, simply a freedom from doubt’ E1.Five participants verbalised spontaneously not having changed their sexual behaviour following a course of PrEP. They perceived a feeling of freedom and well-being: ‘there was a phase, just at the start of taking the PrEP, of a certain sense of all-powerfulness, one is not invulnerable, but almost’ E7).Increased sexual risk-taking was the case, however, for three participants who emphasised a strong increase in risk-taking shortly after the beginning of PrEP combined with a period of reducing the use other preventive strategies , and a new sense of self-esteem, resulting in a better acceptance of their sexuality: ‘it must not make us forget our other objectives in life, the professional side’ E12.In contrast, for some, PrEP paved the way towards a project of being self-responsible .The transcripts are marked by linguistic indices connoting ‘mong MSM , 35  in our sample. Peyrières et al. shows a high prevalence of these behaviours by MSM .This study provides a better understanding of the motivations to engage in PrEP among MSM. Firstly, the persistent fear of HIV infection despite its current representation as a chronic disease; secondly, MSM find that PrEP facilitates a personalised regular follow-up motivating them to take better care of their overall and sexual health; and finally, PrEP changes their lives, allowing them to better live their sexuality through a significant decrease in anxiety and doubt.


Autism Spectrum Disorder (ASD) is often associated with impaired perspective-taking skills. Deception is an important indicator of perspective-taking, and therefore may be thought to pose difficulties to people with ASD . To test this hypothesis, we asked participants with and without ASD to play a computerised deception game. We found that participants with ASD were equally likely—and in complex cases of deception even more likely—to deceive and detect deception, and learned deception at a faster rate. However, participants with ASD initially deceived less frequently, and were slower at detecting deception. These results suggest that people with ASD readily engage in deception but may do so through conscious and effortful reasoning about other people’s perspective. These difficulties are usually connected to their more general problems with perspective-taking; e.g., Baron-Cohen attributes these problems to the inability of children with ASD to “appreciate someone else’s mental states (such as their thoughts and beliefs), and to make sense of and predict their behaviour on the basis of such states” (p. 1141).It is less clear, however, whether the difficulties with deception that children with ASD experience persist into adulthood; however, the limited evidence that has been collected so far suggests that they do. Thus, Happé  found thHowever, in order to accurately detect deception in these studies, participants had to rely on their knowledge of implicit norms that govern social interactions. Thus, to determine that the character in one of Happé’s stories was telling a white lie, participants had to represent and integrate the social norm that one should always appear grateful when receiving a gift. Similarly, in the study of Williams and colleagues, participants had to detect subtle facial and linguistic cues to establish whether the people in the videotapes were lying.per se.It is well known that people with ASD have problems with this type of social reasoning . Participants with ASD were marginally older than participants without ASD (t(51) = 1.77, p = .08); however, we did not expect any relation between age and deception. The presence or absence of ASD was assessed and confirmed for all participants using the Autism Diagnostic Observation Schedule ; the remaining 26 participants had not . The proportions of males and females did not differ across the two groups (Participants with ASD were recruited from the Autism in Context: Theory and Experiment (ACTE) register of volunteers. Participants without ASD were recruited through announcements placed on the internet. Study inclusion criteria included: (i) being between 18 and 60 years old, (ii) having a global IQ above 70, (iii) having normal or corrected-to-normal vision and hearing, and (iv) in the case of participants without ASD, not having any known psychiatric, developmental, or neurological disorders.t(51) = 0.8, p = .43). Furthermore, we measured participants’ Autism Quotient  = 16.8, p < .001); conversely, the mean EQ was significantly lower for participants with ASD  than without ASD  = − 71, p = .001). Table Participants’ IQ was measured using the Wechsler Adult Intelligence Scale  that the opponent was unable to see where the treasure was, and therefore had to guess its location based on the participant’s behaviour. The opponent was programmed so that it always moved in the same general direction in which the participant was moving. The opponent thus moved in a way that was—at least in principle—completely predictable, and its behaviour was similar to how one might expect a naive person to behave.The experiment consisted of two phases: the Control trials, the optimal path was for participants to move directly towards the treasure. In some of these trials, this would result in the participant capturing the treasure; in others, it was inevitable that the opponent would capture the treasure. In Deception trials, the optimal path was to first move away from the treasure in order to trap the opponent using the arrow tiles. There were two types of deception trials: in Deception-C trials, moving directly towards the treasure would result in the opponent capturing the treasure. In Deception-S trials, participants could capture the treasure by either moving directly towards the treasure, or by first moving away from the treasure to trap the opponent. However, the second method yielded a greater payoff, since the opponent would be further away from the treasure than if the participant moved directly.The Active phase consisted of two types of trials. In There were 7 Control trials and 14 Deception trials . Hence, the Active phase consisted of 21 trials in total. The order of the trials was randomised for each participant.In the Passive phase, the opponent always moved first. Participants were unable to see the treasure, and therefore had to guess its location based on the opponent’s behaviour. However, the opponent would routinely  deceive participants by moving away from the treasure first in order to trap participants by means of the arrow tiles. The optimal behaviour from the participants’ perspective was thus to consistently avoid being trapped. On Control trials, this would lead to a slightly suboptimal outcome; on the more frequent Deception trials, however, trap avoidance would lead to a vastly superior outcome. Note that participants were unable to distinguish Control and Deception trials in the Passive phase, since they were unable to see the treasure. Hence, both trial types will be grouped together for the purpose of analysis.Figure  Participants were first trained to move around the grid. Afterwards, they were familiarised with the movement of the opponent, and how the opponent’s moves depended on theirs. Then, the trap tiles were introduced, and participants played five training rounds to familiarise themselves with the workings of these trap tiles. Then, the treasure was introduced, and participants played five rounds to familiarise themselves with the scoring system. After that, the Active phase started, which was always followed by the Passive phase. We did not counterbalance the order of the two phases because we intuited that the Passive phase was considerably more challenging than the Active phase.13 trials were removed because participants failed to move within 10 s . In addition, 30 trials were removed because the responses failed to register (1.3%).Behaviour in the Active phase was coded as optimal or suboptimal. In Control trials, optimal behaviour was to move directly towards the treasure. In Deception trials, optimal behaviour was to first move away from the treasure in order to trap the opponent. Figure Z’s < 1). For Deception-S trials, however, participants with ASD were significantly more likely to behave optimally than participants without ASD , trial number, age, and IQ, including random slopes and intercepts for participants and items . In order to determine if this difference was significant, we constructed a generalised binomial mixed effects model predicting optimal behaviour based on diagnosis, trial number, age, and IQ, including random slopes and intercept for participants and items. There was no significant effect of diagnosis , trial number, their interaction, age, and IQ, including random slopes and intercepts for participants, and random intercepts for items, which was the maximal converging model.Z’s Figure For the two types of Deception trials, there was a significant interaction between diagnosis and trial number , trial number, their interaction, age, and IQ, including random slopes and intercepts for participants and items. There were no significant effects of diagnosis or its interaction with trial number , behaviour , their interaction, trial number, age, and IQ, including random intercepts for participants and items, which was the maximally converging model.t’s t’s For the Control trials, there were no significant effects of diagnosis or its interaction with behaviour , behaviour , their interaction, trial number, age, and IQ, including random intercepts for participants and items.There was a significant interaction between behaviour and diagnosis  or the participants themselves (Passive phase) were unable to see the location of a treasure that had to be captured. Consequently, in the Active phase, one could deceive by steering the opponent onto one of the trap tiles that forced the opponent further away from the treasure. In Deception-C trials, deception was a prerequisite for capturing the treasure; in Deception-S trials, deception merely led to a higher score. In the Passive phase, the opponent would routinely attempt to deceive the participant, and participants had to avoid entrapment—and hence avoid being deceived—in order to reach an optimal outcome.more likely to deceive than participants without ASD. An analysis of the confidence intervals around the parameter estimates indicated that the population difference between people with and without ASD was almost certain to be less than 10%. Even if a more highly-powered study is able to detect such subtle differences, they nevertheless appear to challenge the idea that ASD is characterised by an impairment in the ability to take other people’s perspective.We found that participants with and without ASD were equally likely to deceive in Deception-C trials and equally likely to realise that they were being deceived during the Passive phase. In Deception-S trials, participants with ASD were even However, an alternative explanation for the absence of an effect of ASD is that participants with ASD used socially learned strategies to compensate for their difficulties with perspective-taking, i.e., they derived regularities from observed behaviour and reasoned about those regularities to mimic perspective-taking  used a different type of strategy to pass the experiment, i.e., a strategy that involves conscious and effortful reasoning about the regularities that they observed throughout the experiment. Notice, however, that these compensatory strategies were only partially visible: the increased learning effect was only observed when participants actively deceived; the increased response times when participants had to detect deception.This study highlights the importance of distinguishing theoretically and empirically different ways in which people may engage in deception: either through perspective-taking or through social learning of causes and effects. This aetiological ambiguity generally makes it difficult to draw firm conclusions from the ability to strategically deceive to the ability to engage in perspective-taking , at least in settings that do not draw upon rich knowledge of social interaction.


COVID-19 is a new disease affecting and killing a large number of people across the world every day. One way to improve health care for these patients is to recognize their needs. Nurses, as a large population of health care staff, can be rich sources of information and experience on patients’ care needs. Therefore, the aim of this study was to explore nurses’ perception about the care needs of patients with COVID-19.The present qualitative research was performed using the conventional content analysis approach in Iran from March to May 2020. The participants of this study included the nurses caring for patients with COVID-19, recruited by the purpose sampling method. The data was collected through 20 telephone interviews and analyzed based on the method proposed by Lundman and Graneheim.Qualitative data analysis revealed six main categories including need for psychological consulting, need for quality improvement of services, need for upgrading of information, need for improving of social support, need for spiritual care and need for social welfare.The data showed that patients with COVID-19 were psychologically, physically, socially, economically, and spiritually affected by the disease. Therefore, they should be comprehensively supported by health care staff and other supportive systems. COVID-19 is a newly emerged infectious disease which was first reported in Wuhan, China on December 31, 2019 .Studies on patients with the COVID-19 indicate that they may experience various symptoms such as fever, dyspnea, muscle ache, headache, fear, diarrhea, nausea, vomiting, increased systolic blood pressure, and hemoptysis, that require invasive and non-invasive therapeutic supports during the acute course of the disease , 6. The For a comprehensive patient care, their needs should be identified. Among health care providers, nurses are at the forefront of fighting against the COVID-19. They are in close and constant contact with patients from admission to discharge. Also, nurses are valuable resources to recognize the patients’ needs, clinical manifestations of the disease, evidence-based care practices, nursing management problems, and prognostic factors during the COVID-19 crisis . ExplainThis qualitative study was performed with a conventional content analysis approach.The study population included the nurses occupied in the inpatient wards of COVID-19 of general hospitals affiliated to Lorestan University of Medical Sciences. The participants were selected using the purposeful sampling method based on the length of work experience in COVID-19 wards, total years of work experience, the wards where the nurses were occupied before the COVID-19 crisis, and the participants’ age and marital status. The inclusion criteria were being engaged with caring for COVID-19 patients, willingness to participate in the study, and having at least 2 weeks of working experience in COVID-19 wards. The exclusion criterion was withdrawal from the study for any reason.Given the need for urgent data collection to improve the quality of patient care as well as the restrictions of face-to-face interview, the data was gathered through in-depth semi-structured telephone interviews from March to May, 2020. The characteristics of the nurses occupied in COVID-19 wards were initially obtained by referring to the nursing officials of the hospitals providing care for these patients. Then the participants were selected based on the snowballs theoretical approach. After explaining the objectives of the study and acquiring verbal consent for participation, an appropriate time was agreed for the interview. All the interviews were recorded by an electronic device. The main questions of the study were: “How would you describe a day of caring for hospitalized patients with COVID-19?”, and “What types of care do these patients need?”. Then the interview continued based on the participants’ answers with more detailed questions such as “Would you please explain more about this?”. Of course, the questions differ somewhat based on the position of the participant  and the unit where the nurse was occupied . Using probing questions during the interview, the interviewer guided the process to achieve the study’s objectives.Data analysis was conducted simultaneously with the interviews based on the methods proposed by Lundman and Graneheim . Detail For ensuring of the accuracy and reliability of the data, the criteria of credibility, dependability, transferability, and confirmability were used as proposed by Lincoln and Goba . Detail Detail of ethical consideration mentioned in the another article published of this study .In this study, a total of 20 nurses including 5 men and 15 women with an average age of 31.95 ± 6.64 years and a mean work experience of 7.25 ± 5.9 years were enrolled . The results also showed that the patients were horrified by the sudden death due to the failure of vital organs. Accordingly, one participant stated: “.... there might be nothing notable in the patient’s clinical status, but after a while, he/she would die after a reduction in O2 saturation ...” (p15). Based on the participants’ experiences, one of the reasons for the great fear of death was a restricted burial ceremony for the victims. In this regard, one of the participants said: “... well, I say that the condition is not good because they are not buried now, and they will not be buried on good terms ...” (p14).Data analysis showed that the patients equated being infected with COVID-19 to death and therefore were highly afraid of it. A participant noted that “... the atmosphere was like that the patients really had the perception that they would die of the disease, and there was no returning back ... “ (p14). Another participant mentions: “.... the stigma marked on the patients bothers them....” (p15).According to the data analysis, one of the causes of patients’ anxiety was an impression to have a taboo disease. Data analysis showed that the patients with COVID-19 might perceive the disease as a social stigma and be ashamed of it. One participant described this as “... currently, all people have a bad view on COVID-19 patients....” (p14). Another participant shared the experience as: “ ... for example, we had a COVID-19 patient, a 23-year-old leukemic girl. We gave her hope as much as we could ... to the extent that she could really defeat the virus ... “ (p20).Data analysis showed a feeling of frustration in patients with the COVID-19 disease. One of their basic needs was to give them hope for life and the future. According to the participants, emotional support is one of the main patients’ primary needs. The participants also believed that patients with good mood would successfully recover from the acute phase of the disease. One of the participants, referring to the patients’ needs based on the Maslow pyramid, said: “.... I think the first need of ill patients is oxygen, ...... but those who have better condition need affection, or as Maslow said; the feeling of being belonged … “ (p14). The participants’ experiences also showed that the communication of nurses with these patients could reduce their social isolation problems, anxiety, and stress. As mentioned by one of the participants: “ … they need a strong connection … , in fact, social isolation greatly torments them ... “ (p15).Data analysis showed that COVID-19 patients would experience a difficult time during isolation due to physical problems, loneliness, being separated from the family, and the lack of a definitive treatment for the disease. The participants’ experiences indicated that the patients had been having a hard time because of being abandoned by the family, which would lead to separation anxiety. One participant said: “ … being away from the family is hard for them …” Data analysis showed that the patients needed to receive high quality care services from health staff. Also, data analysis highlighted the patients’ needs for physical support during the disease course. Patients with underlying disorders needed more attention and special equipment. Under this category, there were four sub-categories of physical care, necessity for nutritional therapy, orientation, and isolating of critically ill patients.(p17), and another participant mentioned: “.... they need to be suctioned .... those with catheters need additional care to prevent urinary tract infections .... it is also needed to change their position every two hours ... “ (p20).Data analysis showed that the patients, in terms of the disease severity, needed special attention and support from the health care team. To meet these needs, there are requirements for equipment such as intubation devices, thermometers, medications, etc., as well as health care procedures such as suctioning secretions, catheterization, and other physical care. The participants noted that patients with underlying diseases, who should be taken care of more rigorously, required special attention from the treatment staff. One participant mentioned: “... for example, patients with tracheae have problems in coughing ... they should be suctioned regularly, and on the other hand, their lungs have inadequate function due to the coronavirus ...” (p20), and another participant, referring to patients’ dehydration, said: “.... I see that dehydration agonizes these patients ....” (p15).Data analysis showed that one of the important needs of COVID-19 patients was paying attention to their nutritional needs. The participants’ experiences showed that these patients develop anorexia due to anxiety, stress, dyspnea, and coughing. Considering the nature of the disease, they need to have a proficient immune system and therefore a rich diet and counseling with nutritionists. One participant stated: “... their nutrition is really important and should be rich ...”(p15). Another participant stressed on the importance of familiarizing patients with equipment and its effect on their compliance with the instructions: “.... when I explained to the patient that how the monitor worked, he had a constant eye on it, and whenever his saturation would rise above 90, he would feel calm ... “ (p16).The analysis of the participants’ experiences showed that COVID-19 patients should become familiar with the hospital environment and fully informed of their condition within early hours of arrival to the ward. Since nurses’ protective clothes are unfamiliar to the patients, they must become recognizable by writing nurses’ names or posting their photos. The data showed that familiarizing patients with the hospital environment and simply explaining the function of medical equipment can encourage them to follow therapeutic instructions. The participants noted that fear was a major obstacle to treatment, but patients who were familiarized with the environment and equipment had a good compliance with the instructions. In this regard, one of the participants mentioned: “.... protective clothes surely have an effect on the quality of health care.... most patients don’t even know if I’m a man or a woman ...” (p17).Data analysis showed that being witnessed to the death or aggravating condition of others would cause fear and anxiety and disrupt other patients’ hemodynamic status. The experience of the participants indicated that critically ill patients should be separated from the patients with a moderate-severe disease. One of the participants explained his experience regarding the adverse effects of one patient’s death on others’ spirit: “.... when one of the patients expired, others were frightened thinking that they would be the next... seeing the death of another patient, some patients experienced the fluctuation of blood pressure or a reduction in blood sugar .... “ Data analysis showed that most COVID-19 patients were unaware of the disease’s dimensions and did not follow the principles of disease prevention. This category was divided into two subcategories: “the necessity for improving awareness and fighting superstition” and “institutionalizing a disease-prevention culture”.(p14).Analyzing the data suggested that people have inadequate knowledge about the COVID-19 disease, and in some cases, they have misleading and somehow superstitious beliefs. The participants noted that the patients may delay referring to hospitals due to the lack of awareness and a fear of the disease. One of the participants quoted a patient: “... is it true if one is infected by the virus, they inject a drug to kill him? “ … these superstition beliefs are present among some people ... “(p15).Data analysis indicated that some patients still did not believe in preventive actions and following the disease prevention protocols. In this regard, one of the participants, with respect to patients’ cultural beliefs and the necessity of observing social distancing, said: “ … I have a feeling that our social culture is relatively weak in this area. We go to a patient’s bedside and tell him to put on his mask … this would make him upset .... there should be a culture of self-awareness and self-care ....” Humans are social beings and interested to be in a community and communicate with others. Data analysis showed that in order to provide care for COVID-19 patients, special attention is required with respect to social support so that the patients feel less homesick and lonely during this period. In this category, there were two sub-categories of the provision of familial communications and personal accessories.(p17). Referring to the patients’ reluctance to treatments, one participant said: “... most of our patients whose families did not come were almost disappointed … for example, they would not take their pills and resist treatment .... “(p16).Based on the data analysis, one of the patients’ problems was the lack of familial support. The patients needed to communicate with their families and relatives during isolation and hospitalization. The participants verified that phone or video communications of the patients with their family members created a psychological peace for them and positively affected their recovery process. One of the participants said, “... they need so much psychological support... for example, an old mother felt very well as soon as she saw her son from a distance....” (p16).An analysis on the participants’ experiences revealed that COVID-19 patients would like to use their personal belongings during hospitalization. The nurses noted that providing them with their personal belongings could lead to psychological and mental calm. One of the participants said, “... we had a patient that said she would like to drink tea with her own flask .... while she was very anxious and fastidious and had sleep problems at the nights before … when I brought him the flask, she barely drank a half cup of tea, felt calm, and slept all the night... “(p17).The data analysis showed that one of the patients’ needs was to pay attention to their spiritual needs. The participants’ experiences showed that listening to prayers gave the patients mental peace and a pleasant feeling. Also, the participants recalled that the patients were influenced by verses from the Holy Quran and prayed for themselves and other patients. One of the participants said about the necessity of paying attention to the patients’ spiritual dimension: “.... patients were asking us to pray for them. Sometimes, we were praying together ...” (p15).Data analysis showed that economic problems were among the main concerns of COVID-19 patients. The participants mentioned that some of the patients were constantly thinking of economic issues, and this would create a great deal of stress, affecting the course of their illness. One of the participants said: “ … we had an economically poor patient who was constantly worried about his household and financial issues... what is my family doing now? The income that I was responsible for has actually been cut … all these issues bothered him a lot ... “The current study was conducted to explore nurses’ perception of caring needs of the patients with COVID-19. The data analysis showed that COVID-19 patients were psychologically, physically, socially, economically, and spiritually affected by the disease. Therefore, they should be comprehensively supported by medical staff and other supporting systems.In the present study, the fear of death was reported to be a stressful and annoying factor for the patients. Fear can lead to behavioral disorders and severe psychological reactions including suicide . It has In this study, findings showed that COVID-19 patients were concerned about society’s view on them and feared of being socially rejected. In fact, being rejected by society and the social stigma have been reported among major concerns of patients during epidemics, particularly in the case of COVID-19 pandemic . During The present study showed that frustration was a major problem in COVID-19 patients, and the fact that they needed emotional support as a primary requirement. This finding was consistent with the evidence showing a surge in fear and anxiety during diseases’ outbreaks . Lee et In this study, the findings showed that COVID-19 patients needed to receive high-quality health services. It was found that the patients also had special care needs such as suctioning pulmonary secretions, frequent checking on vital signs, and ventilation. Patients with COVID-19 represent symptoms such as cough, dyspnea, fever, sore throat, and sometimes other nonspecific presentations; nevertheless, only 5% of these patients will require ventilation , 26. In Findings in this study showed that the patients with COVID-19 may develop anorexia nervosa due to the fear and anxiety of the disease. Therefore, there is a critical need for paying attention to the nutritional status of these patients. The importance of this observation has been reiterated in several studies –31. ImprIn line with the findings of the current study, another report showed that anxiety and a feeling of loneliness, as major consequences of COVID-19, relieved after communicating with friends and family members via social media . The finOur findings showed that one of COVID-19 patients’ needs was taking into account their spiritual dimensions. Spiritual care can effectively reduce stress and augment the feelings of wellness and integrity, as well as interpersonal relationships among patients . It seemThe mental entanglement of hospitalized COVID-19 patients with economic issues was another finding of the present study. Reduced financial trades and monetary activities , declineOne of the limitations of this study was that we only focused on nurses’ perspectives; however, the views of patients with COVID-19 could also provide richer information. Therefore, it is suggested to explore COVID-19 patients’ perspectives on the disease. Regarding the urgency of the situation and the fact that the data needed to be collected in the shortest time possible, the performance of validation procedures was compromised. However, the validity of the data was ensured using alternative methods. Another limitation of this study was conducting the interviews via phone calls to reduce the risk of disease transmission for both the interviewee and interviewer. This could have prevented a deep understanding of the phenomenon; nevertheless, the researchers tried to make the phone calls as deep and effective as possible.The aim of this study was to explore nurses’ perception about the care needs of COVID-19 patients. The data showed that these patients were psychologically, physically, socially, economically, and spiritually affected by the disease, highlighting the need for a comprehensive care by medical staff and other supporting systems. Factors such as death anxiety, taboo disease, frustration, and social isolation cause stress and anxiety in the patients, which can be resolved by continuous psychological counseling and providing spiritual care during the disease’s course from the onset of symptoms to a few days after recovery. The COVID-19 patients experience various physical symptoms such as pain, fever, dyspnea, and cardiovascular and nutritional problems, etc. which all need to be addressed by medical teams. The lack of knowledge about the various dimensions of the disease, superstition beliefs, and low compliance with preventive measures indicate an urgent need for improving the public knowledge about the disease. Considering the economic problems and the ensuing global recession, governments along with non-governmental organizations (NGOs) and charities should identify poor and vulnerable patients and endeavor to reduce their problems.


Although approximately 10% of new mothers in Canada develop postpartum depression (PPD), they face many barriers when accessing care. eHealth offers a unique opportunity to provide psychosocial skills and support to new mothers; however, patient populations are not consistently engaged in eHealth development processes. Thus, the diversity of women’s backgrounds and needs are often not reflected in existing tools.This study aims to engage women from a variety of backgrounds and locations around British Columbia (BC) who have previously experienced PPD to determine the unmet psychoeducational needs of women with PPD and how a web-enabled platform used to deliver psychosocial skills and education to assist in the management of PPD could fulfill those needs.Focus groups were conducted in 7 cities across BC with a total of 31 women , with each group ranging from 2-7 participants. Focus groups were cofacilitated by the study coordinator and a local service provider in each community using a semistructured guide to discuss participants’ needs, ideas, and opinions as they relate to the use of technology in PPD management. Transcripts were approached inductively using thematic analysis to identify themes and qualitative description to frame what was observed in the data.A total of 5 themes were identified: bridging gaps to meet needs; providing validation to combat stigma; nurturing capacity to cope, manage, and/or reach wellness; empowering people to take ownership over their mental health; and offering customization to ensure relevance. Each theme identified a need  and a way to address that need using a web-enabled intervention . At the intersection of these themes was the overarching value of promoting agency for women experiencing PPD.Ultimately, new mothers require accessible mental health care that promotes their agency in mental health care decision making. Our participants believed that a web-enabled intervention could help meet this need. These data will be used to guide the design of such an intervention, with the eventual implementation of this resource as a first-line management option for PPD. Diagnostic and Statistical Manual of Mental Disorders as a depressive episode with peripartum onset, including onset during pregnancy and for up to 4 weeks postpartum  I struggled for four years after my second.SUP21, 36, Vancouver, 2 children...so, I only saw (doctor) the one time. [...] Then when I called back and my son was already a year old, they said, “Well, it’s too late.” Like, I guess they only offer help for up to a year.SUP7, 39, Surrey, 2 childrenThey explained how a web-enabled intervention could bridge these gaps:I guess that seems like it might be a nice advantage of an app. Like, you wouldn’t need to be one-year. Under one-year postpartum. You can just access it any time. And benefit from it.SUP28, 31, Burnaby, 1 child, 2 additional children as surrogateEven when eligible for care—for example, less than 1 year postpartum—many participants discussed the barriers they faced in accessing available options, such as the timing of appointments for care and the impact of long wait times to see specialists:...I got referred to the group so often. It’s like, “Yes, you need help. This is the help option,” and I couldn’t access that option. [...] I have friends that volunteered to call in sick so they could look after my son [tearful voice] so I could go, you know? And it’s just that option wasn’t there.SUP25, 42, Victoria, 2 childrenThis was in November, and they weren’t able to give me an appointment until March. So unfortunately, I wasn’t diagnosed until March, like, officially, and that kind of, like, does break my heart and breaks my husband’s heart.SUP12, 37, Burnaby, 1 childA web-enabled intervention was supported as a way to provide care to women who face these barriers, either as a first-line intervention, or as a supplement to in-person care:[...] in my situation here, because resources are scarce [...] especially in northern, rural B.C., it’s hard to access things, so whether that be a counsellor or sometimes even a good internet connection, right? So, I would need a resource to be as self-directed as possible.SUP13, 29, Prince George, 3 children[It] would be great for supplementing and helping a woman before they actually get to see a therapist or start on their medication or something and then would support them through that as well.SUP11, 32, Surrey, 2 childrenabout PPD, including symptoms and potential treatment options. Participants expressed how a lack of knowledge in their friends and family regarding the existence and presentation of PPD could contribute to unmet needs. A web-enabled intervention was endorsed as a way to engage and educate these support people to better assist women by providing information about PPD, ways to help, and how to access care:A pervasive topic across the focus groups was a lack of awareness and understanding regarding PPD. Awareness was defined as knowing of the existence of PPD as a mental health concern, whereas understanding went deeper into knowing Well, I think it’s important for [partners] to be involved. I don’t think that, they don’t understand either. Like, they don’t, I know mine wasn’t. Like, he had no idea.SUP26, 29, Prince George, 1 childOr even signs, too, because I think, a lot of times, they notice that things are going on but don’t necessarily know what to do with that information or what it’s really reflecting, especially if they don’t have any [experience], they’ve never even been exposed to information on postpartum depression.SUP32, 30, Kelowna, 2 childrenAlthough this investigation was focused on the role of a web-enabled intervention in mental health management, most participants expressed the value of its use as a preventive and promotive tool to feel better equipped in what to expect from the postpartum period:I almost wish they made more of a case of it during, like, your pregnancy, you know? Like, “You should anticipate this. This could totally happen to you.”SUP28, 31, Burnaby, 1 child, 2 additional children as surrogateI don’t know if I would have been able to really look at anything while I was in it, but I think beforehand, like if it was available to people that are pregnant, then that might help [...] if I had already been on that app beforehand and, you know, knew what it was all about, then I would have been more open to that.SUP1, 32, Surrey, 1 childUnmet needs, such as a lack of knowledge regarding PPD, were thought to persist because of gaps that exist and are perpetuated by stigma, and participants have underscored how the normalization and validation of postpartum mental health is an effective way to combat stigma:[...] normalization of the experience helps because most of us are sobbing in our homes, you know, thinking that this sucks. And we have nobody to tell, and there’s guilt and shame and all this stuff that comes with it. And it’s actually really common [laughter], um, but [...] it’s supposed to be positive, right?SUP32, 30, Kelowna, 2 childrenParticipants spoke about their experiences with stigma, especially as it relates to notions of being a good mother. They described how it can become internalized and its effects on their mental health. For example, 1 woman expressed:Like, for me, for example because I was feeling so, um, like, um, low, and like so hard on myself, feeling inadequate. You know, like, maybe I should be suffering, so when my husband said, “You should take care of yourself,” it’s like, “No. Like, I deserve to not feel good.”SUP41, 31, Victoria, 1 childValidation of their feelings and experiences was key in addressing this internalized stigma, both through education and normalization of postpartum mental health concerns before they occur and through the sharing of stories from other women who have had PPD to fight feelings of isolation:[...] in the support group, I never felt that. Like, everybody was saying their truth. It was like, “Oh, she is experiencing that. Wow. Okay. I am okay.” There was no repercussion. It was just a safe place to, to feel okay.SUP8, 43, Surrey, 2 childrenExamples of how a web-enabled resource can integrate these features were provided, with 1 participant describing the inclusion of peer and professional encouragement:Yeah, I think just some way of encouraging women whether it be through success stories or a connection with a counsellor, whatever it is, through the app that, um, would just encourage them not to give up and encourage them that it will get better.SUP30, 36, Comox, 1 childAnother participant described what she found useful in the resources she used and how they could be adapted:And seeing that stuff, I don’t know if it was for you guys too, but, like, knowing that it’s not, you’re not crazy. It was just relief to know. I mean, when you read that, you’re like, “Oh my gosh. This is totally what I’m going through.” And it was so relieving, so having stuff on the app like that would be [good].SUP23, 39, Victoria, 1 childIn addition to appreciating validation, participants described how they would want to reciprocate that validation by mobilizing their experiences and knowledge in the interest of demystifying and normalizing PPD, raising public awareness and combatting stigma:Every chance I get to talk about my experience, I do. Like, I posted [...] on Facebook, and I asked everyone to share it. [...] I want someone to feel better, so I think just talking about it is important. Yeah, so you don’t feel like a crazy person, right?SUP26, 29, Prince George, 1 childThey identified that pervasive stigma toward PPD impacted attitudes expressed by family and friends, which was damaging to their mental health:[...] so like, my mom would be like, “This is so weird. I have no idea what’s wrong with you.” Like, she’d actually say that to me. Yeah. She’s like, “I loved my babies instantly. Like, as soon as I saw them, I was, like, in love.” I’m like, “Oh God.”SUP41, 31, Victoria, 1 childThe effects of stigma were woven throughout personal and social interactions and greatly impacted the mental health and help seeking of women experiencing PPD. However, through these experiences, they discovered the power of validation and normalization to combat these attitudes. They also described lessons for nurturing capacity in other women to assist their journey to wellness:I think it would be helpful in terms of normalizing it. Because I think the more resources via app or in person or whichever, helps to normalize it. Yeah, the more information you have, and the more, and right at your fingertips because you can’t always leave the house. Right?SUP30, 36, Comox, 3 childrenThe need for tools to assist in management was clear when participants identified the challenges they faced in coping with and managing their mental health concerns and on their journey to wellness:Yeah, I’d add, like CBT is great, but you have to have so many other things in place before it works. [...] I think a lot of people who don’t have their basic practical needs met, like, “I don’t actually have time to have a break because I have nobody to help me.”SUP10, 30, Vancouver, 1 childI knew that there was something really wrong, so I went, I think, once a week for support group and we did, my doctor tried to get me on meds, too, and I did not want to, so I just went to the support group. We learned meditation. We learned CBT, which was really helpful.SUP8, 43, Surrey, 2 childrenAlso, I, like, had extreme panic attacks about taking the medication. I was so afraid [...] And so I worked with a therapist for probably four sessions before I even took one. [...] within a month, I was like, “Holy shit. I am like a complete, I love my child. I love my life. Wow, the sky is blue.” I was like I can’t believe I was so worried about taking medication that has completely changed my life and made me such a better mother.SUP15, 36, Vancouver, 1 childMany participants described how a web-enabled intervention could be used to nurture their capacity, thus providing the tools and education necessary to facilitate their ability to reach each of these levels of mental health management. Often, these tools were identified as being most helpful before mental health concerns arise, when they could be used as a preventive measure. However, once PPD occurs, many women emphasized the value of connecting them to peers with lived experience and providing evidence-based knowledge to deepen their understanding of PPD and the ability to determine their path to wellness:I think there’s a lot of benefits to having both peers and professionals on it? Because you, you’re gonna trust a professional. They’ll tell you, “Drink 20 cups of water,” and you’re going to be downing the 18th one. As opposed to, like, a peer. A peer is a little bit more approachable, right? And you’re almost...you’re on the battlegrounds with them, so there’s a lot of validity in both.SUP19, 36, Vancouver, 1 childI was obsessed with the question, “Would I ever get better?” and I would ask everybody. [...] I would just plead with everybody, “Does this end?” So, to have success stories built into the app. Might be really helpful.SUP10, 30, Vancouver, 1 child[...] a community hub or a portal where, like, all that information is just. In one place. Because [...] I didn’t like reading about it. But the little bit I did read was from different sources, so if you just had everything in one place.SUP12, 37, Burnaby, 1 childThey also discussed how gaining knowledge from peers and professionals can lead to personal insights and suggested ways of including opportunities for self-reflection to promote these insights within a web-enabled resource:[...] mood tracking and stuff as just a way of, uh, paying attention to it, I think, was the point. Because a lot of the time when you’re depressed, you’re not...really thinking about the specifics of why you feel like you feel.SUP10, 30 Vancouver, 1 childBesides educating themselves, participants endorsed engaging family and friends to assist in nurturing their capacities to cope, manage, and reach wellness:Yeah, I think anyone who might be involved, like someone, if they don’t have a partner or maybe if it’s their roommate or their mom or whoever it is that’s kind of closely tied to them. That could be that support partner.SUP30, 36, Prince George, 3 childrenParticipants explained how having their experiences validated and their capacity nurtured empowered them to trust that they knew what their needs were and how best to meet them. However, they also discussed how having their capacity minimized and their needs dismissed by those they seek support from can leave them feeling disempowered and as though they have no control over their care:[...] when I talked to the person [...] on the help line, um, [...] it was kind of strange, but I, because she almost sounded, made it sound like I was some kind of helpless victim of this thing, you know? But, which to me, didn’t sound like, [...] not very empowering [...] And I told her, “I am not a helpless victim. I know I can’t help the hormones and all of that, but there are things I can do.”SUP43, 44, Prince George, 3 childrenWhen feeling disempowered, participants often reflected on power dynamics within the health care system. Specifically, how their perceived lack of power was a detriment to their mental health and how a web-enabled intervention could promote agency in their pursuit of mental well-being:I didn’t want to do medication, which is what I felt the psychiatrist just kind of pushed. She was very nice about it, but she kind of, I felt like she pushed it too hard.SUP2, 29, Surrey, 2 children[...] did I get help? I don’t think it was helpful. I think that the midwives thought it was helpful.SUP9, 39, Surrey, 2 childrenI find certain questions very intimidating because...what’s going to happen if I say, if I say I am having thoughts of hurting myself or someone else, it doesn’t mean I need to be slammed into a cage.SUP9, 39, Surrey, 2 childrenWhen describing how a web-enabled intervention could bridge these power dynamics, they discussed how it could supplement their relationships with care providers and ensure that they are able to make informed choices as partners in their own care:[...] like, even if it was like, “Hey, if you’re in B.C., like, this is what you need to know in B.C.” Like, step by step by step, “Do this. Do this. Do this.”SUP12, 37, Burnaby, 1 childA common idea across focus groups centered on tracking your mental health using a web-enabled intervention to facilitate care:Then yeah, if you are seeing someone [...] you can take out your app, and you can tell them, “Actually, I’ve noticed that over the last week, I’ve been more anxious. Let’s talk about that” or “I’ve noticed that when I send my son to school, I start feeling like this.”SUP11, 32, Surrey, 2 childrenIn addition, they discussed the importance of their personal insights in determining the best pathway for them to achieve mental well-being. For example, identifying preferences in care options, such as self-care versus specialist care. Many identified self-care as a necessary way to make up for gaps in other care options:[...] the piece that really turned the corner for me was [...] she drew a teapot, and she said [...] “You have all the things going into the tea kettle that are creating the pressure.” So, she listed all of the things that I had talked about, and she said, “You have no outlet to let the pressure out, so and now your brain is exploding, basically.” [...] And so when I feel that buildup of rage, because it usually expresses itself as rage, that’s what I think about like, “My teapot is going to explode. How do I relieve the pressure?” So, I either take the pressure off myself and leave things that are putting pressure on or I go for a walk or I do something else that’s going to help me to calm down. And I know what those things are, so I have my tools in my toolbelt, right?SUP25, 42, Victoria, 2 childrenParticipants expressed how a web-enabled resource could support them in informing, understanding, and realizing their self-care practices:I would like to see something that popped up, like a pop-up that said, “Self-care” [laughter]. Because this is a word I had no idea existed until postpartum.SUP8, 43, Surrey, 2 childrenOverall, participants considered how a web-enabled intervention could assist women by nurturing their capacity and empowering them to reach wellness on their own terms. They also identified how ensuring relevance is integral to these goals.Participants suggested how a customizable interface through which people curate their journey toward mental well-being could offer relevance and make management more effective. Across themes, participants spoke about how current strategies and supports do not reflect their pregnancy and postpartum experiences. Consequently, the need to ensure relevance was highlighted throughout their discussions. Specifically, participants explained how a web-enabled intervention could offer customizable features to tailor resources to meet their needs:I think that’s a really important point for an app because it can’t be one thing for all people. It needs to be, um, personalized to your, you know, what would help you the most.SUP24, 34, Victoria, 2 childrenOn the basis of these customizations, women would then be able to access resources and support on their own terms:[...] just, like, a tiny bite, just a tiny bite because that’s all I could have taken. And then maybe once I’ve taken that bite, there are, like, bigger bites going down. [...] so, like, little, tiny bread crumbs to be like, “Try this” or “Try that” and then, “If you try it and you like it, well here’s a something a little bit different but the same. It might help you differently, better.”SUP31, 32, Kelowna, 2 childrenYes, I think maybe different levels, right? Different levels because sometimes you just need a mom that understands. And then sometimes you need to go to a suicide hotline.SUP1, 32, Surrey, 1 childThey also reflected on their preferences for content delivery strategies and recommended interactive features. These contributions were often informed by their responsibilities and demands  as parents and what would be considered accessible and acceptable:So even if it takes 20 pages, but 20 pages of smaller information because then it’s easier to be like, “Okay. I was on page 5. I’ll continue it later,” rather than getting lost on a whole book [...] but something you can just quickly scroll through while you are breastfeeding, feeding a child, or anything, right?SUP2, 29, Surrey, 2 childrenYou almost have to, like, you almost need to BuzzFeed it [laughter], you know? [...] I’d love to see, like, you know, “Three self-care tips you can do right now.”SUP12, 37, Burnaby, 1 childI think, like, if you don’t want to sit there and read for. Then you can watch the video. You can, like, pick and choose out what you want or what you think relates to you.SUP26, 29, Prince George, 1 childUltimately, participants identified gaps and expressed how a web-enabled intervention could fill their needs for validation, increased capacity, and empowerment by offering relevant content. At the intersection of these 5 themes exists the overarching goal of promoting agency in women experiencing PPD so that they can determine and pursue the most effective and acceptable path to personal mental health and wellness .To actualize the preferences of participants, it was necessary to explore specific recommendations for how their needs could be met through the use of a web-enabled intervention. Explicit examples of this were provided across the focus groups, with participants describing key features related to the emergent themes . Moving Bridging gaps to meet needsPathway to local servicesSelf-directed therapies Availability throughout maternal trajectoryProviding validation to combat stigmaChat forum (with moderators)Peer buddy systemBlog posts to share storiesNurturing capacity to cope, manage, and/or reach wellnessResource hubEvidence-based informationResources for support peopleEmpowering people to take ownership over their mental healthDaily prompts/check-insMental health trackingSelf-care informationResources for holistic careOffering customization to ensure relevanceProfile/baseline assessmentOptions for opting in/out of featuresContent delivery for different learning styles This study aims to determine the unmet needs that persist for women experiencing PPD and to explore how a web-enabled intervention for PPD could assist in meeting those needs. These findings clearly demonstrate that there is a range of unmet needs, including a need for education, validation, empowerment, and accessible care.This reflects the current knowledge base regarding women’s perceived barriers to accessing care and their unmet needs in PPD. As described throughout our themes, these gaps exist on multiple fronts and at multiple levels of mental health management. Stigma is consistently described as a significant barrier to help-seeking behavior -15. As sWoven throughout the themes is a lack of knowledge and understanding of postpartum mental health—another significant barrier to the pursuit of mental well-being -15. ThisOur themes clearly point to the importance of providing a resource that can be tailored to, and addresses, the diversity of needs and complexity of experiences faced by women experiencing PPD. In addition, ensuring that mental health resources are made accessible to women, regardless of factors such as location or income, is crucial.Despite this sample of participants being predominantly well educated and affluent, the majority struggled to access care for PPD. However, financial constraints (which could be linked to income) and a lack of knowledge about PPD (which could be indirectly impacted by education level) are consistently highlighted as barriers to accessing care in the literature -15. The eHealth may provide critical access to information and services through its accessibility and affordability. In 2018, internet connectivity was available to 98% of British Columbians and reached target speeds of 50 Mbps+ in 93% of households in the province, meaning that it is widely available for personal use . AlthougFinally, although out of the scope of this analysis, which pooled all 7 focus groups from across BC into one assessment, the geographic location expectedly played a role in the needs of women experiencing PPD. When discussing a web-enabled intervention, women based in urban areas—especially the Lower Mainland of BC—expressed a need to connect with local in-person resources, whereas women from rural and remote communities, who do not have in-person resources available, required a support that could be used as a stand-alone, first-line resource. Research has shown that women in rural settings have lower rates of PPD detection and treatment, which leads to health disparities in these populations , furtherPatient engagement and acceptability are often overlooked in interventions using eHealth to treat perinatal mental health concerns. All existing interventions in this field rely solely on delivering psychotherapy via technology -30. As ePsychoeducational eHealth interventions provide evidence-based information on a range of health topics and may be used for prevention, education, or treatment purposes . A quickLooking toward web development, the design of this resource will be guided by the needs and preferences expressed by participants, with end user engagement at each phase of research to ensure that the patient’s voice is centered in all decision making. This will include a multidisciplinary advisory committee guiding web development, patient partners involved in discussions of privacy and security, and appropriately representative participant samples in each phase of future research. Our aim is to ensure that end users are able to provide feedback and guidance to co-design a resource that addresses their needs, although compromise may be necessary for the feasibility of some features, especially those with potential privacy and security threats. The next phase of this research will gather qualitative feedback from Indigenous and immigrant women to ensure that the developed web-enabled program is culturally safe and meets the needs of all Canadian women experiencing PPD. Following the integration of the new focus group data into the intervention content, usability testing will be undertaken before the intervention is tested in a randomized controlled trial to ensure its efficacy in reducing depressive symptomatology in women experiencing PPD. Future research should explore women’s experiences of PPD in low- and middle-income countries to determine how this digital health tool could be adapted to provide accessible and affordable care in these settings.This research provided a breadth and depth of insight into the needs of women experiencing PPD that has not been seen before in the literature, specifically as it relates to informing the development of an eHealth intervention. Participants described a multitude of unmet needs that persist because of varying gaps in care and knowledge; however, they also uncovered opportunities to bridge those gaps and meet their needs, in the interests of gaining ownership over their mental health journeys. These findings suggest that a web-enabled intervention is perceived as a welcome addition to supplement currently available resources for PPD and provide concrete recommendations on how it can best serve this purpose. Overall, this study provides an exciting foundation for creating an accessible, acceptable, and effective resource to assist in the treatment of PPD.Despite these findings and the many strengths of the study protocol, gaps remain in the knowledge base that this study was unable to fill. First, based on the difficulty of recruiting for focus groups, we were unable to assess the needs of extremely rural and remote communities, where care options are already scarce. In addition, as this phase of the research included solely non-Indigenous, nonmigrant Canadian women, the sample does not reflect the values and preferences of Canada’s Indigenous and migrant populations. However, this study is part of a larger research project, which will assess the needs of Indigenous women and immigrant women who have experienced PPD, in the interests of representing and understanding the diverse needs of Canadian women.group-think or the conversation becoming biased because of dominant personalities and the need to fit in [In addition, the use of focus groups has some well-established limitations. As focus groups necessitate having multiple participants, ensuring recruitment and attendance can be difficult . This sto fit in . Furthero fit in . Howevero fit in ,70. By i


In recent years, Spanish medical schools (MSs) have incorporated training in communication skills (CS), but how this training is being carried out has not yet been evaluated.To identify the barriers to the introduction and development of CS teaching in Spanish MSs.In a previous study, 34 MSs  were invited to participate in a study that explored the factual aspects of teaching CS in these schools. The person responsible for teaching CS at each school was contacted again for this study and asked to respond to a single open-ended question. Two researchers independently conducted a thematic analysis of the responses.We received responses from 30 MSs . Five main thematic areas were identified, each with different sub-areas: negative attitudes of teachers and academic leaders; organisation, structure and presence of CS training in the curriculum; negative attitudes of students; a lack of trained teachers; and problems linked to teaching methods and necessary educational logistics.The identified barriers and problems indicate that there are areas for improvement in teaching CS in most Spanish MSs. There seems to be a vicious circle based on the dynamic relationship and interdependence of all these problems that should be faced with different strategies and that requires a significant cultural shift as well as decisive institutional support at the local and national levels. The incorporation of CS training into MS curricula represents a major challenge that must be addressed for students to learn CS more effectively and avoid negative attitudes towards learning CS. Research carried out over the last few decades has shown that good clinical communication (CC) has a positive influence on many clinical outcomes and aspects related to the patient and doctor, including physiological results, changes in health behaviour, the clinical relationship, healthcare procedures and the economic impact of healthcare –3. ThereIn 2017, a study was conducted by our group with the participation of 83% (34) of Spanish MSs to explore the current circumstances of CS teaching in Spanish MSs . The stuAs a result, to extend the study, we proposed a new exploration of the current realities of CS training in Spanish MSs, inviting the same academic leaders who participated in the previous study to offer their opinions on the problems and barriers to incorporating and implementing CS training in their own MSs. The aim of this second survey was to analyse the current situation of the CS training examined in the previous study to identify the main problems faced by schools as well as the priority areas for future action to make training more effective.This is a qualitative study that aims to explore the principal problems and barriers to the development of CC training in Spanish medical schools (MSs) based on the opinions of the professors responsible for teaching this domain in the curriculum.http://todofp.es/que-como-y-donde-estudiar/que-estudiar/nuevos-titulos.html). A total of 34 MSs, or 83% of those contacted, replied (28 public and 6 private schools) and provided information on their curricula , characteristics of the faculty and the teaching and assessment methods used in CC training [“What have been (or are) the main barriers to including (in the past) and improving (in the future) student training in doctor-patient communication as part of the undergraduate degree offered by your school?“ There were not any prompts following this single question.In the preliminary study, 41 MSs, which were drawn from the official list of Spanish MSs according to the Ministry of Health in 2017, were invited to participate . Five main thematic categories were identified, each with different subcategories. Table The comments under this category illustrated that the principal barrier is the negative attitudes of academic leaders and university professors who teach traditional subjects and their influence on the way the CS curriculum is incorporated and structured.“The inclusion of CC as an interdisciplinary subject or skill was outlandish and unnecessary, taking time away from real teaching”. (U-5)“Teachers of unrelated subjects or content believe it to be ‘superfluous’, ‘not very serious’, ‘lacking content’, etc.” (U-11)Some respondents who were responsible for the curricula felt that some university professors think that there is no scientific  evidence to support teaching CS:“Many teachers and board members… believe that the important thing in medicine is basic research and medical knowledge in order to get a good result on the MIR exam, so subjects like this distract students from what is important”. (U-21)“It's believed to be a ‘soft science’ by the academic and professional community, who are more interested in technology”. (U-22)Other respondents who were responsible for the curricula thought that academic leaders do not perceive CS to not be useful but to be something that threatens their own teaching statuses:“There are a lot of people in the university, or ‘the establishment’, especially in the pre-clinics, who don't see the relevance of these skills in medicine. There are also clinicians rooted in a medical education model that dates back to the middle of the 19th century”. (U-28)“Because of ignorance and a lack of understanding and consideration by academic leaders, most of whom are heads of departments and/or full-time lecturers, they don't value it and see it as an ‘easy subject’ that takes away teaching time from what is really important for them”. (U-17)Finally, some respondents who were responsible for the curricula believed that many academic leaders think that CS are learned by modelling:“The undergraduate degree administrators don't forcefully or confidently support training in these skills… as they consider it to be something that you learn through imitation”. (U-10)Respondents’ perceptions of the responsibility for CS curricula indicated that academic leaders feel that CS are not very useful:Comments under this category were the most frequent and repeated comments by key respondents; these comments suggest that CS training is primarily included as a legal obligation and is therefore implemented without an adequate teaching plan:“It's (CC is) covered in an ad hoc way as part of another subject, preclinical psychology, where it's taught in a theoretical manner with no practical training alongside other clinical skills that are developed during clinical periods”. (U-16)Incorporated where it is easiest, i.e., together with other secondary subjects:“... it (CC) is crammed in, given no time of its own, with legal medicine, bioethics, …and at different points in time, which makes it difficult to organise. It seems as though there is no other way to incorporate these skills, and so they are crammed in where there are a few credits leftover”. (U-17)Incorporated in a fragmented way with no coherent framework that includes objectives:“...as it's not a ‘respected’ skill by academic leaders, it's only covered in an ad hoc and very limited way as part of smaller subjects, often optional, within different clinical and practical subjects, but with no specific objectives (as though the student would be able acquire them ‘by magic’)...it's a genuinely ‘orphaned skill’”. (U-26)Need to be incorporated into curricula in a structured, transversal way at a supra-departmental level:“An institutional or structural barrier is that curricula do not incorporate the subject in an obvious way. In general, they recognise the need for it but do not explain how it will be carried out and where the necessary credits will come from”. (U-23)Incorporated in an ad hoc, theoretical way during preclinical periods:The respondents identified student attitudes towards CC as a major barrier. They linked these attitudes to a number of different causes.“It's basically covered in second-year psychology when the majority of students are, in my opinion, not mature enough to understand the importance of this topic in their future clinical roles”. (U-13)“The main barrier is that the subject is covered in second-year medicine, at the same time as the Golgi apparatus, cranial nerves and the Starling Law, so for the students, its use is relative, given that it will be at least another two years before they work with patients and can see why it's important to their work as doctors”. (U-28)Negative attitudes towards CS due to biomedical epistemological interpretations:“Many students believe that the education consists of gaining a lot of medical knowledge”. (U-17)“Students tend to want to ‘objectivise’ all the assessment schemes . This makes an overall assessment of communicative skills difficult and entails going through meticulous and debatable evaluations”. (U-11)Negative attitudes towards CS training due to it not being assessed:“Although student attitudes have changed in the last few years... due to (CC) not being a continuous feature of a stable assessment scheme... they don't have enough motivation to study it”. (U-23)Negative attitudes towards CS training due to it not being useful for the MIR exam:“Medical students continue to have a pre-academic profile for the MIR exam that prioritises the absorption of knowledge... so it (CC) has a passive role in clerkships, with no or little feedback or reflection on their communication...they are demotivated” (U-24)Negative attitudes towards CS training because of how it is included and taught in curricula:“By including it (CS training) as something secondary within other subjects, generally pre-clinics, using inadequate teaching method, if any, and with no thought as to how it is assessed, students see it as something that is not very important or related to their own personality” (U-26)Negative attitudes towards CS because of a lack of understanding of why they are useful:“There aren't enough trained associate teachers involved in this subject area to be able to establish proper parameters for communication skills, teaching objectives and teaching methods”. (U-4)“There aren't enough trained teachers to teach it (CC) properly. It is left ‘in the hands’ of the teaching clinicians in charge of clerkships. The psychologists don't generally have trained teachers that know the clinic”. (U-5)The comments in this category referenced the absence of trained teachers in regard to both adequately teaching the content  and adequately planning it in the curriculum:The comments under this category indicated that the teaching method designed specifically for teaching CC poses a significant barrier to CC assessment.“The type of teaching necessary: active learning environments, with simulated patients, video recordings, self-evaluation...” (U-9)“It requires a specific infrastructure for it to be carried out, spaces for simulation, video recording and reproduction systems...” (U-14)Insufficient time:“The main barrier we face in communication workshops is, without a doubt, a lack of time...for students to individually put into practice what they have learned, give subsequent feedback on how to improve any error made in the practice interview with a simulated patient”. (U-19)Structured feedback:“Every student would have to be given personalised feedback while interacting with simulated or real patients”. (U-23)Continuity and commitment of teaching staff:“It's not thought that this type of learning needs to be continually incorporated throughout the degree. It's thought that by merely studying subjects such as psychology, oncology, palliative care or psychiatry, students will learn communication skills...in reality, during clerkships, which is when students are faced with communication problems, they really are alone. In general, there is no feedback given by teaching clinicians”. (U-26)High cost:“This subject would have to receive more investment than others: SP, Gesell chamber...” (U-30)Problems derived from the type of assessment that CS require:“Assessment makes it (CC) a major burden. Exams here are worthless; they (students) should be assessed on what they do, how they really communicate and not what they know” (U-11)“The students have to take an objective test (a simulated exam with a standardised patient) for the skills they've acquired to be assessed...and this is difficult to carry out and expensive”. (U-19)Technical/infrastructure requirements:In this qualitative study, individuals responsible for CS training in their MSs offered their personal opinions on the most significant problems or barriers to incorporating and developing these skills. These key informants agreed on the principal problems: the negative attitudes of teachers and academic leaders, who regard CS as marginal; little investment in educational methodologies and evaluative structures; limited training and promotion on the part of faculty; and the negative attitudes of students towards CS. These barriers have resulted in a teaching approach based on traditional teaching methodologies (lectures and workshops) and assessment strategies (written exams), poor curricular integration, and a theoretical approach that is often detached from clinical practice and taught by non-clinical professors. Although surveys have shown that educational input generally improves CS among trainees , teachinThe general opinions offered and the similarity of the statements by the key informants offer a perspective on the educational context in which the biomedical paradigm is hegemonic, revealing the effect that these barriers and dynamics have on the educational environment. In Fig. To varying degrees, many of the barriers have been identified in recent years. The beliefs that communication is innate, lacking in academic credibility, subjective and unscientific have been identified elsewhere , 30, notAdditionally, the absence of sophisticated  teaching methods and appropriate assessment strategies also represents a barrier, as learning appears to have little impact on students. This barrier is evident both in the lack of training and in the difficulty of and disinterest in investing the required resources. The absence of practical training based on observation and feedback is not, however, exclusive to the Spanish education system –40, nor The study shows that teacher training is key and that a lack of qualified or experienced teachers is a major barrier. In fact, clinicians interested in CS complain that they receive little training and are reluctant to teach and assess skills they themselves have not fully mastered . FurtherThe weight accorded to CS in the Spanish system and the way in which CC is assessed have proven to be counterproductive. In general, Spanish MSs do not always assess CS in a specific way, or they asses CS by using a written exam with multiple choice questions, a list of skills to be completed by the supervisor at the end of the internship or unsuitable checklists. These assessment methods give students the impression that these skills are unimportant or secondary and are not usually well received , 51.Finally, students and young doctors are described as having negative attitudes towards CS and failing to learn CS. While some believe that communication is innate and subjective and cannot be taught , 30, perHowever, despite all of these barriers, particularly the negative attitudes of professors and academic leaders towards CS training, studies have shown that young doctors and students value CS when they are taught experientially using a student-centred approach and when clinical supervisors take a more active role in observing them and offering feedback , 55. YouIndividuals responsible for introducing and developing CS in Spanish MSs identified a set of barriers that make it difficult for students to effectively learn these skills; these barriers represent a set of interrelated problems that largely explain the way in which CS are being introduced and the real priority for them being taught in many of the Spanish MSs. Effectively incorporating CS teaching into MS curricula is a challenge that will require a significant cultural shift and support from all local and national academic and institutional levels as a prerequisite for introducing new educational models that are more in line with new teaching and clinical practice trends.