Therapeutic horseback riding (THR) has a positive effect on the physical, cognitive, and psychosocial functioning of children with disabilities. Parents’ reports of the effects of THR on their children support professionals in individualizing the THR program. With this qualitative study, we aimed to explore parents’ perceptions of changes in the basic life needs of their children with disabilities after six months of THR lessons and to survey parents’ explanations for the causes of these changes. The study involved parents of 13 children with disabilities who were enrolled in a six-month THR program. Parents continuously monitored their children and wrote a report on possible changes in their child’s needs according to Virginia Henderson’s need theory. Qualitative content analysis of parents’ reports indicated only positive changes in 11 children. Most codes were identified in categories “relationships and communication with other people” and “movement and posturing”. Other categories identified codes such as easier breathing, a better quality of sleep, better appetite, better elimination of stool and urine, more independence in clothing and maintaining personal hygiene, and greater interest in play and learning. Parents’ reports are further supported by the assessments of professionals. Most parents think THR is responsible for the noticeable improvements in their children’s quality of life. Therapeutic horseback riding (THR) is a form of mounted equine-assisted therapy that focuses on the physical, cognitive, behavioral, and psychosocial needs of the rider . The useDuring THR, a therapeutic effect is induced on the child  when dirA comprehensive assessment of the effects of THR on children with disabilities must combine a multidisciplinary approach  with the observations of disabled child’s parents. Parents are almost constantly with their child, they know their needs best, and may notice the slightest changes . Thus, pThe previously mentioned studies indicate the effects of THR on children with disabilities through their parents’ perceptions. Unfortunately, the available literature does not yet offer a sufficient number of such studies ,9, whichThus, we expand upon the existing global body of knowledge about THR and contribute to better understanding of how THR affects the basic life needs of children with disabilities. In particular, we sought to address the following research questions: (1) how parents perceive changes in the basic life needs of their children with disabilities after six-month THR lessons and (2) parents’ explanations for the causes of changes that have occurred in their children’s lives.The conceptual framework for this study is based on human basic life needs and has a fundamental source in Need Theory . This thThis six-month qualitative study was conducted in Croatia in 2019 during implementation of a THR lesson plan as a part of European Union (EU) project entitled Developing Socially Beneficial Learning Through Equine-Assisted Therapy (ID UP.04.2.1.02.0186.). Research activities were conducted at the Croatian partner institutions involved in the project (Equestrian Club and Association for Parents of Children with Disabilities from Vukovar). One of the partners was the Faculty of Dental Medicine and Health Osijek, and the task of its nursing BSc students was to implement a modern form of socially useful learning. Teachers of the above-mentioned higher education institution participated in the project and conducted this study.Two weeks before the start of the THR lessons, the instructors conducted training for nursing students on the specifics of THR and working with horses. The training was conducted in four phases: (1) theoretical and practical education of students on specific procedures with horses, (2) teaching students riding skills, (3) educating students on the natural bioenergy of manure, and (4) developing a socially beneficial learning plan through THR activities. Nursing students and teachers spent a week before THR sessions educating parents about the 14 components of basic life needs according to Henderson.Over six months, each child participated in a THR lesson once per week . Each lesson lasted for 25 min with two students, a THR instructor, and a minimum of one parent working with the child riding a horse. Depending on the type and severity of the child’s disorder, the appropriate horse was selected for each individual child. According to the individual program, during THR sessions the children performed leaning forward exercises to touch the horse’s neck, leaning back to touch his rump, and twisting left and right on the horseback while the horse was in a slow, steady walk . NursingThe study involved parents of 13 children with disabilities, aged 4 to 14 . All parFive families were not included in the study because three of them did not want to participate in the study, and two children did not regularly attend THR lessons.During the six months of THR, parents observed their child’s basic life needs and recorded noticeable changes on paper forms provided by the researcher. Due to the anonymity of the participants, the forms included an encrypted ID code (a combination of letters and numbers). Following Bengtsson , non-sugParents were asked to write their reports honestly, with a detailed description of every change in their child’s basic life needs, without restrictions on the amount of written text. Parents were further advised to base their reports on facts consistent with Henderson’s 14 components . The parThe triangulation method was applied to eliminate biases . To miniIn this qualitative study, a deductive approach was employed using content analysis ,26. ContAll participants were informed of the purpose and other details of the study. Children were presented with information tailored according to their age, intellectual, and cognitive characteristics. Participation in the study was voluntary and the participants had the right to withdraw from the study without any consequences. Parents voluntarily signed the informed consent for their own and their child’s participation in the study. The anonymity of the participants was guaranteed, and there was no possibility to determine their identity from the responses. To ensure confidentiality, participants received an encrypted code. Only researchers had access to research data. The study was conducted in accordance with the Declaration of Helsinki, and approved by the Committee of the Faculty of Dental Medicine and Health Osijek (04-2-1-02-0186).The deductively formed categorization matrix included 16 categories (CAT) within two generic categories: (1) parental perception of changes in their child’s basic life needs and (2) parental perception of factors that caused changes in their child’s basic life needs. The final organization of data defined a total of 40 codes within 13 CATs .Qualitative analysis of parents’ reports indicated that parents of 11 children recorded only positive changes in their children’s basic life needs, whereas parents of two children (C10 and C13) did not record any changes . FurtherThe results of the analysis of the parents’ reports are provided below according to the number of identified codes in each CAT.“Our child is content, happier, and laughs more. On every occasion, he is very pleased to meet the horse and THR instructors” (P9) and “Meeting new people is no longer a problem for our child. The child communicates with other people more often and with better quality. He used to say only 3 to 5 words, and now he pronounces up to 10 words in continuity” (P11).Most (seven) codes were identified in CAT “relationships and child’s communication with other people ”. For example, according to parents’ reports, a better mood following THR lessons was observed in ten children, a higher level of calmness and patience in five children, and more frequent communication with other people in four of them. For example, the parents affirmed:“Our child has better movement control. He takes items more firmly and securely. For example, he no longer drops a pen or a glass so often” (P6).A total of five codes are associated with the “movement and posturing” CAT. Parents of eight children reported improved mobility of their wrist and leg joints after THR lessons, and four children had better movement coordination and more autonomy in moving, e.g.,“When we are walking, the child runs and jumps much more and gets less tired than before” (P4).In two cases, parents reported better resilience in their child:“My husband and I no longer have the usual long-lasting evening rituals of putting our child to sleep. Our child has a much peaceful sleep and does not wake up often during the night” (P3).Four codes are identified in two CATs: “rest and sleep” and “elimination of body wastes”. Parents have reported easier bedtime and more peaceful sleep in four children, e.g.,“For the past few years, our child has had constipation problems. She defecated every fourth to fifth day, with intense strain and frequent abdominal pain. The stool was often of very hard consistency. Now she defecates every other day, without accompanying pain” (P12);“The irregular stool in our child now belongs to the past, although the child still uses medications that cause constipation as a side effect. This change in our child is precious” (P3); and “During the day, our child announces the urge to go to the toilet, so we use the usual absorbent products only during the night” (P6).In four children, parents reported more frequent and copious stool, and one child had better control of urinary output, e.g.,“Ever since our child has been included in THR activities, he has a much better appetite and drinks twice as much fluid than before” (P5) and “The child now consumes 3–4 meals a day. Previously, he rejected food and ate twice a day at most” (P1).The three codes are identified in three CATs: “food and fluid intake”, “breathing”, “play and recreation”. In six children, parents reported better appetite and more fluid intake, and in two children consuming more diverse kinds of food, e.g.,“At night, the child no longer suffers from episodes of rapid breathing and sleeps much calmer” (P2).According to parents’ reports, two children found it easier to breathe during the day, without rapid breathing at rest, whereas in one child, parents reported that he breaths more peacefully in his sleep:“Going out in nature and playing with friends became important to our child. Previously, he had separation anxieties and avoided the company of other kids” (P7).In five children, parents reported their greater interest in playing with others, and two children became more interested in spending time in nature, e.g.,“Finally! The child is separated from his cell-phone and goes to the park with his friends” (P5).Parents also said that two children reduced cell-phone use for entertainment purposes:“Our child always had a problem with washing his hands, but now, without us reminding him, the child washes hands all on his own” (P9).Two codes are identified in two CATs: “maintaining personal hygiene” and “learning and curiosity satisfaction”. For example, parents reported more frequent hygiene practices in four children, e.g.,“Our child will have learning difficulties for their lifetime, but we recognized a greater desire for reading content about animals” (P2).In three children, parents reported more interest in learning and easier understanding of school material, e.g.,“It is amazing that the child now puts both socks on independently, which was very problematic earlier” (P6);“The child always asks for protective equipment before horseback riding. Sometimes she asks for a headgear already in the car, on the way to the Equestrian Club” (P8).One code is identified in two CATs: “clothing” and “safety”. In the case of two children, parents identified more independence in dressing as well as desire for wearing protective gear before horseback riding, e.g.,In three deductively formed CATs , no changes were noticed by the parents.An analysis of the assessments submitted by professionals indicates the specific progress in children with disabilities in all six observed areas, which further supports conclusions drawn from parents’ reports .“There are obvious positive changes, but I think they are a result of several influencing factors, not just THR, for example, the impact of child’s development and the medication he uses daily” (P1);“Simultaneously, our child attends neurofeedback and other forms of therapy, and we also work with the child every day. I do not believe that THR was crucial, but the improvements are a fact” (P4).In parental reports, there are noticeable differences in perception of the factors that have caused positive changes in their children. In case of three children, the parents described positive changes but felt that THR was not the only contributing factor . Additio“I think my child’s contact with the horse is a key factor in all the improvements. This is indisputable. We had previously and unsuccessfully tried with various other therapies and failed. THR has improved our child’s quality of life” (P3).In contrast, parents of eight children emphasize the direct connection between THR lessons and positive changes in their children. They identified the child’s contact with the horse’s body, the movements of the horse, and the child’s contact with different people, sounds and sensory stimuli during THR activity as essential (CAT “positive changes due to therapeutic horseback riding”), , e.g.,“According to research questions, our aims were (1) to describe parental perceptions of changes in the basic life needs of their children with disabilities after THR lessons and (2) to analyze parental explanations of the factors that caused noticeable changes in their children.According to parents’ reports, only positive changes in the basic life needs were observed in as many as 11 children after THR lessons, whereas parents of two children did not record any changes.The most improvements were reported in CAT “child’s relationships and communication with other people ”, which is fully supported by the results of other international studies ,11,12,30Eight children involved in our study experienced improvements in CAT “movement and posturing”. Positive changes included better posture, balance, mobility of the limb joints, and coordination of movements, and more independence and confidence while walking, as well as better physical fitness, which is in accordance with the results in other studies ,33,34. FFour parents reported that their children fell asleep more easily after THR, and slept longer and more peacefully (CAT “rest and sleep”). Children with disabilities often have trouble sleeping ,37,38; hThe results of this study showed that four children experienced significant improvements in CAT “elimination of body wastes” after THR. According to parents’ reports, children defecated more often, they had a more copious stool, and announced their urge to go to the toilet. One child had better control of his urine output and went to the toilet on his own. Unfortunately, problems with constipation and painful defecation are common in children with disabilities  as well According to parents’ reports, six children involved in this study had a better appetite after THR and consumed more fluid (CAT “food and fluid intake”). Children with disabilities, due to frequent disorders of sensory experiences , or symptoms such as loss of appetite, have problems with food and fluid intake . In thisThe parents of two children in this study reported that their children were able to breathe more peacefully during the day and night due to THR and regular therapy, without the usual episodes of rapid breathing (CAT “breathing: respiratory and circulatory status”). THR is known to positively influence breathing and circulation stimuli in children with disabilities . BreathiAccording to parents’ reports, five children showed more interest in playing with others after THR and two children reduced their use of a cell-phone for entertainment purposes (CAT “play and recreation”). The observed increase of social integration corresponds with the findings of other similar studies ,9,10,16.Four children involved in this study implemented hygiene practices more often and with increased independence after THR . A literature search showed no available relevant study describing similar benefits of THR, although problems with hygiene practices in children with disabilities are no exception . For exaParents of three children with learning disabilities reported their increased interest in learning after THR and their easier understanding of school material (CAT “learning and satisfaction of curiosity”). This result supports Stickney , who conIn two children lacking normal physiological development, parents reported higher levels of independence in dressing themselves (CAT “clothing”), fully supporting the study in which parents of children with ASD reported their improved motor control, flexibility, and arm coordination, especially when they were dressing themselves .In the case of two children, parents noted their readiness to use protective gear before horseback riding (CAT “safety”). THR is known to stimulate the development of a child’s own body and ego awareness, empowering children to take risks, increasing their self-discipline and emotional control . So, thiParents of two children  involved in our study did not record any changes, which is a result supported by other studies ,22,33,43The parents involved in the present study largely considered THR to be a major factor producing positive changes in their child’s basic life needs. However, parents of three children stated that the improvements are, rather, a result of a combination of THR and the effect of specific therapies , as well as child’s normal psychomotor development . These results are fully supported by Boyd and le Roux’s  study inEight children’s parents were convinced that THR was responsible for all the improvements noticeable in their children. As key factors, they indicated direct contact of the child with the horse’s body and its movements, interaction of the child with different people, and exposure to different sounds and sensory stimuli during THR lessons (CAT “positive changes due to therapeutic horseback riding”). These results are supported by studies that confirmed the therapeutic effect of synchronized horse movements ,9, horseIn this six-month study, participants included only parents whose children with disabilities were involved in a regional THR program. Therefore, the sample is not large enough to generalize the results to all the children with disabilities involved in THR programs throughout the Republic of Croatia. In the future, a study of more than six months duration should be planned and, if possible, more respondents from more than one region in Croatia should be included. Furthermore, future research could include differentiation of various possible factors such as diagnostic groups of children with disabilities, age and other factors. Furthermore, it would be useful to apply a combined research approach and, with quantitative confirmation of the outcomes, contribute to a higher level of objectivity to better understand the specific effects of THR on children with disabilities. Furthermore, future research of parental perceptions should be based on holistic and individualized assessments of children with disabilities in terms of their basic life needs and their independence in performing daily life activities.The results of this study indicate the usefulness and applicability of Henderson’s human needs model in working with children with disabilities. The model can be used by parents and professionals for the purpose of ongoing observation and evaluation of the condition and possible changes in the basic life needs of children with disabilities undergoing THR and other forms of therapy. Furthermore, Henderson’s model can be of significant help in the design and revision of individualized THR programs and part of common practice when working with children with disabilities. This study further justifies the usefulness of THR in the prevention and treatment of various symptoms and side-effects in children with disabilities . Preventing and alleviating these symptoms and side-effects can advance the treatment and rehabilitation process and significantly improve the quality of life of children with disabilities.In this study, we described parental perceptions of the effects of six-month THR sessions on the basic life needs of children with disabilities from the perspective of Henderson’s need theory. The results indicated that parents report only positive changes in basic life needs and an increased level of independence in 11 children with disabilities. These results were largely supported by the assessments by professionals involved in the diagnostic/therapeutic work with children. Most parents stated that THR was responsible for all the physical, psychosocial, and cognitive benefits noticeable in their children. Furthermore, according to parents, all of the above ultimately leads to a generally improved their children’s quality of life. The results are supported by relevant literature. To the best our knowledge, this is the first qualitative study to describe parental perceptions of the effects of THR on children with disabilities applying Virginia Henderson’s need theory. We also described the specific impact of THR on, for example, children’s sleep and rest, personal hygiene maintenance, and elimination of stool and urine, which has not yet been explored in detail in previous studies describing parental perceptions of the impact of THR on children with disabilities. Therefore, we expand upon the existing global scope of knowledge about THR and contribute to better understanding of how THR affects the basic life needs of children with disabilities. Ultimately, the findings can help parents of children with disabilities enrolled in THR programs, therapists, and THR instructors in planning and implementing a holistic approach for assessing and satisfying the basic life needs of children with disabilities, from the aspect of Henderson’s need theory.


We investigated the effect of such admission diagnoses on delivery of patient care in a cohort of older adults admitted to a tertiary care teaching hospital.n = 60, median age 80 years). Age-matched controls met the same inclusion criteria with admission diagnoses other than those of interest .Retrospective matched cohort study conducted at a tertiary care hospital in Vancouver, BC. Cases identified were adults aged ≥65 years admitted to acute medical wards with an admission diagnosis of “failure to thrive”, “FTT”, “failure to cope”, or “FTC”, between January 1, 2016 and November 1, 2017 . Concordance of admission and discharge diagnoses was only 12% for the “failure to thrive” cohort, and 95% for controls. Notably, 88% of the “failure to thrive” cohort had an acute medical diagnosis at the time of discharge. Patients in this cohort stayed 18.3 days in hospital compared to 10.2 days (p = .001).The total time from triage to admission for older adults admitted with FTT and associated diagnoses was 10 h 40 min, compared to 6 h 58 min for controls (Patients with an admission diagnosis of FTT or other associated diagnoses had significant delays in care when presenting to the emergency room, despite often having acute medical conditions on presentation. The use of this non-specific label can lead to premature diagnostic closure and should be avoided in clinical practice. This term was adopted from pediatrics in the 1970’s, and over the years, has come to represent a syndrome of vague symptoms among older adults that includes unexplained loss of appetite, weight loss, cognitive and functional decline, and social isolation, complicated by multiple medical comorbidities and psychiatric factors . DespiteThe prevalence of FTT and related terms has not been quantified, however there has been a general trend of an increasing number of older adults presenting to healthcare, as their prevalence increases in the general population –7. ConcuStudies have also suggested that labels are powerful in the healthcare setting and may alter how patients are perceived , 11. An To date, there have been no studies looking at potential harms that may occur when patients are admitted with a diagnosis of FTT and associated labels. The main objective of our study is to investigate the effect of such labeling on the admission process through the ED as a proxy for measuring delivery of care. We also sought to determine the concordance of the FTT admission diagnosis with the diagnosis at the time of discharge to determine if this label was maintained throughout the hospital admission. We hypothesized that this diagnostic label would be associated with delays in care and that many patients admitted with the FTT label would be later found to have acute medical diagnoses.Identified cases for the study were older adults aged ≥65 years who were admitted with diagnoses of failure to thrive, FTT, failure to cope, or FTC, between January 1, 2016- November 1, 2017 to medical wards under general internists or family physicians. Medical trainees  worked on both services. The same inclusion criteria applied to randomly generated control cases, but who had admission diagnoses other than those of interest  prior to initiating data collection. Individual participant consent was deemed unnecessary for this minimal risk research study, according to Canadian regulations as laid out in Article 3.7 of the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (TCPS2).Patient charts were accessed via the hospital’s electronic medical record system. Basic demographic data collected included date of birth, age, and gender, as well as admission and discharge diagnoses and in-hospital mortality. Elements on past medical history included in the Charlson Comorbidity Index were also collected. Time at triage, time of referral to the admitting service and time of departure from the emergency room had timestamps that were electronically logged. Times of assessment by the emergency room physician and admission service resident were found on the emergency room discharge summary or the consultation sheet.Since vital signs and other objective clinical findings at triage were not reliably or consistently recorded, investigations ordered and interventions performed in the ED were used as markers of patient acuity. These included basic bloodwork , intravenous antibiotics, blood cultures, chest x-ray, and computed tomography (CT) scans. Lastly, involvement of specialized geriatric care  was noted.While it is recognized that data pertaining to patients’ social situation , function  and other markers of frailty , such information was rarely documented and therefore not included.p < .05.We calculated averages and medians for discrete variables and applied Student’s T-test to look for statistical significance, using a cutoff of A total of 120 patients were included in the study, half of whom had an admission diagnosis of FTT and the other half who had admission diagnosis other than FTT who were age-matched to the FTT sample. There were no significant differences in demographics or presence of comorbid conditions between the groups. These results are summarized in Table p = .001).In our cohort, patients admitted with FTT spent significantly more time in the ED, mainly from delays to physician assessment by both the emergency physician and the admitting service Table . It was n = 7) had FTT as a discharge diagnosis and the remaining 88% (n = 53) had acute medical diagnoses. In contrast, 95% (n = 57) of the control group had concordant discharge and admission diagnoses. Of the 5% (n = 3) in the control group who were discharged with other issues, 2 were “multifactorial falls”, and 1 was FTT). These are summarized in Table In addition to delays in the admissions process and prolonged stay in the ED, there were significant discrepancies between admission and discharge diagnoses in the FTT group. Diagnoses were categorized as acute , chronic  and mixed (both acute and chronic conditions listed). In this cohort, 12% , or administration of antibiotics Table . Interesn = 6) for the FTT group compared to 8% (n = 5) for the controls. 38% (n = 23) of patients with FTT had Geriatrics involvement, compared to 8% (n = 5) for the controls. Geriatrics involvement was not associated with longer length of stay.In-hospital mortality was not significantly different between the two groups, at 10% (Several studies have shown that the term FTT is often applied to older adults in the acute medical setting with the implication that there is a social, rather than medical, reason for presentation to hospital , 13. HowThe medical acuity of this cohort of older adults is evidenced by two main findings. Firstly, of those admitted with FTT, 88% had acute medical diagnoses at time of discharge. Interestingly, this observation has been noted in an older study that found the related term “acopia” was recorded as a discharge diagnosis in only 12% of their cohort of 109 patients admitted with that label . AnotherA second factor that points to medical acuity is that this cohort received a number of investigations and interventions in the ED including blood work, imaging and intravenous antibiotics. There was also no statistical difference between the frequency and timing of investigations and use of IV antibiotics between the FTT group and the controls Table . That obOur cohort of patients labeled FTT is medically acute, yet they experienced delays throughout their trajectory in the ED. Previous studies have shown that older adults with similar labels are medically active, yet these studies did not include objective measurements of delays in care, such as length of time to physician assessment, admission, and length of stay in the ED. , 12, 14Previous studies have identified several factors that may pose challenges in the management of older adults in the ED. These include the presence of atypical presentations, polypharmacy, multimorbidity, and barriers in communication stemming from sensory impairment, baseline cognitive impairment, and/or superimposed, evolving delirium , 15. TheWith awareness of these factors unique to older adults, Acute Care of the Elderly units have become more abundant, yet few models exist to address the need for similar care models in the ED. One conceptual model proposed includes a frailty assessment at time of presentation, assignment of case managers to frail older adults, and creation of an intermediate care area to transition those patients out of the ED.  While suThe term FTT suggests an inherent “failure” on the part of the patient and is unfortunately often perceived as a part of normal aging. The term perpetuates the stereotype of older adults as “demented and decrepit”, and being more prone to “aches and pains”, “mental slowness” and “worrying more” , 19. As Older adults labeled as FTT are medically acute and therefore require urgent care. Our study suggests that there may be an association between this term and delays in care, which supports conclusions from previous studies that the use of the label may “hinder the urgent search for treatable, reversible causes of deterioration” . TherefoWhile this study captured a relatively sizeable cohort of FTT patients compared to other studies on this topic, it was performed at a single, urban academic institution, which may limit generalizability. We also acknowledge that our findings may only pertain to medicine patients, as no surgical patients were included in our study population. Due to the case-control design of our study, we also recognize that our results represent an association between FTT and delays in care and not causation.We were not able to determine which health care practitioners initially assigned this label, due in part to lack of written communication between emergency room physicians and admitting services. Even with documentation, there was a noted lack of explanation as to why this term was used. As such, the timing of when this diagnosis was applied is uncertain, and qualitative studies are underway to better ascertain when and where the term first originates. We have also used the Charlson Comorbidity Index as a way of accounting for differences in medical complexity between the control and FTT cohorts but would have preferred to calculate frailty scores should that information have been available to us on the electronic medical record. Valuable information such as functional, nutritional, and cognitive status, medications, or comprehensive geriatric assessments were not reliably available in all patient charts, so these components were not included in the study. Subsequent follow-up after discharge from hospital, such as re-admission or mortality, were unfortunately not included in the study due to the limitations of a chart review design.This study has formed the basis for a qualitative study in which health care practitioners will be interviewed to explore why the term FTT is used in our health care system. It is anticipated that the information obtained during this qualitative study will inform education and interventions to reduce the use of this label for older adults presenting to acute care.Although previous studies have shown that older adults with diagnosis of FTT are admitted for acute illnesses rather than social factors, this is the first study to show an association between an admission diagnosis of FTT and delays in care. The use of this term provides little clinically useful information, and may ultimately pose harm to older adults by delaying diagnosis and delivery of appropriate care. As such, it is our opinion that the use of FTT and associated terms should no longer be used in clinical practice.


To explore the experiences and perceived impact on health and well-being related to participation in a dance group for people with chronic respiratory disease (CRD).An exploratory qualitative study using thematic analysis of semistructured interviews.A community dance group in a UK health centre.Convenience sample of long-term dance group participants.Weekly community dance sessions designed for people with breathlessness, lasting 75 min, led by a trained community dance leader.Convenience sample of eight participants, six females, aged 57–87 years (mean 75), with a median 2-year attendance at weekly dance sessions. Long-term attendance was driven by strongly held beliefs regarding the health and well-being benefits of participation. Four key themes were identified: dance as (1) a holistically beneficial activity, with physical and psychosocial health benefits including improved or maintained physical fitness and psychological well-being, and reduced need for healthcare; (2) an integral part of their life; (3) an enjoyable activity; and (4) a source of deep social cohesion.Dance group participants perceived a broad range of health benefits of relevance to the biopsychosocial impacts of their respiratory disease. The themes identified are useful in the ongoing planning and evaluation of dance as a holistic complex intervention for people with CRD. Further research is required to assess the extent of health impacts identified, and how dance might be most effectively placed as an option in the management of CRD.NCT04006015. The first study of long-term real-world participants of a community dance group for people with chronic respiratory disease and breathlessness.In-depth exploration of participant experience.The sample was from a single group which may limit transferability.Semistructured interviews facilitated a depth of understanding of clinically relevant topics, aiding the potential application of findings.Chronic respiratory diseases (CRD) are a leading cause of global morbidity and mortality,24 25Dance has been shown to be beneficial in healthy people and individuals with a range of medical conditions. Impacts include improved physical performance, function, mood and social engagement, which are all highly relevant for people with CRD.The objective of this study was to explore the experiences and perceived health and well-being impacts of participation in a community-based dance group for people with CRD—‘Dance Easy’.KEJP is a male, 33-year-old respiratory physician who previously worked as a dancer and dance teacher, with experience leading community dance and dance for people with respiratory disease. KEJP has received training in qualitative research methods from the Imperial College, University College London, and through self-directed learning. He is currently completing a PhD at Imperial College, using both qualitative and quantitative methods. Qualifications: MBChB, BSc, MRCP, EADTMH, DPMSA.KEJP and AL are recreational dancers and previous dance experiences enabled discussions throughout the analysis to be explored fully and assumptions challenged within the researchers’ assumptions of what dance is.We performed an exploratory qualitative study using thematic analysis within a critical realist paradigm, to explore the perceptions of participants of a community dance group for people with CRD. The primary focus was their views on the impact of participation on their health and well-being.We used semistructured interviews  in the study. Eligibility criteria included a clinical diagnosis of CRD, age >18 years and able to consent. All participants received participant information sheets and provided signed informed consent.The group started in May 2017, with seven of the study participants present from the first few months. The group meets weekly in a community centre attached to a health centre in London. Participants usually meet in the café from 30 min before the session. The sessions are free for participants, the leader volunteers her time for free and the space is provided by Whittington Health. The original participants were attendees at a ‘Breathe Easy’ support group for people with respiratory conditions, additional members became aware of the dance group through word of mouth.https://www.nqa.org/what-is-qigong- for more information on qigong), progressively complex group dance routines, warm-down, stretching and relaxation. The session leader (SW) is a trained community dance group leader with extensive experience working with people with CRD. Music is played throughout the sessions and includes an eclectic mix of genres, selected by the session leader and participants, to inspire dancing at an energy level to suit the group. Each track corresponds to a specific movement routine. Dances are selected from a repertoire, with new dances added gradually. Though led by SW, participants contribute their opinions, movements and artistic expressions.Sessions last approximately 75 min and include a warm-up, including qigong movements . Reflections and impressions were documented immediately following the interviews, with memo writing continuing throughout the analytical process. Interviews were conducted privately in the room where the dance takes place, or the café, depending on participant preference. Interviews, recorded by dictaphone, lasted 24–43 min, and consisted of open-ended questions, semistructured around the following topics:Experience of respiratory illness and impact on life.Experience of dance group.Perceived impacts of dance group participation.et al.Interviews were transcribed verbatim by KEJP. KEJP and AL conducted thematic analysis based on the process outlined by Braun and ClarkeDemographic and disease-specific information was sought. Breathlessness scores were used to indicate severity, rather than lung function measures as breathlessness relates more closely to patient-related outcomes including mortality and functional impairment.Patients and the public were not involved in the design of the study; however, the study specifically focuses on patient/participant perceptions.Eight regular dance group participants were recruited, representing the group at that time, including six women and two men, aged 57–87 years (mean 75). All reported CRD, primary diagnoses were reported as chronic obstructive pulmonary disease (COPD) (×5), asthma ×2), bronchiectasis (×1); however, multimorbidity was common including arthritis, diabetes, sarcoidosis, visual impairment and haemochromotosis. Four participants had a Medical Research Council breathlessness score of 2, one had a score of 3, three had a score of 1. None used supplementary oxygen. Participants lived in houses, bronchipsychologically the illness has not taken over’ (participant 5). They perceived sedentarism as highly negative, often stating the only choice being to ‘get on with it’ (participant 2). This determination and commitment was driven by the identified themes, which were dance as (1) a holistically beneficial activity; (2) an important part of their lives; (3) an enjoyable activity; and (4) a source of deep social cohesion. Themes 3 and 4 were drivers of themes 1 and 2, but also stood alone so were not considered subthemes , so that ‘emes see .Participants viewed the sessions as a combined exercise, dance and social activity. They described physical, psychological and social benefits, which were synergistic and largely inseparable from one another.It’s a bit of everything, afternoon social activity, because everyone has tea when they finish, or pub. It’s a bit of exercise, a bit of, entertainment, it’s a bit of, overall, learning. (Participant 6)I feel like it’s been a great benefit for me. It has impacted on me’(participant 3). Impacts were described as improvements ‘you’re able to do things now’ (participant 3), or physical and cognitive maintenance in the context of ageing:Participation was perceived as beneficial for overall health status—‘…keeping one’s body and one’s mind active is very important. And that is really the be all of the end all [most important thing]. That’s the object of the exercise. (Participant 2)It helps you maintain a standard as it were, of operation in the world I suppose. (Participant 2)AndAlso when the music comes on, you, about three beats and you’re like, ‘oh’, so I like that because you’re like, it’s about maintaining that brain, that grey brain matter, yeah. And basically keeping you active. (Participant 6)until I was doing the exercise it was bad’ (participant 7), and ‘I think my breathing is better’ (participant 1). And implications for physical function ‘mobility, I think, it’s one of the things that I have found so much better. Because when I joined there were lots of things I found really difficult’ (participant 1).Perceived physical benefits included impacts on the disease and symptoms ‘Perceived mood and cognition benefits were also noted. For example, improvements in confidence,You feel you can do more things. So, if there’s an offer coming up for an outing to a garden all day, I know that I’m going to go. (Participant 4)AndPsychologically the illness has not taken over… because you’re occupying your mind on something completely different, so you can’t say ‘oh I can’t do that, I can’t breathe’, I can have a go. That’s what life’s all about at the end of the day. (Participant 5)I haven’t had a bad bronchitis episode since I’ve been doing it’ (participant 1), and ‘you’re not so prone to picking up all these chest infections’ (participant 3).Impacts on mood were driven by enjoying participation (theme 3) and a sense of the group’s deep social cohesion (theme 4), see It’s just part of my life now’ (participant 3). For some participants dance had been important throughout their lives , while for others, dance only gained importance since joining the group ‘I was your typical wallflower …. I never really got into dancing at all. Till now’ (participant 3).Dance was perceived as an important part of their lives, ‘I wouldn’t call myself twinkle toes [a good dancer]’ (participant 3) and ‘I can’t dance for toffee [I can’t dance well], and I can’t sing, but hey (laughs) who cares’ (participant 1). However, perceptions regarding dance ability influenced how participants described what they do during the sessions. For example, some participants commented that they were not really dancing as they felt that a certain skill level was required for their individual definition of dance, instead describing the sessions as ‘movement to music’ (participant 2). Nevertheless, learning to dance was frequently stated as a component of the sessions, hence differing definitions of dance likely represented differing life experiences of dance, rather than differing views on what they gained from participation in the group.In general, the importance of dance participation was not related to their perceived ability or previous experience—‘I’m learning something new and it’s also, you come in and learn a dance that six weeks ago you never thought you’d get your feet around [never thought you could learn the dance steps]. (Participant 6)This satisfaction related to a sense of mastery was also important. Observation data also noted participants improved over the sessions, particularly completing routines with fewer errors, with a clear sense of achievement-related satisfaction, perhaps as a contrast to a background of decline in other aspects of their functioning. Structured observations also noted that participants were often quite elegantly dressed, which may not be expected in activities seen as purely exercise.All participants greatly enjoyed the sessions, consistently describing it as fun, which was a main driver of attendance. This was repeatedly emphasised as being of major importance, and something participants felt was not appreciated or considered in other therapeutic exercise they had attended. In this sense, dancing was viewed as an end in itself, rather than the means to an end, as was the case for gym-based exercise training. Multiple factors contributed to their enjoyment including a light-hearted and non-judgemental atmosphere, in which participants felt active contributors rather than passive recipients of care.There is this immense feeling of contentment, and it’s great. You know, when you’ve made an effort, you’ve done it, and jolly good. And that’s it. (Participant 2)The atmosphere in the sessions was very relaxed. The element of humour was highlighted in structured observations, with regular group laughter noted, with a very inclusive quality.…before you know it, we’re all in stiches [all laughing]. You know it’s something, you know. Its promoted in the group. You can feel it. You get the buzz. You have a good laugh and, apart from doing your dancing you’re having fun, even with the dancing you’re having fun. (Participant 3)Not feeling intimidated or judged was key to the enjoyment and contrasted with other exercise modalities and settings.I won’t go to the gym where there’s a lot of younger people than myself. Because they can be intimidating. So, I won’t do nothing like that. (Participant 5)I love everyone I’m with’, ‘we’re like a small knit family ’ (participant 6), and greatly valued their relationships with other individuals and the group as a whole.Participants described the other group members in very affectionate terms—‘It’s not just about dancing it’s about the whole, being part of the organisation, being part of a little unit that I think I enjoy coming out. (Participant 6)Having shared experience was extremely important to participants. Participants commented on feeling ‘other’ when in public or with friends outside of the group. Paradoxically, although the group is built around having respiratory disease, not feeling ‘other’ created an environment where the disease could be forgotten, providing a form of respite.I do it for the social side as well. Because it’s very nice to meet people with the same basic difficulties. (Participant 2)As a group, you know, we obviously bonded with each other, well we know each other, it is, you know it’s something that…. I think we all enjoy it. (Participant 3)We kind of understand each other when we can’t breathe. (Participant 6)But I think that for me it’s about forgetting what’s wrong with me until I actually go home. (Participant 6)you got to be up for it, you’ve got to be disciplined’ (participant 4). Yet, simultaneously appreciating that this could be best achieved together.The depth of connection between participants underpinned the holistic impacts described in theme 1. The shared experience enabled participants to develop a combination of acceptance and increased motivation for improvement. This forged a collective self-motivation, with participants seeing their health as their own responsibility, directly related to the effort they put in ‘For me it’s a good thing. It’s basically being with like-minded people, people who understand how you feel. You can see them, you can encourage them to do a little better. I think I’ve actually changed my attitude. Instead of being in denial about not being able to breathe, I think I’ve more embraced it. (Participant 6)This deep social cohesion was attributed to the content of the sessions, particularly the presence of music, and dancing together.Well it means you accept the whole thing. You’re moving with a group of people who have a similar problem. (Participant 2)The supportive atmosphere was also attributed to session leader (SW). SW is very supportive while challenging the participants to do the best they can, which is greatly appreciated by the participants who describe her as ‘a lovely person’. There is a clear focus on abilities rather than impairment, which helps set the tone for the entire group.…the wonderful thing is, nobody’s ever been told ‘you’re useless and you can’t do it’. (Participant 1)(referring to the group leader’s responses) It’s the effort that one puts into it, and that is repaid enormously. (Participant 2)The social relationships that have developed were also contrasted with other types of therapeutic exercise such as going to the gym, where they felt this depth of relationship was not created.If you go to the gym, you’re just doing your own thing, whereas here we are supporting each other. (Participant 1)This study found that long-standing participants in a dance group for people with CRD perceived a range of holistic health and well-being benefits. The dance group had become an important part of their lives. Enjoyment of participation and the development of deep social cohesion between participants were considered key drivers of these impacts.This study has multiple strengths. To our knowledge it is the first study to explore community dance participation for individuals with respiratory disease in a real-world setting. A recent pilot study included qualitative aspects, based on informal group discussions and field notes,Some limitations should be noted. First, sample size was limited by the number of group participants. However, given the exploratory nature of the study, sufficient data were collected to justify the themes. Second, as we only focused on a single group, the transferability of findings cannot be ascertained. Third, more detailed clinical characterisation of the participants’ respiratory disease may have been of interest to people reading this study if considering practical implications for a specific context. However, we collected the relevant data for our research question. Fourth, a degree of selection bias may exist, as study participants were individuals who had maintained attendance, while those who did not enjoy the group no longer participated and were not included in the research. It would have been useful to interview people who no longer attended to explore the reasons for non-attendance. Similarly, the group has a small number of participants, which is likely due to no formal promotion activities because it is unfunded. Queries about the group are managed by the Breathe Easy team and no formal referral pathway yet exists. It is also possible the small group size may be small because potential participants did not see this as a desirable activity, but without further research it is not possible to draw any definite conclusions.Our findings echo some of the findings from the limited existing research regarding dance for people with CRD. A recent study assessing a dance intervention for COPD showed it to be feasible, with secondary outcome measures suggesting improvements in functional capacity, balance, anxiety and depression, physical activity and health-related quality of life.Research exploring the experiences of people with CRD participating in related activities shows some similarities and differences. Regarding PR, a high-value interventionOf note, the study participants did not report severe breathlessness, none used supplementary oxygen and all lived relatively independently. Given the strong evidence base for PR and other forms of exercise in people with more severe breathlessness and disease-related impairment, it would be of interest to explore the use of dance interventions in such individuals. Similarly, they were generally quite active people, who clearly valued various types of physical activity, this may frame their highly positive perspectives, and indicates further research on interventions targeting less active individuals would be of value, as well as groups who meet via the internet.CRDs are common and result in a high burden of morbidity, mortality and related economic implications. Therefore, low-cost, low-resource interventions with holistic impacts on health and well-being should be of broad interest. In particular, the perceived impacts on physical performance, psychosocial health and health resource utilisation are promising. Furthermore, this study highlights the importance of developing enjoyable physical activities that provide opportunity for self-expression for people with CRD to use intrinsic motivation, as an end in itself, but also to support compliance.Participants perceived a broad range of positive holistic health and well-being benefits; viewed participation as an important part of their lives; greatly enjoyed participation; and felt deep social cohesion with other participants. Further research is required to confirm, clarify and quantify these impacts, and assess the cost-effectiveness of sustainable methods of delivery including funding for session leaders and an appropriate dance space.


N,N-Diethyl-meta-toluamide) is considered the gold standard in mosquito repellents, not only for its effectiveness, but also for its safety. DEET has been more extensively studied for safety than any other repellent, and is accepted as completely safe when used correctly (i.e. not consumed or bathed in). Researchers studying botanical repellents, however, often paint DEET as far more toxic than it really is, falsely claiming it is a menace to the public health or even the environment. These claims are unfounded, and often the only evidence given by such publications are references to other publications also studying botanical repellents. Such publications are biased, and may be attacking DEET’s excellent safety record to justify their existence and the need for their research. The inconvenient yet undisputable fact is that no botanical repellent has been proven to be as safe as DEET, and the majority never had any safety testing whatsoever. The automatic assumption that botanical repellents are safer than DEET is the ‘appeal to nature fallacy,’ which also drives most of the market for “natural” repellents, yet natural repellents have side effects and even a body count. Finding a botanical repellent that works as well as DEET and is equally safe is a legitimate research goal on its own, and need not be justified by fear-mongering and irrational chemophobia. Researchers studying these alternatives should strive for integrity, raising the real issue of the lack of safety testing for botanical repellents rather than denying the proven safety of DEET.DEET ( Anopheles species: a systematic review”  against mosquitoes. That paper not only does not test the safety of “chemical repellents” at all, but also actually states that DEET is “considered safe,” and that the rare, toxic effects attributed to it “have been described mainly after misapplication.” Systematic reviews have confirmed that DEET is safe for humans of all ages when used correctly [Asadollahi et al. state, “it has been identified that chemical repellents are not safe for public health ” . Besidesorrectly , 4, makiZingiber nimmonii is “an eco-friendly tool” against mosquitoes, and which, while also making debunked or incorrect claims about DEET, clearly states that the issues of ecological disruption are due to insecticides, not repellents.The authors continue by stating, “the frequent use of synthetic repellents with chemical origin for mosquito control has disturbed natural ecosystems and resulted in the development of resistance to insecticides, resurgence in mosquito populations, and adverse impact on non-target organisms”. A repellent is not an insecticide, so this claim is misleading: it is impossible for repellents applied to skin, such as DEET, to affect mosquito populations, impact non-target organisms, or cause resistance to unrelated compounds. The genes for insecticide resistance do sometimes correlate with resistance to repellents, but that applies to natural repellents as well as synthetic ones . Even ifAsadollahi et al. claim that their systematic review was to identify plant-based repellents that are effective “without causing side effects on human health”. The review however does not provide any information about the safety of any of the plants listed, though likely this is because repellency studies typically do not include tests for safety. Indeed, for most “natural” repellents, there is zero information on safety, yet among non-experts they are automatically assumed to be less toxic than synthetics that have ample, overwhelming evidence to their safety. While the authors do acknowledge that “natural does not equate to safe,” considering their claim to systematically evaluate the safety of natural repellents, it is disappointing that they did not discuss this issue further or cite any of the studies that do exist. Many plant-based repellents are known to be more toxic than DEET at the concentrations necessary to approach its effectiveness, and essential oil poisoning can happen at doses far smaller than for synthetic repellents , with bop-Menthane-3,8-diol), so far the only botanical repellents recommended by the United States Centers for Disease Control and Prevention (CDC) alongside the synthetics DEET, picaridin, IR3535, and 2-undecanone as a safe and effective topical insect repellent [Consider formulations containing oil of lemon eucalyptus (OLE) or its active ingredient PMD  would be an interesting and commercially viable find, it is unfortunate that so frequently the researchers studying botanical repellents resort to fear-mongering about DEET to justify their work. Better to acknowledge that DEET has the strongest safety record of any repellent on the market, natural or otherwise, but that the ‘appeal to nature fallacy’ amongst consumers is driving the demand for “natural” alternatives, and so research into them continues and should also include appropriate safety testing.


Since 2006, 1.7 billion dollars has been spent lobbying Congress and federal agencies in the area of health  module utilizes a simple and efficient Application Programming Interface (API) for parsing, sorting, and organizing XML dataTo begin, all necessary packages are loaded, including ElementTree for parsing, Pandas for the creation of multiple data frames, and defaultdict to organize the central dictionary for the soon-to-be parsed data. Next, the LDA site is accessed to download the folder with lobbying data from the fourth quarter of 2009. An os.listdir function is applied to extract all individual files from this folder. Finally, an algorithm is used to parse through the XML files and convert the congressional lobbying data into a more usable form. See Figure An initial data organization issue related to lobbying records is that these records are grouped by time of filing, not by the time that the contribution took place. For example, the lobbying records from the fourth quarter of 2009 include multiple records that originated from years between 2002 and 2008 but were filed after the fact. To account for this, a special statement is included in the algorithm to ensure that the extracted data includes events from the year 2009 alone.After extracting the data, but prior to performing any analysis, a master dictionary is used to create eight individual data frames, one for each of several keys in the master dictionary: “Filing,” “Issue,” “Entity,” “Org,” “Lobbyist,” “Registrant,” “Client,” and “Government Entity.” Subsequently, another data frame is created by merging “Filing,” which includes amounts of money reported per filing, and “Issue,” which includes umbrella codes and more specific issues of interest. Finally, a Pandas series is formed from the new data frame by grouping amounts by code.To set up the code structure for more specific queries, a search function is developed to identify output based on user input. This function creates an empty list and appends each dictionary item that contains the search term in its “Specific Issues” section, which is a subcategory of each individual “Issue” section. Because the search is based on user input, any term can be searched within the list of dictionaries. The final appended list can then be easily converted into a data frame.Consideration of a wide variety of related terms is essential in the creation of an effective initial query. For the purposes of this data report, the term “pediatric” is chosen because it is both sensitive and specific for medical data in the under 18-year-old population. Using this single term, 35 results are pulled from the entire fourth quarter data frame. Then, key pieces of action and legislation are identified, such as the Improving Access to Clinical Trials Act of 2009, programs to expand medical device testing in children, and budget appropriations for generic pediatric drug trials. Finally, the search results are compared to the previously saved data regarding codes and lobbying dollar amounts spent per issue.A sorted amount-by-code Pandas series shows that the largest sum of lobbying dollars spent and filed in the fourth quarter of 2009 has been filed under “Taxation/Internal Revenue Code,” with an associated value of $527,147,333. Next is “Health Issues,” with $436,651,121.Analysis of the pediatric search results shows that these lobbying disclosures have been filed under a multitude of umbrella codes, including “Health Issues,” “Budget Appropriations,” “Science/Technology,” “Education,” “Disaster Planning & Emergencies,” and “Medicare/Medicaid.” Although this data can be merged with the “Filing”/“Issue” data frame, it remains impossible to make meaningful deductions about amounts spent on pediatric lobbying activities specifically because multiple issues are grouped together with the pediatric-related items, such as one filing that cites the following specific issues in one group:“Support legislation to amend title XVIII of the Social Security Act to provide for coverage of federally recommended vaccines under Medicare, Part B. Support legislation to amend title XIX of the Social Security Act to include all public clinics for the distribution of pediatric vaccines under the Medicaid program. Support legislation to amend the Social Security Act, the Federal Food, Drug and Cosmetic Act, and the Public Health Service Act to ensure a sufficient supply of vaccines and for other purposes. Lobbied to ensure that the Internet would not be used to import counterfeit and defective medical products. Support a rigorous and workable Affordable Biologics for Consumers Act. Support enactment and follow-on Biologics legislation with amendments that strengthen FDA pathway and provide data exclusivity. General matters related to vaccine industry stability, pandemic preparedness, avian influenza”Another unexpected but important finding of this data parsing method relates to the actual dollar amounts that can be extracted from the XML files. First, and most importantly, the XML files do not differentiate lobbying expenditures from income; these amounts are indistinguishable and are not linked to any identifiers that would allow a researcher to parse them out separately. Second, although the amounts appear to be specific to the single dollar on the results from the queries, the forms used to file lobbying reports allow a box to be checked for all lobbying expenses under $5,000, without any space to indicate the actual amount. Finally, in regards to income from clients, the forms used to gather lobbying data allow amounts over $5,000 to be rounded to the nearest $10,000:“Provide a good faith estimate, rounded to the nearest $10,000, of all lobbying related income from the client ”Due to the clear inefficiency of the original reporting forms, this report identifies concerns with the process of lobby reporting at its source. Although the current public LDA database is searchable and the raw XML data is available to download, the system continues to lack transparency.Pediatric research is a topic for which critical analysis of lobbying records may be clinically meaningful, particularly with regards to records originating at the time of the ACA's passage. Further, supporting the development of major healthcare bills that influence patients across the age continuum is essential to countering current governmental efforts to decrease healthcare appropriations.Future research could leverage other data science techniques to assess the value of the underlying text in lobbying records. Potentially helpful methods include natural language processing (NLP), topic modeling, and generalized text analysis algorithms. Refining methods to the text level may illuminate greater detail about inconsistencies in the way lobbying records are written. However, while a greater understanding of lobbying language might be beneficial, this kind of analysis would largely ignore the immense financial representation that lobbying groups have in the United States Congress.More importantly, deeper analytical processes – including greater statistical manipulation of the currency values that are associated with each lobbying record – could be assessed. As mentioned in our results, the limitation in greater statistical analyses is the innate inability to identify the exact amount of money spent on any particular lobbying activity. Only when the forms and procedures used to collect lobbying data are adjusted will data mining techniques be helpful in shedding light on federal lobbying practices, both in and out of the healthcare policy realm.https://www.senate.gov/legislative/Public_Disclosure/database_download.htm. All pertinent code is accessible via Github: https://github.com/eih2nn/UnitedStatesLobbyingDisclosureData.The datasets analyzed for this report can be found on the United States Senate website: EH and CD contributed to conception, design, analysis, and interpretation. EH parsed the data, led all coding, and developed the extraction algorithm. CD wrote the first draft of the report. JK-M and NB contributed to concept development and review. All authors contributed to manuscript revision and read and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Major depressive disorder (MDD) is a global problem with an increasing incidence and prevalence. There has additionally been an increase in depression due to the COVID-19 pandemic. Behavioral activation is considered an evidence-based treatment for MDD. However, there are many barriers that could hinder one’s ability to engage in behavioral activation, with COVID-19 “shelter-in-place” and social distancing orders being current and large impediments. Virtual reality (VR) has been successfully used to help treat a variety of mental health conditions, but it has not yet been used as a method of administering behavioral activation to a clinical population. Using VR to engage in behavioral activation could eliminate barriers that pandemic precautions place and help decrease symptoms of depression that are especially exacerbated in these times.The following case report examines the feasibility, acceptability, and tolerability of VR behavioral activation for an adult with MDD during a global pandemic. This participant was part of a larger pilot study, and the case serves as a description of the VR intervention.The participant engaged in a weekly 50-minute psychotherapy Zoom session for 4 weeks, in which a modified behavioral activation protocol was administered using a VR headset to simulate activities. Data on mood ratings, homework compliance, and headset use were obtained from the headset. Acceptability, tolerability, and depression symptoms were obtained using self-report rating scales.The intervention was feasible, acceptable, and tolerable, as reported by this participant. The participant’s depressive symptoms decreased by five-points on the Patient Health Questionnaire-9 over a month, with a beginning score of 10 (moderate depression) and a final score of 5 (mild depression).The implications of these findings for future research are discussed.ClinicalTrials.gov NCT04268316; http://clinicaltrials.gov/ct2/show/NCT04268316 Depression, classified as major depressive disorder (MDD) by the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), is a global problem with an increasing incidence and prevalence . MDD is More than 322 million people worldwide experience symptoms of depression and about 788,000 people die each year from suicide, with suicide being the second global leading cause of death for people aged 15-29 years . As a reDepressive disorders are worldwide the “single largest contributor to non-fatal health loss” and are among the leading drivers for years lived with disability . This laGiven the severe impact that depressive symptoms have on individuals and society, it is imperative to identify effective treatment options. Many evidence-based treatments have been identified for MDD, behavioral activation (BA) being one of them . BA is dDespite BA’s effectiveness and ease of dissemination and use in primary care settings, obstacles exist to its implementation. First, finding the ongoing internal motivation to become behaviorally activated is not an easy task for people who struggle with depression, due to the nature of the symptoms themselves . There mThe use of technology as an adjunct to or a method of delivering mental health treatments is becoming increasingly popular as a way to fill this treatment gap . One tecAlthough there is minimal risk when using a VR headset, studies have indicated that the side effects may include cybersickness, often comprising three subscales: nausea (N), oculomotor (O), and disorientation (D). N includes increased salivation, sweating, nausea, upset stomach, or burping; O includes fatigue, headache, eyestrain, or difficulty focusing; D includes vertigo, dizziness, and blurred vision -18. The This case represents results from a single subject who was part of a larger pilot study currently being explored to test the feasibility, acceptability, and tolerability of using a VR headset as a way to administer BA during the COVID-19 pandemic. If pleasant activities can be successfully simulated and found effective using a VR headset, this would eliminate many obstacles to receiving care or engaging in pleasant activities such as cost-related impediments, ability-related obstacles, or other access-related difficulties such as the COVID-19 “shelter-in-place” orders. Given the plethora of VR options readily available online for free and the cheaper headset selections, VR is now more publicly accessible than in previous years  new experiences that [he] would not normally be able to do.” He also shared that using the VR headset had helped him to feel better, with the hypothesis that the “novelty helps with depression.” The participant further noted that he found himself “more motivated to do other things after using the headset.” He provided the feedback that the videos were not too short, and he liked that the length of each activity was provided; however, he thought that the motorcycle video was too long and repetitive at 10 minutes.At the beginning of session three, the participant’s PHQ-9 score decreased to 6. During this session, the participant remarked that it was easier for him to engage in VR activities than activities in real life because he keeps the headset nearby, knows it is a short time commitment, and that he will feel better after using the headset. He further stated that after completing a VR activity, he experienced increased motivation to partake in a real life activity, enumerating his thought of “I may as well try something else” after using the headset. The participant also remarked that he used the VR headset to help replace activities he wanted to decrease, such as social media.At the beginning of session four, the participant’s PHQ-9 score was 5. The participant stated that due to activity monitoring he was completing more activities than usual, both in VR and in real life. He also mentioned that using the VR headset provided him with a sense of accomplishment and something to look forward to. He attributed the overall 5-point decrease in his PHQ-9 scores to the fact that he had been increasing his activities, had more motivation after using the VR headset, and was feeling a greater sense of mastery. He stated that the appeal of using VR was the ability to gain exposure to new things, which provided the impetus for him to engage in novel activities in real life, such as visiting new parks. The participant remarked that although there were only 37 VR activities to choose from, he still felt that the experiences were novel since he could look in different directions during each activity. He recalled that the key to frequently using the device was keeping it close by so that he would remember to use it instead of other, less helpful activities. He noted that 5 days prior his psychiatrist increased his dosage of Fluoxetine but stated that he did not currently feel a difference and was informed that the effects would not be felt for “a week or two.”The feasibility, or degree to which VR could successfully be integrated into BA treatment, was measured by commenting on qualitative barriers to use observed. Barriers were assessed by rates of dropout, adverse events, the number of times the headset was used, and the level of presence felt in the headset. The level of presence was calculated on a scale of 0  through 4 (very strongly) for each question; and with three questions, there was a possibility of yielding a score between 0 and 12. The average total presence for the participant was then calculated as 9.53 out of 12. The participant completed the study and did not report any adverse events during the study. Although full homework completion required using the VR headset a minimum of four times per week, yielding a minimum total of 12 times, this participant used the headset a total of 21 times, while completing 15 post-VR worksheets. The participant used the headset six times during his first week, 10 times during his second week, and five times during his third week. Although the participant engaged in 15 of the 37 potential activities, he chose to participate in “Cats in Living Room,” “Bungee Swinging Canyon,” “Rollercoaster,” “Motorcycle Race,” “Swimming with Sharks,” and “Elephant” twice each, while engaging in the other nine activities once.Acceptability of the VR BA treatment was measured using the TAM, with the agreeance choice on the Likert scale represented from 0 (Strongly Disagree) through 4 (Strongly Agree). The number of questions in each category determined the outcome range, which were then averaged. The participant maintained the same agreeance choices on all 15 questionnaires, indicating “Strongly Agree” for “Perceived Ease of Use” (average score: 12 out of 12), “Attitudes Towards Use” (average score: 16 out of 16), and “Intention to Use Technology” (average score: 12 out of 12), while in the “Perceived Usefulness” category, he rated “Strongly Agree” for questions 2 and 3 but “Agree” for question 1 (average score: 11 out of 12).nausea, general discomfort, stomach awareness, sweating, increased salivation, vertigo, burping, and dizzy  to 3  for each item. The participant endorsed symptoms of The total scores for physical tolerability were then summed, yielding a total score of 1.8 out of a potential 48, indicating high physical tolerability. Emotional tolerability was scored from 1 (Strongly Disagree) to 7 (Strongly Agree) per question; and with three questions, there was a possibility of yielding a score between 3 and 21. The average emotional tolerability score for this participant was a 3, indicating high emotional tolerability.This case demonstrates that VR BA was a feasible, acceptable, and tolerable method of delivering BA for an individual diagnosed with MDD during the COVID-19 pandemic. It also describes in detail the intervention that is being studied in a pilot randomized controlled trial (RCT) to be completed in 2021.The participant used the headset more than was required for homework, did not verbally report any adverse events, and experienced an average presence of nearly 80% while using the headset. Although this is a relatively high presence rating, the authors conjecture that it was not higher for two reasons. First, the Limbix headset created a subtle effect that one is looking at the image through a screen, due to the simple device technology. Second, in using a 360° video, to give the illusion of movement, the image moves while the participant remained still, rather than the participant being able to walk around the virtual environment. It is possible that with a more advanced device, the presence rating would be higher. Still, his presence ratings were not correlated with his pre-VR to post-VR mood ratings.The largest feasibility issue was working through COVID-19 “shelter-in-place” and transitioning the study from an in-person to telehealth design. However, the issue was solved by shipping the VR headset to the participant and using Zoom for the session meetings. Thus, the participant was still able to engage in weekly face-to-face sessions with the protocol director.The participant rated the use of the headset as highly acceptable, giving the highest ratings of acceptability to all but one question. He indicated that using the headset was emotionally tolerable, denying any symptoms of agitation. He also rated the use of the headset as largely physically tolerable, providing a rating of about 3.8% intolerability. Although the participant did endorse varying degrees of nausea (N), general discomfort, stomach awareness (N), sweating (N), increased salivation (N), vertigo (D), and dizziness  during three of the adrenaline activities and one nonadrenaline activity, the participant did not discuss these symptoms during sessions and still rated his post-VR mood as the same as or higher than his pre-VR mood after each of the adrenaline activities . Given tThe participant experienced a 5-point decrease in depression symptoms on the PHQ-9 over a month, providing an initial rating of 10, which indicated moderate depression, and a final rating of 5, indicating very mild depression . This deThe strength of this VR BA intervention is that the mood ratings, activities completed, and amount of times using the headset were captured objectively and were standardized on the Limbix headset. Consequently, accurate home practice measurements were made, and the possibility of inaccurate homework reporting was eliminated. Additionally, this study took place during COVID-19 “shelter-in-place,” when real life activities were limited. The fact that this participant experienced mood increases after using the headset provides some evidence and possible potential for using VR to increase mood when real life activities are limited or treatment is being delivered remotely through telehealth.This case study has several limitations. First, many of the quantitative and qualitative measures were subjective and completed by the participant. Although the participant engaged with the headset 21 times, he only completed 15 post-VR questionnaires, and thus, the complete data set was not able to be analyzed after every activity. Qualitative data collection that included further context was needed and is an important consideration for future research. In addition, given that this is a case report on one individual, the results may not be generalizable or help us identify causality. Results may not be applicable to all populations struggling with symptoms of depression, due to the heterogeneity of the disorder. Specifically, the participant began treatment with moderate symptoms of depression, and although BA has been shown to be effective for those with more severe symptoms, it is unknown whether using a VR headset to perform BA would yield these findings . Unlike To the authors’ knowledge, this was the first reported use of VR to administer BA for a person with MDD. This is a retrospective case report that used the data from the first VR BA participant in a larger, three-arm study. This case was a combination of VR1 and VR2 methodologies, as outlined by Birckhead et al , since i


Precision models are making use of the most up-to-date technological advancements – such as genomics and ‘big data’ processing – in an effort to tailor healthcare to each individual. Yet the list of hurdles to successful implementation of precision medicine is no secret. Among the challenges, it was recently suggested in this journal that we must change the ‘mindset’ of patients, practitioners and the wider public (McGonigle, The emerging paradigm in contemporary healthcare,  The prevailing thought is that technological advancements – such as genomics and ‘big data’ processing – will enable us to tailor healthcare to each individual, for example, by identifying genetic biomarkers of diseases.In 2015, President Obama's Precision Medicine Initiative propelled forward a new approach to healthcare research and clinical treatment. Moving away from a ‘one-size-fits-all’ model, the announcement and US$215 million investment endorsed ‘an innovative approach to disease prevention and treatment that takes into account individual differences in people's genes, environments, and lifestyles’ (White House, As we might expect, the list of hurdles to successful implementation of precision medicine has been growing, from technical and legal concerns over data security to ethical issues regarding how to amass and operationalize an open database consisting of patients’ electronic medical records, lifestyle information and genetic data. Among these challenges, it was recently suggested in this journal that we must change the ‘mindset’ of patients, healthcare practitioners and the wider public (McGonigle, 2.medicine aims to provide treatment that will be most effective and bear the fewest undesirable side effects, while hopefully also improving economic outcomes for individual patients (Chen et al., health platforms tend to emphasize the importance of healthy lifestyles, disease prevention and risk awareness (Akdis & Ballas, In its narrower guise, precision et al., et al., more due to targeting smaller populations and accordingly that we should temper the narrative of ‘transformative change’ (Joyner & Paneth, Granted, the precision approach will make use of previously unheard-of social and behavioural information, and it stands to usher in a reclassification of diseases based upon one's molecular profile (Mirnezami et al., As of August 2019, the number of participants in the National Institutes of Health research programme has reached approximately 245,000 (National Institutes of Health, et al., Along with the concerns over data privacy, security, ownership and use, questions of how to justify non-therapeutic research on human subjects appear equally challenging. Here, we see one of the most fundamental tensions in research ethics: that is, determining the extent to which using a selection of individuals for the purpose of benefiting others can be morally permissible. We might suppose there simply is no problem where researchers have obtained the most robust sort of informed consent available. However, as numerous authors have made clear, the traditional standards of obtaining informed consent do not map onto secondary, future uses of subjects’ data. Indeed, consent procedures are often highly questionable – for example, due to obscurities or omissions in terms and conditions documents (Stoeklé 3.In a recent contribution to this journal, McGonigle notes that the success of precision medicine depends upon the voluntary participation of healthy individuals, which, in turn, calls for changing the mindset of patients, healthcare providers and the wider public. Specifically, we will ‘need to embrace the “idea” that genetic information is an important part of medical treatment’ (McGonigle, et al., As a way to ‘tackle’ the ethical concerns, McGonigle suggests making comparisons with historical precedents. The first analogy on offer is a system of voluntary blood donation in Israel, wherein donors ‘receive a government identity card assigning them priority to receive future emergency blood donations’ (McGonigle, consumed, they do not diminish in value (Hand, However, as a precedent for operationalizing precision medicine, the blood and organ donation models understate the extensive change in mindset required. In short, incentivized blood and organ donation systems, such as those seen in Israel, are unlike the data donations needed for precision medicine. At least three important differences can be promptly clarified. First, human blood and vital organs are properly considered scarce and non-renewable resources. Patients’ medical records and genetic information, on the other hand, may be presently unavailable – particularly for legitimate use in large-scale shared databases – but they are surely not scarce in the same sense or for the same reasons. Unlike blood and organs, personal data are very easily duplicated, transmitted and shared with anyone, anywhere. Once data are ue Hand, . For thineeds these resources. By contrast, unless we agree to donate data only upon death, we remain in need of these delicate resources even after donation.Third, and perhaps most glaringly, are the incongruous incentives attached to biobanking models that offer distinct and tangible rewards. As McGonigle showed, on Israel's systems, donors clearly benefit by being prioritized for potential reception of blood or vital organs. Donors benefit their families by allowing relatives to be prioritized. These sorts of immediate rewards simply cannot be translated to incentivizing data donation, nor should they be. It would be far less clear how to be prioritized as a beneficiary of precision medicine. McGonigle notes that data donors can benefit in terms of ‘access to personal health assessment, and … by helping the wider community become healthier’ (McGonigle, et al., et al., It might be thought that incentivizing the contribution of health records and genetic data is morally permissible where subjects can identify with the goals of research or, at least, are not directly coaxed into contributing by the researchers themselves (e.g., Jonas, 4.McGonigle states that the benefits of precision medicine databases ‘may still be unknown, and perhaps at this point inestimable’ (McGonigle,


Milk and dairy products contain many substances beneficial to human health; moreover, the contents of some of these substances can be enhanced. This is also the case of isoflavones which are compounds of plant origin that can be ingested and metabolized by cattle and, subsequently, secreted into bovine milk. An especially healthful substance called equol is ranked among isoflavone metabolites, commonly produced in the digestive tract of cattle. Equol content in milk can be modified by using feedstuffs with different contents of isoflavones or by milk processing and storage.Milk and dairy products are important sources of nutrients in the human diet because they contain a number of essential substances and other biologically active components. Many of these substances can be modified, and thus offer opportunities to use milk and dairy products as functional food. Isoflavones are particularly important in human nutrition due to their diverse pharmacological and antioxidant properties. The clinical effectiveness of isoflavone-rich products is believed to be dependent on their ability to metabolize daidzein to equol, which may directly exert cancer preventive effects. However, only approximately 30–40% of humans are able to produce equol, while animals, in general, produce equol. Equol is the predominant product of bacterial metabolism of isoflavones and can be found in various amounts in some food of animal origin, especially in milk. Therefore, milk and dairy products can be considered to be sources of equol for humans who are not able to produce this metabolite. When the content of isoflavones in milk is to be modified, two groups of factors should be considered, i.e., dietary factors that include the source of isoflavones and the processing effects on feedstuffs and animal factors that include the intake of isoflavones, ruminal and postruminal changes, and the health and physiological status of animals. The approximate content of isoflavones in milk can be predicted using carry-over rates for different dietary sources or using a formula that describes the relationship between equol concentration in milk and formononetin intake. Processing and storage can affect the content and profile of isoflavones in milk and dairy products. Functional food includes natural or processed foods that contain unknown or known biologically active compounds . These cFor the purpose of this review, a literature search was conducted using Web of Science and Science Direct databases. For the section on “Roles of isoflavones in human health, the Web of Science was searched for articles using combinations of search terms “isoflavones” and “menopause”, “cancer”, “antioxida*”, or “*estrogen*”. For the remaining chapters, the search terms included combinations of terms “isoflavones” and “rumen”, “metabolism”, “milk”, “dairy”, or “feed” and were limited to topic/title/keywords. Titles, abstracts, and finally, full manuscripts were manually reviewed for relevance; only articles published in English in peer-reviewed journals and corresponding to the topic of this review were included. Articles published between 1 January 2010 and 1 September 2020 were preferred. Studies that focused on ruminants other than bovine animals or their milk/dairy products were excluded.Isoflavones have been associated with diverse beneficial effects on human health; however, they occur in many chemical forms differing in bioavailability and efficacy. Generally, the most effective are isoflavone aglycones and equol, a metabolite of daidzein .3 and 10−1 nM for daidzein and equol, respectively, and after consumption of a Western diet, predicted maximal plasma concentrations are 101 and 10−2 nM for daidzein and equol, respectively ..91].The most common processes, namely sterilization and pasteurization, do not change the isoflavone level, as thermal stability of isoflavones is up to 120 °C ,91,96; sIn addition, fermentation causes substantial changes in isoflavone content, primarily in the concentrations of daidzein and glycitein. In contrast to fermentation of soymilk, which leads to increased concentrations of isoflavone aglycones, fermentation and ripening of cows’ milk causes high losses of isoflavones ,96,97. SIsoflavones in human nutrition are particularly important due to their wide range of pharmacological and antioxidant properties. However, the clinical effectiveness of isoflavones depends on the ability to metabolize daidzein to equol, which is true only for approximately 30–40% of humans. Thus, alternative dietary sources of equol in human nutrition are desirable. From the dietary sources, equol-enriched bovine milk seems to be the most suitable product for individuals lacking the ability to produce equol from its dietary precursors. This review showed that for the production of equol-enriched milk, it is important to know the quantitative aspects of isoflavone transfer from feed into milk and to study factors that can influence this transfer. Improved understanding in postruminal metabolic processes is needed as they were identified as factors affecting the carry-over rates; furthermore, not all aspects of rumen metabolism are clear.