Older adults have been described as a vulnerable group in the current context of the COVID-19 pandemic. In Canada, where this study took place, older adults have been encouraged to self-isolate while the rest of the population has been cautioned against in-person contact with them. Prior to COVID-19, social isolation and loneliness among older adults was considered a serious public health concern. Using a series of semi-structured interviews with 26 community-dwelling older adults (65+) living in rural Manitoba, we explore older adults’ experiences of isolation and loneliness in the initial stages of the pandemic between the months of May and July 2020. Participants identified a loss of autonomy, loss of activities and social spaces , and lack of meaningful connection at home as factors influencing their sense of isolation and loneliness. Although these loses initially influenced participants’ self-reported isolation and loneliness, the majority developed strategies to mitigate isolation and loneliness, such as drawing on past experiences of isolation, engaging in physically distanced visits, connecting remotely, and “keeping busy.” Our findings call attention to the role of different environments and resources in supporting older adults social and emotional wellbeing, particularly as they adapt to changes in social contact over time. In general, older adults are at a higher risk of contracting COVID-19, they are more likely to be hospitalized, and they are more likely to die from contracting the virus than other age groups . InitialPrior to COVID-19, academics and policy makers declared social isolation and loneliness among older adults a serious public health concern ,6. StudiSocial isolation—an objective lack of social contact or relationships with other people—is correlated but not the same as loneliness ,11. LoneOlder adults’ abilities to adapt to changes in social relationships are generally contingent on a range of mediating individual, social, and environmental factors ,14. PastStudies on environmental factors have focused on high levels of loneliness and isolation in deprived or socio-economically disadvantaged areas , as wellContrary to common belief , the majIt is critical that we examine how older adults are experiencing COVID-19 and public health measures, as the pandemic continues to disrupt social relationships and the ways we navigate our everyday social environments. The aim of our study was to investigate community-dwelling older adults’ experiences of physical distancing, isolation, and loneliness in rural communities in the Canadian province of Manitoba during the COVID-19 pandemic from May to July of 2020. We asked:(1) How has COVID-19 influenced rural-dwelling older adults’ experiences of social isolation and loneliness during initial stages of the COVID-19 pandemic? (2) What factors and strategies influenced their sense of social isolation and loneliness over time?Quarantine Act, requiring those entering Canada to self-quarantine for 14 days. In addition, the Province of Manitoba initially required all out-of-province travelers to quarantine for 14 days. Initially, Manitoba contained the spread of COVID-19 in the spring and early summer of 2020, and most of the early cases were in the only census metropolitan area of the province, the city of Winnipeg. On 4 May 2020, the Province began their plan to “restore safe services.” All social gatherings  were restricted to a maximum of 10 people and all food services remained closed, except for delivery, take-out and patio or walk-up food service. On 22 May 2020, public gatherings of 25 people were allowed indoors and 50 people outdoors and on 29 May 2020 outdoor visits to long-term care were allowed. Over the course of the summer the Province continued to reduce restrictions. However, by the end of July cases began to increase, including rural and small-town Manitoba. Our study focuses on participants’ experiences of initial restrictions and reopening and does not reflect older adults’ experiences as cases increased after July 2020.On 20 March 2020, the Province of Manitoba declared a state of emergency and public health directives resulted in school closures, shuttering many community and non-profit services for seniors, and eliminating visits to older adults in long-term residential care . All “noTo examine older adults’ experiences of physical distancing, isolation, and loneliness during COVID-19 we conducted semi-structured telephone interviews with people aged 65 years and older living in rural settings or small towns with less than 10,000 people . The incn = 20) and retired (n = 22), although several participants were still working either part-time (n = 2) or full time (n = 2). Many participants had a high school (n = 7) or some college or university education (n = 14); three participants had less than a high school education and two participants held graduate degrees. One quarter of participants reported they lived alone.With ethics approval from the University Ethics Committee, 26 participants were recruited through press releases, television and radio interviews, Facebook advertisements, and local active living centres in Manitoba. Participants’ ages ranged between 65 to 89 years. Most participants were female  and proceeded with more questions about their social networks, community, and activities during COVID-19 . Participants were also asked to rate how often they felt lonely during a given week both prior to COVID-19 pandemic as well as currently  using a 4-point scale ranging from 1 , 2 , 3 , and 4 , a commonly used loneliness item taken from the CES-D scale . Asking From July to August, 25 participants took part in a follow up interview. These interviews were also semi-structured and repeated questions in relation to social isolation and loneliness. The open-ended questions focused on what, if anything, had changed for participants over the past month, including contact with family or friends, activities, and sense of community. Based on emergent themes in initial interviews, the guide also included a series of open-ended questions about what helped participants most during the COVID-19 pandemic and mandated physical distancing as well as what benefits and challenges they experienced living in a rural community during this time. Each follow up interview was digitally recorded and lasted between 30 min to an hour and a half.Two interviewers participated in every interview, which supported data quality in multiple ways. One person took in-depth notes during the interview to support the audio-recording and enhance the quality of verbatim transcription. Post-interview, the two researchers discussed initial impressions and identified specific resource needs for participants who expressed need for support at the end of each interview. This allowed the researchers to refine their interview approach and ethical conduct around providing resources to participants as well as begin to develop some initial thematic areas of interest for analysis.First, analyses focused on the questions relating to participants’ reported isolation and loneliness before COVID-19, at the beginning of COVID-19, and one month later to begin to explore participants’ perceptions of how COVID-19 influenced their experiences of isolation and loneliness over time. We then used qualitative thematic analysis to examine what influenced participants’ isolation and sense of loneliness, as well as what conditions mitigated isolation and loneliness. Interview transcripts were coded and organized using Nvivo 12 software . Three researchers coded the first transcript inductively with a focus on participant experiences. The primary researcher continued to code transcripts independently. On a weekly basis during data collection, the three researchers met to code a new transcript, review the code book, discuss divergent interpretations of the data, and come to a consensus on inductive codes. This process of regular initial coding meetings enhanced the credibility and confirmability of analysis by ensuring that interpretations were reviewed and confirmed by multiple researchers who were directly involved in the interviews. After a round of initial coding, the researchers grouped inductive themes under larger overarching categories in line with the research questions. Loss of autonomy and the loss of activities and social spaces were identified as dominant and distinctive challenges during COVID-19, while lack of meaningful connection at home was a significant factor influencing loneliness for the loneliest participants. Past experiences of isolation in rural places, negotiating physically distanced visits, connecting with others, and “keeping busy” were identified as resources and strategies to mitigate isolation and loneliness.n = 12) the feeling of isolation persisted.It is also of interest to consider those who felt isolated pre-COVID; 35% (9 people) reported feeling isolated before COVID-19. Two of these people reported feeling less isolated during their initial interview but had returned to feeling isolated one month later and three of these individuals, while they had reported continuing to feel isolated in their initial interview, reported being NOT isolated in their second interview. In other words, feelings of isolation appeared to have dissipated for a small number of people over the course of the study months.Finally, we can also consider the four people who reported NOT feeling isolated prior to COVID-19 nor during COVID-19 . It is particularly striking that this group of individuals did not feel isolated, given that Manitobans were facing restrictions on their day-to-day activities and contact with others.It is of interest to examine further patterns over time. Of the 16 people who reported NOT feeling lonely pre-COVID, we can see that six people reported feeling lonely at the first interview during COVID-19 (May–June) but then returned to feeling NOT lonely by the second interview. However, seven people who had indicated being NOT lonely pre-COVID were lonely at the second interview, and thus had not gone back to pre-COVID levels. Only three people were consistently NOT lonely throughout all three time periods. Interestingly, four people who had reported feeling lonely pre-COVID ended up reporting feeling NOT (or rarely) lonely by the second interview. The qualitative results can highlight some of the nuances in the self-reported isolation and loneliness of participants.Participants in the study identified loss of autonomy as a distinct factor influencing their experiences of isolation and loneliness during COVID-19. Joann (age 69) explained, “I feel isolated in the sense that I can’t do what I want to do when I, you know.” Similarly, Troy (age 70) said, “…it seemed forced. You know, uh, the COVID police are going to get you if you, uh, go out and do something. And, you know, again, I’m, I am pushing 70 pretty quick and it’s um, my immune system is compromised so, no, there is no chance.” In this case, loss of autonomy resulted from a combination of factors, including restrictions, individual health conditions, and perceptions of risk. Others explained that loss of autonomy was related to the shuttering of community spaces and restrictions on gatherings. As Kim (age 75) elaborated, “Well, living out here where I live, yes, I do feel isolated sometimes, yes. But I had a choice, if I didn’t want to feel isolated, I could go someplace or I could, you know, organize something, do something…That choice is not here now.” Similarly, Maria (age 70) explained, “… in the winter we sort of all batten down, you know, but we used to take little trips, we would go out to a restaurant, um, or whatever. So it was not as isolating.” Participants’ autonomy, choice, mobility and previous strategies for living in isolation were constrained during the initial phase of COVID-19. While many participants regained some autonomy and choice of activities by the time of the second interview, this was not the case for everyone, particularly older participants. One participant explained,“I’m 88 years old and I don’t, when you get that old you’re not expected to last too much longer. And this here has taken away a good part of your last remaining time on earth. Because you’re, what you got pleasure out [of], you don’t get that anymore. So that’s taken away part of our life, that’s not that much of it left anymore. That’s one of the things that’s bothering us”George felt he had lost autonomy, and more poignantly, quality of life during the pandemic. He and some other participants continued to experience a loss of autonomy and social activities even as the province re-opened. The loss of autonomy and choice during COVID-19 was a factor that continued to influence some participants’ experiences of isolation and loneliness, as well as strategies for mitigating isolation and loneliness.Many participants observed that their increased isolation and sense of loneliness was influenced by a loss of everyday social activities and spaces. For example, Shirley (age 89) explained, “You can’t go to the neighbors for tea, the neighbor can’t come here. It was very isolating.” George (age 88) explained, “Well, you’re just bored with life. You just sit and argue with the wife. And that’s all the activities we have [soft laugh].” He described himself walking the halls of his apartment and looking out the window for something to do with his time. Although he was still able to go out to his daughter’s farm to garden, he described himself as bored and lonelier having lost other activities  that filled his day.Shuttering community spaces as well as familial pressure to isolate contributed to loss of social activities for many older adults. For example, Christopher (age 79) said, “I was playing cards about five times a week and now we don’t have cards at the [active living centre]. And the guy I was playing cards with in the lodge [congregate housing for older adults] here, he doesn’t want to play… His son phoned him from [country name] and told him he shouldn’t be playing cards.” In another example, Cheryl (age 75) explained, “the Legion of course is closed. We like to go to that Legion on Friday nights and socialize.” The participant noted how the closure influenced the routine interactions she enjoyed. She continued to explain that she volunteered to cook suppers at the Legion and she volunteered at the active living centre, both of which were closed. In describing their loss of social activities, almost half of participants mentioned lost volunteer opportunities, going to church, and coffee and eating out. Indeed, churches, coffee shops, restaurants, legions, and active living centres provided important everyday spaces for older rural-dwelling adults to get out of their homes and interact with others prior to the pandemic. At the time of the second interview, some participants regained familiar activities and spaces. For example, Jack (age 72) said “… Going to church, we started doing that again.” Although he did not go every week, he helped arrange cohorts to attend service in compliance with restrictions. Other participants commented how some spaces opened, but routines associated with those places changed: “we’re not allowed to have any cup of coffee or anything after church or barbeque even outside or any lunches… we’re sort of encouraged to go home as fast as we could” Cheryl (age 75). Moreover, social exchanges associated with familiar activities and spaces remained limited for most participants during the initial stages of COVID-19.Some of the loneliest participants described specific circumstances in their home environment that contributed to their loneliness. For example. Helen (age 73), who felt extremely lonely at all three time points stated, “Yes. I feel isolated, alone, and lonely, a lot of the time… I got out more. Um, I don’t, I haven’t, I haven’t been able to get out very much because I can’t walk very far anymore.” Like other participants, she had lost places to go, but she also had mobility limitations that made her more confined to her home. In addition, she lived in a housing environment where she felt “…people in here don’t even talk to you [SCOFF], they just stay away from me, you know?” At the time of the second interview, she reported that her feelings and interactions had not changed. This example highlights the importance of environmental resources, like living arrangements and social relations within ones living environment, in mitigating loneliness.In another example, Evelyn (age 71) stated, “I feel lonely quite often because I have lost my partner and my husband here. As dementia robs daily, and there is really no level of conversation at all.” Prior to COVID-19 her husband would walk to a drop-in and the post office in their community daily, while she had several coffee groups she attended throughout the week. Her husband still walked to the drop-in centre and post office and she explained to him daily why it was closed. Being at home caring for her husband living with dementia, Evelyn described herself as increasingly resentful. During the initial stages of the pandemic, she was diagnosed with anxiety and depression. Based on her first interview, the research team directed her to several Manitoba resources, including the daily hello program run by a non-profit organization, which connects older adults with one another for a regular telephone conversation. This participant reported that the daily hello program had helped her in the second interview. This was one reason she felt lonely occasionally in comparison to all the time, as she stated in her first interview.Many participants in the study explained that they had some experience with isolation prior to COVID-19, which they could draw on during the pandemic. This corroborates the relatively high percentage of people reporting that they felt isolated prior to COVID-19 pandemic . For exaIt is important to note that past experiences of isolation were not a positive resource for everyone. Several participants who had recently retired to the countryside, explained that they were isolated before COVID-19, but this was because of challenges related to integrating into a tightly knit community and lack of services and activities for older adults in the area. For example, Danielle (age 65) explained, “Rural Manitoba is, if you’re not born and raised in certain communities, it takes them a little bit of time to kind of include you.” Similarly, Amelia (age 69) explained how COVID-19 restrictions had not really changed their already isolated lives:“First of all, social isolation that everybody has to go through now is basically our life. We’ve been here for four years, there’s not that many activities for seniors that we are aware of. We don’t go to church so there’s no church groups and stuff that we’ve been able to hook up with. So, there’s really nothing that we’ve been able to go to that we have chosen to go to.”Both Danielle and Amelia identified being socially excluded because of the social dynamics and institutions associated with rural places as well as lack of services within their specific rural areas. For some isolated participants, there appeared to be a preference for isolation. However, for others, isolation appeared to be something they were ‘used to’ or perhaps even resigned to, with some attributing isolation to their rural context. It is interesting to note that past experiences of isolation appeared to help some participants cope during COVID-19.Although participants experienced distinct losses and challenges during the initial stages of the pandemic, they also adapted and developed strategies to mitigate isolation and loneliness including physically distanced visits. Some participants engaged in outdoor visits. For example, Gerta (age 69) explained, “My friends and I are meeting at the end of the month, outside potluck at my friends place, and we will all do our social distancing, um, so that’s, we’re trying for that and we will continue.” Although outdoor visits increased during the summer, participants were selective in the way they visited and with whom they visited. Nora (age 73) stated, “We haven’t allowed anybody into our house and not even for washroom privileges.” A small number of participants also had indoor visits. Joann (age 69) said, “our bubble is getting bigger. Because the numbers—we don’t have any, any cases in our region at this time… we actually had a couple other relatives sit inside to have dinner with us, as it was cold outside. So that’s something that we would not have done prior to this, prior to the month.” Participants explained a range of contingencies influencing how and where they visited including home ownership, whether they had access to outdoor space, their health condition and the health condition of their social relations, and perspectives of their social relations. them by not visiting or on how they themselves did not want to put some of their more vulnerable contacts at risk. In other words, interestingly, participants described seeing others as at risk or being seen as an at-risk group themselves. In her second interview, Cheryl (age 75) commented “I’m a little let down that you know some of the families that, uh, with children that we normally would have seen, umm, aren’t too interested in coming near us” and another participant commented, Others commented on how their social network either wanted to protect “I still don’t feel comfortable doing that [visiting] with some of the other people I know because they got diabetes, or they got, uh, a slow-moving form of cancer or something like that, so, you know, it’s expanded a little but, I am getting to the point where I am missing, um, interacting with people”.These comments reveal the increased difficulty of navigating social relationships, specifically co-presence , even if it is physically distanced.Most participants developed strategies for remote connection with others, by phone, text messages, emails, video calls, and social media. For example, Jody (age 75) remarked, “Ah, Facebook is a wonderful thing to keep track of people a little bit and be able to communicate. Ah, if you so desired, the phone is wonderful and so is the computer…” She explained that she had planned to call someone every day, but she found she was too busy with other activities. One quarter of participants described developing routine check-ins with friends, family, or neighbours. For example, in their second interview, George (age 88) explained, “Well, [soft laugh], that’s kinda what keeps us going. The wife, she is happy talking on the phone for several times a day with the family. And they’re checking in on us and we are seeing how things are going with them...” Therefore, participants utilized a variety of means of communicating remotely with each other using telephone or other technologies.Some other participants revealed the limitations of remote connection in terms of meeting ones need for physical touch. Ava (age 80) explained she had regular phone and text conversations with friends and family. She said: “I’m managing fine, you know, when I’m used to having people, it was, it was lonely. And yet, I mean I can’t complain because people do phone and that, but it’s not the same as, like even my daughter, I couldn’t go hug her, you know.” Other participants talked about how much they looked forward to hugging friends at some point in the future, highlighting the importance of physical contact.A smaller number of participants identified a loss of communication during COVID-19, with some of this loss due to limitations of technologies in rural areas. Danielle (age 65) lived in an area without cell service and internet. She explained, “Like you text people now, nobody really answers the phone.” She felt isolated by a lack of infrastructure but also much broader societal changes in how people communicate. Audrey (age 80) commented that even though she continued to contribute to the community she missed the communication and social interactions that used to come with these activities. Of these community efforts she said, “So, you know, it was an isolation. And nobody could come here. I was a drop off place for a gal who sold head bands and masks for the hospital. And so, she would put them in my mailbox outside, and you know, we did not even talk.” Although she continued to connect with community members through volunteer work, it did not meet her social needs in the way it had in the past. Other participants waiting for medical procedures also identified a loss of communication with the hospital that contributed to their experience of isolation during COVID-19. For example, Maria (age 70) explained, “Right now, I feel extremely isolated. I am waiting for gallbladder surgery. I haven’t had any notification from the hospital or the health region, I’m in a lot of pain.” Not knowing what was happening and trying to keep herself in strict isolation to be ready for surgery, Maria felt very isolated in relation to a lack of communication and clear information.Most participants identified “keeping busy” or “filling the day” with household chores, hobbies, getting outside, walking, and gardening, as strategies for mitigating isolation and loneliness. In the face of a loss of activities and social spaces, many participants adapted their activities and the environments in which they engaged in routine activities. Alice (age 75) explained, “There were days where I did not even talk to anybody. I talked to my cat [laughing]… You know what saved me was I did exercises on a YouTube video on my TV.” She missed going to dancing classes and searched for activities to substitute her pre-COVID activities. At the time of the second interview, some participants experienced greater freedom and opportunities to “keep busy.” For example, Evelyn (age 71) explained “I would say I feel a little bit more free, like, than I was. Because I was ordering in my groceries and things like that to start out with. But now I am going into the store and buying my own stuff. Um, going into the hardware store, getting what I need. Fixing, you know, fixing the things that I need to fix. And so, I don’t feel as isolated because I’m interacting.” For this participant who was very isolated and lonely in the first interview, the ability to get out for such small tasks was particularly important. In another example, George (age 88) explained how walking helped fill his days: “instead of going to visit people, if you see one on the streets you wave at him and say hi and keep going.” Many of the things people chose to do to fill their days were independent activities that took them out of the house and enabled brief encounters with others walking on the street or in the grocery store.The COVID-19 pandemic has changed our lives in many ways and continues to have tremendous implications for how we navigate our social environments. For the present study, we had the opportunity to have in-depth discussions with a small group of rural-living older adults over the course of three months during May–July 2020 in Manitoba. Although three months is a brief period, significant changes took place during this time. The longitudinal patterns in self-reported isolation and loneliness we observed suggest that, as time went on and restrictions eased, many older adults were feeling less socially isolated and lonely and were possibly returning to pre-COVID levels. We explored pre-COVID-19 levels of isolation and loneliness as well as factors that lessened or contributed to loneliness and isolation during pandemic restrictions.more isolated because of the profound physical distancing required with the COVID-19 restrictions. One of the unique contributions of this study, is that some older adults identified past experiences of isolation in rural places as a resource for coping with isolation during COVID-19. Like many of the other strategies identified, drawing on past experience was not without limitations, but some older adults suggested it helped them cope. Notably, in this sample of rural community-dwelling older adults, pre-COVID levels of perceived isolation and loneliness were quite high. For example, the present study sample in which almost 20% reported being occasionally (or more) lonely pre-COVID can be compared with 11% of adults ages 65+ reporting this level of loneliness in a Canadian population study . AlthougParticipants explained initial changes as a consequence of losing autonomy and choice as well as social activities and spaces that enabled them to mitigate isolation and loneliness in the past. Participants highlighted the importance of volunteering, going to church, and having coffee or eating out as protective strategies prior to COVID-19. The significant role of volunteering in the lives of study participants is consistent with research on voluntarism within rural communities, which suggests that involvement and opportunities to engage in local volunteer activities can mediate feelings of isolation and loneliness . MoreoveSome participants met their social needs through outdoor or physically distanced visits. It is important to highlight that this research took place in the summer months when weather was more conducive to outdoor visits. Several other factors influenced older adults’ in-person visits including their age, whether they owned their own home or lived in a congregate environment, whether they had access to outdoor space, whether they had neighbours close by, access to transportation and mobility limitations, their health status, the health status of others within their social networks, the number COVID-19 cases in their region, and the perspectives of their social relations. The most consistently lonely participants (those who reported being lonely most of the time) lacked access to many of these resources , highlighting the role of social and economic inequalities in contributing to isolation and loneliness before and during COVID-19 ,35. In aParticipants found ways to connect remotely through phone and video calls, text messages, emails, and social media. Consistent with existing research, some older adults lacked access to telecommunications infrastructure or digital literacy skills to make use of cell or internet services, which influenced their ability to connect face-to-face at a distance ,37. SuchOur study highlights the continued importance of paying attention to the environments and resources surrounding older adults and their influence on isolation and loneliness. Participants who felt the loneliest revealed the importance of resources and strategies for mitigating loneliness in their homes and surrounding communities, including the need for meaningful conversations during times of isolation. This was particularly the case for an isolated dementia carer, in the study, calling attention to the importance of remotely delivered social programs. Indeed, participants’ narratives suggest that both before, and during COVID-19, it was important to have a range of choices, activities, and places to go; this is not surprising, but the challenge ahead lies in how local communities and organizations support initiatives that meet the social needs of older adults safely.Local communities and organizations can learn from the challenges older adults faced and strategies they developed. For example, they can promote the development of modified, flexible or new activities such as online or physically distanced programs and services. The older adults in the study identified limitations of online and remote initiatives, but they also identified low tech strategies for mitigating isolation and loneliness such as telephone check-ins, using telephone support services, physically distanced outdoor visits, and keeping busy . Some of these strategies can be supported at the community level through campaigns to end loneliness, continuing safe volunteer opportunities for older adults, as well as access to safe walking paths and other outdoor community spaces. The early results of this study paint a somewhat hopeful picture—many older adults adapted and, among those who experienced increased isolation and loneliness, many returned to pre-COVID levels of isolation and loneliness—but the pandemic continues. We do not know how older adults’ experiences have changed even six months later. Continued longitudinal work on the impacts of the pandemic is critical to understanding the long-term impacts on social isolation and loneliness. We acknowledge that the three-month window in which data collection took place for this study was a small window of time, yet it was also a time of tremendous change and uncertainty in the lives of older adults. Capturing older adults’ perceptions of this change, through a rating scale and subsequent explanation, as well as their strategies for responding to significant change is important to inform public health policy and practice. Public health policy and practice that is out of touch with, or insensitive to, perceptions and experiences is likely to be ineffective or may even be harmful. Another limitation of our research is that most participants lived with someone and more women than men participated in interviews. In addition, few participants self-identified as racialized or Indigenous. Future research should explore the specific experiences of those who live alone as well as the gendered, classed, and racialized experienced of social isolation and loneliness during this time. Despite these limitations, the strength of this study involved its emphasis on capturing rich descriptions of this very particular time and place, characterized by unprecedented isolation. Future qualitative research should continue to explore older adults’ experiences and responses to change during the COVID-19 pandemic and beyond, with particular attention to their environments and resources.Rural community-dwelling older adults are a diverse group with different resources and strategies influencing their pandemic experiences of social isolation and loneliness; however, they share experiences of living in isolated places prior to COVID-19. Consequently, many had developed strategies to manage isolation and protect themselves from loneliness prior to the pandemic, some had resigned to a degree of isolation attributing it to their rural context, and a smaller number identified as isolates by preference, perhaps fitting into the ‘lifelong isolates’ grouping discussed by Newall and Menec . This is


More nuanced items within internal disciplinary procedure also vary across federations, such as standard of proof and evidence. The purpose of this study is to offer a comparative synopsis of the regulations of 43 IFs governing Olympic and certain non-Olympic sports, to provide a critical overview of specific aspects of the above mentioned factors in the regulations and to identify areas of improvement for the future.Manipulation of competitions has long plagued the sport industry, affecting almost every sport over time. While sharing certain common features, the regulatory provisions and procedural responses to this phenomenon by international federations (IFs), sports’ governing bodies, vary on many aspects, including the definition of the specific offence of “competition manipulation” itself, scope of application, especially in relationship to betting, categories of participants,  Manipulation of competitions has long plagued the sport industry, affecting almost every sport over time,2sport justice”) against an actor engaging in such an offence.For manipulation offences in sport, primary action, whether or not in parallel with state authorities, is ordinarily initiated by the respective governing body in the sport ; types and consistency in awarding sanctions across sports and within a sport/discipline for the same offence; as well as for more nuanced items within procedure such as evidence, notoriously problematic due to the clandestine nature of acts and limited investigative ability of sporting bodies compared to state bodies. This in turn is regularly seen to have implications within adjudication on elements such as standard of proof applicable, also increasingly codified, and when the burden of proof might shift from one party to another.This study is limited to a review of IF regulations, and specifically the definition of manipulation therein, of all IFs with disciplines currently within the Olympic or Paralympic Games ) as well as, for completeness and based on prevalence of relevant offences, a few additional bodies’ regulations, international and regional.Cumulatively, 43 IFs ,Each sport, IF, abbreviation for each IF, respective relevant applicable regulation , and its source are systematically listed in the Annex to this article. The study below looks at IF regulations as effective in December 2020.8Each IF’s regulations  were assimilated and then comparatively analysed for elements within the definition (Part II below), parallel offences (Part III), sanctions (Part IV) and particulars of the specifically applicable dispute resolution processes (Part V). Statistical trends through noting common factors across these elements are represented as graphs to assess common features in how governing IFs regulations treat the same offences.The vast majority of IFs studied have specific regulations on the manipulation of sports competitions even if, for some of them, these specific rules are limited to a few behaviours and provide that, for the rest, the IOC’s 2016 Code applies Fig.  and WS15Only four federations do not provide for any specific rules in terms of the manipulation of sports competitions  – which does not mean they do not punish match fixing categorically. Of these, one FIL nevertheMost IF regulations defer to applicable rules at a “major event” (as defined),At the outset, it is important to note that terms such as “manipulation”, “match fixing” and “competition fixing” are often used interchangeably at the international level both in legislation and academically,23ratione materiae and personae,Generally, it has been noted by several authors,first broad type reflects wording in the IOC 2016 Codenot relevant to this determination are usually listed including participation/attendance in the same event, outcome of event, nature of such outcome, receipt of consideration, effect on an actor’s performance and violation of any technical rules.31The second type of definition which many federations have typically exist within older policies encompassing all types of conduct or ethics within which manipulation can be brought, even if framed after 2016.37The Regulations studied contain both active as well as passive manipulation of sports competitions. Moreover, 39 of the 43 federations include omission within punishable behaviour.39In certain instances, common language is used across disciplinary offences or other violations to include within all of them the omission or passive contributions, bringing within its ambit aiding, abetting, other complicit, encouraging, inciting, inducing, assisting or concealing behaviour.40An intentional act is behaviour committed with conscience and will; conversely, negligent behaviour is committed without conscience and/or without will, while nevertheless remaining at fault through culpable improvidence that can be blamed on the perpetrator.41ignorance” or “having made a mistake” are not a defence.45If intention is provided for by all the IFs that have regulated the manipulation of competitions (the only unclear situation being the IFSCSave for one IF (IFSC) where the applicable provisions are general ones not defining manipulation,47The question arising here is whether the regulations aim to punish only those acts of manipulation that produce financial results or whether the punishability is extended to acts without immediate financial consequences. These include, for example, acts committed with the sole aim of obtaining a qualification or setting a record.50money or the equivalent.53The study of IF regulations shows that both financial and non-financial objectives are in IF regulations’ sights  have alternative ways to define and apply the term “benefit”. FIFA, for instance, does not include the element of “benefit” within its definition of manipulation at all,56Across the IFs, either the term “Participants”,60The actors which might be brought under manipulation regulations or definitions vary across IFs; whether or not an exhaustive list of entities to who the regulations are applicable, and might extend from parties ranging from continental and member federations to individual athletes, judges/referees right up to anyone authorized to “co-operate, collaborate or participate” in a sport’s activities.63ratione personae, through adjudicated IF decisions and on appeal, have been seen to include a range of actors as noted by authors before.67Finally, These actors, i.e. those to be proceeded against committing prohibited acts, might, or might not be “beneficiaries” of such conduct. Thus, as regards the beneficiaries of the manipulation, the question arises as to whether the act is punishable only if it brings a benefit to the perpetrator (as defined) or if it is also punishable when it is committed for the benefit of a third party. Such distinction is either found in the within the definition of the term “manipulation” itself,69Here again, the intention of most IFs is clearly to target both situations in their regulations Fig. .Fig. 4BeConnected to the definition of a “Participant”, and relevant to where/the jurisdiction in which manipulation offences take place, is the definition of what type of situation such regulations come into play. Certain IFs bring all types of activities within their purview,72It is observed that most IFs punish manipulation-related offences in both betting and non-betting sporting contexts Fig. ,73 and u76Under the provisions of regulations applicable to manipulation offences, most federations also define connected, overlapping or other corruption-related offences or sanctionable behaviour. In some cases, it is an overarching previous provision found within applicable regulations such as a code of ethics, prior to a specific set of regulations on competition manipulation being issued. These provisions remain most relevant in situation where no independent manipulation provision is yet defined.Corruption Offences: …d. No Covered Person shall, directly or indirectly, contrive the outcome, or any other aspect, of any Event. e. No Covered Person shall, directly or indirectly, facilitate any Player to not use his or her best efforts in any Event. f. No Covered Person shall, directly or indirectly, receive any money, benefit or Consideration on the basis of not giving their best efforts in any Event and/or negatively influencing another Player’s best efforts in any Event. g. No Covered Person shall, directly or indirectly, offer or provide any money, benefit or Consideration to any other Covered Person with the intention of negatively influencing a Player’s best efforts in any Event. …”78“Usually, the offences of betting on competitions defined to be of a specific interest to the subject of the regulation (see above), corruption or corrupt conduct through the acceptance of a defined set of “benefits” whether or not connected to manipulation, and  insider information are separately defined, over and above the above described offence of competition manipulation. To note, is the distinction made between betting in general and the specification of only certain kinds of betting as prohibited.failure to report, disclose and cooperate with investigations are also independently defined as a related offence across many federation regulations.81Very notably, ITF, under the TACP and the ITF Constitution brings all connected conduct under a robust definition termed “Corruption Offences” which includes as well all the ancillary sanctionable conduct described below. Article D.1 of the TACP reads:In some instances, the offence might be specific to the sport—a relevant recent example is WDSF, where the margin of subjectivity in awarding scores across disciplines is policed specifically to curb the ability for manipulation to occur, through a common applicable code of ethics, with an independent provision within the code prohibiting direct or indirect influence of the course or result of a competition as well.83Finally, it is worth making note of the structure under UEFA’s regulations due to the sheer number of cases adjudicated under their rules as applicable to clubs.91To achieve some degree of harmonization among the very disparate IF regulations, the IOC has published in 2018 Guidelines for Sports Organizations on the Sanctioning of Competition Manipulation (the “IOC Sanctioning Guidelines”).approx. 4 years ban and fine” for the betting-related offence, and “approx. 2 years ban and fine” for the non-betting-related offence. Also, under the IOC Sanctioning Guidelines, recommended aggravating/ mitigating factors globally to consider are: (1) whether the Participant is betting on a competition she/he is participating in; (2) the number and size of the bets; and (3) addiction to betting or other specific personal circumstances.94For example, for the “core” offence of manipulation of sport competitions and corrupt conduct,0–2 years ban and a fine”; however, for obstructing the investigation , the recommended sanction is slightly more severe, i.e. “1-2 years ban and a fine”. Naturally, mitigating/aggravating factors may apply.Another offence considered in the IOC Sanctioning Guidelines is the failure to cooperate, which has two faces: (1) failure to report, meaning that the participant has failed to report, at the first available opportunity, full details of any approaches or invitations received by himself or by another participant to engage in conduct or incidents that could amount to match fixing (Article 2.5 of the IOC 2016 Code), and (2) failure to cooperate with authorities during the investigation, including obstructing such investigation (Article 2.6 of the IOC 2016 Code). For failure to report or to cooperate, the IOC generally recommends a sanction of “These recommendations have had an important impact on the sanctioning regime applied by Olympic and non-Olympic IFs, many of which have chosen to incorporate them in their own regulations on match fixing. This is explained in details hereinafter.The sanctions provided for by the various regulations of the international federations are of several kinds. They range from warning (with or without a period of probation) to exclusion for life, including reprimand, disqualification, return of award, fine, suspension,97Fines are foreseen in almost all the IFs’ regulations to sanction competition manipulation. Sometimes its amount is fixed according to the advantage received by the offender,103ban, suspension or ineligibility, one means a ban on participating in the future sporting events or administrative functions, a future that may be very limited in time but also very distant, if not unlimited.107Under the terms Annulment of the result, deductions of points, return of awards and/or expulsion from the current competition, bans from venues or removal from held positions/membership from a body are also widely known sanctions in the regulations of the federations.108In addition to this, some federations now award restitution, education and rehabilitation programmes, social work, reprimands (sometimes public ones), payment of procedural costs, compensation to victims, an administrative fine , etc. The most “positive” measures envisaged , i.e. rehabilitation programmes, education and social work, are provided for by the FINA,113life bans.116It is important to note that the type of sanction present in regulations of IFs assumes significance as it is, in most cases, deemed final even if appealed from .The question of life bans assumes importance given this finality in awarding such bans. Recent (2021) manipulation-related decisions at the IF level have mostly seen life bans or very long, career ending bans—this is at least the case across the most prominent sports/IF from a match-fixing perspective being FIFA,121sporting death” of the respective person. However, unlike in most similar cases in criminal/administrative law, in sport there are no possibilities to periodically review the sentence with a view to reducing it and to reinserting the banned persons into their sport, nor is there a possibility to obtain grace, in exceptional circumstances. Mutatis mutandis, one may recall that, according to the jurisprudence of the European Court on Human Rights Article 3 (interdiction of torture and of inhuman or degrading treatment or punishment) of the European Convention of Human Rights must be interpreted as requiring reducibility of the sentence, in the sense of a review which allows domestic authorities to “consider whether any changes in the life prisoner are so significant, and such progress towards rehabilitation has been made in the course of the sentence, as to mean that continued detention can no longer be justified on legitimate penological grounds”.Further, it is noted that, from a comparative perspective, life bans are similar to certain criminal or administrative sanctions, such as the interdiction to practice one’s profession or, to some extent, to lifetime detention. A lifetime ban in this context hence equals a type of “Additionally, the issuance of life bans with this regularity requires consideration at the purpose of sanction in these contexts—whether retributive, deterrence or rehabilitation. Having noted the option of rehabilitative sanctions such as social work and education as well that a choice is made to issue life bans indicates a retributive and deterrent approach, which might serve the purpose of keeping such elements out of sport for such time to make sport clean (for the society), but not for assisting the individual. In such cases, the purpose of disciplinary sanctions in sport, could be seen to be different from that in the context of criminal law in society, otherwise.The question of purpose however, remains independent of the consideration of proportionality, also significant as federation decisions are often final (as noted above). This made determination of the quantum an important exercise. To this end, IF bodies may consider aggravating and mitigating factors, or other guidelines, as discussed below, if so codified. Such factors may also sometimes result in the CAS concluding differently.124level of responsibility or …equity”.128Aggravating and mitigating factors are usually listed in connection with sanctions, independent of factors listed as relevant (or “not relevant”) to establishing manipulation. Usually, these include age/youth/experience/inexperience, disciplinary record/prior violations, number of breaches, significance of benefit, potential to affect course/result, whether breach was part of a broader scheme, admission of violation/cooperation/assistance/remorselack of effect on the outcome of the match concerned, in mitigating sentences.131Such factors may be seen in the regulations themselves,It is interesting to note that certain federations make a distinction in their applicable codes between sanctions awarded for the same offences depending on factors involved (independent of the definition of the crime) such as—“fraud” , “fault” , “involvement” (indirect) and “attempting” (result agnostic) in their sections addressing sanctions.133It might be contested that the myriad factors that are present for consideration across federation guidelines result in a large amount of discretion with only vague guidance on how it is to be exercised. Comparing awards within, across sports and with other processes under law providing varied outcomes, compounds this further.Another question is whether there are procedures specific to an IF and, more particularly, whether there is a procedure designed to deal with cases of sports competition manipulation separately. While federation-specific procedure exists in all IFs, only some of them have an independent procedure for match-fixing cases Fig. . This evsport justice”, the sanctions being based in contractstate justice”). Depending on the applicable national law, the latter may be of a civil, administrative/disciplinary or criminal nature.ne bis in idem principle.138Sanctions for competition manipulation may intervene at different levels. First, as noted above, disciplinary sanctions are applied by sports bodies, according to their internal (private) sanctions system  may be challenged in front of the sports bodies’ internal jurisdictional bodies and in arbitration proceedings. The jurisdictional bodies created by sport associations around the world pursue the same goal: to settle disputes, to mediate and to guarantee the correct interpretation of sporting rules and regulations.139At the international level, IF bodies that have issued numerous decisions on manipulation offences include FIFA’s Disciplinary Body and Appeals Body.142Outside of these, notable federations which regularly issue internal decisions include the ITF through the International Tennis Integrity Agency (“ITIA”) which administers the TACP, 2020. At the time of study,  the ITIA lists 23 instances of persons serving sanctions not amounting to life bans and 26 instances of persons serving life bans (one such decisions being for life bans for three persons).145Finally, but not in the least, the ICC has pronounced four decisions through its internal disputes mechanism already on corruption and fixing offences in 2021.148Among the international arbitration tribunals, the CAS was the most solicited insofar as disciplinary match-fixing proceedings are concerned, being the forum to which most federations provide for appeals from their internal disciplinary proceedings.At the federation level, each international federation contains a distinct dispute resolution mechanism through which disciplinary matters are processed—i.e. a manipulation offence sought to be proceeded against by any of these federations in any discipline of any Olympic sport, has a defined channel under through which it can and will be addressed. Among these, some federations have procedures unique to manipulation offences,Certain bodies have more specific reporting, investigation, prosecution and adjudication rules which are applicable.155The standard of proof may range from balance of probabilities to comfortable satisfaction , which vary vastly. In this respect, it is important to note that the prevalence of life bans is significant, particularly in the context of proportionality , impact on athlete careers and the presence of alternative sanctions rooted in rehabilitation.The most important variations across sports concern basic Yet, on a more general level, it was found that there exists disparity in detail or attention within IF regulations, which could indicate the relative significance associated by sport administration in addressing manipulation-related offences, compared to the treatment of other integrity-related offences, and in particular doping.164Third, it was concluded that further consistency in procedural provisions across sports is desirable, aided by having uniform procedural standards applicable within a sport for various offences and across sports, given also, that sanctioning could work at various levels. This is also relevant in the light of increasing calls for protection of rights of parties and more specifically athletes, in internal IF adversarial processes.Last, as a look to the near future, it is noted that newer threats within sports would need more regulatory attention—digital currency being one such example.This research has been made possible due to the support of the Swiss National Science Foundation (SNSF-100011_192497).


A growing body of research has shown that people with dementia are using digital technologies to enhance lived experience. The COVID-19 pandemic has brought new digital opportunities and challenges and so provides a unique opportunity to understand how people with dementia have adapted to this new digital landscape. Semi-structured interviews were conducted with 19 people with dementia and analysed thematically. We generated five themes, showing how participants used digital means to combat the stresses of the pandemic by facilitating social connection, self-actualisation, enhanced well-being and by assisting with activities of daily life. These technologies helped to reduce isolation, provide access to support groups, create opportunities for cognitive stimulation and self-development, and engendered a sense of identity at a time of perceived loss. Despite these benefits, participants also reported challenges regarding cognitive fatigue and usability issues. We recommend that training on how to use digital technologies is co-produced with people with dementia and designers engage with the voices of people with dementia throughout the design process. In turn, this could promote the social connectedness, well-being and self-worth of people with dementia. There are an estimated 54 million people living with dementia worldwide, with numbers set to rise to 82 million by 2030 . DementiA diagnosis of dementia can also have a powerful social impact on a person, negatively affecting their sense of identity, self-worth and self-esteem ; enhanciWith recent medical and policy initiatives focused on diagnosing people in the early stages of dementia e.g. , it has More recently, HCI researchers have adopted an alternative approach that champions personhood and identifies dementia as a social construction . Lazar eThere is a greater need to understand the ways that digital technologies may enhance the lived experience of people with dementia  and thisDuring the COVID-19 pandemic, people with dementia were at risk of negative outcomes. They were adversely affected by a disruption of routines, lack of cognitive stimulation, reduced social interactions, perceived symptom progression and a rapidly ‘shrinking world’ . One keyHere, we adopt a ‘positive technology’ lens to investigate digital technology usage by people with dementia, where positive technology refers to the scientific and applied approach to the use of technology for enhancing personal experience . Riva, MDespite the potential of digital technologies, we recognise that some people with dementia may have faced challenges, particularly relating to access and digital literacy. For example, in work that examined experiences of accessing post-diagnostic dementia care, respondents found online forms of support to be unsuitable and inaccessible for those without access to the internet and electronic devices . The symThe design of digital technologies may also pose challenges for people with dementia. It is also possible that the dominance of digital technologies during the COVID-19 pandemic may have exacerbated already existing inequalities and a ‘digital divide’, not only for people with dementia but also other groups without ready access to the internet or sufficient digital literacy skills . Given tIn this research, we use the COVID-19 pandemic as a case when digital technology usage was enhanced. We ask, ‘how and why did people with mild-to-moderate dementia use digital technologies during the COVID-19 pandemic?’ to garner insights into the benefits and challenges that these technologies confer.This analysis is part of a wider qualitative study that examines the impact of the pandemic on people with dementia . In thisThe study was advertised on Twitter and subsequently shared by the accounts of dementia organisations and networks. The study was also advertised on dementia organisations and networks’ websites and in Facebook groups for people with dementia, after receiving permission from group moderators. Study details were also shared with facilitators of peer support and advocacy groups, who subsequently shared the study with group members. Participants were included in this study if they: (1) self-identified as a person with dementia; (2) lived in the United Kingdom and (3) had capacity to give informed consent.SD = 7.05 years) and 14 having young-onset dementia (i.e. diagnosed before the age of 65). All participants were living with mild-to-moderate dementia. Fourteen participants lived with family members and five lived independently; no participants lived in a care home. All participants reported being users of technology; however, some participants only started using certain types of technology  during the pandemic. Nineteen participants were recruited, with seven identifying as female and 12 as male. Participants were relatively young, with a mean age of 62.47 years . In accordance with the Mental Capacity Act , particiWe generated five themes: (1) Technologies to assist with everyday life; (2) Technologies for social connection; (3) Technologies to feel good; (4) Technologies to find meaning; and (5) Hypercognitive technologies. Participants generally reported positive experiences of using digital technologies, which may be because all participants reported using technologies to some degree. Our themes speak to the adaptability of participants, who used digital technologies to counter the stresses of the pandemic, demonstrating agency and a willingness to use digital technologies.Every Sunday I’d go for a stroll. It is it’s very nice, and I go for a walk most mornings early doors. But I started losing track of where I am. And it’s weird. So now what I’ve done is I’ve just used Google maps and I do photographs of landmarks and keep them on my phone and that’s okay. (P10)Participants described the ways in which they used digital technologies to support everyday life. During lockdown, people were encouraged to remain home, leaving the house simply for exercise. This meant that established routines were disrupted and for some, the outdoors became increasingly unfamiliar see . Some paI’m keeping away from shops because I’m not sure exactly how the system in the shops are working anymore I’m just used to going into a shop, getting what I want, and getting out. There seems to be a system now so that’s very very difficult to try and get to grips with. (P2)By using technology in this way, P10 was able to continue engaging with the outdoors and maintain his independence. Another key way in which people with dementia used digital technologies was for online shopping, primarily food shopping. Many of these participants turned to online shopping because they felt unable to visit stores offline due to a lack of dementia-friendly practices, practical issues with shopping and concerns about contracting COVID-19.We were helped by nobody, and if we didn’t have family to help us, we would be struggling. We tried to do online shopping and it was like a three week wait. You can’t do without food for three weeks. (P6)As I say I’ve been lucky because I’ve had my village shop because I couldn’t get online shopping. (P17)While some participants had success with online shopping, many experienced challenges as they were unable to obtain a delivery slot. Consequently, participants reported feeling anxious about whether they would be able to obtain groceries and often became reliant on the good will of family members, neighbours and others in the local community:We couldn’t get on to do the online shopping because there was no spaces left, you know I’ve had to rely on hubby because family don’t live nearby. There was nothing set up for any help for shopping. I don’t think they looked at the people with dementia as being vulnerable. (P4)It would have helped me if I’d have had a priority online shopping. So, it’s simply the recognition that we exist that wasn’t done at the beginning. (P17)This is consistent with other research conducted with people with dementia and unpaid carers, who also reported struggles purchasing groceries during the pandemic e.g. . In partThese findings suggest that while digital technologies for online shopping may be beneficial in theory, they are only effective in supporting those most vulnerable in society when policymaking is effective. Like It was hard. It was, to see it day after day. It’s the same old every day. It’s a good job I have people to talk to online, because it could have been a lot worse. (P14)Participants reported enhanced levels of loneliness and isolation during the pandemic, reflecting prior work . To combI think on a bad day when you can’t function and can’t think straight, just having someone outside the home and someone who’s got knowledge of dementia is vital really. (P7)Being able to connect with others with dementia was a ‘lifeline’ for some participants. They described using social media and video-calling software to share strategies on how to cope with the stresses of the pandemic, highlighting the importance of speaking to people who faced similar difficulties:It’s not like talking with other people who have got it. You laugh, you joke, you can laugh at yourself. My husband’s still coming to terms with it, and I can’t make silly jokes to make myself feel better because it’s not fair to him. It was very difficult but what they did with the [dementia group], we still have a meeting once a month but on Zoom, so that was lovely. (P1)Being able to connect with people outside the home environment was important for participants, who often felt they could not speak openly with family members. For example, P1 said she could not speak candidly about dementia with family members but could speak freely with her peers online:These statements suggest that participants felt a sense of community among other people with dementia; as P10 stated: ‘We used to be united against dementia, now we’re united against COVID-19’. Here, we are reminded of the value of group membership, which can provide people with the social and psychological resources to counter challenges of everyday life  and may That’s a pretty good bit of technology for me because I just found it so difficult and long-winded to write, that I wasn’t communicating, but now that I’ve got this app. I’ve got it on my phone and laptop. I can still do the odd emails, which is quite good because it’s great to have everybody to help you, but it’s still nice to do stuff yourself. (P12)Some participants experienced difficulties when using digital technologies to connect with others during the pandemic. To maintain their sense of social connectedness, they reported modifying the ways in which they used technology, exemplifying a willingness to continue using it. For example, P12 described his experience of using a speech-to-text application to facilitate communication with others:For P12, a speech-to-text app was important, given that opportunities for communication with people outside of the home environment was limited. These technologies appeared to not only improve the social connectedness of participants but also promote their independence by reducing the need for them to rely on others.We used to meet every month but during this, we’ve met every week online, which has meant that some people that couldn’t get there because they were just too far away sometimes could join us! It opened new opportunities. (P19)Interestingly, some participants felt that videoconferencing software made dementia groups more accessible as it removed the need for travel. As dementia groups moved online, participants reported attending more group meetings; in turn, this expanded their social networks. For example, P19 described her experience of meeting peers weekly (rather than monthly) and connecting with people from different places:These findings suggest that technologies such as videoconferencing software provide opportunities for social connection outside of one’s direct offline networks. Therefore, these technologies may provide one way of countering the ‘shrinking world’ that often accompanies dementia  and has Even though I have Zoom, it’s the people contact, the hugs, shaking people’s hands, seeing somebody you know face to face because we just haven’t had that. (P4)Despite these benefits, participants also discussed the limitations of virtual peer support. While participants said they felt socially connected during group calls, they missed physical expressions of support, such as a hug, handshake or pat on the back:While our findings suggest that interpersonal technologies provided an important coping mechanism for people with dementia during the COVID-19 pandemic, participants’ statements indicate that it was not a direct substitute for in-person support and may not be a suitable long-term means of support.Monday, we have the local councillor come along and we have someone doing chair-obics for half an hour. On a Tuesday is breathing exercises and then there’s an extra hour afterwards for chair-obics. (P5)Participants described using technologies to enhance well-being, consistent with We said pick three songs and say why they were very important to you. Everyone did that and it almost brought you to a time of your life with a story. There’s a story for every song you know, it’s great. (P16)Another way in which participants used technology to enhance well-being included using it for reminiscence, which has been found to have positive short-term effects on cognition, quality of life, communication and mood . ParticiThese findings suggest that reminiscence can be facilitated by digital technologies and was an important coping strategy for some, transporting them to happier times that allowed them to forget about the stresses of the pandemic.It would have got worse, but I’ve found that because we do a Twitter chat, so we’re finding out stuff about what people want to know and it’s just keeping your brain active. If you just sat and watched the television, you’d go loopy, you know you’d go loopy. I found that keeping very active helps. (P16)Previous work suggests that a lack of cognitive stimulation during the pandemic potentially accelerated symptom progression among people with dementia . When reIndeed, many participants were thankful for the cognitive stimulation that digital technologies offered, with some feeling that it provided a protective mechanism against symptom progression. Prior research highlights the importance of cognitive stimulation for people with dementia e.g. . Our finI learned it through YouTube. I can’t see the patterns very well so - on YouTube they do new different patterns that you can do, and they do it from start to stop so it’s usually easier for me so I’ve made quite a few. (P18)Researchers have recommended that technologies should be designed to support the higher-level needs of people with dementia, facilitating activities that boost self-esteem and self-actualisation . ConsistObviously for meetings, for Zoom and Microsoft, other sorts of things, so it is like learning a new skill. (P6)For others, learning how to use technologies was a new skill, which provided them with a sense of achievement. J1 spoke of using videoconferencing software for the first time:I’ve been acting as a liaison officer as a dementia advisor so that the hospital is dementia-friendly. And I’ve been down there once and when the restrictions took place, I’ve had a lot of Zoom meetings and team meetings with them. (P6)Other participants reported using technologies to support their advocacy work. This involved using video-calling software, social media, smartphones, tablets or laptops to give talks about dementia; blog/vlog about lived experience and educate organisations. One participant said he used Zoom to advise a local hospital on how to be more dementia-friendly:Using technologies to facilitate advocacy is important, given that advocacy can be an important coping mechanism for people with dementia, providing a way of regaining purpose, respect and ‘fighting back’ against the disease . Thus, aThe wonders of technology - there’s voluntary work I do that involves people living with this condition at home. (P9)Well church, I have church on Zoom and bible study on Zoom as well on a Tuesday morning which has helped me. (P3)In addition to online advocacy, participants said they used technologies to enhance self-worth by taking part in research, acting as advisors on studies, helping others with dementia, continuing voluntary work and taking part in religious activities:This use of technology engendered a sense of purpose among participants; as one participant stated, it made them ‘feel needed’. Meaningful activity is important for people with dementia as it can preserve dignity and a sense of identity . Our finI overused zoom to start with. On the day, my eyes were dry and tired, couldn’t concentrate. The day after would be a “foggy” day, meaning brain on a real go slow, could do nothing. (P8)People with dementia may face accessibility issues when using technologies, such as difficulties with readability and issues with navigation . In our The face to face I can sort of - not lip read - but sort of know what they’re saying but it’s still difficult, a lot more than a normal meeting because well sometimes it can go that way in a call. (P18)While Zoom fatigue has not been empirically tested or fully conceptualised in research, its effects appeared strong for people with dementia, causing headaches, fatigue and enhanced problems with concentration. This may be because conversations via video-calling software were more demanding for participants. For example, participants described the challenge of managing conversations without non-verbal cues:Non-verbal cues such as bodily contact, eye contact and gestures can promote effective communication with people with dementia . HoweverA lot of Alzheimer’s stuff really, recognizing people, and when I get on the Zoom, I can get embarrassed. So, I just come out of it because I can’t put their names up on the screen and can’t remember who they were from last week, so that’s upsetting really because I don’t feel part of the group. (P7)Participants also described perceptual problems, whereby they found it difficult to process images or recognise others on screens. This gave them headaches, created awkward situations and exacerbated feelings of embarrassment and exclusion:I eventually got around to using technology but I have to have someone on hand or someone to set it up for me unless I’ve done something wrong with technology, I press the wrong button. (P7)I wouldn’t be able to do it if my husband wasn’t here. (P1)Another key challenge concerned participants’ ability to navigate and remember how to use digital technologies. As a result, participants often felt they were reliant on others:Maybe there can be a sort of card that can be sent, when you’re setting up a Zoom meeting, maybe a card can be sent through, or an email, with it on there. (P1)While assistance from family members was necessary, participants expressed that they wanted to use technologies independently. They provided suggestions for promoting independent technology usage among people with dementia, including training courses and dementia-friendly instructions. One participant suggested that accessible instruction cards could be sent to people with dementia:This could be beneficial for people with dementia, promoting their independence by enabling them to use technologies without relying on others. In turn, this may promote self-growth and enhance levels of mastery.We examined how people with mild-to-moderate dementia used digital technologies during the COVID-19 pandemic to examine the benefits and challenges these technologies presented. Using a positive technology lens, we found that digital technologies such as video-calling software and social media hold great potential to boost social connectedness, well-being and self-actualisation among people with dementia. In line with our critical dementia approach, we recognise that such technologies helped many participants to maintain a sense of self as a contributor to society, whether through digital volunteering or through skills acquisition cf . Our finDespite these benefits, participants also outlined the challenges they faced when using technologies. For example, they found it cognitively demanding, experienced perceptual difficulties and struggled to manage online conversations. In some cases, even when technologies were available that could assist with everyday life (i.e. online shopping), these were ineffective as policies did not identify people with dementia as ‘vulnerable’. As there is increasing pressure for offline spaces to be dementia-friendly e.g. , we advoWhile participants demonstrated an ability to learn technological skills, they often expressed a need for training on how to use digital technologies. This training could be particularly helpful for people with dementia who live alone or who may not have support directly available to them. We therefore recommend such training is developed and helpful resources are made available. As one participant suggested, dementia-friendly leaflets could be developed that contain accessible information on how to use technologies, such as email, Twitter and Zoom. However, it is important that resources are co-produced with people with dementia. Other researchers have developed initiatives that aim to support older adults in training their peers to be aware of cybersecurity threats and how to counter them (e.g. CyberGuardians; Despite our promising findings, there are some limitations of our work. Firstly, we did not include operationalised measures of dementia, well-being or social connectedness in the study design and instead relied on self-reports. In the future, such measures could be included to verify diagnoses and further explore associations between technology usage and well-being.Participants were recruited from social media and remotely through dementia networks. Therefore, our sample may have been more likely to have positive views of technology. Consistent with this, the participants in our sample often recognised that they occupy privileged positions to be able to access the internet and digital technologies. This may not be the case for individuals who live rurally or who are from lower socio-economic backgrounds. In the future, researchers could speak to people with dementia from diverse backgrounds and individuals who do not use technology to examine the barriers they face.Our sample was also relatively young, with most participants having young-onset, mild-to-moderate dementia. Research suggests that people with dementia who use technologies such as social media tend to be relatively young , which bIn conclusion, people with mild-to-moderate dementia used digital technologies to facilitate social connection, improve well-being, promote self-actualisation and assist with everyday life during the COVID-19 pandemic. For example, they used video-calling software to access peer support and combat isolation; games and social media for cognitive stimulation and YouTube videos to learn new skills. Participants viewed these technologies as vital in combatting the social isolation, loss of self-worth and lack of stimulation that accompanied the pandemic. Therefore, our findings speak to the ability and willingness of participants to adapt to the stresses of the pandemic and use technology to meet their needs, suggesting that they should be viewed as active agents rather than passive users. Despite these benefits, people with dementia sometimes found it difficult to use technologies, experiencing cognitive fatigue and facing usability issues. In some cases, even when digital technologies were available and could be used to assist with everyday life, these were ineffective due to policies that did not identify people with dementia as ‘vulnerable’ and therefore provided a barrier to accessing basic necessities. In future, we recommend that training on how to use technologies is co-produced with people with dementia and that designers of digital technologies engage with the voices of people with dementia throughout the design process. In turn, this could promote the digital inclusion, social connectedness, well-being and self-worth of people with dementia.


Endoscopic submucosal dissection (ESD) is considered superior to endoscopic mucosal resection as an endoscopic resection because of its higher en bloc resection rate, but it is more difficult to perform. As ESD techniques have become more common, and the range of treatment by ESD has expanded, the number of possible complications has also increased, and endoscopists need to manage them. In this report, we will review the management of critical complications, such as hemorrhage, perforation, and stenosis, and we will also discuss educational methods for acquiring and improving ESD skills. Endoscopic submucosal dissection (ESD) is a form of endoscopic resection that originated in Japan as a treatment for early-stage gastric cancer . Today, We identified studies through a literature search of the database (PubMed), with the last search performed on 31 May 2021. The key words were “endoscopic submucosal dissection” OR “ESD” AND “complication” OR “postoperative bleeding” OR ”traction” OR “perforation” OR “stenosis” OR “training”. We restricted the studies to those written in English.Postoperative hemorrhage is one of the most serious complications associated with ESD. Most postoperative hemorrhages can be treated conservatively or with endoscopic hemostasis, but some cases may progress to the point where interventional radiology or surgery is required and may even be fatal, and endoscopists must manage them appropriately. In esophageal and colorectal ESD, the incidence of bleeding after ESD is low, and there are few cases of shock . In the 2 receptor antagonists (RAs) is expected to prevent postoperative bleeding in gastric ESD, as in cases of peptic ulcer. In fact, PPIs have been shown to be more effective in reducing the risk of post-ESD bleeding than H2 RAs [As maintaining an intragastric pH higher than 5.4 promotes blood coagulation and platelet aggregation , adminisn H2 RAs ,12 and an H2 RAs , suggestn H2 RAs . It has n H2 RAs .There are many reports that suturing and covering post-ESD ulcers are useful for reducing postoperative bleeding. Suturing has been reported to reduce postoperative bleeding in gastric EMR , colorecWith the increase in the elderly population worldwide, the number of people taking oral antithrombotic agents is also increasing. While endoscopic bleeding should be avoided as much as possible, thromboembolic events, such as cerebrovascular events, are potentially lethal and require careful handling. The Japan Gastroenterological Endoscopy Society has issued guidelines on antithrombotic agents for endoscopic examination and treatment . These aPerforation in esophageal ESD may lead to mediastinitis, and perforation in gastric and colorectal ESD may lead to peritonitis, which may be fatal in some cases. The incidence of perforation in esophageal, gastric, and colorectal ESD is 3.2% , 2.9% 2, and 4.8The clip-with-line method is a simple method proposed by Oyama et al. . After tThe S-O clip  is a traction device with a spring attached to the clip arm developed by Sakamoto et al. . SimilarIn esophageal ESD, if the circumference of the postoperative mucosal defect is larger than three fourths of the circumference of the lesion, there is a 90% probability of stenosis during the postoperative healing process . StenosiAlthough various approaches can be used to avoid accidental injury, as described above, it is fundamentally important to acquire a reliable ESD technique that does not cause accidental injury. Although it has been reported that it is generally favorable to start ESD training in the gastric antrum and the rectum because of the thickness of their walls , the incIntraoperative and postoperative hemorrhage, perforation, and postoperative stenosis are critical sequelae associated with ESD, and their prevention and management were presented in detail in this review. There are multiple methods for each of these, and it is necessary to find an appropriate method for each facility. Furthermore, the establishment of training methods for ESD may be a measure to prevent complications in the long term .


The purpose of this study was to examine the characteristics, attitudes, and perceptions of older musicians who participated regularly in a local blues jam. Six core dimensions of eudaimonic well-being and their conceptual foundations provided a framework for examining the way that music-making contributes to subjective well-being during the lifespan of an individual. The following research questions guided this investigation: (1) In what ways do biographical factors and engagement with music influence the lives of older adult blues/rock musicians who participate in a local blues jam? (2) What implications for subjective well-being with regard to music learning might be used to inform music education practices? Interviews and observations over a 2-month period provided data for understanding how lived experiences impacted personal well-being, and musical growth and development over time. Findings suggested that eudaimonic well-being is the result of active engagement in human activities that are goal-directed and purposeful, and a good life involves the self-realization of individual dispositions and talents over a lifetime. Implications for music education include individualized pedagogical approaches that encourage learners to discover a sense of well-being in and through music. The blues jam at The Tavern on the Hill is open to musicians of all ages, but most participants are baby boomers. The jam provides an opportunity to gather, socialize, have a few drinks, and participate in informal, improvisational music-making. Bringing an instrument or set of drumsticks to the jam indicates a willingness to perform. Hot Rod Billie, the owner of The Tavern, motions people carrying instruments toward a clip board so they can sign-up and be called to the stage. Participation is encouraged and expected.schema, cognitive and executive functioning, and the ability to carry out systematic and prioritized attention .The intersection of these constructs made it possible for me to examine individual well-being from the perspective of participants’ lived experiences with regard to individual, cultural and social engagement with music during the course of a lifetime.Music is an integral part of human life. According to Although the wider benefits of music for younger people are well documented , “less aA number of music-related effects, drawing from the positive psychology movement, have been associated with eudaimonic well-being . They inperformance goals, which challenge one’s ability, and learning goals, which are about expanding one’s competencies. Goal-directed behaviors foster a sense of mastery, a construct associated with eudaimonic well-being.Innate psychological needs drive human behavior . Deci anIndividual musical development is shaped by a range of cognitive, social and cultural factors that remain fluid and are constantly changing. Over the lifespan, musical development is characterized by “time-related changes in musical abilities, motivations, functions and musical activities” , p. 367.autobiographical awareness I began my data analysis by highlighting “first impression phrases derived from an open-ended process called initial coding” , p. 4. NElectrified forms of pop and rock music figured prominently in the musical biographies of the participants. Stevie B, a retired law enforcement officer, told me that he started playing drums during elementary school and that his skill level improved considerably after he started taking private lessons. Stevie B’s teacher taught him to play blues-based rock songs by The Rascals, Led Zeppelin, and Cream. During junior high, Stevie started playing in bands. Stevie B. talked a lot about his early experiences; how he enjoyed being in a band, how it was a thrill to be on stage, how music made him popular with girls, and about his fondness for silly songs like “Secret Agent Man.” By age 19, frustrated by the breakup of his band, Stevie B. sold his drums and didn’t play again for 43 years.Morse Code became a musician in the fifth grade when he auditioned and got accepted into the school band. During high school, Frank hung out with friends and listened to jazz, in particular Miles Davis. Frank playing took off when he startedtaking saxophone lessons with “Boots” Mazulli, whose teaching was focused on improvisation and aural skills. After high school, Frank got drafted and served in Vietnam. When he returned home, he started an R&B band called Wadell and the Undone. As a young man, Frank played out four nights per week while holding down a day job as a mechanic to support his family.Frank Morse, leader of the band Frank told me:I always leaned toward R and B and soul music because it’s just in me. It’s not so dry as some of the classic rock stuff is. Soul’s got an undertone going to it all the time and if you can ride that and feel that, it’s nice. It’s very comfortable. It’s a nice place to be.Frank never stopped playing music. He joked, “Probably never will stop. Pat me on the head with a shovel.”Morse Code. As a child, Todd “beat on things when he heard music” so his mother bought him a drum set for Christmas. Todd did not get involved with music in school. He said, “I felt like in school it was all marching band and uh, you know, jazz band stuff and I wanted to play rock n roll.” Todd had to quite taking drum lessons because he did poorly in school. Ultimately, Todd learned to play drums by playing along with LP records by Kiss, The Cars, and Cheap Trick. Todd told me he loved playing the blues, and that bands like Led Zeppelin led him to discover artists such as Willie Dixon and Curtis Mayfield. Todd revealed that the secret of playing the blues and jamming was to “keep things simple and play a groove.”Todd Zabel met Frank Morse at the jam, which is how he got a gig with James DeCosta arrived at the jam early each week so he could set up his amp and effects pedals on stage. When I asked him to tell me about himself, James began with, “I’m self-taught. I’ve been playing since I was about 19. I’m 66 and retired. So basically, it’s like some people have bowling night, I have music. It’s just that simple, you know.” James’ interest in guitar playing began with the Beatles, which prompted his parent’s to purchase a Silvertone electric guitar from Sears. He learned about the blues by hanging out with friends. When I asked about his musical influences, James said:The British blues guys were my thing. Blues breakers, you know John Mayall, Clapton, all those guys. The Yardbirds, Jeff Beck, all those guys. Besides, it was more of an edgy kind of blues that I liked. BB King and Freddy King and Muddy Waters too.James was not in a band, but he attended as many as three different jam sessions each weekend.Shameless. As a child, Chuck wanted to play bluegrass, so his parents bought him a four-stringed banjo. Frustrated with the banjo, Chuck picked the bass when he heard metal bands like Deep Purple and Black Sabbath. During college days, Chuck played in bands and gigged in the Boston area. After college, he “just messed around in the basement, playing along with albums and CD’s.” About 15 years ago Chuck decided to “get serious,” and found a band by attending a local jam. For Chuck, music was primarily a social activity. He was looking toward retirement and thinking about relocating. His musical goals entailed developing a “new circle of musicians” to hang out and jam with.Chuck Boulos was still working as an electrical engineer, but he was thinking about retirement. He spent weekends gigging with a heavy, classic-rock band called Della Erskine grew up singing on a farm in rural Carver MA. She described her childhood as:“…all cranberry bogs, you know, scooping cranberries, raising chickens and pigs and all that stuff. I don’t know if it’s still standing, but our house had an outhouse. We didn’t have a traditional bathroom until high school, after we got an apartment in town. Didn’t graduate. I did not graduate from high school because of a reading disability.”Della attended school in Plymouth where she sang classical, jazz, and pop music in the choir. Outside of school, R&B, soul, and the music of Motown inspired her to become a performer. After leaving high school, Della moved to Somerville, got a waitress job, and started singing in nightclubs. She preferred doing jazz, something quiet and mellow, but she was also comfortable with the blues. Her friends said, “You know Della, you’d be a great blues singer,” so she learned blues standards and got gigs singing with local bands in the Boston area.The youngest participant, Jay Bird (nickname), met Hot Rod Billie at another jam, which is how he found his way to The Tavern. Jay Bird considered himself to be a “second-generation blues musician.” Although he grew up listening to alternative rock in the ‘90’s, Jay Bird learned songs by John Lee Hooker, T Bone Walker, and British rock groups like the Kinks and Cream when he and his friends discovered a parent’s vinyl record collection. Now, at age 42, after raising a family, Jay Bird was looking to get back into music. Jay Bird was introspective about his relationship with music saying, “I find that fascinating that your brain is kind of wired to music and the relationship of music to what’s going on in your life is very connected.”I sought to know how biographical factors and engagement with music influenced the lives of older adult blues/rock musicians. In the following section, I use the words of the participants to illustrate how lived experiences in and through music fostered a sense of well-being.Environmental mastery suggests being able to self-select a particular lifestyle or seek surroundings that satisfy specific needs  is defined as any “increase in knowledge, skill, accomplishment, or personal development that an individual selects and brings about because of his or her own efforts” , p. 2 RoArtistic processes that lead to a “good life,” are embodied during music-making.and eudaimonia are among the ultimate aims of music making and music teaching and learning” (p. 59).Like Della said, “There’s that one song you will hear, and it will just trigger a good, joyful feeling inside of you.” Music classrooms, community music settings, and private studios have the potential to be sites of musical and intersubjective interaction where people can experience “happiness, flow, fellowship, care for others, well-being, and many other attributes of eudaimonia” , p. 70. This study emerged from my desire to explore ways that well-being, in and through music, is central to living a “good life.” Well-being is “at the heart of artistry and what it means to live rightly in the world with others” , p. 1. IUnderstanding the variety of ways that older people perceive themselves in relation to music has the potential to explain how engagement with music and music learning may to contribute to a better quality of life during the lifespan of individuals of all ages. Perhaps this investigation will inspire future research studies on eudaimonic well-being within a broader range of popular and community-based music settings that include people from a variety of age groups and geographic locations. It is my hope that this study will inspire individualized, improvisatory approaches in music classrooms as well as other contexts where humans embody participatory music-making as an act of joy.The raw data supporting the conclusions of this article will be made available by the author, without undue reservation.The studies involving human participants were reviewed and approved by the Boston University IRB Protocol #5312X. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.The author confirms being the sole contributor of this work and has approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.