Substantial numbers of students in Higher Education (HE) are reporting mental health difficulties, such as mild to moderate symptoms of depression and anxiety. Coupled with academic skills challenges, these difficulties can lead to decreased academic performance, low levels of study satisfaction, and eventually drop out. Student support services are facing budget cuts and can only attend to limited numbers of students, usually the ones who present with more severe mental health problems. Moreover, face-to-face contact may not appeal to those students who feel embarrassed by their problems or are afraid of being stigmatised. To address this important problem, an online psychological wellbeing and study skills support system called MePlusMe, has been developed to provide personalised support to its users. In the present study we investigated the feasibility and acceptability of the contents, design, and functionalities of the system.An offline version of the system was introduced to 13 postgraduate and undergraduate students  in a UK HE Institution, who presented with mild or moderate mental health difficulties. The participants evaluated the design of the system, its functionalities, and contents at Baseline and at Weeks 2, 4, and 8.Participants found the system easy to use, professional, and efficient and its contents non-judgemental and informative. Participants stated that engaging with and practicing the techniques targeted at mental health difficulties led to improvements in positive thinking and self-confidence, while the study skills techniques were practical. Suggestions for further improvement included the development of an app and an option for direct engagement with professionals.The findings confirmed the acceptability of the contents, design and functionalities of the system, while providing useful information to inform its further development. Next steps include a feasibility study, which will test and quantify the effects on everyday functioning, mood, mental wellbeing, and academic self-efficacy after using the system, and subsequently a randomized controlled trial, which will evaluate its effectiveness. The life of a Higher Education (HE) student can come with a wealth of exciting experiences, invaluable memories, and new challenges. However, during such a critical period of personal, social, and academic development, some of these new challenges may result in initiating or exacerbating existing mental health issues or in making study skills challenges more prominent . A worryAn increasing number of students in Higher Education Institutions (HEIs) are experiencing mental distress and mental health conditions in the UK. In 2015 the Higher Education Statistics Agency (HESA) reported that a total of over eighty thousand students requested counselling from their HEI’S, compared to sixty thousand in 2013, a rise of over 27% . FurtherIn 2014 HESA surveyed 2843 students and found that the prevalence of depression and anxiety was 15.6% among undergraduate students (13% for graduate students) , althougAnxiety and depression symptoms are the most commonly reported by HE students ; with ovThe effects of mental distress and untreated mental health conditions can be debilitating, and has been highlighted in HE students in the form of decreased levels of academic performance . Study sHEIs often provide on-site student support services which may include academic services, such as essay writing courses, employment services, such as Curriculum Vitae (CV) workshops, and on site counselling. Data requested under the Freedom of Information Act shows that between 2011 and 2016 there was an 84% increase in the number of students contacting the counselling support service at their HEI . MoreoveIn 2011 the RCP reported that access to mental health services on the NHS has progressively narrowed down to focus on high-intensity treatments and severe illnesses, resulting in the clear majority of students presenting with mild to moderate symptoms not fitting the criteria for NHS Primary Mental Health Care . This naAnother limitation of student support services is the lack of continuity of care that students may face when using them . For exaThe RCP  suggestsThere is substantial evidence that supports the effectiveness of computer-based programmes when compared to face-to-face CBT , 34, 35.In recent years, several web-based systems have started to offer psychological support, advice, and information to the public, for example NHS Silvercloud and PLUS . HoweverThe present paper will investigate the feasibility and acceptability of the contents, design, and functionalities of MePlusMe, an online support system designed specifically for HE students who are facing mild to moderate psychological and/or study skill difficulties, or for students who just simply want to take care of their psychological wellbeing and improve their academic competence. MePlusMe is the only system that currently offers personalised interventions in video format for HE students by addressing depression and anxiety symptoms and study skill difficulties. Unlike these, the packages offered by MePlusMe can vary each time depending on the user’s present difficulties, thus facilitating multiple uses from the same user, resulting in an increased likelihood of recurrent and long-term engagement.iConcipio has designed a web-based solution under the name MePlusMe . It is dSeveral filters throughout the system, including a “panic button”, refer students with severe difficulties to other services for more intensive support. The rest of the students can easily use the system by following one of the two available routes. The first is a symptoms-based assessment (Questionnaire route) that invites users to identify the symptoms they experience, and the second is a technique-driven approach (Library route) whereby users select directly their preferred techniques. Both routes lead to a customised package of psychological wellbeing and/or study skill techniques presented in 2D animated video format.The screening questionnaire has been adapted from the following established tools and clinical questionnaires: the Hospital Anxiety and Depression Scale [HADS] ; the GenThe design of the questionnaire addresses symptoms, instead of conditions/diagnoses and the system automatically links clusters of symptoms with specific video techniques. As a result, each package represents the best-fit solution for students tailored to address the specific difficulties they face each time. The library route leads to the package of techniques that students themselves see as best-fit to address their challenges. This route allows students the flexibility to edit their packages at any point by adding the techniques that they prefer or by deleting unsuitable techniques.All the techniques that are provided are evidence-based. The psychological techniques derive from current treatment models such as Cognitive Behavioural Therapy (CBT) and Mindfulness –50 and tUsers are also asked to report how well they are doing over time, starting on the day they undertake the Questionnaire or Library route and then after 2, 4, and 8 weeks. This self-monitoring progress is shown in the form of a motivational graph. When a package is not relevant anymore, students can archive it for later use. Moreover, they can quickly access and restore past packages any time they wish in order to use them again. MePlusMe further offers an integrated, monitored online peer support network. Student engagement is encouraged in this social section of the site, called “Thoughtwall”, a space where students can post their thoughts under their chosen nickname, “like” the shared thoughts of other users, and share their progress graph after completion of a package. They can also share their thoughts and graphs to other sites outside MePlusMe. Finally, students can personalise their profile by uploading pictures of their preference on their “Wall”.Preliminary market research conducted via the use of semi-structured interviews with counsellors and psychologists working in student support services within four UK HEIs  revealed current challenges and positive responses to the enquiry about an online solution . This step enabled researchers to gather an understanding of current support services, the challenges they are facing, and whether an online system could fit into the market. An online survey was subsequently conducted which helped to identify difficulties faced by students at university, opinions on online support systems and what features students may want the system to include, or what may look appealing on the site . FindingTo date, iConcipio has developed the contents of MePlusMe, namely the design and all the initial video techniques and certain functionalities of the platform, with the exception of some automatized ones. The present study aims to collect qualitative data on the feasibility and acceptability of the MePlusMe’s contents in order to further develop the system. Furthermore, data gained from participants will contain user feedback on how engaging they found the media elements of MePlusMe (the video techniques). It will introduce this material offline to UK HEI students who will be administered one of the routes (Questionnaire or Library) and who will then receive their own customised package of techniques. Students will answer questions regarding the system’s design, functionalities, and video contents. They will then be advised to use their suggested techniques on an as and when needed basis. The students will be approached again to answer questions regarding their interaction and satisfaction with the video techniques on weeks 4 and 8 of the study. It is expected that students will enjoy MePlusMe’s personalized, friendly, and easy-to-use design, as well as the multimedia instructional videos alongside their supporting documents. We expect to see sufficient engagement with MePlusMe’s techniques as well as positive feedback about MePlusMe’s design and contents.Undergraduate and postgraduate students undertaking full- or part-time study at the host University were eligible for inclusion. Potential participants also had to be over 18 years old and comprehend English well enough to understand the intervention materials. They also had to present only minor to moderate, and not severe, psychological difficulties, as assessed using the GAD-7 , the PHQParticipants were recruited using various channels, including advertisements posted on the University’s online portal (blackboard), communications from the Student Union and social media. Leaflets about the study were also distributed around the campuses and at the end of some lectures. The University student support services and the student engagement team also provided information about the study to students where appropriate. Recruitment communications included basic information about the study, what it entailed, and the eligibility criteria. The study received ethical approval by the host institution (anonymised for the peer review process).Whether they were recruited online or face-to-face, potential participants were given a link to a webpage where they could read detailed information about the study. They were also presented with the screening statements to decide whether alternative services would be more suitable to them and allow them to exit at this time point. Remaining participants were then presented with the consent form. They had to agree to all statements on the form and register themselves to participate in the study by leaving their contact details. They were then contacted by the research team within a few days of registering to invite them to the face-to-face group session. Each student had to attend a group session only once; twenty face-to-face sessions were offered in total.MePlusMe, the online support system developed by iConcipio, the contents of which was under study here, offers access to techniques tailored to users’ needs and designed to address mild to moderate symptoms of anxiety and depression, as well as study-related difficulties. Following registration, users can either follow the symptoms-route (‘Questionnaire’) or the techniques-route (‘Library’), before they receive a tailor-made package with techniques that best address their needs at the time  to ‘nearly every day’ (scored “3”). The items are negatively framed, therefore higher scores indicate increasing symptoms. Possible scores range from 0 to 21, and scores of 5, 10, and 15 are taken as the cut-off points for mild, moderate, and severe anxiety.The GAD-7 is used as a screening tool and a severity measure for generalised anxiety disorder. It comprises seven items and is scored using a four-point Likert scale ranging from ‘not at all’ (scored “0”) to ‘nearly every day’ (scored “3”). The items are negatively framed, therefore higher scores indicate increasing symptoms. Possible scores range from 0 to 27; scores ranging 0–4 indicate no depressive symptoms, 5–9 mild, 10–14 moderate, 15–19 moderately severe, 20–27 severe depressive symptoms.The PHQ-9 assesses the severity of depressive symptoms. The scale includes nine statements scored using a four-point Likert scale ranging from ‘none of the time’ (scored “1”) to ‘all of the time’ (scored “5”). Higher scores indicate enhanced mental wellbeing. Possible scores range from 14 to 70. England’s population mean score is 51.6 (SD = 8.70) .The WEMWB scale was used to assess participants’ mental wellbeing. The WEMWB comprises 14 positively worded wellbeing statements and uses a five-point Likert scale ranging from ‘http://www.sane.org.uk/) and Nightline (https://www.nightline.ac.uk/), and they would be excluded from the study. However, none of the participants screened out for this reason.PHQ-9, GAD-7, and WEMWB ratings were obtained at baseline and repeated at Weeks 2, 4, and 8. The absence of severe difficulties was also ascertained during the screening phase, where participants were presented with statements with regards to risky and/or aggressive behaviour, unusual sensory experiences or beliefs, and intentions of self-harm, and were prompted to think whether they relate to any of these experiences. Participants who related to any of these statements would automatically be given information on where to seek more appropriate help, including the accessible mental health helpline services SANE  some items of wording were adapted to enhance comprehensibility for the UK setting, for example “term papers” were replaced by “coursework” and (b) two of the 27 items were removed  because they were of limited relevance to the study participants. We used a total self-efficacy score , and so possible scores range from 0 to 250, with higher score denoting greater self-efficacy. Although this item removal will affect the psychometric properties of the measure, we consider this effect to be of limited importance because we are using a total  score, and (because this is an exploratory feasibility study) using scale score only for descriptive analyses.The SEF was used to measure self-efficacy regarding study-related skills. The original scale was developed with U.S. college students and comprises 27 statements that describe positive study-related behaviours  and uses a ten-point scale where 0 means ‘How well are you getting on now in your daily life”, which was measured using a five-points Likert scale ‘not at all well’ to ‘extremely well’.The users’ everyday level of functioning was assessed using the question ““I am currently having a difficult time studying at university”, “I am currently having a difficult time emotionally at university”, “I think the support system (MePlusMe) is a great idea and I want to find out more”, “I have nothing better to do”, “Other, please specify”). They were moreover asked how satisfied they were with the features and the contents of MePlusMe  with response options including “Very poor”. “Poor”, “Fair”, “Good”, “Very Good”, what they liked and did not like about the overall design of the system (open-ended questions), whether they liked the name (“Like a lot” to “Dislike a lot”), whether they liked the “MePlusMe Philosophy” video (“Like a lot” to “Dislike a lot”), whether they used other online support systems  and how they compare to MePlusMe, as well as their overall satisfaction of the system (“Very satisfied” to “Very dissatisfied”). They were also asked to comment on areas for improvement.At Baseline, participants were asked the reason they decided to participate in the study  and practised the techniques , how they felt MePlusMe has helped them so far (open-ended), whether they contacted student support services after accessing the materials (“Yes”/”No”), where they will seek support in the future if need be , how likely they are to recommend MePlusMe to a friend (“Very likely” to “Very unlikely”), and whether they plan to continue using the system after the completion of the study (“Definitely will continue” to “Definitely won’t continue”). They were also invited to share their recommendations to improve MePlusMe. Participants had the opportunity to provide qualitative feedback to questions, where appropriate.At Weeks 4 and 8, participants were asked how often they watched  an online session where students had the opportunity to read in depth information about the study, decide whether they meet the study’s inclusion criteria and sign the consent form, (b) a face-to-face group session (Βaseline), and (c) three online follow-up sessions at Weeks 2, 4, and 8. All data were collected online using the Qualtrics software.The aim of the group session was to introduce participants to the system and its contents, take them through the system’s assessment routes (Questionnaire or Library) and create the individual packages of techniques tailored to their needs. Most of the verbal information communicated on the day were coming from a script to keep the same conditions across participants and to replicate as closely as possible the experience of the fully developed online system .In the first part of the session, participants were introduced to the system by watching a video on the rationale of the system  and werIn the second part of the session, participants were individually administered by a member of the research team the assessment route they preferred (Questionnaire or Library) to identify their current difficulties. They were then asked how well they were functioning in their lives whilst experiencing these difficulties . Participants were then required to name their package of techniques and indicate whether they wished to receive reminders to watch the videos for the duration of the study. A 20-min break followed, during which researchers used the students’ answers to put together their individual personalised package of techniques, upload it in an individual folder on an online storage provider and email students a link to access their folder.After the break, participants were asked to log into their emails and click on the link sent to them to access the folder. The folder contained their individual package of techniques in video format, a document explaining when to use each technique as well as, where applicable, the documents necessary for applying the techiques. Participants were invited to watch at least one video and familiarise themselves with the other video techniques before being asked to answer questions about their experience with the system until that point . At the end of the group session, participants were encouraged to watch the videos and apply the techniques in their own time. Participants were reminded to expect e-mails at Weeks 2, 4, and 8 to complete the follow-up measures. In addition, those who had opted to receive reminder emails, were told to expect these on Days 4, 8, 12, 22, and 45. All participants were reminded to expect e-mails at Weeks 2, 4, and 8 to complete the follow-up measures.Participants were asked to complete questions assessing their degree of current functioning, measures pertaining to their mental wellbeing  and a self-efficacy questionnaire regarding study-related skill  at Weeks 2, 4, and 8. In addition, at Week 4 and Week 8 they were asked to answer questions regarding their engagement with the video techniques, potential after effects from their usage and their overall satisfaction with the system . Participants who had not submitted their answers were sent a reminder 3 days after the date they were due to complete the online survey at weeks 2, 4, and 8.All demographic and scale data and comment responses to open-ended questions were transposed from the MePlusMe system to Microsoft Excel and, following checking and appropriate coding, were entered into an SPSS (version 23) spreadsheet for descriptive analyses. The qualitative data collected via the open-ended questions in the questionnaires was analysed using Thematic Analysis , a commoParticipants were ten undergraduate and three postgraduate students at the multicultural, ‘post 1992’ University in London (University of West London), a UK HEI. As may be seen in Table The responses to scaled questions indicated that these data were sufficiently normally distributed for mean and standard deviation values to be meaningful descriptors: skewness statistics for all baseline findings were found to be between − 0.5 and + 0.5, and the Shapiro–Wilk test was non-significant for all scale measurements.“currently having a difficult time studying at university”, four reported that they are “currently having a difficult time emotionally at university”, seven that “the support system (MePlusMe) is a great idea and I want to find out more”, and two also selected “other”, explaining that they “want to improve coping techniques” and that “I am interested in how things happen and why”.Out of the 13 initial participants eight reported that they are As shown in Table Participants reported both positive and negative impressions of the first MePlusMe video that they watched at Baseline, which explains the rationale behind the system (MePlusMe’s philosophy ). PositiAfter first viewing the MePlusMe videos there was limited subsequent engagement, with the two major factors identified were the fact that no re-watching was needed and time constraints. Some of the comments are listed below and can be seen in Table Participants generally expressed that their engagement with the MePlusMe techniques was a positive experience. No specifically negative outcomes were identified. The major positive outcomes identified were improved positive thinking and enhanced memory, improved self-confidence, reassurance that self-improvement is possible, reassurance that others had similar experiences, practical outcomes through study tips. Some of the comments are listed below and can be seen in Table A high level of satisfaction with the Questionnaire was indicated. As can be seen in Table In addition to the above, participants reported that the reasons behind their likely engagement in the future include the professional design, their confidence that using the system will continue to be helpful and the fact that the techniques were useful. It was also reported that the participants may use the techniques, without having to re-watch again the videos. When asked if they would recommend MePlusMe to others, they reported positively and their reasons for doing so include a sense that others would also potentially benefit, particularly if the scope of the information is expanded and the fact that the advice provided is pragmatic and useful. Suggestions for improving MePlusMe include its development into an app form and the inclusion of an interactive forum that would allow users to engage directly with professionals. The overall impression of MePlusMe’s system was positive and most users were satisfied, as the system was found to be useful and practical, calming, relaxing, and easy to use and navigate through, having a clear and attractive design, being engaging as well as bespoke and tailored to the users needs. Most used the techniques 1–3 times a week or more. Participants were uncertain whether they liked the name “MePlusMe” “a lot” or “a little” with equal numbers of responders selecting these alternatives) and that they had not used other online support systems in the past . None of the participants approached the student support services in the duration of the study, most reported that they will continue to use MePlusMe after the completion of the study, and most of participants claimed that if they will seek support in the future, if need be, they will do so by approaching the student union in addition to using MePlusMe. Negative impressions were also identified and were invariably related to the design and user experience. Specifically, participants reported ambiguity in the wording of the questionnaire used to assign the techniques, videos being too long but also too short and the fact that the material covered is accessible elsewhere. Table The present study investigated the feasibility, and acceptability of the contents, design, and functionalities of MePlusMe. This investigation took place before the system’s online functionalities are fully developed in order to inform further development. Responses included positive remarks as well as useful suggestions for the improvement of the system. MePlusMe was found to be practical, easy to use, engaging, and tailored to users needs, but also in need of enrichment of content and of using more diverse characters. Moreover, the questionnaire and library routes that were provided to the users and the subsequent steps  were successfully navigated by users, showcasing the feasibility of our approach.When participants watched their first video describing one of the techniques, they commented on its simple, professional, and efficient design, as well as on its good style and presentation. Moreover, they found the contents easy to understand and non-judgemental. While some participants found that the audio had a good pace and tone, others considered it to be unengaging and suggested changes in the voice-over, such as speeding it up and using a different voice actor. A lack of diversity and an ambiguity in the wording of the questionnaire were also noted as was the simplicity of the animation and the fact that is was not engaging visually. Participants were divided when it came to whether they liked the name “MePlusMe” or not. Further engagement with MePlusMe videos was limited, as participants found that not many repetitions were needed due to the contents being easily understandable, but also due to time constraints. Overall, the techniques offered by MePlusMe attracted positive comments that included improvements in positive thinking, memory, and self-confidence as well as reassurance that self-improvement is possible and that others have similar experiences. The study skills techniques were considered to provide a pragmatic approach and useful tips. Suggestions for further improvement were also collected. These included the system’s further development into an app and the option of having direct online engagement with professionals via a forum built into the system.n = 13), which though adequate for qualitative [The comments and suggestions made by the participants provide a valuable source of information for the improvement of the system. We will keep developing and adding animated video techniques onto the system. This will give us the opportunity to introduce more diverse characters so that all students will feel that they can relate to a character. Also since videos will vary in length this will even out issues with regards to comments that videos are too long or too short. We will also introduce new narrators so that different voices can appeal to our target group. Moreover, the development of an app, through which users will be able to use the system via their smartphones, is also pending. In addition, the possibility of having direct contact with professionals through the system is already being considered and will take place through emails, video-conferencing and offline face-to-face treatment. Limitations of the present study include the small number of participants (litative  and feasWhen the online functionalities of the system are fully developed a feasibility study will follow, for which the protocol has been already published . This stOnce the system is live, students will be able to use it anonymously, at their own space and time, as soon as symptoms arise and as often as they wish, removing common barriers in help seeking –61. ThisIn addition to the benefits that the users will enjoy, HEIs could optimize their resources should they include online support in their range of services. Systems such as MePlusMe can indeed assist student support services to focus on cases presenting with severe difficulties, which are more pressing and require face-to-face contact. At the same time, MePlusMe can be offered to all students who present with mild or moderate difficulties, as a complementary service alongside the offline services. This way, student support services will emphasize on prevention, in a cost-effective manner . MoreoveMePlusMe, is a multimedia, online system aiming to provide personalized support to HE students facing mild to moderate mental health difficulties as well as study skills difficulties and students who just want to take care of their mental health and improve their academic competence. It is the first system that is designed specifically for HE students that tackles both potential sources of problems, psychological and academic, in a personalized manner. Following a rigorous development process which includes a market research project with counsellors in HEIs, an initial survey of end-users  and a pr


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Animals come in a huge array of types, species and structures, but without realizing it, we have focused our care on those like us, mammals. They look something like us, so it’s easy to empathize with animals like dogs, cats and horses. We see them on magazine covers, worry about their pain and suffering and try to conserve their habitat. Because of this tight focus, we lose all the other animals—invertebrates, for instance, are 98% of the animals on the planet. Even though these animals aren’t mammals, we should still care about their welfare. This paper gives the example of two groups, fish and crustaceans, whose welfare has been overlooked or denied, as an example of how we should care about the well-being of all animals, not just mammals.In the last few decades, we have made great strides in recognizing ethics and providing care for animals, but the focus has been mainly on mammals. This stems from a bias of attention not only in research but predominantly in non-scientists’ attention , resulting partly from discussion about and depiction of animals in publications addressed to the public. This is somewhat due to political pressure, and can result in uneven conservation efforts and biases in targets for welfare concerns. As a result, there has been a huge backlash again, with concerns about pain sensitivity and welfare in fish, and a less focused but more pervasive omission of consideration of all invertebrates. That means welfare efforts are focused on 0.2% of the animal species on the planet, and education about non-mammals, particularly addressed to children, is necessary to broaden this focus and care more fully for the inhabitants of the planet. HoweverHumans, in general, are anthropomorphic, most concerned with us and related species. When deciding which animals should be given moral consideration, Broom  and JoneWhen animals have similar motor actions and facial expressions to us, we empathize with them, and so we ‘like’ and care for them. Individual values of other animals depended more specifically on prior relationship to humans, perception of values such as attractiveness and intelligence, the individual’s previous experience with them and his or her attitudes to nature and wildlife . Given taffect or feeling, and utility or usefulness. The affective dimension is a powerful motivator, as if we can be brought to care about any animal group or species, we will act ethically towards them. Yet the amount of knowledge about sharks, used as a model group, correlated with the positive attitudes to them [To direct care equitably, we must understand how the public feels about animals in order to properly care for them. In general, there are two types of motivational determinants of attitudes we have towards animals , affect  to them , so know to them . Since tWhat animal species do people ‘like’? These are mostly what has been called ‘charismatic megafauna’, again predominantly mammals. Entries for North American wild animals on Twitter found polar bears overwhelmingly mentioned, followed by bison, brown bears, cougars and orca killer whales . Large mAs one goes ‘down the phylogenetic tree’, vertebrates appear less and less like humans and thus their appeal wanes. This is particularly true of fishes, lacking the faces that hold the expressions that we see as indicating positive or negative reactions. Furthermore, as Brown  points oreally do not look like us, the public generally does not care about their welfare. In a pioneering study of perception of invertebrates, Kellert [about an animal species or group, we will not care for it. Ranking within the arthropods by children showed that the most positive ones were for butterflies, the most negative to earwigs [If animals  Kellert  asked pe earwigs . This ne earwigs , less so earwigs . HoweverThis negative attitude is entangled with fear of animals that are sometimes ‘risky’. Jancova et al.  looked aBias can occur in unexpected ways and has practical as well as attentional effects. On covers of ten US conservation and nature magazines, including well-known ones such as Audubon and Natural History, pictures of animals predominantly featured mammals at 40% and secondarily birds at 17% . The speBiases in favour of land animals, as seen above, neglect the marine environment, which constitutes 70% of the area of the planet. It is little featured in communication to the public , but eveThese attitudes lead to a bias towards mammals in conservation programs. For targets of projects sponsored by the San Diego Zoo and the Wildlife Conservation Society , there wJournal of Applied Animal Welfare Science (JAAWS), described on the web as covering “The science of animal welfare”; (2) Anthrozoos, “A multidisciplinary journal of the interactions of people and animals” (3) Animals, self-described as “devoted entirely to animals” (4) Applied Animal Welfare Science (AAWS), focusing on “Behaviour of domesticated and utilized animals” and (5) Animal Behaviour, a research-based journal on “research on all aspects of animal behavior”. The percentage coverage of different animal groups varied but it was always heavily weighted towards mammals   mammals . Papers Animal Behaviour were much more diverse, with 32% mammals, 21% birds and a similar 21% on insects. This looks like a more representative diversity until one remembers that there are twice as many bird as mammal species and 170 times as many insects. Non-insect invertebrates were hugely under-represented, with 2% spiders, 3% crustaceans, and a single paper each on gastropod and cephalopod molluscs, the whole phyla Echinodermata and Annelida. For scientific journals, animals are still mainly represented by mammals. Are scientists not free to consider species that generate interesting problems for them, rather than proportional representation? Of course, but if we do not look widely, we will not see ‘interesting problems’ that fall outside the scope of mammalian diversity. Think of the cephalopods, only recently featured for their different route to intelligence and cognitive ability [The subject groups of recent papers in  ability ,41 and e ability . Part ofAnimal Sentience, after Kay’s [The most contentious research area in non-mammalian welfare is the debate on whether fish feel pain, with opposing sides almost trading insults in er Kay’s  feature er Kay’s  pointed er Kay’s , in an eAnimal Cognition that fish indeed have these characteristics. He also noted that present-day fish species are not ‘primitive’. They are the oldest vertebrate group, but “have not been standing in an evolutionary backwater all that time” (p 2). His information is supported by that of Braithwaite [This is where the problem and the debate come in. Animals that feel pain must be agreed to have sentience, and Broom  pointed ithwaite  who poinithwaite , is an eithwaite  criteriaEnteroctopus dofleini can easily be applied outside the genus to the similar Octopus vulgaris when the European Union regulations on care of cephalopods are enforced, but would be hopelessly inapplicable to the pelagic dimorphic drifter Argonauta argo.Countering this information about behavior, Rose  and Kay Fishes have not been accorded protection by the US Animal Welfare Act of 2010, which protects only mammals and not all of those. Fish are a major food group, around 183 million metric tonnes were ‘harvested’ in 2015. Humans exploit fish in several situations including wild harvesting, amateur catch-and release fisheries, ornamental fish possession by hobbyists, and aquaculture, which is the fastest expanding use of these animals. Wild harvesting of fish has a number of ethical challenges  includinApplied Animal Behavior Science, is a rare exception.Perhaps it is because there are such clear consequences to providing for fish welfare in these situations that there is so much heat in the debate about whether the fish actually feel pain. If they do, all these activities will have to be regulated. Browman et al.  predict The situation of invertebrate welfare is much broader and therefore not so clear-cut, yet in some ways more pervasive than that of non-mammalian vertebrates. Regulators, with some exceptions, have not thought much about welfare protection and ethical treatment for any invertebrates, though see  for an uPortia spiders can make out-of-sight detours and that stomatopod crustaceans may use deception. More recent evidence shows that octopuses can plan an action that will be useful to them in the future and specialize in exploration ’merely’ for acquisition of such information [Why have invertebrates been so poorly protected? Remember that for an animal to be believed to show pain it should be also deemed to be sentient, though Dawkins  believesormation , and thaThe possibility that invertebrates might be sentient led the European Union, when revising its animal welfare legislation, to evaluate whether non-vertebrates were sufficiently sentient that their welfare should be of concern . Cephalocontra to what Browman et al. [Inclusion of cephalopods in the Directive of the European Union (2010) was an important step in ensuring their welfare. So much was not known about cephalopods that, n et al.  would han et al.  covered n et al.  the ethin et al.  a set ofn et al.  publishen et al. , who alsn et al. , althougThe scientific panel that reviewed the extension of welfare in the EU to invertebrates suggested the decapods did have pain. Strong criticisms were raised by non-researchers such as Diggles  and objeThe situation for welfare of insects is far starker, possibly because, with few exceptions, they are perceived as nuisance or pests. Butterflies are seen as attractive  and beesWhat do we do about this attitude, called ‘institutional vertebratism’ by Leather , when di


Contagious yawning, emotional contagion and empathy are characterized by the activation of similar neurophysiological states or responses in an observed individual and an observer. For example, it is hard to keep one’s mouth closed when imagining someone yawning, or not feeling distressed while observing other individuals perceiving pain. The evolutionary origin of these widespread phenomena is unclear, since a direct benefit is not always apparent. We explore a game theoretical model for the evolution of mind-reading strategies, used to predict and respond to others’ behavior. In particular we explore the evolutionary scenarios favoring simulative strategies, which recruit overlapping neural circuits when performing as well as when observing a specific behavior. We show that these mechanisms are advantageous in complex environments, by allowing an observer to use information about its own behavior to interpret that of others. However, without inhibition of the recruited neural circuits, the observer would perform the corresponding downstream action, rather than produce the appropriate social response. We identify evolutionary trade-offs that could hinder this inhibition, leading to emotional contagion as a by-product of mind-reading. The interaction of this model with kinship is complex. We show that empathy likely evolved in a scenario where kin- and other indirect benefits co-opt strategies originally evolved for mind-reading, and that this model explains observed patterns of emotional contagion with kin or group members. Thus accurate social predictions would require a long adaptive process, requiring accurate information about each perceived stimulus and the possible responses. Luckily a shortcut is available: the organism holds an almost identical copy of the “black box” - its own decision making apparatus or neural circuitry, which can be used to extrapolate inferences concerning others’ behavior. Information acquired over evolutionary time and information acquired through individual learning can thus be used to speed up adaptation to social encounters2.Learning enables organisms to adapt flexibly to their environment without waiting for natural selection to take its long and arduous route. However, the more complex the environment, the slower the adaptive gain from either learning or evolution. One of the most complex and relevant environments that organisms encounter is the social milieu. Here individuals are presented with a multitude of other individuals, each with a complex adaptive responses. Predicting these “black boxes”, a process called mind-reading4, a large number of neurophysiological studies have shown that similar brain regions are activated when observing and when performing a specific action, or perceiving a given emotional or sensory stimulus8. These mirroring phenomena supported the view that an observer can decipher an actor’s actions and states through at least a partial simulation of those same neural circuits and internal states elicited as an actor, in what de Waal termed “perception-action mechanisms” PAMs10. Neuroscientists proposed that these brain regions, activated both as observers or as actors, possibly underlie “shared representations” of the perceived stimuli and actions11. For an observer, a potential advantage of activating the as-actor neural configuration is to have access to information about one’s own sensory and motor programs. In the social context this information might help to interpret social cues and infer an observed actor’s actions or intentions12, allowing to solve the complex “black box” problem. We adopt here the term “simulation” to indicate any mind-reading strategy that relies on self-information experienced as an actor, rather than information acquired via observation of others10.Since the discovery of mirror neurons13. We define these events in which a simulative observer performs the same action as an observed actor as accidental coordination . In the discussion we will return to the question of the model’s generality.S, would evolve against competing strategies, either relying on fixed evolved responses (F-strategies) or on learning (P-strategies). Later, we perform an evolutionary invasion analysis, examining how traits determining how simulative strategies inhibit coordination would evolve. We validate these results also with agent-based simulations . We explore a simple evolutionary setup with pairwise interactions: each individual in the population will, at times, be an actor .For each stimulus, we denote the best action for the focal individual, providing the largest payoff, with the same index. Hence, for an actor perceiving stimulus d− Table . Other aB, ∅, C, D and 0 events, and their payoffs. We define the expectation of these probabilities respectively as PB, PC, PD, and P0. These probabilities depend on the mind-reading strategy adopted by an individual, as well as other continuous traits, determining features such as the inhibition of C responses, whose evolutionary dynamics we also explored. The fitness of a focal individual is determined by the sum of the average payoffs obtained as a solitary actor, π+, as an observer π−, or as an observed actor, We consider an evolutionary-dynamics setting with additive payoffs, where the absolute fitness of a focal phenotype is simply given by the average probability of interactions resulting in y°. For large populations, the behavior of y° approaches that of the average for all the strategies in the population. In the solitary actor case, the average payoff is simply We denote with the superscript • the elements related to a focal individual or strategy, while we use the superscript ° to indicate non focal, interacting individuals ai− in response to a social cue si−. First, we implement an “innate” strategy, in which an observer responds to social cues with a fixed si− → ai− mapping that adapts only through evolution, but not learning (Fixed Strategy - F). Second, a strategy in which social responses are only learned through social interactions (Associative strategy - P). In the third type, (Simulative strategy - S) an observer takes advantage of its own as-actor set of responses to infer actors’ behavior. These different cognitive strategies are built with two basic building blocks: representations and cognitive functions.We explore three main mind-reading strategies Fig. , definedRepresentations correspond to the neural configurations and physiological responses associated with a stimulus or action, represented within clouds in Fig. x, defined as intensity. This can be seen as the extent of activation of the underlying neural configuration. Thus formally a representation is a pair, comprising the action or stimulus represented and an intensity, e.g. Cognitive functions, represented in Fig. s via a perception function , that maps it to a stimulus representation learning function l, and in turn performs an action via an activation function α:x, the higher the probability is that l would associate a correct action representation, and that an action would be performed. Learning, defined as the the reduction of the classification mistakes as experience is acquired, occurs in time t at a constant rate λl. The specific mathematical expressions used to describe cognitive functions are reported in Table We assume that an individual’s behavior is only influenced by two variables in addition to its own strategy: the intensity of a stimulus and its own previous learning experience. Regarding the former we assume that the higher p, while observers at a rate p. Hence, the scheme in Eq. si+  and responds with the best action ai+ with higher probability as its experience increases as (1 − p)t. The same also describes an observer, who responds to social cues si−, choosing the best response ai− with higher probability as its experience of social interactions increases as pt. We define this first type of observers/mind-reading strategy as P.Notice that actors encounter stimuli with probability 1 − si+ . Thus we contrast strategy P with a simulative strategy S, in which an observer takes advantage only of the information acquired as an actor, i.e. its own ai+, a potential drawback of this strategy is that this action might be actually performed by the observer, resulting in a coordination event. This could be avoided if the underlying representation ai+, is inhibited. In our model this inhibition is allowed to evolve (see Results and Appendix). To describe the recruitment of the as-actor network when having perceived a social cue γs and γa .Besides social interaction, an observer has also its own experience as an actor to infer of what an individual would respond to a stimulus  γa Fig. : γs reprentclass1pt{minimat spent experiencing a given set of stimulus-action responses. The environmental state specifies the best response for each stimulus, and is thus represented by a mapping S → A. In a constantly changing environment with rate λe and individuals dying at a rate λd = 1, the time experienced by an individual in a given environmental state is distributed exponentially with rate λ = λd + λe. For simplicity, we assume that environmental states are non correlated, so that individuals have to learn the appropriate reactions independently for each. Since strategies F rely on a fixed mapping, their fitness is proportional to the frequency of the most frequently visited environmental state. To be conservative in favor of F-strategies we assume that this is always visited once, so that it is the only experienced environment when In the deterministic model we use a continuous-time model, where both learning and payoffs depend on the amount of time spent in a given interaction type. This corresponds to individuals experiencing a large number of interactions. Stochasticity in the amount of interaction, stimuli and in the learning process is addressed later in our evolutionary simulations, implementing computational agents with simple learning rules. Learning, and thus the efficiency of individuals’ responses, depends on the time (1) Under which circumstances are as-actor networks recruited for mind-reading? (2) Can emotional contagion evolve as a consequence of mind-reading? The first question is addressed here by tracking the frequency of the different strategy-types, In our model a mind-reading strategy is determined by the mind-reading strategy-type and by a number of continuous traits, which affect the level of inhibition of coordination. We focus on two main questions: x = 1 and is sufficient for correct response given that an individual has enough experience, i.e. α(1) = 1 and PB differs between individuals with different mind-reading strategies the evolutionary dynamics of this system are frequency-dependent. We explore this case in the appendix, where we show that different mind-reading strategies can be bistable. Here, we restrict to the simpler frequency-independent case, for which all main results hold. In this case, we can write the replicator dynamics of the system as:j indicates one of the strategies P, F or S, and where π− is higher than those of other strategies. Thus, we can explore under which conditions the different strategies would evolve by simply comparing the expression for the social fitness in Eqs First, we compute the expected probabilities of a B response as actor, and D and C as an observer using one of the three different strategies, indicated by the superscripts P, F and S. These determine the fitness of the mind-reading strategies, following Eq. λe, the rate of environmental change. Strategy F does not rely on learning, but on a fixed mapping optimized by evolution. Hence while this strategy is very efficient for predictable environments (low λe), it cannot adapt to new environmental states. This is apparent in the term P and S use learning to adapt to new environments, and dominate when environmental variation increases. However, P learns only during social interactions, and the probability of successful D responses decreases linearly with p. For this reason, S evolves at lower values of p. Remarkably, S outperforms all other strategies as complexity increases. As information about the social context decreases, the experience gained as an actor becomes more valuable. This result is exemplified by simple analytical expressions obtainable in the simple case of an innate as-actor behavior. In this case the fitness of strategy S is independent of complexity, whereas the fitness of an observer using F or P strategies is λe, whilst that of strategy P also decreases with reduced opportunity of direct as-observer learning p. Therefore S -strategies dominate when environmental complexity increases. This pattern is consistent across the assumptions and models tested. In general, learning as an actor is faster than as an observer , due to the uncertainty involved in social cues. Information about other individuals is inherently noisy or inaccurate, since an observer may not know what stimulus or internal state precisely characterize an actor, or simply might misperceive a social cue. Hence, in complex environments (high λe) or when social stimuli are noisy and inaccurate (low p), using information acquired solely through social interactions may not suffice, requiring a large number of learning instances. Similar results are obtained when individuals can switch from S to p over their lifespan depending on the available information (Appendix).In Fig. S strategies are favored . S-observers have the possibility to make correct inferences only when the focal observer and the observed actor share the same behavioral response, and fail in a fraction ψ of the interactions. Thus, inter-individual differences impact negatively the fitness of S-strategies, reducing the range of parameters for which they would evolve  by looking at how inhibition evolves.In our model coordination is costly for the observer. Eq. S -observer will be able to extract information from its as-actor network, without generating the response usually exhibited as an actor, here C. These cases can be seen as True-Negatives, as inhibition is applied correctly to avoid a costly and inappropriate as-actor response . A second mechanism is to modify the structure of the as-actor network itself to make it easier to inhibit; however this would potentially lead to accidental inhibition of actions when the individual is an actor , even though inhibition is allowed to evolve and other strategies to be used . To see why, note that whenever uB evolves to values higher than uB, i.e. how selective the activation threshold is, decreases proportionally to (1 − p)/p, the odds of a potential false negative (Appendix section 2.2).Remarkably, accidental coordination can evolve even when also the activation threshold can evolve, alone  or simultaneously with ted Fig. . This beAn important biological note is that this simplified model is likely conservative. First, also other as-observer actions could risk of being inhibited. Second, in real life scenarios, stimuli and the activation of neurophysiological pathways are also subjected to noise and variability. This uncertainty increases the chance of false negatives and false positives, and thus likely lead to scenarios that could be represented with smoother, more continuous activation functions, compared to the simplified model presented above. In these cases - that can be represented mathematically with a continuous activation function (e.g. a sigmoid) or normally distributed stimuli intensities - a small probability of accidental coordination always evolve .Finally, note that these results are not dependent on the specific functions used for the simplified model, and they reflect general payoffs underlying the trade-off between increasing the amount of true positives and negatives , and the risk of false poositives (C) and false negatives  and coordination (PC) at increasing r. Therefore we investigate the effects of r on the recruitment of the as-actor network, uD. Our purpose is to estimate the effect of r on the evolutionary equilibrium for Empirical evidence suggests that empathy, contagious yawning and emotional contagion are stronger with kin or in-group members, a phenomenon defined as 23 (see Appendix). We show that the conditions necessary to an empathic gradient analogous to what observed empirically are that c+/c− > d+/d−. Note that the effect of relatedness on coordination is non-trivial: r can either increase  or even decrease uD and PC . An increase is observed provided that a more efficient mind-reading, i.e. an higher proportion of D responses, provides a substantial benefit, either direct and aimed at defection (d−) or cooperation (rd+). Hence a benefit of mind-reading might explain observed behavioral patterns of emotional contagion and empathy. The patterns described above are even stronger when γa is small (Appendix).This can be obtained by implicit differentiation of the invasion fitnessD is the same for higher values of r, while in this context it is of course possible that another strategy Dr other than C or D would be optimal for cooperation. In this case our framework can be applied without changes: an observer would simply use simulative strategies to infer the actor’s response and the best action to cooperate, while inhibiting coordination. Notice that for some intermediate values of r, full coordination and an internal equilibrium where coordination is inhibited can can be bistable  and mirroring or empathy related-regions, also recruited as actors uD, Fig. 27 , and pathologies such as alexithymia and autism, which affect the access to self representations of internal states and in turn perspective taking33. More studies apt to investigate the role of mirror neurons in action recognition could provide further evidence in support of this assumption.We have shown that small probabilities of coordination can be maintained even when costly, and when inhibition is allowed to evolve Fig. . The mod 27 Fig. . Hence, uB) is that a downstream mechanism inhibiting coordination must be able to inhibit the actions driven by internal neural configurations  that are usually experienced as actors, when certain alternative responses are instead advantageous  and it is documented empirically36.The second trade-off , each corresponding to a specific characteristic of a cognitive process. However, the trade-offs that we identified are not determined by the specific implementation or the specific cognitive functions used, as shown by a general evolutionary invasion analysis of the model (Appendix section 2). For example, although we presented uB as the threshold of an activation function, a trade-off between the inhibition of coordination (true negatives) and undesired unspecific inhibition  would emerge for any form of inhibition, with increasing importance the higher the chance of false negatives. This is particularly relevant for the simulative ‘black-box’: even though an observer would like to inhibit coordination, the specific action to inhibit is unclear before this is inferred via simulation.Note that for didactic purposes we presented these trade-offs in terms of simple evolvable traits  is required46.Second, when coordination is advantageous for the actor but not evolutionarily advantageous for the observer, we have shown that cooperation might still occasionally occur because of a missed inhibition of coordination from a simulative observer. For example, contagious distress can inhibit a conditioned response if this causes pain in another individual47. However, we showed that coordination can evolve even when it is not the best possible cooperative response: coordination offers an evolutionary compromise, by synchronizing the internal state of an observer with that of an actor, and reducing the degrees of freedom for possible responses. For example, the perception of distress in the offspring elicits alertness in parents. From this rudimentary form of state-matching empathy, the activation of shared representations of pain or distress could have evolved to elicit prosocial responses, concurrently with the role of oxytocin in reducing avoidance responses triggered by distress47. This is supported by the evidence that the activation of stress-related responses in the observer often accompanies empathy and cooperation (e.g.49).We suggest that the two mechanisms could be phylogenetically related. Simulative strategies, by recruiting the as-actor network, provide a simple proximate mechanism to synchronize the actions of an observer to the internal and motivational states of a recipient individual. Our model shows that the recruitment of the as-actor network and coordination increase when cooperation is promoted by assortment. Thus simulative strategies, evolved initially for mind-reading, could be have been later coopted for empathy and cooperation. A potential criticism is that a coordination of internal states and emotional responses is not sufficient, and may even hinder, cooperation. For example, it has been observed that contagious distress might undermine helping behavior47. However, mind-reading benefits are not restricted to parental care, and in the spectrum of social complexity, parent-offspring interactions are relatively simple: because of their limited interaction with the environment, the behavior of offspring is mostly evolved as opposed to learned. Accordingly, instances of parental care exist throughout the animal world even in the absence of apparent empathy . Thus, even though we cannot rule out that in mammals parental care provided the sufficient complexity to render simulative strategies adaptive, we suggest that simulative strategies might have evolved for mind-reading in a more general social context. Only later, might kin selection have coopted them for cooperation51, or emotional contagion when coordination is advantageous. These conclusions are supported by neurophysiological evidence, showing that the recruitment of the as-actor network extends beyond the cooperative context12; and behavioral studies, showing that contagion in non-cooperative context  is stronger with kin and unrelated but socially close individuals, with whom empathy and helping behavior (e.g. consolation52) are stronger57.It has been proposed that parental care played a key role for the evolution of empathy. Our model is consistent with this hypothesis, since parental care would provide both a selective pressure for cooperation and the understanding of the needs of the offspringOur model suggests potential directions for new empirical studies, that would allow to test some of its predictions. For example, we predict that simulative strategies are more advantageous in unpredictable environments. While empirical evidence seems to support the presence of empathy especially in primates and other mammals, a better characterization of the species in which empathy is present would improve this picture. In addition, more studies are needed both at the intra-specific and inter-specific level to assess whether perspective-taking skills correlate with emotional contagion and empathy driven cooperation. Do species or individuals who simulate more also show more empathy driven cooperation?We also showed that specific features of cognitive processes involved in mind-reading would be necessary and favour the evolution of accidental coordination. Thus, more studies would help to clarify when these conditions apply. For instance, we showed that accidental coordination is favored when inhibitory mechanisms incur the risk of false positives - inhibiting off-target actions. Thus, studies investigating the specificity of inhibitory mechanisms would be precious to clarify the role of the B-vs-C trade-off. Furthermore, more studies would be beneficial in assessing the role and the extent to what as-actor network circuits are necessary for inferences, for example in the case of mirror neurons. Concluding, the characterization of inhibition mechanisms and their specificity at the neurophysiological level will certainly help to understand whether and to what extent accidental coordination contributes to prosocial behavior in different species.33. The fact that information and neural circuits acquired as an actor are used to interpret others’ actions is also apparent for sensory stimuli in the activation of the somatosensory cortex26; for stimuli of different nature in phenomena like mirror touch synesthesia; and possibly even for collective inferences and abstract concepts58 and for inanimate or inter-specific entities (e.g. anthropocentrism59). Furthermore, the role of inhibition of the activation of the as-actor network to interpret others’ actions is apparent in pathologies like echopraxia and echolalia14. As an actor’s cognition is embodied, even an observer’s cognition is required to be embodied, despite the risk of accidental coordination10. Concluding, the importance of information acquired as an actor, either learned or evolved, is pivotal to understand social cognition and its evolution.Our model explores a simple assumption, that experience as actor can be useful to predict and interpret others’ actions, and shows that this has relevant implications and side-effects. First, we show that strategies relying on this source information can evolve under many circumstances. Second, we show that a side effect of the evolution of such strategies is that an observers could fail to inhibit the observed behavior coordinating with the state and actions of the observed actors. These two phenomena provide us with a simple unified perspective on biological phenomena as different as mirror neurons, motor interference, contagious yawning, contagious distress and empathy, and their higher stronger effects with kin. Many other biological pathological and non pathological behaviors could possibly be connected. For example, the comorbidity of alexythymia and autism had already been interpreted as the inability to understand others as a consequence of the impaired awareness of one’s own feelingsAppendix


There is an emergent body of evidence supporting exercise therapy and physical activity in the management of musculoskeletal pain. The purpose of this study was to explore potential barriers and facilitators with patients and physiotherapists with patellofemoral pain involved in a feasibility randomised controlled trial (RCT) study. The trial investigated a loaded self-managed exercise intervention, which included education and advice on physical activity versus usual physiotherapy as the control.Qualitative study, embedded within a mixed-methods design, using semi-structured interviews.A UK National Health Service physiotherapy clinic in a large teaching hospital.Purposively sampled 20 participants within a feasibility RCT study; 10 patients with a diagnosis of patellofemoral pain, aged between 18 and 40 years, and 10 physiotherapists delivering the interventions.In respect to barriers and facilitators, the five overlapping themes that emerged from the data were: (1) locus of control; (2) belief and attitude to pain; (3) treatment expectations and preference; (4) participants’ engagement with the loaded self-managed exercises and (5) physiotherapists’ clinical development. Locus of control was one overarching theme that was evident throughout. Contrary to popular concerns relating to painful exercises, all participants in the intervention group reported positive engagement. Both physiotherapists and patients, in the intervention group, viewed the single exercise approach in a positive manner. Participants within the intervention group described narratives demonstrating self-efficacy, with greater internal locus of control compared with those who received usual physiotherapy, particularly in relation to physical activity.Implementation, delivery and evaluation of the intervention in clinical settings may be challenging, but feasible with the appropriate training for physiotherapists. Participants’ improvements in pain and function may have been mediated, in some part, by greater self-efficacy and locus of control.ISRCTN35272486; Pre-results. This paper identified, through interviews, key barriers and facilitators to implementation of a loaded self-managed exercise programme, with education and advice on physical activity.Two authors independently coded all transcripts, and a clear, transparent and reproducible methodological approach was used in the analysis.The main limitations of this study were the difficulty in interviewing patients lost to follow-up (from both groups) and finding patients classed as ‘non-responders’ in the loaded self-managed group.The study population comprised a single clinical setting, where the researcher was also a clinician.Patellofemoral pain (PFP) is one of the most common forms of knee pain in adults under the age of 40 years, with an estimated prevalence of 23% in the general population.This research was undertaken within a framework of mixed-methods, embedded within a feasibility study comparing a loaded self-managed exercise protocol with usual physiotherapy for people with PFP.The loaded self-managed exercise programme does not align with current UK physiotherapists’ preferred treatment approach for PFP.Therefore, this qualitative investigation aimed to explore potential barriers and facilitators to implementation of the intervention with participants with PFP involved in a feasibility randomised controlled trial (RCT),a priori.A qualitative study was conducted embedded within a mixed-methods feasibility study. To avoid cross-contamination between the two groups, the intervention group was treated by different qualified physiotherapists, who received the intervention training package, to the usual physiotherapy group. To fully explore the aims of this study, patients and physiotherapists receiving and delivering both the intervention and usual physiotherapy were interviewed.This study has been reported in line with the COnsolidated criteria for REporting Qualitative research checklist.This study did not set out to prove or disprove a hypothesis, it set out to generate new data from which an understanding of barriers and facilitators to the intervention and study design might be developed. The authors took an epistemological position described as ‘contextualist’ by Braun and Clarke that sits central on the spectrum of realism and constructivism.A purposive sample of 10 patients with PFP were recruited from the 60 patients who were recruited to a feasibility study, this included patients in the intervention group and those receiving usual physiotherapy. International consensus has defined PFP symptoms as typically developing insidiously with retropatellar pain or diffuse peripatellar pain, aggravated by activities that ‘load the joint’, such as climbing and descending stairs, squatting, running or jumping.Initial recruitment to the feasibility study included gaining written consent for taking part in future qualitative investigations with consent to audio-recording and to publication of anonymised quotations. Participants were initially followed up by a telephone call. If they agreed, a convenient time was arranged to complete an interview. Participants were given the opportunity to discuss any concerns before the interviews started.Ten physiotherapists were purposively sampled, this included those delivering the intervention and those delivering usual physiotherapy. Based on similar studies, we anticipated this sample size would be sufficient to reach data saturation.All participants were interviewed at a convenient time in the hospital-based physiotherapy department. The researcher (BES) introduced himself as a physiotherapist working in that department, and as a researcher conducting a PhD. The researcher explained the aims of the study. Verbal consent was taken to start recording.Semi-structured interviews were designed by the researchers (BES and FM) using topic guidelines with prompts to explore barriers and facilitators to taking part in a loaded self-managed exercise intervention. Patients from both treatment groups were asked about response to treatment, belief and attitude to pain, belief and attitude to physical activity, treatment expectations and protocol parameters. Only those in the intervention group were asked about their engagement with the loaded self-managed intervention. All physiotherapists were asked about their usual practice, personal development, belief and attitude to pain, belief and attitude to physical activity and protocol parameters. Only those delivering the intervention were asked about their engagement with the loaded self-managed intervention, including the training package. The interviews ranged from 5 to 21 min (mean time 11 min) in duration.The interview guide was not piloted, however the researcher maintained a reflective journal, noting down initial thoughts and ideas after each interview.All audio files were collected and transcribed verbatim.The data were analysed using a thematic Framework Method,Data were organised and analysed using QSR International’s NVivo V.11. After 10 interviews per group, it was determined by the researchers that data saturation had occurred as no new thoughts or concepts were generated in the later interviews.This research project has been driven by the views of people suffering from PFP. Patients were consulted for their views, including patient members of the Steering Group Committee. Thoughts and preferences to current programmes of therapy and treatment were requested, and these views have been incorporated into the planning, design, application and dissemination of this study.The 10 patients included 3 men and 7 women, aged between 26 and 37 years (mean: 30.6 years), with a diagnosis of PFP for a mean duration of 25 months (range: 3 months to 10 years). The 10 physiotherapists included 2 men and 8 women, aged between 24 and 58 years (mean age 39.4 years), with a mean of 16 years qualified (range: 3–37 years). Full patient and physiotherapist characteristics are presented in In respect to barriers and facilitators, the five major overlapping themes that emerged from the data were: (1) locus of control; (2) belief and attitude to pain; (3) treatment expectations and preference; (4) participants’ engagement with the loaded self-managed exercises and (5) physiotherapists’ clinical development. Locus of control was one overarching theme that was evident throughout. The findings are presented in relation to existing literature.Locus of control is a psychological construct about the degree people believe they have control over their actions and outcomes.R: And how did you feel about being in charge of that (the exercise)?P8: Yeah. I think it was empowering in a way. (Loaded self-managed)Early interviews raised matters relating to whose authority it was to give the ‘permission’ to return to, or increase, physical activity; including when and how this should be done. Again, clear differences between usual physiotherapy and the intervention could be seen, particularly in relation to physiotherapists’ management approach to physical activity.Ultimately up to the patient really. They should feel in charge of what they do. They need to have control of the situation. If they’re just waiting for somebody else to dictate that, then they haven’t got very good control. But they might need some encouragement or reassurance that it’s okay to actually, if you want to get back to these activities you can. You don’t need to ask me permission really. (T2—loaded self-managed)I would usually kind of bat it back to them and say, ‘Well, what do you think you can do?’ And using the same principles as with the exercises, if you’re getting some discomfort at the time, it doesn’t mean to say you then stop. And just see how it is afterwards, and then modify how much you’re doing in response to how much pain you’re experiencing afterwards. (T4—loaded self-managed)Contrasting the push for an internal locus of control with the intervention was a narrative discussed by some patients receiving usual physiotherapy. For example, participant 4 had indicated she was ‘strongly recovered’, had minimal pain and had returned to almost all of her usual activity. However, she had not returned to the gym yet, and had booked a follow-up appointment with the treating physiotherapist for after the interviews where she hoped to receive the ‘go-ahead’ to return.And this patient narrative was reinforced by the treating physiotherapists’ understanding of their role:I’d assess them functionally. So you kind of break down that hobby or that activity into sections. So if it’s a sport, look at part of it… and if you can’t do two or three of them, it’s not just your knee that’s letting you down. Generally, you’re not quite ready for that. A few of the physiotherapists within the usual physiotherapy group viewed their role more of a partnership with the patient, where decisions about return to activity were agreed mutually.Well, it’d be a mutual thing. A lot of them weren’t sporty, but they would ask and we discussed the suitability. Locus of control is inter-related to the psychological construct of self-efficacy, where it relates to the power of thinking in achieving treatment outcomes.That sense of just you know how much progress you made. A week ago you did 20, and now you did 30 or 40. (P9—loaded self-managed)When I hit the target and I then thought, ‘Oh, I can actually do a few more’, and it’s comfortable to do, I did do that. (P5—loaded self-managed)Previous qualitative work has identified unmet treatment expectation as a potential barrier to treatment adherence,A small number of patients discussed an expectation of hands-on passive treatment.I was more expecting sort of a hands-on approach, more like physio massage when I came. (P8—loaded self-managed)Furthermore, in keeping with themes found in other PFP qualitative work,For me, I wanted answers on why my knee was painful. Because I think, going back 10 years ago, when I first went to my doctor’s, I was told it was ligament damage. And it didn’t clear up, and when I went back, it was like, ‘Well, the waiting list for physio is so long, by the time you get there, you’ll be recovered’. And then, when I went back again, it was like, ‘Well, you’re too young to have steroid injections’. And then, I just always felt I was like, in a sense, sent packing without any answers. And then, I wanted some answers as to why it’s hurting so I could understand it. (P10—loaded self-managed group)Previous qualitative work in patients with PFP found a dominant negative view of physiotherapy,The physio—I don’t know, I was a bit sceptical, to be honest. But yeah, it has given me the result I wanted. (P10—loaded self-managed)All physiotherapists reported that their current practice and preference for treating PFP included an exercise programme. However, in contrast to the majority of UK physiotherapists,But if you think about a VAS or something like that … probably you wouldn’t want your pain to be greater than maybe a 3 or a 4 out of 10. Quite often I tell people to do reps to kind of fatigue, but not to pain. So people are getting a bit of a niggle, if they can manage it, and they can bring the pain level back down quite quickly afterwards. So if they can do exercises, it aggravates it, but within about a half an hour symptoms have settled, then that’s fine. Dissonance between the single exercise approach used in the intervention and treating physiotherapists’ preference was evident. The single exercise approach was not favoured by any of the physiotherapists interviewed:I think possibly the intervention was simpler to do in the fact that it was geared, sort of guided around one exercise. And probably, what I would have done before is perhaps give more exercises and chop and change them maybe a bit more frequently. (T7—loaded self-managed)Additionally, some physiotherapists were very prescriptive with their exercise dosage.Initially I might start with them with 15 repetitions and work to three sets, 2 min break in between. Again, in contrast to the majority of UK physiotherapists,I’m a little less strict on sets and reps. I’m more do what you feel you can. If you’re happier, push on a little bit more. (T3—loaded self-managed)As identified above, most patients were content with the anticipation that exercises would be painful, and indeed this matched current clinical practice with the physiotherapists interviewed, despite not aligning with UK wide current practice.Interlinked to the all themes, particularly locus of control were patients’ and physiotherapists’ beliefs and attitudes to pain. There is a growing body of evidence suggesting that health practitioners with a biomedical orientation to pain are more likely to advise patients to limit their physical activity due to painShe (the physiotherapist) gave me exercises to do. I’ve always been keen on the gym. I go to the gym. I was a doing a lot of the stuff she’s asking me to do, anyway. Or it’s probably more about my technique. I was maybe not doing it as well as I could have done. So I fell back. …So she referred me for scans on both knees—well, referred me back to my doctor. My doctor referred me to an orthopaedist. They referred me for a scan on both knees. The MRI scan showed this knee’s absolutely fine—which it’s not. R: So if they’re not achieving that, would you advise them not to run then?P10: Probably. Yes. I’d probably have a look at them, and if they were really antalgic on their gait, then yeah, tell them not to bother, to work on their weaknesses, and then reassess it a bit later down the line. Because otherwise, they might just end up making their knee 10 times worse because they’re running on a weakened, less controlled knee. Of interest is that the physiotherapist delivering the usual physiotherapy, as described in theme 2, did describe treatment preference not fully aligned with the majority of UK physiotherapists,I think it was sometimes a bit hard to stick to usual physio, because we still keep reading. We try to keep up with what’s happening… So it’s just a bit of reading and then I change ‘usual physio’, it keeps developing as you work. Yet despite this, there was marked differences in the patients’ and physiotherapists’ beliefs and attitudes to pain in the intervention group, compared with usual physiotherapy, demonstrating some reconceptualisation of pain. This suggests the training programme did improve contemporary knowledge of pain science.Yeah, the pain wasn’t excruciating or anything. At no point did I think, ‘I can’t keep doing this’. It was a fairly normal level, I’d say. It wasn’t anything that would make me come back, and say, ‘I’m worried that I’m doing something wrong’, or anything like that. It was fairly normal. I wouldn’t say it was too bad. (P1—loaded self-managed)P7: The physiotherapist said to go ahead and run if it wasn’t going to do any damage. Yes, if it’s painful, stop. My own thoughts have been, I think, changed definitely with this intervention. I think exercise is—I’ve always said to patients that if it’s painful, they can still carry on. But again, like I said, I gave that arbitrary figure. If it goes above this, then maybe taper down… But actually, maybe educating them and telling them, ’Pain isn’t an indicator of damage. You can push through into it a little bit, but it just has to be something that you’re comfortable with'. And I think the thing that changed with me saying that to patients was I am not the one that’s going to dictate that. You’re the one has to go through this. (T3—loaded self-managed)There was one example of mixed messages from the patient, with regard to acceptable and appropriate levels of pain during exercise and physical activity. This may suggest the heterogeneity in physiotherapy advice, as previously discussed in the second theme with physiotherapists, may have a negative effect with increasing levels of uncertainty. This is in keeping with previous research suggesting an iatrogenic effect with physiotherapy treatment for PFP relating to diagnosis uncertainty and fear-avoidance behaviour.He (the physiotherapist) recommend that I didn’t run, which is probably the only thing I don’t do now. I think it was the impact. Like, my knee with my cartilage. That’s why he didn’t recommend it at that point. (P10—loaded self-managed)Only patients and physiotherapists receiving or delivering the intervention were asked to discuss their thoughts about it. Both patients and physiotherapists reported several different ways in which they interacted and connected with the intervention. First, the intervention laid the foundation of reconceptualisation of pain-related fear where the physiotherapist spent a period of time educating the patient about pain mechanisms.Once you’d explained—all the key is in the explanation about pain and how pain works and explaining why they’re doing it from that. And in fact, sort of the particular girl I’m thinking about, she’d stopped going downstairs because of the pain. When I reviewed her last time, she said, ‘Well, I haven’t been avoiding the stairs’ (with no increase in pain levels). So it’s good stuff. (T7—loaded self-managed)Other critical aspects of the intervention discussed by the participants were the self-dosage of the exercise, based on the symptomatic response, rather than being prescribed by the physiotherapist. These aspects were all discussed positively, with no negative features identified.I think for me I’ve got results a lot quicker, so because I was kind of going through the pain with all that. And I definitely stuck with the exercise more, because when I first started with one exercise I might get a bit bored. But I’ve definitely stuck to it more. (P9—loaded self-managed)The simplicity of a single exercise approach was discussed by all the interviewees, predominantly in a positive manner.So I think it’s quite simple, so if I do ever get—the problem starts to occur again, it’s no real problem to just start. (P1—loaded self-managed)However, one physiotherapist admitted to being initially sceptical that one exercise would be enough.And using that single exercise as that treatment. So in terms of my thoughts before, would that be enough for my patients? And the ones I’ve seen, have seemingly done well with just one exercise, rather than having four or five different exercises to do. (T3—loaded self-managed)The key feature of patients self-dosing their exercise, based on the symptomatic response, is an understanding of when and how to progress or regress the exercise. Patients recognised the role of ‘trial and error’ in this process, and the relevance of the pain education prior to the exercise programme being implemented.I do remember, initially, there being kind of a week or two, maybe, where I was kind of finding kind of the right amount (of the exercise to do). (P9—loaded self-managed)I think what you tend to do as physios, we very often tend to be quite prescriptive. And patients do ask that. They want to know how many they should do, how many times a day, whereas this is actually giving them much more their own power of making them decide what they’re going to do. So actually, hopefully, then they’re going to carry on with it in the future. (T7—loaded self-managed)Interlinked to self-dosing was the expected pain flare-ups, when patients overdosed their exercise or physical activity. The physiotherapists’ training programme at the start of the feasibility study covered this topic, with physiotherapists aiming to discuss self-management approaches at preventing and dealing with flare-ups. Despite this, flare-ups remained common place, and were a cause of concern for several patients; suggesting this topic needs additional emphasis in any future training programme.R: Did it worry you when you had those flare-ups?P1: Yeah. There were kind of back-of-your-head thoughts, like, ’What if this time I have done it a bit too far? If it lasts a bit longer, am I going to have to go back in case I’ve damaged it a bit?’ or anything like that. But most of the time, again, was 2 days tops. So I did have kind of a little niggling worry, but nothing to kind of cause me to do anything or anything like that. (Loaded self-managed)Both patients and physiotherapists were asked to reflect on the intervention and their clinical response. For patients, quantitatively, the global rating of change at follow-up  was used to identify responders and non-responders. The scale was dichotomised so that responders were defined as ‘completely recovered’ or ‘strongly recovered’,Yeah. I’m playing football again. Yeah. I’m just kind of—sometimes I can tell I’ve got a little bit of tension there. But I’m not getting pain. It’s not stopping me doing nothing at all. So yeah. (P9—loaded self-managed)And this corresponded from the feedback from the treating physiotherapists, with all physiotherapists reporting favourable outcomes with the intervention.The main emphasis of patients’ and physiotherapists’ narrative was the simplicity of the exercise, the loaded element of the exercise and the self-dosage of the exercise.It is thought that difficulties accessing and understanding research, and professional isolation may act as barriers to implementation of research into practice.I don’t think I ever would have said to people, ‘Don’t push into any pain'. I think over the years I’ve probably got—as research projects and things we’ve done where we’re kind of talking more about it being okay to push into pain, I’ve got more relaxed with it… I think maybe as a junior I might have done, to be honest. So probably when I did my first rotation, I might have been saying more, ‘Very, very low’, or, ‘It needs to be virtually pain free’. But as the years have gone on, probably got more and more relaxed with saying it’s okay, on the back of, I suppose, of the things that have happened in our department and changes in practice generally. I think from when I first started practice, it would have been different. So when I first started, I would often tape the knee, or if they came back and said that it was painful, I asked them to kind of back off. Almost think about off-loading the knee if it was painful. So trying to reduce activity if it was sore. And then I think just as I became more experienced and read more about that type of thing, I got more confident in not using adjunct and trying to use loaded exercise and reassurance about pain. So I think it fits more with my current practice, and I don’t think it was that different. Obviously, I do a lot of pain education with back patients, so I think that was quite easily transferable. (T8—loaded self-managed)Department culture has been identified in previous qualitative work as a facilitator or barrier to change, over and above research evidence and clinical guidelines,I guess in this department we’re quite used to doing that sort of intervention for these patients, so it wasn’t particularly ground-breaking to me, in a nice way (laughter). It’s your (the researcher’s) fault. (T2—loaded self-managed)Oh, it is working in a different environment as well. So when I was in ** I was most of the time by myself in a GP clinic. And you don’t get a lot of interaction. That influence, when you actually have a bigger (department). We talk about loading as well. So we talk about Achilles or tendons and we just keep talking about how everything changes and you just do your own research and you think, ‘Okay’. How to make it better. Two physiotherapists discussed how being part of the research challenged their current practice and resulted in clinical development to both patients with and without PFP. One physiotherapist conferred how the training package and personal reflection of treating study patients challenged him; the second from sparking an interest in research.I think if you tell them, ‘Actually, how do you feel about it. You’re in control’, gives them the onus to take what they do. That’s definitely changed massively. And I kind of do that with other patients now as well, not just the knee patients. I’m a little less strict on sets and reps. I’m more do what you feel you can. If you’re happier, push on a little bit more. (T3—loaded self-managed)In respect to barriers and facilitators, the five major overlapping themes that emerged from the data were: (1) locus of control; (2) belief and attitude to pain; (3) treatment expectations and preference; (4) participants’ engagement with the loaded self-managed exercises and (5) physiotherapists’ clinical development. Locus of control was one overarching theme that was evident throughout.The aim of this qualitative study was to identify barriers and facilitators to the implementation of a loaded self-management exercise programme, which included education and advice on physical activity. Contrary to popular concerns relating to adherence of painful exercises,A key aspect of the loaded self-managed exercise programme is the single exercise method. Previous research with a similar approach in patients with shoulder pain identified this as a potential barrier to implementation, with physiotherapists and patients viewing this with a degree of uncertainty and scepticism.Locus of control is thought to predict health-related behaviours and physical activity,Previous qualitative work has suggested that department culture is a key driver or barrier to change.Implementation fidelity refers to the degree by which the delivery of an intervention adheres to the protocol and description.This research demonstrates that even though physiotherapists have certain expectations around management and exercise prescription, their approach was adaptable to the intervention with only two, 2-hour training sessions; enabling patients to self-manage and make sensible decisions about their own treatment and return to physical activity. The results of this study establish a skill set needed to deliver the intervention, including: complex musculoskeletal assessment; anatomy; tissue healing and remodelling; pain biology; peripheral and central sensitisation; psychological and social factors that might affect pain perception; self-management strategies and education skills. Currently, in the UK, these skills form part of the degree training programme for physiotherapy, further supplemented by the research training package.Two authors independently coded all transcripts, and used a clear, transparent and reproducible methodological approach to data analysis. The author’s clinical and research experience lie within the biopsychosocial framework of musculoskeletal pain. It is worth noting that the interviewer made it explicit to the participants that he was a physiotherapist working in the department conducting the research.Despite efforts to the contrary, the main limitations of this study were the difficulty in interviewing patients lost to follow-up (from both treatment groups) and those classed as non-responders in the experimental intervention group. Four patients were contacted who failed to return any outcome measures, and initially agreed to be interviewed; unfortunately, they failed to attend.The study population comprised a single clinical setting, where the researcher was also a clinician and where clinical trials are often undertaken; it is unknown how transferable the intervention is without the relevant physiotherapy training package.It is possible that the patient sample may differ from other samples within the UK, and how representative these findings are to other populations with PFP is unknown.This qualitative paper has identified some of the barriers and facilitators with participants (physiotherapists and patients) with the delivery of a loaded self-managed exercise programme, with education and advice on physical activity.From the patients’ perspective, facilitators to engagement included effective education around: self-management on exercise dosage; physical activity and flare-ups. This facilitation may have been mediated, in some part, to enhancements of self-efficacy and internalised locus of control. From the physiotherapists’ perspective, these results highlight the importance of ‘control’ and self-management during their assessment and management of patients with PFP.In the context of the UK’s usual management approach for PFP, which showed that a large proportion of practising physiotherapists would advise a patient to cease exercise or physical activity if they experience pain, implementation into general clinical practice may be challenging, but, ultimately feasible.