Holistic care means addressing the patient as a person; providing high-quality care by focusing on individual needs. Our goal is to implement a survey that quantifies the patients’ physical, mental, and spiritual health to enable improvements in client-centered therapy in lower-limb amputees. For this, we worked with a 43-year-old Hispanic male with a medical history of insulin-dependent diabetes complicated by sequential lower limb amputations. The second amputation cost him his job and left him homeless. The patient was hospitalized after developing severe depression, to the point that he had command auditory hallucinations to kill himself. He was discharged back into the community after a three-week hospitalization. However, he was readmitted to the hospital a week later due to a resurgence of suicidal ideation. Our team engaged the patient using the “Holistic Health and Wellness Survey” of Raymond W. Smith, which we used to assess and address various domains of his mental, spiritual, and physical health. We were able to create obtainable goals for the patient for each category on which he scored low in the health and wellness survey. The patient’s overall health and attitude improved substantially through his client-centered therapy, which addressed his quantified health needs; and he began to take an active role in developing short- and long-term goals that he found attainable as he adjusted to life as a double-amputee.This case illustrates the potential for improving client-centered therapy in lower-limb amputees. We believe that providers may benefit from implementing this health and wellness survey to better assess how to provide client-centered care for their patients. Holistic care is a flourishing mission statement in modern healthcare, but it is not a new idea. The founder of osteopathic medicine, Dr. Andrew Taylor Still, believed that a consideration of all elements of a person’s body, mind, and spirit should be incorporated into their care. This type of holistic attention addresses the patient as a person and provides high-quality care by focusing on their individual needs .Limited in mobility, many lower-limb amputees struggle with limited participation in society . In seveMr. H is a 43-year-old Hispanic male with a history of insulin-dependent type 2 diabetes, complicated by bilateral leg amputations and previous hospitalization for depression, with suicidal ideations and command auditory hallucinations of killing himself. He presented to the psychiatric emergency department after telling the residential staff that he was hearing voices and planned to throw himself in front of a bus.Four months before admission, Mr. H’s diabetes had progressed significantly, and he required amputation of his right leg due to complications from his diabetes. This further debilitated him, as he had had a below-knee amputation of his left leg eight years previously, as a result of not managing his diabetes. Around this same time, he began hearing unknown female voices at night, telling him to kill himself by jumping in front of a bus. Since Mr. H had begun to hear voices, he had been thinking about committing suicide. He had never had these thoughts previously. Unable to work as a car detailer and manage his depression, Mr. H had eventually used up his savings and became homeless. The voices did not go away and his mood worsened, and he eventually came to the urgent care clinic in June asking for help. He was subsequently brought in by ambulance to the hospital and placed on 5150 hold for “danger to self.” He was held in the psychiatric emergency department until being transferred to the inpatient psychiatry unit in July for further medical stabilization.After a few weeks of hospitalization, Mr. H was stabilized and discharged on maintenance medications of fluoxetine 60 mg daily, olanzapine 20 mg daily, and gabapentin 600 mg three times daily for major depressive disorder with psychotic features. Mr. H said that his mood had improved and the auditory hallucinations had lessened. He was accepted and discharged to an assisted living facility as part of Housing for Health, a program that provides permanent supportive housing for homeless patients.In August, the patient reported worsening auditory hallucinations, commanding him to kill himself. Although he had a son and a girlfriend, he did not have anyone to talk to about the voices or his suicidal ideation, ultimately leaving him feeling lonely. His thoughts of suicide were prompted primarily by the voices, but when he considered acting on this, it was due to sadness about his immobility, his diabetes, the voices, and his financial stressors due to not being able to work. He did not know what to do when he had these thoughts, and he was unable to describe what had prevented him from committing suicide. He had engaged in activities for distraction, such as making the bed or listening to music, but he felt the voices were overpowering. When asked about his interests, he said that he used to enjoy drawing but he has not drawn in a while because he has not been in the mood to do so. The patient’s mental health was initially monitored with fluoxetine 60 mg daily, aripiprazole 20 mg daily, mirtazapine 30 mg nightly, and lithium 30 mg nightly.Throughout the hospitalization, Mr. H was taken care of by the interdisciplinary team that includes the psychiatrists, nurses, physical therapists, nutritionists, the case manager, occupational therapist, and social worker. In the first 12 days after admission, Mr. H’s overall health did not improve, and the auditory hallucinations, depression, and immobility continued. He evidenced a lack of motivation to feel better, and he had no interest in talking to anyone. As Mr. H did not want to talk to us, we did not understand his needs or goals. Our team engaged Mr. H using the “Holistic Health and Wellness Survey” of Raymond W. Smith. This survey consists of three health domains: “mind,” “body,” and “spirit.” The first (mind) concerns the patient’s mental and emotional health. The second (body) focuses on the patient’s physical and environmental health. The third (spirit) is the patient’s spiritual and social health. Each domain consists of 25 questions, and the patient answers each question using a scoring system of between 0 (“strongly disagree”) and 5 (“strongly agree”). Using this survey, we assessed various domains of the patient’s mental, spiritual, and physical health. We were able to create obtainable goals for Mr. H for each category on which he scored low on the health and wellness survey. For example, Mr. H gave himself a low score for items 1  and 3  in the “body” category, both of these items describing an inability to maintain a healthy diet. In response, we advised him not to eat afternoon snacks or receive extra food from his peers. In the “mind” category, Mr. H gave himself a low score for item 13 (“I maintain peace of mind and tranquility”), indicating that he feels anxious. Mr. H rarely showered in the ward, so we advised him to shower every day because this is known to give feelings of warmth, relaxation, and refreshment [After this hospitalization, he hopes that he will be able to think more clearly and obtain a new prosthesis for his right leg, which would enable him to restart work as a car detailer.Losing a limb has a profound impact on physical, mental, and spiritual health. The association between lower limb loss and impaired functional mobility is well-documented. Lower limb loss is also associated with other physical health problems such as phantom limb and back pain -7. LimitWorse health outcomes are associated with poor rehabilitation results in lower-limb amputees . In one Client-centered therapy helps patients achieve change through an emphasis on patient interests, emotional care, and goal-oriented problem-solving. Client-centered therapy is at the heart of holistic care: taking a mind-body approach to improve patient outcomes. At present, there are no set protocols or significant quantifying measurements to track emotional and social progress in lower-limb amputees due to the subjective nature of patients’ individual impediments.In the beginning, Mr. H had no interest in improving his health. His lack of motivation and unwillingness to communicate with the healthcare team made it more difficult to treat him. However, by implementing the “Holistic Health and Wellness Survey,” we were able to understand Mr. H and create obtainable goals for him in each category in which he scored low: mind, body, and spirit. Obtainable goals are tasks that almost anyone can tackle. These simple, attainable tasks can include skipping afternoon snacks, showering every day, and participating in group activities. Client-centered therapy substantially improved Mr. H’s overall health and attitude because the survey was able to address his quantified health needs. He began to take an active role in developing short- and long-term goals that he found attainable as he adjusted to life as a double-amputee.Holistic care enables us to address the patient as a person and to provide high-quality care by focusing on individual needs. Mr. H’s overall health improved by implementing the “Holistic Health and Wellness Survey” and addressing his quantified health needs. This case illustrates the potential for improving client-centered therapy in lower-limb amputees in the realm of physiatry or psychiatry.


The results suggest that the use of task could affect cross-domain association in metacognitive efficiency. In the third experiment with the same sample size, we used YN judgments for both tasks and did not find a significant cross-domain correlation in metacognitive efficiency. This suggests that the cross-domain correlation found in McCurdy et al. (An important yet unresolved question is whether or not metacognition consists of domain-general or domain-specific mechanisms. While most studies on this topic suggest a dissociation between metacognitive abilities at the neural level, there are inconsistent reports at the behavioral level. Specifically, while McCurdy et al.  found a y et al.  was not y et al.  might be Metacognition is an important cognitive ability that enables us to monitor and regulate our own mental processes and task performance. In experiments, one way to quantify metacognitive sensitivity is to assess the trial-by-trial correspondence between confidence judgments and accuracy in behavioral tasks. An important question that remains unclear is whether the metacognition underlying different processing domains, such as metacognition for visual perception and memory, depend on distinct, domain-specific neurocognitive mechanisms, or on a single, domain-general system that supports metacognition for all mental faculties.Findings from recent neurophysiological studies , and then compute the correlation between the two across individuals. If metacognition is domain-general, the same mechanism should underlie metacognitive responses across domains, and there should be a significant, positive cross-domain association in metacognitive efficiency. Specifically, while McCurdy et al.  reportedn = 34 for McCurdy et al., n = 52 for Baird et al., n around 100) for greater and more similar, comparable level of statistical power.There are a few issues that could explain such discrepancy. The first concerns statistical power. As the two studies had different sample sizes  or one after another in succession . The task is to identify the spatial or temporal arrangements of the two stimuli, e.g., whether the “old word” (that has been previously presented) is on the left and the “new” word is on the right, or vice versa . This may hinder researchers from obtaining comparable measurements on cross-domain association in metacognitive sensitivity, which could be the main reason for the inconsistent results between the two above-described studies, as well as across many other behavioral findings  for different processing domains, namely, vision and memory, and measured the resulting cross-domain association in metacognitive sensitivity. In terms of the use of tasks, Experiment 1 replicated McCurdy et al.  in that n = 100 for each experiment) and using the same stimulus (cluster of circles) for both the visual and memory tasks, which would be different from the designs in McCurdy et al. . Eligibility was determined by the subjects and listed in an online advertisement and consent form for the study; in order to take part in the experiment, all subjects were required to have normal or corrected-to-normal vision  and no history of any psychiatric or neurological illnesses or seizures. All subjects provided consent to participate. Each subject was compensated $4 for completion of each experiment, with the possibility of receiving a $1 bonus if their performance was higher than that of the previous participant.The stimulus for both the visual and memory tasks was a cluster of black-outlined circles with varying sizes against a white background. Positions of circles were randomly determined, with the following constraints: Circles were not allowed to overlap with one another, and the distance between any two circles within the cluster was limited within a certain range, so that circles would not be too far or too close to one another.The visual task was an average-size comparison task. Radius of each circle was randomly sampled from a predetermined average number of pixels. This average radius varied according to a staircase procedure described below. In each experiment, each subject completed 120 trials of the visual task.In the visual 2AFC task  if the subject had consecutively given n correct response(s), and adjusted down by one step size  if the subject had consecutively given m incorrect response(s). If the subject had produce less than n consecutive correct responses or less than m consecutive incorrect responses, difficulty level of the following trial would remained unchanged.For both the visual and memory tasks, task difficulty was controlled using For the visual 2AFC task, difference in the average radius between the two presented clusters was varied to control task difficulty. After each response, the algorithm randomly select between a 2-up-1-down and a 3-up-1-down staircase, and decide the difference in the average radius accordingly. This allowed the 2AFC task performance to converge to an expected value of around 75%. The initial difference in average radius was 6 pixels, and the step size for both increasing and decreasing average radius was 1 pixel. For all trials, the maximum and minimum differences in average radius were fixed at 11 pixels and 1 pixel, respectively.For the visual YN task, difficulty was controlled by varying the difference in average radius between the presented cluster and the “medium” clusters. The initial difference was 4 pixels, and the step size for both increasing and decreasing average radius was 1 pixel. For all trials, the maximum and minimum differences in average radius were fixed at 7 pixels and 1 pixel, respectively.For both the memory 2AFC and memory YN tasks, the same staircase procedure was used. Task difficulty was controlled by varying the study duration of the target patterns. At the beginning of each mini-block, this study duration was determined by a variant of a 4-down-2-up staircase procedure with a step size of 500 ms: if the subject had got all four responses correct in the previous mini-block, study duration for the current mini-block would be reduced by 500 ms, making the memory task for the current mini-block more difficult; if the subject had got two or less responses correct in the previous mini-block, study duration for the current mini-block would be increased by 500 ms, making the memory task for the current mini-block easier; otherwise, if the subject had given exactly three out of four correct responses in the previous mini-block, study duration would remain unchanged for the current mini-block. This staircase procedure would allow memory task performance to converge to an expected value of 75%. Study duration for the first mini-block was 8 s for all subjects. The minimum and maximum study duration for all mini-blocks were 4.5 and 11.5s, respectively.For both the visual or memory tasks, 5% of trials  were catch trials. The catch trials were inserted to ensure that participants were actively attending to the task, and that they correctly understood the instructions. Each catch trial consisted of a stimulus that would make the task extremely easy. If subjects performed poorly on any two catch trials, they would be told that they had not performed well on some of the easier trials and were asked whether or not they would like to continue the experiment.Moreover, subjects who did not give responses within the given time (2.25 s) for four consecutive trials were given a warning, indicating that they should pay closer attention to the task, and that they would not be able to continue the experiment if they failed to do so. Following this, if the subject again did not respond in time on four consecutive trials, their participation in the experiment was terminated immediately.In each experiment, every subject performed both the visual and the memory tasks, with the order of the tasks counterbalanced across subjects. Each experiment took approximately 1 h to complete. All subjects completed all the tasks in one session. As remaining stationary and on task for 1 h might induce boredom or fatigue, subjects were given two short breaks throughout each of the two tasks in order to ensure they retained a sufficient level of comfort and focus.All stimuli and behavioral tasks were created using JavaScript by utilizing jsPsych. The stimuli in the tasks were scaled off of the size of each subject's computer screen, which ensured that the sizes and positions of all stimuli would be the same for all subjects, despite the fact that computer screen size probably varied from participant to participant.To assess metacognitive sensitivity for each modality, we utilized the bias-free psychophysical measure, meta-d'  or memory representation . It is a bias-free measure of sensitivity in, for example, discriminating between “larger” and “smaller” clusters of circles in our visual tasks, or between “old” and “new” patterns of circles in our memory tasks. The meta-d' of a participant is the d' that an observer with “optimal metacognition” and the same first-order response bias would require in order to reproduce the participant's metacognitive (or type-2) responses that have been observed in the experiment  refers to the number of such trials in the experiment, and Probθrefers to the predicted conditional probability of confidence response being y given the stimulus being s and response being r using the parameter values specified in θ based on the standard SDT model. The MLE was carried out using the MATLAB code provided by Maniscalco and Lau  were estimated using the maximum-likelihood estimation (MLE). Formally, let θ be the vector containing the set of parameters to be estimated (including meta-d' and d'). We estimated meta-d' and d' for each participant by finding the θ that maximizes the following likelihood function , a measure of metacognitive efficiency . M Ratio, which controls for the effects of first-order task performance, was also the primary measure of interest in both McCurdy et al.  and BairBecause the study was conducted online, many factors were beyond our control, leading to extreme or unrealistic values of measurements, particularly in task performance. To prevent these extreme or unrealistic values affect our analyses, subjects were excluded if any of the following criteria were matched.First, Cook's D Cook,  was compSecond, subjects were excluded if their first-order task performance  or metacognitive sensitivity was not within a reasonable range. Specifically, if d' was too low, the estimate of M Ratio could become unreasonably large and/or unstable . Therefore, the subject was excluded if d' was below 0.5 for either the visual or memory task. Also, because we used a staircase procedure to maintain a relatively stable accuracy of around 75% for both tasks, we assumed subjects produced confidence ratings based on this level of accruacy. If a subject's accuracy deviated too much from this controlled value, it would suggest that his/her confidence ratings may have been made based on a much better or a much worse performance level. This would create an unnecessary source of variability in the data. Therefore, if the percentage correct was 15% below the expected accuracy  or 15% above the expected accuracy , the subject was excluded. For confidence judgments, a subject would be excluded if meta d' was below 0 for the visual or memory task.n = 96), Experiment 2 (n = 93), and Experiment 3 (n = 94), respectively. In the following Results section, the figures only show data with the above-mentioned outliers removed. For the full set of data showing all 100 participants for each experiment (with outliers labeled) and the corresponding scatterplot of cross-domain M Ratios, please refer to the publicly-available fileset on figshare .As in McCurdy et al. , both taGiven our replication of the main finding of McCurdy et al.  in Experr = 0.0739, p = 0.4815; Figure r = 0.01, p = 0.9215). In short, we replicated the behavioral result from Baird et al. . Thus, not only did we find different results when using distinct types of discrimination judgments across the two experiments, this difference was also significant under a direct comparison.To further probe whether the difference in behavioral results between the two studies can be consistently replicated, we converted Pearson correlation coefficient values for each of the two experiments to z values  using Fisher's R to Z transformation Fisher, . A Z tesThe results of our first two experiments raise the question of what exactly it is about the distinction in judgment type that causes differing results. One possible explanation is that observing a correlation depends on using the same judgment type across tasks. For example, both our Experiment 1 and McCurdy et al.  found siAlternatively, our Experiment 2 and Baird et al.  may haveWith these two possible explanations in mind, we conducted Experiment 3, using YN judgments for not only the memory task (as in Experiment 2), but also for the visual task . If significant cross-domain correlation was found, it would suggest that McCurdy et al.  finding r = 0.0934, p = 0.3707; Figure r = 0.1025, p = 0.3102). Taken alongside the results of our first two experiments, this suggests that the use of a YN task could be the reason for the inconsistent behavioral findings from Rounis et al. , but this was not the case for meta d' for “no” responses . Therefore, it appears that the lack of correlations observed in our Experiment 3, as well as in our Experiment 2 and Baird et al.  = −4.475, p < 0.001], and for Experiment 3 memory task , although the latter did not reach statistical significance . Conversely for our Experiment 3 visual task, meta d' for “yes” responses was lower than for “no” responses , although the difference did not reach statistical significance .In general, it is known that metacognition after “no” responses may be less efficient , meaning that including the metacognitive measure after “no” responses was not a problem for revealing metacognitive correlations. Likewise, in Experiment 2 we also tested for an association between meta d' for “yes” responses on the memory task and  meta d' for the visual task and found a strong trend toward statistical significance . Further supporting the above suggestion, we found that meta d' for “yes” responses on the visual task was not significantly correlated with the overall meta d' for the memory task in Experiment 3 , where meta-d' for “no” responses was higher than meta-d' for “yes” responses.Based on these results, we further tested the possibility that meta-d' for “no” responses is problematic for assessing cross-domain metacognitive correlations, only when it is lower than meta-d' for “yes” responses. In support of this possibility, we found that in Experiment 3, meta d' for “yes” responses on the memory task was significantly correlated with  meta d' for the visual task in our Experiment 3 , whereas this correlation significantly decreased and ultimately disappeared when requiring 2AFC for one task and YN judgments for the other (Experiment 2). We also found no correlation when requiring YN judgments for both tasks (Experiment 3), suggesting that using the same task for both domains may not be necessary for observing cross-domain correlation in metacognitive sensitivity. Together, these results suggest that our failure to find a correlation in Experiments 2 and 3 resulted specifically from YN judgments introducing more ambiguity into the decision process than 2AFC. Further analyses indicated that, specifically, it is metacognition after “no” responses that may be the problem, especially in the memory task.feature while the absence case contains a similar level of stimulus energy despite the lack of that particular feature. This distinction was introduced by Maniscalco and Lau [Maniscalco and Lau . Above we suggested that “no” judgments are somewhat more convoluted or difficult than “yes” judgments, because, in the absence of evidence, it may be difficult to assess certainty. If this is true, this may only apply to our true-detection, memory YN task, but not to the visual YN task, which is akin to “pseudo” detection. This is because, unlike in true-detection tasks, in our YN visual task subjects did not discriminate between the presence or absence of a stimulus; instead they judged whether a stimulus was, on average, big or small. Overall, the pattern of results supports the hypothesis that it is metacognition after a “no” responses in “true” detection that is causing the problem in limiting our ability to reveal metacognition across task domains.Our results agree with other similar studies and may inform their interpretations. As in our Experiment 2 and Baird et al. , both BaSeveral comparable studies also agree with our Experiment 1 and McCurdy et al. . Samaha n = 24. This means that even if the effect was actually there, it was unlikely to have been detected given the sample size, so a null finding is unsurprising.Despite the above agreement, one relevant finding conflicts with our results. As in our Experiment 1 and McCurdy et al.  and MoraAlso, in somewhat of disagreement with our results here, Valk et al.  used 2AFOne may be concerned about the visual YN task used in the present study, as participants needed to remember the examples of “medium” sizes in order to make YN judgments about the average sizes of the subsequently presented clusters of circles. This could make the visual YN task similar to a memory task. However, it should be noted that our visual and memory tasks were fundamentally different in terms of the dimensions on which decisions were made. In the visual YN task, decisions were based on size, which is a visual feature by definition. In both the 2AFC and YN memory tasks, decisions were based on whether a stimulus had been presented before, which is a memory representation by definition. Furthermore, many visual tasks  involve some kind of memory, e.g., after a Gabor patch or a random-dot motion pattern has disappeared, the participant makes judgment about its orientation or motion direction. Involving memory in a visual task does not make a visual task “not visual,” as long as performance in the task still heavily relies on visual perception. For example, in the present study, even if a participant had perfect memory about the “medium” size, visual processes would still be involved in perceiving the size of the tested clusters of circles. Therefore, we believe our visual and memory tasks tapped on different processing domains.One possible limitation about the present study is that our first two experiments were not direct replications of McCurdy et al.  and BairAnother limitation may be that the experiments were conducted online, in which participants' identities or visual and mental conditions could not be verified in similar ways as in experiments conducted in laboratory settings. While this may be a concern for online research in behavioral science in general, it has been shown that (1) online participants produce largely comparable results in both cognitive and perceptual experiments as laboratory participants do  Office of the Human Research Protection Program with written informed consent from all subjects. All subjects gave written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by the UCLA Institutional Review Board.All authors contributed conception and design of the study. ER and NG conducted the study, performed the statistical analyses, wrote the first draft of the manuscript. AL and HL contributed to critical revision of the manuscript, read and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


M age = 10.53, SD = 0.90). The results showed that 42.3% of the schoolchildren did not practice IM to school, 18.1% practiced IM one way , and 39.5% practiced IM both way . These findings underline the importance of parents’ willingness for IM to school, and how the balance between how they perceive their children’s autonomy and difficulty for IM is relevant for greater IM to school.The present study aimed to examine the factors associated with different forms of independent mobility (IM) to school (IM one way and IM both ways) according to their parents’ opinions. To do so, several variables were evaluated: how parents assess their children’s autonomy, the difficulty they perceive for IM to school, reasons for IM/no IM to school, parents’ willingness for IM to school, frequency of children’s IM for leisure activities, children having house keys and dangers perceived in the neighborhood. Family-related socio-demographic variables were also assessed: number of children, position occupied by them in the family, family composition, living with both parents or just one, and each parent’s nationality, level of education and job status. This study examined the data collected from 1450 parents (mothers and fathers) with children studying Primary Education years 4, 5 and 6 ( Childhood is a critical development period when physical activity patterns are established, which will probably remain throughout adolescence and adulthood ,2. The WIn line with Hillman et al. and with Carver et al. ,17, chilDespite these benefits, compared with previous generations, IM has diminished, particularly in countries like France, Portugal and Italy . AccordiPrevious studies ,27,28 haSpending less time playing outdoors means that children in today’s generations are less autonomous. The autonomy concept is defined as a state of being independent or self-governing, and frequently refers to three domains: behavioral, emotional and cognitive . ParentsAlthough variables like perceiving danger in social surroundings have been related with children being allowed less IM, other variables like the number of children and the position they occupy in the family, or parents’ willingness to give them more or less IM, can be relevant. However, these variables have been less investigated ,38. The When analyzing parents’ perceptions and their relation with children’s IM, different studies have shown that IM has to do with parents perceiving their neighborhood with a greater sense of community; that is, their neighborhood provides more cohesion, is better connected and safer, and has nearby schools because it belongs to a smaller area ,41,42,43Recent studies demonstrate the existence of various forms of IM to school that children enjoy, as well as the importance of distinguishing between children who go to/from school alone (IM both ways) and those who only go to or from school alone (IM one way) . Those cBy also considering these research works, the present study aimed to examine a considerable number of variables  in association with IM using a sample formed by the mothers and fathers of children in Primary Education years 4, 5 and 6, and to explore to what extent these variables contribute to predict the IM that parents grant their children. This study specifically analyzed the predictive capacity of the following variables for children’s IM to school: number of children, position the child occupies with their siblings, and parents’ ages, nationality, level of education and job status, parents’ assessment of their children’s degree of autonomy (not autonomous vs. autonomous), parents’ perceived difficulty of IM to school, parents’ willingness for their children to go to school independently, parents’ perception of certain outdoor dangers, parents’ reasons for not allowing IM to school, children’s IM for leisure activities, and children having house keys. These variables were analyzed as possible predictors of different IM forms by distinguishing among no IM, IM one way (only going to/from school) and IM both ways (going to/from school).Letters for participation were sent to 12 schools from Huesca (Spain) to invite them to participate in the study. The research team contacted each school to provide information about the study and the procedure. Eleven of the 12 schools volunteered to take part. Two researchers went to these schools and handed out paper-and-pencil questionnaires to children. Children handed each questionnaire to their parents with a letter providing instructions to complete it. An approximate 10-day deadline date was set to return questionnaires. Children handed questionnaires to their corresponding teacher. Researchers collected questionnaires from schools.SD = 0.90) within a range from 8.16 to 12.88. Only four children were 8 years old and 86 were 12 years old. This study forms part of a larger European project called CAPAS-Ciudad (BLINDED).Data were collected from 1835 mothers and fathers of the schoolchildren in Primary Education years 4, 5 and 6, which usually covers ages from 9 to 11 years old, from the 11 participating education centers  from Huesca (Spain) between February and May 2017. As some families’ place of residence was not in the city of Huesca, 191 cases were removed as they lived in rural areas or did not properly complete the required information. Indeed no families living further than 3.5 km from school were included, and 194 subjects were not considered as they referred to only one parent. Thus the final sample was formed by 1450 parents. Of their questionnaires, 725 were completed by mothers, 718 by fathers, and 7 by the mother’s partner. About 46.8% of their children were boys and 53.2% were girls. The children’s mean age was 10.53 .The questionnaire filled out by parents was “The Independent Mobility of Italian children”  by Francesco Tonucci et al. , translaDoes your child go to school by him/herself? and Does your child come back from school by him/herself? For both questions, the answer options were dichotomous: Yes or No. A dummy variable was created to distinguish: IM to or from school (IM one-way), IM to and from school (IM both ways) and no IM, which scored 1, 2 and 0, respectively.IM to/from school. Parents completed a self-reported measure with the following questions: What is your child’s attitude toward you?, for which there were two options: not autonomous vs. autonomous.Evaluating your child’s autonomy. A question was included that indicated: Is it difficult for your child to go to school by him/herself? Parents had to answer “Yes” or “No” .Perceived difficulty for IM to school. They were asked We do not feel able to let him/her going by him/herself” and “Our child does not want to go by him/herself”. Some other reasons were also provided, such as: I prefer spending this time with my child; my child is too young; my child could have bad experiences.Reasons for not allowing IM to school. Parents were asked to mark whether: “Yes” or “No”.Parents’ willingness for IM to school. Whether parents would have liked their children to go to school without adult accompaniment was measured by the response answers “How frequently does your child do this activity without being accompanied by an adult? and the activities were: 1) visiting friends and out-of-school activities; 2) using public transport; 3) cycling around the neighborhood; 4) buying from a shop; 5) playing outside (in a park or open spaces); 6) going out when it gets dark. All these options were answered on a 4-point frequency scale: “Never”, “Sometimes”, “Most of the time” and “Always”.Frequency of IM for outdoor leisure activities. Besides IM to school, it was considered important to assess the frequency by which schoolchildren performed certain outdoor leisure activities unsupervised by adults. Parents were asked Never (1) to Always (4).Having house keys. Parents answered the following question: How often does your children have house keys?, with answer options ranging from: strongly disagree to (4) strongly agree.Perceived dangers. The assessed barriers included danger related to streets, footpaths and crossing roads, public parks and entertainment areas, buses and public transport, and shops or supermarkets. All the items were assessed on a 4-point Likert scale ranging from (1) First of all, the sample’s socio-demographic characteristics were analyzed. A comparative analysis was done by performing a MANOVA of the variables evaluated for mothers and fathers. As no significant differences were found, further control of parents’ gender was not considered. We next examined the percentage of parents who indicated that their children went to school with no adult accompanying them (IM to school) by distinguishing: who went to school accompanied by adults (no IM); who went to or returned from school alone (IM one way); who went to and returned from school alone (IM both ways). At this point, we also examined whether there were differences in IM based on children’s gender and school year.We analyzed if there were any significant differences in children’s IM level by considering the socio-demographic and parents’ perception variables. To do so, we conducted a MANOVA to analyze any possible differences among the three groups with different levels of children’s IM  in the socio-demographic variables  and the variables related to parents’ perceptions and attitudes . In these analyses, the categorical variables, which were mostly dichotomous, were treated as continuous variables. As there were three groups with different levels of children’s IM, post hoc tests were run to explore the significant differences between means.Finally, in order to analyze the predictive value of the examined variables (socio-demographic variables and the variables related to parents’ perceptions and attitudes) on children’s IM, we conducted several binary logistic regression analyses, in which a dependent variable was established in each case as follows: a) no IM vs. IM one-way  and b) no IM vs. IM both ways . The socio-demographic variables and variables related to parents’ perceptions and attitudes were included in the regression analyses as predictor (independent) variables.SD = 5.03) and 45.38 (SD = 5.43), respectively. Their nationality was mainly Spanish, and their level of education and job status were high. The chi-squared test found significant differences between both parents for all the evaluated variables, except for employment. Compared to fathers, the surveyed mothers were significantly younger, the nationality of more of them was not Spanish and they had a higher level of education.The sample’s socio-demographic characteristics are presented in p = 0.517). However, significant differences in children’s IM according to school year were observed  = 91.75, p < 0.001) for all three school years. Greater IM was found for children studying in Primary Education year 6. Therefore, we included this variable in subsequent analyses.Later, the percentages of the parents who indicated that their children went to school accompanied by adults (no IM), went to or returned from school alone (IM one way), and went to/from school alone (IM both ways) were examined. Our results indicated that 42.3% of parents stated that their child went accompanied by an adult to school (no IM), 18.1% reported that their child went to school or returned from school alone (IM one way), and 39.5% pointed out that their child went to/from school alone (IM both way). Regarding children’s gender, no significant differences between boys and girls in their IM levels were found  = 0.312, As Moreover, differences were observed with the other evaluated variables, which were significant in the perceived difficulty of IM to school and for all the reasons for IM according to each group see . The no As seen in The objective of the present study was to assess those factors associated with different forms of IM to school in schoolchildren studying Primary Education years 4, 5 and 6 (corresponding mainly to the ages of 9–11 years) by considering their parents’ opinions. Of all the participating schoolchildren, 42.3% practiced no IM, 18.1% practiced IM one way, and 39.5% practiced IM both ways. It is noteworthy that over half our evaluated sample went to/from school alone, with most of them doing so both ways. This prevalence is consistent with that found in previous studies conducted in other Spanish cities , even thThe present study shows that those parents who allowed more IM (the IM both ways group) were those with a given family composition as they had more children and the studied children occupied a more intermediate or advanced position with their siblings. As other studies have observed, the children who are neither an only nor first-born child, and can be accompanied by their siblings, have more freedom to move around ,13. MoreDifferences were also found in the reasons explaining IM because the reason why the parents in the no IM group did not like their child going to school alone was because “my child is too young”. However, the main reason for the IM both ways group was “I prefer to spend more time with my child” or “to avoid possible bad experiences”; that is, the parents who did not encourage IM felt that their child was not mature enough and uncapable of IM ,45. In lDifferent factors were found when analyzing the significant correlates of IM for its categories . School year, having more IM for activities like visiting friends, out-of-school activities and going to shops to buy, along with having house keys, were the main predictors of IM to school one way vs. no IM. Regarding school year, one explanation for this finding could be that each school year frames certain changes and independency for children. Indeed it is likely that parents decide to provide their children with more independency to change certain habits at the beginning of the school year than during it; moreover with each school year, children are older and parents could decide to give them more IM to school. The present study also showed that the children with greater autonomy to visit friends, perform out-of-school activities, buy in shops and have house keys also performed greater IM to school. Compared with the IM one way predictors, the IM both way predictor variables were related more with aspects like barely perceiving difficulty, more parents’ willingness for IM and perceiving the children as autonomous, which underlines the importance of distinguishing between both types of IM. One main contribution made by this study is that it showed how the parents who allowed their children more IM (both ways) were also willing for their children to go to school alone. These parents also perceived fewer difficulties in their neighborhood, valued their child as more autonomous, and they possibly perceived that promoting their children’s autonomy was positive for their psychosocial development to a greater extent. In line with this, it would be convenient to analyze the attitudes that parents have about the importance of promoting their children’s autonomy in future studies. In relation to this, a recent study  identifiAnother variable that predicted IM to school both ways herein was a higher frequency IM for visiting friends or performing out-of-school activities. The literature reveals how children with more independence to take a route to school also display more independence to go and perform their out-of-school activities, and to use public spaces in general ,22,55. HOne main aspect of the present study was the high participation rate of the schools in the city of Huesca . Moreover, one highlighted contribution of this study is having analyzed three different forms of IM . Unlike other research works, which have analyzed only IM one way, our study explored many variables associated with IM both ways, a type of IM that implies children’s greater independence. The present research results help to provide a better understanding of the variables that influence children’s IM and could be very useful for developing intervention proposals to encourage it. Certainly, parents are fundamental for their children’s greater IM, and the results offered herein allow us to advance in our knowledge about which family variables (both socio-demographic variables and parents’ perceptions) are related more with IM both ways. Indeed the results obtained herein stress that IM both ways is associated with three interlinking aspects linked with parents’ perceptions and attitudes, namely: greater parents’ willingness for their children to acquire IM, parents perceiving fewer difficulties in their neighborhood, and them evaluating their child as being more autonomous. It would be worthwhile making these variables the priority objective in interventions made with families to favor their children’s IM to school. Some parents’ fears, or the difficulty they perceive with their social setting, may also require making more marked changes in the way cities and communities are organized. In other cases, it might be necessary to revise with families some social rules about conducts associated with being a “good mother”/“good father” as some are possibly linked with their willingness, or not, for their children’s IM to school. It would also be worthwhile analyzing with parents the specific difficulties they have with their children’s IM both ways, what changes should be made in their neighborhood to reduce these difficulties, and to explore with parents what degree of autonomy they actually perceive of their children and how it can be increased by allowing them to see that, as their children grow, their autonomy must increase to favor their better psychosocial development.In the social context in which this research was conducted, we believe that work is being done, and should continue to reach a public policy, to help reduce the perception of difficulty in a neighborhood , schools participating in IM to school, etc.). We also believe that we have to empower children, which is important to allow them to speak so they may participate in how they wish to develop their daily IM . IM can This study has its limitations. First, our results cannot be generalized to other urban or rural areas in Spain, or abroad, as our participants came from one particular city in Spain. Thus future research works should be extended and conducted in other cities of Spain, and should longitudinally bear in mind the perspectives of both children and their parents at the same time, and how they influence IM. Two-way and dynamic influences may exist between the evaluations made by parents and children, which might promote or undermine a children’s autonomy from developing. So both parents’ and children’s perceptions of IM in the same research as part of future studies would be worthwhile, along with their reasons for IM both ways to school.In recent decades, children’s IM to school has substantially reduced, which implies negative consequences for their health and psychosocial well-being. This study has analyzed several family variables associated with different forms  of children’s IM to school, and provides interesting and novel data about these variables. The obtained results reveal that the families which permit more IM (both ways) are those that wish their children to go to school alone, they perceive fewer difficulties in their social setting, and consider their children more autonomous. The results of this study have highlighted the importance of parents’ willingness for greater IM, thus it would be convenient to continue exploring parents’ reasons for this willingness and to what extent their perception of the importance of enhancing children’s autonomy may be related with allowing their children’s IM to school. One of the main contributions of this study is the importance of the parents’ willingness for children’s IM to school, and future studies should examine this variable and what factors influence it in in-depth.Taking into account the importance of parental perceptions, it would also be advisable to develop interventions to make parents aware of the benefits that children’s IM to the school has for the health and psychosocial well-being of their children. Although some environmental and organizational aspects of cities  should be changed to favor children’s IM to school, parental perception of the possible dangers and difficulties for children’s IM, and probably what they think about the behaviors that are also socially expected of a “good father”/“good mother”, could also be key variables to help increase children’s IM to school in our societies.


In the published article, there was an error in the affiliations. “Qinrui Li” should only have the affiliation “Department of Pediatrics, Peking University First Hospital, Beijing, China”. The affiliation list has, therefore, been updated accordingly.The authors apologize for this error and state that this does not change the scientific conclusions of the article in any way. The original article has been updated.


Population-based risk assessment, using genetic testing and the provision of appropriate risk management, could lead to prevention, early detection and improved clinical management of ovarian cancer (OC). Previous research with mostly white British participants found positive attitudes towards such a programme. The current study aimed to explore the attitudes of South Asian (SA) women and men in the UK with the aim of identifying how best to implement such a programme to minimise distress and maximise uptake.Semistructured qualitative focus group discussions.Community centres across North London and Luton.49 women and 13 men who identified as SA , which constitutes the largest non-European ethnic minority group in the UK.Seven community-based focus groups were held. Group discussions were transcribed verbatim, coded and analysed thematically.Awareness and knowledge of OC symptoms and specific risk factors was low. The programme was acceptable to most participants and attitudes to it were generally positive. Participants’ main concerns related to receiving a high-risk result following the genetic test. Younger women may be more cautious of genetic testing, screening or risk-reducing surgery due to the importance of marriage and childbearing in their SA cultures.A crucial first step to enable implementation of population-based genetic risk assessment and management in OC is to raise awareness of OC within SA communities. It will be important to engage with the SA community early on in programme implementation to address their specific concerns and to ensure culturally tailored decision support. This is the first study to explore the attitudes of a UK ethnic minority group towards population-based risk assessment and stratified management for ovarian cancer.The study explored the attitudes of both women and men.Opinions solicited during the focus groups were directly related to information provided about population-based risk assessment and stratified management for ovarian cancer and this may have limited responses.Two female researchers facilitated all the focus groups including those with men, this may have influenced the findings.Ovarian cancer (OC) is the sixth most common cancer among UK women.2Earlier detection of OC could help to save lives and this has fuelled voluntary sector demands for research to investigate approaches for prevention and earlier diagnosis.BRCA1 and BRCA2 genes considerably increase an individual’s risk of OC;https://eveappeal.org.uk/our-research/our-research-programmes/promise-2016/), involves a feasibility trial to investigate whether stratified OC risk management is acceptable to women in the UK general population. In this programme, women will be provided with an estimate of their OC risk and stratified as low, intermediate or high risk. Those with the lowest risk will be provided with information on OC. Screening or surgery to remove the ovaries will be offered to those at intermediate and high risk. In the future, equivalent programmes could be rolled out for other cancers.10Mutations of Positive attitudes to the PROMISE programme were reported among women in the general14 15This study aimed to explore South Asian (SA) women’s and men’s attitudes towards the PROMISE programme and the idea of population-based genetic testing and risk-stratified management of OC, and to identify factors which may influence participation. The SA community is the largest non-European ethnic minority group in the UK, over 5% of the population in England and Wales identify as SA .17 18The study took a constructionist perspective in which meaning and experience are considered to be socially produced and reproduced rather than as immutable individual characteristics.Patients and the public were involved as project steering group members in the design of the overall PROMISE programme and the health behaviour workstream within which this study was delivered. Members of the SA community also contributed by pilot testing our presentation materials for the focus groups.Participants were recruited from the North London Boroughs of Brent, Newham and Tower Hamlets and Luton, areas which have large SA settler communities. Groups were conducted in suitable local community venues between November 2016 and April 2017.Purposive sampling was used to include only individuals ≥18 years old, who self-identified as being of SA ethnicity  and to include a wide spread of ages. At least some conversational English language was needed to take part. Men were included in the study as they may play a role in supporting and advising female family members’ healthcare decisions. Women were excluded if they had (1) a diagnosis of OC and/or (2) previously had genetic testing to find out about personal cancer risk.SA women and men were introduced to the study by local community centre staff (n=53), and through poster and leaflet advertisement at community centres and by a local women’s health organisation (n=9). The few eligible individuals who contacted the research team directly by phone or email were sent the study information and had an opportunity to ask questions. We aimed to obtain a broad range of views and continued to recruit until we achieved data saturation,Seven focus group discussions were held at community centres: five with women  and two with men . Each discussion lasted approximately 75 min. Groups were facilitated by NA, a SA multilingual senior qualitative researcher and KEJH, a research assistant with a master’s level qualification, acting as moderator and note-taker alternatively. A semistructured discussion guide developed from previous workAt the start of each focus group, KEJH and NA introduced themselves briefly , stated the study’s purpose and confirmed what participation involved. Intragroup confidentiality, audio recording and study report confidentiality were highlighted with an opportunity to ask questions. Each participant completed a demographic questionnaire.BRCA1/2 gene mutations, the possibility to test for these and the PROMISE programme’s proposal to offer OC risk-stratified management  and ‘undah daani’ (ovaries) interchangeably. Most participants were aware of the UK’s common cancers mentioning breast, prostate and lung, as well as cervical cancer, and correctly named some of the main risk factors for these. However, the majority had not come across OC and were unaware of the risk factors and main symptoms of the disease.Ovarian cancer…no one’s heard of it. FG4, woman, Luton.…I’m quite aware, I do pick up leaflets and read but I don’t think I’ve come across ovarian cancer, not on TV, not on any sort of media, not on the train, nothing. FG3, woman, London.A few women incorrectly believed that use of hormone replacement therapy or the contraceptive pill would increase a woman’s risk of OC. Older age was infrequently reported as a risk factor and few participants spontaneously spoke about family history or genetic risk. A minority of participants who demonstrated awareness of OC explained that this was due to either having researched the topic online prior to the group discussion (n=1) or from experience of a relative with OC (n=1).Likely due to the lack of awareness, the women had not considered their risk of OC. Some indicated that they did not generally think about their personal risk of cancer. When asked, most acknowledged that they would have some risk of OC, although whether they perceived this to be the same, lower or higher than others in the general population varied within and between the groups.Other populations, I think it’s the same? FG1, woman, London.It’s higher in Asian.But tell me this, I have never heard of any Asian person with ovarian cancer. FG4, women, Luton.BRCA1/BRCA2 genes. After participants had been informed about genetic testing within the group, it became apparent that some had difficulty understanding that (1) the test would provide information about a person’s risk rather than a cancer diagnosis and (2) being at risk did not mean that they would definitely develop cancer.Most participants had not heard of genetic testing for cancer risk and those that had did not know about the specific Based on our presentation of genetic risk and genetic testing for OC, in discussion most participants initially expressed positive views. They felt they would benefit from knowing if they were at increased risk because they could take steps to manage their individual risk.So you are aware of it, and you know how to prevent it, getting information, what are the risks, and how to do your daily activity, your daily lifestyle, maybe that can change… FG2, woman, London.The majority of women indicated that they would accept genetic testing, and several men said that they would encourage female family members to have testing if it were offered, although they acknowledged that ultimately it would be the individual’s decision. Many participants remained positive about genetic testing even after being told that risk information could potentially be less accurate for ethnic minorities. Participants said there were no cultural or religious prohibitions on genetic testing for cancer risk and these aspects of the discussion prompted some Muslim participants to speak of the positive influence that religion has on maintaining good health. In one group, participants referred specifically to the Imam (Muslim religious scholar), and his role in providing guidance to the community on health practices.Your religion wants you to look after yourself. FG1, woman, London.The main concerns voiced about genetic testing for OC risk related to experiencing worry between the blood test and receiving the result, and fear regarding the psychological impact of a high-risk result and what such a result would lead to if received.Untilyou know the outcome, your brain will be working overtime. FG4, woman, Luton.Participants were not fearful of providing blood for the genetic test and some indicated that while they were positive about genetic testing, others might be wary since they may be unfamiliar with OC, genetic testing and fearful of cancer per se.Negative side could be some people, maybe my mother, wouldn’t wanna go to that test, maybe she would be scared, even if she doesn’t have cancer… FG2, woman, London.Other negative aspects, such as the cost to the government or concerns that the test or ‘diagnosis’ could be wrong or inconclusive, were infrequently discussed.Participants endorsed the risk-stratified management approach and accepted the information that there would be clear options for women at each level of risk. No concerns were expressed about receiving different treatment based on level of risk.…you will be able to find out what you have got and according to that you can prevent your, you know, things as well, if you want to go for like a screening or for a minor surgery or whatever it is, it’s good to know what you have. FG1, woman, London.The screening component of risk-stratified management was generally endorsed, and participants felt that within their SA communities participation in current UK cancer screening programmes was gaining traction.Well at least it’s something for your health, good health. FG3, woman, London.It’s best to take a test, best to take a test not to get to that stage, isn’t it? FG7, man, Luton.However, participants talked about there still being some within the SA community who do not accept cancer screening per se. A few participants, mostly men, suggested that some women may not see the need to attend screening in the absence of symptoms. Reluctance to attend screening was also attributed to fear and issues of body privacy and shyness. Women owned that exposing their body to ‘someone else’ could be distressing, irrespective of whether the person was a healthcare professional.What she’s saying is that first, Muslims were a bit scared and they wouldn’t get checks done. They thought that maybe someone else would see them… FG4, woman, Luton.Attitudes towards risk-reducing surgery were mixed. While surgery was acceptable if it was deemed necessary by doctors, men and women said that women would not want surgery unless they had already had children and were of an older age.It depends on age because, any lady who is 50 years up, that time is high risk, she needs to remove that, but 25 years, 30 years, any lady, she has still option for children, so she can’t do that thing. FG2, woman, London.Some men did not agree with risk-reducing surgery and believed that women would not accept it until cancer was diagnosed especially since ‘high risk’ did not mean the woman would definitely develop OC.Until such a time that a person is diagnosed with cancer, I don’t think they will have their ovaries removed. FG5, man, Luton.The majority of women anticipated that their husbands and immediate families would support them if they had genetic testing for OC risk and most of the men also said that they would support their female family members if they wanted to be tested. Several women said they would discuss this beforehand with their husbands and families and/or would share the result.And then obviously going back and discussing it with family what’s come up as well. FG3, woman, London.Both men and women felt that some women would keep genetic testing and their result secret or ‘confidential’ from family and friends:Some people may not want to share it with their family, want to keep it to themselves. FG2, woman, London.Some women, who found the PROMISE programme personally acceptable, had concerns that younger women found to be at high risk for OC could have difficulties finding a husband due to the pronatalist (promotion of human reproduction) nature of SA culture that favours the healthiest women. Others expressed concern that identifying someone as being at high risk or deciding to remove the ovaries could jeopardise existing marriages.…if you get to our age then we would say yes. But for people like my daughter I would advise her not to. Because maybe the husband would leave the wife. FG2, woman, London.Some men indicated that they would not ask a potential partner about their cancer risk and that this would not influence their marital choice. Others spoke of the cultural importance of marriage and a woman’s ability to bear children where removal of the ovaries would be a serious issue.A few participants expressed the view that illnesses such as cancer are predestined and come from God. However, they did not suggest that this meant they would do nothing to prevent illness; instead religion was referred to as a coping resource.…if I find out that I have got this problem; there will going to be ovarian cancer. I would thank God for giving me time to do what I want. FG1, woman, London.Participants were eager for more information to be provided and for OC awareness campaigns within their communities.They don’t even know where it is…Where is the problem? How does it happen? It is very important that we give this information first. FG4, woman, Luton.A variety of methods to reach SA women with key OC prevention, earlier diagnosis and risk management messages were discussed including community-based group sessions and campaigns in the local media targeted at those for whom English is not a first language. Several participants suggested that as English was not their first language or because they could not read English, they would likely encounter difficulties in accessing genetic and screening services.Both men and women indicated that, depending on the individual and situation, SA women would need or prefer to see a female healthcare professional, particularly if a physical examination was needed.Mostly, the issues are about female doctors checking female things and male doctors checking males. FG5, man, Luton.In this qualitative study, we identified a worrying lack of awareness of OC among SA women and men. Others have reported low awareness of cancer risk factors and symptoms among UK ethnic minority groups,Some participants found it difficult to understand the brief presentation provided in the focus groups, it sometimes took several explanations to ensure that participants understood that genetic testing provides information on cancer risk rather than a diagnosis and that high risk did not mean that a person would definitely get cancer. As previously reportedOur main finding that attitudes towards genetic testing for OC risk and stratified management were mostly positive is consistent with other studies,Participants accepted the idea of stratified risk management, that is, that there would be different management options for women with different levels of risk. With regard to the screening element of risk management, uptake of breast and cervical screening in the UK is lower among SA than white women.Risk-reducing oophorectomy was seen as a particular dilemma, principally due to the importance placed on women’s ability to bear children. Some male participants felt that it would be better to wait and see if a cancer develops, catch it at an early stage and then have surgery. It may be that these men were inappropriately applying to OC their knowledge of how other cancers present and develop and this needs further investigation. However, apprehension about this surgery is not unique to SAs.BRCA gene mutation also indicates an increased risk of breast cancer, as this was beyond the scope of the study. The risk of breast cancer would further complicate decision-making as high-risk patients would need to consider increased surveillance for breast cancer or risk-reducing mastectomy. Also, both male focus groups were run by female facilitators; while participants did not express dissatisfaction with this, it may have influenced their responses.This is the first study to explore UK SAs’ perspectives on population-based genetic testing and risk-stratified management for OC, and includes participants with various levels of English language who are often not included in research. However, the opinions expressed by participants with regard to genetic testing and the PROMISE programme were based on brief information which was new to all, and related issues such as insurance and ethics were not spontaneously discussed. Furthermore, the current study did not inform patients that an increased risk of OC due to a Population-based risk assessment and stratified management may be acceptable to many SA men and women in the UK. Attitudes towards cancer screening were positive; however, opinions on risk-reducing surgery were mixed. The study highlights a need for tailored OC awareness campaigns within SA communities. To be inclusive, genetic testing and aftercare services should accommodate non-English speakers, offer appointments with a gender-matched healthcare professional and offer patients support with their healthcare decisions.10.1136/bmjopen-2018-021782.supp1Supplementary data10.1136/bmjopen-2018-021782.supp2Supplementary data