Muslim women are especially vulnerable to sexually transmitted infections (STI) and are at higher risk of under-detection. Evidence on the unique barriers to STI testing and diagnosis among Muslim communities is severely lacking. Understanding the complexity of accessing STI testing and diagnosis in Muslim communities is an area that requires further exploration. We aimed to explore the multilevel barriers to STI testing and diagnosis among Muslim women.We conducted qualitative semi-structured interviews informed by the ecological model of health. This study took place in Riyadh Saudi Arabia in 2019 with women aged over 18. Data were analysed using reflexive thematic analysis.Twenty-eight women were interviewed from different ages, marital status, employment, and educational levels. Muslim women’s perceived barriers to STI testing and diagnosis included personal, socio-cultural, and service-level barriers. Lack of knowledge about STIs, denial, and underestimating the seriousness of infection and symptoms were among the many individual barriers to STIs testing and diagnosis. Religious views towards extramarital sex and negative views of people with STIs is a significant barrier to STI testing and diagnosis. Lack of patient confidentiality and providers’ judgement and mistreatment were also cited as barriers to seeking healthcare.Barriers to STI testing and diagnosis exist on many levels including personal, socio-cultural, religious, and healthcare services, and at policy level. Multilevel interventions are needed to reduce the stigma of STIs and facilitate access to sexual health services among Muslims. It is our recommendation that policy and research efforts are directed to enhance trust in the doctor-patient relationship through better clinical training as well as implementing stricter regulations to protect patients’ confidentiality in healthcare settings. In 2020There are many barriers to STI testing and diagnosis. Some barriers are related to the structure of healthcare services, while other barriers are due to stigma, fear, and embarrassment . Denial The Middle East and North Africa (MENA) region is predominantly made up of Islamic countries. Muslim women are especially vulnerable to under-detection of STIs . Many faIn Muslim countries like Saudi Arabia, STIs are one of the most under-recognised health issues . Saudi AResearch around STIs and HIV in the MENA region and other Islamic countries is mainly focused on knowledge, attitudes towards STIs, and the views towards people living with HIV. Understanding the complexity of accessing STI testing and diagnosis among Muslims is an area that requires further exploration. Due to the specific vulnerability of Muslim women, exploring barriers to STI testing and diagnosis among them is critical. Further research is needed to inform public health policies and interventions aimed at promoting the uptake of testing for STIs in religious communities and addressing the target population’s needs and concerns. Therefore, this study aimed to explore any personal, socio-cultural, and religious barriers, as well as service level barriers including healthcare providers and policy level barriers to STI testing and diagnosis among Muslims.2.2.1.We conducted a qualitative study to gain a deeper understanding of the barriers to accessing STI testing and diagnosis from Muslim women’s perspectives. This study was informed by a conceptual framework based on a modified version of the ecological model of health . The fra2.2.Recruitment took place in a public hospital in the women’s health outpatient clinic in Riyadh, Saudi Arabia, between January and June 2019. This hospital is one of the major public hospitals in Riyadh that provides primary, secondary, and tertiary healthcare services to the public free of charge.Following a purposive sampling strategy, we recruited women from different age groups, marital statuses, educational levels, and employment. This heterogeneous sample allowed for the capturing of a wide variety of views and experiences. The recruitment process was done by the lead author (NA), a young Saudi female public health researcher. Potential participants were approached in the waiting areas of the hospital’s outpatients’ clinics where they were invited to take part in the study. Clinicians and clinic staff working in the hospital were able to provide support with the recruitment process, by asking patients in their clinics if they were interested to participate in the study, explaining the research aims, and handing out information sheets.Before the start of each interview, participants signed the consent form and were given the chance to ask questions about the study. Participants were assured of the research team’s commitment to preserving their confidentiality and anonymity. We continued to recruit potential participants until no further themes were emerging and it was decided that thematic saturation was reached .2.3.One-to-one, face-to-face interviews were conducted, using a semi-structured interview guide developed by the research team. The interviews were conducted in Arabic, the participants’ native language, to allow participants to express their views with ease and confidence.The topic guide was developed based on systematic reviews of the literature on Muslim women’s sexual and reproductive health , 15. QueThe interviews were conducted by the lead author (NA). The interviewer had no prior relationship with the study participants. All interviews were conducted in a private room in the hospital’s outpatient clinics. The interviews were audio-recorded with participants’ permission and ranged from 30 to 60 min. Before each interview, participants were asked to complete a survey to collect socio-demographic characteristics, such as age, marital status, and employment.2.4.All interview recordings were transcribed verbatim by a professional transcription company. The lead author (NA) checked all transcripts against the original recordings. Data was uploaded to ATLAS.ti for data management and coding. The transcripts were kept in their original language as cultural nuances and expressions were lost in translation, which were considered important for the analysis, and subsequent interpretation.An inductive approach to analysis was applied where codes were generated from the data using coding and refinement of themes. Transcripts were coded line-by-line, generating a set of codes based on close reading of the transcripts. A random sample of interviews was coded by another member of the research team (SA). Codes from each transcript were revised, compared, discussed, and amendments were made, where appropriate. Categories were derived from grouping codes to create the analytical framework and the themes were produced through discussions among all researchers. All codes and categories were in English, and all relevant quotes were translated from Arabic to English to facilitate the analysis and interpretation of the study findings.Rigour was enhanced by keeping a reflexive diary, offering a clear account of procedures used, providing evidence from the data for all interpretations made, comprehensive analysis of the whole dataset, analysis of deviant cases and disconfirming data, comparing data between and within cases in the dataset and comparing findings with other studies .3.n = 18) were college educated and employed, with five unemployed, and five college students. Twenty-eight women, aged between 20 and 50 years, participated in the study. Sixteen were married and twelve were unmarried, the majority of women “I know AIDS but can’t think of any other [STI] off the top of my head …”“Syphilis is transmitted through sexual contact, but AIDS I think can be transmitted through saliva and sneezing… What scares me is that I don’t know how to protect myself against it”Women had significant misconceptions regarding STI modes of transmission, symptoms, and treatment. The misconception that STIs are caused by a lack of personal hygiene made it difficult for some women to get help as they were concerned with being perceived as unclean. STIs were also linked with extramarital sex, which also added to taboos and sensitivities around testing and diagnosis."It's not necessarily from sexual intercourse, maybe you used something… For example, from toilets, it's not your fault. Using toilets that aren't sanitary or cleaned properly or maybe you used things that don't belong to you.""It's a sensitive subject. As I told you, maybe because of the idea that STIs are associated with either lack of hygiene or extramarital relations. So it’s a taboo because it’s linked to these two reasons.”3.1.2.Many women perceive themselves to be at no risk of contracting an STI, which can cause delays in testing and diagnosis. Almost all women in the sample believed that men were most likely to engage in extramarital sex. Muslim women having pre/extramarital sex was believed to be unheard of in their community. Since extramarital sex is forbidden in Islam, women believe that religion is protecting them from STIs which also contributes to the low-risk perception.“We have religious immunity against sexually transmitted infections because our religion forbids sexual relations before marriage so that protects us. I think even the cases of AIDS here are transmitted from blood, not sexual contact.”“It’s uncommon here because it’s transmitted through forbidden relations, and thank God, we still are God-fearing Muslims”3.1.3.Women discussed fear of getting tested, and fear of a positive test result, as a barrier to STI diagnosis. It is worth noting that women consistently used gender-specific pronouns (he/him) when speaking about people with an STI.“Maybe it's fear, fear of reality. Fear of facing the fact that I have this. Or maybe he is underestimating the illness. Thinking that it is something simple or thinking that no there is nothing wrong with me. It will go away on its own. I feel mainly not wanting to face reality.”“I think he [the husband] would be scared, scared that someone would talk about him, so I think this would scare them and prevent them from seeking help from the start. There’s also denial, even with minor issues, there’s always denial, and that stops people from seeking treatment. So, imagine if it’s something as big as this. People will certainly be afraid of knowing.”3.1.4.Although participants knew where to seek testing for STIs and HIV, shyness and modesty were among the main barriers to seeking medical help regarding anything sexual in nature. Women were not comfortable with physical and gynaecological examinations, sometimes accepting extreme pain rather than seeking medical care.“My mother, to this day, is still shy, she has seven kids but is still shy. She would rather suffer. She could have a simple problem, and I keep telling her to go see a doctor. And she refuses. She keeps giving excuses and then says: ‘Just leave me alone, it's bad enough I endured being exposed during childbirth just because I had to.’ We keep trying to convince her, but she won’t do it.”“I think shyness would prevent her from getting help. Because after all, it is a sensitive area, it’s not easy to get tested. So shyness would be the first barrier. What if it’s something bad … You also don’t want the doctor questioning your morality”3.2.3.2.1.Almost all women in the research interviews believed that fear of stigma and societal judgment hindered STI testing and diagnosis. Social unacceptability of extramarital sex and extremely negative views towards people living with HIV are significant barriers to STI testing. Some women indicated that social influences play the most significant role in STI testing compared to any other factor.“I think it would be difficult to get help. It would be very difficult for him. Because he is scared of society. Because society has no mercy. Society will not be kind to him. So, he might secretly get checked, if, and only if, he could guarantee confidentiality. He then might get checked. But it would have to be permanently removed from his medical records.”ayb” topics which translate to shameful, inappropriate, and dishonourable. A person is expected to feel “ayb” when violating religious and social rules, especially with regard to sexual health.Women mentioned that socially constructed taboos around sexual health pose a significant barrier to healthcare seeking, particularly for women. Sex and sexuality are often referred to as ““He fears stigma. It’s a disgrace, whether it was a minor infection or a serious one. It relates to such a sensitive area that’s supposed to be ayb and shameful. That’s why they stay quiet and do nothing.”P16: You know what prevents her from seeking help? It’s the concept of ayb in our culture that’s actually scary. When normal people feel something is wrong, they seek help, but not here, she’s too afraid.“NA: Why do you think she would be afraid?P16: Because of our ayb culture. So even if her issue was not sexually transmitted, she would still fear people interpreting it this way.”3.2.2.we live in an extremely connected society”. Living independently of other people and being unconcerned with society’s opinion was considered abnormal.Fear of being exposed through breaches in patient confidentiality, or being seen getting tested, was believed to be worse than having the infection and suffering the consequences. Avoiding societal judgement (making it easier for people to seek help) is believed to be impossible, as ““I don’t think it would be easy to get checked. Because we have other problems. We are not like people from Western countries. Where everyone lives on their own, in their own home … We live a very social life. I’m with people from the moment I wake up to the moment I sleep. The only time I am on my own is when I am sleeping. So, we don't have someone that is anti-social. It is not an option. You have to have social interaction every moment of your day.”“He won’t go [get tested] because he’s afraid he’ll be exposed. To his wife, his family, this fear is worse than anything else including living with the disease.”To avoid being recognised by someone they know and face the consequences of being exposed as having an STI, a participant suggested seeking healthcare privately and using false identification.“They should go to a private lab and either not give their ID or use a fake one. Because even if he was an educated person aware of the consequences of not seeking treatment, his fear of exposure and its consequences might outweigh his desire to be treated.”3.3.3.3.1.A crucial barrier to STI testing is the lack of patient confidentiality. Many women highlighted that some healthcare providers do not respect doctor-patient confidentiality. The issue of compromised confidentiality was often because of healthcare providers discussing their work life in social settings.“Some people don’t respect what you call confidentiality. Even in healthcare, I always hear, for example, a doctor said: ‘Oh, I saw this patient [her name] today.’ I mean a patient you know; I’ve heard many stories. One of my friends was following up with a doctor, something not related to sexual health. And she knows the doctor’s daughter. So, the doctor told his daughter: ‘Your friend came to me today, and she has this and this and that.’ And I mean he is a doctor. He should take confidentiality more seriously. And it wasn't something sexual, it wasn't something Ayb, but still, he shouldn’t share.”“They are all concerned that someone would talk about them to someone. That would scare them and prevent them from seeking help. Even if they go to the hospital, they will call names out loud in the waiting area and everyone would know their name”Although lack of confidentiality was viewed negatively, it was believed to be acceptable to breach patient confidentiality if the woman is wanting to know, particularly in the case of engagement or marriage.“Sadly, we have this issue with having an extremely social life. Everyone knows everyone. So, for example, my friend would come and tell me that I saw this person, getting treatment or tested for something. And I personally believe if that person is marrying a person that I know, I will let her know, because it is her right to know.”Concerns over doctors sharing the diagnosis with spouses were raised by some women. Men would rather keep having sex with their wives and transmit an infection than tell them that they might have an STI.“Some people even keep this from their wives to the extent that they might even keep having sex and transmit the infection to her rather than tell her that he has been diagnosed with something … It's only a disease that, with time, will find a cure. But no, he will think this will compromise his manhood. He’ll think it is a scandal and no one should know about it.”3.3.2.Healthcare providers’ judgement and mistreatment were cited as a barrier to STI and HIV healthcare seeking. Due to the socio-cultural unacceptability of STI risk factors, individuals seeking testing can be subjected to poor treatment or discrimination by healthcare providers.“We need healthcare providers to not look at patients with contempt and disdain or judge them to be a bad person. We need to have a safe space for patients. We also need to educate them about confidentiality.”“I noticed that doctors can be very judgemental sometimes. Of course, not all but some, and this judgement would make me closed off. I wouldn’t be honest.”“We fear judgement when seeking help for these things [STIs]. Because we believe these things are a punishment from God for committing forbidden acts”3.3.3.Many participants suggested ways of improving STI testing by using codes instead of people’s names and identity documents when seeking medical care. They also suggested that test results should be removed from the patient’s permanent medical records, as it is possible for anyone working in the institution to access the patient’s medical records.“The problem in our community, family names are well-known, so anyone in the hospital might recognise the family name. I think maybe if we used numbers or codes instead of people’s names it would encourage more people to get tested and seek medical help.”Women believed that it is preferable to go to a foreign doctor to protect patient privacy, explaining that it would be less likely for a non-Saudi doctor to recognize the family name, and therefore risk being exposed by someone they know.“They [healthcare providers] need to know that it is not okay to share patients’ information. We live in an interrelated community. People know each other. So, I feel that to avoid being exposed, people will seek non-Saudi doctors. Saudi doctors would know your family name, they might know someone that knows someone, and they could talk. You can’t even go in public without seeing someone you know. So, they could share the information without intentionally meaning to share it.”To make it easier for people to access STI testing and diagnosis, some women suggested that people should seek treatment outside the country to avoid societal judgement and risk exposure.“Because we are so fearful of society’s judgement, if the person is educated and is concerned about his health, it might actually be easier for them to seek help outside the country. Whether it was testing or treatment. He might need to leave the whole society to seek help.”4.Barriers to STI and HIV testing and diagnosis exist on many levels including personal, socio-cultural, religious, healthcare providers, and policy level barriers. Personal factors include lack of knowledge about STIs, denial, low-risk perception, fear of a positive result, and fear of being exposed due to breaches in confidentiality. Consistent with our findings, fear of a positive test result and fear of the disease were reported among the most significant barriers to testing and diagnosis . The perOur research revealed that Muslims believe that they have “religious immunity” against STIs. This was consistent with previous literature where the low perception of risk was influenced by strong religious beliefs , 15, 17.Low perception of risk can lead to significant delays in STI diagnosis, particularly for married women who have never engaged in premarital sex. For many Muslim women, their husbands are their first and only lifetime sexual partners, so they assume that they are at no risk of contracting an STI , 20–22. Women in this research explained that people in Saudi Arabia are afraid of seeking medical care for a possible STI out of fear of being exposed either by healthcare providers or by someone in the healthcare facility. Worries about being exposed directly through breaches in patient confidentiality, or indirectly by being seen getting tested, is a significant obstacle to STI diagnosis and treatment , 25–27. Healthcare providers’ prejudice, judgement, and mistreatment of people with an STI can prevent at-risk individuals from getting tested and seeking treatment. Healthcare providers’ judgement and discrimination against people living with HIV have been consistently reported in the literature as a barrier to HIV testing , 32. OurOur research revealed that stigma and shame associated with HIV and STIs acted as a barrier to testing and diagnosis. Stigma is a major obstacle to combating HIV/AIDS globally , 33–35. 4.1.This is the first qualitative study, to the authors knowledge, to explore barriers to STI testing and diagnosis in the MENA region. Our findings are transferable to Muslim communities around the world, as many Muslims share similar cultural values and traditions . InterviQualitative interviews were conducted in Arabic, the participants’ native language. Some cultural references are not easily translated, and some of the meanings might have been lost in translation. Yet, the translation process can analytically productive and a critical challenge that can add to interpretations , 41.Face-to-face interviews discussing sensitive topics  have the potential to introduce social desirability bias. Guaranteeing the privacy of the participants and ensuring confidentiality throughout the interviews encourages participants to provide their honest accounts.4.2.One of the reasons for delayed STI and HIV testing is a lack of knowledge and understanding of STIs. It is therefore essential that healthcare providers carefully assess their patients’ understanding of common STIs and the presentation of symptoms, offering advice and tests accordingly.One of the most important barriers to early STIs testing and diagnosis is concern over breaches in patient confidentiality and fear of exposure. It is crucial to enforce stricter codes of practice against breaches in patient confidentiality by all staff in a healthcare setting. It is our recommendation that policy, research, and training programs are developed to promote the public’s trust in doctor-patient professional relationships and confidentiality in healthcare settings.Although there are currently sexual health clinics offering anonymous testing in Saudi Arabia, those clinics are private and tests are expensive, making them inaccessible to everyone . It woulExtensive public health efforts need to be directed toward reducing the stigma and discrimination against people living with HIV/AIDS among Muslim communities. The extreme stigma and discrimination towards high prevalence groups , act as a significant barrier to seeking testing and treatment. It is imperative to develop programs directed toward the general population to tackle stigma, shame, and judgement. Professional training programs and national policies and regulations should be developed to improve access to sexual health services for all members of society regardless of personal beliefs or behaviours. This needs to be explicitly emphasised in healthcare settings and among service providers.4.3.Better quality studies on the barriers to STI testing and diagnosis, particularly in the MENA region, are needed. However, conducting high-quality research can be difficult in some countries due to restrictions on data sharing and reporting , 44. Imp5.Barriers to STI testing and diagnosis exist on many levels including personal, socio-cultural, religious, healthcare settings and policy level barriers. The results suggested that lack of knowledge, fear, confidentiality breaches, and stigma associated with STIs act as barriers to early testing and treatment. There is a need for multilevel interventions to facilitate access to sexual health services and reduce the stigma attached to STIs and HIV in Muslim communities. It is our recommendation that policy and research efforts are directed to promote the public’s trust in the doctor-patient relationship and implement stricter regulations to protect patients’ confidentiality in healthcare settings.ethics@ucl.ac.uk.The datasets presented in this article are not readily available because of confidentiality concerns. Requests to access the datasets should be directed to UCL ethics committee: The studies involving humans were approved by the UCL ethics committee (Reference no. 10157/001) and the hosting hospital in Riyadh, Saudi Arabia (Reference no. FWA00018774). The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.NA, SA, ND, and JB: conceptualization and writing – review and editing. NA: data curation. NA and SA: formal analysis and writing – original draft. NA, ND, and SA: methodology. All authors contributed to the article and approved the submitted version.


This study aims to understand how virtual livestock fences (VFs), introduced to the UK in 2020, were being used and to identify the animal welfare opportunities and challenges of VF systems. VF systems work by training livestock to respect a virtual fence line by pairing an audible warning tone with an electric shock. Semistructured interviews were conducted with key stakeholders (n = 8), including policymakers, leading conservation managers, and regenerative farmers. We found VF systems were utilised in three main settings: 1. Extensive grassland, where physical fences were prohibited or uneconomical, such as national parks or mountains; 2. Conservation grazing, where livestock grazing is primarily used to manage habitat for biodiversity, such as nature reserves; 3. In mob, strip, or rotational grazing systems, where VFs replace physical electric fencing to reduce workload. This study finds that, in extensive settings, VFs can help safeguard livestock from dangers and aid stockpersons to locate and care for animals. However, in restricted settings, VFs are less predictable and controllable for livestock than physical fences, resulting in livestock (cattle) receiving a greater number of electric shocks than experienced with physical electric fences. The use of VFs in a restricted setting poses a significant risk to livestock welfare. Protocols are needed to encourage best practices and help prevent the misuse of VF systems.Virtual fences for livestock facilitated by a GPS shock collar (GPS-SC) and phone app were introduced to the UK in cattle herd trials in 2020. Technology which uses aversive shocks to control livestock movement on farms and in other settings poses a significant risk to livestock welfare. There are currently no welfare protocols in place in the UK to ensure the ethical use of GPS-SCs. The objective of this study was to understand how GPS-SCs were being used in practice in the UK and gather data to assist researchers and policymakers in the future research and development of a welfare protocol for the UK. We studied how the technology performs in terms of welfare challenges and opportunities, covering extensive livestock production, conservation settings, “rewilding”, and regenerative farming practices, where the technology is currently being applied. Semistructured interviews were conducted with key stakeholders. In-depth interviews (n = 8) supported the previous literature that the use of GPS-SCs in restricted grazing settings poses a risk to animal welfare. This is due to the wavering virtual fence boundary line (which is affected by satellite movements), a lack of visual markers, and, in some “rewilding” and conservation settings, livestock keepers, which require training and support to enable optimal welfare in practice and prevent misuse of the technology. Results also indicated that there are opportunities for enhancing livestock welfare with GPS-SCs in very extensive farm settings, where targeted care can be facilitated by using the data to monitor and track livestock using GPS-SCs, and which can also prevent cattle injury or fatality through virtual pastures designed to protect livestock from hazards such as roads or bogs. Future research is needed to focus on minimising shocks in the training period and to better understand the value of visual electric fences in the training process. GPS shock collars (GPS-SCs) for cattle have been gradually introduced to the UK market over the last 3 years through the Nofence© company  in trials on farms and in conservation grazing settings to address three main opportunities for fencing grazing livestock ,2. FirstEuropean countries are developing policies to move towards rewarding farmers for ecosystem services, such as the European Green Deal and the Environmental Land Management (ELM) Scheme, developed in England ,4,5. GraTM , and Nofence©, have the potential to facilitate mob and other intensive grazing systems [As a baseline, the welfare opportunities and challenges of VF systems can be assessed using the Five Freedoms . GPS-SCs systems , or may  systems , which c systems  and data systems . NofenceMost experiments to assess both the efficacy of GPS-SCs and the welfare of livestock using this technology to measure and evaluate stress experienced by livestock exposed to electric shock use the cognitive theory of stress (CATS) ,16. TherSome cows were also observed to confidently lead whilst others were timider and reacted quickly by “running away” when hearing other cows’ audio warnings . The ratWhen cattle are contained with visual electric fencing, research demonstrates socially learned avoidance , suggestTM website information also confirms that each animal will need to receive between five and seven shocks to learn to associate the audio cue with the electric shock. The greater number of shocks experienced by livestock in VF systems compared to visual electric fences is a welfare concern [Within the groups tested, the number of shocks experienced before learning to associate and respond correctly by stopping or turning was on average 2.5 shocks, and ranged between 1 and 6 shocks per audio warning  and 1–6. concern ,25.Both McSweeney et al. (2020)  and UmstThe Electronic Collar Manufacturers Association™  have developed voluntary codes of conduct in the use of shock collars to contain dogs. They explicitly require visual markers to help dogs recognise a boundary by sight, as well as through an auditory warning. Future research should therefore focus on the use of visual fences to optimise welfare as part of VF training protocols for livestock. There is no recent study directly comparing the two fencing systems . TherefoThe Five Freedoms predominantly focus on reducing negative welfare: 1. Freedom from hunger and thirst; 2. Freedom from discomfort; 3. Freedom from pain, injury, or disease; 4. Freedom to express normal behaviour; 5. Freedom from fear and distress . RecogniThe authors cannot find evidence of research, guidelines, or policy relating to the number or strength of electric shocks considered “acceptable” on welfare grounds during training or post-training. In contrast, the Electric Collar Manufacturers Association (ECMA) have formulated a voluntary code of conduct for dogs and cats using containment collars . Shock cTM found that 800 volts in pulses of less than 1 s was successful for containing cattle [The Nofence© VF system emits an aversive shock at 0.2 Joules at 3 kV for 1.0 s [g cattle ,21. Currg cattle ,38,39.High shock levels can lead to adverse reactions in cattle, expressed as lunging forward and bawling . Most stThere has been a clear call for the regulation of GPS-SCs to ensure the welfare of livestock, standards for use, and the training of stock people together with independent monitoring to ensure welfare compliance . The autAs the environmental land-management scheme (ELMS) is rolled out alongside the Animal Health and Welfare Pathway ,46, farmThis study therefore sought to: 1. Understand how users are currently applying the technology in practice; 2. Discover the key stakeholder opportunities to enhance sustainable husbandry systems; 3. Understand the key welfare challenges of applying GPS-SC technology in extensive, regenerative, and conservation grazing settings that need to be overcome to improve cattle welfare at pasture . To be aExisting farmers, land managers, and other stakeholders with practical experience were targeted to evaluate how the GPS-SC works in the field in relation to livestock welfare. As the technology is currently expensive and in development, the number of candidates did not equate to wider data collection using quantitative methods. Possible candidates were defined as those with experience in using the collars in practice, who tended to be leaders or innovators in their field, including a range of stakeholders from farmers and conservation land managers to policymakers or developers of the technology. In addition, welfare stakeholders are defined as those with expertise in livestock management or leaders in their field who have in-depth knowledge of livestock welfare. As such, qualitative methods to understand a range of stakeholders’ attitudes, behaviours, and experiences were utilised. Recruitment was conducted using both networks known to the authors via email or telephone and research by the first author. As the purpose of this study was to identify a range of attitudes, experiences, and behaviours associated with GPS-SC use, rather than the relative frequencies of these across a representative sample of stakeholders, this sampling strategy was deemed appropriate. Ten possible participants were contacted by phone and email to request an interview, with 80% of potential candidates interviewed (n = 8). A profile of interviewees can be found in Semistructured interviews were carried out to ensure standardisation across stakeholders, as well as the flexibility to follow up and explore the themes that arose. Open questions were chosen to allow interviewees to talk in-depth, but with a guided focus to enable the interviewer some opportunity to compare and evaluate feedback based on a set of iterative questions ,47. A prAfter the semistructured interview had taken place, the recordings were transcribed and read in detail to ensure the clarity of the transcription. All data were then entered into NVivo for thematic analysis. Themes were then identified by the first author through open coding, which searched for patterns as well as variance in stakeholders’ answers with regards to attitudes, experiences, and behaviours associated with use of GPSSCs, and the welfare challenges and opportunities associated with the technology. Analysis of the transcripts found 11 emergent themes. To assist with clarity in presenting the results, participants were numbered and coded as follows: Livestock Manager (LM); Policymaker (P); Technology Developer company (D). For example, Participant 5 is a livestock manager; therefore, their code is P5.LM.The first theme to emerge in relation to animal welfare and the application of GPS-SCs on-farm was participants’ experience and expertise with animals. Two participants did not have any farming (P6.LM) or animal expertise (P3.D), but had become extremely interested in the GPS-SC technology because they valued the environmental benefits and wanted to work with the company who was developing the technology:My engagement comes from a soil health and climate perspective (P3.D). As one participant (P6.LM) stated, they saw the cows:As a tool (P6.LM).This was in the context of conservation work and restoring biodiversity within a project working to re-establish the seminatural calcareous grassland on common land. A further indication that GPS-SCs are being applied in practice and increasing in popularity in a conservation setting was confirmed by P7.P, who said:It’s (GPS-SC’s) becoming more and more of a thing—people buying up big estates and doing rewilding (P7.P).This suggests that some people applying this technology may be new entrants, novel livestock keepers, and GPS-SC users. It is therefore important that training in livestock husbandry, behaviour, and welfare is delivered in conjunction with GPS-SC training. For example, P6.LM said they had:Recently done a day training course on animal welfare for stock checking (P6.L).Previously, P6.LM had not taken much interest in the welfare of the cattle, saying of the conservation group:We’re not stock people (P6.LM).However, since the course, this stakeholder expressed an interest in animal behaviour and welfare, where they had learnt the five freedoms and how to observe livestock. For example:(We learnt to) approach them from a distance and watch them before they know you are there to see them interacting (P6.LM).This theme indicates that the provision of protocols for GPS-SC technology should be included together with husbandry, behaviour, and welfare training, and would benefit users and facilitate optimum livestock welfare, especially in conservation grazing settings where users are potentially less likely to have livestock education. Verifiable welfare assessments, protocols, and stock-keeper training are key government policy goals  for imprThe second theme that emerged from the data focused on the welfare benefits when using GPS-SCs in extensive grazing and conservation settings. There was a consensus that this technology was, with some exceptions, beneficial for livestock management, and welfare benefits included tracking livestock and being able to exclude livestock from hazardous areas, which supported the previous literature  that GPSIn extensive systems, there was less mention by participants of the shocks associated with the collars, and a clear emphasis on the welfare benefits. These included being able to track livestock in remote areas and target care. For example, stakeholder P7.P could see the benefits:A big problem in actually checking stock daily and keeping within standard requirements—but often they can’t find them—so absolutely, if they had GPS collars, then you know, you can track them down in that sort of extensive environment and check them as you need to (P7.P).The same stakeholder also noted that rewilding and extensive systems do:Have problems with quite high mortality, because stock isn’t checked as regularly (P7.P).Another stakeholder also highlighted the convenience of GPS-SCs for managing animals in conservation grazing settings:GPS tracking from a time management point of view, would make you check them far more easily. Therefore, you would do it more regularly, whereas I think in some extensive situations, they’re not monitored as much as they might be. And particularly in sort of conservation grazing situations where you’ve potentially got, you know, ditches and valleys and wet areas and you know, if animals get stuck or any of those sorts of problems, then clearly being able to easily find them. It’s very much of a of a benefit (P7.P).Furthermore, all LMs commented on how much the app provided them with novel information about livestock movements and time budgets, which offered insights into cattle behaviour. For instance, looking at the data on the app, P5.LM said:I think I have learnt a bit more about animal behaviour from watching them move with the collars on (P5.LM).This stakeholder went on to demonstrate on the app how they can identify the changes in activity before, during, and after the birth of a calf. Understanding animal behaviour, and being able to track it on the app, could not only help prevent suffering and pick up on diseased or sick animals early , but alsMost participants also explicitly talked about how very large pastures, by definition, ensured the cattle rarely encountered the VF, and this was considered a welfare benefit by LMs. As an illustration of this, P5.LM said:The bigger the paddock the better and the only time we get issues is when they are in a small area, when you are trying to train them—as soon as they are in a big open space, and they can express their behaviour more naturally the thing (GPS-SC) works better (P5.LM).more varied diet was cited by participants as a welfare benefit of using the technology to extend grazing. This was seen as a positive outcome for both nature recovery and livestock health and welfare. Research, however, has not been conducted to establish whether cattle in these settings are indeed provided with the added opportunities of novel food they would choose and prefer [There was a clear consensus that it was normal and natural for cattle to be grazing and outside, and that GPS-SC technology enables an extension of grazing and browsing into hitherto unfenced or unfenceable areas, which potentially provides animals with novelty and choice. A d prefer , and, moThree participants identified that the animals could express other natural behaviours beyond grazing, such as scratching, choosing a more comfortable place to rest and cud, and seeking out different shelter or shade, tantamount to the positive welfare opportunities . For exaYou can see them enjoying the sun on the south bank and then go into the trees or hollows to get out of the weather and they love to find a tree to scratch (P6.LM).Another stakeholder also identified several other positive welfare opportunities as a result of observing the cattle in this environment:I’ve learned that they like to rub a lot on things and they like a variety of diet (P4.LM).These observations by users of GPS-SCs support several of the “Good Life” objectives for cattle—a comfortable physical and thermal environment, as well as an enriched environment which provides novelty and choice . There aThey love the old man’s beard and they seem to go for the ivy (P5.LM).ivy served just as well as a tasty inducement.Likewise, another stakeholder (P6.LM), talking about a moving pasture using a hay net to lead the cattle, observed that However, there were also trade-offs in terms of welfare in extensive and seminatural settings, highlighted by one stakeholder, due to the natural environment and consequent abundance of flies and midges. P5.LM noted that, in conservation settings, the cattle suffered more from flies and biting insects than on conventional farmland, saying:I treat them more often with fly repellent than at my father’s farm (P5.LM).This could lead to unnecessary suffering and discomfort , and goeSo, I think that’s really important (positive interactions with the cattle through daily handling) and it is a temptation to, for example, you can move the animals from your bed, and allocate them to a new pasture, but I think there’s no replacement for Ground Truthing that in the flesh on the ground (P4.LM).This observation suggests a trade-off with the “Good Life” objective’s positive experience with stock-keepers , and tharewilding” settings. They observed that rewilding projects were increasing and that sometimes livestock are introduced into these environments and treated more like wild animals with little or no husbandry intervention. Stakeholders quoted anecdotal evidence that this was justified under the banner of being “natural” and as part of the process of rewilding. The welfare concerns were expressed as follows:Finally, a lack of animal experience and expertise, which has an impact on understanding animal behaviour and welfare, was noted by participants (n = 2) as a potential concern in “I think it’s only going to become more of a thing, in terms of you know, this rewilding environment, but having responsibility for the animals that you then put in that environment is, you know, this really is really key, the idea you just sort of let them go off and look after themselves. I’m afraid it’s not quite good enough (P7P).Overall, stakeholders suggest that extensive livestock systems would benefit from the GPS-SCs. This is in line with the previous literature ,10. HoweThe fourth theme which emerged was welfare issues in intensive grazing settings. Most (n = 5) of the participants highlighted how the collars could be used in a farming system with mob, strip, or rotational grazing schemes. Participants (n = 2) commented how it would save time and labour moving the pasture with the aid of the phone app. However, half of the participants (n = 4) had reservations regarding livestock welfare in these settings due to the lack of visual markers as an added stress for cattle already herded together and compelled to graze closer to the boundary to obtain fresh grass. There was a sense from participants (n = 3) that, in this setting, the GPS-SCs would be more likely to cause welfare issues. For example, one stakeholder said:For mob grazing uses, the collar is, maybe a bit too much kind of a pressure in terms of welfare—I think it’s probably really annoying to the animals where in intensive operations with daily or twice daily moves, the areas are quite small and visually because there wasn’t a visual on it. They can see an electric fence but with collar boundaries, they can’t see it and they’re constantly being harassed by this beeping noise, and if they ignore it they get an electric pulse (P4.LM).push and shove each other in close proximity. They were also concerned that there will be welfare challenges associated with an unacceptable number of shocks and stress in an otherwise already pressured environment for the cattle. This is supported by previous reports [Another stakeholder (P5.LM) also had concerns about the technology being used in this setting, as the cows  reports ,44.All of the LMs observed that the boundary, which is not fixed, as with a visual fence, but moves around due to the satellite technology, is problematic from a welfare point of view:The boundary moves, moves and wavers, doesn’t it? It’s not a sort of set line (P5.LM).One LM also noted that this was disconcerting for the cattle:But the GPS signal does just wander around a little bit so you can get a situation where they are stood grazing perfectly still and happy, and then they haven’t moved but they get a warning. And they just have to turn around because the signal has sort of moved towards them (P6.LM).It was also noted by some participants that cattle prefer not to interact with the fence. However, one LM noted that, when the forage is getting scarce in a paddock, the animals begin to interact more with the boundary:If they can they avoid going near the boundary (P5.LM).A wavering line together with confined spaces could impact animal welfare, causing pain, fear, and distress , and doeWhen I’m operating behind an electric fence I’m signalling to those animals, I’m calling them they’re getting a cue. They can see what I’m doing. So, they know, they associate that action, those cues with fresh grazing and a sort of positive reward and something as being safe. It’s difficult to recreate that in a virtual sense (P4.LM).This experience supports the existing literature  that creTo summarise, one LM talked about the lack of visual cue, the wavering boundary line, and the necessity for cattle to interact with the boundary to obtain the fresh grass, saying:I think that does totally mess with the psyche of the animal (P4.LM).These experiences, highlighted by participants, confirm that there are greater risks to livestock welfare in a confined grazing setting where GPS-SCs are used to facilitate mob, strip, rotational, and some conservation grazing settings. A clear set of protocols need to be developed to ensure there is a training regime and post-training protocol which minimises shocks, so to ensure welfare is guaranteed and in line with government policy .There was a wide consensus around the importance of successful, comprehensible training for cattle or other livestock where GPS-SCs are used. As highlighted in the existing literature, there was broad agreement between the participants that the process had to ensure that cattle find the system predictable and controllable to ensure good welfare . For exaThe virtual fence has to be predictable and controllable for the animal in order for us to say that, you know, we’re happy with the animal welfare (P3.D).In support of this assumption, another participant stated:We need to be sure that animals understand what the audio means and that they can avoid the discomfort of the pulse. And we need to do everything we can to help that with our system (P2.D).too many shocks or escapes, the user is followed-up with a call from the company. All LMs reported that interactions with the app and text message alerting them of escapes worked well. However, there is no existing research on the impact of shocks from a welfare perspective and, consequently, what is, for example, an acceptable threshold. Despite existing literature reporting that some animals are not able to learn how to interact with the VF [These statements show that technology companies understand the importance of comprehensive training and work towards ensuring predictability and controllability for the livestock by monitoring the outcomes of collar use remotely as part of their service. For example, if an animal escapes from the virtual paddock, the user is sent a text message. And crucially, if there are h the VF ,42, noneIf there’s anything wrong, then we would look at the ratio between audios and pulses. And if that wasn’t very equal, then it’s evident that the animal isn’t understanding what it’s supposed to do, but we haven’t had any animal never understand (P3.D).This finding may be due to improvements in the design of the technology or training advice given by the company, or due to the small sample size of participants in the current study. The latter was not properly understood , and furVisual cues were mentioned mostly by the land manager participants interviewed (n = 4). Some participants deliberated if there should be visual cues to aid cattle comprehension of the VF system and thereby reduce the number of interactions and shocks the cattle received. For example, one LM said:I think the other thing really is about those visual cues. I’ve always tried to set my virtual boundaries somewhere near resembling physical features. So, a hedgerow or a fence or something that the animals can associate the signals they’re getting, with what they can see. Because I think otherwise, they’re happily grazing along in the field and they get the beeping wondering, what on earth did I just move into?—It’s a bit like a bird flying into a glass window (P4.LM).Similarly, another participant stated:There needs to be visual lines for them to be able to associate the audio alarm with the boundary (P7.P).desire lines (P5LM) are used by livestock.This knowledge and experience from practitioners support the existing literature ,26,51 thThis theme draws on the experience and insight of one participant (P5.LM), who suggested a modification to the way cattle are trained to reduce the number of shocks experienced during the initial contact with the VF using both visual cues and a change to the design of the training paddock. Based on an experiment this practitioner did with cattle untrained to the collars, they found that the herd can be contained in a field with gaps in the fence without the cattle being shocked :So some I haven’t trained the cows and used the collars just to secure real fences where there is a weak spot and they have learnt the system without going through—running through—but when you put the line right across an open field they don’t necessarily learn anything from getting 3 zaps (P5.LM).The participant explained that this test showed that, on this occasion, the cows turned away when they encountered the VF without running through, even though they had no prior training, suggesting that a visual cue aided their learning process. In relation to reducing the number of shocks, the participant suggests:There is something to be said, from a welfare point of view potentially, if they can just gently interact with the boundary (P5.LM).This practitioner suggested setting the VF boundary along the visual fence, but 5 m in from the visual fence rather than across the open part of the field, according to the instruction manual. In describing the system they plan to use this year (2022), they stated:Put the VF just 5 metres inside the boundary and then they won’t be able to run through it and get 3 shocks. I think they can learn just as well from getting one shock and then trying it again rather than running through it ... and getting beep zap, beep zap, beep zap escape, I don’t think they learn much from that it is just the way the manual is written to train them (P5.LM).The interview with this practitioner supports the conditioning theory and associative learning theory , and cou“Belts”, “zaps”, “pulses”, or “shocks”?pulse” on their website, and this behaviour was supported in the interviews. For example, one D using the word “pulse” talked about the experience as “uncomfortable” and preferred not to use electric “shock”, as it suggested a more painful experience.This theme explored the language used by different stakeholders and revealed a difference in the perception of pain experienced by the animals. It was found that the technology developers consistently use the word “zap”. This participant also raised the issue of audio warnings and zaps directly at the start of the interview, consistently using the word “zap”, and was very keen to show exactly how many “zaps” each animal had had. For example:On the other hand, one LM familiar with visual electric fencing consistently used the more prevalent and, arguably, stronger farm term “Look, this one has had 63 to 1 and this one has had 36 to 2 (P5.LM).pulse” was less concerned about the number of shocks a cow received, but made an observation about the combination of cues:By contrast, another LM using the word “The beeping noise and pulse was probably really annoying to the animals (P4.LM).This LM was more concerned about the overall experience of the GPS-SC, from when cows were fitted with the collars through the whole process in practice. In contrast, another LM was actively motivated to find ways to reduce the number of shocks cattle experienced during the training period through modifications to the VF line in training paddocks, as discussed in the theme advancing training for optimal welfare.Using the word “pulse” can make the electric shock seem less painful than if the word “shock” or “zap” is used, and it was noted that, when one user reported accidently shocking themselves whilst handling the collars, they changed their vocabulary and used the word “belt” instead, describing the experience as:I got a hell of a belt off it! (P8.LM)Use of language has been shown to affect the way people perceive emotions and feelings in others . As animAll the LMs showed a keen interest in how the data from GPS-SCs highlight animal behaviour and personality traits. As the data record all the movements of the herd and individuals within it, this provides valuable information about how cows interact with each other and the VF, as well as other resources in the environment. Social learning, as evidenced in previous literature ,19,22, wSome animals just will get shocked more than others. Some will learn from others and never get shocked. Like100 and 112 they won’t go anywhere—just hear the others, follow the others, and just hear the beep and turn around. Whereas others just have so many more interactions with the boundary (P5.LM).Personality differences were also highlighted by the participants, supporting the existing literature ,23 whereThere are noticeably always the leaders and the followers (P4.LM).This variance has been identified as a welfare concern , and demMost of them are 34:1 but look here 63:3 that is Peanut, Peanut’s a troublemaker anyway (P5.LM).One particular animal who is always out the front exploring—the kind of questions that go through my mind about how the herd dynamic is working and what’s going on in animal mind—who steps over the line and who doesn’t? (P4.LM)The findings from this theme support the previous literature, which suggests that optimum welfare could be maximised by choosing cattle with less adventurous personality traits when using VFs . ProtocoNearly all participants (n = 7) recognised that interactions between livestock and visual electric fences are not recorded, whereas every interaction with the VF is recorded and monitored, and this was a source of puzzlement to participants when asked to consider welfare and GPS-SCs. As a typical illustration, one LM observed after considering how it was difficult to compare the differences between visual electric fences and VFs:Nobody keeps any data on how many electric shocks cows get on a daily basis from a normal electric fencing unit (P5.LM).This observation supports the previous literature that there is limited research  and no rFurther research on the comparison between visual electric fences and VFs through monitoring cattle where visual electric fences are used would also inform users if, or to what extent, livestock learning can be accelerated by the introduction of visual aids. Accelerating the learning process and ensuring livestock receive the minimum number of shocks in the process is a welfare priority supported by all stakeholder participants in this study, and would enhance the welfare of cattle at pasture ,45.There is currently no legislation around this technology, and this study observed the attitudes within the technology company reflecting this fact. For example, when asked if there was a minimum age for a calf to wear a collar, two Ds answered:We don’t have a set recommendation (P3.D)—we trust the farmer—he knows his animals best (P2.D).Despite the current lack of legislation, the technology company does provide plenty of advice and clear guidance , and thiWe say (to the farmer) 1. Is the animal physically strong enough to handle the collar? and 2. Is the animal mentally mature enough to understand the system? (P3.D)Further evidence that the technology developer is committed to ensuring the best outcome was expressed by this statement:We have the back office system, it is where we catch up on any collar that isn’t performing the way we expect it to perform. And that allows us to sort of have that end-to-end control if there’s anything going wrong (P3.D).Typical problems encountered were expressed by one LM as follows:I make sure there is water and shade well within the boundary so they never have to interact with the boundary to get to water and shade (P5.LM).Hunger or thirst will drive cattle to escape the fence and interact with the boundary, incurring an unacceptable number of shocks. This was confirmed by one D, who said:The key bit is to remember enough feed, water and to be in an environment that the cattle are comfortable. So don’t sort of think that you can just put any cattle anywhere (P2.D).stuck between boundaries and encounter signals and shocks from all sides. All participants also reported that there was a short delay between switching off the collar to move the paddock, and problems would occur if the user forgot to switch off the collar before changing pastures or after loading up a trailer. These issues would lead to livestock being repeatedly shocked as they were driven in the trailer out of the VF boundary.All stakeholders talked about designing the virtual paddocks in such a way as to preclude angles under 90 degrees, or narrow corridors where the cattle can become Animal welfare is a key government policy and industry aim ,27,45. WThe recruitment method used within this study does not provide a statistically representative sample from each of the stakeholder groups. This means biases may have been introduced, particularly with regards to recruiting participants who were enthusiastic or had reservations about the technology, and therefore it is likely that similar and polarised experiences, attitudes, and perceptions are presented. In addition, demographic information of the interviewees, such as age, gender, and years of experience within their stakeholder group, were not reported, which limits our understanding of the study population and the context in which their views are positioned. Given the stated limitations of this study, these findings are not considered a comprehensive representation of the stakeholder challenges and opportunities of GPS-SCs to achieve optimum welfare in a conservation or farm setting. However, this study does highlight valuable, in practice, knowledge, which supports the findings from existing literature, and crucially highlights the areas for further research and policy development. The authors advocate for collaboration with farmers and land managers who are already implementing this technology to ensure the negative welfare consequences of GPS-SCs are minimised, and the positive welfare opportunities highlighted are realised in practice.This study indicates that the provision of protocols for GPS-SC technology, together with other training and support, such as joint learning and assessment, would benefit users, facilitate optimum livestock welfare outcomes, and mitigate challenges to livestock welfare ,54,55,56There is evidence to suggest that, in conservation grazing and rewilding settings, users are less likely to have livestock expertise. As the UK government is developing environmental land-management schemes (ELMSs) to reward land managers for ecosystem services, more people will be encouraged into this sector, where livestock are seen as key to achieving environmental objectives. Therefore, stock-keeper training and protocols for the use of GPS-SCs are a priority in these settings and support key government policy goals for animal welfare ,45.Stakeholders interviewed during this study state that, on balance, in very extensive grazing schemes, livestock welfare could be improved by the introduction of GPS-SCs . This woData from this study indicate how language describing electric shocks can influence the way people perceive animal pain or discomfort . From a


Understanding the patients’ problems is essential to improve their quality of life. Through interviews and observations with patients, caregivers, and medical staff, we aimed to identify the various issues experienced by head and neck cancer patients during the treatment process and suggest improvement directions. As a result, the patients wanted to obtain comprehensive and reliable information during the treatment process. The patient also wished the medical staff could explain things easily so they could understand. For continuing long-term treatment, it was important for medical staff to encourage the patients and build a relationship with them. To successfully treat head and neck cancer patients, we need to consider what information should be delivered, how we should provide it, and how we can encourage them to support their emotions.Based on the treatment journey, this study aimed to present insights into improving the patient-centered service experience for head and neck cancer (HNC) patients. We interviewed and observed patients, caregivers, and doctors. We conducted a qualitative content analysis and service clue analysis to identify barriers and enablers to patient care and to derive insights into the patient experience (PE). We received feedback from doctors considering the priority, importance, and feasibility of improvements and classified the insights into three service experience aspects, to suggest improvement directions. As a result, the ‘functional’ aspect of service experience stressed the importance of a comprehensive guide to the treatment process, delivery of reliable information, use of easy-to-understand terms, repeated summary explanations, the establishment of close and flexible linkages between departments, and the provision of educational programs. Regarding the ‘mechanic’ aspect, the use of large and clear visuals for patients, to easily understand the care information provided by medical staff was distinguished. In the ‘humanic’ aspect, patients’ psychological stability, trust in doctors, and doctor’s encouragement and support through maintaining a positive attitude were prioritized. This qualitative study provided integrative insights into the HNC patient experience, through the application of service design methodologies, such as a patient journey map, participatory research methods, and service experience clues. Patient-centeredness is one of the critical elements of high-quality care , and hosDue to the importance of PCC, many centers are trialing a user-centered approach through collaborations with designers, to improve PE ,6. This Service design aims to understand the user experience and suggest meaningful insights for a user-centered solution. It is a practical approach to PCC in healthcare  and inclMeanwhile, it is crucial to understand what types of service are provided to patients to improve healthcare. Since one small and specific clue can significantly impact the evaluation of the patient’s medical service experience, service clue management is critical to improving the patient’s healthcare service satisfaction and the service experience. Service clues are related to various aspects of service experience, depending on their type. It is necessary to understand the types of clues and seek service improvement plans accordingly. Berry et al.  introducHead and neck cancer (HNC) is relatively rare compared to other cancers, with limited access to treatment information. Due to the anatomical characteristics of HNC, a loss of the essential functions of eating, speaking, and breathing occurs ; patientThus, improving the physical and psychological well-being of patients with HNC is crucial to improving the overall patient experience, increasing satisfaction with medical services, increasing treatment adherence, and encouraging positive treatment outcomes. Therefore, we aimed to analyze the PE throughout the patient journey of patients with HNC and present a service design strategy for improving the PE at each journey stage. In this regard, the specific research questions were as follows:RQ1. What are the enablers and barriers to patient experience at each stage of the treatment journey for patients with HNC?RQ2. Which service design strategies be suggested to improve the experience of head and neck cancer patients at each stage of the treatment journey?Service design methods such as interviews, observations, and journey maps were used to understand the barriers and enablers (B/E) from the patient’s perspective. Through qualitative content analysis of the patient’s narratives and analysis of service clue types, the patient’s needs at each stage of the treatment journey were visually structured. Since the patient’s treatment journey includes various stakeholders, such as the patients, doctors, families, and caregivers, the opinions of doctors, caregivers, and patients were comprehensively reflected to understand the B/E of the patient’s experience. The study consisted of three phases: (1) identifying the treatment journey of HNC patients, (2) analyzing the B/Es to PE, and (3) drawing insights for improvement . In the Interviews were conducted with doctors, patients, and caregivers, to understand the HNC treatment journey and identify specific actions, touchpoints, and emotions for each journey stage. Interviewees were directly recruited by an otolaryngology specialist from outpatients who had been diagnosed with head and neck cancer. The doctor introduced the purpose and content of the study to the patient and briefly explained the purpose and method of the interview. When the patient and guardian agreed to an interview, an in-depth interview was conducted immediately after outpatient treatment or on a different date. The interview was held in a separate private room in the hospital and lasted about an hour. The interviewees included all patients diagnosed with laryngeal, pharyngeal, or oral cancer who required surgery or were undergoing rehabilitation. The reason for this is that there is little difference in the treatment principles for each subsite, regarding the process that patients experience after treatment, problems and complications, and the needs of patients.We also made observations during clinical counseling, to precisely understand the users’ activities, physical space, and facility layout, including the furniture, doctor –patient interactions, objects being used, and users’ attitudes and behaviors, if researcher participation was permitted. Based on the user research, a five-phased HNC treatment journey was structured. For the journey map, we identified the specific stages of the HNC treatment journey and analyzed the user’s actions, emotions, and touchpoints related to each stage. The user’s actions were indicated in the order of specific actions that occurred at each stage, and the emotions felt by the patient at each stage were described. A touchpoint is a point of contact where patients, caregivers, and medical staff interact. The touchpoints included various types, such as the pain and emotion of the patient, language to convey information, hospital system, image data, and explanation tools.In the second phase, we took an inductive approach to analyzing the user research data. Qualitative content analysis and service clue analysis were applied to the semantic analysis of interview data, to understand the B/Es to PE. For the content analysis, following the method introduced by Graneheim and Lundman , we initInterviews were conducted with one specialist and two residents, to understand the treatment process. Based on the interviews, a JM of HNC patients was created, which consisted of five stages: ‘studies for cancer diagnosis and staging’; ‘pre-operative counseling’; ‘getting operation consent’; ‘surgery and recovery’; and ‘rehabilitation and follow-up’ . We alsoThe patient’s emotions showed substantial negative aspects of anxiety and worry throughout the journey. In stage 2, it was found that the patient’s trust in the doctor regarding the surgery revealed a positive desire for treatment. In stages 4 and 5, if the surgical results were good, the will to live was strongly formed as a positive emotion. For each stage of the previously created JM, a content analysis of the data collected during user research was conducted to derive meaning units, which were classified into enablers as positive factors, and barriers as negative factors. Then, each factor was classified according to the corresponding touchpoint and what type of service clue corresponded to each was analyzed. Enablers correspond to a factor that is helpful or necessary to improve the patient’s medical experience. This addresses aspects that need to be further strengthened for providing satisfying HNC PE in the future. On the other hand, barriers correspond to content where users complain of discomfort or have negative evaluations during the treatment process. This refers to the aspects that need to be improved for future PE. For example, considering the touchpoint ‘website’ in The touchpoints of ‘patient’s emotion’, ‘anxiety and worries about life after surgery’, and ‘concerns about a long treatment journey’ were found to be barriers to HNC PE. These two barriers correspond to ‘patient’s feelings’. They can be summarized as an insight into the ‘need to alleviate anxiety and worry about the long-term treatment journey and life after surgery’. This insight represents a humanic clue, because it deals with the emotional aspect of humans.The following insights were identified at each stage of the journey during the above analysis process.In Stage 1, from the content analysis of user research data, 13 enablers  and 11 barriers  were identified. Taken together, 11 insights  were elicited, two of which were identical (marked as *). Thus, the following 10 insights were finally derived, as shown in Among these, ① and ③–⑦ correspond to the ‘functional’ aspects of improving PE, such as the content and method of information delivery and the hospital system. Insight ② is related to the ‘mechanic’ aspect of improving visible elements, and ⑧–⑩ involves patient emotion and the interaction between the doctor and the patient, corresponding to the ‘humanic’ aspect.“The doctor didn’t use many technical terms in English but explained it in Korean, making it easier to understand and better. It was also good that the doctor didn’t just pass over something like inflammation and checked it properly.” (1-7a)⑤ “At first, I searched for cancer-related information on the Internet, but there was no detail, just bragging about the hospital they work at. There is no information at all on the internet.” (1-10)② “It’s the first time I’ve heard of cancer, so I wondered if it couldn’t be done without an incision, and the names of cancers were so diverse and difficult that it was hard to understand. I didn’t know anything, so I pretended to understand and said, ‘Yes, please do well’ when the professor said a lot.” (1-1)⑧ In Stage 2, 22 enablers to strengthen PE  and 12 barriers to be improved  were identified. The synthesized result revealed 17 insights  as shown in Of these, ①–④, ⑥–⑦, and ⑬–⑮ relate to the ‘functional’ aspect regarding the content and method of information delivery and the hospital system. Points ⑤ and ⑧ relate to tangible tools corresponding to the ‘mechanic’ aspects; ⑨–⑫ and ⑯–⑰ concern the interaction between the doctor and the patient, representing the ‘humanic’ aspect. “I think it would be comfortable if the doctor explained, ‘You’re in this condition now, but it will change like this in the future.’ I wonder how long the surgery will take, whether I can return to my daily life after surgery, how the evaluation test is conducted, and whether there is a ward to be hospitalized. It would be nice if the doctor could tell me about how many rounds of chemotherapy should be done after surgery.” (2-3a)② “It was nice that the doctor looked at my condition through an endoscope to see if I had healed well and explained it well. However, it was difficult to understand the explanation with CT images.” (2-17a) ⑤ “We know it’s the worst, but when the doctor speaks negatively, we lose heart. We hope to be at least a little hopeful.” (2-2b)⑨ Stage 3 involved seven enablers  and 20 barriers  regarding HNC PE improvement. Together, a total of 14 insights  were derived, as shown in Of these, ③–⑦, ⑪, and ⑬ relate to the content and method of information delivery, representing the ‘functional’ aspects; ①–②, ⑧, ⑫, and ⑭ correspond to the ‘mechanic’ aspects, dealing with hospital environment, such as space and furniture arrangement; and ⑨–⑩ are related to the interaction between the doctor and the patient, representing the ‘humanic’ aspect. “The doctor gave an explanation that is difficult to understand at once, but it seemed important. But all of them were hard to understand, so I didn’t even know what was more important, and it was not even in my head. If that’s the case, I think focusing on what’s really important is better.” (3-6b)③ “The text on the consent form was too small to read, the terms were difficult to pronounce, and the explanation took too long. I understood it at first, but later I couldn’t remember anything. I couldn’t even find a place to sign it, so the doctor marked it for me.” (3-2b)⑧ “From the day I found out he had cancer, I think I am also a cancer patient. I can’t even tell you how hard it was mentally, very much.” (3-3b)⑨ Stage 4 included 12 enablers  and 12 barriers  for HNC PE improvement. When synthesized, 14 insights  were drawn, and two factors were identical (marked as *). Thus, a final 13 insights were determined, as shown in Among these, ①–④ and ⑩ correspond to the content of information delivery and the hospital system, representing the ‘functional’ aspects; ⑤ and ⑫–⑬ relate to the provision and use of physical tools, engaging in the ‘mechanic’ aspect; and ②, ⑥–⑨, and ⑪,relate to patient psychology and pain and present insights for improving PE, representing the ‘humanic’ aspect.“My brother was in the integrated nursing ward for a month, but I couldn’t visit even once because of COVID-19. So, the nurses in charge informed me of the patient’s condition in detail by text message every evening. I thank them so much.” (4-12)① “Even the slightest change in the symptoms after the surgery scared me, and I was worried about whether this was normal or a complication. I wish the doctor would let me know in advance that the symptoms will change like this in the future and what is normal.” (4-13)⑫ “I don’t care about anything else, but it’s uncomfortable to breathe and talk. I need to get treated well and exercise hard from now on. My tongue is still swollen so I can’t speak fluently.” (4-7b)⑥ Stage 5 identified 14 enablers  and 13 barriers  for HNC PE improvement. From these, 17 insights were drawn, as shown in Of these, ④–⑪ correspond to the ‘functional’ aspects, such as information delivery content, hospital system, and educational programs; ⑫–⑭ relate to physical means, tools, and environments, representing ‘mechanic’ aspects; and ①–③ and ⑮–⑰explain the ‘humanic’ aspects, dealing with patient’s negative feelings and doctor’s empathetic attitude.” No detailed guidance was provided on how to behave and rehabilitate after discharge. I only heard that I should quit drinking and smoking and exercise regularly. That was all I got from the hospital.” (5-22)⑤ “In fact, if it’s the same way, I’m better off closer to home.” (5-16)⑫ “The first time I visited the professor after discharge, he encouraged me to say that I had endured the difficult surgery well. He helped and encouraged me a lot. The professor did well with the surgery, so I should have hope while receiving rehabilitation treatment.” ① The result of visually structuring using a JM, by synthesizing the above analysis, is shown in In this phase, by reclassifying the PE factors and the related insights identified in phase 2 into the three types of service clues, according to the attributes of the factors, we tried to identify which factors should be considered for PE improvement and what are the implications for improving HNC PE by service clue type. To this end, the ten PE factor categories classified using the attributes were divided into three service clue types. The critical insights derived at each stage of the treatment journey were summarized according to each service clue and factor type, as shown in The ‘functional’ clue dealing with the technical aspect of providing a specific service for improving PE included five PE factors: information delivery content, information delivery method, hospital system, treatment cost, and education program. In information delivery contents, a comprehensive guidance of information related to the overall journey process consisting of five stages was required. For the information delivery method, easy-to-understand terms for patients in journey Stages 1-3, where many explanations about treatment methods and processes are made to the patient, were highlighted. In hospital system, links and communication between departments were emphasized for Stages 1, 4, and 5, to reduce patient waiting times and ensure the consistent delivery of treatment information, in consultation with other departments. In Stage 2, a customized support service for the patient that considered patient circumstances was required, along with a text message service, enabling interactions between the patient, caregiver, and medical staff and for updating the patient’s pre-operative study results. In Stage 5, an additional consultation window with the medical staff, patient continuous communication with the medical staff through administrative support, and discomfort minimization during the long-term treatment process were identified as important issues. Regarding treatment costs, government and insurance support were particularly emphasized in Stage 4. In Stage 5, educational programs were emphasized, regarding providing smoking cessation and abstinence programs, cases of overcoming cancer in other patients, and the latest HNC treatment technology trends.The ‘mechanic’ clue, dealing with objects or environments perceptible by the senses, for improving PE was related to information delivery tools and the hospital environment. For information delivery tools, a reliable and easily accessible information delivery medium was identified as necessary in Stages 1, 4, and 5. Patients wanted as much information about treatment as possible in the early cancer diagnosis and recovery stages after surgery. In Stages 2–4, the use of clear and visible visual data that elderly patient could easily understand was emphasized. Stages 2 and 3 required a communication tool that could replace language, considering patients with difficulty in communicating verbally. In Stage 4, before and after surgery, a flexible communication tool or medium that enabled active information sharing and emotional expression among patients, caregivers, and medical staff was required. Regarding the hospital environment, in Stage 3, securing an independent counseling space for patient stability and interaction with the doctor was necessary. Thus, the arrangement of space and furniture to improve and support interactions between the patient and the doctor and help the patient focus on obtaining operation consent should be considered. In Stage 5, according to the prolonged rehabilitation treatment, it was necessary to establish convenient means of transportation and a comfortable treatment environment, considering patient convenience.The ‘humanic’ aspect of PE dealing with user interactions, attitudes, emotions, and behaviors included needs related to the patient’s pain, patient’s feelings, and doctor attitudes. In patient’s pain, attention to nutrition supply, preparation of countermeasures, and active response to patient pain after surgery were required in Stages 4 and 5. Regarding patient’s feelings, active support and encouragement from caregivers and medical staff were needed. It was also necessary for the patient to understand the treatment journey in advance, by guiding them through detailed information for each stage, to alleviate negative emotions and maintain emotional stability. Empathy and encouragement of the caregiver’s grievances about caring for the patient after discharge were also crucial in Stages 4 and 5. In Stages 2 and 5, maintaining a positive attitude toward treatment by building trust with the doctor helps increase patient satisfaction with the PE. For doctor’s attitude, at all stages of the journey, except for Stage 3, the positive attitude of the medical staff, empathy, and encouragement of the patient played a vital role in the PE.Above, we considered the PE factors and related insights that should be considered to improve HNC PE by service clue type. The insights for each stage of the journey presented in We conducted three focus group meetings with HNC doctors to identify the relative importance of the factors that should be considered for improving HNC PE. We received feedback on the priorities and importance of the PE factors and related insights from two highly experienced HNC doctors, who both closely directly or indirectly interact with patients and fully understand their situation and needs. As a result, six insights were evaluated as necessary for the functional clue about information content. Three insights for information delivery methods, two for the hospital system, and two for the education program were evaluated as significant. Regarding the mechanic clue, the ‘use of large and clear visuals that are easy to understand and recognizable by older patients’ was evaluated as necessary for the information delivery tool. For the humanic aspect, three insights related to the patient’s feelings and three insights related to the doctor’s attitude were each evaluated as significant. The PE factors evaluated as relatively necessary during the feedback are marked with ** in Considering these feedback results, the information content that patients acquire during the treatment process is critical to improving the experience of HNC patients. In addition to the method of delivery of this information content, the painful emotions felt by patients during the treatment process, and the positive attitude of medical staff who respond appropriately to them can also be interpreted as key.In summary, the early stages of the journey (S1–S3) involved the patient’s cancer diagnosis and treatment method delivery . Thus, uIn this study, the following results were derived through a three-phased process. In phase 1, user interviews and participatory observation identified a five-staged HNC treatment journey process. For each stage, relevant user experiences were collected, including main actions, touchpoints, and patient emotions.In phase 2, the barriers and enablers of PE were analyzed for each journey stage through content analysis of the collected user research data. As a result, ten insights were derived from 13 enablers and 11 barriers in the first stage. In stage 2, 17 insights emerged from 22 enablers and 12 barriers. In stage 3, 14 insights were derived from seven enablers and 20 barriers. In stage 4, 13 insights were identified from 12 enablers and 12 barriers. In stage 5, 17 insights were derived from 14 enablers and 13 barriers.In phase 3, the insights derived from each stage were classified according to the three service clue types and categories of PE factors. The ‘functional’ aspect of service experience included five categories and 40 insights, stressing the importance of a comprehensive guide to the treatment process, delivery of reliable information, use of the easy-to-understand terms, repeated summary explanation, the establishment of close and flexible linkages between departments, and provision of educational programs . Regarding the ‘mechanic’ aspect, two categories and 15 insights were included, such as using large and clear visuals that patients can understand easily. Three categories and 23 insights were included in the ‘humanic’ aspect, highlighting patient’s psychological stability, trust in doctors, and doctor’s encouragement and support by maintaining a positive attitude.First, for the ‘functional’ aspect, regarding information content, the overall process of the treatment journey for HNC patients should be guided in the early stages of the journey. As framing the holistic picture of the journey from the patient’s perspective (who must undergo a long-term treatment process) can help maintain emotional stability, the information content a patient needs at each journey stage is different. Thus, the information provided at each stage should be classified. An integrated database should also be established to provide the information for each category and to patients in a JM, where the treatment journey can be easily identified.Second, as part of the ‘functional’ aspect, to maintain long-term and continuous treatment, educational programs should be provided in which patients can participate or receive information after discharge. Through providing a rehabilitation guide booklet and smoking cessation and sobriety education programs that can be referenced after discharge, information for continuous rehabilitation and self-management should be delivered to patients needing psychological support.Third, with regard to the ‘mechanic’ aspect, stages 1-3 are when a patient first encounters HNC and is inundated with information. For elderly patients with reduced memory, a means to understand and accept information more efficiently is needed. As it is difficult for these patients to understand treatment information verbally, regarding information delivery methods and tools, large and clear visual data, such as human body models or illustration images, should be used as additional explanatory tools.Fourth, regarding the ‘humanic’ aspect, HNC is a relatively rare cancer that requires long-term and complex treatment, and most patients experience depression and anxiety. To support patient emotions and to alleviate patient anxiety and worries, as well as to encourage a hopeful attitude throughout the treatment process, a video about overcoming cancer or a community for HNC patients could be provided for information exchange and psychological support between patients.We conducted a convergence study of the medicine and service design by applying the JM methodology. As a result, we could reveal PE barriers and enablers that medical staff were perhaps unaware of. In addition, it was possible to derive realistic improvements through close interaction with the medical staff. As a result of our study, various items at each stage of the HNC patient’s journey were identified as factors related to patient experience improvements, including functional aspects such as information and systems, mechanic aspects related to specific objects or facilities to support function, and humanic aspects such as the emotions and attitudes of patients and caregivers. This aligns with previous research , which rSince this study conducted interviews with a small number of patients and caregivers, it is difficult to generalize the results. However, a qualitative research analysis was employed to discover in-depth insights into the patients, by conducting repeated observations and interviews over the journey stages for a small group of users who fit the purpose of the study. As Nielsen et al.  mentioneApplying service design to the medical field is a critical strategy for providing quality care from a patient’s perspective. Since the patient’s journey is complex and includes diverse aspects, it is essential to interpret the various viewpoints and complex data delicately. A JM is a valuable tool for understanding the relationships and patterns between meanings, by visually structuring complex patient needs. Thus, it is of great help to holistically understand where and how the patient’s treatment experience occurs for each journey. Employing a qualitative methodology that collects patient needs through interviews and observations and systematically analyzing the contents through an inductive approach can provide more in-depth insights than the quantitative measurement of patient satisfaction. The results of this study can be used as reference materials for researchers interested in creative methodologies for improving PE.By applying the creative methodology of service design, we employed three integrated perspectives to improve the experience of HNC patients. First, rather than dividing the treatment journey of HNC patients into fractured stages, the overall journey flow was examined in an integrated manner, to identify the changes and differences in the patient’s needs at each stage. Second, to improve HNC PE, the perspectives of caregivers and medical staff, and the patient’s perspectives were, directly and indirectly, reflected through a participatory method. Third, to identify the implications for improvement, three aspects of technical support, tangible tools, and human interactions were integrated and viewed, by applying three service experience clues: functional, mechanic, and humanic.The study’s findings could be applied to real patient-centered treatment. Patients can easily understand the treatment process, maintain a good doctor–patient relationship, and actively participate in their treatment. This might effectively improve the treatment outcomes of difficult-to-treat HNC. It could be widely applied to cancers other than HNC, or other diseases. In that case, the efficiency of medical care would be increased, while maintaining the doctor–patient relationship in the entire medical field.