A growing number of apps to support good mental health and well-being are available on digital platforms. However, very few studies have examined older adults’ attitudes toward the use of these apps, despite increasing uptake of digital technologies by this demographic.This study sought to explore older adults’ perspectives on technology to support good mental health.A total of 15 older adults aged 50 years or older, in two groups, participated in sessions to explore the use of digital technologies to support mental health. Interactive activities were designed to capture participants’ immediate reactions to apps and websites designed to support mental health and to explore their experiences of using technology for these purposes in their own lives. Template analysis was used to analyze transcripts of the group discussions.Older adults were motivated to turn to technology to improve mood through mechanisms of distraction, normalization, and facilitated expression of mental states, while aiming to reduce burden on others. Perceived barriers to use included fear of consequences and the impact of low mood on readiness to engage with technology, as well as a lack of prior knowledge applicable to digital technologies. Participants were aware of websites available to support mental health, but awareness alone did not motivate use.Older adults are motivated to use digital technologies to improve their mental health, but barriers remain that developers need to address for this population to access them. Late-life mental health is often overshadowed by physical health. However, mental illness is common in older adult populations, with estimates suggesting that depression is more common than dementia in later life . Prevaleflourishing to describe states of positive mental health , just to say, “well I suggest you go for a walk” or whatever it churns out, really. I think that’s good. Cos [because] you don’t always want to bother somebody, like these ladies have said, you don’t.Participant 15, female, age 55Loneliness was a particular source of concern for participants. Many recognized that loneliness was detrimental to health and mood. Participants discussed how they used technology to alleviate loneliness.I will switch the radio on sometimes, but the visual contact of the TV makes me feel that I’m not on my own... It’s company, you see people.Participant 15, female, age 55Participants mentioned that they were motivated to use technology to play music because it helped to improve their mood. Participants used a wide variety of different technologies to source music, including YouTube .If I want a lift, an uplift, I go and put rock and roll on, or summat [something] a bit lively.Participant 14, male, age 75I put music on. Put YouTube on and type in what I fancy listening to.Participant 10, female, age 68Yeah, I like the YouTube [sic] for all sorts. Er, but music is, does relax me.Participant 9, female, age 69Apps designed to support mental health were considered helpful in normalizing the experience of poor mental health. After testing apps that described commonly experienced symptoms of depression, anxiety, and stress, participants highlighted how reading these accounts provided them with a sense of normality.It makes you feel normal, because you’re seeing it written down.Participant 12, female, age 56Video games were also seen as helpful, as a way to distance oneself from one’s problems and improve current mental state through distraction.It’s if like, summat’s [something has] happened or you know, so it will take your mind if you’re concentrating on one thing. Just gives you that bit of respite.Participant 14, male, age 65Participants recognized these benefits in a game within an app entitled WellMind that was explored during the study session.Oh there’s playing a game with a kind of snake and an apple, you have to move a bar and hit the apple and things...I suppose it’s a kind of concentration of the mind.Participant 12, female, age 56Participants also recognized a number of barriers to the use of digital technology to support mental health. First, participants suggested that low mood was likely to affect readiness to engage with digital technologies.I do wonder if you could be so low, that you couldn’t be bothered to go on a computer.Participant 11, female, age 66Participants also commented that the fear of the consequences of using technology to support mental health may also prevent them from engaging with mood-reporting tools, such as apps, to support mental health.Where the fear is of something unpleasant happening to you, like you’re being taken, taken into an institution, then you’re not going to admit any symptoms that you might think could be interpreted that way.Participant 8, female, age 68Some participants mentioned that using technology to self-diagnose could be problematic, since it could result in patients mistakenly believing they had a rare or extreme medical condition.To research online a specific problem, you know, say diabetes, is ok, but to research and put in what problems you’ve got that come up with some outlandish thing is wrong. I don’t agree with that. The doctor tells you that.Participant 6, male, age 69As well as these concerns, there was a sense that human contact was superior to technology when it comes to mental health and that dealing with people was preferable to using technology.If you really feel down and you really need some help, can a computer...don’t you think physical contact or speaking to someone is far more important?Participant 13, female, age 60Some technology usability issues were discussed, which, while not specific to apps to support good mental health, nonetheless created barriers to successful engagement. Many of the apps evaluated by participants assumed a certain level of prior knowledge on the part of their users. For example, some apps use a cross (X) symbol on buttons to close a text-entry box, while others used a swipe action to move between options. For some participants, these assumptions caused difficulties, as they did not always have the required prior knowledge, skills, or experience.If you push that cross does that mean it cancels it out? Yes. Right. You do it.Participant 12, female, age 56No I think it, does it, oh.Participant 13, female, age 60Dexterity was also an issue raised by several participants. One of the apps tested by participants was Pacifica. This app featured a circular slider for users to report on how they were feeling. Participants suggested this action would be particularly difficult for someone who had had a stroke.I think, if they’ve come out of hospital and had a stroke, that turning one  might be quite difficult for them.Participant 15, female, age 55They also suggested that poor dexterity may be a barrier to the use of games within apps to support mental health.I think that you’ve...that snake game, your hands have to be quite good.Participant 12, female, age 56Yeah, dexterous.Participant 11, female, age 66Yeah, your dexterity has to be pretty good for that one.Participant 12, female, age 56Further, usability-related barriers found in this study included difficulties reading small fonts; for example, Participant 15 stated, “The print’s too small, can you make it bigger?” There was also a sense that using technology is effortful and time-consuming; for example, Participant 2 stated, “When you go on a computer, you’ve got to log on and all that blah, blah, blah.” Some participants also mentioned that they experienced fear when completing certain activities on digital platforms; for example, Participant 13 stated, “I don’t know why I’m afraid of downloading apps.”Participants demonstrated an awareness of multiple uses of digital technologies to support mental health. These included online doctor’s appointment booking systems, National Health Service (NHS) and other health websites for researching health conditions, meditation apps, and YouTube videos for relaxation. One participant expressed confidence using the NHS website and saw the potential benefits of using it. Here, she reacts to a vignette in which the person described is imagined to be experiencing symptoms of depression.I suppose for this one, this red one, you could like, look up a...NHS site, Moodzone, they do audio tapes that, they do tapes that actually give you some inspiration towards feeling better.Participant 13, female, age 60Many participants referred to CDs, tapes, and online resources for mindfulness, though one participant was unsure about digital delivery.How does mindfulness work online?Participant 1, female, age 66Another participant found it difficult to use such resources alone.I’ve got those tapes that they’ve given me to teach me how to relax. I find that, I can’t do it on me [sic] own. But I can do it say if you was [sic] with me, and we just, meditated together, I could do that. But on my own, I’m finding, “oh I haven’t washed the pots, I haven’t done this, I haven’t done that,” you know.Participant 15, female, age 55Thus, although participants showed an awareness of various ways in which digital technologies can be used to support mental health, awareness alone may not be enough for participants to start using such tools successfully. Indeed, not everyone was convinced there is a role for technology in certain situations.I don’t know how technology would help.Participant 9, female, age 69This study used the COBALT principle of user as expert to understand the motivators and barriers to older adults’ use of technology to support mental health. New findings presented in this work include that self-reliance, averting loneliness, normalization, facilitated expression, and improving mood can be motivators for older adults to use technology to support their mental health. Some apps and websites included in the study were found to offer functions that assisted users in understanding their mental states and in facilitating behaviors that would promote well-being, flourishing, and mental health. The study has also illuminated possible reasons older adults might avoid using technology to support mental health, including low mood itself, fear of consequences, and a preference for human contact.The participants expressed an interest in using technology to alleviate low mood, for example, by listening to music on YouTube or playing games within apps. They expressed how playing games, such as that within the app WellMind, could be a helpful distraction from unwanted thoughts and may help to concentrate the mind. Prior research has highlighted that technology can provide older adults with opportunities for enjoyment and fun . This stFindings here reflect how older adults may turn to technology to manage symptoms of low mood and alleviate feelings of loneliness by themselves, without reaching out to friends or family. Participants described how using apps to record their mood and receive activity suggestions may be preferable to speaking with others when experiencing low mood, to avoid being seen as a burden. Peek et al  also fouThe participants identified a number of barriers to using technology to support mental health. Discussions revealed how symptoms of poor mental health may affect readiness to engage with technology. Comments included the fact that feeling depressed was likely to magnify difficulties with usability of digital technologies. The Diagnostic and Statistical Manual of Mental Disorders lists lack of motivation and reduced pleasure in daily activities as symptoms of major depression  and partSome usability issues with the apps and websites were identified. For example, the use of interactive COBALT activities revealed that some participants struggled to understand the meaning of relatively standard symbols and dialogues within apps and websites. This suggests that apps and websites must address accessibility and universal design features to maximize their usability and reach to all potential beneficiaries, rather than assuming prior knowledge. Similar findings were reported by Eisma et al , who demAnother perceived barrier to using technology to support mental health was the perception that using digital technology might result in automated decisions about treatment being taken. When discussing the use of digital technology to report on mood, participants suggested that fear of being institutionalized could affect honesty in self-reports. Prior work has indicated the benefits and psychological attachments older adults have to ageing in their own homes ,43; the Although this study has produced novel insights into older adults’ attitudes toward the use of technology to support mental health, it does have some limitations. First, there were few participants with very low levels of education or very limited experience of technology, meaning results may reflect a greater awareness of, or ability with, technology among participants than is representative of the population at large. Second, the majority of participants in this study were female, meaning views of older males may be underrepresented. Third, while the inclusion of participants aged 50 and over enabled us to gain a more diverse range of perspectives, it also means that not all points may be relevant to all age groups. Future studies that examine the relevance of each theme to more homogenous subgroups of older people would therefore be useful for learning more about the different types of potential users of mental health technologies.This study has revealed that older adults are motivated to use digital technology to support their mental health, in particular to promote self-reliance, avert loneliness, and improve mood. However, low mood, fear of consequences, and a preference for human contact may prevent successful engagement with these technologies. Further work is needed to understand how the use of music and games within apps and websites might help to address symptoms of mental illness in older adults and to understand how different states of mind, such as low mood, might affect older adults’ readiness to engage with technology. Developers of apps and websites designed to support mental health that could be used by older adults should be mindful that technical jargon and commonly used symbols may not be understandable to all older adults. They should also be aware that guidance provided with such tools could be helpful in reassuring users that using these tools will not reduce human contact with health professionals or result in adverse consequences.


Deborah Mayo uses the heuristic of a visit to the museum of inferential statistics to contextualize her philosophy of inference via severe testing; that is, of inferences based on claims having passed stringent statistical probes with highly reliable methods Mayo, , p. 10 sError and the Growth of Experimental Knowledge , and Mayo places it as a cornerstone of her philosophical-practical triangle for understanding statistical inference, together with her works ge Mayo, , and Errce Mayo, 1. The boThe book is, thus, insightful for readers who first come across Mayo's philosophy of statistics, although they will miss a compelling tutorial for severity testing, as the text often engages the statistics wars—even book reviewers get caught by the war theme more than by the inferential one; , and enhances it by focusing on the ad hoc learning that we may gain from controlling and dispelling errors from our methods of enquiry . Inferential errors may be found at any, even multiple levels, in the link between data collection and theory (p. 87). Indeed, both formal and informal auditing are needed to make sure errors are envisaged, identified, and controlled before we are ready to substantiate an inference. Failing an audit, we have bad evidence, no test (p. 5). For good inferences we require both a genuine desire to find things out and, at minimum, weak severity: a sound attempt at ruling out ways a claim may be false (p. 5). For optimal inferences, however, we require strong severity: a stringent procedure highly capable of finding flaws in a claim if such flaws existed (p. 14).So, once we brush over the statistics wars, what does per se—although data is evidence for a claim just to the extent that the claim has passed a severe test with such data (p. 108)—nor about the probability of a claim—whether the data renders the claim improbable (p. 10).Yet passing a stringent test is not enough for moving from weak to strong severity. It is the entire procedure which needs to be stringent: audited (p. 269), multi-tested , piecemeal testing to resolve instantiations of Duhem's problem (p. 83), formal and informal scrutiny , etc. The aim is to achieve lift-off (p. 15) via an argument from coincidence (p. 14) rather than because of frequentist performance in the long run. Indeed, it is not so much that three reliable scales are able to measure a weight discrepancy with a smaller margin of error over time but—and here is Mayo's insight—that they inform us with great probability if any of the scales is unsound now (p. 15). Upon finding no error despite the strong probes, we may infer that an error is absent; meanwhile the convergence of weight discrepancies allows for an argument from coincidence and lift-off: “an inference more reliable and precise than its premises individually” (p. 15). Thus, Mayo's severity is about methodological severity—about how well-tested a claim is —not about inferential severity In brief, the book is insightful for those new to Mayo's philosophy of statistics and provides a thorough view of the statistics wars. For the concerned methodologist, it also demarcates severity tests from significance tests and power analyses, and provides an excellent—albeit at time confusing—framework of methodological falsificationism for better science.JP initiated and drafted the review. MP-S, JP-L, DF-N, and JP revised and edited the manuscript. All authors approved the final version of the manuscript for submission.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


One curious aspect of human timing is the organization of rhythmic patterns in small integer ratios. Behavioral and neural research has shown that adjacent time intervals in rhythms tend to be perceived and reproduced as approximate fractions of small numbers . Recent work on iterated learning and reproduction further supports this: given a randomly timed drum pattern to reproduce, participants subconsciously transform it toward small integer ratios. The mechanisms accounting for this “attractor” phenomenon are little understood, but might be explained by combining two theoretical frameworks from psychophysics. The scalar expectancy theory describes time interval perception and reproduction in terms of Weber's law: just detectable durational differences equal a constant fraction of the reference duration. The notion of categorical perception emphasizes the tendency to perceive time intervals in categories, i.e., “short” vs. “long.” In this piece, we put forward the hypothesis that the integer-ratio bias in rhythm perception and production might arise from the interaction of the scalar property of timing with the categorical perception of time intervals, and that neurally it can plausibly be related to oscillatory activity. We support our integrative approach with mathematical derivations to formalize assumptions and provide testable predictions. We present equations to calculate durational ratios by: (i) parameterizing the relationship between durational categories, (ii) assuming a scalar timing constant, and (iii) specifying one (of K) category of ratios. Our derivations provide the basis for future computational, behavioral, and neurophysiological work to test our model. Integer ratios can be written as a fraction: 1.5 equals 15/10 or 3/2, but small if the result of the division can be written as a small integer number divided by another small integer number e.g., 2/3, but not 23/51  tend to exhibit small integer ratios? Why are humans drawn to rhythms with such a peculiar mathematical property, in both perception and production? Does this property reflect a special quirk of music perception and/or motor sequencing, or could it be explained by domain-general aspects of cognition? Can we explore these alternatives through mathematical formalism? Here, we explore mathematically the possibility that the human bias toward small integer ratios may be explained by a combination of scalar expectancy and categorical perception.We begin by outlining the relevant classical frameworks for human timing, and go on to summarize the evidence in support of the small-integer ratio bias in rhythm perception. We then present our proposal linking the frameworks to the bias through mathematical formalisms. Specifically, we draw on the scalar property of time interval estimation to formulate a simple model of categorical perception that may result in an integer ratio bias Figure , and linTwo major theoretical approaches, among several, have been suggested to account for the mechanisms behind human timing  with the periodicity of external stimuli at multiple time-scales Buzsaki, . SpecifiRecent behavioral research investigated human priors for durations in rhythmic patterns  and of ratios r = , such that ri = di+1/di. Perception of a rhythm rinduces a representation z = , with a strong tendency to categorize. The vector z is a sequence of a small number of unique phenomenal interval-ratio categories that represent the observed data r. More specifically, the notation zi = k identifies that interval ratio ri is attributed to phenomenal category k  ∝ p(ri|zi = k)p(zi = k). Our focus is the prior distribution over categories, p(zi = k), equivalently G. Alternatively, it would be possible to model learners' assumptions about a likelihood distribution as a source of bias  directly. Our approach to the prior is closely related. Like Jacoby and McDermott  has a Gaussian form should be tested in future work, but is in line with existing work and a fair first approximation.Jacoby and McDermott  recentlycDermott , we exprK-dimensional Gaussian mixture of interval ratio categories, and the data likelihood as i.i.d. Gaussian underlying these categories, such that the marginal distribution of interval ratios has the form:We write the prior as a k = 1, …, K a weight in the mixture, φk, which determines its relative prominence as a category; a category mean μk, which specifies the expected interval ratio underlying this category; and a category variance σk. The assumption we make is that weights are constant: Here, the prior assigns to each Gaussian G: only few categories exist .All four assumptions are empirically based and independent of each other. Now, k Figure , which ik extends from Combining this idea of a parameterized overlap with scalar properties, each cluster s Figure  can be wand their ratio asSubstituting (5) into (4) provideswhich can be simplified and rewritten asEquation (7) requires, to be well-defined, that its right side is positive, namelyG can be calculated using the recursion equation:Operationally, the category means following from the constraints on 1, we can compute μk for all k ≤ K using Equation (9)  Figure .post-hoc knowledge that the prior is characterized by categories centered at small integer ratios, do the constraints we laid out structure the prior such that integer-ratio clusters are predicted by setting μ1 to the smallest possible integer ratio?These quantitative tools enable the formulation of several questions. Given our ck in a certain way?An alternative approach might be to assume that one ratio is e.g., The x-coordinates for the intersection point, expressed as s Figure :which simplifies as:c's is proportional to the logarithm of the ratio of the two means.Equation (11) means that the difference of squares between k = μ1 = 100ms and μk+1 = μ2 = 200ms in (11), the equation becomes To make an example with actual numbers, if one substitutes μc's), it is admittedly difficult to interpret psychophysically.As the right side of Equation (11) is always strictly positive, rk and the scalar constant s : which values of μ1 result in r being integer ratios and s, Equations  support a potential link between scalar timing and integer ratios, as they include the integer ratios s Figure . These gs, s, s as an a priori known, one-valued constant (s = 0.025). To improve the model further, the variance of s might be estimated by replications of previous psychophysical experiments such as those by Friberg and Sundberg (The perspective we offer here creates the basis for expanding not only into theoretical but also empirical work on Sundberg  and MadiSundberg . Values We explore quantitative links between scalar timing and the human bias toward small integer ratios. The arguments we provide reduce the explanatory space to a few hypotheses. One possibility is that integer ratios are not a human cognitive primitive, but rather a simple by-product of other cognitive constraints, and their interaction.in-vivo recordings of neural populations and compatible with the observed small integer bias.Alternatively, the scalar timing framework might not be the most suitable one to explain the integer-ratio phenomenon of human rhythm. If one adopts oscillatory frameworks, integer ratios might simply arise from the oscillatory properties of brain activity, and so can scalar properties and categorical perception. Small integer ratios in particular would just reflect epiphenomena of harmonics of one oscillator or the interaction between two or more oscillators (Collyer et al., In any case, scalar timing and oscillatory theories are simplifications, i.e., approximate descriptions derived from confined experimental set-ups. Neurally and behaviorally, the dissociation or compatibility between scalar timing and oscillatory theories is more complex than it may appear in higher level cognitive theories, and only detailed neural models will enable us to define the actual underlying mechanisms.AR and BT conceived the idea and performed the mathematical derivations. All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The purpose of this article is to describe the origins of patterns of strengths and weaknesses (PSW) methods for identifying specific learning disabilities (SLD) and to provide a comprehensive review of the assumptions and evidence supporting the most commonly-used PSW method in the United States: Dual Discrepancy/Consistency (DD/C). Given their use in determining whether students have access to special education and related services, it is important that any method used to identify SLD have supporting evidence. A review of the DD/C evidence indicates it cannot currently be classified as an evidence-based method for identifying individuals with a SLD. We show that the DD/C method is unsound for three major reasons: (a) it requires test scores have properties that they fundamentally lack, (b) lack of experimental utility evidence supporting its use, and (c) evidence supporting the inability of the method to identify SLD accurately. The study of intelligence and education have long been intertwined.cognitive profile analysis: examining intra-individual differences in IQ test scores.2The popularity of intelligence assessment grew even more after David Weschler  publisheExamining cognitive profiles became popular among clinical psychologists, but there were individuals who noted that there was little experimental evidence to support their interpretation .3 In facDespite the lack of experimental evidence supporting the interpretation of cognitive profiles, it remained popular with clinicians. To some extent, the lack of evidence was acknowledged. Instead of limiting the practice of cognitive profile analysis, however, it was re-framed. First, instead of score variability being due to an “unorganized or disordered personality”, it was more likely due to some problem with cognition or learning. Second, interpreting cognitive profiles could not be done by just any psychologist. Instead, it was a skill that could only be acquired through intensive training with clinicians who were well-versed in the method—i.e., it was an art instead of a science .In the mid-twentieth century, the popularity of the cognitive profile analysis began to manifest itself in special education . School/Despite the dearth of experiments supporting the practice, the idea that learning difficulties could be diagnosed, and subsequent interventions developed, through examining cognitive profiles has continued to remain popular among clinicians and educators. In fact, a whole cottage industry has developed around the use of cognitive profiles. Individuals interested in this approach to IQ test score interpretation can choose from a variety of workshops, books, software, and even online certificate programs in order to hone their skills in finding and interpreting various cognitive profiles.patterns of strengths and weaknesses (PSW). The purposes of this critique are to describe the origins of PSW methods as they relate to specific learning disability (SLD) identification and to provide a comprehensive review of the assumptions and evidence for one particular PSW method: Dual Discrepancy/Consistency  does not believe that an assessment of psychological or cognitive processing should be required in determining whether a child has an SLD. There is no current evidence that such assessments are necessary or sufficient for identifying SLD. Furthermore, in many cases, these assessments have not been used to make appropriate intervention decisions. However, § 300.309(a)(2)(ii) permits, but does not require, consideration of a pattern of strengths or weaknesses, or both, relative to intellectual development, if the evaluation group considers that information relevant to an identification of SLD.  , it could be that Intelligence ← Third Variable →Achievement . Or perhaps Intelligence ⇆ Achievement ; that is, intelligence and academic achievement attributes could be working together, each “causing” each other.Gc and a hybrid of Gf and Gv) and academic achievement attributes (reading and math abilities) in students referred for special education. Every student in their sample had data at two time points, with time 1 (T1) being approximately three years from time 2 (T2). Watkins et al. fit a series of cross-lagged models to examine the relations across time. In their “best” model (M2), Gc, Gf/Gv, reading, and math at T1 were specified to be direct causes of academic achievement at T2. While Gc and Gf/Gv were non-negligibly related to academic achievement, the best predictors of reading and math, respectively, at T2 were reading and math, respectively, at T1.For example, Watkins et al.  examinedGc and Gf/Gv at T2. The GcT1-readingT2 and Gf/GvT1-mathT2 relations for M2 were statistically the same (up to the sign) as the readingT1-GcT2 and mathT1-Gf/GvT2 relations in M3.The third model (M3) Watkins et al.  examinedWe are not necessarily advocating for a position that academic achievement attributes “cause” intelligence attributes. What we are arguing is that determining the nature of causality between intelligence and academic achievement attributes is much more difficult than showing IQ test scores and standardized academic achievement scores are correlated .Third, correlations provide information about what is likely true in aggregate for a population, not what is true of each and every member in that population . That isIf intelligence attributes were causally related to academic difficulties, then we would expect that IQ test scores and academic achievement test scores would be related. The presence of correlations between IQ test scores and academic achievement test scores, however, does not imply that intelligence attributes are causally related to academic difficulties—no matter how robust the correlations. Consequently, assuming that correlations between IQ test scores and academic achievement test scores in a population implies that the former is causally-related to SLD in specific individuals is a false cause fallacy.The fifth type of support comes from the few experiments designed to study DD/C that ask and answer the wrong questions. As described in ns ranging from 29–42) based on the DD/C or other “conceptually similar” PSW approaches, as well as a comparison group of students without identified SLD :If then Va=Vz−Vx .Scores from IQ and academic achievement tests are, l scales ,76. One ditivity . When a V represents values for the attribute of length, then length scales have additivity. As an example, let Using V represents, say, values for the attribute of Comprehension-Knowledge (Gc)? Do scores on an Gc as much as individuals with 115 Gc the same amount as individuals with 105 Gc between the individuals with 80 Gc as the individuals with 115 What happens if 0 IQ? No .Gc as a change from 100 Because values on the IQ scale represents the number of SDs an individual’s raw score is from some reference point  and raw scores are made to follow some type of symmetrical distribution , it would be very difficult to make the argument that a change from 65 Gc is, say, 100 Gc were the same as the average raw scores in the norming group. It provides no information about the individual’s actual level of Gc.A unit is “real scalar quantity, defined and adopted by convention, with which any other quantity of the same kind [of attribute] can be compared to express the ratio of the two quantities as a number”  (p. 6). Gc that is different than The major implication of IQ and academic achievement tests using ordinal measurement scales is that the values have heterogeneous orders . That isHistorically, most SLD research—like much other research in psychology—has been predicated on the ideas that psychological attributes are being measured on interval scales . This asO subscript represents the original score scale, N represents the new score scale, S is an individual’s score, M is the sample mean, and The DD/C method requires that all test scores be placed on an IQ scale  so they can be directly compared. Thus, if the original scores were on, e.g., Scaled Score scale , they have to be transformed to the IQ scale. This is done through the linear transformation in Equation  are allWhen the transformation in Equation  is appliTake values on the Scaled Score scale (ScS), for example. It has an SD of three, meaning that each value represents one-third of a SD. If these scores are transformed to the IQ scale, however, now each value represents one-fifteenth of a SD. In other words, the scores now give the appearance of having more information because each IQ scale score value ostensibly represents a more precise level of the attribute.A more concrete example is given in In other words, information that was not available in the original Scaled Score scale now appears to be present on the IQ scale. How can this be, though? There is nothing about a score transformations that provides additional information about an attribute. However, that is exactly what appears to happen as a consequence of these score transformations. Thus, these transformations give the appearance of false score precision—a precision that does not exist.One could argue that putting all scores on the same scale is convenient, and any ensuing false precision that results is a minimal price to pay for the convenience. That argument may be plausible if no high-stakes decisions were associated with the scores, but that is not the case with SLD diagnoses. According to the DD/C criteria, a score <90 Admittedly, the DD/C developers do not always make hard distinctions between score values. For example, they wrote “sole reliance on standard scores and cut points should be avoided in any diagnostic approach to determining disability, particularly SLD”  (p. 124)exploratory, with the goals of hypothesis generation and pattern detection [We suspect that DD/C developers’ answer to this question would be something along the lines of: it depends on the evaluator’s clinical judgment, e.g.,  (p. 406)etection . The prietection .Our understanding of the DD/C process is that the developers used an exploratory philosophy, but believe the resulting information allows for confirmatory conclusions. For example, Flanagan et al.  stated tScores are exchangeable when they measure the same attribute and are expressed in the exact same unit . ConceptFlanagan et al.  argued tFloyd et al.  examineddifferent reasons than students who do not meet the diagnostic criteria [Functionally, a major assumption of all discrepancy frameworks—both IAD and PSW—is that individuals who have academic difficulties and meet the discrepancy criteria are qualitatively different from those individuals who have academic difficulties but do not meet the discrepancy criteria. That is, students who meet diagnostic criteria for SLD using IQ test scores have poor academic achievement for criteria .Two meta-analyses have been published summarizing research as it relates to this assumption for SLD in reading ,101. BotA related assumption is that certain IQ and achievement test score patterns only, or mostly, occur in the presence of SLD. Otherwise, these PSW would not be a marker for SLD. Little research has been done investigating this assumption, but what has been done indicates that it is not uncommon to exhibit a PSW in IQ and academic achievement test scores. For example, using a nationally representative sample of over 7000 individuals who were given the same IQ and achievement tests, Stafford  found thThe DD/C method has been around for over a decade in one form or another. However, there are only a few published experimental studies of it. The experimental studies that have been published—especially by individuals without CoIs—have shown problems with the method. Specifically, it lacks sensitivity in identifying individuals with an SLD.Miciak et al.  examinedStuebing et al.  simulateKranzler et al.  examinedFlanagan and Schneider  raised aAnother criticism Flanagan and Schneider  raised wThe DD/C method requires using the X-BASS software ,108. TheGc has the same weight in contributing to the FCC regardless of the subtests a clinician used to assess Gc? Or do the weights vary by the subtests used? In either case, how does subtest selection influence the predictive ability of the FCC? As another example, Flanagan et al. [The X-BASS software ostensibly provides users with a rigorous method for determining strengths and weaknesses associated with the DD/C model, but it has never undergone peer review so little is known about it. For example, it is unclear exactly how the FCC is calculated. Alfonso  noted itn et al.  (pp. 377These are the types of questions that need to be answered to vet the software thoroughly . Until sEvidence-based assessment (EBA) as an approach to clinical evaluation that uses research and theory to guide the assessment process . SpecifiBased on the evidence presented in this article, the DD/C method does not appear to aid clinicians in making accurate decisions about SLD. Specifically, the criteria appear to be problematic because they are not sensitive to distinguishing between those who have low achievement but not SLD versus those with a low achievement test score and SLD. Thus, the DD/C method does not appear to meet the first criterion for EBA.at least 14 subtests, which can take many hours. Moreover, if the two subtests that assess the same broad ability happen to be discrepant, an additional subtest needs to be administered, which adds additional time. Thus, the DD/C does not appear to meet the second criterion for EBA.Since the DD/C method requires gathering multiple scores from IQ tests—in addition to the myriad of other data required to make decisions related to exclusionary factors—using DD/C increases the time and financial costs associated with the SLD identification process ,112. ForThe third criterion for EBA—the impact the assessment has on clinical outcomes for the individuals being assessed—is essentially a question of treatment utility. That is, do the score patterns from IQ tests aid in developing academic interventions ? There hConsequently, since DD/C does not meet any of the criteria for EBA, we believe that it cannot currently be classified as an evidence-based method for identifying SLD. Consequently, DD/C likely does not qualify at this time as an “other alternative research-based procedure” for identifying SLD via IDEA. Although the criteria for a SLD identification procedure being “research-based” are not specified in the IDEA regulations, it is difficult to imagine any set of scientific criteria under which DD/C would currently be found acceptable given: (a) its untenable assumptions, (b) the lack of experimental studies supporting its use, and (c) the experimental literature not supporting its use.In this article, we described the DD/C method for identifying an SLD. Although PSW methods in general, and DD/C methods in particular, are often described by their proponents as something new and revolutionary, this is not the case. These methods have been articulated in the professional literature for decades and prominent assessment scholars regard them as a reissuing of cognitive profile analysis that have long been regarded as problematic . In spitalchemist’s fantasy—where advocates seem to believe that the powers of clinical intuition enable them to transform questionable practices into clinical gold. We were unable to locate any compelling research evidence linking use of the DD/C method with increased diagnostic precision or developing/implementing viable positive educational outcomes—a situation even PSW proponents now acknowledge [Although our understanding of these matters remains is far from certain, almost every study that has directly assessed the potential diagnostic utility of the DD/C method has furnished evidence that it is not very useful for identifying individuals with SLD. Nevertheless, the method continues to be disseminated widely in questionable publications  and profnowledge . Insteadnowledge  (p. 134)misuse as “wrong or improper use; misapplication; an instance of this” [The Oxford English Dictionary defines of this” . Based oof this” ,124. Usi


Healthy diet remains the primary means to prevent chronic diseases among those with prediabetes. We conducted a mixed methods study, consisting of a cross-sectional survey and in-depth interviews to assess factors associated with fulfilling the healthy plate recommendation, and to explore reasons for the behaviour among primary care patients with prediabetes in Singapore. The prevalence of meeting the recommendation was 57.3%. This was positively associated with being married and negatively associated with being Malay, frequency of eating out weekly and frequency of deep-fried food consumption weekly. The recurrent themes for not meeting the recommendation included family influence, perception of healthy food being not tasty, lack of skills to prepare or choose healthy food, difficulty in finding healthier options when eating out, and healthy food being costly. The recurrent themes for meeting the recommendation included family influence, self-discipline, fear of disease complications, education by healthcare professionals, mass media influence and health promotion campaigns. Much more remains to be done to promote healthy eating among these patients. There were different levels of facilitators and barriers to healthy eating. Apart from the individual and interpersonal levels, practitioners and policy makers need to work together to address the organisational, community and policy barriers to healthy eating. Prediabetes (intermediate hyperglycaemia) is a high-risk state for diabetes that is defined by glycaemic parameters that are higher than normal, but lower than diabetes thresholds . In indiLifestyle modification remains the primary means to prevent diabetes and cardiovascular diseases among those with prediabetes . Other tWhile studies have been conducted to investigate the prevalence and correlates of healthy diet in those with prediabetes, gaps still exist in at least 4 areas ,12,13,14The burden of prediabetes and diabetes is high in Singapore with a multi-ethnic distribution . Malays We used the mixed methods approach, comprising a cross-sectional survey (quantitative phase) followed by in-depth interviews (IDIs) . The explanatory sequential design was used where the first phase involved the collection and analysis of quantitative data, while the subsequent qualitative phase built on these results and explained why they occurred. Based on the quantitative results where participants were categorised according to whether they met My Healthy Plate recommendation, qualitative interviews were conducted sequentially to explore facilitators and barriers for the behaviour in more detail. The purpose of IDIs was to explore the participant’s perspective on the research topic. The participant was considered the expert and the interviewer regarded as the learner. The aim of interview was to learn everything the participant could share about the research topic from his or her world view to gain insights and to better understand the target group .The cross-sectional survey took place in 8 out of 20 polyclinics in Singapore between July 2017 to January 2018. Polyclinics are public healthcare institutions which house primary care doctors and other healthcare professionals such as nurses and dietitians to provide primary care services. They manage about half of the patient population with chronic illness in Singapore . At the The inclusion criteria for participants of the survey were (i) community-dwelling patients with prediabetes who were Singapore citizens or Singapore Permanent Residents, aged 21 to 79 years, (ii) diagnosis verified by oral glucose tolerance test (OGTT) and diagnosis code, and (iii) currently following up at any one of the 8 polyclinics. At the time of the study, participants who had progressed to diabetes or converted back to normoglycemia based on the last laboratory test and diagnosis code were excluded. The sampling frame came from the polyclinic headquarter database where patients with a diagnosis code of “impaired fasting glycaemia (IFG)” or “impaired glucose tolerance (IGT)” without “diabetes mellitus” were identified. For IFG, the fasting plasma glucose at the point of diagnosis must be 6.1 to 6.9 mmol/L and the 2-hour post OGTT plasma glucose < 7.8 mmol/L. For IGT, the fasting plasma glucose must be 6.1 to 6.9 mmol/L and the 2-hour post OGTT plasma glucose 7.8 to < 11.1 mmol/L. These definitions were consistent with that of the World Health Organisation . ParticiTo detect a prevalence of 60% who reported not meeting the recommendation, with precision of 5% and CI of 95%, would give an estimated minimum sample size of 283. Accounting for a 70% response rate, we aimed to recruit 400 participants for the survey.For each participant, the questionnaire was self-administered, with the recruiter being nearby to provide clarification if required. The questionnaire was available in English , MandariThe variable assessed was whether participants reported meeting My Healthy Plate (version of MyPlate in Singapore) recommendation. According to the 2015–2020 Dietary Guidelines for Americans, MyPlate recommendation consists of 5 food groups . Half ofBefore the study, we reviewed the literature to select the possible factors that could contribute to differences in meeting My Healthy Plate recommendation. These could be broadly categorised into 3 main groups, sociodemographic factors, medical history and dietary habits. Sociodemographic factors included sex, ethnicity, marital status, education level, housing type, current work status and age. Medical history, and dietary habits such as frequency of breakfast, main meals, snacks, eating out, deep-fried food and sweet dessert consumption were also assessed. p < 0.10 were selected for multivariable analysis. A backward stepwise approach was performed to obtain the adjusted PR (aPR) and 95% CI, where only variables with p ≤ 0.05 were included in the final model. For clinical relevance of findings, we reviewed the literature a priori to select the possible sociodemographic, medical and dietary habit factors that could contribute to differences in meeting the recommendation. This also helped to inform the independent variables that were assessed in We obtained the prevalence of participants who reported meeting the recommendation. Those on special diet were excluded from subsequent statistical analysis. Bivariate analysis between meeting the recommendation and each independent variable were carried out. Categorical variables were compared using chi-square test, ordinal variables with the Mann–Whitney U test and continuous variables with the independent-samples t test. We then evaluated the association between meeting the recommendation with each variable using mixed effects Poisson regression model, accounting for clustering by polyclinic venue, to obtain the crude prevalence ratio (PR) and 95% CI. Poisson rather than logistic regression was used as the prevalence of those meeting the recommendation was common (>10% of the study population) . We consOf the 433 participants who took the survey, 48 underwent IDIs at the National University of Singapore from September 2017 to April 2018. Participants were asked to indicate in the survey questionnaire whether they were keen for the IDIs. Maximum variation sampling strategy was then used to recruit a purposive sample from diverse backgrounds, based on the criteria of sex and whether they reported meeting the recommendation. A priori to recruitment, 4 matrices based on these criteria was created . Participants who had expressed their interest earlier and fulfilled the criteria for each of these matrices were contacted for the IDIs. The interview was conducted using either one of the two topic guides depending on whether they reported meeting the recommendation using the SEM as a framework. This was available in English, Mandarin and Malay, and were pilot-tested before study commencement to ensure coherence and flow of questions. The guide consisted of open-ended questions according to the SEM from individual, interpersonal, organisational, community and policy levels to explore and better understand the participants’ reasons for their behaviour. The interview was conducted in the participant’s preferred language and was audio recorded with consent. All interviews were conducted by the first and seventh authors to ensure consistency. Duration lasted from 30 minutes to an hour. Data saturation was reached.The interviews were transcribed verbatim and checked for accuracy against the recordings. Interviews in Mandarin and Malay were translated into English before transcription. These were then imported into NVivo 11.0 and coded line-by-line. The first and seventh authors coded and analysed the data in parallel, independently. We carried out thematic data analysis. This involved reading and re-reading through the transcripts to identify the initial codes. These were then collated into potential subthemes and themes. Several meetings were held to review, define and name the subthemes and themes guided by the SEM. Any discrepancy was resolved by group discussion involving all team members. The study was approved by the National Healthcare Group Domain Specific Review Board . We obtained written consent from all the participants of this study. A total of 433 out of 948 approached were recruited, giving a participation rate of 66.8% for the survey. The main reasons given for non-participation were “busy” and “not interested”. Participants mirrored the total NHG Polyclinic patient pool with prediabetes in sex, marital status and age except for ethnicity. There was a higher proportion of those with other ethnicities in the total NHG Polyclinic patient pool with prediabetes (3.5%) compared to the study sample (1.2%). Out of the 433 participants, 248 (57.3%) reported meeting My Healthy Plate recommendation, 175 (40.4%) did not report meeting the recommendation and 10 (2.3%) were on special diet. Of note, 53.2% of the participants ate out at least 4 times weekly. “I have some knowledge on these diseases. Hypertension, diabetes, kidney problems, generally I know. Unhealthy diet is the main risk factor for these diseases. I know, so I try to avoid and prevent.” . Participants also had the skills on healthy eating such as how to choose healthy food, “Like coffeeshop, you need to see whether you know how to find healthy food. For example, like the mixed-vegetables stall, try to choose the steamed fish and the vegetables. Don’t eat the vegetables that are stir-fried till oily. Eat the steamed ones, like those cabbage that are cooked with water, that’s healthier compared to the stir-fried ones.”  and how to prepare healthy food, “Hmm, yes, I can do my salad. I know how to prepare my salad in a healthy way, with different vegetables and fruits, and with minimal seasoning and sauce.” . At the intrapersonal level, participants reported meeting the recommendation as they had knowledge on how diet could affect health, “I’m a very disciplined person. You can bring me to a buffet lunch or dinner. I don’t eat like everybody else, grab everything you see. I’ll exert self-control and just eat what is healthy, like the vegetables and fruits, rather than the meat.” . For others, it was to fulfil their personal priorities and concerns. Work was one such example, “One aspect is the need to work. If I am healthy, I can take care of myself and continue to work.” .Other participants attributed this to self-discipline, “...my children will say ‘mom that’s salty, don’t eat’ or you know, they will say ‘this is too fat, don’t eat’, you know what I mean? They will remind me and keep a look-out on my diet.”  or through education by family, “Like if I buy certain things, my eldest son will teach me to read the food label and tell me, this is not good, artificial, a lot of additives. So, it’s more or less indirectly encouraging me to buy better quality food, more healthy food.” . For some, the family prepared healthy food, particularly the wife or mother in the household. This was highlighted by male participants who were married, “My wife knows that it is very important for the family to avoid unhealthy food, so I do not need to tell her what to do […] leave it to her. She goes to the wet market or supermarket to buy the more healthy grocery and uses them to prepare our meals.” . For others, their family members’ experience of disease motivated them, “Because I don’t want to end up like my parents, you know, they have high blood, high cholesterol, high sugar. That is why I must control my diet, it is very sad to see how they suffer from these diseases.” . The main recurrent themes were observed at the interpersonal level where family influence from spouse and children played an important role in meeting the recommendation. This could be in the form of reminder cues from family, “The doctor from the polyclinic gives me advice on the percentage of various food that should be on the plate. Like carbohydrate one-quarter, with half a plate of vegetable and fruits and the other quarter is protein. This information is very useful, and I have been doing it since then.” . For others, a conducive work environment facilitated them to meet the recommendation, such as their workplace providing healthier eating options, “I always eat at my workplace canteen because they serve brown rice. They also have the more healthy options there.” . At the institutional/organisation level, participants reported meeting the recommendation because of influence from healthcare professionals in polyclinics and hospitals, “The notices in the neighbourhood on living healthy, like those encouraging you to pick up healthy eating are very useful, particularly when you are eating outside. They serve as reminders to me.” . For others, it was the influence from community health talks, “Because I attend this community health talk, diabetes talk which also teaches you the type of food you are supposed to eat, the healthy plate.” . At the community level, there was the influence of health information in the neighbourhood, “I don’t want to fall sick, I don’t want to see doctors so often, so I have to take care of my health. Healthcare cost in Singapore is still too high despite the various subsidies, every time I see a doctor, still have to fork out a certain sum of money, so have to stay healthy by controlling my diet.” . For some, it was due to the influence from mass media, “Hmm sometimes television programmes. Now they got very interesting programmes, teach you how to cook healthy. Like that Body SOS, Channel 8, that one.” . For others, it was due to influence from the national healthy eating promotion programmes, “I think the Health Promotion Board has always been promoting healthy living, healthy eating, there was one time when I went for the roadshow and got to be educated on what I am supposed to eat, and what I am not supposed to eat. Then I follow.” .At the societal/policy level, participants reported meeting the recommendation to avoid high healthcare cost, “Because we feel it is really difficult to take the brown rice. Brown rice feels coarser than white rice, it just doesn’t taste good.”  or they could not resist the temptation of unhealthy food, “When we think about the food, we can’t overcome the temptation and so we will give in and eat it. For example, fried food like chicken wings and fast food like burgers, it is just too nice and tempting for me. I just have to take them regularly. If not, I feel something is missing.” . Other participants lacked the knowledge on healthy food, “No, I don’t know what constitutes a healthy diet, I will just eat whatever I like.” . Yet others lacked the skills to choose healthy food, “I don’t know which one to choose for the vegetables and fruits, which one is healthy, which one not so, which one is suitable for me who have prediabetes.”  or to prepare healthy food, “Because my cooking is all standard, you add the oil, the salt, and the sauce. But if you ask me to cook healthy food, like reduce the oil, reduce the salt, don’t use the sauce, then I don’t know how to cook already. Also, I have been cooking white rice all my life, now you tell me change to brown or red rice, I don’t know how to cook, how to make it tasty like white rice.” . There were also barriers pertaining to vegetables such as they were easily perishable, “So, vegetables cannot put in the fridge you see, very fast will spoil. So, I seldom want to prepare and cook vegetables.”  or they did not like the way vegetable were prepared when eating out, “It is difficult to get vegetables cooked the way which I like outside. I like my vegetables to be cooked at home.” .At the intrapersonal level, participants did not report meeting the recommendation as they perceived that healthy food was not tasty, “When I eat at home, I eat whatever my wife cooks, when I come home from work, the food is already cooked so I just eat it. I also cannot control what she cooks, because at home she will decide what to buy and what to cook.” . For some, they need to accommodate other family members, “For health reason, brown rice is better, but no choice, if you put brown rice then it is only for me to eat. My children all don’t eat, my wife doesn’t eat.” . For others, it was the family norm of eating unhealthily, “My whole family eats white rice since young, it has become a habit, a culture in us. Now say change to brown rice, not easy, it takes time for us to adjust to the new taste of brown rice.” . The influence of friends was important for some, “…because you have to maintain your social life. You cannot say to your friends, I cannot eat, I only take healthy food nowadays, that’s anti-social and unfriendly.” .The main recurrent themes were observed at the interpersonal level where family influence played an important role in not meeting the recommendation. Participants expressed that they had no control over food choices at home, “There is only white rice available at the workplace canteen, and you don’t find any brown rice or wholegrain. So, I have to eat white rice.” . At the community level, participants experienced barriers pertaining to community-based programmes, including their not being time-friendly, “Sometimes I want to join some activities at the community centre, like for example there was one on healthy diet, but it was in the morning like 9am and it’s our working hours.” . The cultural food norm was important for some, particularly the Malays, “Malay food like beef rendang, nasi lemak, biryani, curry chicken, these are usually found in our family gatherings, festival occasion gatherings and wedding banquets. We also eat these at home too. These foods are usually deep-fried and prepared with coconut milk, if not lots of sauces and gravy. I seldom see vegetables or fruits being taken with these foods. Even if there are, it will not fulfil the healthy plate requirement because the rice and meat will take up almost the whole plate.” . For others, the social eating norm was highlighted, particularly among the Malays, “We also have a lot of family and friends gathering, festive gatherings and wedding banquets to attend. In these occasions, it is very difficult to eat healthily because everyone will be taking the white rice, curry, the food cooked with coconut milk. It is standard for us to eat these. This is a part of us since we all like to eat these not only at the gatherings, but also at home. It is very weird for anyone to ask for brown rice or healthier food options in these gatherings, it would also appear that you are not part of the community.” . At the institutional/organisation level, participants did not report meeting the recommendation because their workplace did not provide healthier food options, “Yes, the price of healthy choice is a form of deincentivisation to consumers [...], you choose to eat healthily, but you are penalised by the price…” . Others faced barriers, such as difficulty in finding healthier options, “I mean, most of the hawker stalls, what they offer is minimum in vegetables. You also don’t see stalls that sell fruits or salads. Most of the food they offer is high in carbo and some protein. The fibre in hawker food is usually not enough.” , and small vegetable serving sizes, “Like I say, you eat outside, you order the vegetables, they give so little. Then most of the food that you order from the hawker centre or coffeeshop also do not come with vegetables.” . The temptation of food advertisements in the mass media was highlighted by some, “There are a lot of advertisements on food, a lot of promotion especially fast food on TV, then a lot of nice photos […] these are tempting to the public. So being human, once you are hungry, you will be tempted, and you will lose your motivation.” .At the societal/policy level, participants found healthy food to be costly, Close to 3 in 5 primary care patients with prediabetes reported meeting My Healthy Plate recommendation. This was more prevalent among those who were married, and less prevalent among those who were Malays, those who ate out more often weekly, and those with more frequent deep-fried food consumption weekly. Facilitators and barriers to healthy eating were found at multiple levels, with family influence as a major recurrent theme. Our proportion (57.3%) was at the higher end of the range compared to other studies where the prevalence of healthy diet varied from 23.5% to 59.0% ,11,35,36Married individuals were more likely to report meeting the recommendation compared to those who were single. The IDIs suggested that this could be due to family influence, particularly spousal influence; it was usually the wife in the household who decided on the groceries to buy and the food to be served during mealtimes. Previous research in the West also found that spouses played an influential role in their partners’ health behaviours, particularly for dietary behaviour . In the Compared to the Chinese, Malays reported a lower prevalence of meeting My Healthy Plate recommendation. The IDIs suggested that cultural food norms and social eating norms would impact healthy eating in the Malay community. Abdullah and colleagues reported that Malay adolescents had significantly greater preference for local-based and Western-based food patterns, whereas Chinese adolescents had higher preference for a healthy-based food pattern in Malaysia . Local-bMeeting the recommendation was negatively associated with those who ate out more often weekly. Consistent with a systematic review, eating outside of the home was associated with a higher total energy intake and energy contribution from fat in the daily diet . Two larOur findings indicated that healthy eating is complex. Future interventions should not only consider intrapersonal and interpersonal influences when aiming to promote healthy eating among this group, but also need to target the organisational, community and policy environments. This means that nutrition promotion strategies for the Asia Pacific region should focus at multiple levels of influence that broadens options for interventions. Policy and environmental changes could potentially benefit a wider population, in contrast to interventions that reach only individuals who choose to participate . In addiThis study has some limitations. Firstly, during the qualitative phase, we did not show the transcript to the participants to confirm whether their responses had been accurately documented. However, the interviewers mitigated this by regularly paraphrasing and “checking back” with the participants to ascertain the veracity of their responses. Secondly, there was sole reliance on self-reported data of which social desirability bias could not be excluded. To prevent survey fatigue and to ensure reasonable participation, we chose a more subjective shorter measurement rather than the food frequency questionnaire (FFQ) or the Healthy Dietary Index questionnaire. Although steps were taken to reduce the social desirability bias as described in the Despite the limitations, there were various strengths. This was one of the very few studies to adopt a mixed methods approach in understanding the correlates, facilitators and barriers related to meeting My Healthy Plate recommendation among primary care patients who were at high risk of diabetes. The mixed methods approach enabled triangulation as some of the correlates in the quantitative analysis were also recurrent themes in the qualitative analysis. The IDI findings helped us to better understand the correlates of meeting My Healthy Plate recommendation in the study population. Data saturation was also reached for the qualitative analysis. Although the study sample was not generalisable to all Singapore individuals with prediabetes, it largely mirrored the total NHG Polyclinic patient pool with prediabetes. Much more remains to be done to promote healthy eating among primary care patients with prediabetes seeking care from NHG Polyclinics in Singapore. There were different levels of facilitators and barriers to healthy eating, with family influence as a major recurrent theme. Apart from the individual and interpersonal levels, practitioners and policy makers need to work together to address the organisational, community and policy barriers to healthy eating.


Inappropriate use of antibiotics is a worldwide issue. In order to help public health institutions and each particular physician to change patterns of consumption among patients, it is important to understand better the reasons why people accept to take or refuse to take the antibiotic drugs. This study explored the motives people give for taking or refusing to take antibiotics.Four hundred eighteen adults filled out a 60-item questionnaire that consisted of assertions referring to reasons for which the person had taken antibiotics in the past and a 70-item questionnaire that listed reasons for which the person had sometimes refused to take antibiotics.Appropriate Prescription, Protective Device, Enjoyment , Others’ Pressure, Work Imperative, and Personal Autonomy. A four-factor structure of motives not to take antibiotics was found: Secondary Gain (through prolonged illness), Bacterial Resistance, Self-defense (the body is able to defend itself) and Lack of trust. Scores on these factors were related to participants’ demographics and previous experience with antibiotics.A six-factor structure of motives to take antibiotics was found: Although people are generally willing to follow their physician’s prescription of antibiotics, a notable proportion of them report adopting behaviors that are beneficial to micro-organisms and, as a result, potentially detrimental to humans.The online version of this article (10.1186/s12889-019-6834-x) contains supplementary material, which is available to authorized users. Antibiotics consumption is on the rise in most countries, especially in countries forming the BRICS  group . InapproPrescription by a physician is certainly not the only reason to take antibiotics: Patients consume many over-the-counter pharmacological substances, and antibiotics are just one of them. In France, antibiotics are available only on a physician’s prescription, but they may be borrowed from family members or they can be bought on the Internet. The reasons for antibiotic use by patients have, until now, not been examined in a systematic way. Studies about patients’ expectations regarding antibiotic prescription converge on the view that physicians tend to overestimate patients’ expectations , 7. StudAlthough instructive, these studies do not tell much regarding the psychological motives that govern patients’ behaviors regarding antibiotics use. As shown in previous studies on patient’s motives for attending or refusing to attend health centers  for undeThe participants were a convenience sample of adults enrolled during daylight hours by two trained research assistants. Participants were approached in different public areas of Toulouse, France . Seven hundred fifty persons were approached, and 418 (56%) agreed to participate. All the participants who agreed to take part in the study had been prescribed antibiotics in the past by their physician. Most of the time, they have decided to take them but sometimes, they have decided not to take them or to discontinue the treatment. All participants provided informed consent. Their demographic characteristics are shown in Table Two separate questionnaires were created (a) a 60-item questionnaire listing reasons for which the person has taken antibiotics in the past, and (b) a 70-item questionnaire listing reasons for which the person has sometimes refused to take antibiotics. A list of 100 items was created on the basis of previous literature on antibiotics consumption , 21–23 aThe common wording of all items – “One of the reasons why I have been led to take (to refuse to take) antibiotics was” – was chosen to reflect the fact that several motives can be operating at the same time or at different times for the same person . A 15-poParticipants answered individually in a quiet room. Half of the participants were presented with the reason-to-take-antibiotics items first and then with the reason-to-refuse items. The other participants were presented with the items in the reverse order. The questionnaires took approximately 50 min to complete. Then, participants were presented with a questionnaire regarding their demographics and personal experience with antibiotics. The research adhered to the legal requirements of the study country: informed consent was obtained and participants’ anonymity was respected.Mean scores of the reason-to-take items and of the reason-not-to-take items were computed. Two separate exploratory factor analyses were conducted, one on each set of items. They showed that 24 reason-to-take items and 34 reason-not-to-take items did not load (correlation < .30) on any factor or loaded on more than one factor. They were removed from the analyses, and a second set of factor analyses was conducted. Six interpretable factors (68% of the variance) with eigen-values ranging from 1.11 to 14.43 were observed in the reason-to-take condition, and four interpretable factors (66% of the variance) with eigen-values ranging from 1.45 to 14.88 were observed in the reason-not-to-take condition. Varimax rotations were performed. Ten mean factor scores were computed. A series of forward linear stepwise regression analyses was conducted with the demographic characteristics as the independent variables and the ten scores as the dependent variables.One hundred and forty seven males and 271 females aged 18–85 years participated in the study. The mean scores of the reason-to-take items ranged from 2.21 to 9.75 (out of 15). Main results of the first exploratory factor analysis are shown in Table Appropriate prescription since it loaded on items expressing the idea that antibiotics were prescribed by a qualified physician and that this prescription looked reasonable to the participants’ eyes. The mean of the four items with the highest loadings was 8.46--SD (standard deviation) = 4.89--, the highest value observed. The second factor—Protective device (11% of the variance)—expressed the idea that antibiotics can protect the body from bacterial invasion, M (mean) = 5.78, SD = 3.71. The third factor—Enjoyment (11%)—expressed the idea that antibiotics were considered as a quick fix allowing someone to go out and celebrate the week-end as usual . The fourth factor—Others’ pressure (10%)—expressed the idea that antibiotics were taken mainly in order to reassure close relatives . The fifth factor—Work imperative (8%)—expressed the idea that antibiotics were taken mainly to be able to achieve important work . Finally, the sixth factor—Personal autonomy (7%)—expressed the idea that through the taking of antibiotics one can shorten one’s dependence upon others .The first factor (21% of the variance) was labelled Secondary Gain since it loaded on items expressing the idea that through prolonged illness one can benefit from increased social support and one may also be able to control more easily one’s social environment . The second factor—Bacterial Resistance (14% of the variance)—expressed the idea that the irresponsible use of antibiotics may facilitate the process of bacterial resistance . The third factor—Self-defense (10%)—expressed the idea that the body was able to defend itself against the infection, in particular when it was not severe . Finally, the fourth factor—Lack of trust (8%)—expressed the idea that one may not always be fully confident in the prescriber’s competence .The mean scores of the reason-to-refuse items ranged from 2.29 to 10.61 (out of 15). Main results of the second factor analysis are shown in Table Appropriate prescription was significantly associated with gender—ß (beta) = .16--and number of children (ß = −.13). Protective device was only associated with change of treatment (ß = .18). Enjoyment was associated with age (ß = −.14), number of therapies (ß = .15) and concerns with public health issues (ß = −.10). Work imperative was associated with gender (ß = .13), number of antibiotic treatment in the past year (ß = .09) and change of treatment (ß = .13). Secondary gain was only associated with age (ß = .17). Bacterial resistance was associated with personal experience of inefficacy (ß = .15), conviction that antibiotics are in general useless (ß = .13) and expressed concerns about resistance (ß = .27). Self-defense was associated with personal experience of inefficacy (ß = .13) and expressed concerns about resistance. Finally, Lack of trust was similarly associated with personal experience of inefficacy (ß = .15) and expressed concerns about resistance (ß = .18).Table The most strongly endorsed motive to agree to take antibiotics, especially among females and patients with children, was that they had been prescribed by a physician. This reason was, however, associated with the idea that the physician’s prescription was at the same time judged appropriate and reasonable. This means that, if in general people were willing to follow the prescriber’s recommendations, they were unwilling to do so blindly.The second most strongly endorsed motive, especially among females, and among people who had experienced trouble with antibiotics in the past, was work pressure. In addition, the persons invoking this kind of motive tended more than others to take antibiotics on a regular basis. Antibiotics may thus be viewed by some people as a way to enhance performance at work.The third most strongly endorsed motive, especially among people who had experienced trouble with antibiotics, was related to the fear and suffering engendered by the infection. It is logical that people in bad health who have experienced unsuccessful treatment are willing to take, more than others (and at times to ask for), antibiotics to protect themselves; that is, to keep themselves able to be well and to perform well in their environment.Three other kinds of motives were also found, although they were less strongly endorsed than the others: close relatives’ concerns, personal autonomy, and enjoyment. The first two motives were related to family and social life but the third one is more concerning. People who more frequently than others endorsed enjoyment-type motives tended to discount the severity of bacterial resistance. They were younger and reported having taken antibiotics more than twice the past year. This suggests that a small, but not negligible segment of the sample (18%) considers that antibiotics are just consumption goods that can be freely used.The most strongly endorsed motive to refuse to take antibiotics was that one’s body was seen as not severely endangered by the infection and, as a result, would be able to defend itself successfully. This result was consistent with findings by Jonsson and Haraldsson . This kiThe second most strongly endorsed motive to refuse was directly related to concern about bacterial resistance. This result was consistent with findings by Finkelstein et al. , but thiTwo other motives to refuse antibiotics were found: (a) the presence of secondary gain associated with prolonged illness, especially among older people, and (b) lack of trust in the prescriber, especially among people who had had troubles with past treatment with antibiotics and at the same time reported behaving in a way that is paradoxical because it was potentially dangerous for themselves .The study has at least two limitations. First, motives were assessed through self-reports. Participants’ responses were, however, clearly structured: If they had consciously decided to misreport their motives, responses would have been given in a more or less random way and, as a result, no clear factor structure could have been found. Now that the complete structure of motives is known, it will be possible, in future studies, conducted in collaboration with physicians, to contact people who have recently been prescribed antibiotics, to ask them whether they have taken these antibiotics, and, using a shortened six-item (or four-item) version of the questionnaire, to assess the reasons why they have taken them (or not taken them or discontinued the treatment). Second, the sample was conducted in a single site in France. Its results must, therefore, be generalized with care to other populations in the country, namely to those who live in rural settings. In addition, the two models of motives have been issued from exploratory factor analyses. They need to be confirmed on other samples, using confirmatory factor analysis, and measurement invariance has to be assessed .Appropriate prescription, although the leading motive, was not rated as highly as could have been expected: its mean rating was located only slightly above the center of the response scale. This implies that people would be willing to take antibiotics if instructed to do so and at the same time, for example: (a) told that antibiotics will attenuate their physical suffering or (b) reassured that, owing to taking antibiotics, they will be able more quickly to achieve an important task.People are generally willing to follow their physician’s prescription of antibiotics. In our study, however, Although most people seemed to be aware that bacterial resistance was a big public health issue, a minority (about 21%) did not agree with this view, and, what is more concerning, they were mostly among those who reported that, when they are ill, they do not hesitate to use antibiotics simply in order to go out and have fun with friends. It should be explained to these people that when ill, the best they could do is to stay at home and try not to contaminate large groups of people.Although it is certainly a good thing that people sometimes are unwilling to take antibiotics, there seemed to be a gap between the wisdom or altruism of their reasons and what they reported regarding their behavior. They were aware more than others of the public health issue and also of their body’s capacity to defend itself against infections, but at the same time they also tended more than others to report behaviors that were at variance with their motives. In particular they did not hesitate to stop treatment before it had been completed; that is, to do what would facilitate mutations and adaptations in microorganisms. In fact, they seemed to be essentially acting out of previous negative personal experience with antibiotics because their statements regarding bacterial resistance as a big public health issue were more rhetorical than grounded in even minimal understanding . In othFinally, one out of five participants expressed lack of trust in physicians and treatment with antibiotics. Unfortunately, these people, more frequently than others, reported behaviors that were potentially more dangerous to themselves  than anything physicians could recommend or prescribe in these circumstances.Overall, a notable proportion of people report adopting behaviors that are more beneficial to micro-organisms than to humans and other animals; that is, behaviors that are likely to increase bacterial resistance. If taught that bacterial resistance is a planetary health concern, these people would certainly not be surprised, and a huge majority would agree. They would even be likely to report behaviors such as shortening the duration of treatment and using past-prescribed antibiotics as proofs of their good intentions. As a result, they must be taught that their behavior is counterproductive, and that their small actions have global consequences.In summary, in each instance of consultation involving prescription of antibiotics--and particularly if physicians have detected erroneous beliefs, physicians must remind patients that antibiotics help fight dangerous micro-organisms, that temporary isolation is often the best way to limit contagion, that stopping treatment before completion is exactly what helps micro-organisms to become stronger, and that inappropriate action by a minority can affect the whole human population. This information must, however, not be delivered in a confrontational way: As stressed by the promoters of motivational interviewing , motivatAdditional file 1:Questionnaire. (PDF 305 kb)


Dr. Xiaoqian Zhang  was an outstanding clinician, therapist and medical educator, a member of the Academic Divisions of the Chinese Academy of Sciences, he is considered to be the founder of the modern Chinese gastroenterology PUMCH, . As a doDr. Zhang was born on December 28, 1897, in a family of teachers, Changsha, Hunan Province. In 1914, he chose to enter Hsiang-Ya Medical College studying medicine, for he realized that “poverty” which leaned to industrial salvation was not the only contradiction at that time, the destructiveness of “disease” was as deep as it was Zhang, . Under tJournal of Clinical Investigation on progress in blood volume, which was highly appraised by peer scientists and had been widely referenced in professional literature throughout the world . During the residency period in PUMCH, because of his excellent performance, he got an opportunity to study in the Johns Hopkins Hospital for one year in 1927. Under Prof. Harrop’s supervision, he immersed in the study of human blood volume. In 1928, he published two research articles in the e Chang, . In the e Chang, . Since tAfter the “September 18th Incident”, the Japanese aggressors pressed in step by step. Dr. Zhang, who had been working in PUMCH for 13 years at that time, decided not to work under the control of the invaders. In 1937, he accepted the invitation from his alma mater and moved back to Hsiang-Ya Medical College to continue his study. Unfortunately, as the Japanese aggressors advanced southward, Hsiang-Ya could no longer survive in Changsha. Teachers and students left school one after another, and the college was deep in crisis. At the most dangerous moment, Dr. Zhang took over the role of dean and decided to move the whole college westward to Guiyang. They overcame various difficulties, taking 40 tons of teaching equipment and books with them. Students, faculty staff and their families, approximately 300 people, finally reached Guiyang in one week. In the winter of 1944, the Japanese invaded Guiyang and the college was in panic again. At that time, Dr. Zhang once again led the teachers and students to set foot on a long journey to Chongqing and continued their classes until the end of the War (Rong and Liu, After the founding of New China, Dr. Zhang, the dean of Hsiang-Ya Medical School for 11 years, was invited to return to Peking Union Medical College Hospital again to assume the rehabilitation of internal medicine. Under his inspiration, many elites from the south area and even overseas gathered at PUMCH with the same mission Fig. . He tookPUMCH has always attached great importance on clinical practice which was also what Dr. Zhang insisted on. He devoted all his life to the clinical practice of internal medicine and made many achievements in the field of internal medicine. When it comes to the diagnoses for patients, Dr. Zhang could always hit the mark when opinions varied and could recall every symptom of a patient accurately even after quite a long period which relied on his special “notes” to a great extent. He always carried a small notebook during outpatient service or ward rounds and would record everything he deemed important or doubtful Fig. . He beliIn the middle of 1960s, a female patient who would shock once catching a cold came to PUMCH. Dr. Zhang had a familiar feeling with the patient and asked about her medical history and found out that she had been hospitalized in PUMCH due to dystocia hemorrhage 30 years ago. However, the original medical records and data were completely gone because of war. After thoroughly digging into a pile of his old special “notes” and fragments of memories,he was suddenly enlightened. The original hemorrhage caused necrosis of the pituitary gland, leading to hypopituitarism, resulting in deficiencies of endocrine thyroid glands, adrenal glands and lacks in emergency response. When the patient was subjected to an emergency infection, the shock would occur. Based on this, she was diagnosed as Sheehan’s syndrome. She was given thyroid and adrenal cortex hormones as an alternative treatment, and then her condition improved quickly PUMCH, .Many of his lifelong mottoes has been praised until now like “Tread, as if on the thin ice; Walk, as if on the brink of a deep gulf” Ge, . In the Dr. Zhang was erudite in medical knowledge and clinical experience and was well known for his profound theoretical foundation, but he never slacked in the pursuit of advanced knowledge and studied sedulously during his lifetime. He spent almost every Sunday morning in the library. After cataract surgery, he wanted to read once seeing things. In case other people might stop him, he ordered a car to the library by himself regardless of his ophthalmologist’s dissuade. When he was caught by others, he laughed and said humorously, “it seems that one cannot do anything wrong but you know I haven’t read books for such a long period”. On that day, he kept reading until the closed bell rang for several times. When Dr. Zhang was already an octogenarian, his students advised him not to go to the library on Sunday. He replied, “medical science nowadays is developing so fast and I could hardly catch up with it without continued learning” PUMCH, .On August 8th, 1987, Dr. Zhang passed away in Beijing, at the age of 90. There were two regrettable things for him: one was “the Clinical Supplements” had just started; the other was his desire of continuing outpatient service until the age of 90 never came true. As what was written in “Hippocrates: The Oath of Medicine”: “In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves”. Dr. Zhang used “caution, prudence, dread and fear” as his life motto and carried out the oath all along Zhang, .He devoted all himself to save the nation via medical science; he paid close attention to people’s livelihood and regarded the patients as his “teacher” Ge, ; he was A hundred and twenty years later, Dr. Zhang’s edification, forthright admonition and his voice and expression still emerge in our mind. China has been undergoing a radical change after Dr. Zhang’s period, and PUMCH, the hospital he dedicated his whole life to, is now also heading into a new era. China has already grown up with a more advancing healthcare system and healthier people which were just the destination Dr. Zhang had been struggled for throughout his life Zhang, .