We validated the questionnaire in two pilot tests with samples of university freshmen students. The final questionnaire contains 45 items, including both multiple choice and Likert scale response formats. Cronbach alpha showed good reliability for each section of the questionnaire. In conclusion, the PUGGS questionnaire is a reliable tool for investigating public understanding and attitudes towards modern genetics and genomic-based technologies.In this paper we present the development and validation a comprehensive questionnaire to assess college students’ knowledge about modern genetics and genomics, their belief in genetic determinism, and their attitudes towards applications of modern genetics and genomic-based technologies. Written in everyday language with minimal jargon, the Public Understanding and Attitudes towards Genetics and Genomics (PUGGS) questionnaire is intended for use in research on science education and public understanding of science, as a means to investigate relationships between knowledge, determinism and attitudes about modern genetics, which are to date little understood. We developed a set of core ideas and initial items from reviewing the scientific literature on genetics and previous studies on public and student knowledge and attitudes about genetics. Seventeen international experts from different fields ( The underlying motivation for developing the Public Understanding and Attitudes towards Genetics and Genomics (PUGGS) questionnaire is to facilitate investigation into the relationship between three key elements: belief in genetic determinism, knowledge of modern genetics, and attitudes towards modern genetics and genomic-based technologies. As we use the expression here, “modern genetics” encompasses advances in genetics and related areas over the past twenty years, including genomics and genomic-based technologies such as pharmacogenomics and new cancer therapies. Modern genetics and genomics adopt a more systemic understanding of genes and their functioning within cells than earlier genetics, conceiving environmental and epigenetic factors as playing an important role in the development of traits and diseases , 2, althIt is important to clarify from the very start how we understand the word ‘belief’ in our study. Belief is the state of mind in which a person thinks something to be the case, with or without there being convincing reasons that something is the case with factual certainty . In scieAnother concept that seems important to explain is ‘understanding’, which we take to mean making sense of a certain idea by connecting it with other ideas we already know, making it intelligible in this manner .Research over the past twenty-five years has shown there is a small positive link between knowledge and attitudes in science in general , 13. HowAt the same time, studies within genetics education and public understanding of genetics persistently show that the public and, more specifically students, have rather low knowledge of genetics. Genetic deterministic views about the nature of genes, behavior and biological traits have been found among students, teachers, textbooks, and the public –22. GeneDespite the low knowledge level, opinion polls indicate that the public are generally positive towards genetic applications where there are clear medical benefits, such as genetic testing for diagnosis and treatment of disease , 24, 25.Overall, the relationship between determinism, knowledge and attitudes about genetics is unclear. Most of the previous studies have focused either on genetic literacy (knowledge), or on attitudes towards genetics, and often on narrow aspects of genetics or genomics. As far as we can tell, there are no questionnaire instruments currently available that, in a single instrument, address all the three issues: (i) belief in genetic determinism, (ii) knowledge of modern genetics and genomics, and (iii) attitudes towards modern genetics and genomic-based technologies. We have therefore developed the PUGGS questionnaire in order to facilitate further investigation into the relationships between knowledge, genetic determinism and attitudes towards modern genetics and genomics. We report here how we built and validated this questionnaire as a reliable tool to investigate those relationships. The PUGGS questionnaire can be used, for example, to find out to what extent the public knowledge reflects perspectives on genetic determinism, and whether this in turn influences their knowledge and attitudes towards applications of modern genetics and genomics.Deterministic understandings of genetics typically focus on a one-to-one relationship between genes, proteins, functions, and traits, as if particular traits or diseases were generally related to a single gene. Genetic determinism is often implied in common expressions such as “the gene for intelligence”, and ignores the influence of environmental and epigenetic factors , 26. NevWhat is at stake is that the deterministic gene is an instrumental concept that has predictive power and plays an important role in some explanations in genetics and molecular biology, but cannot be conflated with the molecular gene , which iIn the last two decades, however, research in genetics has evolved into genomics and our understanding of genes and genomes and how they relate to development, phenotypic traits, cell physiology, among other features, has radically changed , 37–40. Genetic science now tells us that, despite the usefulness of the deterministic gene as an instrumental concept in some explanatory tasks, in realistic terms it is not possible for any trait—even so-called “single-gene disorders”–to be determined by genes only, due to the influence of epigenetic and environmental factors , 2, 42. Despite the progress of genetics as a research field, the developments in scientific understanding seem not to have reached the public: genetic deterministic beliefs still prevail to a great extent, according to the literature , 43–45. Studies of mass media portrayals of genetics also generally indicate a predominant discourse of determinism , 32, 45.Studies on how genetics is taught in schools generally indicate that the predominant mode of genetics instruction, as well as the content of genetics textbooks, prime students to think deterministically , 52, 53.Students in high school find genetics particularly challenging to learn because it requires reasoning across multiple organizational levels: between genes, proteins, cells, tissues, and organs , 57. StuThe concept of attitudes has been borrowed from the social psychology field into other areas such as public understanding of science and science education research. Fazio  gives a Whilst public knowledge about modern genetics seems to be low, studies on public attitudes towards genetics and gene technologies indicate that the public are generally positive towards genetic applications, particularly if there are clear medical benefits , 24, 25.Very few studies have investigated the possible links between attitudes towards genetics and belief in genetic determinism and/or genetic knowledge. A study about attitudes towards genetic testing among the Dutch public found no association between people’s attitudes towards genetic testing and their level of genetic knowledge or belief in genetic determinism . A studyWithin genetics education, several questionnaire instruments have been developed for testing students’ genetic literacy—particularly among university students. Smith, Wood and Knight  developeScales for measuring belief in genetic determinism have been developed, for the most part, in studies relating genetic determinism to sociopolitical issues such as social prejudice and psychology, racism, sexism and genetic discrimination , 34–36. The majority of determinism items have been measured using a Likert scale . However, an Australian study by Molster et al.  used a dIn turn, most of the studies in public attitudes towards genetics have been conducted using large opinion polls looking at biotechnology in general, mostly in Europe and the U.S. –67, but Whilst there are clearly many questionnaires already available, each looking at specific issues or areas of modern genetics and its applications, some testing knowledge and others testing attitudes, there is a need for a coherent instrument addressing multiple purposes. First, there is a need to develop an instrument to encompass both knowledge and attitudes about modern genetics. In that way it will be possible to investigate the still-unanswered question regarding the relationships between knowledge in genetics and attitudes towards genetic applications. Second, belief in genetic determinism has only in limited ways been included in previous instruments, and mostly in the context of socio-political and ethical issues such as racism and sexism. Therefore, we aimed at developing an instrument that, in a more context-independent way, investigates the level of genetic deterministic beliefs. Third, modern genetics and genomics have changed rapidly during the last decade, and, thus, there is a need for an instrument that covers a range of topics that have recently become quite relevant, such as, for instance, epigenetics. Based on these three gaps we have developed the PUGGS questionnaire in order to make it possible to inquire, with the same instrument, if there are any relations between young adults’ knowledge of modern genetics and genomics, their attitudes towards genetic applications, and their beliefs in genetic determinism.The questionnaire was found to have high content validity and good internal consistency, which means that it can be used to give a reliable measure of belief in genetic determinism, knowledge of modern genetics and genomics, and attitudes towards applications derived from these fields.The research project has been approved by the Committee for Ethics in Research from Federal University of Bahia Nursing School, no. 1.023.782. This section describes how the questionnaire was developed and refined in response to several measures of content validity and internal consistency.The overall process of developing the PUGGS questionnaire involved the following main steps: item development, validation, and pilot testing. For the validation, we tested for content validity and internal consistency (reliability). The questionnaire was revised two times and piloted two times in response to the results of the validation. It was developed in English, translated into Portuguese, and thereafter validated with back-translation, since the pilot testing involved Brazilian students. The steps of the questionnaire development are shown in The PUGGS questionnaire consists of five sections: (1) Background information, (2) Belief in genetic determinism, (3) Knowledge about gene-environment interaction , (4) Knowledge about modern genetics and genomics, and (5) Attitudes towards applications of modern genetics and genomics , and knowledge about modern genetics and genomics (section four). These core ideas are like “knowledge benchmarks” that the science education and genetics communities consider important for high school education and general public knowledge , 71. We The core ideas about gene-environment interaction (Section 3) are about whether and how genes and environment interact in the development of phenotypic traits, which can in turn influence their degree of commitment to genetic deterministic thinking. They reflect the transition from a deterministic to a probabilistic understanding in genetics, as shown in The core ideas in modern genetics and genomics (Section 4) are divided into three sub-areas: (1) characteristics of the genome, (2) gene function and expression, and (3) epigenetics. These sub-areas represent key conceptual domains, currently deemed essential to genetics literacy , 71, as To define the core ideas, we drew heavily on several curriculum benchmarks in genetics that outline what high school students ought to know and what content should be taught , 74, on gene therapy; genetic testing; prenatal genetic diagnosis; personalized medicine and pharmacogenomics. These topics were chosen on the basis of what is considered important for the public to know about such technologies now and in the near future [The attitude section of the questionnaire (Section 5) covers four topics within modern genetic and genomic-based technologies: r future , 9. SomeIn the next step, we developed a set of questions (items) that would test the core ideas. Where it was possible to relate our core ideas and topics to existing items in other questionnaire instruments, we gave priority to these items since they had already been validated and tested. Hence, most of the items in our questionnaire are based on items that have been used in previous studies, but we have modified them in order to match our core ideas. We also used the combined expertise in genetics and genetics education of the authors to help select and refine the items. Some of the items were also developed by the authors themselves.Section two (belief in genetic determinism) consists of a task in which students were asked to indicate the relative importance of genes or environments for various traits presented in a table . For building the table of traits task, we browsed several high school biology textbooks published in Brazil, which were submitted by publishing companies to a Brazilian National Program that distributes textbooks for public high schools across the country. We searched these textbooks to find examples of traits and diseases that are commonly mentioned in genetics education, since we wanted respondents to have heard of them. The table of traits task was designed with a Likert-scale response format, from “only environmental differences contribute to the traits” to “only genetic differences contribute to the traits”. The answers were originally scored on a ten-point scale, but later reduced to a five-point scale in the revision process (see section 4.1.1. above). We assume answers to this task are based more on beliefs about genetic determinism than on knowledge.Section three (knowledge about gene-environment interaction) consists of a set of True/False/Don’t know items designed to measure deterministic understandings of genes and traits . We included a “Don’t know” option in order to uncover topics or concepts that respondents potentially have not heard of before. We consulted previous determinism scales , 61, 77,The items about modern genetics and genomics (Section 3) were largely based on items from previous questionnaires , 64 as wTo develop the attitude items, we reviewed items used in previous questionnaires about attitudes towards genetics and gene technologies , 68–70. Our initial questionnaire, used in the first pilot, had 51 items and 20 core ideas See the .We conducted two measurements of content validity: Firstly, the initial questionnaire was evaluated by a group of experts from different fields, and consequently revised. Secondly, the revised questionnaire was piloted to 207 first year university students and 19 of them were interviewed about the comprehensibility of the questions. Their responses were taken into consideration in a second revision of the questionnaire.To test the content validity of the core ideas and items, we invited international experts from a range of fields related to genetics to evaluate the initial questionnaire and the core ideas. The experts were personally invited by email; thirty-two were invited and seventeen responded and evaluated the questionnaire. Of the seventeen experts who responded, four were working as biologists or geneticists, eight were working in genetics education, four in the field of sociology of biology, and two in the history and philosophy of genetics (one of them was both geneticist and educator). In addition, four of them had extensive expertise in designing assessment instruments in science education.The experts were given a feedback sheet that they were requested to fill in, which contained the questionnaire items and the core ideas to which they were related. For the core ideas we asked: “Please indicate if you have any comments to the core ideas, for instance if you think some are unnecessary, if some should be altered, or if other core ideas related to modern genetics and genomics are missing.” For the section on Background information they were asked to comment on whether they thought some of the questions in the section should be changed in any way, and why. For the table of traits task we asked them to provide any helpful comments on the table as a whole. For the knowledge items on gene-environment interaction and on modern genetics and genomics they were asked to answer the following three questions with “yes”, “no” or “maybe” for each item: (1) Does the question test the core idea?; (2) Is this a quality question?; (3) Is it redundant? For the attitude items they were asked to answer with “yes”, “no” or “maybe” whether or not each item adequately probed for positive or negative attitudes towards the topic in question. They were also asked to provide any useful comments to any aspects of the questionnaire as a whole .In the first revision of the PUGGS questionnaire, the experts’ comments were analyzed for themes, for example, if several of the experts made similar comments to a particular item, this was especially considered. Also, items with a lot of negative feedback were particularly taken into account in the revision process, as well as the experts’ corresponding suggestions for improvements. Many of the experts provided useful comments on how the items could be improved, and some also suggested new items. The entire questionnaire and the core ideas were altered in the first revision process.During the first pilot study, the questionnaire was administered to seven different classes on different occasions. At each of these sessions, after completing the questionnaire, two or three students were asked to participate in a short 3–5 minutes interview about their comprehension of the questionnaire items. We asked them three questions: 1) Did you find any of the questions difficult to understand?; 2) Why is the question difficult?; 3) Are there any words you didn’t understand?Internal consistency  is a measure of the strength of items that occur together within respective sections or themes, to see, for example, if there is a correlation between different items that test the same idea . InternaThe internal consistency of the PUGGS questionnaire was measured in two pilot tests. The first pilot test was conducted following the first revision in response to the expert feedback. The questionnaire was then revised a second time, in response to the internal consistency results of the first pilot, as well as the response from the students’ evaluations during the interview. A second pilot test was conducted and the Cronbach alpha was measured a second time.The questionnaire was developed in British English, but needed to be translated to Brazilian Portuguese for the pilot studies because they were conducted in Brazil. One of the authors, who is a native Brazilian and also fluent in English, translated the questionnaire to Brazilian Portuguese. An independent researcher, who is a geneticist and also bilingual in Brazilian Portuguese and British English, translated the Portuguese version back to English, in a process called “back translation” . This was done in order to validate the translation. The authors then compared the back-translation with the original English version to see how similar they were. The two versions were overall very similar, but the comparison revealed some ambiguity in the meaning of a few of the items. The ambiguities were discussed amongst the translators and authors, and necessary changes were made in both the original English version and the Portuguese version. For example, the word “diet” in the original English version had to be changed to “eating habits”, otherwise the direct translation of “diet” in Portuguese would be confused with “being on a diet”.The first pilot study of the questionnaire was conducted in November 2014 in order to validate the questionnaire after the first revision. The questionnaire was administered to 207 first-year students enrolled in an Interdisciplinary Bachelor Program at a Brazilian Federal (public) university in Northeast Brazil. The majority (33%) of the students were studying humanities as their main field of study, followed by arts (25%), health sciences (22%), and science & technology (18%).We chose first-year university students because they are representative of young adult Brazilians who have completed high school. It was important that they had obtained high school education , so that they would have a level of knowledge about genetics and genomics that would allow for a more powerful study. Moreover, as we are interested in investigating attitudes toward genetic- or genomic-based technologies, Brazilian citizens who completed high school are more likely to be in the population with an income that could allow them to benefit from these technologies, given unequal access to them, and thus they are more likely to have formed some attitude towards them. Alternatively, we could have chosen students at the end of high school, but we considered that first-year university students would have almost the same amount of knowledge, and it would be easier to sample them in a single university.Our sample is representative of an “educated youth” in Brazil, and is by no means representative of all Brazilians. There may be cultural variations within a country, and the questionnaire is most likely less applicable to groups of society who are less educated, such as those who did not finish high school. However, by using freshmen students we have a population of citizens that have taken high school, which is a large proportion of young adults. In Brazil 35.9% of the population 25 years of age or more have completed high school education, according to 2010 census data, IBGE 2010) . The queThe questionnaires were administered to the students during regular classes, at the end of their first term in the university.They were asked to fill in the questionnaire whilst two of the authors of this paper were present. The questionnaire took on average 20 to 25 minutes to complete .A second pilot study was conducted after the second revision. We administered the second pilot to a new set of first-year students from the Interdisciplinary Bachelor Program at the same university, during February 2015. 78 students answered the questionnaire in the second pilot study. Of these, the majority were studying science and technology (33%) as their main field, followed by humanities (30%), health (17%), arts (15%) or other (4%). They were recruited during their enrollment, whilst they were waiting in line. We invited them to fill in the questionnaire in a separate classroom.All participants gave written informed consent before answering the questionnaire and being interviewed (the informed consent form was translated from Portuguese into English and is provided in the Psych package) . All the questionnaires with more than 8 missing answers  were eliminated from the sample. Since the calculation of the Cronbach alpha does not support missing answers, we used modal value imputation method to replace the missing data [The completed questionnaires were analyzed for internal consistency (reliability) using Cronbach alpha with the statistical packages SPSS (version 22) and R .Some very minor adjustments were made to the background information (section 1) of the questionnaire. For section two of the questionnaire (table of traits), our initial version had a list of traits and disorders where respondents were asked to mark, on a scale from 0 to 10, the relative importance of environment and genes for each trait (from 0: Environment is most important to 10: Genes are most important). Several of the experts pointed out problems with this scale, mostly because it reflected a heritability scale (0 to 100% heritability). They advised us to reduce the number of points on the scale, and to use simpler categories. We therefore reduced the scale from a 10-point to a 5-point Likert format (from 1: For section three (gene-environment interaction), the general advice from the experts was to make the items shorter, simpler, and less specific, so that detailed knowledge about specific traits or diseases would not be required from the respondents. For instance, the original item 4 read as follows: “A gene can be associated with several different traits—for example, the breast cancer gene mutation (BRCA2 gene) is associated with prostate cancer and melanoma”. In the revised version this item became: “A single gene can influence several different health problems”. On the basis of the experts’ responses, a majority of the items were modified, some were removed altogether, and some new items were added, improving content validity.The items in section 4 (Knowledge about modern genetics and genomics) and section 5 (Attitudes) received fewer critical comments by the experts, and were generally considered satisfactory.Of the nineteen students that were interviewed about their comprehension of the questionnaire items, ten said they did not understand the items on epigenetics, because they did not know what epigenetics is. We also asked them if there were any words they did not understand, and ten of the students said they had never heard of epigenetics, two said they had not heard of Tourette’s syndrome (one of the diseases in the table of traits) and one said he did not know what pharmacogenomics is. Consequently, we removed the item “Tourette’s syndrome” from the table of traits task, but we kept the items on epigenetics and pharmacogenomics, because even though students had not heard of them, they understood what these items were asking. Moreover, their knowledge on epigenetics and attitudes towards pharmacogenomics are part of the data the questionnaire intends to gather. Apart from these remarks, all the other questions were understood. Seven of the students did not report any problems at all.The results of the internal consistency of the PUGGS questionnaire after the first revision are shown in On the basis of the Cronbach alpha results, as well as the students’ feedback in the interviews, the questionnaire was revised a second time. We also explicitly attended to items with a high frequency of “don’t know” responses, and assessed whether the wording of these items were confusing, thus making them difficult to comprehend, or if the content was simply too difficult. We also used the student interviews to address these issues, since the students had the possibility to address all questions and their difficulties. We did not explicitly consider the number of correct and incorrect answers to each item during the revision process, because we felt that the students’ feedback in the interviews and the number of “don’t’ know” responses addressed the issue of item difficulty more adequately. However, in most cases the number of respondents answering “correct” on an item was lower if the item had a high amount of “don’t know” responses. Examples of this are given below.For the table of traits (section 2) we removed the items “coronary heart disease”, “haemophilia”, and “Tourette´s syndrome” because over 15% of the respondents answered “Don’t know” on these. Moreover, in the interviews two students said they had never heard of Tourette’s syndrome.e.g., diabetes, Alzheimer’s disease, personality, intelligence, either by substituting the item with a more general statement, or by substituting a specific example with a more common trait. For instance, an item on Alzheimer’s disease had the highest amount of “Don’t know” answers (36%), and only 37.2% correct answers, so we changed it from “Alzheimer’s disease is influenced by one gene only” to “A person’s height is influenced by one gene only”. The number of correct answers in the second pilot increased to 56%.The original thirteen items on gene-environment interaction (Section 3) underwent the most extensive revision, since they had the lowest estimate of reliability . In order to avoid unnecessary confusion, we removed double negatives (items with a negative statement that probed for a “disagree” answer in order to remain positive). For instance, the item “Traits and diseases caused by a single gene are not very common” was modified to “Most human traits and diseases are caused by a single gene”. This item also had 26% “Don’t know” answers and only 19.3% correct answers in the first pilot, indicating that it was difficult to understand—but this increased to 78.8% correct answers in the second pilot. We also removed potentially difficult examples in items, We also tried to improve the readability and clarity of the items in Section three by making them simpler and shorter. We deleted altogether four items that were either too complicated, or potentially misleading. This included an item on levels of biological organization, because it was too long and complicated (with 18.8% “Don’t know” answers); an item on diabetes, because it was too specific and also redundant; and two items on mutations, because they were too difficult for the intended respondents . For the remaining items the amount of “Don’t know” answers was fairly low (ranging from 0.5% to 9.7%).The Cronbach alpha in Section 4 (Modern Genetics and Genomics) was good (0.69) and it was not necessary to make many changes in the corresponding items. However, we removed two items due to potential inaccuracy: for instance, the item “Humans have about the same amount of genes as a fruit fly”. We made some minor changes in the formulation of some of the items to improve clarity, for instance by removing double negatives . Respondents frequently answered “Don’t know” to many of the items in this section. In particular, between 43% and 58% respondents answered “Don’t know” on the items on epigenetics. Despite this, we decided to keep these items since they represent newly established concepts in science and society, and answering “Don’t know” to newer concepts can give an indication as to whether people have heard about them or not. This is important in the context of this instrument since an understanding of epigenetics  could be a possible factor inhibiting genetic deterministic beliefs.In the Attitudes section, very few students answered “Don’t know” (ranging from 0% to 5.8%), indicating that they understood what was being asked in these items. This was also confirmed in the students’ interviews. Also, the overall Cronbach alpha for the Attitudes section was very good (0.85). We therefore did not change much in this section, except for some of the wording—in particular, we modified double negatives, since they are potentially confusing. For example, in the subsection of gene therapy the item “I would be worried about gene therapy being used to modify or enhance physical attributes such as athletic performance” was modified to “I think gene therapy should be used to modify or enhance physical attributes such as athletic performance”. There were also two items in the subsection on genetic testing that had double negatives and this sub-section had the lowest Cronbach alpha score (0.54) of the four attitude topics. These items were subsequently modified so that they would be easier to comprehend. Although removing these items would have had a positive effect on the Cronbach alpha for each of these subsections, we opted to modify instead of removing them because we think that the items cover important issues within genetic testing and gene therapy.We also changed some of the answer options: Since the questions on gene-environment interaction (Section 3) and modern genetics and genomics (section 4) are predominantly knowledge questions, we changed the modalities for these from a Likert to a True/False response format: In the first pilot, we used a Likert scale for all items, with the options “strongly disagree/disagree/agree/strongly agree/don’t know”. This was changed to a True/False (and “Don’t know”) format for sections 3 and 4 in the second pilot. We decided to include the “Don’t know” option because it gives valuable information about the topics and items students know less about. We removed it from the Attitudes section (Section 4), since very few students marked this option. We also decided to remove the “Don’t know” option from the table of traits task (Section 2) since this task is capturing belief in determinism, rather than pure knowledge, and therefore assume that most students can answer this task regardless of how much knowledge they have.After the questionnaire had been revised a second time, another pilot test among a new sample of students (n = 78) was conducted and the Cronbach alpha was measured a second time for the parts of the questionnaire that had undergone substantial revision (Section 3 on gene-environment interaction). The new alpha score for the items on gene-environment interaction was 0.67, which was acceptable . This inWe have developed and validated a questionnaire instrument (the PUGGS questionnaire) that can be used to test young adults’ understandings and attitudes towards modern genetics and genomics, levels of belief in genetic determinism, as well as to investigate correlations between them. To our knowledge, no such instrument currently exists, and therefore the PUGGS questionnaire fills an important gap in research on genetics education and public understanding about genetics.The instrument underwent two revisions in order to reach an acceptable measure of validity and reliability. Prior to the first revision a group of seventeen researchers from a variety of fields including genetics, genetics education, and history, philosophy, and sociology of science reviewed the proposed items and provided suggestions for improvements. This resulted in an initial revision that improved the content validity.The instrument was then piloted to 207 undergraduates in a Brazilian Federal university and the internal reliability was measured, revealing weak consistency among the items measuring gene-environment interaction (Section 3). The questionnaire therefore underwent a second revision and second pilot test (with 78 freshmen students from the same university), paying particular attention to those items measuring gene-environment interaction, but also generally improving the readability and clarity of the entire instrument. This improved the internal reliability of Section 3 to an acceptable level . The other sections already had a good measure of reliability in the first pilot  and some are more environmental . We opted for two extra categories on either side of the middle category, in order to accommodate for this variety and to allow for more interesting results . One could argue that, in reality, no traits are either “only environmental” or “only genetic”, and that these categories are therefore misleading, but we had to simplify the categories somewhat in order to measure high or low scores in beliefs in determinism.In the section measuring beliefs in genetic determinism (Section 2), students were presented with a list of common traits and asked to indicate the extent they thought genetic and environmental differences contributed to each trait, answering on a Likert response format. Our scale includes five points . A previous study by Molster et al.  had onlyOne way of using the table of traits in future analyses might be to present a chart of all the respondents’ answers, in order to visualize the responses. A possible way of analyzing the answers could be to pick out the traits that are more obviously environmental or more obviously genetic, and see how the respondents’ answers compare to a scientific interpretation or consensus. For instance, if a respondent answers “largely genetic” to “interest in fashion”  this would indicate a strong deterministic view.The set of nine questions that followed the table of traits were designed to measure the respondents’ knowledge about gene-environment interaction, as a way of obtaining additional information related to putative commitments to genetic determinism. For instance, more knowledge about the interaction between genetic and environmental factors in the development of traits would indicate less determinism. This section yielded an acceptable Cronbach alpha (0.67) after the second pilot . CompareAnother possible explanation for why genetic determinism is difficult to measure, is that perceptions of the relationship between genes and traits are not only rooted in people’s knowledge, but also in their values and social practices , making In sum, determinism scales tend to be developed in the context of particular topics, and as part of larger studies, and are probably not very reliable for use on their own. Therefore, we advise others to use items on determinism in the PUGGS questionnaire in combination with the other sections of the instrument.The overall Cronbach alpha for the section on modern genetics and genomics was 0.7 , indicatMoreover, knowledge of concepts involved in epigenetics is becoming increasingly important for understanding modern medicine, such as personalized medicine, and direct-to-consumer genetic testing. The genetics education community calls for a greater emphasis on the teaching of genomics in the high school science curriculum, with less focus on transmission genetics and Mendelian inheritance , 52. DesThe overall Cronbach alpha for the whole section on attitudes was 0.85, indicating very good reliability. This means that we can assume that the items in the attitudes section are measuring what they are supposed to measure.The answers in the attitudes section indicated that the students were well aware of the various applications of modern genetics and genomics, since very few answered “Don’t know” to the attitude questions (in the first pilot). Therefore, the students were able to give their opinions concerning the topics in question.Two of the topics in the attitudes section covered personalized medicine and genetic testing, which are becoming increasingly common in public health. In 2010 roughly 10% of the drugs approved by the U.S. Food and Drug Administration had labels with pharmacogenomics information, and genetic testing is common for certain conditions such as breast cancer . GeneticThe PUGGS questionnaire was developed and validated among college freshmen students in Brazil, and we consider it generalizable to other populations of young adults with at least a high school education in most Western societies. We consider this the first validation step in an ongoing work, and additional studies are needed to validate it for other population segments/groups. We therefore encourage others to apply the questionnaire in different contexts to secure the generalizability. For example, the current research group are already planning to test out the questionnaire among physicians, to see how their knowledge compares to college students.In future studies, we also suggest that the PUGGS questionnaire can be used to analyze the relationship between beliefs in genetic determinism, knowledge about genetics and genomics, and attitudes toward genetic and genomic-based technologies. For example, one could compare respondents with high and low scores in knowledge of modern genetics and genomics and see whether they score differently in beliefs about genetic determinism. It may also be possible to inquire into how genomic knowledge or belief in genetic determinism is related to attitudes towards genetic and genomic-based technologies. Evidently, other associations can also be explored. A practical benefit of such research could be in science education, where educators could use the questionnaire to map students’ knowledge, attitudes and belief in genetic determinism, and tailor the classroom instruction accordingly. It may also be important for teachers to find out how knowledge and attitudes about modern genetics shape each other, so that potential obstacles to learning may be addressed.The instrument may be applied to diverse groups of people, for example, for measuring knowledge and attitudes towards modern genetics and genomics among health personnel, genetic counselors, biology or medical university students, educators, health communicators, or journalists. Multinational comparative studies will also be possible, especially in the context of genetics education and genetic literacy, where analyses in some regions or countries may reveal areas of knowledge or attitudes that demand attention.The full version of the PUGGS questionnaire is available in the S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.S4 Table(DOCX)Click here for additional data file.S5 Table(XLSX)Click here for additional data file.S6 Table(XLSX)Click here for additional data file.S1 Text(DOCX)Click here for additional data file.S2 Text(DOCX)Click here for additional data file.


Perspective traces the evolution of certain central notions in the theory of Generative Grammar (GG). The founding documents of the field suggested a relation between the grammar, construed as recursively enumerating an infinite set of sentences, and the idealized native speaker that was essentially equivalent to the relation between a formal language (a set of well-formed formulas) and an automaton that recognizes strings as belonging to the language or not. But this early view was later abandoned, when the focus of the field shifted to the grammar's strong generative capacity as recursive generation of hierarchically structured objects as opposed to strings. The grammar is now no longer seen as specifying a set of well-formed expressions and in fact necessarily constructs expressions of any degree of intuitive “acceptability.” The field of GG, however, has not sufficiently acknowledged the significance of this shift in perspective, as evidenced by the fact that  observations about string acceptability continue to be treated as bona fide data and generalizations for the theory of GG. The focus on strong generative capacity, it is argued, requires a new discussion of what constitutes valid empirical evidence for GG beyond observations pertaining to weak generation.This  While linguists agree on this focus, they nevertheless tend to uncritically assume that judgments of the acceptability of strings constitute data for GG. But this assumption is baseless, and a renewed discussion of GG's empirical basis is in order.There exists a contradiction between the near-universal acceptance of acceptability judgments as a source of data for Generative Grammar (GG) on the one hand and the theory's express focus on LSLT) defined as the “primary concern” of syntactic theory “to determine the grammatical sentences of any given language […]” (57). Chomsky (SS) elaborates:Chomsky , LSLT de Chomsky , SS elabL is to separate the grammatical sequences which are sentences of L from the ungrammatical sequences which are not sentences of L […]. The grammar of L will thus be a device that generates all of the grammatical sequences of L and none of the ungrammatical ones.” .“The fundamental aim in the linguistic analysis of a language LSLT, 95); hence, “the sequences generated by the grammar as grammatical sentences must be acceptable, in some sense, to the native speaker […]” . The adequacy of a grammar can be assessed by “[determining] whether or not the sequences that it generates are actually grammatical, i.e., acceptable to a native speaker” . Consequently, “the linguist's task [is] that of producing […] a grammar [that generates] all and only the sentences of a language […]” .The set of sequences so determined “corresponds to the ‘intuitive sense of grammaticalness’ of the native speaker” (Early View (EV), the idealized native speaker is the human equivalent of an automaton in the theory of formal languages, which accepts (recognizes) or rejects a given string depending on whether or not it is part of the set of legal sequences. While the importance of hierarchical structures underlying the sequences was recognized to be of central importance, the formal systems used at the time—Post-style rewrite rules plus transformational rules—ultimately enumerated strings .Later works of Chomsky's are explicit in rejecting the EV and its view of the idealized native speaker as a human automaton. Perhaps the first clear articulation of this shift appears in Chomsky , where wlanguage as a set of sentences is a corollary of the shift of the focus of attention from sentences to structures:This dismissal of the view of a “For each sentence, the grammar determines aspects of its phonetic form, its meaning and perhaps more. […] [It] is said to ‘weakly generate’ the sentences of the language and to ‘strongly generate’ the structural descriptions of these sentences” Chomsky, , p. 220.strongly generates structural descriptions (SDs), not strings; the latter can at best be said to be generated in some weak sense, in that the “phonetic form” associated by the grammar with any SD has sequential properties  in fact “[A] GG will not generate the set of sentences that a speaker-hearer will regard as acceptable; indeed, it is virtually a criterion of adequacy that it should not, since so many different factors enter into such judgments”  one way or another”  cannot be interpreted in this way.Chomsky ((I know) [who [John [kissed _]]]x is such that John kissed x”)(“which person (I know) [who [John [kissed Mary]]]wh-operator has no variable to bind, and consequently cannot be assigned an interpretation. Importantly, we cannot simply “neglect” the fronted wh-phrase and interpret (2) as meaning (I know) John kissed Mary, a fact that Chomsky attributes to the principle of Full Interpretation—an interface condition, in current parlance. Does this mean that we want to block generation of (2), while allowing generation of (1)? Chomsky explicitly denies this, arguing that such a move would redundantly replicate the effect of Full Interpretation. Consequently, both SDs in (1) and (2) are grammatical (generated by the grammar); the “deviance” of (2) is due to an extraneous principle of interpretation. But the fact that the string deriving from (2) is “deviant” per se is of no immediate concern to the theory of grammar.In (2), the LSLT (145), the goal of the theory is not to construct a grammar that generates a set of well-formed formulas including Colorless green ideas sleep furiously but excluding Furiously sleep ideas green colorless, but to explain why the SD assigned to the latter cannot be mapped onto an analogous interpretation. The naturalness of the typographical or acoustic object is of no immediate relevance to the theorist , the empirical success of GG depends on its ability to correctly model the speaker's knowledge of sound-meaning relations, not the intuitive acceptability of strings:On this “Linguistic expressions may be ‘deviant’ along all sorts of incommensurable dimensions, and we have no notion of ‘well-formed sentence’ […]. Expressions have the interpretations assigned to them by the performance systems in which the language is embedded: period” Chomsky, , p. 27.In later works, Chomsky entertains the idea that generation of SDs proceeds freely via the operation Merge, with constraints imposed only by external systems. For instance, Chomsky , p. 111 “Merge can apply freely, yielding expressions interpreted at the interface in many different kinds of ways. They are sometimes called ‘deviant,’ but that is only an informal notion. […] The only empirical requirement is that [the interfacing systems] assign the interpretations that the expression actually has, including many varieties of ‘deviance”’ Chomsky, , p. 144.Chomsky , p. 3f. On this RV, there exists no notion of well-formedness that is given independently of whatever is strongly generated by the I-language. The grammar does not specify a set of legal strings but an infinity of SDs; the only empirical success criterion is that the SDs postulated by the theorist have the properties in interpretation and externalization they do.While the field ostensibly embraced the focus on SGC and SDs championed by Chomsky, the EV remains widely adopted in actual practice. Grammaticality and acceptability are standardly equated, and I-languages taken to determine sets of well-formed strings/sentences. The following quotes, randomly culled from popular textbooks, are representative:grammatical if native speakers judge it to be a possible sentence of their language” , marginally well-formed, or ill-formed ” Carnie, , p. 14.“[A] sequence of words is called a string. Putting a star at the start of a string is a claim that it isn't a grammatical sentence of the language in question” Adger, , p. 4.sic] is to obtain a form of information that scarcely exists within normal language use at all—namely, negative information, in the form of strings that are not part of the language”  adherence to the EV, acceptability judgments continue to take center stage in GG, and a good deal of the literature on experimental syntax has been devoted to refining their elicitation Sprouse, . Sprousemodulo performance-related factors). This view is most explicitly espoused by Frampton and Gutmann , ignoring the fact that this notion has no obvious relevance on the RV. A direct outgrowth of this ideology is the extensive reliance on highly stipulative features as licensors of structure-building Chomsky, , p. 6, lHeilikes Johni is “unacceptable,” or that it lacks the intended reading; we can say that (2) above is “deviant,” with an implicit understanding that we're referring to the absence of an interpretation analogous to (1). This innocent informal usage aside, however, the “(un)acceptable” status of sentences remains the de-facto empirical benchmark for theoretical proposals within GG, and informal observations about weak generative capacity, clad in technical terms, are standardly elevated to the status of generalizations to be accounted for (cf. the case of islands mentioned above). The field must overcome these limitations and move on to a theoretical characterization of possible SDs  and their interface properties . Despite this shift, the field has retained a methodological obsession with the intuitive well-formedness of strings and associated notions such as “overgeneration” (E-language).Chomsky , p. 63 nThe author confirms being the sole contributor of this work and approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Despite increasing vaccine coverage level, Indonesia is still in distance with target of Global Vaccine Action Plan (GVAP) . In 2012The aim of this study was to assess the socio-demographic factors influencing Acehnese inhabitants’ view related to vaccine. A cross-sectional survey was conducted during Nov 2014 to Mar 2015 and Aug to Dec 2015 in 11 regencies of Aceh. A set of validated questionnaires was used to assist the interviews. To elicit the view related to vaccine, two questions regarding the importance of the vaccines to prevent diseases and the safety of the vaccines for children were asked with responses on a Likert-type scale ranging from “1=strongly disagree” to “5=strongly agree”. The view related to vaccine was dichotomized into “good” and “poor” based on an 80% cut-off point. A logistic regression analysis was employed to analysis the data.We included data of 1059 participants in the final analysis. Approximately, 33% of the participants had a poor view regarding vaccines. Education, occupation, monthly income, and economic status were associated with the participants’ perspective regarding vaccine while age, gender, marital status and type of residency had no association .Puskesmas -, hospital-, and Masjid (mosque)-based approaches (Low education, working as farmer, low economic status and low monthly income were associated with a poor view related to vaccine. Therefore, these groups should be targeted to increase vaccination coverage in the future. One of the visible efforts is to increase the knowledge and attitudes regarding vaccination and this could be implemented using proaches .In addition, one of the focus groups that should be targeted is that of student/ university students, as their views regarding vaccine have no difference compared to farmers. Therefore, intensive vaccination campaigns focusing on those groups might be required in the future to enhance the correct understanding of vaccination.


Following an interpretive approach, 10 focus group interviews were conducted to produce data for a qualitative content analysis. When the adolescents mentioned PA, they mostly referred to spontaneous PA rather than organized PA, and expressed that they enjoyed their PA engagement, which they stated was promoted by the variation of PA, available options for PA, their physical skills, and the presence of peers. They reported that social support from family and friends facilitated their PA, and they offered several suggestions regarding how the school environment could better support their PA. From the perspective of self-determination theory (SDT), the results stress the importance of facilitating intrinsic motivation with a supportive PA environment in which adolescents can satisfy their needs for autonomy, competence, and relatedness. Despite increasing socioeconomic inequalities in the health and well-being of adolescents, the voices of adolescents in disadvantaged communities regarding facilitators of physical activity (PA) have received relatively little attention. In response, the purpose of this study was to illuminate what adolescents in a multicultural community of low socioeconomic status (SES) in Sweden convey concerning facilitators of PA. Adolescents ( There is a broad consensus that taking part in physical activity (PA) and sport from an early age is important for developing a foundation for lifelong physical engagement in healthy PA experiences ,2. In reYet, earlier findings have to be understood within the context of the time and space in which they occurred . During The United Nations Convention on the Rights of the Child emphasizes that every child has the right to express his or her opinion and be heard in all matters affecting his or her health and well-being . In obseAccording to SDT, humans have three innate psychological needs—autonomy, competence, and relatedness—that are essential to their psychological functioning, including mental development, integrity, autonomous motivation, and well-being ,19. AutoBy embracing an interpretive approach, this study was based upon the notion that the always-constructed and contextual experiences of adolescents are complex and accommodate shared realities . To captThe second-largest city in Sweden, Gothenburg, has experienced widespread socioeconomic segregation, and the district of Angered is one of the most segregated. According to Swedish standards, Angered is characterized by a high proportion of non-native residents, long-term unemployment, low educational level and average income, the need for long-term financial assistance, and poor life expectancy . AngeredIn August 2014, all seventh graders at the mentioned school were recruited for the How to Act? research project, an empowerment-based, health-promoting school intervention focused on food and PA habits. Between September and October 2014, all adolescents (12–13 years of age) enrolled in the project were invited to participate in the present study. All 54 adolescents agreed to participate; however, one student was absent during his scheduled focus group, which resulted in a sample of 53 adolescents (21 boys and 32 girls). Prior to enrollment in the project, both the adolescents and their parents or legal guardians received information regarding the project, including its purpose, that participation was voluntary, and that they could leave the study at any time, and the adolescents and their parents or legal guardians provided the researchers with their written informed consent. The project and the present study were approved by the regional ethical review board (Dnr: 469-14).To produce data for the study, 10 focus group interviews were performed, each attended by 4 to 6 adolescents; 4 were conducted with girls only, 3 with boys only, and 3 with both genders. The interviews lasted for an average of 69 min (range: 44–97 min). The procedures of the focus group interviews appear in greater detail elsewhere .Qualitative content analysis ,28 was cTo understand what facilitates the PA of adolescents, it is necessary to recognize how adolescents talk about PA in general. When the adolescents in the study discussed PA, they stated that PA need not be exercise or organized sports, but can even be active commuting to and from school or going for a walk with friends. Some of the adolescents mentioned organized PA  as a leisure-time activity, and organized PA in terms of physical education (PE), although the adolescents more often highlighted spontaneous PA  as a common leisure activity (the following quotations illustrates if it is a boy (b) or a girl (g), using pseudonyms, and from which focus group (FG) the quotation is retrieved ), as exemplified by one of the adolescents: Interviewer: Do they usually play football there?Anna (g): They’re always, you know, at the playground. Just go there, and you’ll see everyone you know. And it’s always football, so you can just go there and play. (FG 1)Another spontaneous form of PA that the adolescents underscored was playing games outdoors , as shown below:Interviewer: Do you play any games [outdoors]?Malik (b): Yes, cops and robbers!Interviewer: Cops and robbers?Malik (b): Yes! And hide-and-seek.Caleb (b): Zombie tag. (FG 4)Although spontaneous PA has decreased in Sweden significantly during the last few decades , spontanIn response to the study’s aim, two major themes were identified—one was the possibility for enjoyment, and the other was social support and a supportive environment—as well as six categories, all of which illuminate facilitators concerning the adolescents’ PA . In whatThe adolescents stated that for them to engage in PA, the PA should be fun. What constituted fun PAs varied, however, and as did the activities that the adolescents mentioned , as illustrated below: Interviewer: How come you play football then?Zavier (b): Because it’s fun. Jamel (b): Because it’s fun. (FG 7)Overall, the findings are consistent the results of previous studies, which have highlighted the need for adolescents’ PA to be fun ,33, and In some of the focus groups, the adolescents mentioned that boys, in general, are more physically active compared to girls. In other focus groups, however, the adolescents described different views on whether boys are more physically active than girls. The adolescents’ reasoning ended with the idea that PA engagement depends more on personality and personal preferences, as illustrated below: Interviewer: Are there any differences between boys’ and girls’ leisure time activities?Hamza (b): Boys usually participate more in sports.Interviewer: More than girls?Amarion (b): No, not how I see it.Interviewer: What do you think?Amarion (b): I don’t want to distinguish between the sexes. There are girls who play a lot of sports, and there are guys who are not so much into sports. So, it depends on how you are as a person.Interviewer: It’s not about sex, but about who you are and what you like?Mina (g): Yes, what you like. (FG 9)However, research has shown that boys are generally more physically active and participate more in sports clubs than girls , and in Ahmad (b): And dance. Albanian dance.[The other adolescents burst into laughter.]Ahmad (b): What? I like it! (FG 4)Leisure time activities such as dance are commonly viewed as being feminine , and it The adolescents suggested that it is essential to try different activities until one finds activities that he or she personally enjoys. They also mentioned variation as a way of making PA fun. For example, the adolescents highlighted that they liked PE because it provided them with the opportunity of choosing and trying several different PAs. Traditional teaching in PE supplies pupils with a version of “sports light” , and thiInterviewer: How come you like it [PE]?Grace (g): Because you try different activities. You don’t do the same thing every lesson. (FG 5)Similarly, in relation to organized sports in sports clubs, the adolescents suggested that it is important to try different sports until you find one that you like, as illustrated by of one of the adolescents:Jazmin (g): You can try different ones, until you find a sport that you like. (FG 3)In a similar vein, Martins et al.  showed tSome of the adolescents mentioned that PA was especially fun when they felt skilled and competent at the activity, which was mentioned in relation to PE, spontaneous PA, and participation in sports clubs. The adolescents stated that they felt competent when they learned new skills and developed their physical abilities. Similarly, some of the adolescent girls mentioned that they liked to play basketball in PE because they were good at it, as seen below:Interviewer: Is there something else that you would like to do in physical education that you think is more fun?Kayla (g): No, not really. We girls like to play anything, as long as we’re good at it.Sara (g): Basketball.Kayla (g): Yes, girls like to play basketball because they’re skilled at it. (FG 2)When the adolescents discussed feeling competent, they neither mentioned winning nor focused on performance. Instead, they emphasized the importance of doing their best and having fun, as exemplified in one of the focus groups:Interviewer: Is it important to win?Filip (b): No, not as long as you play well. Malik (b): And have fun.Filip (b): Then, it’s not important to win. Malik (b): As long as you have fun. (FG 4)It is therefore problematic that organized PA, in sports clubs, usually focuses on performance-based results with a win-at-all-costs mentality, and encourages competitive pressure cf. ,38) inst inst38])The adolescents mentioned that being physically active together with friends contributed to their sense of fun during PA. Social interaction as an important motivational factor was exemplified in one of the focus groups, as follows: Interviewer: How is it that you engage in sports?Caleb (b): To have fun and spend time with friends.Jamal (b): You can hang out with your friends.Malik (b): You’re with friends. You play together, you swim together, and you wrestle together. (FG 4)This finding aligns with the results of several previous studies that have shown that friends are an important part of adolescents’ engagement in PA, and that being physically active with friends makes PA fun ,33. BeinAltogether, this theme illustrates that professionals  who work with adolescents should create opportunities for adolescents to engage in PA that they find fun and enjoyable, while also seeking to reduce the competitive and performance-based nature of PA. According to the adolescents, fun and enjoyable PAs offer options and variation , opportunities to learn and develop , and comradery . From a SDT-based perspective, it is essential that adolescents’ PA occurs in an environment that supports their need for autonomy, competence, and relatedness cf. ,19). It . It 19])When the adolescents discussed whether they engaged in organized PA, they mentioned their parents’ support as an essential factor that, without which, would make it difficult for them to participate in organized PA. The adolescents also expressed a wish for their family members to be even more supportive of their PA by, for example, engaging in PA together with them or showing that they cared about their PA, as exemplified by one of the adolescents:Interviewer: What would it take for you to engage in some  activities?Yesenia (g): That you get some help with it. If you’d like to start something, then that someone shows that they care about it. You could tell your parents what you’d like to do. And then they could help you with it. (FG 1)Moreover, the adolescents reported that it is easier to be physically active with friends. If they were to join a sports club, for instance, then they stated that they would feel safer if a friend joined as well. They also mentioned that if friends had tried a sport, then they could ask them how it was, which could pique their own interest in trying it. Arguably, if adolescents are surrounded by friends who are members of sports clubs, then that circumstance could increase the odds of them also joining the sports club. As one adolescent explained, it is also easier to be physically active somewhere other than home, especially with friends: Yesenia (g): I think it’s much better to train somewhere other than home, because if you do it at home, then you might skip a few workouts sometimes, but if you do it with someone else, you have to do it, you know. If you’re working out with someone else, you have to, like, get up and do it. (FG 1)Overall, these results are consistent with the findings of previous research, which have shown that social support from family and friends is associated with adolescents’ PA levels . The quoThe adolescents had several suggestions for how the school environment could become more supportive of their PA. Some mentioned that they would like longer breaks at school so that they could have more time to go outdoors and be physically active, as illustrated below:Interviewer: What would you do if you had longer breaks?Kayla (g): We’d go outside.Sara (g): Nothing.Kayla (g): We’d, you know… we’d go outside—at least I would.Naima (g): I would, too. Layla (g): We’d go out and chase each other, play hide-and-seek. (FG 2)In a similar vein, children in Pawlowski et al.’s  study idOverall, our findings for the theme demonstrate that professionals working with adolescents in PA contexts could explore adolescents’ sources of and opportunities for social support, as well as encourage adolescents to seek support from family and friends. Because social support from family members is essential for adolescents’ engagement in PA , it is iThe facilitators of PA highlighted by the adolescents can be summarized as illustrated in Focus group interviews allow the participants to make their voices heard and to express themselves freely ; hence, As the literature specifies , we aimeFor a comprehensive discussion regarding the trustworthiness of the study findings, see Jonsson et al. .When the adolescents discussed PA, they mostly referred to spontaneous PA in the neighborhood  instead of organized PA . To the best of our knowledge, the importance of spontaneous PA seems to be specific to the sample, as spontaneous PA has decreased significantly over the last few decades among children and adolescents in Sweden, in general. Arguably, spontaneous PA thus facilitates the adolescents’ daily accumulated PA. As such, it is essential that the neighborhood area where the adolescents often socialize is designed to encourage spontaneous PA . The adolescents highlighted the need for PA to be fun and enjoyable and without a competitive or performance-based orientation. For them, PA was fun and enjoyable when they engaged in a variety of forms of and had options for PA, learned and developed new skills in PA contexts, and were physically active with friends. They also mentioned that social support from family and friends facilitated their PA engagement, and they had several suggestions regarding how the school environment could better support their PA . From an SDT-based perspective, it seems important to facilitate adolescents’ intrinsic motivation with a supportive PA environment that satisfies adolescents’ need for autonomy, competence, and relatedness. Because the adolescents highlighted that PA should be fun and enjoyable and without a competitive or performance-based orientation, for future directions, it might be of interest to employ a similar approach as this study among adolescent sports club members.


Integrated control programs, emphasizing preventive chemotherapy along with health education, can reduce the incidence of soil-transmitted helminthiasis and schistosomiasis. The aim of this study was to develop an educational animated cartoon to improve school children’s awareness regarding soil-transmitted helminthiasis, diarrheal diseases, and related hygiene practices in Côte d’Ivoire. The key messages included in the cartoon were identified through prior formative research to specifically address local knowledge gaps.In a first step, preliminary research was conducted to assess the knowledge, attitudes, practices, and beliefs of school-aged children regarding parasitic worm infections and hygiene, to identify key health messages to be included in an animated cartoon. Second, an animated cartoon was produced, which included the drafting of the script and story board, and the production of the cartoon’s initial version. Finally, the animated cartoon was pilot tested in eight selected schools and further fine-tuned.Koko et les lunettes magiques” was produced by Afrika Toon, in collaboration with a scientific team composed of epidemiologists, civil engineers, and social scientists, and the local school children and teachers. Pilot testing of the animated cartoon revealed that, in the short term, children grasped and kept key messages. Most of the children who were shown the cartoon reported to like it. Acceptance of the animated cartoon was high among children and teachers alike. The messaging was tailored to improve knowledge and practices for prevention of helminthiases and diarrheal diseases through prior identification of knowledge gaps. Integration of such education tools into the school curriculum, along with deworming campaigns, might improve sustainability of control and elimination efforts against helminthiases and diarrheal diseases.According to the questionnaire results, children believed that the consumption of sweet food, eating without washing their hands, sitting on the floor, and eating spoiled food were the main causes of parasitic worm infections. Abdominal pain, diarrhea, lack of appetite, failure to grow, and general fatigue were mentioned as symptoms of parasitic worm infections. Most of the children knew that they should go to the hospital for treatment if they experienced symptoms of parasitic worm diseases. The animated cartoon titled “ Koko et les lunettes magiques”. The animated cartoon was pre-tested in eight schools and further developed. Our study found that children could retain most of the information provided by the animated cartoon. It is suggested that such a tool, integrated into the school curriculum, together with deworming campaigns in Côte d’Ivoire, might improve the sustainability of control and elimination efforts against soil-transmitted helminthiases, diarrhea, and schistosomiasis.Soil-transmitted helminthiases, schistosomiasis, and diarrhea remain important public health issues in sub-Saharan Africa. Health educational animated cartoons can help raise awareness and improve hygiene practices, and thus contribute to the control and elimination of these diseases. For the development of an educational animated cartoon, we first evaluated the knowledge, attitudes, practices, and beliefs of school-aged children in Côte d’Ivoire regarding soil-transmitted helminthiases, diarrhea, and schistosomiasis in order to identify setting-specific health messages for our animated cartoon. We found that children believed that the consumption of sweet food, eating without washing their hands, sitting on the floor, and eating spoiled food were the main causes of parasitic worm infections. As a next step, the alpha version of the animated cartoon was produced and given the title: “ Ascaris lumbricoides, Trichuris trichiura, and hookworm) are among the most common neglected tropical diseases (NTDs) [Infections with soil-transmitted helminths  ,2. Indees (NTDs) . Parasits (NTDs) ,5. Althos (NTDs) , the mais (NTDs) . Importas (NTDs) . Inadequs (NTDs) .Although health education and sanitation are two important components of primary health care emphasized by the World Health Organization (WHO) as a basis for the prevention and control of communicable diseases , there iThe potential of educational videos is well established, as they can engage and inform at the same time. This is of importance, particularly for younger school-aged children as their attention span is limited. Videos can display real-life situations that children can readily grasp. It is essential that the messaging of videos is tailored to the context of the target population. Hence, a preliminary assessment of the knowledge, attitudes, practices, and beliefs (KAPB) of a population can allow the identification of appropriate messages to be incorporated into a story that entertains and engages the audience, thus rendering the educational tool popular and effective in different age groups .A. lumbricoides and T. trichiura) were found with a prevalence of less than 5% each [In Côte d’Ivoire, NTDs are of considerable public health relevance –20. Rece 5% each .The aim of the current study was to develop an educational cartoon that might help improve school children’s awareness regarding STHs and diarrheal diseases, and related hygiene practices in Côte d’Ivoire. The study was guided by experiences and lessons from previous investigations in the People’s Republic of China where a health educational video proved useful for lowering the incidence of STH reinfection rates and improving STH case management. In particular, “The magic glasses concept” employed in the educational video proposed by Bieri and colleagues was applied for the current research ,22.Ethical clearance for the study was obtained from the ethics committee of Basel  and from the ethics committee of the Ministry of Health and Public Hygiene in Côte d’Ivoire (reference no. 76-MSLS-CNER-dkn). Local community and school authorities were visited and informed about the purpose and procedures of the study before commencement of the field activities. Because this study involved the participation of school-aged children, each of them provided a written informed consent signed by their parents or legal guardians prior to enrollment. Children assented orally. Participation was voluntary and children could withdraw any time without further obligations.Koko et les lunettes magiques” was done in three distinct phases , a foreign-borne population  and an allogenic population . In the Tiassalé setting, phase 1 of the study took place in two villages, namely Niamoué and Tiassalékro. Phase 3 was carried out in four villages, namely Niamoué, Boussoué, Binao, and Tiassalékro. In this area, the villages have school groups (two schools or more in the same place) but we worked in only one school per village.In western Côte d’Ivoire four main regions , belonging to the district des Montagnes, are populated by four main ethnic groups, including Guéré, Toura, Wobé, and Yacouba. The ethnic composition in western Côte d’Ivoire is more homogeneous compared to the south-central part. Indeed, most people are native ethnic groups of the region. For this study we chose the Man setting in the Tonkpi region that has been the focus of our research activities since the late 1990s. Phase 1 of the study took place in Kogouin and Krikouma, while phase 3 took place in Dompleu, Zê, Krikouma, and Kogouin. Each village is small and has only one school.To identify key messages pertaining to parasitic worms, diarrhea, and hygiene-related practices that should be included in the cartoon, we carried out a KAPB study using the following methods: (i) questionnaire survey, (ii) focus group discussions (FGDs), and (iii) direct observations among children aged 9–14 years. The KAPB study was carried out in December 2013 and focused on knowledge regarding STHs , treatment and prevention of STH infection, hygiene practices (after defecation and before eating), and information sources and preferred entertainment media . The target sample size was 120 children (80 school enrolled and 40 non-enrolled). The quantitative questionnaire utilized was pretested in a school that was not part of the presented study sites.Eight FGDs were carried out with school children only, four each in the Tiassalé and Man regions. Each FGD included eight children (four girls and four boys). In direct observations it was assessed whether schools owned latrines (places of defecation), whether children were washing their hands after using the latrines, and whether they were using the bush instead of latrines. Questions or issues that were not addressed in the questionnaire were caught up in the interviews (FGDs) and observations. During the entire formative research, a cartoonist accompanied the social sciences team to become acquainted with the setting and obtain a deeper understanding of children’s risk behaviors.Koko et les lunettes magiques” was completed in May 2014.The whole process of cartoon production (including the changes made after the pilot testing) took place between December 2013 and August 2014, as summarized in Koko et les lunettes magiques”. Subsequently, children were administered a questionnaire in order to evaluate how well the cartoon messages resonated with them, whether or not children liked it, and perception of the overall length. The specific feedback from children and teachers guided the final fine-tuning of the cartoon production. Educators interested in participating watched the cartoon together with the school children and contributed qualitatively by making suggestions in separate interviews. Relevant observations were utilized for the improvement of the cartoon.In May 2014, following the production of the first complete version, each of the eight schools were visited and children invited to watch “The quantitative data collected from the KAPB questionnaires was double entered and cross-checked in EpiInfo version 6.04 . Using STATA version 10 , frequency tables were generated. Qualitative data gathered from the FGDs were recorded, transcribed into Microsoft Word and then imported into MaxQDA version 1  for qualitative data analyses. The data were coded and analyzed to identify the frequency at which coded information and content categories occurred. A triangulation approach was used for analysis of the data derived from the three different methods .A total of 106 children, aged 9–14 years, were interviewed; 33 in Kogouin, 25 in Krikouma, 28 in Niamoué, and 20 in Tiassalékro. Eighty-two children (77%) attended school, while the remaining 24 children (23%) were not enrolled at school. Non-enrolled children in the selected communities were fewer than expected and the planned number of 40 non-enrolled children could not be reached.worms give diseases”, “worms kill people”, “worms give belly aches”, and “they consume your blood and eat your vitamin”. However, children were unable to attribute scientific names/medical terms to parasitic worms and commonly used words such as microbes, worms, Guinea worms, and leeches. According to the children, there are several types of worms  and they may have different colors .Children’s knowledge of parasitic worms was investigated regarding causes (transmission), symptoms, and available treatment. In the FGDs, children reported that ““When you eat too much sweet banana, it causes worms in the belly” and “You have worms when you always eat sweet foods”. In addition, the concept of dirt appears in conjunction with consumption of food and water: “We must not collect things from the ground to eat” or “One should not drink any kind of water because there is water that if you drink it, you’ll have worms”. Walking and playing on dirty ground was also mentioned as a source of contamination: “If you go to places where people throw garbage, you’ll have worms” or “If you walk on worms, they will come into your feet and after enter into your belly”. Moreover, children mentioned that playing in dirty places and eating without washing hands were causes of parasitic worm infections.The questionnaire findings were confirmed by the FGDs. Children said: When a person is infected with worms, he will be hungry just after eating”.In terms of symptoms related to parasitic worms that may give rise to recognize parasitic worm diseases, When you have worms in your belly, they give you drugs at school which kill them”. The exact names of drugs used to kill parasitic worms were not known by children.Most of the children knew that they should go to a health care center for treatment if they experienced symptoms of worm diseases. In Kogouin, 10% of the children reported that parasitic worms can also be treated with traditional medicine . Some chcan cause other diseases such as diarrhea, measles, fever, typhoid, or dysentery”. For some of the children, parasitic worms can lead to death: “I’m afraid because I can die.” For others, the concern was due to the doubt caused by the presence of parasitic worms in the stomach: “We don’t know what it can cause in your belly” and for those who knew the consequences of parasitic worms it is “because when you eat, your belly will hurt”, “worms in your belly will drink your blood”, and “they also remove the vitamin in your body”. Finally, parasitic worms are attached with economic costs because parents will bring the child to the hospital and spend money. In contrast, children in Tiassalékro (60%) and Kogouin (55%) believed they cannot contract intestinal worms because they do not play near the garbage, they wash hands before eating, they eat well, and they can be dewormed. For these reasons, they were not afraid of having worms .vs. 8%). A similar pattern was found for hand washing before food consumption  and in the health centers .Koko et les lunettes magiques” is a 15-minute story about clean water, use of latrines, and hand washing with the aim of improving health- and hygiene-related knowledge and practices towards preventing intestinal worm infections and improving hygiene  that allow Koko to see the environment as if he was seeing through a microscope. Hence, Koko sees the parasites and how the transmission to humans occurs  and the communities . In brief, “s occurs . Koko ans occurs .Koko et les lunettes magiques” is available online (https://www.youtube.com/watch?v=PCNLEK5Ityw).List of the key messages formulated by the research team following the preliminary assessment. It includes messages that aim to increase the knowledge on good hygiene practices, while filling identified knowledge gaps and re-enforcing already existing knowledge.Always use latrines and avoid open defecation Always wash your hands with water and soap after defecation (because otherwise you can contaminate food and other objects/people with your hands)Always wash your hands with water and soap before eating (to avoid ingesting microbes that will make you sick)Always wash fruits and vegetables with water before eating them raw (to avoid ingesting microbes that will make you sick)Do not walk and play outdoors without shoes to avoid parasitic worm infectionsYou must go to the hospital when you have diarrhea and abdominal painAlways cover the latrine to prevent the spread of flies (they can contaminate the food and make you sick)Fruits well washed and consumed in moderation are healthy and do not cause diarrheaYou must drink clean water  to prevent diarrheal diseases (because dirty water harbors germs that will make you sick)Always cover food to avoid flies on it, as they can contaminate food with germs that will make you sickAvoid bathing in the river, stream, lake or creek because there is a risk of getting infected with schistosomiasisWhen a child has intestinal worms, its physical and cognitive development may be impaired and it cannot concentrate at schoolThe pilot testing was conducted in eight schools. Four were in the Tiassalé region  and four in the Man region . All children from grades 3–5 were invited to watch the cartoon. A total of 401 children participated in the KAPB survey.Most children who watched the cartoon reported to like it . The questions posed to children pertained only to specific information that was provided through the animated cartoon. After screening, most children in Tiassalé and in Man knew that people should defecate in latrines. Only a few said that they could also defecate in the bush. Hand washing after defecation was recognized as important hygiene behavior . In addition, hand washing before eating was considered a good practice. Finally, children were aware that fruits should be washed before eating .Children reported that people should consume water obtained from pumps rather than from unprotected surface. For some children in Boussoué (16.0%), Niamoué (34.0%), and Zê (14.0%), however, villagers could also consume creek and river water. Furthermore, children reported that food should be covered to prevent contamination. Only a small proportion of children referred to flies as a means of transmitting pathogens. Wearing shoes was recommended by children because walking barefoot can result in worm infections. With regard to the reasons given for not bathing in the river, children in Man cited more schistosomiasis compared to those from Tiassalé who mentioned dirt in the river and creek. These results are presented in more detail in Stomach aches were the most frequently reported sign of parasitic worms in all villages surveyed, while diarrhea was also frequently mentioned. In Tiassalé, only diarrhea and stomach ache were mentioned as suggestive signs for the presence of parasitic worms. In Man, additional symptoms were given, such as general fatigue, lack of concentration at school, failure to thrive, lack of appetite, and incapacity to think clearly . In contrast, in other communities, a large proportion of children were not afraid because they reported to not put themselves at risk and if they did contract parasitic worms, it was possible to remedy this situation through access to deworming drugs. The latter part of children were those living in villages close to the towns of Man and Tiassalé, thus we conjecture that they had better access to information and treatment and thus were less afraid of parasitic worm diseases. This emphasizes the importance of assessing the KAPB in a representative sample of the target population before developing a health educational tool.Koko et les lunettes magiques” targets a very specific population, namely school-aged children. Indeed, the main character of the animated cartoon is an 8-year-old boy and the story is designed in such a way that the audience (children) can identify themselves with Koko. Nonetheless, other adult characters  are also integrated in the story. Hence, adults can also identify themselves with the story told. The animated cartoon was developed for school-aged children and discussions are underway with the education sector how to integrate it into the school curriculum. However, the cartoon can also be screened at public places for entertaining and educating adults, since it simplifies complex issues.“Koko et les lunettes magiques” can be seen as an entry point of a larger health education intervention package that will allow rapidly attracting children’s (and adults’) attention. However, it is essential that messages are reiterated during discussions, drawing assignments or group work (the type and combination of these methods would depend whether the intervention is school-based or community-based) in order to consolidate the knowledge gained and to make sure that the most important messages are understood correctly. Indeed, the pilot testing revealed that although children retain most of the key messages right after the screening [“creening , some kncreening . When thcreening –40.Koko et les lunettes magiques” was developed to educate school-aged children in an entertaining and context-specific manner. Clearly, children liked the animated cartoon and the pilot testing revealed that children could keep the transmitted information shortly after they were shown the cartoon. In a recent intervention study in 25 schools of western Côte d’Ivoire the cartoon has been tested for its effect on KAPB in the short term and results of the study will be presented elsewhere. An important next step will be to validate the cartoon on its effect on the KAPB regarding STH infections, schistosomiasis, and diarrheal diseases in the mid- and long-term. It is essential to validate such health education tools in different social-ecological contexts in order to create evidence-based and locally adapted designs for sustainable integration of health educational packages into school curricula along with regional deworming programs against STHs, schistosomiasis, and other NTDs.In conclusion, “S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.


DEAR EDITOR1,2 There is no consensus on a single superior treatment for DD.Dupuytren’s disease (DD) is a benign, fibroproliferative disorder of the hand resulting in contracture of the digits. Traditionally, surgical treatment (fasciectomy or dermofasciectomy) has been the gold standard. Needle aponeurotomy and collagenase injections are newer alternatives with potentially higher recurrence rates and lower efficacy in severe cases.3 With potentially unreliable information being accessed by patients, it is important to assess what is being viewed. We aimed to analyse the content of videos on Youtube concerning DD. Youtube is a free, publically accessible website where users upload and view videos on various topics including healthcare. It is an unregulated information source, making it difficult to verify the credibility of its content.YouTube was searched using the terms: “Dupuytren’s contracture”, “Dupuytren’s disease” and “Dupuytren’s treatment”. Results were sorted by relevance, the first 40 videos from each search were included and duplicate videos or videos without dialogue were excluded (n=55). Two medical professionals independently assessed the source, content and educational quality of 55 videos. The source of a video was determined by identifying those who featured in the video or those who had uploaded the content, through the information available to the viewer. The source of each video was divided into medical professional, news/TV, patient/public and non-profit organisation.Content was assessed for the mention of general background information on DD, surgical treatment options, needle aponeurotomy, collagenase injections and other treatment alternatives. It was noted if a video only had a single focus or was an advertisement. Educational quality was assessed and divided into the following categories; useful to patients, useful only to medical professionals, not useful or misleading. For a video to be deemed “useful to patients” it had to be scientifically accurate and in keeping with what is widely accepted in literature about DD. Additionally, it had to avoid the use of medical jargon and assume no prior medical knowledge; otherwise, it would be considered “useful only to medical professionals”. Videos were “not useful” if the information was solely anecdotal, with no emphasis on education about the disease or treatment options. “Misleading” videos either failed deliver accurate disease information or promoted treatment with no evidence base. The majority of videos were uploaded by medical professionals (34), with the remainder by News/TV (10), patient/public (9) or non-profit organisations (2). Seventy percent of videos that were “useful to patients” were produced by medical professionals. Seventy-six percent of videos focused only on one treatment modality, of which 46% were on collagenase injections. These videos had the least number of mean views and more than half were advertisements.Those video s “only useful to medical professionals” were all produced by medical professionals; they provided less general disease information (43%) and focused on the technicalities of surgical treatments (71%). They also received the highest number of mean views, although had the fewest number of mean “likes”. The videos deemed “not useful” only discussed treatment options, with 80% having a focus on only one treatment modality, 50% of which focused on collagenase injections . p=0.002). Youtube is a free video-sharing site containing over 100 million videos. Anyone can publish videos on the site regardless of their qualifications or intention. The health information available can vary from informative, to promotional, to misleading and potentially harmful. Due to the growth and popularity of the site, it could be considered a powerful tool for health education. The videos deemed “misleading” discussed general disease information in 75% of cases; however, the validity of the information was frequently questionable. Videos deemed “misleading” advocated treatments with no established evidence base, compared with videos “useful to patients”  provided a comprehensive overview of all treatments. 4,5 and patients viewing these videos could be misled into thinking that these treatments are superior, and may be disinclined to accept surgery even if clinically indicated. It was interesting to note a disproportionate amount of coverage on collagenase injections and needle aponeurotomies, in conjunction with the finding that 37% of these were found in videos made by medical professionals that were deemed ‘advertisements’. We speculate that the production of these videos may be influenced by the cost benefits of being able to offer a quick, ‘office-based’ alternative to surgery. Needle aponeurotomy and collagenase may not be suitable for all patients,There is accurate and useful information available on the topic of DD on Youtube, but it is interspersed with misleading and potentially harmful information; moreover, few videos provided a balanced overview of all available treatment options. Patients should be aware of the source and intent of the video, and be prepared to filter them accordingly. Patients should put preference on viewing videos uploaded by medical professionals, as we have found that they provide the most accurate information. Youtube relies on patients being able to locate quality content, and we believe there is a call for professional medical societies to produce videos that outline all available treatment modalities, including the risks and benefits of each, and to which patient group the treatments are most appropriate. So as useful patient education videos are available on YouTube but are interspersed between ones that are potentially misleading, there appears to be a disproportionate amount of information focusing on needle aponeurotomy and collagenase injections. Patients should be aware of the source and intent of the video, and put preference on viewing those produced by medical professionals.