Physical activity is recognised as important for diabetes management and improved overall health of individuals with diabetes, yet many adults with diabetes are inactive. Healthcare professionals have been identified as key to promoting physical activity, including individuals with diabetes, but are ill-prepared to deliver this. Our paper evaluates the barriers/facilitators of healthcare professionals’ delivery of physical activity guidance to adults with diabetes and aims to inform efforts to investigate and enhance their preparedness to promote physical activity.A sequential mixed method, two-phase design was adopted involving a purposeful sample of healthcare professionals. Phase one was an online pilot survey designed to test assumptions around healthcare professionals’ knowledge, training and preparedness to deliver physical activity guidance. Phase two comprised eighteen semi-structured interviews, thematically analysed to provide an in-depth exploration of healthcare professionals’ experiences of delivering physical activity guidance to adults with diabetes.Healthcare professionals are committed to promoting physical activity to adults with diabetes and are reasonably confident in giving basic, generic guidance. Yet, significant challenges prevent them from achieving this in their practice, including: lack of education and training around physical activity, diabetes and health; ignorance of recommended physical activity and diabetes guidelines; lack of awareness of referral options; limited time and accessibility to appropriate resources. Nevertheless, healthcare professionals believed discussions around physical activity needed to be an integral part of consultations, incorporating improved communication strategies for conveying key physical activity messages.HCPs have a key role in the promotion of physical activity to people with long-term conditions such as diabetes and they are identified within both the strategic policy context and national interventions for physical activity. Yet, this study indicated that HCPs face multiple and at times complex barriers to physical activity promotion generally and with diabetes patients. Conversely HCPs also reported what works, why and how, when promoting physical activity. Rich information derived from the day-to-day, working healthcare professional is integral to shaping future practices going forward. The bottom up, iterative design adopted in this study provides an approach to tap into this information. Diabetes and its consequences are a major problem for health systems around the world, reaching epidemic proportions over the last 30 years . WorldwiContemporary national programmes for increasing PA focus on the promotion of PA, including for those people living with a long-term conditions, for example diabetes . As partWhile HCPs appear confident prescribing medication, screening, treatment and diet interventions for patients living with diabetes, there is less confidence and consensus among HCPs regarding the promotion of PA . This coAllaying these fears are important since a physically active lifestyle is critical for blood glucose management and overall health in individuals with diabetes and prediabetes . Adults Adopting person-centred, behavioural approaches in this context may improve the chances of achieving the desired PA outcomes. These approaches indicate that regular positive experiences promote the motivation and capability to adopt a behaviour, whereas negative experiences can lower motivation and perceived capability , 25. HigTherefore, the aim of the work was to conduct a formative evaluation of HCPs working in primary care and the community around the delivery of PA guidance for those with diabetes. The evaluation details information relating to the characteristics, decisions and behaviours of these HCPs, to inform and develop future education and training programmes for this group and, therefore, improve diabetes service provision in respect of PA. An important aspect of the study was to identify the challenges faced by HCPs and understand what worked less well and why, important criteria for the successful management of PA promotion interventions . Here weThis exploratory research study adopted a sequential mixed method design. The quantitative survey element of the research was implemented first and the findings were used to inform the qualitative interviews. As this study was exploratory, a non-probability sample of experts practicing within the field of diabetes and physical activity were recruited. This type of approach has been used previously in PA research to provide more in-depth accounts from health and social care professionals . This inParticipants were first approached through General Practice surgeries and the researchers’ existing links with community organisations. An initial email was sent to HCPs inviting them to participate by the research team. Those that wanted to take part were given an information sheet and asked to provide written consent.The first phase of this study utilised an online pilot survey with HCPs. It was designed to test assumptions around HCPs knowledge, levels of training and preparedness to deliver PA guidance to patients living with diabetes. The findings from this pilot phase were used to determine the most appropriate lines of questioning and issues to be unpicked during the semi-structured interviews in phase two. The second phase of the study was based on a phenomenological approach that focused on HCPs experiences . This waA small purposive sample of HCPs participated in the bespoke online pilot survey, hosted by Qualtrics . The pilReflecting the importance of using iterative bottom up and exploratory approaches when understanding and investigating HCPs practices , individN = 6) in phase one, there is an increased risk of disclosing information about individuals. For example, there are many cells with small counts, under 5. Although the tables themselves do not reveal the identity of an individual, there is a risk that combining or linking tables within this data set may result in a secondary disclosure. By adopting a policy of small number suppression, data cannot be reported from phase one. Nevertheless, data from the pilot study suggested that although many participants were physically active themselves, there were significant shortfalls in training and knowledge around PA promotion for people living with diabetes. As a result, confidence to deal with the practicalities of delivering PA guidance in an appointment setting appeared low.Descriptive statistics were used to describe data from the online pilot survey. All analyses were undertaken using IBM SPSS Statistics v25. Due to the sample size  participated in phase 1, some of whom participated in phase 2. A total of 18 HCPs , participated in Phase 2. Of these, 15 participants were General Practitioners (GPs) and 3 were nurses employed either in a General Practice surgery on in the community. We present the results using a series of themes and selected excerpts in the following section which follows an approach we have used previously in the published literature , I’d probably just say, ‘you should do more’ and that would probably be about where my medical training ends on that front” (HCP 9).One of the most striking aspects of the interviews was that all HCPs, except one, stated that they had received little or no pre-registration education in physical activity or exercise (PA/E), both as a mediator for a healthy lifestyle or for preventing and managing diabetes, as part of their undergraduate or post-graduate training. The little training that they had received around PA/E was generic, in terms of being “good for your health” rather than specific to diabetes. As one HCP commented,“It’s (PA/E) not in a GP curriculum, it’s not in GP training, it’s not in undergraduate training. So, unless you’ve found someone enthusiastic or somewhere to go and you’re interested in learning, it wouldn’t be something you’d do” (HCP 9).“Well, I guess when it comes to diabetes specifically, we know a lot about the disease, the physiology, and I guess the drug management, but when it comes to the physical activity side of stuff I can’t think of a single time I ever had any kind of lecture or group session to do with that. I think physical activity in general is really poorly taught to doctors, and when I’ve had to learn stuff I’ve had to go and… It’s all very self-directed. I have actively to go and seek that information out. I can’t think of a single time either at medical school or during my… or my training when we covered those topics” (HCP 13).The exception to this was one HCP, whose initial degree included information on PA/E and at-risk groups. Other than this, any training or education in PA/E and diabetes that HCPs had received was undertaken whilst in their current role as part of their continuous professional development (CPD). This was largely undertaken on an ad-hoc basis and by individuals who took the initiative and chose to complete self-directed learning, for example, e-learning modules on the British Medical Journal website or attendance at study days. However, unless HCPs had an interest in PA/E, it was not an area in which they would voluntarily seek training, as exemplified by these HCPs,“There was never anything that was like here’s how to manage diabetes, on the lifestyle measure, physical activity. It was much more on the lines of, ‘right, diabetes, you need to discuss diet, you need to start thinking about medication’” (HCP 11).For those HCPs who had completed CPD training on PA/E and diabetes, the focus was on type 2 diabetes, rather than type 1 diabetes or pre-diabetes. The emphasis was on medication and diet, and not PA/E, as a way of managing diabetes, as highlighted by one participant,“I did actually do a diabetes job for four months. I wouldn’t say exercise was really discussed and since then, exercise-wise, pretty much zero CPD-wise” (HCP 8).Worryingly, even for those who had previously worked in a diabetes-specific role, PA/E was not a recognised component of diabetes management,“There isn’t one consistent guidance for diabetes…I wouldn’t know if there was an authority to follow in the UK. NICE has a little bit of guidance about it, but again, it’s fairly broad” (HCP 9).All the participants were unfamiliar with any guidelines relating to PA/E and diabetes and had no idea where to go to find out specific information. Some participants referred to the British Medical Journal (BMJ) or the National Institute for Clinical Excellence (NICE), largely because they chose to be proactive, but the information sought mainly related to the treatment of diabetes rather than PA/E:“I think I’d probably just have an image of what I’d say in my head, but that’s not based on being up-to-date…that I’ve read in the last 5 years” (HCP 10).Of greater concern was the fact that only a small number of participants were familiar with the generic PA/E recommendations according to the CMO guidelines. Of these a few could recite the number of minutes for moderate and high intensity exercise per week, but as one HCP stated, this was despite having read any guidelines,“I was giving a talk to F1s (Foundation doctors) and I showed them the Government guidelines and the Chief Medical Officer guidelines [for PA/E]. We asked the question, ‘have you seen this before?’ I think one person put their hand up to say they’d seen it. It was a group of 30. No-one knew the guidelines” (HCP 9).In addition, those HCPs involved in delivering medical training commented on the fact that even new doctors were unaware of the current PA/E guidelines for the general population,“I can’t speak for all doctors, but I have a feeling that the sentiment is shared, we kind of feel a bit out of our depth when it comes to physical activity in general, especially when it comes to physical activity and diabetes” (HCP 13).Given the lack of training and education or awareness of where to find information on PA/E and diabetes, some HCPs stated that they felt their day-to-day practice was compromised in respect of delivering PA/E guidance to their patients,“I guess most of the guys I work with would say, ‘you should do more exercise’ or ‘you should eat better’. Everyone has an opinion, but it’s based on their opinions rather than necessarily formal training…so we give the advice that we think is best” (HCP 9).Nevertheless, they provided advice to their patients, which was largely based on opinion rather than recommended guidelines or policy,“I’m definitely a less is more doctor. If I can stop people’s medications, then I’m thrilled. But that’s why I sought it [PA/E] out, because there’s good evidence now that exercise and weight loss is probably at least as effective, if not more effective, than medication [for type 2]” (HCP 1).Even though most HCPs had not received any formal training in PA/E in general or as a means of managing diabetes, and furthermore, were unaware of current PA/E guidelines, HCPs believed that many of their peers were aware of the need for more people to adopt lifestyle recommendations. They referred to the importance of exercise, diet and losing weight as generic considerations for the population in general, but also, as a means of reducing the likelihood of developing pre-diabetes and type 2 diabetes. Some HCPs placed a greater significance on PA/E rather than medication as a more effective way of managing type 2 diabetes,“I also try to say they don’t need to specifically go out and exercise, but if they put some music on at home and they do lots of house jobs in that day, they actually use quite a lot of energy…Try and look at what you’re doing in a day and see where you can build in activity. When you do it regularly it becomes behaviour” (HCP 2).A misconception as to what constitutes PA, as opposed to exercise, was prevalent amongst HCPs. When asked specifically about this issue, many believed there were a lot of mixed messages around PA, exercise and sedentary time, in terms of their meanings and recommendations for increasing activity. For those HCPs who could differentiate PA from exercise, they made a distinction between the two when advising patients and were able to emphasise the importance of fitting activity into everyday life,Some HCPs believed that the existing PA/E support which was currently available was aimed at structured, formal exercise and not every day PA, when, in fact, the reverse should be the case with HCPs encouraging people to be more physically active within their everyday environment.“I wouldn’t be 100% certain about how much time or information they’re [patients] given about exercise” (HCP 11).It was clear that there was no ‘one size fits all’ approach regarding HCPs delivery of PA/E guidance to their patients, irrespective of whether a patient had diabetes. Each HCP tackled PA/E differently depending on their role. Amongst GPs there were some commonalities. For example, they referred to the lack of time and not being able to fit PA/E, alongside other priorities, into one consultation. Therefore, the bulk of the responsibility for PA/E guidance was left to the practice nurses, although many GPs thought nurses probably placed a greater emphasis on diet rather than PA/E. When asked, GPs were unclear about the exact nature of the advice proffered by the practice nurses,“I look at the person holistically – look at their medication, look at their current physical activity and look at the overall gains of physical activity to mental health, but also the weight loss and the impact that that will have on their physical health in reducing their blood sugars and the stabilisation of their diabetes” (HCP 6).In fact, practice and community nurses stated that they did address PA/E with all their patients who had diabetes, regardless of the type. This was achieved through an individualised, person-centred approach, focusing on a patient’s diabetes in the context of their lifestyle,“Then if we both thought they weren’t doing enough, or they’d like to do more to help their condition, I’d probably explore the type of things that they would be interested in doing, that they could sustain doing…rather than telling them what they should” (HCP 10).HCPs in general reported that of the patients they saw with diabetes, the majority had type 2 or pre-diabetes. Therefore, the emphasis was on weight loss or calorie counting through a combination of diet and PA/E. HCPs tried to give practical advice according to the individual and sought to ascertain: firstly, the level of PA/E that the individual was currently doing and secondly, determine whether the individual knew the recommended amount of PA/E that they should be doing. Finally, HCPs presented opportunities for being more active which were tailored to the individual’s lifestyle and, therefore, more likely to appeal to the individual,“On a 1-10 scale, with 10 being really confident, probably like 3-4. My advice to them would probably be really generic lifestyle and physical activity advice that I’d give to anyone. Specifically, how I’d tailor that to diabetes [type 2], I would not know how to” (HCP 13).Most HCPs felt reasonably confident in giving basic, generic PA/E advice to their patients. This consisted of exploring the activities that patients currently engaged in and encouraging patients to be more active in the context of their everyday lives. However, when asked about giving PA/E advice to those with diabetes, specifically type 2 diabetes, there was a divergence of opinion amongst HCPs. Some were reluctant to offer advice,“Someone who was pre-diabetic and overweight, I’d feel pretty confident. If there was someone who had poorly controlled type 1 who was on high doses of insulin, I’d feel quite nervous about giving too specific advice about how much physical activity they could safely do…I’d probably avoid the conversation altogether, to be honest” (HCP 10).Others reported feeling confident that they could apply their knowledge, however limited, to pre-diabetes and type 2 diabetes, but unless they had received specific PA/E training in relation to type 1 diabetes, they lacked the confidence to deliver PA/E advice in this context,“If you can get that engagement with them, that’s the other big thing. I think a lot to do with that is if they’re confident with you, you’re giving good messages…and they’re comfortable with you” (HCP 17).An important point raised by a few of the HCPs was the level of confidence that patients placed in their HCP. They felt that this was a significant factor in determining if a patient engaged in PA/E. Key to this was the perceived knowledge of HCPs around PA/E and the way information was delivered. Essentially, if HCPs seemed confident and knew what they were talking about, this instilled confidence in their patients,“I wouldn’t actually know what’s available because it changes all the time according to funding and stuff in the area” (HCP 3).Most HCPs had limited knowledge about appropriate community services and support for patients who wanted to be more active. This was the case regardless of whether their patients had diabetes. They cited insufficient time to research what was available, an inability to keep track of local services and not knowing who to contact as the main factors,“I found that there wasn’t very much information out there and that made it difficult for me to refer people in. People need to know…they’re asking you what it’s about and you think, ‘there’s only so much I can tell you’” (HCP 5).Even when HCPs were aware of a local service, most notably, Exercise on Prescription, the National Diabetes Prevention Programme or DESMOND (Diabetes Education and Self-Management for Ongoing and Newly Diagnosed), they were unclear about how to access information to pass onto their patients,In terms of in-house referrals, HCPs tended to signpost patients to either the practice nurse, visiting dietitian or in the case of one practice, a gym/personal trainer service.“I would argue that it  would come better from being from your GPs surgery than it would from the local authority. For the average lay person on the street, I suspect if they’ve got a health issue they’re not going to go on the council website, they’re going to come to us. And then if we send them to someone else to do it, that’s a barrier, in something that’s already got 20 barriers to doing the exercise” (HCP 1).The consensus was that if everything was in one location, there was an increased likelihood that patients would engage,“There’s no good scheme to refer them to. There’s a pre-diabetes education session, but it’s a one-off session and it’s theoretical. I don’t think it’s enough to make someone change” (HCP 9).Some practices offered free education sessions for those with pre-diabetes or newly diagnosed type 2 patients. However, HCPs were unsure about the content of these sessions, whether PA/E was covered in the curriculum, and even whether they were effective,“The only thing that drives me absolutely insane is the fact that the funding is completely the wrong way round. We’ve got QOF  targets for their HbA1c, their blood pressure, whether they’ve had their feet checked…and there’s no mention of exercise or weight loss. I would love the funding to be attached to sustained weight loss or sustained activity, or at least providing them with discussions about their activity. It would actually focus the problem on what’s actually underlying, rather than how they’re actually fixing it” (HCP 1).All HCPs highlighted the need for a greater emphasis on PA/E, in medical school curriculums and as part of CPD, both generic and applied to specific conditions such as diabetes. In the patient consultation, HCPs thought that PA/E should be an integral component, rather than, at best, an add-on at the end. HCPs referred to the fact that currently, there is no requirement to discuss PA/E in a consultation because it is not linked to a target and, therefore, not incentivised,“I’d probably say a one-page summary outline with reference to all the kind of key facts, with evidence supporting it, as to what we ought to be doing as clinicians for patients with diabetes, exercise and how to go about delivering that” (HCP 13).When asked what HCPs needed to help them focus on PA/E in the consultation, they referred to concise information, i.e. a leaflet like the existing diet sheets, which was regarded as more convenient than having to look on a website,“Some sort of resource in that way in which you can click on to things and it takes you to something a bit more specific for you and gives you more tailored advice, would be useful” (HCP 18).Likewise, regarding patient education and PA/E, HCPs thought that information needed to be succinct with clear guidelines for the patient to follow. Also, tailored patient information was important. It was suggested that one way of achieving this was through an interactive patient hub or one-stop shop,“Just getting the information across. May be some tips on how to get that information across and how to approach it with those patients, because they’re not always the most receptive to the information we try to give them” (HCP 12).Many HCPs stated that PA/E promotion should be part of the practice nurse role rather than GPs since practice nurses saw patients with diabetes on a more regular basis. In addition, HCPs felt they needed improved strategies for communicating PA/E guidance effectively,“For me it’s how we can get experts to make sure the resources are up-to-date, in an easy to find place, that’s marketed to the clinician and realistic to what we can do in practice” (HCP 9).From an HCP perspective, time was often a constraint on whether they delivered any PA/E advice. HCPs stated that if they had up-to-date and readily available information on current PA/E recommendations and local services, they would be more likely to discuss PA/E in what was often a time-pressured consultation,HCPs represent an important ingredient in efforts to promote PA within the population , 31, 33,With those thoughts in mind, this study identified both the strengths of HCPs and the challenges they face in their efforts to promote PA for patients with diabetes. In line with previous research , our stuThe commitment to PA promotion, including to those patients with diabetes is important, given the pivotal role of HCPs in national strategies and programmes designed for promoting PA, including those focused on patients with long-term conditions , 13, 39.That said, it is important that HCPs feel efficacious and knowledgeable in promoting PA to patients, including possessing an understanding of patients’ needs, motives and determinants, in addition to the current PA guidelines .In the UK, multiple HCPs present with diverse levels of training and experience . In thishttp://www.exercise-works.org/). Yet this does little to solve the immediate training needs of HCPs currently in post, including those in our study, where other options are needed. Also, it is important to mention that having accurate knowledge of the dose of activity recommended for health benefits is not enough to translate into improved PA promotion for the population alone. Doctors and indeed all HCPs must be confident and competent in administering advocacy, promotion and counselling skills [Looking forward, research has identified that future medical students want to receive more training on PA  and repog skills  and thisHCPs in this study reported that there were options to engage in CPD and indeed several participants identified professional bodies that offered CPD opportunities with accreditation and as part of nationally recognised programmes. This is a step in the right direction, but HCPs reported needing to be motivated to seek out these CPD opportunities, some of which they accessed through their own volition. With those thoughts in mind, the RCGP are collaborating with Public Health England on the GP Clinical Champion Programme for PA , 51. Thihttps://www.sportengland.org/our-work/health-and-inactivity/moving-healthcare-professionals/).Given the importance of competence and confidence in PA advocacy , for thoA further component of PA promotion by HCPs is an awareness of PA opportunities. In this study, HCPs referred to a lack of awareness of local services and options for referring patients into local PA programmes operating in the community . This isTo support HCPs attempts to promote PA and in response to the pressures faced by HCPs, Moving Medicine (MM) was launched in 2018. MM is an interactive, evidence-based, internet tool to support brief advice in PA across a range of diseases and conditions . ImportaThis study has several limitations and strengths. Limitations include a lack of representation from nurses who take on an important role in PA promotion , 60 and In thinking about how such activities are deployed, the authors encountered reluctance from some GPs to speak with outsiders or researchers from beyond their own professional circles. The strengths included an approach which identified a lack of presumed knowledge of the guidelines around PA and diabetes and an understandable anxiety amongst participants about this. This in part may have contributed to some of the difficulties when recruiting HCPs for this study, especially GPs. In overcoming this challenge, a further strength was the training of co-author and GP as a researcher who was involved in data collection. This helped address some of the preconceived misgivings about speaking with outsiders  preferriThis evaluation presents new insights into the preparedness of HCPs for delivering PA guidance to adults with diabetes and also valuable information for how to undertake research in this setting and these groups. Using a sequential mixed method, two-phase approach, we have identified the factors underpinning the decision-making processes and behaviours of HCPs, as well as the challenges they face, when promoting PA to the diabetes community. Importantly, we have provided an opportunity for HCPs to tell their story through insightful accounts and through a trusted source. Given the importance of PA within the strategic and policy context for PA, rich information derived from the day-to-day, working HCP is integral to shaping future practices going forward. With those thoughts in mind, we provide the following recommendations.Undergraduate education focused on PA and health conditions, including type 1 diabetes, type 2 diabetes and pre-diabetes.CPD opportunities for PA training and diabetes.Mentoring of HCPs who are new to the role or who just lack confidence in their ability to disseminate advice on PA to those with diabetes.Accessible, central database of current local PA providers.Tailored resources (web-based and printed) for HCPs and patients with diabetes.Consistent, joined-up approach between primary, secondary and community services regarding PA promotion for those with diabetes.PA services / programmes tailored specifically to patients with diabetes that are affordable.Continued and on-going dialogue with HCPs about their needs when promoting PA.Adopting a qualitative approach in investigating the barriers and facilitators that HCP face include non-supporters when developing interventions that help facilitate their engagement and involvement.


Scientific Reports 10.1038/s41598-017-12318-2, published online 20 September 2017Correction to: In this Article we uncritically employed the terms ‘travelling wave’ and ‘travelling wave-front’ to describe the spread of the Neolithic. There is, however, a distinction between these terms which relate to two different models of dispersal. In Archaeology, the term ‘wave-front’ has been largely associated with the demic diffusion model of Ammerman and Cavalli-Sorza (1971) where the population of previously occupied territories is kept at carrying capacity even after the wave-front passes through them. By contrast, in a travelling wave model the population of previously occupied territories would decrease back to neutral growth levels once the wave moves out of those territories.As a result, in the Conclusion section,3, as indicated by the SPD across the entire research area.”“However, contrary to its interpretation as episodes of population growth and sudden collapse, their sequential staggering through time and space, identified here for the first time, suggests that they rather correspond to the demographic signature of a travelling wave-front. In this interpretation, the ‘boom’ is linked to the arrival of new people, whilst the ‘bust’ must be understood as due to outgoing migrants, resuming their spread into a new region. This interpretation is consistent with the expected properties of demic diffusion, as only the wave-front experiences a noticeable demographic pressure, whilst the meta-population follows a neutral growth curveshould read:3, as indicated by the SPD across the entire research area.”“However, contrary to its interpretation as episodes of population growth and sudden collapse, their sequential staggering through time and space, identified here for the first time, suggests that they rather correspond to the demographic signature of a travelling wave. In this interpretation, the ‘boom’ is linked to the arrival of new people, whilst the ‘bust’ must be understood as due to outgoing migrants, resuming their spread into a new region. This interpretation is not consistent with the expected properties of demic diffusion, as only the regions being passed by the travelling wave experience a noticeable demographic pressure, whilst the meta-population follows a neutral growth curveThe conclusions of the Article are unaffected by this change. The authors apologise for the error and any confusion caused.


Objective: At the end of the Practical Year (PY), medical students decide on a specialization. Individual motivational factors and barriers play a central role in the choice of the subsequent subject area and the place of establishment (city/country). The aim of this study was to document the barriers of PY students within the General Practice (GP) tertiary elective over time. Methodology: Two guided interviews were conducted with each participant (N=19) as part of qualitative process monitoring – a pre-interview at the start and a post-interview after completion of the PY. Evaluation of the interviews was based on Grounded Theory. Results: 13 barriers could be deduced from the 38 interviews. The most frequently cited barriers were “expected workload”, “recreational opportunities”, “work-life balance” and “compatibility with family”. 13 of the participants were firmly committed to continuing GP training, 12 of whom aspired to opening a practice in a rural area. Another three were considering GP training, three had decided against it after the PY. After the PY, some of the previously anticipated individual barriers were now perceived in a more differentiated manner as a result of practical experience. The barriers “work-life-balance”, “compatibility with family”, “recreational opportunities” and “infrastructure” had been largely eliminated. Conclusion: The PY General Practice Tertiary itself appears to have a positive impact on the individual barriers expressed before the PY. Targeted experience with a PY in General Practice at the end of study seems to be a solution to increase the attractiveness of the subject.  The nationwide provision of GP care in rural areas presents a challenge in the German health care system . During Even young physicians, who have already decided in favor of General Practice, are aware of barriers to setting up practice in rural areas. The aspects most frequently discussed in the literature are unfavorable conditions for reconciling work and family life. These include poor job prospects for the life partner, poor infrastructure, the financial risks involved in setting up practice, suspected low earning potential and an expectation of a higher workload and social responsibility , 6], , , 9]. In. In9]. IThrough various measures, politicians and committees of medical self-government are trying to create incentives for practicing medicine in rural areas , 12]. I. I12]. IThe qualitative monitoring of PY students in the GP Tertiary Elective presented here in rural GP surgeries intended to document changes in the attitudes towards the subject area and towards potential future practice in rural areas over time. To explore individual expectations and experiences, a qualitative approach was chosen. The participants (TN) were interviewed in two guideline-based one-to-one interviews. The interviews were conducted at the beginning of the Practical Year (Pre) and at the end (Post).In the period from October 2014 to July 2017, PY students taking the GP elective were invited to participate in the study at the medical faculties in Erlangen, Würzburg and Regensburg (n=37). All PY students from Erlangen (n=33) were also offered a place in a rural teaching practice in combination with an expense bonus of €650 per month (in the GP tertiary). For the training of PY students in GP, the GP Institute of the University Hospital Erlangen has 33 teaching practices at their disposal. All medical student trainers must regularly take part in various CPD courses on medical education. For the study, eight practices in rural areas  were selected. Inclusion criteria were the rural location , sufficient size and equipment, as well as positive evaluation results. The teachers of the eight rural practices completed a separate CPD course in medical eduction in December 2014. This included learning objectives for the PY GP Tertiary, tips for organizing and integrating the students into the daily routines of the practice, as well as practical feedback training. Based on the available literature, different guidelines were developed for the pre- and post-interviews. The pre-interviews were divided into the topics “Individual perception of General Practice”, “General Practice at university”, “Choosing the PY General Practice Tertiary” and “Choosing a teaching practice in a rural area”. The post-interviews focused on “Experiences in the General Practice elective", “Individual perception of General Practice” and “Future planning”. The key questions were supplemented by further questions, some of them spontaneous and partly based on the results of the pre-interview survey, in order to make it easier for the interviewers to adapt flexibly to the course of the interview and to increase the depth of the interviews. In the course of data collection, the guidelines were adapted to the evaluation results and thus developed further. The interviews lasted 33 minutes on average (13-68 minutes). They were conducted in person or over the phone by a medical doctoral student (KL) and a non-medical scientist (CM). The interviews were digitally recorded, transcribed and anonymized. The data was evaluated based on “Grounded Theory” . The evaThe results present the statements of the pre- and post-interviews of 19 PY students . Of these, 13 participants completed their PY in one of the selected rural practices, six participants in urban practices. After the PY, a total of 13 participants had definitely decided in favor of specialization in GP . Three took specialization in GP into consideration and a further three decided against it. A rural place of work was conceivable for a total of 13 participants . For six participants this was not conceivable . Of these, three participants preferred setting up practice in an urban area  and another three participants preferred work in another specialization . Only two participants who had completed the PY in a rural practice ultimately decided against setting up practice in the countryside. One participant for personal reasons and the other as they had already settled and started a family. A description of the sample is shown in Table 1 In the interviews, we asked the students about the barriers they perceived to General Practice in rural areas. There were 13 barriers, most commonly “anticipated workload”, “effects on the family”, “recreational opportunities” and “work-life balance”. The barriers could be assigned to two main categories in the evaluation. For three participants the barriers “External factors: finances, bureaucracy, health care system”, “diagnostic uncertainty”, “one-sidedness of the GP profession” and “proximity in patient contact” were decisive for turning their back on GP. In the following, after each quote the TN number, interview , training inclination (WB)  and the inclination towards setting up in a rural area  are indicated.In the pre-interviews, participants suspected a higher workload compared to other subject areas. Following practical experience, this was confirmed, but was more differentiated due to more flexible working hours. “Well, of course it’s a lot of time you end up investing, [...] But in return you also have the advantage of being free at lunch time, for example.” While in the pre-interviews some of the participants were expecting inadequate and sometimes even poor pay for GP activities, no more comments were made on the income of a GP in the post-interviews. Instead many statements were made on the required business knowledge, the bureaucratic burden of a practice and restrictions on medical work by the health care system.“Well, basically you end up running a medium-sized company, but never having learned anything of business admin [...], never anything about accounting, that’s shocking.” The work of a rural GP and, in the eyes of one participant, limited range of activities led to two participants turning their backs on the option.  “And then you leave it to wait-and-see and then next time around it’s gone and you never know what it was.” TN 5 Post, WB-, Rural-)For the majority of the participants, however, these two factors were a motivation for a career in General Practice. “[...] and using guidelines and evidence-based structures, you were able to gain confidence in dealing with patients. [...] you’re a doctor on your own and you can be a very good doctor.” In the pre-interviews, rural practice was seen as more intensive and more time-consuming than other fields. “[...] this huge amount of time each week, that can really finish you.” In the post-interviews, this was relativized by the practical experience, especially in the rural practices. The workload fluctuated depending on the organization of practice structures. Chaotic daily schedules stood in contrast to well-functioning teamwork or practice organization. One very common suspicion voiced in the pre-interviews regarding the causes of the lack of young rural doctors was the assumption that cities are probably more attractive due to a more varied offer of recreational opportunities. “Maybe in the countryside, to put it bluntly, there’s too little going on.” In the post-interviews, most participants were showing a willingness to compromise on the distance between home and work, as well as the accessibility of urban activities. Travel times up to 45 minutes were considered acceptable. In the pre-interviews, many of the participants associated working in a rural area with an unsatisfactory work-life balance due to patients being able to contact you around the clock. This was not confirmed by the participants in the post-interviews. It turned out that especially group practices were perceived to offer a good work-life balance. The separation of home and workplace was a good solution to this problem. “Therefore, I think that in the context of group practices, [...] that it is definitely possible to have a pleasant work-life balance as a GP.” Compatibility with having a family was an important influencing factor for the participants. In the pre-interviews there was the expectation that the work in a practice would be more compatible with having a family than working in a clinic. This was to be put to the test in the PY and was subsequently confirmed, based on the possibilities of group practice, part-time work and more flexible working hours. “I think, especially as a female GP, [...] it’s easier to manage having a family than, for example, as a senior physician in a clinic, with loads of weekend shifts, emergency shifts, being on-call etc.” Nevertheless, one criticism that was mentioned in the post-interviews was that settling in the countryside could also fail due to having to move a whole family.“And that’s usually the reason why it fails, ’cos the family has to tag along. [...] especially your partner, but also the kids [...] they got their school, their friends, making it less likely you’ll move.” A partner requiring job opportunities is another inhibiting factor when considering a career in a rural practice. “That’s what we always said, if the partner can’t come, you won’t go.” With regards to the patient structure, predominantly elderly patients were expected in the pre-interviews. After the tertiary elective, however, the participants reported a broad distribution of the patient population. The infrastructure of rural areas was also seen as a limitation in the pre-interviews. On the one hand, few supermarkets, secondary schools leading to university and kindergartens, and on the other hand by poor public transport.“The kids may have to travel far to school or to any sports or music lesson.” Having experienced work in rural practices, this barrier was considered hardy worth mentioning in the in the post-interview. A particularly close doctor-patient relationship in rural practices was already expected in the pre-interviews. However, only a small section of the participants later saw this as a barrier. “[...] such close, long-term patient contact [...] I’m not that kind of person.” The medical profession was also seen as a way of integration into the community. “Well, I think, with a job that [...] really brings personal benefits for the locals [...] I think it’s easier.” In rural practices, pre-interviews expected there to be a very large catchment area due to the low density of doctors and long trips to carry out home visits and patients having to travel far to see a specialists or get to the nearest hospital. No uniform perception could be derived from the post-interviews. For one participant long distances were generally unattractive, another was accustomed to these due to their own rural origins. Another participant thought that although the distances were longer, the speed you could travel at was higher compared to similar travel distances in a large city.A list of the barriers with further anchor citations is shown in Tab. 2 at the attachment 1 . The “work-life balance”, “patient structure” and “integration in local community” barriers changed equally in both groups as described above. The barriers “workload”, “recreational opportunities” and “large catchment area” remained constant in the urban group, while they largely decreased in the PY rural practice group, partly due to compromise. The barriers “infrastructure” and “compatibility with family” were only mentioned in the post-interviews by the PY students of the rural group and had reduced as a result of their experiences in the PY. Also, “job of the partner” is only an important factor for the rural practice group and persists after the PY. The barriers “External Factors: finances, bureaucracy, health care system”, “diagnostic uncertainty”, “one-sidedness of the GP profession” and “proximity in patient contact” only played a role for the three participants, who ultimately decided against specializing in GP.Before the start of the PY GP Tertiary, clear barriers were perceived both to GP and setting up a practice in a rural area. After the PY, it became clear that the previously expected individual barriers were now perceived in a more differentiated manner and were partially completely eliminated by the practical experience. A comparison of the PY experience with personal inclinations led to a reassessment of the previously expressed barriers, often through reaching compromises. Especially the barriers “poor work-life balance”, “poor compatibility with family”, “lack of recreational opportunities” and “poor infrastructure” were largely reduced by the experience. The fact that all but three participants are interested in specializing in GP also suggests that the barriers to the subject can be minimized solely by experience in the PY and the resulting adjustment of perception. When examining the practice setup trend, it is surprising to note that most participants, both from rural and urban practices, prefer setting up in a rural area and only a few decide on setting up practice in the city for personal reasons.The workload was perceived by our participants as high, but was accepted due to the flexible distribution of working hours during the week and the lack of weekend shifts. In addition, a well-regulated work-life balance was also perceived in rural practices. Similar findings were found in a study by Maenner et al. ]. He alsFor many of our participants, the close doctor-patient relationship and chance to support whole families is one of the main motivators in choosing a specialist area. Patient-centered work has already been identified as the most important factor for future GPs . SimilarThe attractiveness of urban vs rural areas in our study was directly related to the personal willingness to drive to the nearest city to engage in a certain activity. With regard to the longer distances in rural areas, travel times of 30 minutes for home visits and the commute to work, and 10 minutes for travel to shops and educational facilities for children are also considered acceptable in the literature . AccordiThree participants decided to turn their back on specialization in GP as a result of their experience in the PY GP Tertiary. The reasons were the lack of business knowledge, the expectation of a low income and a high administrative effort and coincide with known barriers from the literature , 6]. An. An6]. AThe life-partner’s career situation also represents a barrier to setting up practice in rural areas which is discussed in the literature , 9], , . More thPractical experience in the GP Tertiary also seems to be useful as a baseline for future education in other subject areas. The flexible continuing education regulations allow young physicians to leave ultimate specialization goal open, as, for example, training in GP and internal medicine show a large overlap with 18 months of inpatient basic training in internal medicine . In a reThe present study refers to a small, regional cohort in northern Bavaria and therefore can only be generalized to a limited extent. However, it can serve as a guide for further multi-center studies. Recruitment took place only among the students registered for a GP PY, which could result in a selection bias. Recruiting among all PY students would only have been constructive for capturing cross-sectional barriers, not their changes during the GP Tertiary. The financial expense allowance for participants choosing rural practices may also have influenced the choice of practices. But this made the practicalities of transport or even changing residence more feasible for students. Despite the small sample size we see the design of a qualitative process monitoring by means of pre- and post- interviews as a strength. By flexibly adapting the questions to the flow of the conversation, a detailed exploration of their own expectations and barriers was achieved. Targeted job experience at the end of studies seems to break down barriers to GP in rural areas. Enable such targeted job experience could be an approach to increasing the attractiveness of GP in rural areas, thus providing an early incentive to young medical professionals to ensure future GP health care in rural areas. The framework conditions for the implementation of such work experiences are created by the catalog of measures in the Master Plan for Medical Studies 2020. With the support of politicians and municipalities, a wider implementation of such an approach would seem practicable and evaluable.The present study was part of a medical doctoral dissertation at the Friedrich-Alexander University, Erlangen-Nürnberg (FAU). The study was funded by the Bavarian Ministry of Health and Care (G31a-G8060-2014/167-3). The Ethics Committee of the Friedrich-Alexander University Erlangen-Nürnberg had no concerns regarding the study (Ref: 336_14 Bc).The authors declare that they have no competing interests.


The Wind Blew Me There—Memories of a Ship’s Surgeon Aboard the Barquentine Verona.” Were truer words ever uttered?“A youth with a heartbeat cannot circle most of the globe for a year without being profoundly altered,” writes tropical medicine colleague Barnett Cline in the preface of “In 1965, Cline had not yet chosen global public health as his calling when boarding the 138-foot schooner as a sole medic and fellow tar for a crew of twenty-five. At the end of his voyage, the world looked a lot different; so did his future career. Cline would subsequently complete a PhD in epidemiology at UC Berkeley; work on dengue and schistosomiasis for CDC’s field lab in San Juan, Puerto Rico; expand his work (mainly on helminthiases) to sites as far-flung as Egypt, Cameroon, and Malaysia; and eventually serve as Professor and Chair of Tropical Medicine at Tulane University’s School of Public Health and Tropical Medicine. In short, his life-adventures were just beginning when his marine odyssey ended in an ancient Greek village where he and his wife Nancy later owned a home for thirty-five years.In one respect, however, ascending Verona’s gangway seems a laudable act of courage when viewed through the lens of time. Four years earlier, the ship’s skipper had survived a terrifying white squall, which not only claimed his square-rigged brig “Albatross,” but also the lives of his physician-wife Alice and four high-school-aged sailors. Although Cline immediately took to Christopher Sheldon when they first met in Bogota , as independent accounts would later attest, the skipper had a darker side.After sharing this eye-popping intel, Cline—a former ASTMH President—interweaves modern reunions with Verona shipmates with captivating stories of people and cultures he encountered on a long and exotic itinerary. His ports of call included the Galapagos, Pitcairn Islands, French Polynesia, Cook Islands, Samoa, Fiji, New Hebrides, Papua New Guinea, Taiwan, Hong Kong, Thailand, Malaysia, Andaman Islands, India, Sri Lanka, Maldives, Yemen, Saudi Arabia, Egypt, Lebanon, Greece, Malta, Spain, and Portugal. That the book’s chronology is not precisely linear adds to its freshness.“…fifty years later, Cline recalls performing emergency surgery while on the Galapagos Islands, dodging the arrows of hostile natives in the Bay of Bengal, experiencing a mutiny mid-Pacific, and acquiring a cave house overlooking the Aegean Sea on Santorini, Greece. Cline also shares medical moments that tested his education and gave him invaluable real-world experience in emergency and tropical medicine.”Then there’s the pure adventure and thrill of this travelogue-cum-memoir, nicely “teased” in an Amazon blurb.The Wind Blew Me There,” let me simply say: this is a one-of-a-kind memoir well worth enjoying and sharing! The following interview with its author was conducted in July 2018.Since further details might spoil the delight of reading “At my medical school—Baylor—the reigning gods were DeBakey and Cooley. If you weren’t transplanting hearts, you weren’t a real doctor. So I was initially caught up in the excitement of surgery, and I held on to that interest through my rotating internship at Tulane. At that point, I was accepted into Tulane’s surgery program. I was supposed to complete two years in the Peace Corps to fulfill my military requirement—remember I couldn’t join the Navy because of a high-frequency hearing loss I didn’t know I had until my pre-entry physical examination—and then do the residency.But now I’ve got to step back because tropical medicine seeds were actually planted in Panama as a senior medical student. Back then I had a two-month fellowship at the Gorgas Memorial laboratory, which included a lot of field exposure and some clinical work and also introduced me to Karl Johnson and Ron McKenzie, who were both members of the Society. My Peace Corps experience in Bolivia reinforced my interest in working in remote areas, and the year at sea gave me added time to grow and reflect. Eventually, I decided that practicing surgery would not be consistent with the big-picture career I wanted.Here’s a final connection with the Society. It was Karl Johnson [another former ASTMH President and founding Director of CDC’s Special Pathogens Unit] who saw me off as we sailed into the Pacific. I think he would have liked to have climbed aboard as well! Later, in 1993, when I was greatly honored to serve as ASTMH President, Karl roasted me before my Presidential address. That’s when he described me as a risk-taker and showed a photograph of my boarding the Verona. Before that moment, I had never thought of myself as a risk-taker.Well, I don’t think there was a single, over-arching revelation that came to me during the year. But every port of call exposed me to a new culture, language, cuisine, geography, and history. It was just fascinating to absorb all of that. In addition, there was the sailing experience itself. When I was on night-watch from midnight to four, or from four to eight in the morning, I felt connected to mariners through the ages. I’d see whales and porpoises frolicking—water spouts and active volcanos—I also did a fair bit of free-diving and scuba-diving. It was a never-ending set of experiences.Some 24-hour gale-force winds in the South China Sea were our biggest scare. Of course, at the time, we were really too busy to be scared; it was only after the winds subsided and we thought back that we were terrified. Waves were crashing all over the place and in order to be at the wheel or on deck for any purpose, you had to harness yourself so you wouldn’t be washed overboard.At the beginning, I was naive about the skipper, and I had full confidence in him. And maybe I didn’t want to see the flaws that later became pretty obvious. It took a while for the whole crew, me included, to realize we were at risk. Finally, when we were approaching one of the French Polynesian islands and he neglected to give the order to drop sail because he was totally inebriated, we almost crashed into the shore. So that’s what finally woke us up. We couldn’t ignore that.It was a five-year process. First came my partial retirement, and then complete retirement, which gave me the time not just to reflect but to look at the thousands of photographs I shot on the trip. After digitizing three hundred, I could actually sit down and work with them in my computer, which was a critical step. But discovering my journal was even more important. After I found it and started reading, it was like I had gone to the moon! Finally, I found letters my parents had kept in a box. All this plus my detailed photographic notes were the material I needed.But the real catalysts were the photographs, because each one brought back so many memories. One in particular of a crewmate made me wonder: where is that guy? So I actually found him living in the mountains of western Honduras and arranged a trip to meet with him. That experience, in particular, convinced me that my book could go beyond high adventure and present special individuals and characters.A final bit of advice? Keep careful notes! If you don’t, memories can be treacherous.The most satisfying responses I’ve gotten are from strangers. For example, one gentleman told me he enjoyed the book so much that he gave a copy to his nephew, hoping it would encourage him to take a year, get off the merry-go-round, and expand his world.“The fact that the story took place in the mid-60s, long before social media, Instagram, Snapchat, Wi-Fi, and the ‘see-me-now’ world adds to its special allure. It harks back to a simpler, more lovely world where adventure was more genuine and, perhaps, more plentiful.Then there was only the sextant and dead reckoning for navigation versus the constant, exact whereabouts of anyone, anytime, anywhere on earth.”I absolutely agree. After I reflected on Bob Lux’s words, I realized it’s absolutely true that the voyage I took—for the exact reasons he stated—could not be replicated today. And that makes me appreciate all the more the uniqueness of my experience.


The findings highlight a controlling aspect in engagement and a dynamic interplay between the processes as mutually determining the quality and the intensity of the interaction. Recommendations are provided for examining control as a main emotional, cognitive, and behavioral mechanism in problematic and/or addictive social media and smartphone use.Adolescents actively use social media, which engages them cognitively, emotionally, and behaviorally. However, the underlying psychological mechanisms of engagement have not been adequately addressed. The present study examined adolescents’ psychological processes as these develop in their everyday interactions via social media. The sample comprised six focus groups with 42 adolescents from UK-based schools. Data were analyzed using constructivist grounded theory. The resulting concepts related to individual, social, and structurally related processes, highlighting a synergy between the processes underlying use and a gradual reduction of control as individual, social, and structurally led processes emerge, conceptualized as the ‘ Adolescents benefit from the use of social media applications (‘apps’) and features  on major platforms, but empirical evidence suggests a minority also struggle to use them in moderation . The difAdolescent social media use is associated with major psychological processes underlying use. Psychological processes are operationally defined as cognitive, social, or behavioral mechanisms relating to an individual’s pattern of thoughts, emotions, experiences, and/or behavior, and are critical in increasing the vulnerability for developing a disorder, or are involved in its etiology or maintenance , with imSelf-presentation, disclosure of personal information, and surveillance—the act of watching and being watched [supportive interactions and social connection enhance positive affect [Main user functions of social media share three crucial processes: Cognition, communication, and cooperation. The sharing of content produces communication and may result in a form of collaborative work within the community of users . These t watched —constitu watched . Evidenc watched  and indu watched , while se affect .fear of missing out (FoMO), reciprocal liking, and social competition [electronic aggression—defined as aggressive acts enacted in the digital environment, such as mocking, making insulting or threatening comments, spreading rumors [online disinhibition effect. This is operationally defined as conscious and subconscious reactions to online experiences fueled by the absence of face-to-face communication and the anonymity or distance afforded by online communication [trolling  and perceived as hurtful (by the victim); …part of a repetitive pattern of negative offline or online actions; and performed in a relationship characterized by a power imbalance”  or bantxclusion ) to morealance” Current empirical evidence concerning social media addiction emphasizes uses, antecedents, impacts, and risk factors conducive to social media use . Howevegrounded theory, a qualitative methodology most appropriate for research concerned with understanding phenomena [constructivist grounded theory [The present study applied henomena  and prodhenomena . More spd theory , which id theory , while sd theory . This epN = 42) aged 12 to 16 years  were selected in collaboration with three local secondary schools in the East Midlands area of the UK, including a mix of an all-female school and two co-educational schools. Students were primarily white (63%), black (22%), and Asian (15%), with an almost even gender split , and from diverse socio-economic communities: Upper socio-economic class (20%), middle class (54%), and lower class (26%). The study targeted adolescents due to the: (i) high online usage this age group exhibits, and the vulnerability to peer evaluations and risk behaviors [Participants  heehaviors , and . A semi-structured focus group guide was developed based on key perceptions of concerns and psycho-emotional problems arising from the various uses of social media. Given that the sample was adolescents, it attempted to elicit processes involved through the main social media uses, concerns, incidents, and experiences arising from use followed by perceived impacts. Data were collected from six adolescent focus groups from three schools in the East Midlands area over a period of two months. Upon agreement for participation, information sheets about the nature of the study were distributed electronically from the school administration to the parental community, along with parental opt-out forms. The sign-up for participation was conducted by the schools’ administrators and there was no compensation or reward provided for participation. Each focus group lasted 60 to 100 min, and was audio-recorded and transcribed verbatim with the use of NVivo 12.00 software. Adolescents were asked to discuss specific uses and practices, motivations for use, and any problems, concerns, and intervention needs.Some people post anything, and they don’t care, to be fair. I wish I could be more like that…and I don’t judge them for that, I am just overthinking…” (FG2F4). This was labelled “preoccupation”. Subsequent similar iterations were compared to the initial incidents and through the process of constant comparisons formed categories, such as ‘cognitive salience’. These categories were higher in level and more abstract and formed the building blocks for the theory development and integration. These categories were then formed into higher order categories with more abstract headings based on their functions and interactivity with the other processes. Memo writing was constantly updated as the analytical process evolved. Theoretical sampling was met through the meaning the adolescents attached to those interactions and examining representativeness and regularity of the categories in the subsequent focus groups. Hypotheses about relationships amongst categories started to be formed and checked against new data, and broader structural conditions emerged and were integrated in the analysis  until reaching saturation [Coding took place initially using open coding, followed by axial and selective coding. The analysis was conducted simultaneously to coding the data, starting off with concepts, which were the basic units of analysis and gradually built up as new data emerged with repeated concepts grounded in the data. For example, one participant mentioned: “turation . This cocognitive and emotional processes and termed as ‘engagement to control’ content, relationships, and self-presentation; (ii) socially-constructed, termed as ‘controlling the relational self’; and (iii) structurally led processes (driven by the platforms’ designs encouraging a specific repertoire of behaviors), termed as ‘hooking and hunting’. Social processes were based on group responses and were empowered by group dynamics, whereas structurally led processes were platform-related mechanisms aiming to reinforce engagement.The study’s findings highlighted several complex and inter-related processes underlining adolescent social media engagement and embedded in adolescent social media user functions, comprising three types of processes : (i) IndHeightened self-consciousness, cognitive salience, and vigilance. Students reported experiencing a state of higher self-consciousness (awareness of oneself and actions) and alertness (“Makes everybody a lot more self-conscious” (FG2F6)), instilling arousal as a result of their presence and engagement in social media. Participants attributed this to the photographs and content that adolescents posted and to expectations for feedback to their posts, either in the form of ‘likes’ and/or comments. This elevated state of preoccupation with personal appearance was viewed as magnified via the photo-sharing culture of platforms, and judgmental peer attitudes on social media leading to a constant need for enhancement of photos and content. Additionally, peer expectations for instant availability created pressure for checking. Leaving notifications or messages unattended was perceived as a sign of being ignored, which created communication complications. Adolescents therefore reported experiencing a state of constant salience and vigilance for new content: “Users’ permanent cognitive orientation towards online content and communication, as well as their disposition to exploit these options constantly” [stantly” , p. 1.Exhibitionism, social comparison, and appraisal. Adolescents exhibited specific friendships on social media as evidence of time spent together or as a way to garner support and approval from peers: “They do it to show how close you are and that you have a funny relationship but at the same time it might be embarrassing for the person” (FG4F3). This was often conducted by contemplating peers’ considerations regarding a physical feature, while others chose to disregard others’ perceived insecurities for appearance when posting a group photograph, which was a common cause of concern and misinterpretation amongst peers. Therefore, a state of arousal and overthinking was expressed also about the level of self-disclosure. Similarly, the practice of sexting—the act of sending and/or receiving sexually explicit texts and images [It’s like you scroll through Instagram and automatically I don’t mean to be but I’m like the most judgmental person” (FG2F1). To balance out the highly critical environment of the more public social media platforms , relational closeness was sought through exchanges of intimate day-to-day experiences that were free from social comparison and scrutiny.d images —was ofted images . AdolescDistractibility and procrastination. Distraction refers to the removal of attention away from a negative situation to a neutral or positive one and is considered a cognitive strategy to regulate emotions [When I’m doing homework, it is very distracting, one question might take me like an hour, because I chat on my phone” (FG1F1); or (ii) internal interruptions, in the form of preoccupation with (and expectations to) receive comments and messages: “So even if I put it in my bag say if I have Maths, then I am like: Oh, maybe that person might be texting me, I am going out to check my phone” (FG6F3). This mental shift was viewed as impacting focused engagement in schoolwork and as a detrimental process in social media engagement. Additionally, adolescents experienced feelings of procrastination, using social media to delay tasks, “Snapchat it is quite an easy way out, it’s accessible for people who want to procrastinate a bit” (FG4M2) and viewed as influenced  by their ability to control their distractibility.emotions , which memotions . A majorRelational closeness for social facilitation. Students reported a need to have both a public and a private discourse online with Instagram as the main public platform and ‘Finstagram’—a second more private Instagram account and Snapchat to serve as platforms for the exchange of intimate, informal moments and experiences amongst an inner circle of friends: “…people now have created second accounts, because they are so self-conscious” (FG2F3). In social situations, adolescents experienced social facilitation in two ways: (i) Using social media as a means to overcome social discomfort or social anxiety by replacing ordinary moments of waiting , and (ii) as offering a boredom-reducing solution when in the presence of ‘unwanted’ others.Separation anxiety to fear of loss of self-control. Adolescents experienced anxiety and negative mood states when not having their mobile devices, when unable to contact or access content (nomophobia). Self-control was viewed as compromised due to FoMO and the constant pressure for availability. Adolescents preferred to keep devices physically away during homework (“I made my brother hide it while I was revising. It was so like addicts” (FG2F4)), yet they experienced a difficulty resisting attending to notifications or direct messages. A difficulty was also expressed where sleep time routines were violated, and sleep compromised either due to reading notifications or purposeless scrolling through feeds.Mood modification. Adolescents experienced volatile emotions as a result of online interaction. Mood was often dictated and altered by (i) negative peer responses, (ii) inability to access devices, and/or (iii) feeling unable to communicate with friends ). However, participants also reported an inflated sense of self and entitlement for liking and approval in relation to self-presentation. The curation of personal identity online was raised as a critical daily task, fulfilling users’ needs to gain acceptance and enhance one’s social status within the online community. Therefore, in response to the increased effort to identify, upgrade, and post the preferred image were reciprocal expectations for liking and approval. However, the practice of enhancement often took extreme forms beyond identification in real life, viewed as causing disillusionment, distrust, and higher aggression as a result.Deindividuation of self to conform to group norms, (ii) diffusion of responsibility and ensuing social disinhibition, (iii) relational aggression on the continuum, (iv) interpersonal surveillance and mirroring, and (v) social disruption.Adolescents also discussed processes they experienced as a result of belonging to various online groups. These processes were identified as: (i) Deindividuation of self to conform to group norms. Loss of personal will and the tendency to follow and agree with other in-group opinions or actions was experienced by adolescents as either passive tolerance or indifference. Peers often expressed succumbing to the common spirit of the moment despite personal disagreement ). To an extent, this process was facilitated by conforming to group norms and by passively tolerating bad behavior through inaction, indifference, and/or aggressive acts. Adolescents experienced a high degree of group influence in group chat situations, where peers tended to exhibit social desirability rather than supporting a peer who was in distress: “In group chat, if someone says something, it’s a lot easier for people to agree with them rather than back the other person up: If they tell you, ‘you’re fat’ or whatever, then it’s a lot easier to agree, rather than saying—that’s not right!” (FG4M2).Diffusion of responsibility and ensuing social disinhibition. Adolescents experienced a loss of responsibility “I think on social media it is a lot easier to physically move your fingers and type in words and actually say something to someone because you can write anything but would you say that on their face?” (FG4M1) and conforming to the group dynamic expressed as inactivity or tolerance of bad behavior towards other peers, “It’s easier to say anything, you’re more brave online, not scared” (FG5F1).I wanna look at what other people are doing…When you don’t want to talk in person, people would say things they would not dare say to their face, and they do it online” (FG2F2). Adolescents viewed the absence of face-to-face communication and facial expression as facilitating uncivil ways, causing considerable distress to the recipients of the messages. Social disinhibition was experienced as a great degree of freedom online and a greater sense of confidence and feeling less fearful online, without consideration for the consequences: “They can’t see you, can do whatever you want to, it feels like there is less consequences, whatever you’ve typed…because they’re behind a screen. You’re shielded” (FG3M4). Social disinhibition was viewed as taking different forms and was expressed in various degrees of severity with behaviors online perceived at times as evolving into some form of cyberbullying “And even if you have an argument with one friend, you can just screenshot it and then there is so much going on: ‘why did you screenshot it?’—they send you the argument, the text messages, people are more touchy finding out things on social media” (FG6M2). “Some people text you, who you don’t even know and judge the pictures that you have posted. But you just say something back and block them, just like, ‘Bye you are blocked’ but sometimes it can get quite nasty, like bullying” (FG5F5). Lack of physical cues or facial expressions led to an almost automated mindless empowerment and taking the step to articulate a negative comment, not shared otherwise in a face-to-face conversation: “The fact that you don’t see them if you are talking about a problem, you can’t see them and is easier and you can say something mean that you would not say to someone’s face” (FG1F1). Misinterpretation of intention escalated to larger issues and a spiraling of events magnified out of proportion, spilling over to offline relations and vice-versa. Additionally, feeling forced to participate socially was viewed as another source of frustration, which activated social disinhibition. Relational aggression on the continuum. The expression of hateful comments was a common adolescent experience, “With social media people don’t quite know if you are saying a joke because they don’t see the sarcasm, something might start up as a joke it might spiral into other things and people might end up hating each other with just a few words on Instagram. It happens quite often” (FG6F6). The online environment was viewed as facilitating the exhibition and attraction of relational aggression. Being able to freely express themselves without face-to-face contact facilitated harsh attitudes towards others. Such behavior appeared to be observed more on specific content transient platforms , which reinforced the degree of indifference or aggression: “Especially with Instagram, there have been certain circumstances where people can be very manipulative or bullying…people would say things they would not dare say to their face” (FG5M7). In the case of fallouts, adolescents criticized the practice of screen-shooting the arguments and sharing the screenshots amongst friends. Online sext-shaming was another expression of relational aggression. Sexting images with inappropriate content was viewed as a frequent practice for adolescents with an emotional impact: “People do things that shouldn’t do. People texting other people and screenshots and sharing again, it happens quite often” (FG2F6); “It feels horrible, when you give someone trust and then they back down on that trust –it really upsets you” (FG2F3). Another form of social disinhibition was ‘phubbing’, which has been operationally defined as a persistent engagement in smartphones by checking emails and social networks, playing games, listening to music, or other activities as a way of avoiding face-to-face communication [Diffused responsibility stemmed from group dynamics and perceived peer pressure  and a lnication . AdolescInterpersonal surveillance and mirroring. Surveillance of peers’ activities online was acknowledged as a common practice related to FoMO: “I’m very nosy, it’s a way to see what others are doing and get some feedback on what is going on” (FG6M2). Social media celebrities and other famous individuals were viewed as influential amongst the teenage population: “Those people you follow, you see their hobbies, interests, fun videos and you end up spending loads of time on it” (FG3M5).I think with celebrities and models, when posting a selfie and they put their body and we think it looks amazing! so we are like OMG, I need to get my body like that, but this is wrong” (FG3F2). Additionally, adolescents expressed concerns that private actions enacted online may arrive in the public domain, with ensuing feelings of embarrassment and shame.Mirroring influencers’ body images and setting goals based on these standards was common yet was contradicted by perceptions of unrealistic and unhealthy standards of beauty, which were being promoted online. Despite the initial enthusiasm expressed about the ideal standards, adolescent participants advocated against the promotion of unhealthy practices of individuals promoting negative mental health and peers who mirrored unhealthy types of views, behaviors, and appearances, “Social disruption. Adolescents experienced peers as being antisocial in offline social situations  as initial peer gatherings were eventually turned into online interaction in the presence of others, “These people are all on their phones, they are unsocial, but that happens a lot …it is cutting up the social aspect of life” (FG1F6). This differed from phubbing because it was not an intentional act to avoid an unwanted peer. Social disruption incurred due to the common practice amongst adolescents in many offline social situations to drift off and eventually withdraw to their smartphones, exhibiting a preference for online interaction, despite the initial interest to interact. This practice was extended to school break-time or other social instances, with peers exclusively engaged with their smartphones, disregarding the presence of schoolmates or friends. Disruption was also being experienced by distraction and the inability to impose self-control by ignoring smartphone notifications. Overinvolvement with smartphones was considered a disruption of naturally occurring social interaction and lack of balance: “I think people are trying to have a balance between social life and their social media life” (FG4F3).Hunting’ was experienced during the acquisition of strategies to achieve a higher reward potential, such as actively seeking to maximize opportunities for reward and reinforcement, while ‘hooking’ entailed strategies which endorsed habit-forming behaviors and processes among adolescents.‘Habituation, automaticity, limited time content, and psychological investment. Adolescents experienced social media use on their smartphone as an automatic process with constant smartphone checking. Use was not ceased even during school lesson time, homework, or sleep routines. Adolescents reported always carrying their devices with them, except for mealtimes due to family or school rules out of fear that the device might be taken away. This habitual use was associated with a state of high self-consciousness and preoccupation regarding new interactions and/or new content. Additionally, if unable to check or perform specific routines . Adolescents experienced psychological investment and a bond with their peers on social media, and no adverse effects would motivate them to give this up: “Go to check my streaks first thing in the morning so I don’t lose them. Nothing comes in the way of having your streaks, your life depends on them, maintaining those streaks” (FG5M2).platform ), adolesTriggering activation and anticipation of reciprocation. Adolescents often expressed their social media use having been triggered by environmental cues : “I find it quite hard when somebody messages you and it is personally directed to you, it leads you to open it and then get distracted. It is a temptation” (FG3F1). Expectations of instant attendance to notifications was expressed as a key behavior, which led to a constant state of alertness. Not answering back and delaying reciprocation was experienced as a sign of ignoring and neglect by the other individuals and viewed as requiring an apology. Cue activation was also internal and hypothetical, denoting preoccupation about inability to instantly interact, “So even if I put it in my bag say if I have Maths, then I am like: Oh, maybe that person might be texting me, I am going out to check my phone” (FG6F3). Similarly, an inability to reply instantly was associated with feelings of anger, agitation, and/or compulsive tendencies.Reward and reinforcement seeking. A key process for adolescents was reward-seeking in the form of followers, ‘likes’, and/or ‘streaks’. Adolescents devised strategies to increase their popularity levels , and photos judged as not good enough determined adolescents’ emotional state and state of self-confidence. Enhancement and enrichment were experienced by adolescents due to novelty, innovation, and variability in social media, which further reinforced engagement. Novelty in platform content was considered a positive feature benefiting and providing adolescents with increased opportunities for exposure . This practice differed from any other traditional media but was viewed also with some skepticism due to its questionable quality. Fake news or poor quality of news was normalized as part of the reality of exposure to social media.Wanting more and tolerance. Higher reward-seeking led adolescents to constant strategies to correct and upload new photos with higher ‘approval’ potential. The number of friends was a direct measure of popularity “People think like if you’ve got more followers then you get more likes because more people will follow you” (FG2F2) and being associated with peers with a higher number of friends was considered a successful strategy to reach a higher number of likes in their uploaded photos. Another strategy used was the application of enhancement techniques . However, use of filters was perceived as reaching hyperbolic levels, altering appearance to the extent of deception. Additionally, adolescents perceived a discrepancy between what companies defined as the norms of beauty and what adolescents decided to promote. Social media were perceived as an arena where although various possibilities of norms can co-exist , ideal image standards of beauty dictated adolescents’ choices. This led to a constant negotiation of reaching the ideal versus the normal, and reinforced interaction: “And it makes you want to change yourself. If for example, I shade it differently, and I put something different from what I last put on, I don’t get as many likes, so clearly, I’m not good enough. Makes your self-confidence go down. You wanna take another one and try to make up for it” (FG4Μ5).The psychological processes evidenced comprised three core categories and formulated a theoretical model termed ‘the control model’ of engagement, highlighting control mechanisms and processes on three levels involved in social media engagement : Individreward and triggers) further reinforce individual processes , and increase opportunities for social processes to take place . Continued use was encouraged and facilitated through habituation, reinforcement, and further investment in the medium, content, and relationships. Therefore, loss of control was experienced at an individual level with a gradual change from a self-referential state and preoccupation with controlling perceptions of personal identity and representation online, to control of group interactivity with structural processes partially determining, facilitating, or reinforcing psychological and emotional outcomes. For example, the process of preoccupation appeared to lead to higher online vigilance, which could be related to checking and habitual enactment, associated in the literature not only with time investment but with psychosocial problems  [Structurally induced processes  . Dependicontrol model’ of engagement identified: (i) The inter-relationships between individual, social, and structurally induced processes in defining social media engagement; (ii) the gradual transition from a state of individual controlled use to a state of reduced control through the interaction of processes, determining attitudinal and behavioral outcomes; and (iii) control of self-concept, content, and relationships as a principal agent of online engagement—which goes beyond uses and gratifications in social media use.Therefore, the emergent ‘self-preoccupation with adolescents’ online identity, (ii) cognitive salience of the online environment, and (iii) vigilance in adolescents [Social comparisons and fear of critical appraisal and evaluation by peers also led to heightened self-consciousness. Preoccupation with online identity signaled a state of constant alertness and arousal manifested in more frequent and intense engagement, which appeared to interact with cognitive salience and vigilance of the online content [On an individual level, the findings highlighted separation anxiety as a psychological process underlying adolescent user engagement associated with (i) an increased state of lescents . The extlescents ,54. Soci content . It is p content , decreas content , and wit content .distractibility [Distraction is an emotion regulation mechanism of moving attention from negative emotions to non-negative issues [facilitation [Additionally, checking behaviors appear to have a cognitive impact due to the repeated external interruptions and attentional micro-disengagements or internal interruptions due to vigilance, leading to tibility . Distrace issues , and a me issues . Despitelitation ,62 or shlitation .deindividuation, social facilitation, and diffusion of responsibility. First, social facilitation theory [deindividuation theory of aggression [The present study’s findings highlight the existence of social processes relating to a negotiation of control due to group dynamics. This involved the transitioning from a state of controlled engagement to a gradual loss of control within online group membership. This model of engagement draws from two psychological models with their key processes of n theory  explainsgression  denotes gression ,65. Extegression , while rgression  reduces gression ,67.aggression  and social disruption. This confirmed evidence highlighting increase in adolescent loneliness [inflated sense of self, which emerged as a process afforded by social media, might contribute to impulsive behaviors, potentially in the form of more aggressive interactions. The present findings highlight that relational aggression online ranged on a continuum from online disinhibition to various forms of cyberbullying, potentially implicated in psychopathology . As an ddiction  and probddiction ,73.social comparisons on social media negatively affect mood, emotions, appearance, and physical health perception [exhibitionism, manifested through (i) showcasing high-profile friendships—boosting the reputation of the adolescent amongst the in-group—(ii) sexting, and (iii) sext-image sharing. The photographic image was evidence of time spent together with socially influential peers and uploading became a continuous act. This process may be underlying a behavior that has been termed ‘selfitis’—the constant act of selfie-taking with its compulsive nature [mirroring of behaviors of influential others and interpersonal surveillance confirming increased engagement [Social comparisons and appraisals were other social processes, which appeared to partially underlie cognitive preoccupation and vigilance with potential mental health impact . Negativrception ,76, disorception , and medrception . The userception . Relatede nature ,80. Sexte nature . Additiogagement  and a cogagement .Hooking’ processes  aim to attract and retain adolescent attention and engagement through mechanisms encouraging habituation and constant checking [The present study’s findings also highlight the emergence of platform-related, structurally induced processes, and identified two types of mechanisms depending on their function. Social media activities per se have been suggested to be potentially addictive , with emchecking . For exachecking , potentichecking .psychological investment in social media activity and devices, which provide access to content and are related to separation anxiety [Hunting’ processes  comprised active manipulation for higher reward acquisition, triggered primarily by the variable reward reinforcement similar to gaming, acting as potential antecedent to problematic use due to reinforcement sensitivity [Additionally, adolescents experienced a state of  anxiety . Psychol anxiety , and inc anxiety . Excessisitivity ,89 and nsitivity . Howeversitivity , particuThe associations proposed were grounded within the particular set of data, which highlighted an indicative pathway. However, given the heterogeneous nature of use, these could not be considered exhaustive or comprehensive as they depend on a host of factors, which could influence outcomes differentially and may not be addressed within the framework of this research study. Additionally, the model can neither prescribe how transient or longer lasting these processes are nor their specific impact on adolescent mental health. Limitations of the present study also pertain to issues of generalizability due to the study’s exploratory nature using small homogeneous focus group samples. Additionally, self-reporting concerns and problems may be inaccurate due to social desirability and selective memory.The present study’s theoretical and prevention implications are important in terms of understanding problematic processes and embedding mechanisms to control them either by substituting them with positive ones or stopping their escalation. The theoretical implication refers to mapping inter-related processes, which may lead to problematic or addictive social media use and adds to understanding a process-oriented model of problematic social media use, which accounts for a more systemic view of processes. This highlights the interplay between the individual and the situational environment, which has been overlooked in the cyberpsychology literature. In terms of practical implications, one key research area recommended to further investigate is relational aggression, which may be addressed by interrupting the process of deindividuation and promoting empathy and personal responsibility online or by providing information on how to respond to harmful social media content effectively and foster reinforcement for prosocial behaviors and support provision to others. Additionally, the study provides insights that may be embedded in media education, such as conflict-resolution skills and perspective taking . Furthercontrol model’ of social media engagement. The model emphasizes the psychological process of control as a key mechanism, moving beyond uses and gratifications, and designates a gradual transition from a state of controlled engagement at an individual level, into a potential gradual loss of control when the social and structural processes come into interplay. Additionally, it describes the interrelationships between the three levels of processes, which may take on different power positions depending on the relation between the parameters and the level of engagement. Based on the current literature, these major psychological functions merit further investigation, as given a conducive context  may act as antecedents of or risk factors for problematic smartphone use for a minority of individuals. Depending on the quality of engagement, the meaning attached to the interaction, and the frequency of use, a minority of adolescents may be predisposed to engage in social media use in a problematic or addictive way.The findings of the present study highlight the existence of control mechanisms and processes involved in social media engagement, which led to a theoretical model defined as the ‘Equally, the above study highlighted an emerging area of research—the importance of design mechanisms within the social media environment, which play a significant role in the initiation and maintenance of online engagement. More research should be encouraged to understand how persuasive design elements capture young peoples’ attention and reinforce both active and passive social media use. Critical to this endeavor is the engagement of young people in the research process and in providing them with a voice that raises their concerns and promotes their recommendations for improving their online experiences ,93. This


We carefully read the article by Castaner et al. , which wFirst, the authors did not assess the methodological quality of the included studies. Systematic reviews have become increasingly important in healthcare and are considered the “gold standard” form of evidence for assessing the effectiveness of therapeutic interventions. One of the key steps in a systematic review is the assessment of methodological quality for eligible studies. A clinical study with inappropriate study design may result in multiple biases, such as selection bias, performance bias, attrition bias, detection bias, and reporting bias . General2 statistic to quantify heterogeneity.Second, the authors did not report the publication bias and heterogeneity. We suggest that publication bias should be assessed by statistical tests , as well as the IThird, the authors did not follow the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) ; also, tFinally, the search string was reported in the review ““Obesity” and “Microbiota”.” The authors did not include a detailed search statement in the supplemental materials; so, readers have to assume that the search in “Methods” represents the true extent of the search strategy. We suggest that the authors provide us with a complete search strategy to strengthen the credibility of the review.