The theory of stages in cognitive development is one of Jean Piaget’s enduring legacies, but it has also borne the brunt of much criticism. It maintains that intelligence develops in an invariant sequence of stages, and, in this paper, I situate Piaget’s conceptions of stages historically and functionally in the context of genetic epistemology, his research programme. I highlight some of the objections raised, and I show how the disparity between the conceptions of theoretical and empirical stages in Piaget’s theory is commensurate with the fuzzy-structuralist model of the relationship between theory and empirical research conceived by Rudolf Seising on the basis of Lofti A. Zadeh’s fuzzy set theory. Further, I propose a fuzzy conception of the notion ‘stage’, which not only captures its ordinary use in fuzzy space between theory and empirical research but also does justice to both the construct validity and quantitative variability of stages in empirical research. I therefore open a fuzzy-structuralist perspective on the Crisis of Variability afflicting Piaget’s stage theory during the 1970s and conclude retrospectively that the rift it caused was not necessary since the invariance and variability of stages is not irreconcilable. It is testimony to Jean Piaget’s legacy that people still associate stages with the cognitive development of children even in non-academic circles. Endurance and recognition in the general public are, however, poor measures of the acceptance Piaget’s stage theory of cognitive development enjoys amongst developmental psychologists. Kesselring , 375 makThe stage theory is used in Piaget’s work in two fundamentally different ways. As a rule, three stages are discerned in experimental contexts. Children are set specific tasks designed to reveal cognitive abilities, and their performance is usually divided into success, partial success or failure. Besides categorising task-related performance according to degrees of success, Piaget also used ‘stage’ in his stage theory to designate characteristic forms of cognitive behaviour that manifest in an invariant sequence during cognitive development. In contrast to the consistency in the number of stages in experimental contexts, the number of stages in the latter, theoretical, context varies considerably .Why does everyone speak of stages? One tries to construct stages because this is an indispensable For Piaget, then, the stages were a means to an end, not an end in themselves. However, a heuristic can give a false impression. A classificatory tool facilitating the analysis of developmental mechanisms might be regarded as a convenient convention used to parse cognitive development into artificial divisions. Indeed, the variety of stage models advocated by Piaget lends support to this impression. For Piaget, however, the stages are not simply convenient conventions; they describe natural divisions in cognitive development Piaget, , 814–5. Finally, the stage models characterize cognitive development in terms of cognitive structures that undergo an invariant sequence of transformations. The degree of abstraction in the stage models is thus extremely high, and this reflects Piaget’s interests not in the psychological subject but in an epistemic subject. For Piaget  have found support in a great majority of studies;The horizontal décalage  characterizes sample means, but are not found in all individual subjects;The quantitative aspects  show considerable variations. . The results are then presented in developmental curves for each of the tasks investigated. A developmental curve plots the age groups  in the interval .’ :For the mathematical theory of fuzzy sets, he also generalized the concepts of operations on classical sets. He defined equality, containment, complementation, intersection and union see Fig.  relatingµA(x) = µB(x),A = B if and only if µA(x) ≤ µB(x),A⊆B if and only if A, if and only if µA←(x) = 1- µA(x),←A is the complement of µA⋃B(x) = max (µA(x), µB(x)),A⋃B if and only if µA∩B(x) = min (µA(x), µB(x)).A⋂B if and only if In the early 1970s, Zadeh wanted to apply his theory of fuzzy sets in non-technical fields like linguistics and psychology. He initiated interdisciplinary discussion with the psychologist Eleanor Rosch and the linguist George Lakoff, who were also working at Berkeley at the time. Rosch’s research, especially, showed that concept categories are graded; consequently, she argued that concepts are not adequately represented by classical sets.Clearly, Rosch’s research also has implications for psychological concepts, especially those in everyday use. If stages of cognitive development, for example, are graded concepts, then they cannot be adequately represented by classical sets. Later, Rosch  went on In ordinary usage, the term ‘stage’ is applied to individual children or groups of children in the process of cognitive development; however, it is not being used in either the theoretical or empirical sense since neither the cognitive structures characteristic of a stage nor the successful performance of a particular cognitive task are serving as criteria for its attribution. This concept of stage thus hovers somewhere in the fuzzy space between theory and experiment in Seising’s model. Moreover, certain kinds of cognitive behaviour are prototypical when attributing a stage of cognitive development in ordinary usage. Nevertheless, performance at particular cognitive tasks, regardless of whether they are considered prototypical or not, can only provide empirical evidence that a particular stage of cognitive development has actually been achieved. Moreover, no matter how overwhelming the empirical evidence appears to be, it will never be completely conclusive. ‘Stage’ in ordinary usage thus appears to be a graded concept. In my opinion, these considerations warrant attempting to operationalise such stages in fuzzy space in terms of fuzzy sets. In order to simplify matters, however, I will confine myself to the attribution of such stages to individual children.C={Children in the process of cognitive development}A universe of discourse can be defined as follows:i at the concrete-operational level, the child has fulfilled a criterion for the particular stage but cannot be judged to have attained it on the basis of this success alone. Theoretically, each stage is characterised by a number of cognitive structures, and the tasks are designed to elicit empirical evidence for their attainment. However, task performance is subject to quantitative variation, since décalage coupled with cultural, socioeconomic, situative, psychological, biological, etc. factors influence performance. Hence an Inuit child, for example, may well be at the concrete-operational stage as far as spatial tasks are concerned but not yet for conservation tasks and vice versa for African children of the Baoulé.Empirical evidence is required to attribute a stage of cognitive development to a child; however, assuming a child performs a task tAlthough successful performance at a single task alone is not sufficient grounds for attributing a stage, it might be argued that several tasks fare better. However, preferences in cognitive structures have no theoretical basis. Regarding some structures as prototypical would therefore be artificial from the theoretical point of view, and it would run the risk of introducing bias and hegemony into the attribution of stages , where µTi ∈ 4Child c is a member of the class of task performers Ti than tj and more successful at tj than tk, for instance. A particular child in the sample age group may therefore be able to perform ti and tj but not tk; indeed, a child may be able to perform all of the tasks but one successfully, and to refuse to acknowledge this achievement by the attribution of a stage would seem unduly harsh. Via degrees of success, on the other hand, performance at all the tasks would be taken into account while avoiding the excessive weight given to a single failure at any particular task. Rather than assessing performances dichotomously with success and failure, a higher degree of success at ti than at tj and at tj than tk could be attributed to a child at a particular age; a stage could then be assigned on the basis of degrees of success rather than actual successes and failures.A stage is characterised by a number of cognitive structures; theoretically, success in all of the tasks attesting to these structures is therefore required in order to warrant attributing a stage of cognitive development to a child. However, this is an ideal that cannot be realised in practice. Moreover, success at performing tasks varies empirically; a higher proportion of children within a particular age group may be more successful at, say, task ti for i = 1…n. Let Ti denote the class of task performers for a particular age sample group, and S, the stage performers. Ideally, the class of stage performers is constituted by those children who are able to perform all of the tasks ti for i = 1 … n successfully. Consequently, the class of stage performers is formed by the intersection of all the classes of individual task performers:In general, a number of cognitive structures characterise a stage, which are investigated empirically by a number of experimental tasks, t1 ∩ T2 ∩…∩ Tn.S = TIdeally, a child must be able to perform all of the tasks in order to be predicated with being at a particular stage; however, it is desirable in the attribution of a stage to avoid bias and hegemony on the one hand and giving excessive weight to a single failure in the face of substantial cognitive achievement on the other. Whilst the dilemma is unavoidable in terms of the dichotomous categories of crisp classes, fuzzy classes appear to offer a way out.S(c) denote the membership value of a child c in the class of stage performers S. Clearly, the membership value in S will depend on the membership values in Ti for i = 1…n just as membership in S is dependent on membership in Ti’s for crisp classes. Using the rule Zadeh defined for the intersection of fuzzy sets, the membership value in S can therefore be calculated from the membership values of the classes of task performers Ti for i = 1…n as follows:Let µS(c) = µT1 ∩ T2 ∩…∩ Tn (c) = min (µT1(c) … µTn(c)).µFor any child, c, then, the membership value in the class of stage performers S would depend on the membership values in the individual classes of task performers.S(c) depends on those of the µTi’s, which are determined on the basis of developmental curves. On the other hand, assessing whether children belong to a stage would not require arbitrary choices between performance in either spatial or conservation tasks for the concrete-operational stage, for example, which would unfairly prejudice against either Baoulé or Inuit children at particular ages, since the criterion for assessment is fixed by the minimum membership value of class performers.With this fuzzification, the stage membership value would reflect quantitative variation due to decalage, cultural, socioeconomic, situative, psychological, biological, etc. factors since µGenetic epistemology as conceived by Jean Piaget is a science of the growth of knowledge, and, in Piaget’s research programme, the stage theory played a pivotal role. Intelligence was found to develop discontinuously in an invariant sequence of qualitatively discrete steps; stages thus represented a natural classification of cognitive development for Piaget. However, he never regarded the stages as an end in themselves; they were a means to determining the mechanisms of cognitive growth. In other words, the stage theory was a stepping stone in the genetic-epistemological research programme, albeit a necessary one. Nevertheless, it has borne the brunt of much criticism. Broadly, I have touched on some of the criticism commonly levelled at Piaget’s stage theory in this paper, but criticism concerning the lack of discontinuity between Piaget’s stages has taken centre stage.I have highlighted the compatibility of Piaget’s stage theory with the fuzzy-structuralist model conceived by Seising to represent the continuum connecting theory and empirical research. Stages in the theoretical layer are qualitative, each stage being characterised by specific cognitive structures, and an invariant sequence of stages resulting from qualitative transformations of these structures represents cognitive development. The stage theory is monolithic and universal; however, it pertains to an epistemic subject. In the empirical layer, on the other hand, stages classify the actual performance of children at particular tasks according to success. Theoretization goes hand-in-hand with abstraction from the particulars of the task at hand and the individuals performing them. In addition, it is accompanied by a shift from quantitative change to qualitative transformations. Empirization, on the other hand, goes hand-in-hand with quantification, and it is accompanied by quantitative variation in the rate of progression through the stages measured chronologically by age.A number of different stage models can be found in Piaget’s work. Some can be disregarded since they belong to an earlier, superseded phase of his work. These notwithstanding, several models were still in use post 1936. In light of fuzzy structuralism, however, one inconsistency in the stage models is understandable. The disparity between empirical stages, which focus on successful performance of specific tasks, and theoretical stages, which emphasise qualitative structures and their transformations, is symptomatic of differences inherent in theoretical and empirical layers of any science. Nevertheless, differences in the stage models within the theoretical layer still remain, leaving Piaget’s stage theory vulnerable to criticism on grounds of inconsistency.However, the term ‘stage’ is not only employed in purely theoretical or empirical contexts. It is also used in order to characterise the level of cognitive development achieved by a child or groups of children on the basis of empirical evidence. Used in this way, it is not related directly to a theoretical entity, the epistemic subject, nor to the classification of specific performances of a given child at particular tasks according to success; in the words of Hertz , 4, it iThe stages of cognitive development are clearly characterised in theory, yet there is a great deal of variability in empirical results. Moreover, the qualitative aspects of the stage theory had been largely confirmed experimentally (cf. Saxe, Cognitive structures characterise the stages of cognitive development in Piaget’s stage theory. In theory, stages thus have crisp contours, and transitions from one stage to the next is discontinuous; however, the crisp contours of the qualitatively discontinuous theoretical stages soften into silhouettes in the fog of empirical variability. The difference between theoretical and empirical stages is reminiscent of the very disparity between theory and empirical research in the sciences that inspired Zadeh to develop fuzzy-set theory, and, focusing especially on the way the concept ‘stage’ is typically used between theory and empirical research, I have argued that a fuzzification of this concept could reconcile the discontinuity of theoretical stages with the gradual blurring of boundaries as quantifiable stages of empirical research gradually replace their qualitatively crisp counterparts. In short, the fuzzy conception of stages as set out in this paper appears to correspond to the way the concept is typically employed; it also appears to do justice to the construct validity on the one hand and quantitative variability in empirical research on the other whilst reconciling the lack of discontinuity in empirical stages compared with their theoretical counterparts.Finally, the Crisis of Variability was precipitated by quantitative variation in the chronological age of children achieving stages and the rate of progress through them, which did not correspond well with the theoretical expectation of discontinuity between the different stages. Historically, two reactions were evident: some researchers abandoned Piaget’s stage theory for less universal, less monolithic positions, whilst others remained loyal but had to explain away the variability in terms of methodological artefacts (see Dasen and Heron


This article discusses the current knowledge on the role of the neurological structures, especially the cerebellum and the hypothalamus, and compares the information with human medicine. Micturition is a complex voluntary and involuntarily mechanism. Its physiological completion strictly depends on the hierarchical organisation of the central nervous system pathways in the peripheral nervous system. Although the role of the peripheral nervous system and subcortical areas, such as brainstem centres, are well established in veterinary medicine, the role of the cerebellum and hypothalamus have been poorly investigated and understood. Lower urinary tract dysfunction is often associated with neurological diseases that cause neurogenic bladder (NB). The neuroplasticity of the nervous system in the developmental changes of the mechanism of micturition during the prenatal and postnatal periods is also analysed. Micturition is a two-stage storage process and periodically voiding urine  and the Web of Science (http://www.webofscience.com). The keywords used were “micturition”, “urination”, “neural control”, “neurophysiology”, “bladder dysfunction”, “neurogenic bladder”, “dog”, “canine”, “cat”, “feline”, and “humans”. The search of PubMed was conducted using the Boolean Operators AND and OR . In addition, the Textbook of Veterinary Internal Medicine by Ettinger et al., 8th ed., and veterinary neurology books  were also reviewed.The literature reviewed was based on MEDLINE/Pubmed  and external urethral sphincter (EUS), and normal function of these organs and tissues is required for an appropriate micturition. The body of the urinary bladder is composed of three layers of smooth muscle, which make up the detrusor muscle  that makes up the pudendal nerve. This prevents urine leakage, and cholinergic efferent neuronal cell bodies in the pelvic nerve are inhibited. All these mechanisms prevent leakage and perpetuating filling. When the stretch receptors (A-delta mechanoreceptors) register the stretching limit, which is18 mL/kg or 50 cmH2O in anaesthetised dogs, an action potential is initiated . Micturition does thus not take place randomly or involuntarily but is part of a rather complicated behaviour directly related to the survival of the individual or species. This means that spinal cord micturition control must also be under the regulation of the emotional motor system  are regulated by a complex system involving the autonomic, PNS and CNS, which work together to control and modulate the activity of smooth and striated muscles of the bladder and urethra. The micturition reflex is modulated by the integration between the CNS and PNS allowing voiding in an appropriate site and situation. The integration with the limbic system also regulates the emotional and hormonal state. Visceral activities (bladder and urethra) are also regulated by the cerebellum, generating integrated and coordinated somatic-visceral responses to adapt to changes in internal and external environments.Consequently, in healthy animals, micturition depends not only on the neuro-physiological pathway functions but is also influenced by changes in age (neuroplasticity), experience and learned behaviours.


Currently, there are very few studies examining pet ownership in Aotearoa, New Zealand (NZ) and the factors that influence pet owners’ practices. To facilitate better pet management and enhance companion animal welfare, it is vital to understand current pet owners’ practices and the factors that influence pet owners’ behaviors. This knowledge will inform effective human behavior modification interventions that will benefit animal welfare and ensure pets in NZ are living a good life. This study investigates pet owners’ practices in their households, using an online survey conducted between January and March 2019 involving adults residing in NZ. In addition, we explore what veterinary care pet owners access. There was a total of 2744 participants in the survey, with 2385 respondents answering the pet ownership questions. Of these, 885 (37%) owned both cat/s and dog/s, while 652 (28%) and 609 (26%) owned cat/s only or dog/s only, respectively. Data analysis using the demographics of the respondents provides insights into some of the factors associated with differences in the pet owner practices highlighted by the survey.This study used an online survey distributed between January and March 2019 to adults residing in Aotearoa New Zealand (NZ) to investigate cat and dog owner practices. Of the 2385 respondents, 885 (37%) owned both cat/s and dog/s, while 652 (28%) and 609 (26%) owned cat/s only or dog/s only, respectively. Nine percent of respondents (n = 212) did not own a cat or dog when the survey was administered. Gaps were identified in the practices of NZ pet owners with regard to regular grooming, immunizations, and deworming treatments. It was also found that many pets, especially cats, were allowed to wander freely both inside and outside the house. Collectively, these gaps in practice raise parasitology and infection concerns which may impact negatively on animal welfare and may increase the prevalence of zoonotic diseases. This study also revealed the need to improve desexing practices, particularly in dogs. Respondents in the survey expressed the wish to have pets regardless of the financial strain they may impose, indicating that future research should focus on reducing the financial burden of pet ownership along with promoting positive pet ownership practices. Our findings suggest the need for better education resources about pet ownership which are easily accessible and target diverse populations. The findings of this study will aid in developing appropriate educational resources to promote animal welfare and increase pet-related knowledge among the NZ populace. Companion animal pet ownership in Aotearoa, New Zealand (NZ) has been estimated to be 64% of households, according to Companion Animals New Zealand (CANZ) . This raGlobally, pet–human interactions have been the center of many research studies due to the complexity of the bond ,5,6,7,8.Regardless of the health and well-being impacts for the pet’s owner, the owner should be encouraged to ensure their pet are able to “express a rich behavioral repertoire, use their abilities, and fulfil their potential through active engagement with their environment” . This deCurrently, there are very few studies examining pet ownership in NZ and the factors and variables that influence pet owners’ practices considering the wider range of identities and beliefs in NZ, which may influence these activities . To faciFurry Whānau Wellbeing research project  doesn’t leave the property” and “They [my dogs] roam free on our farm, but do not leave the property”.Nearly all respondents indicated that when their cat/s were inside, they were free to use the family furniture  and sleep on or in their owner’s bed . Only 3% (n = 42/1527) of respondents restricted their cat/s to designated areas while inside. A minority of respondents allowed their cat/s to eat food from and sit on kitchen surfaces . Again, many of the respondents chose to leave a comment to clarify their responses. The major themes were that most cats could “Go wherever they please except on surfaces where food is prepared or eaten” but that it was “Difficult to tell/train as they [cats] tend to do as they please, when they please—haha” and “Technically they are not allowed on the bench…but cats really don’t give a damn about rules”. The presence of a dog was typically indicated as a reason as to why a respondent’s cat was allowed on the bench/table. For example, “The cat eats from the bench because of the dogs as they will eat the cat food” and “They have a designated spot on the bench so the dog can’t eat their food”. Some cats had designated rooms at night. For example, “Has his bed in own room”, “They are not allowed in the bedrooms at night. They have an outdoor cattery to give them safe outdoor space away from other cats and wildlife” and “Husband allergic so [the] bed’s banned”.Gender was found to impact worming practices, with females being more likely (92%) to worm their dog/s according to the product instructions, compared to males (86%) and gender diverse (75%). As age of the respondents increased, there was a decreased likelihood of the dog/s being flea treated according to product instructions and the owner cleaning their dog’s teeth. Ethnicity also influenced the likelihood of professional teeth cleaning, with fewer Māori dog owners including this in their pet care practices when compared to NZ European and other ethnicities . As household income increased, the owner’s likelihood of cleaning their dog’s teeth decreased, and the likelihood of professional teeth cleaning increased. Interestingly, as the qualification (education) level increased, the likelihood of professional teeth cleaning decreased.Ethnicity also influenced desexing practices with fewer Māori owning a desexed dog compared to NZ European and other ethnicities . Having a rural upbringing also decreased the likelihood of a dog being desexed. In contrast, if the owner currently lived in a town or city, there was an increased likelihood of the dog being desexed and regularly groomed. As the number of adults in the house increased, the dog was less likely to be desexed. Likewise, with an increasing number of children in the household, there was a decreasing likelihood that the dog/s were desexed.Gender influenced selection choices for ‘My cat is wormed according to product instructions’  and ‘My cat has caused me financial stress’ , with males being less likely to select these. Ethnicity was not found to be associated with the choice selections for each of the statements. An increasing age range was associated with a decreasing likelihood that a cat/s were being flea treated as instructed by the product, having up-to-date vaccinations, being occasionally groomed, having their owner clean their teeth, and causing financial stress. Increasing household income was associated with an increased likelihood that the cat/s teeth were cleaned, and their nails were clipped by a veterinarian. Conversely, increasing household income was associated with a decreasing likelihood of causing financial stress and the owner cleaning their cat’s teeth. Qualification level influenced whether cat/s were desexed, and their teeth were cleaned by a veterinarian. Furthermore, if the cat was a pedigree, all of these increased in likelihood as qualification level increased. Those brought up rurally were less likely to select ‘My cat vaccinations are up to date’ (73% versus 78%), and ‘My cat’s teeth are cleaned by the veterinarian when needed’ (37% versus 47%) and more likely to select ‘My cat’s teeth are cleaned by me when needed’ (12% versus 8%). Those respondents currently living in a town or city were more likely to have cat/s that were flea treated according to the product instructions (92% versus 86%), had their teeth cleaned by a veterinarian when needed (46% versus 40%) and their nails clipped (37% versus 31%). As the number of children in a household increased, the likelihood of the cat/s in the household being desexed decreased, as did the likelihood the cat/s were wormed, had their teeth cleaned by a veterinarian, had their nails clipped, were regularly groomed and had caused financial stress. As the number of adults in a household increased, there was a decreased likelihood of a respondent’s cat/s causing financial stress.The following comment summarized the collective sentiments of many with regard to veterinarian checks and flea and worm treatments,They should have veterinarian checks and flea and worm treatments etc. when needed. But if you have experience in what to look for health-wise, i.e., keeping an eye on their weight, energy, behaviour changes, water consumption, physical changes etc., and don’t want to use chemicals on them all the time (flea worm treatments etc.) I don’t think it should have to be a constant thing to do, as long as you’re checking and looking out for them and get them treatment/checked with any concerns or if it’s been a long period since they were checked or they are elderly etc.Several of the respondent’s comments highlighted the perception that worming and flea treatment may not always be necessary; for example, “In Southland, fleas are not a problem so we don’t use a flea treatment. We would if our dog/s needed one though” and “Worming should be given on the advice of a veterinarian to avoid resistance”. Vaccinating young dog/s was viewed as important and some thought adult’s dog/s were over-vaccinated; for example, “Puppy vaccination are super important but we over vax adult dog/s.” One respondent commented that “Veterinarian care where I live is all owned by one company. It’s very expensive and they often pressure people into unnecessary vaccinations and products”.Another common theme in the comments was that all “…breeders should be registered, and all other dogs should be desexed to prevent the number of strays and puppy-farms around”. A common perception regarding desexing was that it was being performed when the animal was too young; for example, one respondent wrote, “Desexing is done far too early; again, the evidence shows you should wait for the dog/s to fully mature, so their hormones have settled and they’ve finished growing, usually around two years of age.” One respondent went further and wrote,I have read that it’s best that dogs are desexed after their growth plates have closed, around 18 months which is best for the dog/s if the owner is responsible. However, that’s not always the case, so it would be great to see ovary-sparing-spay and vasectomy rather than traditional ops on younger dog/s so they can keep their hormones needed for correct growth.This study investigated NZ pet owners’ practices and the findings have identified several common practices that if changed could ensure pets are living a good life within the broader one welfare context. Our findings indicated that NZ pet owners value having pets and view them as being beneficial to the household despite the fact that approximately one-fourth of respondents reported that owning a cat and or dog creates financial strain. This supports earlier research demonstrating the presence of beneficial impacts of pet ownership on the owner’s quality of life ,36,37. HThe present study found that both cats and dogs were often allowed to roam freely in the house, a finding that is consistent with some overseas studies ,39. InteToxoplasma gondii, which can infect all birds and mammals (including humans) as its intermediate hosts. Infection occurs via the consumption of raw meat or milk contaminated with T. gondii tissue cysts, or via the consumption of raw vegetables or water contaminated with T. gondii oocysts shed in cat feces [T. gondii’s definitive host is the cat which was introduced to NZ in the 18th Century [T. gondii. The risk of toxoplasmosis alone presents a strong argument for all cats to be kept enclosed. Pets with outdoor access and contact with other animals have an increased risk of parasite infection and or infestation [One zoonoses of particular concern globally and to NZ is toxoplasmosis. This disease is caused by the protozoan parasite at feces . T. gond Century . Infecti Century . Toxopla Century ,48, Hect Century , the NZ  Century , and var Century , some wiestation ,50,51.Recently, Pennelegion et al. conducted an online survey in the United Kingdom (UK) to investigate the deworming practice among dog/s and cat/s owners, although the authors did not explore the respondent demographics association with deworming practice . The resThe parasitology concerns raised in the above discussion emphasizes the responsibility of veterinary clinics to effectively implement one welfare measures to control and prevent both zoonotic and non-zoonotic infestations and to ensure that pet owners are adequately educated on the importance of appropriate external and internal parasite treatments, frequency and administration methods according to evidence-based guidelines. The results of this survey indicate this may be an issue as a number of respondent comments highlight the lack of trust and pet owners’ perception that veterinarians are motivated by money rather than the best care for their pets . This coInteresting differences in the vaccination rates between dog/s and cat/s were uncovered in this study. Approximately three-quarters (76%) of cat and 91% of dog owners confirmed that their pets’ vaccinations were up to date, results which agree with previous studies ,60. HoweOverpopulation is another animal welfare and public health concern, along with being an environmental and conservation issue as predation level increase. Cat and dog overpopulation has been attributed to relinquishment and abandonment of pets, as well as to birth rates, with the latter emphasizing the importance of desexing . PreviouRecent studies have shown that the appropriate desexing age varies between different dog breeds and can range anywhere from six months up to two years, depending on the age at which dogs reach puberty ,72,73. EIn agreement with other studies, the majority of respondents (80.7%) got their dog’s nails clipped when needed ,25,28,35As with nail clipping, teeth cleaning, whether performed professionally or by the owner themselves, was also more likely occur for dogs (73.9%) than cats (53.0%). Not surprisingly, households with greater earnings were more likely to get their pets teeth professionally cleaned, unless from a rural upbringing, and then the owner was more likely to do it. The respondent age also influenced teeth cleaning practices of the owner cleaning their cat’s or dog’s teeth. For dogs, ethnicity also influenced the likelihood of professional teeth cleaning, with fewer Māori owners including this in their pet care practices compared to NZ European and other ethnicities . Interestingly, as the qualification level increased, the likelihood of professional teeth cleaning of cat teeth increased but dog teeth decreased. This may suggest pet owners are more confident cleaning the teeth of dogs than cats (which are often less than compliant) making dental care cats potentially costlier as owners are reliant on veterinarians. This notion is supported by the observation that the household income was positively associated with professional teeth cleaning. These results align with a recent study finding that indicate that cat owners have relevant information about the dental health of their pets, but that preventative actions are not taken often enough to promote excellent oral health in cats . NegativThe study data demonstrate approximately double the dog/s owners performing essential grooming for their dog/s (nails clipping and coat brushing) in comparison to cat/s owners. Less than half of the cat respondents reported they performed teeth cleaning, nail clipping, and hair grooming, with some of the respondents saying the grooming practice had not been necessary or that their cat/s were not compliant. These findings suggest that the primary welfare difficulties for cats in the NZ are related to a lack of information or awareness of cat welfare requirements and safe handing techniques. Consequently, cat behavioral problems may arise that result in owners relinquishing their pet, cat suffering, and or cat illness such as periodontal disease ,77. ThesAlthough the online survey enabled more respondents from across NZ, which was one of the study’s strengths, the self-selected responders were disproportionately more female respondents, and Māori were underrepresented when compared to NZ demographics . Thus, tNew Zealanders value their pets regardless of the financial difficulty they may cause. Nevertheless, household income was found to influenced several pet ownership practices such as teeth and nail care but, interestingly, not vaccination or desexing. Future research should, therefore, examine methods to minimize the cost burden of pet ownership. Several gaps were identified in the practices of NZ pet owners’ with regard to regular grooming, immunizations, and deworming treatments. It was also found that many pets, especially cats, were allowed to wander freely both inside and outside the house. Together, these gaps in practice raise parasitology and infection concerns which may impact negatively on animal welfare  and may also increase the risk of zoonoses becoming both a public health. Our findings highlight the need to improve accessibility to veterinary services and culturally appropriate educational resources, especially for lower-income households, older age groups and those who live rurally. There appears to be a specific need to promote safe handling techniques for dental care and grooming and canine desexing practices. Consequently, the present study offers a foundation for future research into the development of human behavior interventions in NZ, with the ultimate goal of boosting pet owners’ awareness of responsible pet owner practices within a One Welfare context and working towards all pets in NZ living a good life.


The original article has been corrected.The article: “Minimizing sevoflurane wastage by sensible use of automated gas control technology in the flow‑i workstation: an economic and ecological assessment”, written by Alain F. Kalmar, Nicky Van Der Vekens, Fréderic De Rydt, Silvie Allaert, Marc Van De Velde and Jan Mulier was originally published electronically on the publisher’s internet portal on 3 January 2022 without open access. With the author(s)’ decision to opt for Open Choice the copyright of the article changed on 19 February 2022 to ©The Author(s) 2022 and the article is forthwith distributed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit


Sex workers may use Information and Communication Technology (ICT) as a means to mitigate occupational health and safety (OHS) risks by exchanging harm reduction techniques  on blogs and social media. ICTs can also assist sex workers in creating online communities, where community members can act as each other’s safety check-ins, an additional harm reduction technique. In Canada, there is a paucity of research around ICT usage by sex workers for managing occupational health and safety. The objective of this study was to qualitatively examine the needs and preferences of Canadian sex workers when using ICTs in the delivery of strategies for occupational health and safety. Using a theoretical framework derived from a Social Ecological Model perspective, semi-structured interviews were conducted via phone, with a mixed gender sample (N = 22) of sex workers, between April and July 2020. OHS risks were found to be related to structural determinants, client behaviours, and lack of experience and knowledge when newly entering sex work. Participant accounts revealed a socially cohesive online community; however, sex workers reported difficulties in finding these communities, particularly when entering sex work. Such barriers to supportive communities were attributed to the criminalized, hidden nature of sex work that resulted in the fragmentation of harm reduction techniques across several online platforms, such as blogs, YouTube videos, closed electronic chat groups, and open online sex worker supportive communities. Moreover, these platforms and/or their content could potentially disappear without warning, either due to the platform provider seeking to evade possible prosecution, or because new legislation was introduced banning such content. Recommendations for further research include the co-design with sex workers of an innovative, secure, easily accessible, sex worker-only ICT OHS tool, utilizing a web hosting service located in a country where sex work has been either legalized or decriminalized. Sex work, like many occupations, has its own unique set of occupational health and safety (OHS) challenges. Some of these challenges include violent clients, clients refusing to use condoms, harassment (either on the street or online), and the risk of their occupation being revealed to friends, family, and the general public  –9. TheseAlthough ICTs present the opportunity to support the OHS of sex workers, censorship of Internet content related to sex work has made it more difficult for sex workers to communicate OHS strategies and share information on violent clients , 14, 16.Research around ICT usage by sex workers has taken place in India (8 studies), Australia 5 studies) and the UK (5 studies), resulting in 18 studies in total . Compara studies OHS frameworks documented in the literature are relevant to formal workers protected by OHS legislation. However, these frameworks do not apply to Canadian sex workers, as they are considered informal workers and the law (PCEPA) criminalizes their work. For this research project, a theoretical framework derived from McLeroy’s Social Ecological Model  assistedFor this research project, the community-based research (CBR) approach was employed. CBR has been influenced by the work of Paulo Freire . His resSex workers were invited to participate in the research if they met the following inclusion criteria: aged 18 years or older, able to speak English, working in Canada, have worked or were currently working in sex work, and possessed a cell phone capable of receiving text messages and/or accessing a website, Facebook, and/or Twitter.A multi-pronged strategy was used to recruit sex worker participants. A presentation on the research project at Maggie’s premises by the lead author (TB) (pre-COVID-19 pandemic) resulted in engaging 7 participants via purposive sampling . PurposiPhone interviews, ranging from 40 minutes to 2 hours in length, were conducted by the lead author (TB) between April and July 2020. All interviews were audio-recorded and stored on a secure University of Toronto server accessible solely by TB. Interviews were transcribed verbatim by a professional transcription service. Transcripts were subsequently imported into NVivo version 12  , a qualiThe qualitative analysis proceeded using Braun and Clark’s thematic content analysis approach . TB and Drawing on phone interviews with a mixed gender sample (N = 22) of sex workers, participants ranged in age from 20 to 53 years old (33.55 years on average), with a range of 1 to 32 years in sex work. In terms of gender, participants identified as either cisgender women, cisgender men, trans women, or non-binary. In terms of sexual orientation, participants identified as either bisexual, gay, heterosexual/straight, or pansexual/queer/fluid. Sex workers performed a variety of sex work, including escort , working online, camming, dancer, phone operator, massage, and dominatrix. The demographic profile of participants is available in From participants’ accounts, the following broad thematic areas were identified: (1) the landscape of ICT use by sex workers in Eastern Canada, (2) the OHS risks associated with sex work, (3) current use of ICTs to mitigate OHS risks, and (4) the potential use of ICTs for OHS risk mitigation.Sex workers reported the importance and utility of ICTs for their business activities. All 22 participants reported ownership of a smartphone, with some sex workers having a separate phone for their work, and a separate phone for personal use. Texting was the most often used method of communication with clients. Sex workers expressed that the camera on their smartphone allowed them to take high quality pictures and videos, which became especially important during the COVID-19 pandemic when their work had moved online to sites where people paid to view their photos . In addSmart phone or laptop, your two best friends in this industry. (…) because I’m an indoor worker, we live by them. It’s how we create our clienteles, it’s how we build our business. It’s not like we do a lot of public street work kind of idea. So, it’s a different avenue to go through.” (I-SW21)“While smartphones and laptops were used on a daily basis to access the Internet and social media, sex workers referenced the digital divide  as they a lot of my friends aren’t wealthy enough to have data plans (…) would just be the texting and calling, if you don’t have a data plan” (I-SW1)“Although having ICTs as business tools were advantageous, sex workers expressed that using smartphones and other ICTs brought upon new risks. Sex workers highlighted that the constant availability of their online workspace led them to continuously work , often at the expense of their own physical and mental health. To counteract the risks of occupational burnout when working online, sex workers reported that they learned to establish boundaries around their work schedule.one of my issues being independent early on was, I just was on my phone all day, working and keeping up (…) you have to figure out a balance and if you’re working on your phone, you can always be working.” (I-SW2)“Sex workers recounted additional risks when using smartphones and other ICTs. Sex workers explained that the risk of “outing”, or being exposed as a sex worker, is present due to having an online presence. Sex workers also spoke about the risk of arrest due to having a smartphone that records texts sent and received, as well as locations frequented, as the phone becomes a de facto diary.It can be used as evidence, do you know what I mean? You know, because if you’re text-messaging, you know what I mean, clients, you’ve got to be mindful of, you know, making sure you don’t have a call log, you don’t have a text message log (…) the smartphone, as much as it has a lot of positives, it’s also now being used against us to criminalize us.” (I-SW7)“The sex workers outlined several risks associated with their occupation, which fell under three categories: structural determinants, clients, and entering sex work.Structural determinants. Although participants expressed that they would like to work together out of a shared location, the laws in Canada prohibit this type of work environment. Sex workers noted that criminalization not only isolated them physically from other sex workers, but also prevented them from communicating safety information to each other through verbal, paper, or online modes. Sex workers talked about websites and social media platforms that had removed sex worker content after the passage of FOSTA/SESTA in the United States.they keep shutting down all of our safety sites, like all of the sites we used to talk to each other and find this [OHS] information.” (I-SW22)“Sex workers related that in the context of criminalization, the police were not considered a resource for their protection but rather an added risk to their safety and wellbeing. In case of assault, robbery, or harassment, sex workers reported that they would not, or be very reluctant to, contact the police, as police will not arrest the client, instead, they will arrest the sex worker.it’s very challenging for a lot of sex workers to contact police if they’re, you know, experiencing abuse, like when they’re doing their work because … because it’s highly criminalized, and a lot of sex workers are not out. It’s scary. And a lot of times police don’t care. They don’t take it seriously. They discriminate against sex workers.” (I-SW6)“Sex workers mentioned that working in a criminalized industry deprived them of formal labour protections, and they were aware that their occupation was viewed as having no merit.the stigma associated with sex work and the laws that are in place that make it so that we can’t fight for our rights within the workplace and our rights to safety.” (I-SW17)“Sex workers recounted the poor attitudes, stigma, and discrimination they faced when accessing health services, which prevented them from being open about their occupation and made seeing a health professional anxiety provoking. The participants noted that such attitudes towards sex work also permeated throughout their personal lives, often leading them to lie or keep their work hidden from their friends and families. Sex workers also discussed the marginalization they experience from having their work stigmatized, and that this feeling of marginalization prevented them from seeking out a supportive community.the laws that are supposed to protect us, and they really just cause further damage and ostracize us, and push us to a place where, you know, like we have to, you know, lie about what we do to be able to get a house (…) the law influences how the rest of the world perceives us, and that includes accessing social services, that includes accessing healthcare, that includes accessing housing.” (I-SW17)“OHS risks with clients. Sex workers indicated that the most pressing OHS concern they faced, regardless of their gender, was violence. Clients, whether new or recurring, could become violent, particularly if they were intoxicated. Sex workers recounted the types of violence that they had experienced, for example, sexual assault. One participant recalled a particular act of violence, confinement, where they had accepted an outcall [a location other than the sex worker’s home], and the client then proceeded to confine the sex worker to the client’s premises. Sex workers also discussed the risk of acquiring sexually transmitted blood-borne infections (STBBIs) [(STBBIs) . ParticiI was, like, you know, I said, I thought so. I said, dammit, that’s come off. And he went, I thought it felt better. And I was like, oh, you knew and you said nothing? So we did have a talk about it, and I said to him, I said, that’s not cool. And he said, yeah, but you get screened. I said, that’s not the point, not the point.” (I-SW18)“Entering sex work. Several participants discussed that they were not aware of best OHS practices in the industry, such as screening clients and setting boundaries, when they first engaged in sex work. Early in their career, sex workers recalled that they booked appointments made solely on the basis of one text or e-mail from the client, without further screening the clients. Some sex workers recounted a lack of knowledge around consent and establishing boundaries  either when they were setting up the appointment or once they were in the room with the client. Sex workers reported difficulty in accessing resources that would help them understand safety in sex work and that the current laws prevented them from operating safely.I would only have to trust my gut feeling over a few texts or emails. And that didn’t seem safe for someone who didn’t really know what she was doing and had never done it before (…) what happens in the room you learn on your own. Like you learn how to enforce your boundaries.” (I-SW15)“Obtaining OHS information. The Internet was perceived by participants as an essential source of information, a conduit into connecting with an online community. Sex workers reported using Google to search for sexual health information, legal information, safety concerns for escorts, and sex work in general. Sex workers mentioned that they found community-based organizations (CBOs) that were run by and for sex workers, and for the first time in their sex work career, accessed bad date lists on the CBO’s website. Escort review boards, blogs written by sex workers, and sex worker websites were also useful sources of information identified by participants. Sex workers also recounted using social media platforms such as Facebook groups, Reddit, YouTube, and Twitter, and through these platforms, networked with the more experienced sex workers they found online.you really just got to use Google, YouTube, try to get on Twitter, talk to other girls, find out what they’re doing to keep themselves safe.” (I-SW19)“Screening. Sex workers reported that they used screening to determine whether it was safe to meet a client who found them through their ads or website postings. Participants explained that their ads contained very specific protocols, such as how to contact them , where the appointment will take place , as well as terms of the encounter . Clients who did not follow the outlined protocols would be refused, while those following protocols would be further screened, for example, based on their use of respectful language. Sex workers indicated that screening helped them ascertain whether their boundaries would be respected, and whether they would be physically and emotionally safe during the encounter.that goes back to the initial screening, where I’ve had text conversations and I’ve got a feel. So some people behave in certain patterns. (…) it is, in my opinion, very important for me to have a feel for who’s coming.” (I-SW18)“Bad date lists. Sex workers accessed bad date lists from several sources: locally, from CBOs; escort review boards, which are either local or Canada-wide; or lists available for a fee. Other sex workers reported exchanging bad date information through Twitter, group chat, or Google sheets. When encountering a disrespectful or violent client, sex workers described that they would block the client on their phones, report the client to a bad date list and inform their network of colleagues. Sex workers agreed that bad date lists had kept them from seeing a potentially violent client.“Because they give me a better sense of security around who I’m going to see. Bad date lists have saved me from seeing potentially violent clients in the past and they’re especially vital I find when you’re a new worker because those are the workers that predators tend to target because they don’t know about these long-standing predators that workers who’ve been around for a while are familiar with already. (I-SW22)Although bad date lists were a valuable OHS tool, not all sex workers used them, due to accessibility issues. Some sex workers explained that if they did not have access to a bad date list, they tapped into their network to obtain information about a client. Some sex workers shared that they were not aware of the existence and availability of bad date lists. One sex worker described that online bad date lists can only be accessed on a device with Internet access. Sex workers described that to have access to a bad date list, the sex worker had to be vouched for by another sex worker that already had access to the list. Sex workers agreed that vetting access helped prevent clients from scanning bad date lists.the thing about a blacklist is you want it to be kept secret. You know you don’t want clients to have access to it because if a client figures that he’s on the blacklist he can just change information (…) you have to make sure that it’s something that’s secure. And that it won’t be outed and that’s something that’s always a little harder online and especially with a group of a lot of people.” (I-SW15)“Buddy system. Some sex workers explained that prior to meeting a client, they text a group of friends or colleagues, using WhatsApp, Twitter, or other electronic messaging software, to apprise their network of their location and scheduled end time of the encounter. This OHS strategy was referred to as a safety call, buddy system, or check-in group.I also started up the one Twitter group that I said, we have the group chat, that group is a check-in group as well.” (I-SW17)“Online communities. Sex workers have found online communities in community-based organizations (CBOs) websites that were run by and for sex workers. Sex workers also described finding online communities on escort review boards, blogs written by sex workers, and sex worker websites, as well as social media platforms such as Facebook and Twitter. Sex workers described that the strong online communities they had created provided support, kept each other physically safe, helped each other manage their mental health, and together fought the stigma imposed upon them by social norms.I was so grateful that I found the community and how helpful it’s been, because we really protect each other, because otherwise, you know, we don’t survive (…) technology has really changed the way we network and take care of each other that way, I would say, because yeah, it’s–and you just put a trigger or content warnings about whatever you’re going to talk about, so–If you want to narrow it down, I would say, in terms of technology, that definitely helps in terms of processing and getting the support that we often really can’t get elsewhere (…) I’m also a moderator of a mental health group chat, and I’m also in a group chat for just general support for Toronto, mostly escorts.” (I-SW2)“Although sex workers described how their current usage of ICTs assisted them in managing the OHS risks associated with sex work, they also highlighted the limitations of their current use, including challenges associated with finding other sex workers online and the prospect that safety information may be taken down due to local regulations and legislation related to sex work content on the Internet.there is more resources that are coming about, and the thing is, is that with the laws in place, it’s technically a liability. (…) you can’t really just put out a list on how to screen, you know, that’s something we have to do privately together. (…) So I’m very hopeful that in the future that we’ll be able to access to more resources and tools like that, but it’s one of those things where it’s like there are people putting forth laws right now that are making that hard.” (I-SW17)“The participants in this study, regardless of gender, envisioned an innovative, secure, easily accessible, sex worker-only ICT OHS tool to address these limitations.I think it would be invaluable. I don’t think I can out into words just how invaluable that would be. (…) a strategic and well-thought-out and easy to access platform, would be wonderful. And something that’s interactive. Interactive to me means everyone can access it, you know, a login or a password provided for sex workers, a verification process.” (I-SW18)“Their specific recommendations are further articulated in The results of this study provide insights into the usage of ICTs by Eastern Canadian sex workers to manage their OHS risks. Guided by the Social Ecological Model , this stAs reported in previous research , 38–40, Although previous studies have found that transitioning to indoor online work has isolated sex workers from each other , this stParticipants in this study mentioned the impact of sex work stigma on their OHS risks, consistent with the risks identified in Benoit et al.’s 2018 study on prostitution stigma. Notably, participants described how judgement on the part of healthcare workers could result in avoidance of health care services , as has Finally, a community has been found to help in learning harm reduction techniques for sex work . IndividThis study has several limitations. A limitation related to the COVID-19 pandemic is that the study did not include sex workers who hid their occupation from their housemates and therefore could not openly speak on the phone about their experiences with ICTs. Two other limitations of the study are that only a small number of transgender sex workers participated, and only one street-based sex worker was interviewed, limiting the transferability of our findings to these groups. Lastly, sex workers in urban centres who use ICTs in their work were interviewed, excluding sex workers in rural and remote areas, as well as those without ICTs. Future research will be needed to ensure that any ICTs developed as a result of these recommendations are also of use to sex workers in rural and remote settings.This study adds to the emerging research that examines, in collaboration with sex workers, the use of ICTs in their work, and more specifically, the use of ICTs in the delivery of strategies for OHS. Despite the legislative constraints imposed on sex workers with regards to communicating safety information, either in physical or in online spaces, sex workers continue to make creative use of the ICTs available to them. However, these constraints result in OHS information being scattered across various platforms such as blogs, YouTube videos, closed electronic chat groups, and open online sex worker supportive communities, creating access challenges, particularly for individuals new to sex work. Moreover, these platforms may disappear without prior warning, either due to the platform provider seeking to evade possible prosecution, or because new legislation is introduced banning such content. Innovative, secure, easily accessible, sex worker-only ICT OHS tools, designed by sex workers for sex workers, may assist in reducing the on-the-job risks sex workers face on a daily basis, until legislative changes are implemented which reduce the OHS risks associated with criminalization.


In recent years, university teaching methods have evolved and almost all higher education institutions use e-learning platforms to deliver courses and learning activities. However, these digital learning environments present significant dropout and low completion rates. This is primarily due to the lack of student motivation and engagement. Gamification which can be defined as the application of game design elements in non-game activities has been used to address the issue of learner distraction and stimulate students’ involvement in the course. However, choosing the right combination of game elements remains a challenge for gamification designers and practitioners due to the lack of proven design approaches, and there is no one-size-fits-all approach that works regardless of the gamification context. Therefore, our study focused on providing a comprehensive overview of the current state of gamification in online learning in higher education that can serve as a resource for gamification practitioners when designing gamified systems. In this paper, we aimed to systematically explore the different game elements and gamification theory that have been used in empirical studies; establish different ways in which these game elements have been combined and provide a review of the state-of-the-art of approaches proposed in the literature for gamifying e-learning systems in higher education. A systematic search of databases was conducted to select articles related to gamification in digital higher education for this review, namely, Scopus and Google Scholar databases. We included studies that consider the definition of gamification as the application of game design elements in non-game activities, designed for online higher education. We excluded papers that use the term of gamification to refer to game-based learning, serious games, games, video games, and those that consider face-to-face learning environments. We found that PBL elements , levels, and feedback and are the most commonly used elements for gamifying e-learning systems in higher education. We also observed the increasing use of deeper elements like challenges and storytelling. Furthermore, we noticed that of 39 primary studies, only nine studies were underpinned by motivational theories, and only two other studies used theoretical gamification frameworks proposed in the literature to build their e-learning systems. Finally, our classification of gamification approaches reveals the trend towards customization and personalization in gamification and highlights the lack of studies on content gamification compared to structural gamification. In recent years, most universities use e-learning platforms to deliver courses. Teaching in the form of e-learning is a modern supplement, and sometimes even an alternative to traditional education Górska, . EspeciaGame technologies create opportunities for higher education institutions to redesign and innovate their e-learning models to support learning experiences among learners For research question 3:(gamif* OR gameful OR “game elements” OR “game mechanics” OR “game dynamics” OR “game components” OR “game aesthetics”) AND .(gamif* OR gameful OR “game elements” OR “game mechanics” OR “game dynamics” OR “game components” OR “game aesthetics”) AND  AND (framework OR method OR design OR model OR approach OR theory OR strategy).IEEE,Springer,ACM,JSTOR,SEMANTIC SCHOLAR, SAGE,Science Direct.We conducted our research by searching the databases using the search query formulated previously. We performed our search in the Scopus and Google Scholar databases as the first is one of the most professional indexing databases and the second is the most popular, so it helps to identify further eligible studies. The search was performed in December 2021. Although the Scopus database indexed the publication abstracts, most of the articles were not available through Scopus, and the articles were retrieved from the following publishers:The exception was some articles that could not be accessed. We also performed a backward snowballing search to identify further relevant studies by scanning and searching the references of papers marked as potentially relevant  Adaptive gamification considers that users have different motivations, so it consists of personalizing learning experiences according to each learner profile. Whereas ‘one size fits all’ gamification uses the same gamified system  for all learners. For ease of use, we will use ‘A’ character for adaptive approaches and x for ‘one size fits all’ ones.Profundity from pedagogical perspective  structural gamification refers to the application of game design elements to motivate the learner through an instructional content without changing it (Garone & Nesteriuk, Validation This group categorizes papers that provided a validation of the proposed approach through empirical evidence showing its application to e-learning systems in higher education.Given our review’s main interest in e-learning in higher education, we will classify the last 17 approaches of Table Table Furthermore, Table Moreover, Table Through this systematic review, we identified several papers on the gamification of e-learning in the higher education context. In recent years, the research on gamification in e-learning has been getting traction, and the number of research articles and systematic reviews of research articles is increasing. As a summary of the existing approaches of gamification in e-learning in higher education, we notice the following points:The systematic review showed that gamification of learning systems is nowadays a hot topic, and research in this field is growing rapidly as well as for e-learning in higher education context, as it is shown by Fig. In general, gamification theory helps in training and shaping participant behavior, however, in our systematic literature review, we observed from RQ1 that the majority of applied research on gamification is not grounded in theory and did not use gamification frameworks in the design of the learning system under study. This highlights the fact that there is a real gap between theoretical and applied work on gamification. One reason may be that existing approaches are very theoretical and cannot strongly assist designers and practitioners when gamifying learning systems, as pointed out by Toda et al. . This alTo better understand this phenomenon and to find a rationale for this lack of using theory and, thus, the lack of logic behind the use of certain game elements over others and their random linking and combination in gamified learning systems, we addressed the research question RQ3. In the latter, we analyzed the gamification approaches available in the literature and classified them into different categories based on a variety of criteria. Our results revealed that the gamification elements guidance approaches that provide taxonomies of game elements that can be incorporated into learning systems constitute the majority of the approaches that have been proposed for application in online learning in higher education. Those did not provide the psychological and behavioral changes that correspond to each game element. Instead, the older gamification theory was based simply on the behavioral outcomes that come from using gamification and the motivational needs behind it and did not provide details on how to implement them or details on what elements to use.Using appropriate game elements can lead to higher levels of user motivation, whereas inappropriate game elements can demotivate users (Hallifax et al., On the other hand, through our systematic literature review, we can see from RQ3 the recent emergence of data-driven approaches through machine learning techniques (Knutas et al., In many learning environments, pedagogy assumes that all learners have homogeneous characteristics (Kamunya et al., Another recent and relevant issue is the extreme lack of content gamification. Indeed, the motivational impact of certain game elements varies with the user activity or the domain of gamified systems (Hallifax et al., Another common study design issue illuminated by our review is the lack of validation of the proposed gamification approaches through statistical analyses. In addition, most applied research on the gamification of online learning systems in higher education has not explored the gamification frameworks suggested in the literature.In this work, we conducted a review of the literature on gamification elements used in digital higher education, the way they are combined, and the different gamification approaches proposed in the literature to gamify learning systems. We analyzed a total of 90 papers to answer the three research questions formulated for this study.This review identified points, badges, leaderboards, levels, feedback, and challenges as the most commonly used game elements in digital higher education. However, in terms of using gamification theory, our review found that the majority of applied gamification research is not theory-based and has not used gamification frameworks in the design of gamified learning systems. Although some experimental studies attempt to adapt psychological and educational theories available in the literature as gamification approaches, the resulting systems are not very clear, and there is no rationale for choosing certain game elements over others. Consequently, it can be concluded that these gamification approaches cannot strongly assist designers and practitioners in gamifying their learning systems. In addition, theoretical gamification approaches in e-learning in higher education should focus on understanding the effect of each single game design element and the behavioral changes that outcome from its use.Moreover, based on the results of this review, we can observe the trend towards data-driven approaches through the use of machine learning techniques, especially in adaptive gamification approaches. This involves the adaptation of gamification elements to user profiles. On the other hand, although we have noticed the increasing use of gamification elements that are suitable for content gamification and make the content more game-like, such as storytelling and challenges, there is still a lack of gamification approaches that address content gamification. In fact, this is still an immature research area in gamification design in e-learning in higher education.  Future works should pay more attention to the pedagogical side of learning systems and the task under gamification. Apart from that, further research is required to compare theory-driven to data-driven gamification approaches, in terms of which one is the better or perhaps evaluate the effectiveness of a combination of the two, and go so far as to propose a hybrid gamification approach, which does not exist yet and might solve several gamification design issues.Regarding future work, efforts should focus on building a holistic approach by considering all the aspects that constitute the environment. Among those,  personalization according to students’ profiles, gamified subject, educational context, learner’s culture, learner’s preferences, level, playing motivations and experience with games.Finally, we have seen that most of the design approaches suggested in the literature are not empirically explored. Therefore, statistical analyses and comparative studies should be conducted to draw more robust and generalizable conclusions to validate the existing gamification approaches in the literature.


Tuberculosis (TB) often concentrates in groups of people with complex health and social issues, including alcohol use disorders (AUD). Risk of TB, and poor TB treatment outcomes, are substantially elevated in people who have AUD. Médecins sans Frontières and the Belarus Ministry of Health have worked to improve treatment adherence in patients with multi-drug or rifampicin resistant (MDR/RR)-TB and harmful use of alcohol. In 2016, a person-centred, multidisciplinary, psychosocial support and harm reduction programme delivered by TB doctors, counsellors, psychiatrists, health-educators, and social workers was initiated. In 2020, we described patient and provider experiences within the programme as part of a wider evaluation.We recruited 12 patients and 20 health-care workers, using purposive sampling, for in-depth individual interviews and focus group discussions. We used a participant-led, flexible, exploratory approach, enabling participants and the interviewer to shape topics of conversation. Qualitative data were coded manually and analysed thematically. As part of the analysis process, identified themes were shared with health-care worker participants to enable their reflections to be incorporated into the findings.Key themes related to the patients’ and practitioners experience of having and treating MDRTB with associated complex health and social issues were: fragility and despair and guidance, trust and health. Prejudice and marginalisation were global to both themes. Counsellors and other health workers built a trusting relationship with patients, enabling guidance through a multi-disciplinary approach, which supported patients to achieve their vision of health. This guidance was achieved by a team of social workers, counsellors, doctors and health-educators who provided professional and individualised help for patients’ illnesses, personal or interpersonal problems, administrative tasks, and job searches.Patients with MDR/RR-TB and harmful use of alcohol faced complex issues during treatment. Our findings describe how person-centred, multi-disciplinary, psychosocial support helped patients in this setting to cope with these challenges and complete the treatment programme. We recommend that these findings are used to: i) inform programmatic changes to further boost the person-centred care nature of this program; and ii) advocate for this type of person-centred care approach to be rolled out across Belarus, and in contexts that face similar challenges.The online version contains supplementary material available at 10.1186/s12913-022-08525-x. Despite decreases in global tuberculosis (TB) incidence, multidrug-resistant/rifampicin-resistant TB (MDR/RR-TB) remains challenging, with approximately half a million people infected globally . The EasEvidence for improved packages of care are needed where comorbidities are managed, and health staff and family members need to be sensitised to the complexities of this patient group in order to support these patients to complete TB treatment –11. The In Belarus, the commission of doctors of the treating institution can request the involuntary isolation of TB patients with poor treatment adherence in a hospitalisation centre,  which haSince 2014, Médecins sans Frontières (MSF) has worked with the Belarus Ministry of Health (MOH) to improve MDR/RR-TB treatment adherence and outcomes and to support a WHO recommendation to reduce involuntary isolation  by proviWe conducted a qualitative study to describe the patient and provider experience of the PCMPS programme for patients with harmful use of alcohol and MDR/RR-TB in Minsk, Belarus.This study took place in Minsk, Belarus, where the estimated number of MDR/RR-TB patients starting treatment every year is around 200. Around 35–45 of these would be enrolled into the PCMPS programme each year. The study took place, within the existing PCMPS programme in the last quarter of 2020.Newly-diagnosed MDR/RR-TB patients in Minsk were admitted to the in-patient department at the Republic Scientific and Practical Centre of Pulmonology and Phthisiology (RSPCPP) of the National TB Programme. Patients with suspected AUD or harmful alcohol use, according to ICD-10 criteria,  were refThe care package, provided alongside the MOH’s standard package of MDR/RR-TB care by MOH and MSF staff, includes individual and group counselling, patient education, mental health support, psychiatric care, and social support around 1–3 times per week in person or by phone. TB treatment adherence was ascertained by a nurse through directly observed or video observed treatment. Patients classed as having low risk to adherence received the baseline programme; moderate patients were provided with more intensive counselling; and those at high risk received harm reduction packages, mandatory assessment by a psychiatrist, and anti-craving medication where appropriate. The definitions of care used in the project are in Table We conducted 12 in-depth interviews with patients, and three focus group discussions (FGDs) with 20 health-care providers, in October and November 2020. We used a participant-led, flexible, exploratory approach, enabling participants and the interviewer to shape topics of conversation. We chose the collectivist, multi-vocal focus group as a method as it provides additional insights from group interaction . PatientThere were around 50 patients in the programme at the time of the study. Participants were purposively selected to represent the full range of perspectives, until data saturation was reached,  in the pDue to COVID-19 restrictions, nine interviews and all FGDs were conducted by phone. In-person interviews were conducted in a private space, using infection, prevention and control measures for TB and COVID-19. Two participants had a second interview as it was not possible to finish all the questions in one sitting. Separate FGDs were conducted for MOH and for MSF staff, and a third FGD was held for study investigators who were also implementers. The length of the interviews varied from 15 minutes to 1 hour, and FGDs were between 1 and 2 hours.Audio-recorded interviews and FGDs were transcribed verbatim in Russian then translated into English. Data were sorted and coded manually. Transcripts were analysed thematically, using elements of grounded theory by two co-investigators (RH & BS) using Microsoft Word and Excel to identify patterns in the data; these were constantly compared and refined, with the aim of revealing the experiences of the participants rather than externally imposing interpretations . Data thThe response rate among patients was 75% (12 interviewed of 16 invited); three of six women (50%) and 9 of 10 men (90%) participated, and age ranged from 32 to 56 years. Reasons for refusal were not given. Not all invited health workers could take part, due to other commitments at work. Providers from one of the clinics did not take part due to having less engagement with the project. Tables Several key themes emerged, in relation to participant and practitioner experiences of having and treating MDRTB with complex health and social problems: perceptions of fragility and despair, and guidance, trust and health pertinent to the programme. With prejudice and marginalisation described globally across both themes as enabling despair and fragility, with the potential to undermine effective guidance, trust and better health. The coding tree can be found as Fig. Patients expressed vulnerabilities exacerbated by their physical and mental health and social wellbeing. Anxiety and weakness caused by TB symptoms and side-effects of TB treatment and difficulties in their lives were described, as well as a fear of death and sickness. Although some patients felt healthy, others felt extremely sick from TB. One patient described the feelings of fragility caused by the disease:“I have a feeling that I want to vomit. Like an old man, you see, it’s just that tuberculosis was like snow on my head”, [Patient F]Receiving a diagnosis and treatment as an in-patient was described as traumatic by patients and staff. Practitioners described how patients experienced: “rather high anxiety levels at the admission stage because the patients do not understand their diagnosis at all” [MSF Staff]; a patient referred to this stage as “a nightmare” [Patient H]. For many patients, the anxiety experienced at the beginning of treatment was exacerbated by the fear of the effects of the disease on their loved ones. Additionally, some patients were living with HIV infection, hepatitis C, heart disease, or diabetes. These difficulties were recognised by staff:“If you take tuberculosis, HIV, hepatitis C and social issues all intertwined, it is a heavy load altogether. The chance they will get to the end of such a serious treatment is pretty low” [MSF staff]Patients in the IPD were often struggling with muscle weakness; others described coughing up sputum and blood. Most experienced treatment side-effects. One patient said: “I feel tired, weak, and I don’t want anything. It’s hard to move. Everything gets hard [after taking the pills]” [Patient J].The complexity of circumstances for many patients was referred to through their experience of abusing alcohol or other drugs alongside living with TB:“When I was taking drugs, every day was like Ground-hog Day. Each day was the same. Wake up, look for money, steal something.” [Patient C]Patients and health-care workers reported that alcohol would be used as a means of dealing with stress, for example: “I washed it down with a drink. I didn’t want to believe I had TB” [Patient E]. The topic of substance abuse wasn’t easy for some participants to discuss or admit to during interviews. For example, one participant said of alcohol abuse: “I know such people, but I’ve got no such challenges. My family comes first for me.” [Patient H]. Counsellor reflections of why participants were not open with alcohol use refer to fear of consequences of being labelled alcohol dependent, which included, for example, potential loss of custody of children.Economic worries including joblessness or homelessness were an issue for most patients. Some had jobs but they tended to be casual, low-paid manual labour that left them with economic insecurity. Their TB diagnosis prevented some patients having access to employment, but not all were eligible for disability benefits: “I can’t get a regular job. I can’t get a pass from the medical commission to get a job if it can harm me in any way … I don’t understand why they don’t give me a disability group [Patient J]”.Patients described feelings of physical and emotional isolation, especially where hospitalisation was implemented through the MOH involuntary isolation and treatment system. One patient who had been in and out of prison several times described involuntary isolation and treatment as “a terrible mess. They don’t take patients for humans …. it’s very scary out there. Worse than in prison.” [Patient G].Many patients described living a lonely and isolated life, with deaths of family members, perceived betrayal, prejudice and marginalisation by family or friends, sometimes due to health issues and diagnoses. One described how his only remaining friend was his dog, and how he felt terribly disappointed by humanity. Another described how this feeling of rejection, prejudice and marginalisation by those around had contributed to his lack of determination to complete treatment or take care of himself: “I faced the situation when the closest people let me down … I was in such a mental state that I felt that no one needed me and they did not care about me.” [Patient A].The second set of themes relates to the patient and practitioner’s description of guidance, trust and health and its connection to the PCMPS approach. Patients and practitioners stated the importance of being able to build a trusting relationship, and this being a cornerstone for the success of the programme. For those in isolation, counsellors represented relationships that they otherwise might not have:“Well, it’s always nice seeing them. They always bring something new, new issues, new stories, they tell about what is going on outside the fence, what’s the news. They support and sympathise with us. They are people like us. We also share our news, though little is happening here”, [Patient E]Counsellor-educators also said that the programme worked through their ability to build trust with a patient. This was often not as simple as following guidelines. Counsellor-educators said that they had to use “… charisma and emotions. You smile or tackle a patient’s personal issues if he’s eager to talk about it. So, you build up trust.” [MSF Staff].Patients with problems with employment or other social issues were referred to a social worker. If they had other medical problems, the counsellor could help them articulate these and receive the care they needed. This was described as an interconnected experience in which trust was central: “The patient can get help from all sides, and he has people he trusts. He realizes he is not alone in certain processes.” [MSF Staff].Patients described counsellor-educators as inspirational, trustworthy, and professional. Patients described how counselling helped them deal with conflict with partners, financial or administrative stressors, or fears surrounding TB:“Here, when I had some issues with my wife, I also contacted [the counsellor-educator]. Well, it is he who helped me. I am glad that I have someone to contact, to talk, to seek advice. Sometimes even not about the disease, but about real life, as they say, situations. So, I’ve got his phone number, we are always connected. I am glad that there is such an organization and I have someone to address.” [Patient A]MOH doctors felt that counselling as part of the programme meant that patients ‘felt treated as human-beings – which doesn’t normally happen in their lives’ [MOH staff]. Furthermore, one MOH practitioner described how MSF counselling staff could go further and “dig deep into their souls … trying to uncover their deepest fears. And in fact, they often manage to do it.” [MOH staff].Health-care workers described teamwork and integration of health workers’ differing specialties as essential components of the programme, enabled through having a clear-cut system, finding common ground, and being able to manage crises. Staff met weekly in cross-discipline meetings to discuss patient care:“That’s where we work together with MOH over the patient’s problem. That’s when we meet together, when we know what’s going on and when we have a single objective to quickly solve his issue. This is quite effective”, [MSF Staff]In follow up discussions, staff agreed that the programme could potentially go further and integrate more with hepatitis or HIV care, to ensure doctors could treat more than just TB at a single visit, and that patients felt like a human being rather than ‘incomprehensible flesh’ [Patient E]. MOH staff felt that ‘group meetings with different specialists’ [MOH staff] is particularly helpful in patients who are not following guidance on health education.Most patients described real strength in themselves and a resolve to get through, that was essential for treatment success: “I’ve made up my mind. I’ve got a will power. I want to be cured. I want it to be all right, to go on living”. [Patient E] For some patients, this resilience and determination were learned through surviving army life or previous imprisonment. Determination for many was gained through finding love, or improved relationships with those around them. For example, one patient said “Maybe I’d keep drinking if I’d not met my girlfriend who provided some support …. I have others. I have my mother. I have a wonderful mother. She always supports and helps me” [Patient C].Many patients talked about the importance of trust: the trust they had in their loved ones, and, in some instances, in practitioners who treated them humanely and with care. One patient said: “I am a distrustful man. Trust nobody. Well. But I trusted him [the doctor]. And I tested him. And when you trust a person, you know … Well, he didn’t give me away to anybody … He treated me like a person whom he is close to. More, he treated me fondly” [Patient K].The prejudice, rejection and stigma experienced by patients and their friends and families exacerbated feelings of marginalisation. These feelings were, in some instances, amplified by practitioners who were not following a person centred approach, particularly those treating patients in involuntary isolation. For example, one patient, after 1.5 years of involuntary isolation, said: “It’s not clear at all whether this is a treatment, or I’m in a madhouse, it’s not clear at all” [Patient F]. Some patients described the negative experience of approaches where the doctors only care about adherence to TB treatment, and were not interested in other aspects of a patients’ health:“But they already have such an attitude that you are not a human being, but a piece of some incomprehensible flesh... [the doctor] says to me ‘The main thing for me is your lungs, and about the rest, I don’t care.” [Patient E]Some MOH practitioners perceived patients who had a substance abuse and imprisonment history as problematic, stating that: “not just healthcare practitioners are challenged by those patients. They are a burden to other healthcare facilities … as well as to their families and, in fact, to the whole world.” [MOH staff]; while another said “they all want to have fun, they don’t want to work”. [MOH staff].Not all patients were able to engage with the programme or build trust with the care givers. One MOH staff felt that at least one patient had stopped their TB treatment due to the person-centred approach, as they felt the patients, especially those who had drug problems or a criminal history in some instances were being “indulged” [MOH staff]. Programme psychiatric staff said that patients with other drug use or untreated personality disorders could be the hardest to engage. Patient participants said that there was nothing to be done for patients who were not engaging with the programme until they developed self-determination to get better: “I would say if someone does not need that support, drinks throughout the treatment. You’ll not help them until they start wanting it.” [Patient C].Our study describes the personal situations of a group of patients who often experience poor treatment outcomes, and their perceptions of a programme that is able to engage with them. We illustrate that support and good guidance from a trusted practitioner team, and from reliable loved ones, helps patients to navigate MDR/RR-TB treatment and other challenges faced in everyday life. This was achieved by building trust with patients, leading to better understanding of their complex needs and enabling the provision of holistic care to meet these needs. The importance of “disrupting the cycle of mistrust” between patients and providers has been described in a study of TB care in South Africa . QualityThe programme was able to help address the complex social issues and feelings of marginalisation experienced by patients. However, loneliness and emotional isolation were sometimes worsened by public-health measures involving extended periods of isolation in hospital. Many patients described the psychological difficulties of being locked up for long periods. Involuntary isolation and treatment can lead to psychosocial problems such as loneliness caused by not being able to see a long-term partner, or issues linked to not being able to go about normal social and economic activities . In our Some patients described the negative experience of being treated as “incomprehensible flesh”, where doctors treated their lungs but ignored their other health problems. For some, this de-humanising treatment was painful reminder of the poor treatment they had received elsewhere in their lives.The PCMPS programme presents a foundational support to include other specialities; for example, coinfections such as HIV treatment at a single doctor’s appointment, or for patients to receive sessions with a group of relevant specialists. The benefits differentiating the person-centred approach could include adherence success for coinfections such HIV, TB, and hepatitis C, especially for injecting drug users, have been reported elsewhere –41, and Not all patients were able to engage with the programme, especially those with use of drugs other than alcohol or undiagnosed personality disorders. The concurrence of personality disorder, substance abuse and harmful alcohol use has been well described –45. The The study design offered a chance for participants to tell their stories to an outsider who had no responsibility in the programme; however, an association of the researcher and translators to programme implementation could not be ruled out, meaning that some participants may have felt compelled to respond positively in interviews. To mitigate this the researcher reflected on role and responsibility throughout and translators were trained in qualitative research methods, and impact on the process was discussed and reflected upon between members of the research team. There may be some bias in responses in that some patients who were interviewed early on in data collection received in person interviews, whereas all later interviews and focus groups were conducted over the phone due to Covid-19. Interviews over the telephone may have restricted the interaction between interviewer and interviewee and removed the possibility for observation. On the other hand, telephone interviews are participant-centred, using a ‘virtual’ communication method that is increasingly common,  the telePatients and providers described how the person-centred, holistic approach of the PCMPS programme could lead to an improvement in the ability to cope with life and to complete treatment. Patients valued support from specialised health-care workers who they were able to trust, who treated them as human beings, and who could give them professional help with their illnesses, interpersonal problems, administrative tasks, or finding a job. Health care-workers in the programme appreciated its multidisciplinary nature, which enabled them to solve patients’ problems holistically, after building an initial trusting relationship. The programme should also be integrated further with other specialities such as HIV care. The programme should be adapted in instances where providers were not able to build trust, notably in people who use drugs other than alcohol or are suspected of personality disorder. We recommend that findings from this study are used to inform programmatic changes to further boost the person-centred care nature of this program. Finally, we recommend that the overall positive findings on the experience of this program by patients and health care-workers, are used to advocate for this type of person-centred care approach to be rolled out across Belarus, and in contexts that face similar challenges.Additional file 1.