Teacher well-being is not only relevant for the effectiveness of individual teaching and student learning but also for general school quality and societal functioning, because teacher well-being is related to lower burnout risks and lower attrition. Previous research identified social relationships in school as a crucial source of teacher well-being. However, studies investigating the role of teacher–student relationships as a determining factor for teacher well-being are still scarce. This study takes a qualitative approach toward investigating the role of dyadic teacher–student relationships in teacher well-being. We analyzed twenty-six semi-structured interviews with Swiss primary school teachers, using a qualitative content analysis. The results showed that dyadic teacher–student relationships played an important to a very important role in the everyday life of teachers and were a source of both positive and negative emotions, cognitions, and physical sensations. The quality of the dyadic teacher–student relationship was reflected in the social–emotional competence of both teachers and students. Conflicts were not necessarily inhibiting teacher well-being. The findings of this study can be used to inform teacher-training institutions, as well as authorities, on how to support teachers in building relationships with their students and, in turn, foster their well-being. Teachers play an important role in students’ success, satisfaction, and achievement . To explThe important role of teacher well-being calls for scientific answers to the question of what contributes to its development. Among a plethora of possible well-being sources, three main sources have been identified: contextual factors, personal factors, and interactive factors ,10. HoweReviews of the literature summarize the important role of social relationships as a source of teacher well-being and call for more in-depth studies ,12,13. AThe teacher–student relationship is a construct that has a variety of definitions and conceptualizations . For exaTeacher well-being has received growing attention over the past decade and has been empirically investigated using a variety of different concepts. In a recent review of the literature, Hascher and Waber  structurFirst, he pointed out that well-being should be regarded as subjective. Objective circumstances may influence subjective well-being, but they are not necessarily part of it. Rather, objective circumstances are evaluated differently by different people, for example, depending on their goals, values, or culture. Second, it must be considered that subjective well-being does not only consist of the absence of negative factors but also includes the presence of positive factors. Third, subjective well-being can be conceptualized differently in the temporal dimension. Drawing on research from the field of well-being psychology )Second, the role of the dyadic teacher–student relationship in teacher well-being may depend not only on its importance for a teacher but also on its quality. Although it can be assumed that dyadic teacher–student relationships of diverse quality are linked differently with teacher well-being, studies examining the importance of social relationships with individual students rather than their relationship with the class as a whole are still scarce. Previous empirical studies have found associations between dyadic teacher–student relationships and both positive and negative teacher emotions ,54,55,56Third, the role of the dyadic teacher–student relationship in teacher well-being may not depend solely on its importance for a teacher and its quality; rather, various teacher competences may have an impact. It might be important how teachers regulate emotions, cognitions, and physical sensations triggered by dyadic teacher–student relationships. For example, deep-acting emotion regulation strategies may help maintain a positive relationship with the student even when a situation elicits negative teacher emotions, such as anger caused by disruptive student behavior or disappointment linked to students cheating. Moreover, teachers’ social–emotional competence may be important in fostering a relationship quality with students ,64, becaThis study aims at contributing to the existing literature by analyzing well-being-supporting and well-being-inhibiting dyadic teacher–student relationships from primary school teachers’ perspective. We followed a qualitative approach and aimed to extend the extant literature in two key ways. First, we considered teacher well-being as a multicomponent construct, particularly by integrating the often-neglected physical component of teacher well-being. Second, we addressed teacher–student relationships from a dyadic perspective that differs from the teacher–class relationship on the collective level. Because studies indicate differences between school levels, this paper focuses on primary school teachers. For primary school teachers, compared to secondary school teachers, dyadic teacher–student relationships have been associated with greater emotional intensity due to greater proximity , and socResearch Question 1: How do primary school teachers evaluate the importance of dyadic teacher–student relationships with regard to their well-being at school?Research Question 2: How do primary school teachers describe dyadic teacher–student relationships that support teacher well-being, and what professional strategies do they report for fostering those supportive dyadic teacher–student relationships?Research Question 3: How do primary school teachers describe dyadic teacher–student relationships that inhibit teacher well-being, and what professional strategies do they report for coping with those inhibiting dyadic teacher–student relationships?First, we recruited only primary school teachers who had at least three years of teaching experience, as the literature points out that especially early career teachers explore their role as a teacher in the first years of their teaching career, which may lead, for example, to uncertainty in classroom management ). This resulted in a sample of total 495 students from 26 classes, including 244 (49.3%) female and 251 (50.7%) male students. All participating teachers stated that they felt comfortable to very comfortable at school during the weeks prior to the interview.This study is part of the project “Teacher Well-Being (WoLe)”, which was carried out by the Department of Research in School and Instruction at the Institute of Educational Science at the University of Bern. We conducted semi-structured interviews with primary school teachers from the German-speaking part of Switzerland, based on a top-down sampling procedure following predefined criteria. nagement . Second,ionships . Third, We followed a qualitative approach and conducted semi-structured interviews in German. According to Spilt and Koomen , interviWe analyzed and condensed the recorded and transcribed interviews in accordance with the structuring qualitative content analysis , using tWe contacted potential participants by e-mail and invited them to take part in the study at a time convenient for them. We recruited all participants on a voluntary basis and assured them complete anonymity and confidentiality, as specified in a written consent form. Participants could withdraw from the study at any time. All teachers received the results by e-mail and were invited to participate in further discussions.We piloted the relationship map before conducting cognitive interviews  with twoThe first author completed most of the coding, whereby selected text passages were discussed during team meetings. Furthermore, another team member coded additionally a third of the interviews. We calculated the intercoder agreement based on the percentage of agreement (code overlap for segments of at least 90%) by using MAXQDA 2020. This resulted in a good corrected kappa value  of κ = 0In the following sections, the main results regarding the three research questions are presented and illustrated with quotes from teachers. As the interviews were conducted in German, the selected quotes were translated into English by the first author and approved by the second and third authors. The participant number (P01–26) and the position in the transcript are indicated with examples; for instance, P03 pos. 24 indicates an exact quote from participant number 3 at position 24 in the transcript.When I think about the individual students, they influence my thinking. I take care of the child. Depending on the relationship, it is easier for me. I worry less. I also feel good, or happy to come to school and see the child again. I see them often, five times a week. […] Yes, the relationship is very, very important for my well-being”“.All 26 teachers confirmed the importance of dyadic teacher–student relationships for teacher well-being, with 15 teachers attributing a high importance and 9 teachers attributing a very high importance to their individual well-being. One teacher explained the importance as follows:joy when students expressed trust in them  or provided a positive emotional response . Teachers reported pride when they established a good relationship with a student . When a student actively sought contact, satisfaction was reported . Teachers mentioned being uplifted, as if one “had three coffees”, after a successful parent meeting ; sleeping well ; and feeling relaxed or relieved when students expressed gratitude after a great effort on the part of the teacher . Certain dyadic teacher–student relationships were associated with fun during learning processes due to “being on the same page”  and easily connecting to the individual child’s needs :Fun, fun, fun with learning. Right? From that point on, when the relationship is good, from that point on, you can have fun while learning. Before that, you cannot. But when you get it right, and you are both on the same page […] on the same respect level, but also on the same understanding level. From then on, you can really have that fun with learning” “.In all interviews, teachers reported dyadic teacher–student relationships as a source of positive emotions, cognitions, and physical sensations. Teachers talked of burden to maintain a time-consuming relationship with a student with special needs that left no resources to meet the needs of other students in the class . Another teacher had the impression that a child felt uncomfortable in her presence, which led to anxiety . A teacher spoke of disgust with herself after becoming aware that she had treated a student unfairly because of her own behavioral patterns and triggers . A teacher reported frustration when no progress had been made in the quality of the relationship despite many efforts . A teacher talked about one dyadic teacher–student relationship that led to a feeling of powerlessness on the part of the teacher as to how best to support this student . A difficult dyadic teacher–student relationship led to teachers’ worrying in the evening about the causes of existing conflicts  or about how to help a child in a difficult situation . The extent to which a difficult dyadic teacher–student relationship can affect teacher well-being was illustrated by the description of a teacher who has taught a student with difficult socio-emotional behavior and who strongly criticized the teacher. The teacher described becoming ill, suffering from various colds, and not wanting to get up anymore . Some teachers also reported that a difficult dyadic teacher–student relationship had almost caused them to leave the teaching profession in the past, as expressed by one young teacher as follows:If I regularly noticed that I was not getting along with the children, then that would be a reason for me not to do this job” “.Teachers also addressed dyadic teacher–student relationships as a source of negative emotions, cognitions, and physical sensations. For example, one teacher experienced it as a The reported positive and negative effects of dyadic teacher–student relationships on teacher well-being should not be understood as an exhaustive list; rather, they represent the multifaceted spectrum of dyadic teacher–student relationships as a source of teacher well-being.We describe teacher well-being-supporting dyadic teacher–student relationships based on (1) how teachers located those relationships on the relationship map and (2) the representation of the three most prevalent subcategories of each category of the student and teacher relationship schemas. When asked to identify around three dyadic teacher–student relationships that support teacher well-being the most, teachers classified a total of 107 relationships, with 45 (42.1%) being a relationship with a male student and 62 (57.9%) being a relationship with a female student see . Of thospersonality, intelligence, and special education needs in regard to extroverted students (n = 11), students high in agreeableness (n = 7), and students with high intelligence (n = 8). For example, one teacher spoke of working with an intelligent student leading to satisfaction and joy:He is just clever. We can discuss or explain things at a slightly higher level than with other kids. It’s just exciting to not only talk about the 4th grade material” “.When teachers talked about dyadic teacher–student relationships that support their well-being, most teachers talked in terms of students’ relationship behaviors included students’ active relationship building with the teacher (n = 17), shared humor (n = 10), and issues related to lack of respect for the teacher and disciplinary problems (n = 11). Students’ active relationship building with the teacher was experienced by one teacher as follows:I come into the classroom and he is already running toward me with something that he either wants to show me what he has done or that he wants to ask me (laughs)” “.Key discussion topics related to student motivational behavior of the students, teachers (n = 10) talked about motivated students who like coming to school, are concentrated on their work, contribute their own ideas to the lessons, or try to implement tips from the teacher. Few teachers (n = 3) spoke of unmotivated students. Motivated students can come along with a good feeling for the teacher:I can rely on her, she is doing her best. And she also comes up with questions when she does not understand something. And that is a very good feeling for me. So I do not have to ask at home: ‘Oh, why did she only do three tasks and they are all wrong?’” “.Regarding the socio-emotional behavior of the students, positive interactions with classmates (n = 7) were described as having friends in class and being integrated. On the other hand, some teachers (n = 4) talked about students involved in negative interactions with classmates. For example, for positive interactions, one teacher explained that a student was an important tie in the social network of the class, contributing to its cohesion and therefore supporting her well-being:That’s what this class needs, maybe that’s what makes me feel good, because she’s so important, such a rock for the class. She holds the class together a bit, which is important” “.Concerning the performance behavior, the high performance of students (n = 11) and few students showing low performance (n = 3) were mentioned. High performance led to joy and pride among teachers, as the following example illustrates:I cannot take credit for it, but I am proud of this girl. I can also praise her a lot and that is what we teachers extremely like to do” “.Regarding personality in the context of well-being-supporting dyadic teacher–student relationships. Teachers described themselves in terms of extraversion (n = 1), agreeableness (n = 1), and as being emotionally stable or calm (n = 1).Then I think maybe it has a little bit to do with my nature. Well, I am a very calm person and I am not someone who panics easily” “.Teachers rarely talked about their own relationship behaviors, teachers most often talked about their active relationship building with students (n = 15). Extracurricular activities, such as school trips, provided opportunities for initiating personal conversations with students. However, even in school, “chitchat times” before or after class can also be a platform for bonding. One teacher shared how she actively connected with the students when greeting them in the morning:I just ask: ‘How are you?’ in the morning. Or: ‘What did you eat?’ Or: ‘How is your hamster?’ Or yes, often it is conversations like that in the morning when they come. I think that is where I can have a lot of influence” “.When describing their n = 14) was an important topic. Through the understanding of a student’s response pattern, anger can be prevented. One teacher shared that a first step in gaining understanding for her begins with greetings in the morning. The look in the eyes, i.e., blurred or clear; and the posture, i.e., relaxed or sluggish, provided the teacher with important clues about the students’ well-being. However, to develop an understanding of students, teachers pointed out the importance of looking at their own behavior patterns, as illustrated in the following quote:And I think to really sit down and deal with these children who evoke something in you that actually has to do with you and your history. […] how can I change the focus and meet the child in a new way” “.Furthermore, the understanding of students’ behavior (n = 13). When a student needed a lot of support, the relationship could be strengthened through the intensive coaching, leaving room for progress and a sense of influence and satisfaction for the teacher. Even if a teacher had not yet found the right support measures but supporting a student was perceived as challenging and not overwhelming, teachers reported well-being in the long run when they eventually succeeded:Challenge, self-reflection, frustration, but it is exactly this frustration that makes me reflect […] It is on so many levels afterwards where you feel well-being, that you have […] you have chosen the right path” “.Almost with the same frequency as understanding the student’s behavior, teachers talked about their  support of the student . Clarifying parent meetings, which represented a turning point in the dyadic teacher–student relationship, as well as generally cooperative and supportive parents, were mentioned. Teachers described that, on one hand, the quality of parental involvement may influence teachers’ perceptions of the relationship when perceiving parents’ appreciation. On the other hand, teachers reported that they think the quality of parental involvement also influences students, as they came to school less skeptical or were able to open up to the teacher:With this child it was important that I had a good relationship with the mother first. I have the feeling that as soon as he knew ‘Mommy says at home, it’s ok at school, and the teacher does it well’, then he was able to open up” “.Concerning n = 6) and collaborating with  teachers and specialists (n = 3) who supported their understanding of student’s behavior based on additional information.Other strategies mentioned by teachers included giving the relationship enough time to develop or improve (We describe teacher well-being-inhibiting dyadic teacher–student relationships based on (1) how teachers located those relationships on the relationship map and (2) the representation of the three most prevalent subcategories of each category of the student and teacher relationship schemas. When asked to name two to three dyadic teacher–student relationships that inhibit teacher well-being the most, teachers classified a total of 74 relationships, with 53 (71.6%) being a relationship with a male student and 21 (28.4%) being a relationship with a female student . Of thospersonality, intelligence, and special education needs in regard to emotionally unstable students (n = 7), introverted students (n = 4), and students with suspected or confirmed special education needs (n = 7), such as attention deficit hyperactivity disorder. One teacher expressed disappointment with an introverted student who solved tasks like a “machine”:It’s simple—there’s just no output coming, no emotion from him, just really very little. Maybe I am a little disappointed in the sense of ‘Hey, you could do so many cool things to talk about, also with the other kids, but you ONLY sit there and concentrate on yourself’. Maybe it’s selfish of me too, but I just think that would be so nice” “.When teachers talked about dyadic teacher–student relationships that inhibit their well-being, most teachers talked in terms of students’ relationship behavior of the students included lack of students’ respect for the teacher and discipline (n = 18), as well as active (n = 11) and non-active (n = 11) relationship building with the teacher. One teacher worried about how her own feelings were affected by a student’s provocative behavior, causing her to almost explode.What worries me is that it can trigger feelings in me so that I really almost explode. And how she can influence me with her behavior […] That makes her really challenging. Sometimes I am standing here and she is doing something at her desk two steps away from me. Things like eating at school, or playing with her toys, even though we agreed that they are not allowed. She does that often in a row and really provokes me” “.Major discussion topics related to the motivational behavior of the students, teachers (n = 11) talked about unmotivated students who forgot to do their homework, could not find it, or did not make an effort to solve the tasks set by the teacher. This led to anger, annoyance, and frustration on the part of the teacher, because available resources were not being used, and this usually meant extra work for the teacher, as illustrated in the quote below. Nevertheless, teachers (n = 9) also talked about motivated students.Sometimes I get angry at the child because I think we have already discussed doing a reading comprehension once a week so many times. I asked, ‘And, did you do it now?’ and he answered ‘No, I do not feel like it!’” “.Regarding the socio-emotional behavior of the students, more teachers described students involved in negative interactions with classmates (n = 9) inside and outside the classroom  than students involved in positive interactions (n = 2). Although aggression was not directly expressed at the teacher, it had a negative impact on the dyadic teacher–student relationship and could lead to sleepless nights, as illustrated by the following example of an incident outside of the classroom:One incident that shocked me was that he was fighting with a boy so much that he just lashed out. Then the grandmother of the other boy came […] This boy threw the worst things at her like ‘Your son deserves to die!’ […]. I did NOT know what to do anymore. And when you get into a situation like that, I realized that my relationship with him changed too. It’s not his fault, it was a change. It was not against me, but in some ways, it was against me. It was extremely challenging, I had sleepless nights” “.Concerning the performance behavior, low performance of students (n = 10) but also good performance (n = 7) was described. Low performance led to nervousness in one teacher:But somehow I have the feeling that the child cannot mobilize its full resources. And that makes me a little nervous” “.Regarding n = 0) about their own personality in the context of well-being-inhibiting dyadic teacher–student relationships. When describing their relationship behaviors, teachers most often expressed an understanding of student behaviors (n = 22). Teachers talked about the fact that it is hardly possible to have an equally good relationship with all students, that conflicts are part of daily school life, and that not all students have a need to be close to the teacher, things they first had to learn to accept. Meeting students’ behavior with understanding was a challenging process for some teachers and required daily effort. Teachers most often explained difficult student behavior in terms of socialization in the parental home. For one teacher, getting to know parents led to increased understanding of a student’s behavior and helped her find her own “peace”:Much of what the parents represent you then recognize in the child, including the problems that are passed on or lived through the child. And much can then be explained in the child. Sometimes it helps to find peace and say, ‘Okay, I just need to show the child that there is something else’. And suddenly the child can develop. You know where the problem lies” “.Teachers did not talk (n = 18) resulted in anger at themselves and feelings of helplessness. In the case of lack of progress, teachers talked about resignation at a certain point, potentially leading to leaving a student on the side. Teachers also reported that when a student needed a high level of support, they were unable to adequately support other students in the class. This generated discomfort and a feeling of being drained, as illustrated in the following quote:He is a totally interesting boy and I like him, really a lot. That is the dilemma. He is not well supported; he needs so much support that we cannot give him because he does not have the right for extra hours. We will probably get a class assistance because he is pretty much draining us with the attention he needs. […] That is where I do not feel comfortable anymore because I realize I am not doing justice to the other students, because I am spending so much time on him. This is difficult for him and also for the other children” “.Furthermore, teachers claimed that not being able to adequately support a student (n = 14), whereby teachers described different methods ranging from small interventions  to severe interventions . Those measures were accompanied by a range of sensations such as pity or rage:Anger. I get really ‘Ahh.’ […] I then explode. I really explode by saying ‘It just does not work like that’. But then it is over. And then I am fine again” “.Disciplinary interventions were the third main topic  teachers and specialists (n = 8). It was perceived as helpful to be able to exchange ideas about difficult situations, to be able to delegate something from time to time, or to get valuable tips. In addition, teachers (n = 6) mentioned difficult parental involvement, for example, because parents did not support the disciplinary interventions of the teacher. One teacher described her difficulties in not letting her relationship with the student be negatively affected by her poor relationship with parents:Lately I had a case where I really had to turn quite strongly away from the mother because I realized that her dislike of me was influencing my relationship with the student. I really had to take a pair of scissors in my hand, purely mentally, cut the umbilical cord and say: ’This is a person here, this has nothing to do with my student over there.’ And that was hard. That was hardcore, honestly. I have never experienced that so strongly before, I was a bit scared” “.Concerning n = 5) was also mentioned as a strategy to deal with well-being-inhibiting dyadic teacher–student relationships:A principle of mine is ‘Never start the day on yesterday’s broken glass’. Every day is a new chance for every child. This is an important principle, and I have had good experiences with it. We can have conflicts, but the children also have to learn that they are over at one point and then it is good again” “.In addition, resetting the relationship and giving it another chance . We also investigated how they describe dyadic teacher–student relationships that support or inhibit teacher well-being and what professional strategies they report to foster or cope with those dyadic teacher–student relationships (RQ2 and RQ3). We conceptualized teacher well-being as a multicomponent construct that includes emotions, cognitions, and physical sensations and focused specifically on teacher–student relationships from a dyadic perspective, i.e., between the teacher and an individual student. Valuable implications for research and teacher education institutions, as well as authorities supporting teacher well-being, can be drawn from the findings.Regarding the first research question, the results confirmed that dyadic teacher–student relationships play an important role for teachers in everyday school life and are a source of a variety of positive and negative emotions, cognitions, and physical sensations. This finding aligns with the results from previous studies examining the role of the fulfilment of the need for social belonging in teacher well-being ,49. InteRegarding the second and third research questions, examples of dyadic teacher–student relationships supporting or inhibiting teacher well-being varied across individuals. Interestingly, both positive and negative relationship qualities  were present in both supporting and inhibiting dyadic teacher–student relationships. We therefore suggest that the combination of different relationship qualities is crucial. According to the multicomponent construct of well-being, we hypothesize that a dyadic teacher–student relationship supports teacher well-being when teacher well-being-supporting qualities outweigh the inhibiting ones. As suggested by other authors ,81, thosDespite the diversity in teachers’ description of dyadic teacher–student relationships, some differences between relationships that support and relationships that inhibit teacher well-being were discovered. Almost all of the dyadic teacher–student relationships described as supporting teacher well-being were characterized by intense closeness. Characteristics of those relationships included students’ active relationship building with the teacher, motivation, positive interactions with classmates, and humor, indicating the important role of students’ active involvement in interactions with teachers. Similar student behavior emerged in Claessens et al.’s  study ofLooking at the relationship maps, the first thing that stands out is that there were three times as many well-being-inhibiting dyadic teacher–student relationships with male students than with female students. Similar findings have been found in other studies, in which teachers more often referred to relationships with male students when selecting high-conflict relationships e.g., ,55). Bec. Bec55])Interestingly, conflict and closeness were not mutually exclusive. This can be interpreted as an indicator of high social–emotional competence of teachers. Almost all teachers expressed understanding for a student’s situation and described how they used cognitive reappraisal  and regWhile the teachers, despite the difficulties, described relationships with positive development or at least had hope for it, some teachers also reported rigid negative interaction patterns when the same conflicts occurred again and again or  support did not bring progress. Trapped in such patterns of relationships, a certain resignation became apparent among teachers. As reported by Newberry and Davis , teacherDespite experiencing well-being-inhibiting dyadic teacher–student relationships, all teachers reported feeling well or very well at school. Dyadic teacher–student relationships should be viewed as only one source that, in combination with other aspects, influences teacher well-being ,13. TherOur findings demonstrate the important role that dyadic teacher–student relationships play in teacher well-being. As our results show, dyadic teacher–student relationships can be a source of positive and negative emotions, cognitions, and physical sensations, and, therefore, they can be a resource for or a threat to teachers’ well-being. It is therefore essential that relationship building is not left to chance and professional strategies for developing and dealing with dyadic teacher–student relationships are addressed as early as possible, as part of the initial teacher education. In particular, (pre-service) teachers should be encouraged to train their social–emotional competence . For exFirst, individual understanding of different relationship qualities may vary among teachers )The present study illustrates the role of dyadic teacher–student relationships in teacher well-being. It gives insights into the variety of emotions, cognitions, and physical sensations triggered by the relationships and the importance teachers ascribed to them. Descriptions of teacher well-being-supporting and -inhibiting dyadic teacher–student relationships were found to be complex, with certain relationship qualities  being present in both types of relationships. This supports the idea of treating relationship qualities of positive and negative valence as independent. We discovered some key differences in both types of relationships . To establish and maintain teacher well-being in the context of dyadic teacher–student relationships, teachers’ social–emotional competence and professional strategies, such as successful parental involvement and collaboration with  teachers and specialists, seem impactful. It would be beneficial if teacher education institutions and authorities actively supported teachers in building high-quality relationships with their students by providing learning opportunities, time, and resources. Support in this area would be beneficial not only to teachers’ well-being and, thus, their retention in the teaching profession but also to students’ academic success.


The rapid population aging in China, characterized by a higher prevalence of illnesses, earlier onset of diseases, and longer durations of living with ailments, substantially engenders challenges within the domain of older adults’ healthcare. Community home-based elderly care services (CHECS) are a feasible solution to solve the problem of older adults’ care and protect older adults’ health. The aim of this study is to investigate the relationship, heterogeneity effects and influential mechanisms between older adults’ use of CHECS and their self- reported health.The study employs the Instrumental Variable technique and empirically investigates the relationship, heterogeneity effects and influential mechanisms between older adults using CHECS and their self-reported health using data from the China Longitudinal Aging Social Survey from 2018.The findings indicate, firstly, that using CHECS considerably improves older adults’ self-reported health. Secondly, the heterogeneity test reveals that the effect is more pronounced for older adults who are under the age of 80, have functional disabilities, are free of chronic diseases, have never attended school, reside in lower-income households, are single, rarely interact with their children, and live in central urban or city/county regions. Thirdly, the mechanism test reveals that the “social network effect” and “family care effect” are the key influence channels of using CHECS.An empirical foundation for the policy reform of community home-based care for seniors is provided by this study with the limitations to discuss the other socioeconomic aspects such as government health expenditure and discuss the specific services aspects such as health care. The findings carry substantial implications for improving the health of older individuals and provide suggestions for establishing a socialized aged care system in China. On the one hand, the amount of family care for older adults is declining due to the rapid changes in population structure and the social economy, which indicates that the traditional model of eldercare has not been able to adequately satisfy the expanding demands of older adults , 5. On tCommunity is the basic unit of social governance . The “agUncertainty persists on whether using CHECS improves health outcomes for the elderly population. On the one hand, a substantial body of evidence demonstrates that CHECS can enhance older health by fostering a sense of community and maintaining social networks through aging-in-place . On the Previous research examined at CHECS’s impact on older adults’ health from a variety of angles. Three or more things need to be improved . In termper capita household income, living arrangements, emotional support from their families, and living region (community location). The results are helpful for expanding CHECS’s area of study on the health of Chinese older people. We seek to more fully grasp the impact of the current CHECS and offer a crucial practical guide to further optimize CHECS supply, illuminating the execution of future policies on the growth of CHECS in China.This work develops a 2SLS model and uses “the perceived rate of CHECS at community level” and “except for individuals, the utilization rate of CHECS at community level” as instrumental variables based on data from the China Longitudinal Aging Social Survey (CLASS) in 2018. The goal of this work is to investigate the impact of using CHECS on the self-reported health of Chinese older adults. Additionally, we conducted an empirical analysis of the impact of using CHECS on the respondents’ self-reported health in various groups, taking into account the respondents’ age, physical limitations, chronic illnesses, education, 2.2.1.The cross-sectional data from the China Longitudinal Aging Social Survey (CLASS), conducted in 2018 by the National Survey Research Center at Renmin University of China (NSRC), served as the basis for this study’s analysis. A nationally representative sample of adults over 60 was chosen for the survey using a stratified, multi-stage, probabilistic sampling technique. Within this methodology, a nationally representative sample of 11,419 participants was selected from 28 provinces, excluding Hong Kong, Taiwan, Macau, Hainan, Xinjiang, and Tibet. Highly trained interviewers conducted face-to-face interviews to systematically and comprehensively collect information pertaining to the essential attributes, physical and mental well-being, lifestyle choices, intergenerational relationships, long-term care service necessities, and social support resources of older participants. The CLASS dataset for 2018 consisted of a total of 809 variables. The survey’s primary objectives were to assess the basic conditions, current situation, personality and emotional traits, lifestyle, activities of daily living (ADL), instrumental activities of daily living (IADL), personal background, family structure, and level of physical health of older adults. For this study’s data, a survey conducted in 2018 questioned about the availability of community home-based elderly care services (CHECS) and how often older adults used them. The total number of valid samples was 9,654 after accounting for unreachable and missing values for important variables. Throughout the entire interviewing process, participants remained anonymous and voluntary.2.2.2.2.1.The question, “In overall, how do you rate your health?” is posed to CLASS respondents. The following categories of responses are possible: very good, good, fair, poor, and very poor. To create indicator variables for very good or good health, we recode this variable.2.2.2.CLASS respondents are asked, “Whether you have used the social services provided by the community.” CHECS includes door-to-door visit, senior citizen service hotline, visiting the doctor, daily shopping, providing legal aid, daily care, deliver meals to older adults, day activity center and spiritual comfort. The possible response categories are “yes” and “no.” If all the services were not utilized, independent variables “UCHECS” were assigned a value of 0.2.2.3.The self-reported health of older adults may be affected by unobserved factors, such as the price and quality of CHECS , which m2.2.4.In order to apply controls on the impact of other factors on self-reported health of older people, we introduced 17 variables at the individual, family, and community levels.Four different types of control variables were established at an individual level, including physical health levels, socioeconomic status, natural features, and health behaviors. Age, the logarithm of each person’s annual wage, and the number of cohabitants are all examples of continuous variables. All of the following dichotomous variables have values of 1 for females and 0 for males, 1 for non-agricultural and 0 for agricultural, 1 for being married and 0 for everyone else, 1 for having commercial insurance or social security and 0 for not, and 1 for having chronic illness and 0 for not. Additionally, gender, household registration, marital status, whether or not one smokes, whether or not one has chronic illness, and whether or not one is married are all dichotomous variables. Education is coded as dummy variables out of four categories: never received education (omitted group), primary school, junior high school, senior high school or above. Daily activities include 2 different activity types – ADL and IADL, which is coded as dummy variables out of four categories: limitations in neither ADL nor IADL (omitted group), limitations in ADL, limitations in IADL, limitations in both ADL and IADL. ADL including “dressing, bathing, eating, walking indoors, going to the toilet, and bowel control,” IADL including “going up and down stairs, walking outdoors, using transportation, shopping, managing finance, carrying goods, preparing meals, and housecleaning.” In the CLASS questionnaire, interviewees were asked whether they could independently complete 6 ADL and 8 IADL, if any one of the activities cannot be completed independently, we identified the respondents as ADL/IADL limited.per capita household income, number of surviving children, family financial support, and family emotional support. The logarithm of per capita household income and number of surviving children are continuous variables. In the CLASS questionnaire, for every surviving child, the interviewee was asked “How much cash, food, or gifts did this child give you in the past year?” and “How often did you meet up with this child in the past year.” Based on the first question, we constructed the variable “family financial support.” If any one of the children gave cash, food, or gifts to the respondent, we assigned the value of 1, otherwise, the variable “family financial support” was assigned a value of 0. Based on the second question, we constructed the variable “family emotional support.” If the respondents saw any of their children at least once a month, then the family was considered to provide emotional support and was assigned a value of 1. Otherwise, it was assigned a value of 0.In terms of family level, we introduced four characteristics: Finally, we also introduced two community characteristics: whether having senior centers and other facilities in community, and community location. In the CLASS questionnaire, respondents were asked “Does your community have any of the following activities or facilities.” The possible response categories are: senior citizens activity center, fitness centers/facilities, chess room, reading room, outdoor playgrounds, other else, and none of the above. If the respondent answered “none of the above,” then the community was considered not to provide activity place or facility for older adults and was assigned a value of 0. Otherwise, it was assigned a value of 1. The variable “community location” was constructed based on the question “Which type of area respondents live in?.” If the community was in the central urban region of city/county, the variable “community location” was assigned a value of 1. Otherwise, it was assigned a value of 0.2.2.5.We examined the mechanisms from two perspectives: family care and social networks. Social isolation and self-efficacy are the two factors used in this study to measure the social network. In order to quantify social isolation on a multidimensional level, this work chooses three indicators: emotional support, social adaptability, and perception of the social environment. Based on the inquiry, “Have you felt unaccompanied for the past week?” we created the variable “emotional support.” Older adults were regarded to be receiving emotional support if the respondents said “no,” and a value of 1 was assigned. If the respondent answered “sometimes” or “often,” it was assigned a value of 0. We constructed the variable “social adaptation” based on the question “Society is changing so fast that it is difficult for me to adapt to the change.” If the respondents answered “fully disagree” or “relatively disagree” or “between relatively disagree and relatively agree,” then the older adult was considered more likely to adapt to the current social changes and was assigned a value of 1. If the respondents answered “relatively agree” or “fully agree,” it was assigned a value of 0. We constructed the variable “social environment perception” based on the question “Current social changes are more and more detrimental to older people.” If the respondents answered “fully disagree” or “relatively disagree” or “between relatively disagree and relatively agree,” then the older adult was considered more likely to believe that changes in the current social environment are not disadvantageous to older adults and was assigned a value of 1. If the respondents answered “relatively agree” or “fully agree,” it was assigned a value of 0. For self-efficacy, based on the question “Have you felt useless in the past week?.” It was assigned a value of 1 for the respondents who answered “no,” and 0 for the respondents who answered “sometimes” or “often.” This work measures family care according to the question “Whether you feel this child does not care enough for you?,” CLASS asked this question to respondents about each surviving child. If one of the children answered “occasionally,” “sometimes” or “often,” the family was considered to have provided enough care for older adults. Otherwise, it was assigned a value of 0.2.2.6.2.3.In order to test the impact of using CHECS on older adults health, the following benchmark regression model is constructed:icX indicates other demographic control variables and social environmental variables that may affect individual health.where the subscript i represents the individual code, subscript c represents the community code. SRH represents the dependent variable indicating the self-reported health of respondent i who lives in community c. UCHECS indicates whether individual i living in community c used CHECS. 1 may be biased, because the error term icμ may contain unobserved factors related to CHECS utilization and resident self-reported health, and a possible reverse causation between CHECS utilization and self-reported health , we conducted eight sets of stratified analyses. Due to the various individual features and care requirements, the demand for CHECS varies greatly for older adults at the period of life decline. Furthermore, the development of CHECS in China differs significantly between urban and rural locations. Daily life support, medical care, and health services are more readily available in urban areas where the CHECS system is more complete . In ordeThe results in Panel A and Panel B show that the impact was more evident for people aged 80 or above and people with ADL or IADL difficulties. This may be due to the fact that people who are older and have limited physical abilities usually have poorer physical function, and the informal care has not been able to address significantly the needs of them . TherefoWe can see from Panel C that using CHECS had a significantly stronger impact on the self-reported health of people without chronic illness. Older adults with chronic illness are more likely to require medical care services and have higher requirements for medical skills and improvisational abilities for service personnel. However, in China, CHECS suffer from lack of qualified LTC professionals, limited service/low service quality, and unrealized integrated care .We can see in Panel D and Panel E that using CHECS had a more positive impact on the self-reported health of people who have never received education and from low-income families. This may be because these older people are more likely to be in a disadvantaged position and have lower requirements for their life quality and elderly care services .We can see according to Panel F and Panel G that for Chinese older adults living alone and having less family emotional support, the greater positive effect of using CHECS on their self-reported health. This may be due to the fact that people who live alone or do not have frequent contact with their children need more formal care from the society to meet daily life needs, and need more external companionship to fulfill emotional needs .Panel H shows the estimated coefficient is higher in the central urban region of city/county regions than other regions, because the economic strength of the region and the government’s financial resources caused by the urban and rural two-dimensional structure lead to a lower level of infrastructure of social support and services for older adults in rural regions .3.4.The aforementioned findings show that using CHECS had a considerable impact on the elderly Chinese people’s self-reported health. The putative processes are further examined in this part from the viewpoints of the “social network effect” and the “family care effect.” We estimate the subsequent model:icM represents the mechanism variables, namely, emotional support, social adaptation, social environment perception, self-efficacy, and caring from children reported by respondent i who lives in community c. Among them, the first four variables are designed to test social network effects; the last variable is designed to test family care effect. ϑic is an error term. Other variables are defined in the same way as in m1, which captures the causal effects of icUCHECS on icM, is of central interest to our study.where 4.Community-based home-based eldercare is a significant strategy to boost the efficiency of social care services in China against the backdrop of the decline in family care. One of the first comprehensive research to investigate the effect and mechanism of utilizing CHECS on the self-reported health of older persons is this one. Utilizing instrumental variables to address the endogeneity issue and a nationally representative sample, we discovered that utilizing CHECS significantly improves the self-reported health of Chinese old people. To further support the fulfillment of Healthy Aging and Active Aging, we advise the government to boost the supply of CHECS and enhance their spatial accessibility.Based on the results of the heterogeneity analysis, using CHECS did not have a significant impact on the self-reported health of older adults who are aged under 80, without functional disabilities, had chronic diseases, had received education, and live in households with higher income levels. However, there was a significant positive effect for older people who are aged under 80, with functional disabilities, without chronic diseases, had not received education, and live in households with lower income levels. These results mean that the current CHECS can only meet the needs of older adults who have lower requirements for their life quality and long-term care, reflecting that the quantity and quality of elderly care services provided by the community are a little lower , and lacAdditionally, we found that using CHECS had a substantial influence on older adults who reside in the center urban sections of city/county regions, but not on those who reside elsewhere in terms of self-reported health. We propose that more support be given towards developing home and community care services in rural areas, thereby enhancing their general well-being, taking into account that nearly half of China’s older adults live in rural areas  and oldeBesides the above conclusions, heterogeneity analysis results identified that the use of CHECS had a significantly positive effect on self-reported health of older adults living alone and living with others, often interacting with their children and seldom interacting with their children, and a more pronounced positive effect on older adults who lived alone, and seldom interacting with their children. These results showed that using CHECS can effectively mitigate the negative effects of empty-nest on the health of older adults.Based on our findings, we made the case that using CHECS can indirectly affect the self-reported health of Chinese elderly citizens through the “social network effect” and “family care effect.” To be more precise, the “social network effect” referring to the use of CHECS makes older people more likely to feel accompanied, more likely to adapt to the current social changes, less likely to feel that the changes to their social environment were detrimental to them, and more likely to feel useful to society. The “family care effect” referring to the use of CHECS greatly increases the likelihood that older people believe their offspring have always cared about them, which suggests that utilizing CHECS significantly boosts older people’s chances of interacting with younger people .5.Based on 2018 CLASS data, we empirically estimated the causal impact of using CHECS on the self-reported health of Chinese older adults. We constructed a 2SLS model and exploited “the perceived rate of CHECS at the community level” and “except for individuals, the utilization rate of CHECS at the community level” as instrumental variables, which effectively addresses the endogeneity problem. The results show that older adults using CHECS can significantly improve their self-reported health, especially among people who under the age of 80, with functional disabilities, without chronic diseases, have not received education, live in households with lower income levels, live alone, seldom interact with their children, and live in the central urban regions of city/county regions. Moreover, this paper examined the possible mechanism. The results show that older adults using CHECS through “social network effect” and “family care effect” to improve their self-reported health.However, there are certain limitations in our study. Firstly, due to the limitations of cross-sectional data, we could not discuss the long-term effect of using CHECS on the self-reported health of older adults. Secondly, although we have dealt with the endogeneity problems by using the 2SLS model, we have not distinguished the categories of CHECS. Different types of CHECS used by older adults may have different impacts on their health, this aspect can be further explored in the future.bjwei@sdfmu.edu.cn.The data analyzed in this study is subject to the following licenses/restrictions: data can be provided by the corresponding author on request. Requests to access these datasets should be directed to YH: Conceptualization, Data curation, Investigation, Project administration, Supervision, Formal analysis, Methodology, Software, Writing – original draft, Writing – review & editing. BW: Funding acquisition, Resources, Validation, Visualization, Supervision, Writing – original draft, Writing – review & editing. YL: Project administration, Supervision, Writing – review & editing.The author(s) declare financial support was received for the research, authorship, and/or publication of this article. This work was supported by Research program of Medical and Health Science and Technology Development Plan Project of Shandong province (no. 202103070653).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Virtual data collection methods and consent procedures adopted in response to the COVID-19 pandemic enabled continued research activities, but also introduced concerns about equity, inclusivity, representation, and privacy. Recent studies have explored these issues from institutional and researcher perspectives, but there is a need to explore patient perspectives and preferences. This study aims to explore COVID-19 patients’ perspectives about research recruitment and consent for research studies about COVID-19.We conducted an exploratory qualitative focus group and interview study among British Columbian adults who self-identified as having had COVID-19. We recruited participants through personal contacts, social media, and REACH BC, an online platform that connects researchers and patients in British Columbia. We analyzed transcripts inductively and developed thematic summaries of each coding element.Of the 22 individuals recruited, 16 attended a focus group or interview. We found that autonomy and the feasibility of participation, attitudes toward research about COVID-19, and privacy concerns are key factors that influence participants’ willingness to participate in research. We also found that participants preferred remote and virtual approaches for contact, consent, and delivery of research on COVID-19.Individuals who had COVID-19 are motivated to participate in research studies and value autonomy in their decision to participate, but researchers must be sensitive and considerate toward patient preferences and concerns, particularly as researchers adopt virtual recruitment and data collection methods. Such awareness may increase research participation and engagement.The online version contains supplementary material available at 10.1186/s12874-023-01933-5. Due to the COVID-19 pandemic, many research groups started conducting research activities virtually. In this study, we invited individuals who had COVID-19 to share their views about how researchers recruit patients and get their consent to participate in studies about COVID-19. Through interviews and focus groups, we found that British Columbians who had COVID-19 are motivated to participate in COVID-related studies, as long as researchers maintain usual precautions around data privacy and accommodate preferences for participation. Future studies may use these patient perspectives to make informed decisions that will increase and support patient recruitment, consent and retention in research studies.The online version contains supplementary material available at 10.1186/s12874-023-01933-5. In December 2019, an outbreak of coronavirus disease (COVID-19) was reported in Wuhan, Hubei Province, China . Early iSome institutions transitioned to virtual methodologies and consent procedures in response to COVID-19 , 7. BC’sUnder-representation and lack of generalizability systematically denies minority and vulnerable populations the opportunity to benefit medically from research, and limits our understanding of disease etiology and ability to provide safe and efficacious care to the most vulnerable , 16. By A number of studies have explored ethical considerations of adapting recruitment and consent approaches during the pandemic from the perspectives of research institutions , researcWe conducted an exploratory qualitative study to gather COVID-19 patients’ perspectives about research participation in the context of the global pandemic. The Behavioural Research Ethics Board at the University of British Columbia approved this study, including the verbal informed consent procedure for this study (H21-00048), and all participants provided verbal informed consent.Our study population included adults (≥ 19 years) living in BC who self-identified as having had COVID-19. We used multiple strategies to recruit eligible participants. We endeavored to continue recruitment and data collection simultaneously to achieve data saturation, but practically recruitment ceased when no additional volunteers came forward within a reasonable timeframe. We used snowball sampling through personal contacts, for which there was an established relationship with some of the researchers prior to study initiation.We also used convenience sampling through recruitment advertisements posted online. We posted recruitment advertisements on the COVID-19 Long-Haulers Support Group Canada Facebook group and on REACH BC to target individuals who had COVID-19. The COVID-19 Long-Haulers Support Group Canada is a private Facebook group, of which the research team are not members. We leveraged personal contacts to post the recruitment advertisement to the group on our behalf in January and February 2021. We instructed interested participants to self-identify by contacting the research team directly but were otherwise unaware of any subsequent activity on that post. REACH BC is publicly funded, web-based directory that allows British Columbians to search and volunteer for research opportunities . We keptWe used a discussion guide during the semi-structured focus groups and interviews, which the research team developed collaboratively to address themes related to research participation among COVID-19 patients  led the focus groups and interviews. We provided participants with study information, including background and study rationale, and consent forms prior to each session and obtained verbal consent at the beginning of each session. We audio recorded all sessions, which a research assistant (KM) transcribed verbatim.NVivo qualitative data analysis software . Two analysts  independently coded all transcripts inductively, and then met to discuss and revise the preliminary coding structure. Other team members  used the codebook to analyze at least two randomly selected transcripts and provide feedback. The two analysts  reconvened to discuss and revise the first iteration of the coding structure. We re-circulated the revised coding structure to the team, and with their approval, we  independently re-coded all transcripts again according to the revised coding structure . Participants recruited from REACH BC provided their date of birth as part of the registration process. The median participant age for those recruited from REACH BC was 47, ranging from 23 to 78 years old. More than half of participants reported having a background or education in research, science, or healthcare, and/or having previously participated in research. Many are early pandemic survivors.From February to April 2021, we held two focus groups with six and four participants, respectively, followed by six one-on-one interviews. Focus groups and interviews were 20 to 67 min in duration. Participants described variable experiences with COVID-19, in terms of severity, duration, timing, and use of medical services. Many participants reported having contracted COVID-19 in the first year of the pandemic when limited diagnostics and treatment were available. Most self-managed at home or sought alternative avenues of care  and only one participant reported having gone to the emergency department. A few participants described long-term effects they attributed to COVID-19, including fatigue and an inability to return to routine activities.Participants identified key factors that would affect their willingness to participate in different types of research about COVID-19, including approaches to recruitment and consent. We conceptualize these factors thematically in terms of autonomy and the feasibility of participation, overarching attitudes toward research about COVID-19, and privacy concerns and protections, summarized in Table Autonomy in participation was an emerging theme from discussions about participation in COVID-related research. Many participants discussed elements of autonomy in participation, in terms of wanting to be able to opt-in and opt-out of research themselves, removing data from a study, deciding the frequency, timing, and format of participation, and determining who could use their data. This theme was present across discussions of all types of research and was particularly the case in the context of research on hospital records and having multiple researchers contact them to participate in various studies.“I find like, there should be some appreciation for – for the patients and the public who give their time for the research…it’s really hard to make the time in a work day, so you actually have to take time out of your work day.” (Participant 6)“…as long as our time is respected, my time is respected. As long as I know what I’m getting into at the start of it, then I don’t feel like it’s terribly burdensome. I agree with Participant 9, I don’t want to receive a call at 7 o’clock in the morning or at 10 o’clock at night.” (Participant 7)The feasibility of participation also affected participants’ willingness to engage in COVID-related research. Time was a primary concern for many participants, especially for interview-based research, whether time of day or week and duration or time required. When discussing the prospect of participating in multiple studies, participants also considered the frequency of participation. Similarly, the location of the research was likely to have an impact on the participants’ willingness and ability to participate. Ultimately, participants wanted to evaluate the practicalities of research participation and whether participating fit their schedules and preferences. Respect for time and location were related, with a few participants highlighting the need to manage scheduling if travel was required.“…ask people what’s the best time of day to talk to you, because some of us are better in the morning, some rest all day and we have a good hour at 3:00, others it’s in the evening.” (Participant 3)“…I think it does matter where somebody is in their recovery, and we’re all in different places…it’s really unpredictable for a lot of us. Like when we wake up in the morning – we don’t know what kind of day we’re going to have, we don’t know necessarily what we’re going to be able to handle on that day until we’re actually going through it. It’s very hard to plan anything because of that.” (Participant 4)While autonomy and feasibility of participation were associated with participation in other research, they are particularly vital for COVID-19 patients who may be at various recovery stages and health statuses at the time of the research. A few participants discussed the impact of long-term COVID-19 symptoms on their physical ability to complete tasks, while a few others were concerned with the psychological aspect of recovery. The burdens of time and recovery stage co-occurred, with a few participants noting that sensitivity to health status was necessary in considering time to participate.Participants with a more positive perception toward or interest in research were more likely to state that they would be willing to participate in various types of COVID-19-related research. This was driven, at least in part, by the perceived impact of participating, which participants viewed as producing both personal and social benefits.“…just to know that people are using my data could be very validating for some of us…it would help with that feeling of being counted in some way.” (Participant 4)“I think that COVID was like, for me personally, a really negative experience. Especially being in isolation and – and when you come out of it…research is a great way to kind of make some positive out of the experience...” (Participant 8)On a personal level, participants discussed having an interest in research and that participating in research offered opportunities to feel represented and to find a positive outcome from a negative experience. For some participants, a positive attitude toward research also translated to a lower level of concern about being contacted by multiple researchers.“Yeah, I’m pretty busy so [being contacted multiple times] may – it may wear on you a little bit…But, I mean, you know with something as new as this, you also want to help too. I think it’s your civic duty…to help out and try to get through this.” (Participant 12)“I think it’s important to be a part of that kind of research, because it has the potential to help others.” (Participant 13)On a social level, most participants discussed research participation as an altruistic act and a civil duty. Many participants also viewed COVID-19 as an extraordinary time, which increased their willingness to participate in research about COVID-19 compared to other topics. This was particularly the case for research on hospital records. Participants emphasized the importance of research on COVID-19 to address the seriousness of the pandemic and to capture differences among the various population sub-groups who had COVID-19.“I would want to know how the information is going to be used, and where it’s going to be stored.” (Participant 1)“I would like to evaluate who’s doing the research, how they’re doing it, and what they’re doing with that information before I’m giving access to it, because there’s all types of people that research.” (Participant 9)Some participants were concerned with potential misuse of personal health information collected for research on hospital records or biological samples. Participants discussed misuse in terms of having their health information used against them to affect employment, insurance, or ability to travel, sold or commercialized, or used for illegitimate research purposes.“I think my main hesitation with [research on my records] would be if it was tied to more personal information about me, or more of my medical history. If it’s just statistical information…if it doesn’t tie it to me – as much, then that’s a little…less unnerving.” (Participant 13)“As long as it’s anonymous I don’t care, ‘cause I know how much work it is to get the data...” (Participant 3)Some participants said that de-identification, as is current practice, was necessary if researchers were using their personal health information without consent, but many also felt that de-identification would increase their comfort in participating in research even if they had provided consent.“…I think that what the BCCDC is doing now, reach out to people who’ve tested positive, is a good way… they were just calling people to say ‘do you consent to be contacted?’.” (Participant 7)We asked participants how they felt about privacy rules in BC that some institutions interpreted as prohibiting researchers from contacting hospitalized patients directly for research purposes without their prior consent and by other institutions as permitting Consent to Contact. A few participants had favorable views toward Consent to Contact. Although only one participant expressly stated that they disagreed with it, a few others articulated views consistent with this position, for example, by stating that the researchers could call them and obtain consent over the phone. One participant preferred a centralized approach like the BCCDC’s Consent to Contact Registry.“I completely understand informed consent, consent to contact and the importance [of] it, but I do think that in times like COVID, you have to re-assess what the framework is – because that’s what we’ve been doing the whole time, is re-assessing what we have, what works and what doesn’t, and what we can change during these times.” (Participant 8)We asked some participants whether the circumstances of the pandemic would change their acceptance of broader consent and their perspectives on obtaining Consent to Contact. Participants had split views toward this topic, with four out of seven indicating that they would give exemptions given the unique circumstances of the pandemic. A few participants in opposition to changing the rules highlighted alternative modes of obtaining consent for future contact.Participants discussed ways to communicate research opportunities and strategies to reduce the burden of participation among COVID-19 patients, focusing on maintaining the feasibility and autonomy of participation.“Well, I – I guess it depends on the age group. Because if you’re thinking about young people, obviously the best way to reach would be to advertise on social media…” (Participant 11)Participants suggested approaches to communicate research opportunities, which aligned with the ways that they heard about the current study. Some participants mentioned REACH BC, and a few mentioned other academic networks, posters in healthcare settings, and community-based nurses. Regarding the preferred mode of communication, some participants favored emails, citing the flexibility of being able to respond on their own time, and some mentioned social media, news media, or letters.“…REACH BC is a really good platform where people can sign up and volunteer…” (Participant 14).“…it’s helpful to know exactly what to expect, before starting.” (Participant 1)“…I would assess how beforehand if there was going to be a burden or not, and then make a decision. Like, is this going to stress me out, how tired am I? And…the option to say ‘I’m actually not going to do it’ ...” (Participant 9)To reduce the burden of participation, many participants wanted autonomy and the ability to choose scheduling and response modality, as well as the choice to participate in general by being able to opt out or withdraw from studies. A few participants wanted to receive advanced notice of the expectations of their participation, study procedures, and questions.The characteristics of those conducting the research were also a consideration. Participants highlighted the need for researchers to be sensitive to trauma, to build trust, to use plain language, and to show appreciation to participants.“I think sensitivity around the fact that this is – has been a very traumatizing illness for a lot of us, would be the key thing for me.” (Participant 4).“So, yeah, I think there needs to be clear, plain language…” (Participant 3).To our knowledge, this is the first study to explore patients’ perspectives about consent and recruitment for COVID-19 research. Patient involvement ensured our research questions and findings were relevant and important to patients. In this study, 16 individuals who had COVID-19 provided valuable insights to inform recruitment and consent methods for future research. We identified four main findings: (1) participants want autonomy; (2) altruism and self-interest are motivating factors for participating in COVID-19 research; (3) decisions concerning consent waivers for COVID-19 research depend on privacy protection measures; and, (4) remote and virtual approaches are preferred modes of contact and research delivery for COVID-19 research.Autonomy is the most frequently mentioned theme in this study. Participants wanted the choice to hear about research opportunities, to decide whether and how to participate in research, and to determine how their data are used. Similarly, previous studies , 18, 19 Most participants highlighted altruism and self-interest as primary motivators for enrolling in COVID-19 research. This was consistent with results from a multi-national study reporting that altruism and personal interest were primary motives for participation in COVID-19 clinical trials. Similar results were also reported in health services research –23 and sSome participants expressed privacy concerns for waiving consent, particularly for COVID-19 research using hospital records and biological samples. However, most participants indicated they agreed with consent waivers for de-identified data. Our findings suggest that many participants lacked awareness of existing governance structures that already protect individuals’ data, especially when consent is not in place. Although there are resources to assist health organizations in developing data and information governance structures, such as the Canadian Institute for Health Information’s Health Data and Information Governance and Capability Framework , we are Participants identified advantages and barriers to several modes of contact and research delivery. They did not seem categorically opposed to any of them but leaned towards remote and virtual approaches . Most participants liked having the REACH BC platform as a central hub for research opportunities, and preferred email for communications and virtual meetings for interviews. Remote, virtual approaches are advantageous to reducing the burdens of time and cost of participating. These approaches are essential in the context of the pandemic or future infectious disease outbreaks, in which participants may undergo different recovery stages or social isolation. Of note, our participants did not discuss potential challenges and consequences of remote and virtual approaches that rely on self-identification among interested volunteers with high health and technology literacy, including under-representation of specific populations, reduced data richness, limited generalizability of results, or exclusion of populations lacking access to internet and electronic devices . Based oSelection bias is a major limitation of this study. Convenience sampling limited representativeness of our study sample. Our sample is geographically limited, having only recruited adults living in BC, and is not representative of visible minorities. Our sample also consists mainly of individuals with higher education and experience in research, which may lead to more favorable views toward research in general and increase their likelihood of responding positively toward being contacted for research opportunities. Similarly, by virtue of digital recruitment and data collection methods, participants likely had higher levels of digital literacy and access to a computer with Internet. Given the timing of the study, many participants are early pandemic survivors, many of whom had COVID-19 before vaccines were widely available. This may have increased the perceived urgency of research at the time compared to those who may have had COVID-19 in later waves. As a result, these findings may not be representative of the entire population affected by COVID-19 and may not be generalizable to individuals commonly inadvertently excluded from health research. Future studies should seek to assess the themes identified in this study among a broader sample in different jurisdictions through quantitative methods or using similar methods when researchers urgently seek to address a new health problem, and a limited pool of patients are available for research participation.In this study, we sought to explore COVID-19 patients’ views on research participation. We identified several considerations related to autonomy, privacy, and modes of contact. Despite patients being motivated to participate, researchers must be considerate of their preferences and concerns, while being mindful of pragmatic aspects of participation. Patient perspectives are increasingly relevant in the design and implementation of research studies, particularly as researchers seek novel ways to conduct research in the pandemic. Research recruitment methods should prioritize patient autonomy, while seeking to increase the engagement of under-represented and marginalized groups as we increasingly adapt virtual and remote methods of recruitment and data collection.Below is the link to the electronic supplementary material.Supplementary Material 1Supplementary Material 2Supplementary Material 3Supplementary Material 4Supplementary Material 5


Depression and anxiety are common in adolescents, but most affected will not get any formal help. Digital mental health technologies  are a potential way to extend the reach and increase adolescents’ access to therapies, at a relatively low cost. Many young people can access the internet and mobile technologies, including in low- and middle-income countries. There has been increased interest in integrating technologies in a range of settings, especially because of the effect of the COVID-19 pandemic on adolescent mental health, at a time when services are under pressure. This clinical review gives an overview of digital technologies to support the prevention and management of depression and anxiety in adolescence. The technologies are presented in relation to their technological approaches, underlying psychological or other theories, setting, development, evaluations to date and how they might be accessed. There is also a discussion of the potential benefits, challenges and future developments in this field. The reaDigital technologies can vary in design (e.g. website-based or delivered via apps) and can include a range of digital elements  to help personalise and better meet the range of needs and preferences of users. Some of these technologies are supported by contact with a healthcare provider or other professional. At one end of the human support continuum, this can include a service that is delivered by a clinician digitally in ‘real time’ (e.g. therapy provided via videoconferencing). At the other end of the continuum, resources and interventions are ‘pure self-help’ and therefore involve no human support to an individual user.n = 700 000) of those aged between 11 and 18 years reported having no access to the internet at home from a computer or tablet  with no restriction regarding publication dates up until March 2021. The key search terms used were: ‘teen*’ or ‘young’ or ‘youth’ or ‘adolescen*’ or ‘child*’ or ‘paediatric’ or ‘pediatric’ AND ‘internet’ or ‘social media’ or ‘telemedicine’ or ‘cellular phone’ or ‘mobile phone’ or ‘smartphone app*’ or ‘mobile app*’ or ‘digital’ or ‘web-based’ or ‘website*’ or ‘ehealth’ or ‘e-health’ or ‘mhealth’ or ‘m-health’ or ‘online’ or ‘computer*’ AND ‘depress*’ or ‘mood’ or ‘anxiety’. We also searched reviews, guidelines and reference lists.were articles with information on the evaluation of digital technologies to prevent and manage depression and anxiety (diagnosis or symptoms) in adolescents (primarily aged 13 to 18 years old); andwere papers published in English in a peer-reviewed journal.Studies were included if they:Papers were excluded if the technologies were developed for adults or primarily for physical health and well-being, or were diagnostic, screening, monitoring, communication or data management digital tools.n = 5503 papers). Then the full texts of the studies on the included digital technologies (n = 33 technologies) were read in more detail and the relevant information was summarised. Key papers on the evaluation of each technology were cited. Key authors were contacted for further information, especially on how to access each technology. As this was an educational and descriptive review, and not a formal systematic literature review, an inclusive and pragmatic approach was taken in summarising the relevant papers. We have supplemented the key findings from the literature with our own reflections as practitioners or researchers working in the field.The titles and abstracts were screened (via Mendeley) by F.H., S.S.A., B.W. and R.B.J. , whereas others are supported by practitioners (guided). Most technologies had elements of co-design with potential users in their development, particularly those produced in recent years , and we include other programmes with emerging evidence, in particular where there has been feasibility testing. Most technologies identified in our search are not yet available outside of research projects. However, we also refer to available technologies that did not meet the inclusion criteria. We discuss the overall effectiveness and challenges (including accessibility) of technologies later. Further information on each technology (e.g. screenshots) can be found on the websites and papers cited in Early digital mental health technologies for adolescents have tended to be structured in modules or sections, and were often adapted from conventional face-to-face or established manualised approaches. One of the earliest online programmes for depression and anxiety to be trialled in young people is MoodGYM. This is a fully automated, interactive and self-directed modular CBT programme, accompanied by a workbook. It aims to change dysfunctional thoughts and beliefs, improve self-esteem and interpersonal relationships, and teach skills such as problem-solving and relaxation. MoodGYM was developed originally in Australia for young people and adults, but has been used and evaluated in several countries , which is a depression prevention intervention developed in the USA. This consists of interactive modules based on CBT, behavioural activation and IPT, and a component to provide support to parents. It is based on previously manualised and face-to-face approaches  is cited in the NICE  guidelinStressbusters is a modular CBT programme for depression developed from a manualised treatment programme in the UK, and it is also cited in the NICE  guidelinAnother early CBT programme developed in the UK is Think, Feel, Do Stallard . This isMore recent examples of modular interventions for depression include the LEAP Project, informed by spiritual principles  from Canada Rickhi , and iCBBRAVE-ONLINE is one of the first online interventions specifically for anxiety and has been trialled with both children and young people. This intervention is based on CBT and has interactive sessions, animations and games. It was originally developed in Australia, but has been evaluated in several countries Spence . Cool Te‘Serious games’ are a form of ‘applied games’ and are in essence computerised games designed for ‘serious’ purposes, for example to improve mental health outcomes. ‘Gamification’ in digital technologies refers to gaming elements used to enhance an intervention's appeal, outside of a fully bespoke ‘serious game’. Both serious games and gamification have been highlighted as ways to potentially increase the impact of mental health interventions  is CBT in serious game format developed in New Zealand Merry   is a computer game to support CBT for anxiety and low mood. This was originally designed for children and can be played during face-to-face therapy sessions with a practitioner. Users navigate a three-dimensional world and meet characters who introduce CBT concepts using audio, animation and video, and can learn behavioural activation, relaxation and mindfulness skills. There is online training for therapists, and evaluations include a naturalistic deployment study , derived from the Coping with Depression course. Cognitive restructuring of thinking patterns is at the core of the six-session course. It is facilitated by a practitioner and has been evaluated in mental healthcare agencies in The Netherlands , a social media-enabled mental health platform developed in Australia. It is based on CBT, mindfulness and positive psychology, and promotes social support. Rebound integrates peer-to-peer online social networking, individually tailored interactive psychosocial interventions/modules, and expert mental health and peer moderation, and has been evaluated in a pilot study Rice .SOVA  is a moderated social media website for young people with depression and anxiety, developed in the USA. It includes a blog with positive content , psychoeducation, social media guidance and links to existing resources, and there has been feasibility testing Radovic .Some programmes have been developed to be integrated in schools or educational settings. For example, Climate Schools Combined is a universal intervention developed to prevent substance use and mental health problems, particularly depression and anxiety, in young people. The programme is based on psychoeducational, CBT and harm minimisation approaches, and consists of interactive modules and illustrated ‘comic-book’ storylines. It has been evaluated in schools in Australia Teesson .Smooth Sailing is a universal school-based mental health service for depression and anxiety in secondary school students. This uses a stepped-care approach informed by mental health help-seeking theories. A website assists in screening young people and allocates them to face-to-face school counselling or online multimedia psychoeducational and CBT approaches, at various intensities and follow-ups. This has been evaluated in Australian schools O'Dea .The e-couch Anxiety and Worry programme is another intervention based on psychoeducation and CBT. It comprises six sessions, including three ‘toolkits’. There is a ‘CBT toolkit’ on addressing cognitive aspects of worrying, a ‘relaxation toolkit’, which includes mindfulness meditation exercises, and a ‘physical exercise toolkit’. It has also been evaluated in schools in Australia Calear .Several technologies for depression and anxiety in adolescents are in development or undergoing evaluation, taking advantage of emerging digital elements (e.g. chatbots) to increase interactivity and personalisation, so that the technologies are engaging and meet the needs and preferences of users.Shamiri-Digital is an innovative single-session intervention for depression, anxiety and well-being. This consists of modules on growth, mindset, gratitude and value affirmation, particularly in response to various challenges. This was adapted originally from a group-based form, and the digital format has been evaluated in Kenya Osborn . Depis.NThe SPARX team in New Zealand has also developed the Quest-Te Whitianga app for anxiety and depression. This incorporates CBT, positive psychology, mindfulness and promotes interpersonal skills. Its development was informed by that of SPARX, and it takes a modular approach with a selection of activities and games on different ‘islands’. For example, there is a gratitude journal on the ReMind Island and a relaxation and mindfulness activity on the ReLax Island Christie .The Quest-Te Whitianga app will be integrated into a wider platform called HABITs  Thabrew . This isMoodHwb is a programme for young people with depression and their families/carers, developed in Wales . It is dOther emerging technologies include Smartteen, a CBT-informed programme for depression evaluated in India  and CBT-informed technology for self-harm, developed in the UK Stallard . ExampleTechnologies developed for general youth mental health often include information on depression and anxiety. For example, BiteBack is a youth positive psychology programme (Manicavasagar kcl.ac.uk/research/keepcool).Technologies have also been developed and adapted to support young people during the COVID-19 pandemic and beyond – including the supportive Aroha chatbot on HABITs in New Zealand Merry  and Keeponemindpsyberguide.org) and Beacon (beacon.anu.edu.au). These have different approaches to reviewing and recommending technologies. The NHS closed its Apps Library site in late 2021 and will link to recommended apps throughout the NHS website . There are also mental health websites with information on youth depression and anxiety, for example YoungMinds (youngminds.org.uk), the Royal College of Psychiatrists , the National Centre for Mental Health (ncmh.info/resources/) and the Lowdown (thelowdown.co.nz).Available technologies (some of which might not have been identified in our search) are also listed on websites, such as PsyberGuide  or programmes developed primarily for adults , and some of these involve subscription costs.There are several other factors to consider when choosing the most appropriate digital programme for depression or anxiety, as noted earlier. Young people and families/carers need to consider whether the technology is appropriate given the user's characteristics, such as their age, development, gender identity, and the nature and severity of their difficulties. In a scoping study, Fleming et al  concluderangatahi (adolescents). This work was overseen by a Kaumātua (respected Māori elder) as well as a cultural advisory group. These efforts were employed to create a programme that would be maximally appealing and relevant to Māori (as well as non-Māori) adolescents . Some might prefer to engage only with face-to-face therapy or self-help in printed literature format. Therefore, it is important that young people have a choice, where possible, regarding how they access support.Given the fast pace of digital technology and culture, there are a number of possible future developments in digital mental health practice and research. Technologies are likely to become more complex, flexible and personalised, including the use of avatar-based virtual therapy. For instance, a study is underway that explores whether a virtual reality intervention provides a more engaging user-directed experience than a comparable purely web-based intervention (Schleider Collaboration and co-design with young people and other stakeholders are recommended throughout the research cycle of technologies, including the development, evaluation and implementation stages (see stakeholder involvement in To help with the faster translation of findings into the community, more flexible and rapid models of development and evaluation in the ‘real world’ will be needed, for example using digital ecosystems that support rapid retesting as the technologies evolve Rice . HoweverAlthough there are studies involving certain subgroups, young people with intellectual disabilities and specific difficulties will have particular needs and preferences, and should be involved further in research. Digital technologies might be particularly helpful for those who have difficulties with verbal communication. More technologies could be developed for children and younger adolescents, and those who might provide support, such as peers, families, carers and practitioners. Further attention is also required on developing or adapting technologies to tackle the mental health difficulties arising from the COVID-19 pandemic/crisis across the world, including in LMICs Ford .A number of digital technologies have been developed and evaluated to support young people with depression and anxiety, and some have been cited in guidelines for the management of depression in young people NICE . There aData availability is not applicable to this article as no new data were created or analysed in this study.