Comparing Arabic to other languages, Arabic lacks large corpora for Natural Language Processing . A numbe With the growing use of social media sites worldwide over the last ten years, sentiment analysis (SA) has recently become a prominent and useful technique for capturing public opinion in many different disciplines. SA, or “opinion mining,” refers to a computational process of gathering individuals’ opinions, feelings, or attitudes towards a particular event or issue . SA has Classical Arabic (CA), as in the book of Islam’s Holy Quran, Modern Standard Arabic (MSA) used in newspapers, education, and formal speech, and Dialectical Arabic (DA), which is the informal everyday spoken language, found in chat rooms and social media platforms. The Arabic language consists of 28 Arabic alphabet letters, eight of which come in two forms  corpus  corpus  included) corpus  and has https://catalog.ldc.upenn.edu/LDC2005T20). This dataset has been the main resource for some state-of-the-art systems and tools such as MADA (One of the earliest Arabic datasets created as an MSA Resource was the Penn Arabic Treebank (PATB) . It cons as MADA , and its as MADA , and YAM as MADA .https://nyuad.nyu.edu/en/research/centers-labs-and-projects/computational-approaches-to-modeling-language-lab/resources.html). Using the Gumar corpus, a Morphological Corpus of the Emirati dialect was created . Of the Arabic dialects, as mentions before, the Egyptian dialect has had a wealth of attention; the earliest Egyptian corpuses are CALLHOME , and MIK created , consistIt is clear from tags = API.trends. place  from the tweepy library. Additionally, we used the Twitter accounts of these companies as search keywords.To build the dataset, we used Python to interact with Twitter’s search application programming interface (API)  to fetchAs the aim of this collection was to allow for a longitudinal, continuous study of telecom customers’ sentiments, we gathered data continuously from January to June 2017, mainly because this period includes customers’ reactions to the Saudi Communications and Information Technology Commission’s new index, which refers to complaints submitted to the authorities . While sFor our own further experimentations, in order to reduce computational costs and time in constructing our working AraCust corpus, we chose a sub-sample of Saudi tweets randomly from the dataset to prevent bias . The priThe sample size decision was based on a pattern-extraction experiment using Network Overview, Discovery, and Exploration Node XL . Node XLThe size of our AraCust corpus of 20,000 Saudi tweets  is in lihttps://www.geonames.org/), a geographical database that includes 8 million place names for each country, which includes 25,253 place names for Saudi Arabia.As the companies we targeted were from Saudi Arabia, we further filtered the tweets based on user location and time zone to identify Saudi tweets. Saudi Arabia ranks seventh in the world in the number of personal accounts on social media . We founFinally, in the context of our data collection process from Twitter, it is worth mentioning that ethical concerns of using social media data have stirred an ongoing controversy in research communities in terms of confidentiality and privacy. The availability of social media data is thought to potentially expose social media users to risks. Although social media data is prominently public still, the emergence of profiling by business owners for business purposes has led to criticism and apprehension. Regarding our own study, on Twitter, users’ phone numbers and addresses are not made public, to provide some level of privacy. Additionally, in our current research, we further deleted any phone numbers or names that were included in the tweets themselves, for additional privacy. Finally, we collected only the tweet texts, time, and location, without collecting any other user-related information from them.To avoid noise in the corpus, cleaning was performed on the dataset. One way of cleaning is removing spam, thus any tweet with a Uniform Resource Locator (URL) was excluded, as in Next, the words in the tweets were tokenized, which means that sentences were segmented into words for easier analysis, as in  •alif “أ“.Replacing the Arabic letters “أ“, ”إ”, and “أ“ with bare  •ya ”ئ“.Replacing the letter ”ئ“, ”ئ“, and ”ئ“ with bare  •Replacing the final “ة” with “ة”. •If a word starts with “ء”, replacing it with “أ“. •Replacing ”ؤ“ with ”ؤ“.m, the emojis were deleted, and the prefix ““”ال “Al” was removed.As stemming algorithms do not perform well with DA words , they weBefore doing the sentiment analysis task, it is important to analyze the corpus. This includes the data types that we will deal with in the classification and prediction experiments, as well as the features that originate from the nature of the corpus, which may affect the model’s performance. Our data analysis involved many feature set analyses, from character-based to dictionary-based, and syntactic features . This exFrom the exploratory data analysis, we observed first that there were more negative tweets than positive tweets for all three companies see . We inteThe ten most frequent words in the corpus and their number of appearances in the corpus are given in The most frequent bigram on the corpus, as shown in pr(t) and negative rate nr(t) for the most frequent words (term t) in the corpus as follows  val in the corpus: tw is a tweet in corpus C; and bool1 is a Boolean function: valence a function returning the sentiment of a word t in a tweet tw and term_freq_df [t] is the total frequency of the word t as both a positive and negative word in the corpus: bool2 is a Boolean function: Has Prayer feature in the classification task; this feature allows us to evaluate whether the existence of a prayer in a tweet increases the classifier’s performance.These results led us to use the The feature set analysis is illustrated in Word-based features  include Sentence-based features include the mean number of words for each sentence, the standard deviation of sentence length, and range (the difference between the longest and shortest sentence) .Before the SA, we needed to train the classifier and create a readable version for the machine using corpus annotation. Annotation is the process of assigning interpretative information to a document collection for mining use . Hinze eSeveral approaches used to annotate the corpus, including the manual approach, which depends on human labor, and the automatic approach, which uses an annotation tool.Gold Standard Corpora (GSC) are an important requirement for the development of machine learning classifiers for natural language processing with efficiency; however, they are costly and time consuming and thus there are few GSCs available, especially for Arabic  to express sentiment orientation . The outSarcasm is a form of speech in which a person says something positive while he/she really means something negative, or vice versa . To ensure a high quality of the manual annotation process, clear guidelines were needed to maintain consistency between annotators .As recommended by To encourage a thorough examination of the tweets and high-quality results, the annotators were paid. Moreover, to ensure fair pay, in order to determine the annotators’ wages, we conducted a pilot study to calculate the average time they needed to annotate the tweets, as recommended by Before we began the annotation process, the annotators were provided with annotation guidelines in both Arabic and English in a one-hour session; some of the annotation guidelines are shown in To build a gold standard Arabic corpus, three rotations were used to annotate the corpus. As mentioned before, we divided the corpora into three based on the Telecom companies STC, Mobily, and Zain. They started the first rotation by annotating the STC corpus, then the Mobily corpus, followed by the Zain corpus. After the first rotation, we reviewed the annotators’ choices and discussed them with them before the new rotation started. After the second rotation, we calculated the similarity percentage between A1 and A2, A2 and A3, and A1 and A3 for the three corpora. At the third rotation, we asked the annotators to revise the labels for the corpus that have low similarity percentages. After the three rotations, the author revised the three annotation labels done by the annotators and compared their choices, using voting to make decisions. We found that 83% of the tweets were labeled with the same label by the A1 and A3, 75% of the tweets were classified with the same labels by A2 and A3, while 74% of the tweets were classified by A1 and A2 with the same labels.The annotators faced some challenges in the annotation process, similar to those experienced in prior research , such asQuoting and supplications: It is difficult to define the sentiment of a tweet author whose tweet includes a quote or supplication, and to determine whether the author agrees with the sentiment of the quoted author. The annotators chose the sentiment that was expressed in the quote or in the supplication. Then, we checked the sentiment that they allocated. We did not ignore or remove the tweets with quotes or supplications, because the quotes/supplications were a form of expression of author sentiment.•  Sarcasm: It is extremely hard to detect sarcasm in a tweet, because the explicit sentiment is different from the implicit sentiment. Nevertheless, as people are better at this than machines, annotation of tweets with this label is invaluable due to the difficulty of the sarcasm detection task  was used. We used the similarity index as an early indicator of the annotators’ agreement. Fleiss’ Kappa  was usedk Fleiss  (the frequency of each term within the document), and term frequency–inverse document frequency (TF–IDF) . We found that term presence is the best feature to use with binary classification, in line with what was found by ).This study used a sentiment analysis on GSC AraCust to measure customer satisfaction. To validate the proposed approach, we developed a simple questionnaire of two questions. The questionnaire is oriented towards the customers whose tweets were mined, to compare the predicted customer satisfaction using the proposed approach with actual customer satisfaction using the questionnaire .We made an automatic tweet generator in Python (the tweet has a link to the questionnaire) to all 20,000 users whose tweets we had previously mined, but the respondents totaled just 200. The tweet generator was created using a code in Python for sending tweets that have two things (the link to the questionnaire and mentions to the Twitter accounts of participants). To save time, the code completed this procedure automatically . The queThe unbalanced numbers of participants between the three companies reflects the real distribution of the users of the Saudi telecom companies. The number of unsatisfied and satisfied users for STC is shown in These results can provide insights for the decision-makers in these companies regarding the percentage of customer satisfaction and help to improve the services provided by these companies. These results should encourage decision-makers to consider using Twitter analyses for measuring customer satisfaction and to include it as a new method for evaluating their marketing strategies.This study set out to fill gaps in the literature by proposing the largest gold-standard corpus of Saudi tweets created for ASA. It is freely available to the research community. This paper described in detail the creation and pre-processing of our GSC AraCust, explained the annotation steps that were adopted in creating AraCust, and described features of the corpus, which consists of 20,000 Saudi tweets. A baseline experiment was applied on AraCust to offer benchmark results for forthcoming works. Additionally, a baseline experiment was applied to ASTD to compare the results with AraCust. The results show that AraCust is superior to ASTD. Further generalization of the dataset use can look into other aspects of the communications of customers of the three majors Saudi providers of telecom services—serving, for instance, a total of 41.63 million subscribers who use mobile voice communication services. Furthermore, we have informed the telecom service companies of our results at every step of our investigation, and these results, dataset, and overall methodology may be used in the future to improve their services for their customers.10.7717/peerj-cs.510/supp-1Supplemental Information 1Click here for additional data file.10.7717/peerj-cs.510/supp-2Supplemental Information 2Click here for additional data file.


Developmental stuttering (DS) is a disturbance of the normal rhythm of speech that may be interpreted as very debilitating in the most affected cases. Interventions for DS are historically based on the behavioral modifications of speech patterns , which are useful to regain a better speech fluency. However, a great variability in intervention outcomes is normally observed, and no definitive evidence is currently available to resolve stuttering, especially in the case of its persistence in adulthood. In the last few decades, DS has been increasingly considered as a functional disturbance, affecting the correct programming of complex motor sequences such as speech. Compatibly, understanding of the neurophysiological bases of DS has dramatically improved, thanks to neuroimaging, and techniques able to interact with neural tissue functioning . In this context, the dysfunctional activity of the cortico-basal-thalamo-cortical networks, as well as the defective patterns of connectivity, seems to play a key role, especially in sensorimotor networks. As a consequence, a direct action on the functionality of “defective” or “impaired” brain circuits may help people who stutter to manage dysfluencies in a better way. This may also “potentiate” available interventions, thus favoring more stable outcomes of speech fluency. Attempts aiming at modulating (and improving) brain functioning of people who stutter, realized by using NIBS, are quickly increasing. Here, we will review these recent advancements being applied to the treatment of DS. Insights will be useful not only to assess whether the speech fluency of people who stutter may be ameliorated by acting directly on brain functioning but also will provide further suggestions about the complex and dynamic pathophysiology of DS, where causal effects and “adaptive''/‘‘maladaptive” compensation mechanisms may be strongly overlapped. In conclusion, this review focuses future research toward more specific, targeted, and effective interventions for DS, based on neuromodulation of brain functioning. Developmental stuttering (DS) is a neurodevelopmental disorder characterized by speech dysfluencies such as blocks and repetitions, especially occurring during the first part of words and sentences. Associated motor symptoms (such as muscular spasms) may be evident, especially in the orofacial districts, which could not be strictly related to the motor programs of the intended utterances of speakers. DS appears during childhood  to treat other conditions and of targeting the thalamus or the basal ganglia system  stuttering in a better way. In this perspective, very recent evidence has suggested to combine neuromodulation techniques with more “conventional” interventions. Neuromodulation is able to “boost” brain functioning by means of non-invasive brain stimulation (NIBS) techniques   are considered as fundamental hubs , and temporoparietal cortex are often a part of altered neural circuits related to stuttering , where an anode or a cathode is placed on the scalp (in correspondence of the region of interest) modulating the resting membrane potential of neurons, generally resulting in increased or decreased excitability of the neural target, respectively   is delivered using the patterns of sinusoidal current at a defined frequency ; this interacts with the physiological oscillations of the brain, possibly resulting in their better entrainment/synchronization, thus modulating (possibly improving) their functioning , delivering an alternating current with random amplitudes and frequencies. In this case, stimulation may be delivered at high random frequencies , Huang et al.  uses burNon-invasive brain stimulation is normally characterized by a limited spatial resolution in a neural level. This problem may be partially mitigated by using advanced neuronavigation methods (based on the magnetic resonance information) as well as by using more “focal” TMS coils and tES configurations. In the latter case, for example, the use of particular montages and electrodes  may be useful to reduce unspecific stimulations, thus limiting the heterogeneity of findings and effects  using the keywords “transcranial,” “stimulation,” and “stuttering” resulted in a total of 31 articles, but only 6 were the studies using a neuromodulatory approach in DS. Three additional reports taken into consideration in this review (one in a “pre-print” form) were found thanks to a more general search on the web. The first attempt, which is aimed to verify the modulatory effects of tES on the brain functioning of people who stutter, has been published in 2017  neural targets: inferior frontal regions (which include the Broca's area) and the SMA “complex.” These cortical areas are considered as a part of complex and wider speech/motor networks, comprising different structures such as the temporoparietal cortex, associative and primary sensorimotor regions, and the basal ganglia. In addition, inferior frontal regions and the SMA “complex” are directly interconnected through axonal fibers constituting distinct fascicles, such as the FAT, which have been shown to have a role in DS  in the left hemisphere, and/or inhibiting the activity of homologous regions (and networks) in the right one see  [the indThe SMA “complex” is another promising candidate for the efficient neuromodulation of the impaired/abnormal networks in stuttering . In these studies, anodal tDCS  is applied on brain regions such as the left frontotemporal cortex. In the end of treatments (and in follow-up phases), improvements in the indexes of speech fluency and brain functioning  will be evaluated.Similarly, other controlled clinical trials evaluating the effect of neuromodulation in DS are currently running as reported on the web  consider also physical concomitants and the duration of dysfluencies  , deserve further consideration, investigation, and replication. As a matter of fact, current insights may be very useful not only to improve speech interventions in DS, but also to obtain a further and better understanding of neural dynamics involved in stuttering. This should be done because the use of neuromodulatory NIBS, in DS, is very recent: protocols need to be optimized to better understand their effects and interactions with brain functioning.On one hand, findings suggest that increasing the neural activity of the left inferior frontal cortex may help in improving speech fluency  network” that has been shown to be defective in DS, thus resulting in difficult preparation, initiation, and control of voluntary, “precise in time,” and “complex” motor sequences  network” also exists   may also help in improving speech fluency, in DS  inferior frontal cortex, the cortico-basal-thalamo-cortical system (including the SMA “complex”), or the temporal cortex , is evident. An effective communication among them is constantly needed through the discrete patterns of connections such as the FAT, the fascicles connecting anterior and posterior parts of the brain, and corpus callosum. In the end, bilateral inferior frontal cortices may be promising targets for a non-invasive neuromodulation in stuttering, with reversed effects in the two hemispheres. Attempts also suggest that acting on the temporal cortex or, especially, on the cortico-basal-thalamo-cortical networks of people who stutter, may be a promising approach to reduce speech dysfluencies. In the latter case, the SMA “complex” may be a more achievable cortical target for acting on “defective” brain dynamics, and likely for improving the functioning of these wider and complex neural networks.The evidence also suggests future perspectives of neuromodulatory NIBS in stuttering: attention should be paid to the implementation and the investigation of new and more focused protocols of interventions. In this context, it could be useful to increase an understanding of the neural effects of “pure” neuromodulatory NIBS trials  on the neural networks of the people who stutter   (see Etchell et al., In conclusion, neuromodulatory NIBS may be a promising and useful approach to “boost” more conventional interventions in stuttering, thus resulting in an improvement of speech fluency in a better way. At present, the stimulation of neural circuits comprising the inferior frontal cortex and the SMA “complex” may be the more effective approach. Secondarily, temporal cortex may be also considered for additional investigation regarding its potential to serve as a further neural target that is useful to improve DS (compare with Moein et al., PB: manuscript conception, writing, editing, bibliographic search and elaboration, and conception and realization of figures and tables. BM: manuscript conception and editing, bibliographic search and elaboration, and conception and realization of figures and tables. FM: manuscript editing and conception and realization of figures and tables. GDB: manuscript conception and editing. GC: manuscript conception and editing and bibliographic search and elaboration. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The handling editor is currently organizing a Research Topic with one of the authors PB.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.


What are consequential world problems? As “grand societal challenges”, one might define them as problems that affect a large number of people, perhaps even the entire planet, including problems such as climate change, distributive justice, world peace, world nutrition, clean air and clean water, access to education, and many more. The “Sustainable Development Goals”, compiled by the United Nations, represent a collection of such global problems. From my point of view, these problems can be seen as complex. Such complex problems are characterized by the complexity, connectivity, dynamics, intransparency, and polytely of their underlying systems. These attributes require special competencies for dealing with the uncertainties of the given domains, e.g., critical thinking. My position is that it is not IQ, but complex problem-solving competencies for dealing with complex and dynamic situations, that is important for handling consequential global problems. These problems require system competencies, i.e., competencies that go beyond analytical intelligence, and comprise systems understanding as well as systems control. Complex problem solving is more than analytic intelligence. The editors of this Special Issue have asked me to respond to the statement: “How intelligence can be a solution to consequential world problems”. What exactly are consequential world problems? Why should intelligence (intelligent behavior) be relevant to their solutions? What other skills would help in solving global problems? The answer I give here to these questions is based on my personal opinion, rather than on an evidence-based review of the literature.Who defines “consequential world problems”? It is not easy to scale and prioritize the challenges to mankind, because there are many different perspectives. How, then, to define global problems? As “grand societal challenges”, one might define them as problems that affect a large number of people, perhaps even the entire planet, including problems such as climate change, distributive justice, world peace, world nutrition, clean air and clean water, access to education, and many more.The world around us presents many challenges to mankind—not only human-driven climate change but also the demand for food and water for a global population that may soon reach 8 billion people. Clean air and clean water are not widely available in large parts of the world, driving migration from failed states to more promising ones.The United Nations have compiled 17 “Sustainable Development Goals” that represent a collection of such global problems. These goals are concerned with the survival of planet Earth and its inhabitants. They are the blueprint to achieve a better and more sustainable future for all. They address the global challenges we face, including poverty, inequality, climate change, environmental degradation, peace, and justice.What is psychology’s answer to these grand societal challenges? The research on problem solving is my preferred perspective on these challenges. Problem solving is a processual view on intelligence  solution;Information needed for the solution has to be actively searched for;There are dynamics in the problem situation (one cannot wait forever for a solution).The “General Problem Solver”  was, at Today’s version of this is called “artificial intelligence”. This again promises to solve problems of many different types, but again, there is some disillusion concerning AI’s abilities when considering “adversarial perturbations” e.g.,  and misscomplexity, in the sense that many variables are involved; (2) connectivity, reflecting the fact that relationships exist between variables; (3) intransparency, referring to missing or inaccessible information important for the problem-solving process; (4) dynamics, in the sense of the possibility of changes of a given situation over time; and (5) polytely , referring to there being many goals and objectives that are possible and could be pursued.As a consequence of the limitations of problem-solving research focused on puzzles, towers, and other “toy problems”, the use of computer-simulated microworlds was proposed e.g., . The useHow are complex problems different to complicated problems? For complicated problems, solutions exist, and experts are needed (and found); for complex problems, there are no experts available, because these problems are novel and have no known solution see .Contrary to expectations, the successful handling of complex problems does not correlate with intelligence , according to early studies  might argue that, with respect to the anticipated rising sea level and myself living far above sea level, there is no threat to me as a person. However, with empathy (as part of a broader understanding of intelligence), one could imagine the threat to people living on an island in the Pacific Ocean exposed to a rising sea level.Our current concept of intelligence is missing an ethical dimension. During the education process of individuals, we do not solely teach facts and knowledge; we also teach values. The education process, in general, is a process of character formation. One of the long-term results of character formation can be seen in the development of wisdom. In her recent review, Similarly, The University of Cambridge Institute for Sustainability Leadership (CISL), as reported by Crime and Punishment). This “something more” could be values and wisdom. “Values” adds to the noncognitive variables and “wisdom” to the cognitive variables. This could make an important difference.Complexity continues to increase, and creative solutions to complex problems are urgently needed e.g., . To addr


Stephen Szára, a Hungarian psychiatrist and chemist, often considered the “father of DMT” (N-N-Dimethyltryptamine), died on August 1, 2021. In the nineteen-fifties he became interested in the concept of model psychoses and the role of psychedelics in psychotherapy, and was the first to study the psychotropic effects of DMT, an alternative molecule he synthesized after Sandoz had declined to send LSD behind the iron curtain (arguing that such a powerful psychotropic drug might be dangerous if used unscrupulously). Szára recruited thirty volunteers, mostly young physician colleagues who received full psychedelic doses. He emphasized their common phenomenological experiences: “When these experiences, such as God, or strange creatures, appeared in our DMT studies, we did not philosophize about them but, as psychiatrists, we simply classified them as hallucinations.” He also theorized, “What DMT might do is to slow down and stop reality testing  and let the Default Mode Network release the stored images and symbols into the perceptual system. It is the brain that stores and releases archetypal images into our altered consciousness.” His later passion, arising out of these psychedelic drug studies, was conceptualising brain/mind interactions and developing computer simulations of multi-neuronal pathways: “by learning the mechanisms by which they affect the brain we may find keys to unlock the mysteries of the brain/mind relationship”.Dr. Szára earned his DSc and MD from the Budapest University of Medicine, and established a research laboratory in a psychiatric hospital. However, three weeks after the Hungarian uprising in 1956, he left Hungary illegally, “with a briefcase containing a change of underwear, a couple of sandwiches, my two doctoral diplomas, test-tubes containing the newly discovered DMT, and 2 dictionaries: German/Hungarian and English/Hungarian, in search of a new life.” After some time in refugee camps, he contacted Professors Hoff, Arnold and Hoffman at the Viennese University clinic and traded some DMT for a chance to participate in their LSD study. In Berlin he was a guest researcher at the Free University with Professor Selbach, and in May 1957 attended the First International Congress on Psychotropic drugs in Milano. Later that year he took up a position at NIMH with Joel Elkes at St. Elizabeth’s Hospital in Washington, and subsequently explored the metabolism of DMT and related compounds in healthy and schizophrenic volunteers in Julius Axelrod’s lab.This is when I met him, my uncle Pista, as a 17-year old AFS exchange student visiting Washington. He led me through his lab and talked about his experiments, and this single evening quietly inspired my own scientific research career. Who would have imagined that twenty years later I would also be fascinated by the neurotransmitter serotonin (genetic affinity?), become a visiting fellow at NIMH, share a house with him, and spend our daily commute to Bethesda talking about psychedelics?In 1968, Dr. Szára joined the Center for Studies of Narcotics and Drug Abuse as Chief of Clinical Studies and conducted research on marijuana and THC. In that same year he was charged with reporting to the Director about the hippie scenes in SF, LA and NY, surely a sociological adventure for a psychopharmacologist. In 1974, when NIDA was created, he became Chief of the Biomedical Branch in the Division of Preclinical Research.Dr. Szára was an Emeritus Fellow of the American College of Neuropsychopharmacology and Collegium Internationale Neuro-Psychopharmacologicum. He was also recipient of the Alcohol, Drug Abuse, and Mental Health Administration Administrator’s Meritorious Achievement Award and the Kovats Medal of Freedom from the American Hungarian Federation.The complex neurotransmitter mechanisms underlying the subjective DMT experience are still not fully elucidated. As an endogenous compound in both plants and animals it has been considered a possible neuromodulator. Given its limited neurotoxicity, DMT may have therapeutic significance. It is indeed a tribute to his foresight, that nearly 70 years later, after a long hiatus where psychedelic drugs were deprecated and even outlawed, his prediction that these interesting molecules might be useful in psychotherapy is now undergoing a new wave of research.


Comparing the cognitive capacities of nonhumans to those of humans can be quite difficult, particularly given that humans can be questioned directly  but that most nonhumans must be tested by various indirect means that might not demonstrate the full range of their capacities. A few nonhumans, however, have acquired some level of symbolic representation , which allows for a limited form of interspecies communication that can be used for direct questioning. Why have so few nonhumans acquired this skill, and what are the advantages of having it? I describe a specific training procedure, the Model/Rival (M/R) protocol, that enabled several Grey parrots to learn some level of referential communication; I discuss the specific elements of such training that are both necessary and sufficient for successful acquisition and how lack of any of these elements can cause failure. I also describe some experiments that were facilitated by interspecies communication, and how acquisition of this ability might affect the extent to which nonhumans can process information.Psittacus erithacus). I will describe the original format developed by Todt, the relationship to other forms of observational learning outlined by other researchers, and the adaptations that I devised. I will describe how my undergraduate trainers and I isolated the various components that constitute the technique and explain how each is necessary, but how only the combination of all components is sufficient for successful implementation—and how improper implementation can lead to failure. I will briefly summarize the results of proper implementation—including the importance of interspecies communication itself as a technique for studying animal cognition.In this paper, I will review the Model/Rival (M/R) technique that has been used to establish interspecies communication with Grey parrots ( Thus, any speaker of English would instantly understand what is being communicated by the label “green” in the latter case—as would a nonhuman who has also acquire some level of symbolic reference.Determining the cognitive capacities of nonhumans is not a simple task; just the act of devoting a special issue to the topic makes the problem abundantly clear. A form of the Heisenberg uncertainty principle always exists when performing such studies—i.e., the process by which measuring occurs can affect the result. Moreover, given that most such experiments are comparative in nature and that human cognition is the standard against which nonhuman abilities are most often measured, the fact that humans and nonhumans are generally tested via very different techniques complicates the issue even further. For example: other than in studies with pre-verbal infants, humans are most often tested using their language abilities—by simply being asked pertinent questions—whereas nonhumans are mostly incapable of being tested in that manner. However, what about those nonhumans who actually can be questioned in the same manner as humans? Specifically, what about nonhumans that have acquired some level of symbolic representation (a term I use interchangeably with symbolic reference): that is, what about nonhumans who understand the semantic and pragmatic use of noniconic symbols—be they auditory/vocal, manual, or lexical—to stand for (but not be limited to) items such as physical objects and their attributes, various concepts, relations among these items and concepts, and actions that can be done to or with these items? Here I am utilizing Deacon’s assertions about reference ; that reSuch nonhumans can be tested via the use of interspecies communication . InterspPsittacus erithacus), was taught such a form of interspecies communication. I will review the various components that constitute the training technique, explain how each is necessary, and demonstrate how only the combination of all components is sufficient for successful implementation.Although I will spend some time discussing how acquisition of symbolic representation may actually affect cognitive capacities see , the maiIn the late 1960s and early 1970s, several projects were initiated in order to train nonhumans to communicate with humans. Their choices of species were based on the idea that subjects should, like the great apes, have a close phylogenetic relationship to humans (reviewed in ). Other Despite the material discussed above, until my research birds such as Grey parrots were still consistently dismissed as mindless mimics , and eartheir initial hesitation about handling snakes, and then imitating the actions of this successful person), they could make some inferences about general learning mechanisms [This study caused me to delve deeper into the various issues involved in determining how to establish referential communication and led to my examining research on social modeling theory and its applications ,14,15. Schanisms . Overallchanisms ,11. I deOne principle states that the student’s level of competence must be taken into account during all aspects of training. Researchers had already determined, for example, that human children most easily and most often acquire whatever is just slightly beyond their current abilities—whether it be new labels, actions, etc. . FindinA second principle of this theory is that the modeling must help the student understand how new material relates to current problems and what advantage is conferred by learning the new material. Practically, training is therefore most effective when: (a) the student sees and then practices the targeted behavior under conditions similar to those in its regular environment, and (b) the appropriate use and consequence of the behavior are explicitly demonstrated  correlate well with specific aspects of an individual’s environment , (b) haReference—reference, for the most part, involves content; that is, what signals “are about” [e about” . Referene about”  describeFunctionality—functionality  involves the pragmatics of signal use: when a signal is to be used and the effects of using information in the signal [e signal ,25. Funce signal . FunctioSocial interaction—the three major functions of social interaction can be clarified by examples [shape of this one is square; the shape of that one is round”). Next, social interaction can emphasize common attributes—and thus possible underlying rules—of diverse actions . Finally, social interaction is what allows input to be continuously adjusted to match the receiver’s level . Interaction may also provide a contextual explanation for an action and demonstrate its consequences . Interactive input of various forms thus facilitates learning.examples . First, In sum, reference and functionality concern how a label is used in the world, social interaction highlights various components of its use, and all three are necessary for meaningful learning . Importaintrinsic reward), and not an irrelevant item like a piece of food (an extrinsic reward), the bird thereby observes the closest possible connection between the object and the label to be learned. The trainer gives praise and transfers the named object to the human partner to reward correct answers. Incorrect responses are punished by scolding and temporarily removing items from sight. Thus, the second human is a model for the parrot’s responses, and its rival for both the trainer’s attention and acquisition of the item. The second human also illustrates consequences of errors. The model must try again or talk more clearly if the response was deliberately incorrect or garbled; that is, the model is subject to corrective feedback, which the bird observes. The parrot is included in these interactions, being queried and rewarded for successive approximations to correct responses; training is adjusted to its performance level. If a bird is inattentive or accuracy regresses, trainers threaten to leave. Note that the procedure also clearly demonstrates how the two trainers jointly attend to the object in question, another aspect of social interaction input thought to be important for acquisition of referential labels [In honor of Todt’s breakthrough, I continued to call the revised training protocol the M/R procedure. However, several modifications were made in this new design. The major changes are the demonstration of referential and contextual use of labels, and of corrective feedback among two human trainers and the parrot in order to demonstrate the targeted vocal behavior . The parl labels .Unlike M/R procedures used by other researchers (see ), ours ay with label “y”, receive y, toss it, and then request x as the reward.Although giving the parrot the object it had just labeled emphasized the referentiality and functionality of the label, this procedure also, of course, confounded identification of an object with the request for the object. We thus subsequently had to teach the birds (again through the M/R technique) to use “I want x”, which enabled them to request unrelated, preferred rewards while learning labels for various items that they found of little or no inherent interest . SpecifiWe maintained strict controls during training and testing , butWith the help of this modified technique and these housing conditions, my most successful subject, Alex, acquired labels for over 100 different objects, seven colors, five shapes, exact numbers (up to eight), and categories; he acquired concepts of same/different, bigger/smaller, addition, numerosity, something akin to ‘zero’, and functional use of phrases such as “I want x” and “Wanna go y” where x and y were appropriate object and location labels  Grey parrots Kyo, Alo, Griffin, and Arthur. For these new subjects, I could provide input that varied with respect to various amounts of reference, functionality, and social interaction. I therefore contrasted sessions involving standard M/R tutoring on some labels with sessions on other labels that used audiotapes, videos, as well as variants of M/R and video input that involved different levels of human interaction. Moreover, to see what could happen if we did make changes in Alex’s learning environment, I also exposed him to a variant of M/R training.were reviews and thus were not engaging, and he occasionally erred or interrupted with requests for other items and changes of location, which enabled us to demonstrate the same corrective feedback as usual [To test how learning might be affected if input totally lacked reference, context, and social interaction, I used two juvenile parrots, Alo and Kyaaro, contrasting their training via audiotapes with the standard M/R protocol. In the audiotape sessions, juveniles sat on a perch and listened to tapes while isolated from each other and the rest of the laboratory, and no objects were associated with the sounds presented over the speaker . The twoas usual ,11. As iil ee bam ba oo yuk chil gal, was derived from Korean count labels both to permit comparisons with children [Bam (pronounced /baem/) and ba were substituted for the Korean sam and sa because of Alex’s occasional difficulty in producing “ss”. Alex thus did not initially observe any modeled connection between labels and their referents: that is, his input would lack as much reference and functionality as possible compared with his standard training [x for stating “I want x” [x would have no referential relation to the count labels on which he was being trained); errors in the string  would elicit scolding, time-outs, and corrective feedback [What would happen if we provided plenty of social interaction , but elchildren  and to btraining ,35. Corr want x” , but x wx”) for a correct response. Training, therefore, lacked functional meaning and all but minimal reference. The procedure did, however, maintain joint attention among bird, humans, and the pictured numbers.The training failed before we could even begin to collect data . AlthougAlex eventually did acquire the modeled string of number labels, but his results differed in two striking ways from those for utterances learned in standard M/R sessions ,35. Firskey!” “Do you want key?”, etc. These sentences carefully framed the label, allowing for repeated label use while minimizing possible habituation [key!”), but never the object, although it could see the object to which the label referred. Two birds, Alo and Kyaaro, received such training on two labels in this variant, which was compared with their training on two other labels via the standard M/R protocol. Labels for this and all subsequent experiments were chosen according to the same criteria used for the audiotape study. We attempted to provide equivalent exposure to the several labels being trained  removed and social interaction was strongly reduced but not eliminated during training . Based oituation ,41. The ned (see ). Both bIn “basic video” sessions, Kyaaro and Alo received input that demonstrated reference but avoided social interaction and minimized functionality in different ways than did M/R variant 2; again, labels trained in this manner were contrasted with other labels trained with the standard M/R procedure. Here, we again made videotapes of M/R sessions with Alex and two humans, then exposed the juveniles to those tapes , but nowBecause of research that (at least at the time I was performing these experiments) suggested that normal children learn more about labels from video instruction if they watch with an interactive adult who emphasizes important points, asks the children questions about what they are viewing, responds to the children’s questions, and even corrects the children’s comments  and becx!” or “I have an x!”), concurrently manipulating the corresponding item. Griffin thus saw behavior somewhat related to that in M/R sessions, where a trainer would say, “Yes, you have an x!” when rewarding the model/rival. The solo trainer demonstrated the association between label and item but did not model functional label use or errors. As in M/R sessions, Griffin was also queried about the object (“What’s here?”). Any of his attempts at the label would be noted and rewarded with the item; thus, only if he attempted a label would he experience its functionality. As in M/R training, if he erred on a label, a trainer would tell him to “Try again,” “Say better,” etc. We ensured that he was queried at the same rate and in the same way as in M/R training, so these solos differed only in lack of human-human modeling and were not a series of drills. Interestingly, Griffin did not utter any targeted label during or immediately after 50 sessions but did so after two or three subsequent M/R sessions involving the same items. Because birds usually need about 20 M/R sessions to fully and clearly produce a novel label , Griffi modeled . Such betrainers for labels for novel items, colors, shapes, etc.; maybe he understood who was an appropriate source of information, and that Griffin was not? Only several years later were we able to train Alex to query Griffin). Unlike most of the other modifications to the M/R procedure, this one had some success. Griffin learned two labels trained in these sessions. Acquisition was, however, notably and considerably slower than in the standard M/R procedure, requiring about twice as many sessions for acquisition to occur. Many possible reasons exist for this slower rate of acquisition aside from the lack of role reversal; these are discussed in detail in [Here we wanted to see what might happen if a parrot experienced full reference and functionality, modeling, corrective feedback, but no role reversal, and if lack of role reversal might be mitigated by the use of a conspecific . Thus, Getail in . Anotherall together provides sufficient means for full and rapid acquisition to occur; lack of any one of them may result in various levels of failure.The numerous experiments described above clearly could not examine every combination of various possible levels of input with respect to reference, functionality, and social interaction. For example, we did not test what would happen if, in the standard M/R condition, models never erred and thus the birds never saw corrective feedback. Premack  presenteIn some studies, symbolic processing plays an important role not specifically because it enables more complex processing, but because it facilitates training and/or eliminates confounds that can detract from the claims of success in other species. In each of these studies, the parrot could be taught a label for a concept, rather than being required to derive the concept over thousands of trial-and-error tests, and then could be exposed to transfer trials to examine how well the concept was understood.For example, in studies of optical illusions, humans are simply asked what they see. However, such is rarely the case for nonhumans who are tested to determine how their perception of the same stimuli compares to that of humans. Nonhumans instead are generally subjected to intensive training procedures to enable them to discriminate the initial stimulus, followed by tests on their recognition of similar patterns; results often are contingent upon statistical averaging over hundreds of trials of pecking/touching behavior to a very limited set of choices. The data thus are often highly variable and dependent upon details of the experimental design (reviewed in ). Alex, It is also likely that Griffin’s understanding of symbolic representation assisted him in other experiments. That is, he might have used symbols as place-markers to assist in tasks requiring memory ,62 and eAs noted above, Premack  has arguFor example, most nonhumans have considerable difficulty demonstrating an understanding of relational concepts, such as ‘bigger–smaller’, unlike tasks involving concrete concepts such as color, where something that is “red” is always “red”, in relational tasks the sample that is, for example, the smaller object on one trial  can be the bigger object on another . Most subjects are trained to derive one concept over large numbers of trials  and then the other through large numbers of reversals —in this training paradigm, however, both concepts may actually never be acquired, in that a subject without symbolic reference may simply learn “choose X” versus “avoid X” , almost every nonhuman tested plus pre-verbal children can distinguish exact quantities for sets up to about three . The ANSOnly a very small number of individual nonhumans have acquired the form of symbolic representation described here—a few nonhuman primates, a few marine mammals, a few Grey parrots (summarized in )—and sucIt is important to recognize that none of the nonhuman individuals in these studies on symbolic representation acquired all the complexities that are inherent in human language (even with what one hopes was fully appropriate training); much is yet to be learned about the reasons why. Nevertheless, the acquired level of interspecies communication in this unique subset did enable an examination of their cognitive capacities in ways that would have been much more difficult, if not impossible, by other means. Again, I have not tried to review the entire field of animal cognition, but have focused on my specific area of expertise, the abilities of Grey parrots. Given that these birds are evolutionarily separated from mammals by over 320 million years of evolution , and yet


Children with cancer are at high risk for clinical deterioration and subsequent mortality. Pediatric Early Warning Systems (PEWS) have proven to reduce the frequency of clinical deterioration in hospitalized patients. This qualitative study evaluates provider perspectives on the impact of PEWS on quality of care during deterioration events in a high-resource and a resource-limited setting.We conducted semi-structured interviews with 83 healthcare staff  involved in recent deterioration events at two pediatric oncology hospitals of different resource levels: St. Jude Children’s Research Hospital  and Unidad Nacional de Oncología Pediátrica . Interviews were conducted in the participant’s native language (English or Spanish), translated into English, and transcribed. Transcripts were coded and analyzed inductively.Providers discussed both positive and negative perspectives of clinical deterioration events. Content analysis revealed “teamwork,” “experience with deterioration,” “early awareness,” and “effective communication” as themes associated with positive perception of events, which contributed to patient safety. Negative themes included “lack of communication,” “inexperience with deterioration,” “challenges with technology”, “limited material resources,” “false positive score,” and “objective tool.” Participants representing all disciplines across both institutions shared similar positive opinions. Negative opinions, however, differed between the two institutions, with providers at UNOP highlighting limited resources while those at SJCRH expressing concerns about technology misuse.Providers that care for children with cancer find PEWS valuable to improve the quality of hospital care, regardless of hospital resource-level. Identified challenges, including inadequate critical care resources and challenges with technology, differ by hospital resource-level. These findings build on growing data demonstrating the positive impact of PEWS on quality of care and encourage wide dissemination of PEWS in clinical practice. Pediatric patients with cancer are at risk for clinical deterioration due to multiple factors, including cancer-related complications and treatment-associated toxicities . Up to 3Almost 15 years ago, the Institute for Healthcare Improvement identified rapid response systems as a core mechanism to decrease preventable morbidity and mortality . To aid Although robust data exist describing the quantitative impact of PEWS on patient outcomes , qualitaInterviews were conducted during the fall of 2018 at two hospitals dedicated to the care of children with cancer: Unidad Nacional de Oncología Pediátrica (UNOP) in Guatemala City, Guatemala and St. Jude Children’s Research Hospital (St. Jude) in Memphis, USA. Study design and methods have been previously described .St. Jude and UNOP were chosen due to their similar patient volume, size, and recent PEWS implementation , 11. In While similar in organization, the two participating hospitals have different resources. St. Jude employs more than 40 oncologists and 8 intensivists, while UNOP has 9 oncologists and 4 intensivists. The nurse-to-patient ratios in the PICU and inpatient wards are 1:1–1:2 and 1:4–1:6 in UNOP, while they are 1:1 and 1:2, respectively, at St. Jude. The estimated survival rate for children treated in Guatemala, an upper middle-income country, is approximately 65% compared to >80% in the United States, a high-income country. For these reasons, UNOP is considered a resource-limited setting, while St. Jude is considered a high-resource setting.We recruited physicians, advanced practice providers (APP), and nurses at UNOP and St. Jude who were familiar with PEWS and had recently been involved in the care of a patient with a deterioration event . A total of 83 interviews were conducted Table 1 The bilingual research team developed an interview guide to elicit provider perceptions of PEWS and its impact on the care of pediatric oncology patients with recent deterioration events . Similarly, at St. Jude, physicians mentioned how communication aided decision-making and allowed teams to develop plans together: “I called the attending, the fellow … and we were all in there so, we decided to go ahead and do push-pull-bolus on him” .At both hospitals, “teamwork” was a key theme that contributed to positive perceptions of care delivery during deterioration. Participants from all disciplines described how working together helped patient management during these acute events. Ward physicians in both institutions highlighted how their co-workers offered to help when they had critical patients or other urgent tasks: It was in collaboration: the oncologist who was in charge of the service, the intensivist on duty, the intensive care personnel and the infectious diseases specialist all helped and the treatment decision was taken together” .In addition to supporting other providers within their own discipline, participants described how interdisciplinary collaboration improved patient care: “So, I think in my case I’ve always taken measures, if not time appropriate, at least in my shift, transfer if required or if not, it is handled in the service but always with quick response” ; “I think it was an appropriate move to have her have him evaluate it, because especially as a young adult your heart rate and respirations don’t have to be too terrible high for you to rank up to a four, so I think it was okay” .Respondents’ previous experience with critically ill patients impacted their perceptions of clinical deterioration events: respondents with more experience caring for critical children were more likely to describe positive perspectives. This concept was described similarly at both St. Jude and UNOP: “via themes associated with positive perceptions of deterioration by encouraging teamwork and helping identify deterioration for those with less experience.All interviewees spoke positively about the impact of PEWS on the quality of patient care. PEWS were seen to directly improve care delivery through aiding with early clinical assessments, timely interventions, and effective communication between disciplines. Through this, PEWS also indirectly led to improvements in patient care Now we seem to be warding off a lot of that and we’re getting a lot more [activations of the rapid response team] and a lot more catching these kids earlier on in their disease process” . Similar sentiments were seen at UNOP: “We have not taken care of a respiratory arrest on the floor, since all patients have been transferred on time with the use of PEWS” . Having a system that facilitates and justifies the escalation of patient care was a recurrent concept.In both hospitals, PEWS prompted early evaluation, coded as “early awareness.” Respondents from all disciplines described PEWS as an alarm triggering timely evaluation or intervention. At St. Jude, an ICU provider mentioned: ““Also it helps us to go with the doctor and have a backup to tell him that this is happening” . Physicians perceived a benefit to the whole care team: “In a way it empowers staff because many times the staff at the bedside don’t feel like they’re heard” .PEWS was also described as enabling interdisciplinary communication, which in turn fostered teamwork and led to positive perceptions of care. Nurses described how PEWS helped them express their concerns to physicians: As participants reflected on critical patient events, they also described negative perceptions of care delivery, which focused on lack of communication, inexperience, challenges with technology, and limited material resources, while PEWS influenced negative views due to false positive scores and the objective nature of the tool Table 3.“The nurse didn’t communicate to the doctor and the doctor didn’t monitor the patient” . Similar impressions were shared by clinicians at St. Jude: “A patient had a rapid response called and transferred to the ICU, and the primary provider was never notified” .Participants described lacking and ineffective communication during deterioration events leading to negative perceptions of care delivery. In both settings, providers negatively described instances in which physicians were not notified of deteriorating patients. At UNOP a participant stated: “For example, all the ventilation and tachycardia, intensive is in charge of that part; ward nurses were not prepared for [clinical deterioration], it had almost never happened, then we brought the nurses from intensive care” . A physician at St. Jude mentioned that when new healthcare providers start working in their hospital, they have no experience with deterioration in this patient population, so it takes more time to start the appropriate interventions: “Some people would have sent this kid to the ICU immediately, but you have a patient needing high levels of care, with a resident who just got out of first year and has no experience with St. Jude in terms of the unique medical knowledge” .At both institutions, providers with negative perceptions regarding critical deterioration events often cited lack of experience with patient deterioration as a variable that may contribute to negative perspectives. At UNOP, a physician noted that ward nurses are not used to performing critical interventions: “The patient required intensive care and we hadn’t space in the ICU, so we moved him to intermediate care” . At St. Jude, participants did not describe infrastructure limitations. Instead, negative perceptions of deterioration events were linked to challenges caused by technology limitations. For example: “Another major barrier, and this is kind of a barrier with communication with the ICU, is that the nurse practitioners on-call on the on-call schedule, often the only number listed is not a pager that they have, or a cellphone that they have, but an office number, is an issue” .Availability or lack of resources influenced the perception of deterioration events and differed by institution. At UNOP, negative perspectives of events focused on the lack of infrastructure impacting the ability of teams to follow the escalation pathway and provide appropriate critical care to deteriorating patients. Specifically, a participant mentioned: While PEWS contributed to positive perceptions of care delivery, 90% of participants also mentioned negative aspects of PEWS. PEWS were perceived to directly contribute to inadequate care delivery by raising false positive alerts and the objective nature of the scoring tool. PEWS indirectly contributed to inadequate care delivery through limited material resources and challenges with technology.“There’s also a sense of, we get patients who for whatever reason, may have a higher score, but clinically are quite stable” , and “[It] creates alarm fatigue, because, you know, it’s mild tachycardia, but, there’s absolutely nothing, and really there’s nothing wrong with that heart rate and nothing for us to be concerned about at all” . At UNOP, respondents mentioned receiving consults on patients that have a high score but do not need a critical intervention: “…Sometimes the consults that I have had are things that … there are other factors … that could affect certain values of the PEWS and maybe it is not a patient that is unstable and that needs an emergency intervention” . Exclusively at UNOP, false positive alerts led to a perception of excessive use of resources: “It harmed the unit by bringing a girl who did not need to, that was the bad thing and we lost resources” .Some participants felt that the PEWS score did not correlate with the clinical impression of the providers, indicating a false positive score, defined as a high PEWS score triggering a rapid response team activation or ICU consult without true need for care escalation. Although false positives were mentioned at both institutions, perceived outcomes secondary to false positives differed between hospitals, causing a sense of alarm fatigue at St. Jude and overuse of resources at UNOP. At St. Jude, participants stated: “Basically, the computer’s doing everything for you and you don’t use your coworkers to help you out” . An ICU nurse said that it takes away the nurses’ clinical ability to evaluate the patient: “I don’t think they’re looking at the patient, they’re looking at numbers, numbers, numbers” and come up with a clinical judgment “because the scoring system is so objective, I think it takes away a lot of the nurse’s ability to think for themselves” . This theme was not identified within UNOP interviews.The strictly objective nature of the tool, coded as “objective tool,” was viewed negatively at St. Jude, with participants describing PEWS as too automatic: “Before, I remember that we transferred patients almost ventilated to intensive, then it was very late … but now if we can say that in its entirety, it may be that one or the other that escape but almost all patients are transferred early” .A subset of participants  worked at their respective institutions prior to PEWS implementation, providing insight into the impact of PEWS on patient care Table 4.“We did not even handle the vital signs, but we had a nursing assistant who wrote down the signs” . In addition, at UNOP, PEWS encouraged nurses to complete a physical assessment on each patient, which was not consistently done previously: “If you do the [PEWS] you are required to do a total physical examination, maybe before we didn’t do that 100%” .At UNOP, PEWS was described as positively changing patient care and improving safety. Ward nurses stressed that PEWS led them to prioritize vital signs: “They’ve kind of calmed down that judgment towards the nurse which helps they understand this is the [PEWS] score this is why we’re being called, it’s not the dumb nurse doesn’t know this or that” . As a result of these changes, participants felt patient safety improved: “In the 13 years I’ve been here, it’s probably been the most impactful on patient safety” .At St. Jude, ward nurses believed that the implementation of PEWS helped with prioritizing patient care and facilitated activation of emergency response systems. Ultimately, PEWS helped mitigate the nurses’ feelings of criticism for calling a rapid response: A model describing our findings regarding provider perceptions of the quality of care delivered during clinical deterioration and the direct and indirect impact of PEWS is summarized in This study builds on the growing understanding of the importance of PEWS in the care of hospitalized children with cancer in settings of varying resource levels. Our study provides additional insights into how providers perceive the impact of PEWS on the quality of care of deteriorating patients, including how it enhances teamwork and effective communication, builds on clinical experience, and promotes early awareness of clinical deterioration.Despite interviews focused on clinically deteriorating patients, all participants, regardless of discipline or resource setting, mentioned positive characteristics of care delivery in these acute situations. The positive themes concentrated on the perceived efficiency of the team providing care and using PEWS to improve clinical outcomes. Our findings support the idea that PEWS increases interdisciplinary communication by empowering providers and thus improving teamwork, contributing positively to the perception of the quality of care delivered during deterioration events . One of Previous research has shown that PEWS assists with the early identification of deterioration, thereby promoting patient safety and improving outcomes . Our finAt both institutions, barriers to care escalation existed that were beyond the scope of PEWS: technology at St. Jude and limited resources at UNOP. Although one of the benefits of PEWS is optimization of available resources , the lacUnsurprisingly, perceptions of deterioration events were influenced by providers’ degrees of clinical experience. Nonetheless, our study suggests that PEWS helps those with less experience to feel more comfortable as it provides an additional aid for patient management. In addition, the objective nature of PEWS is often described as a strength, as it allows for a standard and objective approach to deteriorating patients. Providers in this study did not always view the objectivity of PEWS as positive, pointing to frequent false positive alerts (high PEWS in patients without true deterioration). Although many aspects of PEWS scores are based on objective criteria such as vital signs, the PEWS used at St. Jude and UNOP contains an additional point for both provider and family concern, adding subjectivity to the scoring. Clinician perceptions regarding the value of objective PEWS criteria in contrast to individual clinical knowledge as the most reliable source of decision-making likely impacts the perceived value of PEWS in these settings. While high scores triggering patient evaluation that does not result in escalation of care are inherently needed for the correct use PEWS, this may result in a perceived overuse of critical care resources, especially in settings where these are more limited. Ultimately, for maximum acceptability and efficacy, objective tools should be paired with provider clinical judgement .This study has several limitations. Despite interviews focusing on patients that required unplanned transfer to the ICU, social desirability bias may have prevented people from fully expounding on the negative elements of these events . This coIn summary, our study shows that providers that care for children with cancer find PEWS valuable for improving quality of care, regardless of hospital resource-level. These findings build on a growing literature supporting the overall positive impact of PEWS on clinical care, thereby encouraging widespread implementation of PEWS in pediatric cancer settings. We also identified shortcomings of PEWS that can be used to improve its use as part of ongoing quality improvement. Further studies, including analysis of the impact of PEWS in other care settings and among different patient populations, will deepen our understanding of the impact of quality improvement interventions and our ability to optimize their use to improve team dynamics and patient outcomes globally.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by St. Jude Children’s Research Hospital and Unidad Nacional de Oncología Pediátrica. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.Conception and design: MG, DG, and AA. Collection and assembly of data: MG, DG, MR, DV, AMA, FA-K, JG, BM, and AA. Data analysis and interpretation: MG, DG, GF, and AA. MG, DG, and AA were responsible for drafting initial manuscript.Accountable for all aspects of the work: All authors. All authors contributed to the article and approved the submitted version.Funded by the American Lebanese Syrian Associated Charities.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.


Love Island (2016–2020) as a case study, this paper explores the extent to which reality dating shows perpetuate sexist attitudes towards women through a heteronormative focus. Examining the operation of gender roles in Love Island, in the context of emotional intimacy and physical intimacy, this paper proposes that the performance and portrayal of heteronormative ideals disadvantage women. Specifically, by presenting female contestants as overly emotional and irrational, outdated stereotypes surrounding emotionality and hysteria are reproduced within Love Island. Moreover, the stigmatization of sex-positive women in Love Island demonstrates the existence of a sexual double standard wherein male contestants are celebrated for their sexual prowess, while female contestants are shamed and deemed unruly, by virtue of their sexual dominance. Fundamentally, this paper contributes to research on contemporary sexualities by demonstrating how, despite the cultural shift towards greater gender equality, traditional gendered ideals continue to exist in heterosexual relationships, which serve to disadvantage women.Using episodes of ITV2’s  In sociological research and popular culture, “masculinity” and “femininity” are conceptualized to be reflexive constructions, adapting alongside social, cultural, and political developments . In recoLove Island as a case study to examine the operation of gender roles in contemporary intimate relationships, conceding that the representation of gender roles in Love Island perpetuate heteronormative ideals that serve to disadvantage women.According to traditional gendered scripts, intimate relationships were divided into masculine and feminine variables, whereby men performed an instrumental and dominant role, while women adopted emotionally expressive qualities . HoweverLove Island were analyzed to uncover patterns and trends in contestants’ attitudes and behavior. The premise of Love Island surrounds observing a group of young, heterosexual singles, referred to as “islanders,” isolated in a luxurious villa for 8 weeks, in the pursuit to find love. Islanders “couple up” with a contestant of the opposite sex during the initial coupling ceremony, and over the duration of the series, couples are put to the test by new arrivals, eliminations and weekly “re-coupling” ceremonies. Finally, the series draws to an end when the public vote for a couple to be chosen as the winners of Love Island, and the winning couple is put to one final test when presented with the decision to either choose the £50,000 prize money or choose love. Attracting criticism across its’ six series’, episodes from series 2 to series 6 of Love Island were selected as the sample, with scenes that caused conflict and controversy chosen for textual analysis. Due to practical limitations, it would not be feasible for all episodes to undergo textual analysis, therefore, following the recommendation for qualitative samples to “be of a size that can be managed in practical terms” , in which it is argued that “the confirmation of a man’s sexuality through a woman is imbricated in his need to be validated as masculine by other men” : 59, malor this” : 73, as Love Island perpetuates a simplistic and dichotomous vision of femininity, wherein one’s femininity is determined by their sexuality. Congruous to this narrative, the “good girl” is positioned against the “bad girl,” and while the “good girl” practices virtues of abstinence and chastity, the “bad girl” embraces her sexuality and occupies a dominant sexual role  like the numbers.Maura: Jesus, Molly!Molly-Mae: Sorry, no disrespect but like cause obviously you’re so like, you know, sensual and you love it so I thought maybe the number would be higher than 5, but kudos to you. I’m proud of you, keep those numbers low.Maura: Yeah, I don’t do one-night stands.(Further, by distancing herself from a narrative of sexual promiscuity when admitting “I wouldn’t just sleep with someone, I’ve never even had a one-night stand” (Love Island perpetuate sexist and heteronormative attitudes which serve to disadvantage women.Upon analysis of the ten selected scenes, it can be argued that representations of gender in Love Island reinforces a negative representation of women, in which women’s emotions are not only exploited to attract viewing figures (Love Island confirms traditional gender norms surrounding women’s emotionality. Moreover, with existing stereotypes surrounding women’s emotional instability, jealousy, and paranoia, men are able to call on women’s emotions and label them “crazy” when gaslighting them (Love Island often deny and trivialize their partners’ suspicions surrounding deception and infidelity by referring to stereotypes that posit women as emotional, paranoid and irrational, despite their doubts being justified. In a similar regard, recognizing that women tend to be more emotionally expressive, male contestants deliberately provoke their female partners to elicit an emotionally charged response. Adam Collard rolling his eyes and smirking during a confrontation with his partner Rosie Williams (Love Island.Specifically, this paper concedes that the use of the “money shot” : 168 in  figures , but to  figures , Love Ising them . As demoWilliams  and MichWilliams , therefoWilliams . Hence, Love Island reinforces gender norms surrounding the male sex drive discourse, in which an expectation remains that men “have stronger sexual urges and a greater need for sex than women” (Love Island, therefore, perpetuates outdated assumptions of femininity, wherein one’s femininity is determined by one’s sexual activity, thus perceiving dominance in sex to be unfeminine and “unladylike” (Love Island draws attention to the existence of a sexual double standard in heterosexual relationships, whereby men are rewarded with masculine status for their sexual accomplishments, while women are shamed and punished.Moreover, n women” : 142. Acn women” , this paadylike” . In thisLove Island, this paper demonstrates the existence of traditional roles in contemporary intimate relationships and explores the extent to which such roles facilitate sexist attitudes towards women. Fundamentally, this paper depicts how, despite a cultural shift towards greater gender equality, traditional gendered ideals continue to exist in heterosexual relationships, which serve to disadvantage women. However, despite Love Island perpetuating outdated and sexist ideals, particularly regarding women’s emotionality and sexual promiscuity, exposure to these attitudes in a public forum allows the Love Island audience to occupy an objective stance, whereby viewers are able to critically assess intimate relationships and recognize problematic themes (Love Island. Hence, while reality television may present problematic behaviors and attitudes towards women, such images provoke a public debate and encourage cultural change.Albeit examining a limited number of scenes from ITV2’s c themes , as indi


Swimming ability among children in the city of Malmö, Sweden is strongly affected by socioeconomic differences. We investigated to what extent mediating health and lifestyle factors, such as children’s eating, sleeping and physical activity habits, as well as the characteristics of the social and working environment at both school and home, could explain the socioeconomic gradient in swimming ability.Our study population included children who started their first-grade school-year in 2012 or 2013 at any of the public primary schools of Malmö, Sweden. Cross-sectional, self-reported questionnaire-based data about health status and swimming ability in the fourth grade (age 10) were included from the Pupil Health Database (ELSA) for 3468 children.Children’s self-reported swimming ability was strongly associated with both individual- and school-based sociodemographic variables. Nine health, lifestyle and environmental variables were identified as potential mediators and included in the final model. Four of these variables, “Activity”, “Outdoor time”, “Social relationships at home and on the free time”, and “Positivity about future”, were significantly and positively associated with children’s ability to swim.Social support, optimism for the future and an active lifestyle were positively associated with children’s swimming skills; however, compared to the socioeconomic factors, these health- and lifestyle factors contributed very little. It is possible, that interventions concerning children’s swimming ability in lower socioeconomic neighbourhoods, should in addition to children’s swimming lessons, target the whole families with the goal of increasing their possibilities for socialising and engaging in different kinds of recreational activities.The online version contains supplementary material available at 10.1186/s12887-021-03094-0. Swimming is a potentially life-saving skill and learning to swim in an early age may reduce the numbers of children drowning , 2. SwimDespite it being part of the school curriculum, large differences in swimming ability in children exist between different Swedish municipalities, with low swimming ability being more common in areas with a high proportion of families with a low socioeconomic status and immigrant background –6. AccorThe process of learning to swim is presumably, like any other kind of learning, strongly affected by personal motivation . Many vaIn the present study, we investigated to what extent certain mediating factors could explain the observed socioeconomic differences in learning how to swim among children. Among these factors were, for example, self-reported eating, sleeping and physical activity habits, as well as the characteristics of the social and working environment at both school and home. We hypothesised that variables that are generally associated with well-being, such as regular eating and sleeping habits, interest in sports and outdoor activities, active social life and general comfort at both school and home, would increase the swimming ability of children in the fourth grade.n = 708) to restrict the sample to those who have had the opportunity to learn swimming in Sweden. An additional 62 children with missing data on their swimming ability, and four children that were attending a school for autistic children were excluded. That left 3468 children as the final study cohort.This study included children who started their first-grade school-year either in August 2012 or in August 2013 at any of the public primary schools of Malmö, Sweden. Cross-sectional, self-reported questionnaire-based data about the health status and swimming ability in the fourth grade (2015/2016) were obtained from the Pupil Health Database (ELSA) with an initial sample size of 4242. We excluded those who were born outside Sweden  into ELSA database. For the present study, self-reported data regarding health and socioeconomic status and swimming ability  were retrieved from the ELSA database for the children in their fourth grade. In addition, we used a school-specific socioeconomic index , which is regularly calculated by Statistics Sweden, and is based on following data for children at each of the schools: sex, years since arrival in Sweden (if immigrated), education of the parents, if the parents are receiving public income support, and family composition.Individual-level sociodemographic variables, including participants’ family composition, parental country of origin and profession, were combined into one “Social Prerequisite Index” (SPI)  was used as binary outcome variable and the interquartile levels of the SPI and SDI calculated among all included children as exposure variables. Background characteristics of the study population and crude associations between variables are shown in Table To identify potential mediator variables among the pooled health and wellbeing scores, we first explored associations between the exposure-variables (SPI and SDI) and each of the 14 pooled score variables and in linear regression analyses Table S.a. TherP < 0.001), thus indicating a better goodness of fit by model B.Background characteristics of the study population are depicted in Table Several factors that potentially mediate swimming ability in children of Malmö were investigated in the present study. The strong influence of socio-demographic characteristics, on both individual and school level, was evident. Among the behavioural- and lifestyle factors, scores for “Activity”, “Outdoor time”, “Social relationships at home and on the free time”, and “Positivity about future” were found to affect the relationship between socioeconomic variables and children’s swimming ability. Including both sociodemographic and health- and wellbeing-related variables, appeared to increase the fit and the percentage of correctly classified estimates in our statistical model, compared to when only sociodemographic variables were included to the model. However, the difference between models was marginal, and striking associations between individual- and school-level sociodemographic condition and swimming ability remained even after the health- and wellbeing-related factors were taken into account.Behavioural theories, such as the Social Cognitive Theory and the Ecological Model, emphasize that health behaviours, including various physical activity skills, are not only determined by physiological and genetic characteristics of an individual, but also by socio-environmental factors, such as knowledge, self-efficacy, motivation, interpersonal relationships and possible barriers  –20. SwimOur score of “Social relationships at home and on the free time”, consisting of responses to three statements  was a possible indicator of children’s perception of their home environment and support network. Feeling secure and having support from one’s family, has been previously reported to be fundamental to any kind of learning processes, as well as a promotor for physical activity –25. ChilThe score of “Activity” was based on the responses to four questionnaire statements: “I am actively participating in physical activity (PA) lessons at school”, “I bike or walk to school”, “I am doing sports and moving a lot in my spare time”, and “I have free time hobbies ”. Since positive responses to all these statements reflect high motivation for physical activity, experience in learning new skills and a generally active lifestyle, it was not surprising to find a significant positive relationship between this score and children’s ability to swim. Similarly, positive responses to the statements included in the “outdoor time score” (“I’m outdoors during the breaks” and “I am often outdoors after school”), are likely to reflect an individual’s habit of regular physical activity and an active lifestyle . Self-efParticipants who selected “future is looking bright” (“Positivity about future”) choice had higher odds of being able to swim 200 m than those who did not agree with the statement. This finding was not surprising since expectations regarding personal abilities and future outcomes are central to the formation of human behaviour and strongly affect motivation to learn new skills , 31, 32.Swimming proficiency may affect several aspects of the human quality of life. Besides being a good all-round way to exercise, swimming is known to alleviate symptoms in children diagnosed with various chronic conditions –37. OutdOne way to increase children’s interest in acquiring swimming skills could be by demonstrating the wider possibilities for activates that build on good swimming skills, also in other school subjects than the physical education . Since the intrinsic motivation (or “fun”), is the most influential factor in children’s desire to learn physical activity skills –12, beinPrevious literature, as well as the present study, has highlighted that in Sweden swimming ability is generally lower among children from families with low socioeconomic status than among children from socioeconomically stronger families , 6, 38. The strengths of the present study were the availability of data on sociodemographic factors both at the individual and the school level and the relatively large sample included. In addition, the participation in the health examinations entered in the Pupil Health Database was high, which limited the risk of selection bias. However, using self-reported data and a cross-sectional study design were significant limitations of our study. Since no documented school grades concerning swimming ability were available, it is possible that some children may have over- or underestimated their swimming skills. However, it is reasonable to assume that the misclassification regarding over- and underestimation of one’s swimming ability was non-differential. There is also a potential for reverse causality since individuals who can swim, maybe generally more active which may result in increased wellbeing and positivity. A prospective cohort study, also including data on attitudes towards swimming as well as engagement and swimming ability among the parents, would elucidate drivers as well as barriers to swimming ability among children further.Socioeconomic factors are strongly associated with children’s swimming ability. Lower socioeconomic status at both individual and school level is associated with lower odds of swimming anility among children. While most of the sociodemographic gradient in swimming ability remained unexplained in our study, social support, optimism for the future and an active lifestyle, however, were associated with sociodemographic conditions and also positively associated with children’s swimming skills. Interventions should thus, in addition to children’s swimming lessons, target the whole families with the goal of increasing their possibilities for socialising and engaging in different kinds of recreational activities especially in lower socioeconomic neighbourhoods. Swimming, as an activity has many positive health effects, both physiological and mental. Learning of these benefits may influence children’s will to acquire swimming skills. Having “fun”  is, however, the most commonly reported intrinsic motivator by children and youth for participating in different kinds of sports and should therefore be in focus when designing the interventions. Our findings can be used to target groups of children both at individual- and school-level with greater needs for support in swimming training.Additional file 1.