Accessed 07 Jun 2021; WHO (2020a) What is Health Promotion. www.who.int/healthpromotion/fact-sheet/en/. Accessed 07 Jun 2021; WHO (2020b) NCD mortality and morbidity. www.who.int/gho/ncd/mortality_morbidity/en/. Accessed 07 Jun 2021). Couple this WHO mandate with current academic research into the processes of ageing, and the ingredients or regimens that have shown benefit and/or promise of such benefits. Now is the time for public health policy to ‘not let the perfect be the enemy of the good,’ but to progressively make health-promoting nutrition recommendations.Globally, there has been a marked increase in longevity, but it is also apparent that significant inequalities remain, especially the inequality related to insufficient ‘health’ to enjoy or at least survive those later years. The major causes include lack of access to proper nutrition and healthcare services, and often the basic information to make the personal decisions related to diet and healthcare options and opportunities. Proper nutrition can be the best predictor of a long healthy life expectancy and, conversely, when inadequate and/or improper a prognosticator of a sharply curtailed expectancy. There is a dichotomy in both developed and developing countries as their populations are experiencing the phenomenon of being ‘over fed and under nourished’, i.e., caloric/energy excess and lack of essential nutrients, leading to health deficiencies, skyrocketing global obesity rates, excess chronic diseases, and premature mortality. There is need for new and/or innovative approaches to promoting health as individuals’ age, and for public health programs to be a proactive blessing and not an archaic status quo ‘eat your vegetables’ mandate. A framework for progress has been proposed and published by the World Health Organization in their Global Strategy and Action Plan on Ageing and Health (WHO (2017) Advancing the right to health: the vital role of law.  As political, social, cultural, technological, and moral factors change and evolve, concepts and terms can be redefined to reflect the current understanding. “Health” is a term that policy-makers have had difficulty agreeing on its definition in the last century. In 1948, the World Health Organization formulated what seemed to be a ground-breaking definition of health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” . In 2011Regardless of how “health” is defined by policy-makers, today’s consumers want to be empowered to manage their own health, and the increased focus on self-care is often exacerbated by current public health challenges, including non-communicable diseases and/or pandemic. Adoption of a healthy lifestyle, including dietary patterns and when appropriate, oral supplementation, is often included as part of the self-care and self-management tools and interventions to optimize health and nutritional status in individuals at different life stages and facing health challenges and goals , 95.As good nutrition is recognized as a key component of healthy development, well-being, and disease prevention, nutrition research from all sectors is in the quest of understanding what we need to eat to be healthy across the life course. With the advancement of scientific research and as new discoveries are made on the roles of essential nutrients and non-essential nutrients, including bioactives, a newer framework may need to be created and applied so that scientific research can be properly translated to help inform policy-makers to address public health concerns.This paper is proceedings from the Council for Responsible Nutrition-International (CRN-I)’s 11th Scientific Symposium. The purpose of orchestrating and moderating these annual symposia is to bring current scientific thoughts espoused by academic, industry and policy experts primarily to an audience made up of delegates to the annual Codex Alimentarius (Codex) Committee on Nutrition and Foods for Special Dietary Uses (CCNFSDU). In 2020, the CRN-I symposia occurred as a series of virtual webinars. Previous symposia have focused on optimal nutrition , healthy“Revolutions” are events that have a major impact on all sectors of society. “Population Ageing” is a demographic revolution, caused by two main factors: (1) an increase in life expectancy and (2) a decline in fertility rates, and it is now occurring at an unprecedently short period of time. To give an idea of the speed of population aging, the life expectancy at birth in the early 1950s in Brazil was approximately 50 years. Today it is 77 years, a gain of more than 25 years in seven decades of time . UnfortuUntil the 1990s, the preponderant view was that ‘Population Ageing’ was strictly a ‘developed world’ issue, with few voices pointing out that it would soon hit the developing world and fast (Table In 1982 the United Nations organized the 1st World Assembly on Ageing (WAA) in Vienna, Austria . The resCritical for such change in perception was the pivotal work of the World Health Organization (WHO), through a series of meetings of experts that culminated with the launching of the Active Ageing Policy Framework, which has had a lasting impact on policy development on ageing worldwide , 125. WHThe Madrid International Plan of Action on Ageing was focused on three pillars, (1) Older people and development, (2) Advancing health and well-being into old age and (3) Ensuring enabling and supportive environments. Since its launching, the UN Sustainable Goals were adopted and, for the first time ever, ageing was incorporated into the specific Sustainable Development Goals (SDGs) such as Good Health and Well-Being, Gender Equality, No Poverty, Zero Hunger, Reduced Inequalities, etc. Capturing the spirit of the SDGs, the WHO has launched, at the beginning of 2020, with the support of the UN and its specialized agencies, the Healthy Ageing Decade. It encompasses four major areas: (1) Changing how we think, feel and act towards ageing, (2) Strengthening primary health care to be responsive to older people, (3) Create age-friendly cities and communities and, (4) Provide older people who need it access to long term care.The second major SDG is termed “Zero Hunger”…but it encompasses not only an end to hunger, but just as importantly, achieving food security, promoting sustainable agriculture and improving nutrition. The aged population in both developed and developing countries are very vulnerable to food insecurity. Not only do nutritional needs change as we grow older, but in times of scarcity younger people are often prioritized by families and aid programs. The WHO conclusion is that global nutrition can be achieved by: “(1) making improvements in the nutrient density of food, particularly vitamins and minerals; (2) maintaining intakes of energy and proteins; and (3) recognizing and supporting older people who are poor, isolated and lonely to access healthy meals” .Specific nutrients and bioactives with the ability to improve not only the nutrition of the aged population, but also at any age include, protein and amino acids, omega-3 fatty acids, and Vitamin D.A reduction in lean body mass and an increase in fat mass is one of the most striking and consistent changes associated with advancing age. Skeletal muscle  and boneA meta-analysis  of longiIndeed, this lack of a strong association between lean mass (as a surrogate measurement of muscle mass) and outcomes in elderly people has led to several consensus definitions of sarcopenia that include measures of muscle strength and/or physical performance in addition to measures of lean mass alone . A proje3-creatine (D3Cr) dilution method uses the assumptions that about 98% of the total body creatine pool is sequestered in skeletal muscle and that creatine is turned over in muscle through the conversion of creatine (Cr) to creatinine (Crn). The additional assumption of this method is that an oral dose of a tracer quantity of deuterated creatine (D3Cr) is 100% bioavailable and once absorbed is transported across the sarcolemma and sequestered in sarcomeres. The excretion of Crn and measurement of D3-enrichment in urine Crn provides an opportunity to “sample” the intra-myocellular enrichment of D3Cr and, thus determine the dilution of the oral label in the whole-body creatine pool in skeletal muscle. Importantly, the measurement does not require dietary control and relies on a single spot, fasted urine sample taken 48–96 h after dosing. The enrichment of urine D3Crn reaches isotopic steady-state at about 48 h after dosing and remains stable for about 48 h  radiation at 290–315 nm) . It is n2) and cholecalciferol (vitamin D3). Ergocalciferol is derived by UVB irradiation of ergosterol, which is found in fungi and plants. Cholecalciferol is formed from the effect of UVB irradiation on the skin as discussed above. The action of sunlight on the skin converts 7-dehydrocholesterol to previtamin D, which is metabolized to vitamin D by a temperature-dependent isomerization. Vitamin D is then transported via the general circulation to the liver, where the enzyme 25-hydroxylase converts it to 25 hydroxy-vitamin D (25 OHD). The kidney is the site for further conversion to the active metabolite known as 1,25-dihydroxyvitamin D 2D3.)  for eicosapentaenoic acid  and docosahexaenoic acid  that was recently published in detail elsewhere . Herein,EPA and DHA can be synthesized from a variety of dietary precursors with alpha-linolenic acid  being the most important from a nutritional perspective . While tAn approach for bioactives with potential health benefits when consumed in the diet, but that are not nutritionally essential, has been proposed , 70, 92.To establish a DRI for EPA and DHA, it will be critical to establish their causality in terms of disease reduction. While a valid surrogate could be considered as a biomarker of disease risk, given the potential pluripotent effects of EPA and DHA it is unclear what this surrogate could be. While the roles of EPA and DHA in neurodevelopment, inflammation and cognitive decline were considered, the effects on cardiovascular disease and premature births are of note. From the perspective of nutrition, there exists a relatively large literature examining randomized controlled trials RCTs) of EPA and DHA supplementation on cardiovascular disease endpoints. Several recent meta-analyses of RCTs have suggested there is a reduction in CVD risk upon EPA and DHA supplementation and importantly one recent meta-analysis demonstrated a dose response , 54. NevSince, the last IOM report setting an AI for ALA, knowledge about the relationship between EPA and DHA intake and disease risk has advanced along with improvements in biomarkers of intake , 89 and It is no surprise that the global population has and is increasing, now nearing 8 billion humans. Though the curve continues its upward path, there are projections that show by mid 21st Century, the global population will reach a peak and the transition will be to an older world, with the substantive increased proportion of older people, especially the 80 + subgroup, which is the fastest growing from 14 million in 1950 to 384 million now, and counting. For the most part, we are all living longer than our forebears…with many population subsets living 30–35 years longer than at the turn of the 20th Century. Unfortunately, as life expectancies have increased, a term referred to as the ‘Longevity Revolution’, there has not been a parallel increase in the ‘healthy life expectancy’  , 132. Asjoie de vivre during whatever life expectancy we are able to achieve.One significant macronutrient category that is critical, though often overlooked as the person or population ages, is stressing the need for adequate protein and amino acid intake. Without sufficient protein intake, lean body mass decreases, as evidenced by decrements in muscle and bone mass. The term, ‘sarcopenia’, refers to this age-related phenomenon, and often is accompanied by a parallel increase in body fat mass, such that to the casual observer, weight and body morphology appear to be in stasis. Frailty is the logical consequence of the loss in musculature and the increase in bone fracture. Data demonstrate that there is an annual 3.6% reduction in muscle mass accompanied by a consequential lowing of habitual gait speed and decreased grip strength in men aged 83.4 ± 3.9 years. Addressing this issue, with appropriate nutritional strategies is important to allow a healthy life expectancy that can be a source of The bioactive constituents, omega-3 fatty acids can be obtained from the diet, but only if the consumer understands the sources and concentrations needed to achieve as robust a benefit as possible. Omega-3 fatty acids, primarily docosahexaenoic acid (DHA) are added to fortified foods, especially infant formulas, as studies demonstrated that without maternal milk DHA, the non-breast-fed infants had very little DHA in their frontal cortex, with plausible decrements to visual acuity and cognitive function. Subsequent randomized control trials have demonstrated benefits to DHA fortification and supplementation on not only cognitive function, but also term birth weights, body lean and fat mass ratios, blood pressure and body weight.The pro-hormone, vitamin D has a plethora of physiological activities, however, its role in immunity is of utmost interest, not only every day, but maybe more so during a global pandemic. WHO notes that there is a high prevalence of low vitamin D status globally, and in the US, the Dietary Guidelines for Americans (DGA) for 2015–2020 indicates that people in the U.S. do not consume enough dietary fiber, vitamin D, calcium, and potassium. These under consumed nutrients, are considered nutrients of public health concern because low intakes are associated with poor health outcome(s) . One of As presented in this paper, inflammation and its sequelae are thought to play a decisive role in the onset and development of many degenerative diseases, such as atherosclerosis, cardiovascular disease, cancer, and neurodegeneration. Chronic low-grade inflammation, also termed ‘inflammaging’ is insidious and leads to cellular changes that become manifest in many of these diseases, often in old age, hence their effect on the quality and quantity of one’s healthy life expectancy. There is possibly a bidirectional interchange between oxidative stress and inflammation, such that proven antioxidant and (poly)phenolic nutrients may play a role in lessening inflammation and inflammaging.The end goal for this paper and the examples presented, is to establish or at least propose for regulatory consideration, public health goals to alleviate or at least ameliorate the scourges of debilitating health as one approaches the limit of our specie’s lifespan. The recommended beneficial regimens, including increased protein and amino acids, omega-3 fatty acids, Vitamin D at doses above the RDA, and (poly)phenols/antioxidants, needs more research. Astute consumers could evaluate the personal advantages to adopting one or more of these academic recommendations, and the data would suggest a longer life in good health for that individual, though one would never know how many years of benefit were objectively added. On a population basis, true improvement could be quantitated if sufficient individuals were to truly adopt one or more of these proposals, but without governmental public health recommendations or ingraining these counsels into dietary guidelines, school lunch programs, social service feeding plans, etc., that population ‘clinical trial’ will not commence.Life should not be a journey to the grave with the intention of arriving safely in a pretty and well preserved body, but rather to skid in broadside in a cloud of smoke, thoroughly used up, totally worn out, and loudly proclaiming ‘Wow! What a Ride!’” [Society’s response to population aging will require a vision to harness the years spent in ‘good health’  to those hoped for extra years of life. In essence not only more years to life but also more life to years. A fundamental transformation in public policies and institutions is required to ensure a future that celebrates diversity yet narrows health inequities, within and across countries. “ Ride!’” .


In our review paper [We thank Bracke and colleagues  for theise”, and  “…since ew paper , derivedew paper . In the −² melanopic irradiance) that we derived from our melanopic-illuminance curve is similar to that by Phillips et al. (2019) after two hours of light exposure following dim-light melatonin onset . However, as we stressed in our original article, it is delicate to compare datasets collected using different protocols. It should be clear to the readers that the results displayed in Figures 4 and 5 of our review article have been obtained within specific laboratory settings, and that the associated conclusions are specifically, although not always exclusively, applicable to the experimental conditions under which data were collected. In their commentary, Bracke and colleagues  compare For the same reasons, it is fundamental to keep in mind that mathematical models, as the one we proposed in Figure 5 of our review ,3 to expAdditional potential sources of variability that should also be taken into account before translating mathematical models into applications in real-life conditions include: age ,27, chroper se .Bracke and colleagues  are of ta much higher melanopic irradiance will be required for the same monochromatic response” in conditions of freely-moving pupils. This is a valid point as indeed a free pupil constricts in response to light exposure [−² melanopic irradiance with dilated pupils  [−² melanopic irradiance with freely-moving pupils. In other words, a ~4-fold higher melanopic irradiance is required in freely-moving pupil conditions, as compared to dilated conditions to elicit the same half-maximal response (melatonin suppression). This result is close to the proposal by Bracke and colleagues [Bracke and colleagues raise an important point about the influence of the pupil diameter on melatonin suppression . They arexposure , and theexposure . To addrexposure  from datexposure  with theexposure . We find, 2019c) , and at Altogether, we share the concerns by Bracke and colleagues  that fun


We read with interest the article by Ramos-Rincon and colleagues about patients with COVID-19 dying in acute medical wards in a Spanish University hospital ,3. The Idepth; it can mean any level of sedation until death, including, more narrowly, continuous deep sedation (CDS).“Palliative sedation” thus implies an intentional switch to using sedative medication to reduce a person’s level of consciousness, rather than for incremental symptom management. In practice, this will sometimes mean only light sedation (drowsy but responding to voice), and at other times, continuous deep sedation . Therefore, without qualification, “palliative sedation” does not imply any particular However, in the Materials and Methods section, the authors unambiguously define “palliative sedation” solely as CDS. Thus, it appears that the article is not about the whole of “palliative sedation”, but specifically CDS. This narrower focus does not sit well with the statements in the Introduction that the WHO definition of palliative care implies that palliative care necessarily entails palliative sedation, and that “the use of palliative sedation is an indicator of the quality of end-of-life care”.These two statements are debatable in general, specifically with regard to CDS. The second is particularly surprising because it is supported by reference to an article which nowhere mentions palliative sedation, but rather discusses the use of midazolam and morphine for symptom management in patients in an Australian tertiary care hospital dying from COVID-19 . It is aThe study’s inclusion of patients whose death was not directly related to COVID-19 and who died from other conditions  is a potential confounding factor. Further, the drugs and doses presented in Table 2 look very similar to those used in routine symptom management. The drugs listed in the sedative infusions include hyoscine butylbromide—used to reduce “death rattle” but totally non-sedative—so we wonder whether the authors are just reporting the incidence of the use of morphine and other drugs in these patients. Information on the doses these patients were receiving before moving to “palliative sedation” would help in deciding whether any increase in an infusion could, perhaps, be considered as the next step in symptom management or a deliberate shift to an intentional suppression of consciousness.The most common symptoms treated by CDS in this study were dyspnea at rest, pain and agitation/delirium. The median doses of morphine and midazolam used were 40 mg and 15 mg, respectively . For the same three common reasons in the Australian study , the median final 24 h doses of morphine and midazolam were 45mg and 12.5 mg, respectively . These dnot palliative sedation or deliberate CDS, but is largely secondary, i.e., the co-incidental result of enhanced symptom management. Precision is therefore essential when discussing the use of sedatives at the end of life, particularly when using the term “palliative sedation”.The median duration for “palliative sedation” of about 22 h (IQR 10–41) reported in this study suggests that many of the patients included were very close to death. For most people, a reducing level of consciousness leading to coma is part of the natural dying process: progressive organ failure results in the accumulation of toxic metabolites, which leads to depression of both the cerebral cortex and brainstem. Sedatives will tend to accelerate and potentiate both a reduction in level of consciousness and cardiorespiratory failure. The relative contributions of sedative medication and of natural dying to the depth of reduced consciousness are difficult to determine. However, we suggest that in most people, reduced consciousness at the end of life is probably


The global importance of English and therefore the teaching of the English language has made the English language curriculum an integral part of all levels of teacher education, including early childhood education. The purpose of this study was to first explore the beliefs about the teaching of English to very young learners held by pre-service pre-primary teachers in Macau and then to see whether these beliefs were reflected in their microteaching. Qualitative content analysis performed on the written reflections and transcriptions of the microteaching videos of 75 pre-service pre-primary teachers found that their beliefs about classroom practices, lesson planning, and English as a foreign language (EFL) learners and learning were the most predominant beliefs exhibited in their reflections and were evidenced in their microteaching. Less predominant, but still salient, were their beliefs about the goals of language learning, assessment, teaching, pedagogical knowledge, and content. No observable practices were found regarding the pre-service teachers’ beliefs about the role of teaching, learning to teach, microteaching, the self, the subject, hearsay, self-assessment, and schooling. The current study found that with only limited exposure to EFL teaching methodology from a single course, the pre-service pre-primary teachers were able to implement some of their beliefs about several important aspects of teaching English to very young learners. TeacherWhile a range of factors have been explored as potential catalysts for change in teacher beliefs, teacher education, which provides both theoretical and practical training, has been one of the most investigated areas . Still,In the last forty years, studies about teacher beliefs have made a significant contribution to our understanding of teachers and teaching . In geneTeacher beliefs vary by teaching context and the stage in a teacher’s teaching career ,33. WhenEarly childhood educators must master teaching techniques  that reqSuch beliefs can be encouraged or influenced by teacher education. Previous studies found an increase in the novice teachers’ efficacy beliefs after receiving teacher training ,44,45; aPre-service teachers’ classroom teaching can be affected by factors originating within or adjacent to teacher education programs ,48,49. FNumerous studies have investigated the relationship between teacher beliefs and practices ,53,54,55Educators have attempted to bridge the divide between beliefs and practice by incorporating practical teaching components into their education courses ,53. As oThe purpose of the current study was to explore the beliefs of pre-service pre-primary English teachers in the Macau Special Administrative Region of China and to examine whether these beliefs influenced their pedagogical practices inside the classroom during microteaching activities with their peers. The purpose of this study was accomplished by conducting a case study; this allowed the authors to observe the pre-service teachers’ beliefs through the pedagogical decisions they made during peer microteaching. As cases are bounded by time and activity , the autSeventy-five third-year pre-service pre-primary education majors enrolled in an English language learning in early childhood course were recruited as participants in the study. They were all female and between the ages of 20 and 21. The 16-week 3-credit course aimed to prepare students to teach English to pre-primary pupils who learn English as a second or foreign language, emphasizing the practice of various language activities. In addition, students learned to design, adopt, and adapt different teaching materials and teaching aids to plan English lessons for pre-primary pupils. At the end of the course, the education students should have gained an understanding of various language teaching approaches and their underlying theories. Although less emphasized, the course also trained students in classroom English, lesson planning, and teaching pronunciation. Course content was delivered through lecturing, and students were required to complete weekly readings, engage in peer microteaching, reflect on their beliefs about teaching English to pre-primary level learners in Macau, provide oral feedback to their peers about their microteaching, and take a final exam.The majority of class sessions were devoted to the discussion  of assigned readings, microteaching, and providing peer and teacher feedback on the microteaching. To aid in the successful integration of theory and teaching approaches into discussions and lesson planning, some class sessions were also reserved for teacher-led lecturing. Presentation slides accompanied the lectures. The assigned readings and lecturing were intended to enhance the understanding of theory, teaching approaches, and related concepts. Students were required to be active listeners during lectures and active readers when reading the assigned readings; they were asked to take notes during the lectures and on the reading materials covered. Prior to microteaching, the pre-service teachers wrote very short lesson plans that included sections on the target students, rationale, goal(s), learning objective(s), materials, assessment, and procedures. After engaging in microteaching, the pre-service teachers received written feedback from their teacher educator, and they were encouraged to provide oral feedback to their peers. The teacher educator required the pre-service teachers to offer oral feedback to their peers on both areas for improvement and areas that were handled well. These learning activities were aimed at developing the pre-service teachers’ teaching philosophies for teaching pre-primary pupils EFL in the Macau SAR. The required course readings were taken from eight sources (mostly teacher education textbooks) that focused on the teaching of English to young learners. The topics covered included: children learning a foreign language, children learning language through tasks and activities, children learning spoken language and pronunciation, children learning words, children learning through stories, classroom English and classroom management for teaching children; creating, adapting, and evaluating activities for young language learners; syllabus and lesson planning for young learners, and young learner assessment.Mwords = 463, SDwords = 230). These handwritten reflections were digitized prior to data analysis. The second data collection occurred at weeks 10 and 11 when the participants engaged in 5–10 min in-class peer microteaching activities . The microteaching was video recorded, and these 75 recordings were then transcribed verbatim. The transcription resulted in 57,107 running words .Data was collected from the participants twice during the 16-week course. The first data collection occurred at week 9 when the participants were asked to individually write a reflection on their beliefs about the teaching of English to kindergarten students in the Macau SAR. The participants were allowed to write their reflections in English or Cantonese (their native language); however, all of the participants wrote in English. The 75 written reflections totaled 34,692 running words  procedures outlined by Schreier  were useAfter the participants’ written reflections and microteaching transcripts had been coded see , the twoFour strategies were used to enhance the reliability of the results of this case study. First, prior to coding, an external expert  was invited to assess the validity of the coding frame . The expAnalysis of the written reflections revealed 16 themes related to the pre-service pre-primary teachers’ beliefs about teaching EFL to very young learners. Eight of these beliefs were found to be reflected in the teachers’ microteaching with varying degrees. The proportion of the participants that held these eight beliefs  and practiced these beliefs in their microteaching ranged from 20% to 96.43%. These beliefs included beliefs about (1) classroom practices, (2) lesson planning, (3) EFL learners and learning, (4) the goals of language teaching, (5) assessment, (6) teaching, (7) pedagogical knowledge, and (8) content. None of the participants implemented all these beliefs in their microteaching. The remaining eight beliefs were not reflected in the teachers’ microteaching. These consisted of beliefs about (1) the role of teaching, (2) learning to teach, (3) microteaching, (4) the self, (5) the subject, (6) hearsay, (7) self-evaluation, and (8) schooling. The most salient beliefs practiced by the participants were their beliefs about classroom practices. Classroom practices were defined by Li and Oliverira [Stories and games can] attract students to study the language. Both can make students feel interest[ed] and [become] willing to join in. We can change the content of game[s] and use them in other lesson[s]…Stories can develop children’s formal language use, including vocabulary, phrases, grammar, listening, and oral skills...[while] games [can be used to] focus on phrases or single words.During the microteaching, Participant 4 used a Winnie the Pooh game that incorporated singing to teach weather vocabulary.Participant 4:…Now I want to play a game with you. This game [is] call[ed]—weather reporter. Winnie the Pooh and his friend want to go outside, but they don’t know how’s the weather. And [can] anyone help them?Student A: Yes.Participant 4: Ok. [Does] anyone want to help them? Yes. You pick a doll [from] this bag. Ok, find his house. [Participant 4 points to a poster with different characters and their homes with different weather. The student must match the doll pulled from the bag to the picture and then tell the weather.] How’s the weather?Student A: Windy.Participant 4: Ok, let me sing [it] again. How’s [the] weather?Student A: Windy. It’s windy today.Participant 4: Wow, you did a great job. Please go back to your seat. And then, who?Students: Me!Participant 4: Ok! One, two, three, go! Lucy! Wow, Jessica! Go find his house! Sing the song! How’s the weather?Student B: Sunny!Participant 4: How’s the weather?Students: Sunny!Harris and Hodges  defined Participant 62: Good morning, everybody.Students: Good morning.[Participant 62 shows a picture of a girl waking up.] First, could you come [to] the front please? Can you do [the action] with me together? [The student and Participant 62 stretch as if they had just woken up.]Participant 62: OK. Before we start today, I want to talk to you about what we going to do. Today we are talking about things that we do in the morning. OK? After we wake up in the morning, OK?... OK. So, this is wake up. Thirty-six of the participants mentioned their beliefs about EFL learners and EFL learning in their written reflections. They wrote about their future target students by describing their ages, mother tongue, and expected English proficiency. They also explained how the age of the learners required creative approaches for teaching language including designing lessons that were child-centered and activity-oriented. For example, Participant 9 believed that young learners in Macau should be taught English using the English language as long as a teacher offers proper scaffolding:[Young learners] can be taught English as a second language using English. We know that like ESL [English as a second language] learners, EFL learners in Macau will have many chances to speak or listen [to] English outside the class, such as watching TV [or when] shopping. So, they will notice and want to learn that language. As for the[ir] teacher[s], we need to [provide learners] exposure to English through games and tasks. Teachers can be guides-ensuring students reach their potential by develop[ing] their ZPD [zone of proximal development] through the use of scaffolding.During the microteaching, Participant 9 considered the target students’ contextual background and their current ZPD. During the microteaching, she mentioned that the students already knew the order and names of the 26 letters. Below is an excerpt from the microteaching where she builds on this previous knowledge mentioned in her lesson plan to have students increase their listening fluency in order to understand the names and sounds of the letters through involvement in game play.Participant 9: Yes. Today I want to play a game with you. I will start [some] music [and]…when I start the music, you need to follow me [to] walk around the classroom. Can you see all over the classroom there are some letters?Students: Yes.Participant 9:…listen to my instruction, and I will say “Can you see a letter B?” and then you need to quickly find the letter before the music stops. Understand?Students: Yes.Participant 9: Really?Student A: Should…should I bring the letter back?Participant 9: Yes, bring it to me and show the letter to me. Ok? So, are you ready?Students: Yes.The beliefs about the goals of language teaching refer to the beliefs about the “creat[ion of] skillful L2 users with all their extra attributes, not shadows of native speakers” .Participant 72: Today we are going to play a game–a very fun game. After playing this game, I believe that most of you will remember all the names of the fruits. Ok? And here are five flash cards in my hand. And all of you should have a flash card. So, I will just hand them out. Dara, Ruth, Suzie, and Tricia. So, hey, just look at me. What am I holding in my hand?Students: Apple.Participant 72: Yes, very good. It’s [an] apple. So, I am holding an apple in my hand. I am going to say this: “apple down, apple down, apple down, then orange down”. So, the student who is holding an orange needs to follow me and do what I did. You can say any…[of] the five fruits, ok? You can also say banana, or you can say lemon, or you can say pear. So, can you guys do it?Students: Yes.Teachers’ beliefs about assessment regard beliefs about “the act or process of gathering data in order to better understand the strengths and weaknesses of student learning, as by observation, testing, interviews and other techniques” .The two participants that wrote about their assessment beliefs felt that there were two types of assessments. The first type of assessment occurred right after teaching and was used by a teacher to assess learning of “just taught material”. Another type of assessment was used to assess whether what students had previously learned had been retained; this type of assessment should be provided at a later date. They referred to these as “immediate assessment” and “delayed assessment,” and those assessments could be given as games the young learners would play. More specifically, Participant 54 wrote about how assessments need to be administered in a clear way, or learners may be confused:The number of assessments can [be many]…but the assessment in [a] game may not [be] efficient or effective [if] I [do] not provide a clear instruction of the game rules. The kids may misunderstand the rules.During the microteaching she used direct questioning that required students to verbally provide answers. This was a form of what was referred to as “delayed assessment,” as she was confirming their knowledge of previously taught color words.[Participant 54 shows a card with a color square.]Participant 54:…Who can tell me the colors that we learned last time? What is this? Student A: This is red.Participant 54: OK. What color is it?Student B: It is orange.Participant 54: And then what color is it?Student C: It is yellow.Participant 54: Yes. And the last one, what color is it?Student D: It is green.Participant 54: Great!“Beliefs about teaching…referred to the preferred ways of teaching by teachers” .Preparation include[s] pre-teaching of language items and vocabulary. [These] prepare the learners to be able to complete a core activity successfully.When teaching left, right, forward, and backward, Participant 67 first pre-taught these four words using pictures and her body movements before asking the learners to perform the same body movements when she sang a song that included the targeted words.[Participant 67 performs the action]: step one, step two, and clap your hands twice. Ok, listen, pay attention. [She sings the song.] “The teacher says move forward, the teacher says move right, the teacher says move backward, the teacher says move left”. Very good.Participant 67:…Ok, I will sing a song. When I sing the word forward, you should do the forward action like this Other participants mentioned that effective teaching included activities that gradually increased in difficulty, or that teaching incorporating the native language (Cantonese) should be used to reduce difficulty. For example, Participant 4 believed that Cantonese should be used before using English when teaching. She considered that teaching in this way could “create a positive environment for learners” by “scaffolding the kids when they cannot understand well”. During the microteaching lesson about “a rainy day,” she moved between the two languages. She also used Cantonese to first introduce the language content she was going to teach in English before switching back to English to teach that language content.Participant 4: Can anyone tell me what is your feeling on [a] rainy day?Student A: Water.Teacher: Yes. On [a] rainy you may get wet! 它會令到我們濕了。然後呢，我們需要帶什麼？雨傘！然後呢，要穿雨衣。還有，雨鞋。 [It makes us wet. And then? What do we need to bring? Umbrella! And then? We need to wear raincoats. What else? Rain boots.] Please read after me. Rainy.Students: Rainy.Participant 4: Rainy.Students: Rainy.Participants’ beliefs about pedagogical knowledge refer to those beliefs about “being a teacher, involving methods and techniques of teaching predicated on two conceptions of pedagogy: the liberal, emphasizing the autonomy of the child; and the conservative, emphasizing the authority of the teacher” A teaching method [using] a lot of physical movements and experiences to assess teaching and learning...Young learners listen and do actions and follow instructions. While they feel energetic [they also feel] relaxed…they are learning and absorbing language.Two participants held beliefs about content and were found to demonstrate these beliefs in their microteaching. Beliefs about content refers to “[k]nowledge of the subject and its organizing structures” . Participant 70: OK now we are going to learn new phrases today. 我們今天要學習一個新的詞組叫  body. Repeat. Body.Students: Body.Participant 70: Again.Student A: Body.Participant 70: What does it mean?Student B: 全身 [body].Participant 70: 對表示我們的全身。 Body, OK? Body.Students: Body.Teacher: Good. And now we are going to do an exercise. I will ask you some questions and then you answer me. When I say body, everyone does this action, OK? Defined by Keiler  as “whatA teacher is a guide [and] a planner...[Teachers as guides] lead children through different activities by giv[ing] them instructions. For example, when introducing a new game, the teacher can scaffold the learners to understand the directions. [A teacher can be a] planner [when] the teacher design[s] or picks suitable activities at [the] right difficulty level, [for the] right social context, [containing the] right values and [that helps] achieve the goal. Beliefs about learning to teach are teachers’ beliefs regarding “[k]nowing how to learn from classroom teaching experiences. It means planning these experiences in a way that affords learning and then reflecting on the outcomes in order to maximize the benefits that can be gained from the experiences” I [was] a[n] English tutor for 3–5-year-old kids whose first language is Cantonese. At that time, I tried many methods to teach vocabulary in English, but I found it [was] hard for them; then I realized I shouldn’t force them to learn language so quick[ly]. Then, I tr[ied] to motivate them and found many jokes and even magic [tricks] to make them interest[ed in the lessons]. Then they start[ed] to have passion [and] focused on my teaching. That’s when I noticed what I should do is to first motivate kids, and then be their guide [who can] lead them to learn English step by little step.Teachers’ beliefs about microteaching refer to how teachers feel about the “technique in teacher education that uses short, specific episodes of teaching, usually videotaped, for analysis and instruction” Microteaching [provides] a good practice for us to try [things] and share ideas about planning activities for kindergarten [students]. It enables us to learn from one another and inspires some new thoughts.Beliefs about self refer to the participants’ beliefs about themselves, emphasizing that “…teacher self-efficacy and teacher emotions can be important ways for us language teachers to enhance our overall quality” Beliefs about hearsay are the participants’ beliefs regarding “[w]hat is done or written, as well as…what is spoken” without evidence-based support Beliefs about self-evaluation are teachers’ beliefs regarding “judging the quality of their work, based on evidence and explicit criteria, for the purpose of doing better work in the future” . When I think about my microteaching, I [get] very nervous. My chosen theme is birthday…but I think I can’t show the theme very clear[ly]…I think that I can do a good job [and] not [be] too fast or slow. And I [have] done a good job in teaching the birthday song in the past…In terms of teaching aids, birthday scenes, birthday cakes, and candles can be used…[and] I can arrange the classroom like [a] birthday party so that children can feel the birthday atmosphere [is] more realistic... I can think of more ways to interact with students, giv[ing] students more opportunities to speak and act, [and I can] try to avoid speaking too much…The tone of my speech should be lively and [I should] try to speak as smoothly as possible.Beliefs about schooling refer to the participants’ beliefs regarding “their own student experiences…[that] guide their interaction with and evaluation of ideas presented in course- and field-based experiences, causing them to accept, modify, or discount those ideas” The findings showed 16 different beliefs about various aspects of teaching English to very young learners held by the pre-service pre-primary teachers after participating in an English teaching methodology course in a bachelor of pre-primary education program. Eight of the beliefs were reflected in their classroom microteaching in varying degrees, while the remaining eight beliefs were not implemented in their practices. These differences can be explained in relation to the course content and activities, the student teachers’ background, and the sociocultural factors that may influence the teachers’ beliefs and practices.Most notably, beliefs about (1) classroom practices, (2) lesson planning, and (3) EFL learners and learning were the most predominant among the participants. Also, these beliefs were reflected quite well in the teachers’ classroom microteaching 83–96%). This could be due to the prevalence of these aspects in the course. Specifically, the pre-service teachers spent a large amount of time learning how to deal with classroom practices such as setting up learning tasks, giving instructions, and classroom management. They also completed a significant amount of practice designing lesson plans for microteaching. While discussing and repeating these two aspects of classroom practice, the student teachers were told to keep in mind the characteristics and socio-cultural backgrounds of their target learners, as well as their learning goal. This might have led to the development of teachers’ beliefs about EFL learners and learning. It should be noted that, within the bachelor of pre-primary education program taken under study, this course was the only one that specifically focused on the methodology of teaching EFL. Therefore, it is not surprising to observe that these three beliefs were held by the majority of the participants and were largely implemented in their practice. It should be mentioned that the course was successful in developing the pre-service teachers’ beliefs and practices regarding these most important aspects of EFL teaching methodology. These findings support Reynolds et al.’s  study wi–96%. ThiWhat is more notable about these findings is the pre-service teachers’ beliefs observable in their microteaching. Previous studies in teacher education research looked mainly at the development of teachers’ beliefs. The current study showed that the teachers could implement some of their beliefs about important aspects of English language teaching to very young learners in their microteaching. Specifically, the development of beliefs about classroom practices, as well as beliefs about EFL learners and learning, are particularly important for the participants in the current study. As opposed to previous studies regarding EFL pre-service teachers’ beliefs about teaching practices where the teachers were exposed to various courses of EFL-related subjects and EFL teaching, the participants in the current study were only exposed to EFL teaching methodology in this course because their bachelor program focused on early childhood education and not language education. Therefore, these beliefs and practices would be very significant for them, helping them prepare for the subsequent practicum experience and for real teaching in the workplace.The second set of beliefs that were relatively evident in the pre-service teachers’ practices included beliefs about (1) the goals of language learning, (2) assessment, 3) teaching, (4) pedagogical knowledge, and (5) content (from 20% to 55% match observed in microteaching). These mismatches seem to be natural because not all beliefs could be reflected in the classroom practices due to the complex nature of the teaching. Similar findings were also reported in the literature in that teachers’ beliefs and practices are not always congruent ,53,56,84 teachingRegarding the remaining reported beliefs, there were no observable practices related to any of these beliefs. These included beliefs about (1) the role of teaching, (2) learning to teach, (3) microteaching, (4) the self, (5) the subject, (6) hearsay, (7) self-assessment, and (8) schooling. This result appears to be surprising. However, this may be due to the fact that the microteaching lasted from only five to ten minutes, which did not allow the practice of these activities to occur. Secondly, some of these beliefs may not be easily shown in practice, even when the teachers were observed for a more extended period of time. For example, beliefs about schooling  may only be revealed in practice in the end-of-term teaching sessions where the teachers spend more time giving students feedback concerning a period of study. It should be noted that the absence in the microteaching of aspects related to these beliefs does not mean that the teachers or the course failed. The development of the teachers’ cognitive aspects, such as teachers’ beliefs, knowledge, and understanding, were particularly important because such development could help pre-service teachers reflect on their on-going teacher learning process during the course study, the practicum, and the initial period of formal teaching. Such processes would help teachers to become reflective practitioners  and subsThis study has several limitations that need to be mentioned as a caveat to readers as they interpret the findings. Firstly, the microteaching lessons lasted from five to ten minutes each; therefore, there were not sufficient opportunities for the teachers to illustrate all the teaching aspects related to the 16 belief themes. Firstly, this limitation was due to the fact that the current study was conducted with two intact classes in a bachelor of pre-primary education program, and the duration of microteaching was fixed according to the course guidelines. Secondly, the study was qualitative in nature, but it involved a large number of participants, which limited the study data to observations and written reflections. Future studies could employ stimulated recall interviews following participants’ microteaching to take an emic view and gain more insights into the matches or mismatches between teachers’ beliefs and practices. Thirdly, another possible limitation is that the teachers’ beliefs were captured at a particular moment in time after they had received around two months of English teacher education and engaged in peer teaching. Future studies could take a longitudinal study design to document the trajectory of teachers’ beliefs throughout their teacher education program. For example, future studies could ask student teachers to keep a journal to reflect on their own microteaching, as well as that of their peers, throughout the English language teacher education course.The current study explored the beliefs of pre-service pre-primary teachers about EFL teaching for very young learners and whether such beliefs were reflected in their microteaching. Analyses of written reflections and microteaching by the participants (75 pre-service teachers) showed that the teachers held 16 beliefs about various aspects of teaching EFL to preschool learners, although not all of the teachers held the same beliefs. Some of these beliefs, such as beliefs about classroom practice, lesson planning, and EFL learners and learning, were held by the majority of the teachers and were clearly reflected in their microteaching. However, eight of the beliefs were missing in the teachers’ classroom practices.This study provided several novel insights into the current literature of teacher education research. Firstly, it was one of the few reported attempts to explore the beliefs and practices of pre-service pre-primary EFL teachers, an underexplored research area. Most of the previous literature focused on either EFL teachers who were pursuing a bachelor’s degree in EFL teaching, or on early childhood teachers in general. The current study showed that a well-designed educational course could equip pre-service teachers to develop various beliefs and practices regarding important areas of EFL teaching. Classroom practice, lesson planning, and appropriate conceptions of EFL learners and learning are perhaps the most important areas of learning for pre-service teachers. The teachers in the present study clearly showed these beliefs in their written reflections and microteaching. This could be seen as a sign of the success of the course, which might be due to the richer exposure to these aspects during the study processes. This suggests that future similar educational courses should emphasize experiential and reflective learning components which can help teachers shape their beliefs and practices regarding these essential areas of teaching in preparation for their practicum and initial formal teaching experiences.It should be noted that this study was not designed to investigate the match or mismatches between pre-service teachers’ beliefs and practices. Instead, the main purpose was to explore what beliefs the pre-service teachers may have developed during their EFL teaching methodology course, and what aspects of these beliefs may be reflected in their microteaching. The exploratory nature of the study allows us to provide some useful insights into the learning and development of some cognitive aspects and practices related to EFL teaching in a particular context. Apart from the more prominent finding that eight beliefs were reflected in the teachers’ microteaching, the other findings may also have important implications. While it may be due to the fact that the limited microteaching duration did not allow the teachers to implement their beliefs into practice, this finding may also suggest that EFL teacher education course designers should clearly articulate the objectives of the course so that particular activities can be prioritized. By providing future pre-service teachers with sufficient opportunities to reflect on what they learn, the teacher educators will allow them the chance to shape their understanding, knowledge, and beliefs about important aspects of teaching EFL to young learners, motivating them to implement such beliefs in their microteaching. Thus, pre-service teachers will be prepared for their practicum and initial formal teaching.


We perform a large-scale randomized controlled trial to evaluate the potential of machine learning-based instruction sequencing to improve memorization while allowing the learners the freedom to choose their review times. After controlling for the length and frequency of study, we find that learners for whom a machine learning algorithm determines which questions to include in their study sessions remember the content over ~69% longer. We also find that the sequencing algorithm has an effect on users’ engagement. However, to fulfill this promise, it is necessary to develop adaptive data-driven models of the learners, which accurately quantify their knowledge, and efficient methods to find teaching policies that are optimal under the learners’ models7, adapt empirically to learners10, or optimize engagement12. In contrast, research in cognitive sciences has focused on measuring the effectiveness of a variety of heuristics to optimize the review times informed by psychologically valid models of the learner’s knowledge using  randomized control trials17. Only very recently, Tabibian et al.18 has introduced a machine learning modeling framework that bridges the gap between both lines of research—their framework can be used to determine the provably optimal review times under psychologically valid models of the learner’s memory state whose parameters are estimated from real review and recall data using a variant of half-life regression12. However, in the evaluation of their framework, the authors resort to a natural experiment using data from a popular language-learning online platform rather than a randomized control trial, the gold standard in the cognitive sciences literature. As a result, it has been argued that, in an interventional setting, an actual learner following the rate of study may fail to achieve optimal performance1.In this context, research in the computer science literature has been typically focused on finding teaching policies that either enjoy optimality guarantees under simplified mathematical models of the learner’s knowledgeWe perform a large-scale randomized controlled trial involving ~50,700 learners of at least 18 years of age in Germany who use an app to study for the written portion of the driver’s permit from December 2019 to July 2020 and gave consent to participate in the trial. The goal of the randomized controlled trial is to evaluate to what extent a machine learning algorithm that builds upon Tabibian et al. can help people learn and remember more effectively. However, rather than optimizing the rate of study as in Tabibian et al., which is typically chosen by the learner, the algorithm determines which questions to include in a learner’s sessions of study over time. To facilitate research at the intersection of cognitive science and machine learning, we are releasing open-source implementation of our algorithm and all the data gathered during our randomized control trial.n = 10,151 learners), the questions of each study session were chosen using our machine learning algorithm. In the ‘difficulty` group , they were chosen in circular order proportionally to the initial difficulty, i.e., easier questions first. In the ‘random` group , they were chosen uniformly at random with replacement. The only difference in app functionality across groups was due to the item selection algorithm and learners do not know to which item selection algorithm they have been assigned. Moreover, in the ‘select’ group, as long as there were questions that the learner has not reviewed at least once, these were chosen first in order of initial difficulty, i.e., easier question first. By the end of the randomized controlled trial, we recorded more than ~16.75 million answers to ~1900 questions by ~50,700 learners in ~628,000 study sessions. Most of the learners were based in Germany (99.1%), they were evenly split between male (50.8%) and female (49.2%) and the most common age group was 18–24 (64.7%), followed by 25–34 (28%).During the randomized controlled trial, each learner was randomly assigned to a ‘select’, a ‘difficulty’, or a ‘random’ group throughout her entire usage of the app . Moreover, since we do not expect any algorithm to help learners who are cramming for tests, we do not use data from the 32,445 learners who used the app for less than 2 days. After these preprocessing steps, the resulting dataset contains ~894,000, ~3.3 million, and ~693,000 unique  reviewing sequences due to 1564, 7582, and 2335 learners, respectively  in 66.7% of the cases. Moreover, the median decrease in the median empirical forgetting rate for learners in the ‘select’ group was ~48% and ~40% when compared to learners in the ‘random’ and ‘difficulty’ groups, respectively, and the corresponding median increase in the median half-lives was ~92% and ~40%.We first compare learners of the ‘select’, ‘difficulty’ and ‘random’ groups in terms of normalized empirical forgetting ratec is the intercept term, Tmedian is the median time for the last (test) review, wT captures the impact of the spacing effect, and  capture the effect of being assigned to ‘random’ or ‘difficulty’ group, respectively, relative to being assigned to the ‘select’ group. Table T − Tmedian is negative indicating that the more spaced the reviews are, the lower is the final normalized empirical forgetting rate. The results also suggest that, since wdifficulty > 0 and wrandom > 0 across all #reviews, learners in the ‘select’ group have lower forgetting rate and, since the coefficients for the other groups seem to increase with number of reviews, the competitive advantage offered by our machine learning algorithm increases with the number of reviews.To further analyze the influence of each algorithm on the normalized empirical forgetting rate, we also fit the following regression model to the data for a fixed number of reviews:In terms of engagement, learners of the ‘select’ (‘difficulty’) group were 50.6% (47.6%) more likely, in median, to return to the app within 4–7 days than learners of the ‘random’ group. However, learners of the ‘select’ group were also more likely to stop using the app in the initial 2 days than those of the other groups. Refer to While our results have direct implications for the learning of large sets of paired-associate items by young learners using machine learning-based instruction, we acknowledge that more research at the intersection of cognitive sciences and machine learning is needed to generalize our results to different populations of learners, different materials, or other tasks. In this context, it would also be interesting to compare our algorithm with stronger baselines and experiment with different feedback modalities to further understand which aspects are most responsible for the improved engagement and performance.t and r = 1) or forgot (r = 0) the answer to the question. Here, note that in the learning app that we used in our randomized experiment, the learner is tested in each study session, similar to most spaced repetition software and online platforms such as Mnemosyne, Synap, and Duolingo, and the seminal work of Roediger and Karpicke19.Given a set of questions N(t), which counts the number of study sessions up to time t. Following the literature on temporal point processes20, we characterize this counting process using its corresponding intensity u(t), i.e., E[dN(t)] = u(t)dt, and think of the set of questions 24, to estimate the probability mi(t) that a learner recalls (forgets) the answer to a question i at time t. Under the exponential forgetting curve model, the recall probability depends on the time since the last review Δi(t) and the forgetting rate ni(t), we use a variant of half-life regression12 proposed by Tabibian et al.18 , n(t), Δ(t), p(t)) of the recall probability of the answers to the questions t0, tf].The SELECT algorithm Given a set of questions 18. However, in contrast with Tabibian et al., rather than optimizing the rate of study, we optimize the selection probability of each question in each study session. In q ≥ 1 is a given parameter, which trades off recall probability upon review and the size of the study sessions—the higher its value, the shorter the study sessions. In practice, in our randomized trial, the app presents questions according the order given by the selection probability and the user chooses the size of the study session. Therefore, our results are agnostic to the value of the parameter q.To solve the above problem, we resort to the theory of stochastic optimal control of jumps and proceed similarly as in Tabibian et al.Finally, since the optimal selection probability depends only on the recall probability, which is estimated using the exponential forgetting curve model, we can implement a very efficient procedure to construct study sessions, which we name SELECT refer to .Further information on research design is available in the Supplementary InformationReporting Summary


The health of transgender men (trans men)–individuals who identify as men and were assigned a female sex assigned at birth–is overlooked globally. This mixed-methods exploratory study sought to understand the lived experiences, health, and social needs of trans men in Lima, Peru to bring visibility to specific health needs and inform responsive and holistic public health efforts.Between July 2016-January 2017, 46 trans men in Lima, Peru participated in a mixed-methods study. Four focus group discussions were conducted, complemented with 10 one-on-one interviews to explore in-depth issues that arose in groups. Two individuals participated in both a focus group and an interview. All participants completed a brief survey assessing sociodemographic characteristics and experiences with healthcare, mental health, and stigma. Audio files were transcribed verbatim and analyzed using an immersion crystallization approach to identify themes.Participants had a mean age of 24 years (range 18–48). Trans men reported a lack of awareness and information among medical providers, avoidance of healthcare due to discrimination and maltreatment, an absence of public services for medical gender affirmation , and unmet mental health needs. Trans men described health as multidimensional and influenced by social, economic, and legal contexts including family, school, employment and work, legal identity recognition, discrimination in public spaces, and peer support. Violence, stigma, and intersecting forms of oppression were described as limiting social and legal recognition of trans identity a central dimension of health. Peer support, often in an online environment, was described as important to resistance and well-being.Findings demonstrate that the physical and mental health of trans men, as well as unmet needs for healthcare services, are influenced by a complex set of social, economic, and legal challenges due to the social exclusion of trans people in Peruvian society. Results are a call to action for stakeholders in Peru to guarantee the rights, health, and wellbeing of this community. Transgender men (trans men)–individuals who identify as men, male, or another masculine gender identity different than their female sex assigned at birth–remain an overlooked population globally, including in Peru . In the While research in transgender health is expanding, trans men continue to be underrepresented in the global health literature , 7. ThisAlthough transgender people are recognized as a group of “special protection” in the National Human Rights plan , legal fThe objective of the study is to raise visibility, document, and understand the healthcare needs and contexts shaping the health and well-being of transgender men in Lima, Peru to inform responsive public health efforts.Between July 2016-January 2017, 46 trans men in Lima, Peru participated in an exploratory mixed-methods study to assess and comprehend their health and social situation, in the context of their lived experiences, socialization dynamics, and access to public services.The study was conducted by the UNICXS project, an anti-violence reporting and response project focused on transgender health and human rights in Lima, Peru. Trans men were purposively sampled and recruited through community-based methods and partnerships with local community members and groups. A transgender man peer recruiter posted study flyers and invited individuals to participate in the study through in-person or online outreach, such as one-on-one at community events or through the posting and publication of a study flyer in a Facebook group with trans men community members. Inclusion criteria for study participation were: (1) ages 18 years or older; (2) female sex assigned at birth who feel and/or express a masculine gender identity, regardless of any process of bodily transformation or medical gender affirmation; (3) reside in Lima at the time of the study; and (4) able to give informed consent.Data collection sources were in-depth interviews, focus group discussions, and a brief survey. Four focus group discussions with 8 to 10 participants each were conducted , complemented with 10 one-on-one interviews (n = 10 trans men) to explore in-depth issues that arose from focus groups. Two individuals participated in both a focus group and interview . The interviews and focus groups were held at offices at Centro de Investigación Interdisciplinaria en Sexualidad Sida Y Sociedad (CISSS-UPCH), at the Universidad Peruana Cayetano Heredia (UPCH).Participants received compensation equivalent to US $10 for time taken to participate on focus groups and surveys. The protocol was reviewed and approved by the Institutional Ethics Committee of UPCH in Lima, Peru (No. 66604) and The Fenway Institute at Fenway Health in Boston, MA USA (No. 771415). All participants provided oral informed consent to the researchers who conducted focus groups and interviews. Only the researchers and the transcribers had access to the audio and text transcription of focus group discussions and interviews.Three sources of data were collected. Focus groups and interviews utilized semi-structured qualitative guides which covered the following areas: socialization , access to education, work, health, experiences of discrimination and violence, social and community support, and life expectancy. Focus groups and interviews were audio recorded and transcribed verbatim. Any confidential or personal information that could potentially identify participants was removed.At the time of the focus group discussions and interviews, participants were also asked to complete a brief survey. To better understand participants’ sociodemographic characteristics, the survey assessed: ; gender identity ; gender development milestones ; gender affirmation (current use of and access to hormones and surgeries); healthcare experiences and stigma in healthcare (4-items); mental health (PHQ-2 screener); and emotional and social support (4-items).Focus groups and interviews were analyzed using an immersion crystallization approach , 17 to iCentro de Lima .Characteristics of the study sample are presented in forever”, “for as long as I can remember”, and “since I had the use of reason”. Trans men reported first telling another person about being transgender at a mean age of 18 years (range ages 8–30 years).As shown in Themes regarding healthcare experiences and unmet health needs of participants coalesced around six primary topics: (1) Avoidance and limited use of healthcare; (2) discrimination in healthcare; (3) Lack of awareness and information among medical providers; (4) Unmet medical gender affirmation needs; (5) Sexual and reproductive health needs; and (6) Mental health needs.Document Nacional de Identidad) and discrimination experiences deterred him from accessing healthcare:Participants described avoidance and limited use of healthcare due to previous experiences of maltreatment and associated high levels of mistrust toward health providers and the medical establishment. All participants (100%) reported discomfort with healthcare providers as a deterrent to accessing health services. More than half (55%) reported not feeling comfortable interacting with health personnel or talking about their gender identity with them (53%). Almost three quarters (72%) reported not trusting that providers could help them with medical gender affirmation processes. Only 11% reported having ever disclosed they were transgender to a healthcare provider. One participant described how the non-recognition of his gender identity on his National Identity Document , the name your appearance and that stuff, right? I mean, I´ve been in the hospital and seen physicians or nurses making gestures or saying things that don´t make me feel good. So I´ve never liked seen a doctor”“(FG #1).Overall, 69% of participants reported experiencing discrimination or mistreatment from health personnel in relation to their gender identity. One participant recounted his experience:Yes, then I went in and left, and they kept looking at me weird. Well, the doctor up to then (was) super polite and everything, but when they were going to check me, the nurse came and started talking: ‘Is she a woman or a man?’ and I (was) super uncomfortable, and until now I have an abscess there and I have not been (back) to be seen.”“(FG #2)In addition to discrimination from healthcare personnel, participants reported experiences of discrimination and mistreatment from others in the healthcare environment, including from front desk and administrative staff , security personnel, and fellow patients.I have never liked going to the hospital or a doctor because of my DNI… my name and my appearance.” (FG #1)A common barrier that participants described to accessing care  was the need to present a DNI. Participants discussed how their DNI reflected the sex assigned at birth, drawing attention to the discrepancy between their current gender identity and assigned sex at birth. As one participant described: “Participants reported a widespread lack of awareness and information regarding transgender identity and health needs among medical providers. One participant narrated an experience he had with an uninformed provider this way:Of course, I had already made my transition, I had my hair cut, I went with my mother, I remember and the doctor checked me. I had not menstruated for about 4 months and I was worried. The doctor took my mom out of the office and told me hija (daughter) you are pregnant. I told him that was impossible. What happened was that I had a tumor on my right ovary that I had to have removed and the tumor was so big it was the size of a ball. The doctor, like he did not have much understanding at the time (about transgender issues), did not have the required education in the subject of trans men.”“(FG #1)I would like to society to recognize us. We exist. We are people. We are not one, we are many… We need respect we need to our identity.” (Interview #6)Frequently trans men described the lack of clinical training and protocols in Peru for providing healthcare to transgender people, especially for trans men, as an unmet health need. Further, participants described that while transgender women had some visibility in Peruvian society and within medical institutions, trans men were erased. As described, “Nearly all participants described gender affirmation as a health priority. Medical gender affirmation characteristics of the sample are presented in Participants reported accessing information about hormone therapy through the Internet or peers. Approximately 30% reported having used male hormones, although the majority of participants (94%) reported wanting to use them. Of those using hormones, all reported using intramuscular injection. Pharmacy (83%), clinic or health center (33%), or private practice (8%) were the most commonly reported procurement sources for hormones.Participants described the absence of public health services for medical gender affirmation and the importance of making medical gender affirmation accessible, particularly in the context of societal stigma:It’s important because if you physically look like a man, people will think you are a man, and they will treat as such. The problem if you still have feminine characteristics people will see you and think ‘here something is weird’.”“(FG #4)Information regarding access to surgical procedures for trans men was described as rare relative to access to hormone therapy. Participants described both the high costs of surgery and the limited number of providers offering transgender surgical interventions as key barriers to accessing these types of gender-affirming services. The procedure participants mentioned most was chest surgery . Yet, only one participant reported having undergone chest surgery, although more than 90% reported the desire to have that type of surgery.Due to unavailable medical gender affirmation policies and procedures within in public health institutions, participants described primarily accessing behavioral gender affirmation practices, such as, relying on binding, using constrictive materials to flatten the breast tissue and create a male-appearing chest, and packing, using a non-flesh penis or other material to give the appearance of having penis. Participants expressed a need for early gender-affirming interventions, wanting publicly available services for trans men in late adolescence.I have never gone, ever. I’m 24 and I haven’t stepped into a gynecologist’s office. Not as a man, not as a woman. Ever.” (FG #1)Participants did not describe gynecological care as a health need. When asked if they had ever been screened for cervical cancer , the overwhelming majority said they had not. As one participant reported: “Anticipated stigma and associated anxiety deterred participants from accessing gynecological care, even when needed and/or among those who had accessed care reported evading follow-up care. Participants note the difficulty in seeking this type of “female” care as a man, which they viewed as exacerbated by the absence of trained healthcare providers:I haven´t gone because I don´t know how, because I know it would be a problem. First, by saying your [legal] name and why you’re going to a gynecologist, if you look like a man; then, with the gynecologist. What am I going to say? Like, there is no one who is, let’s say, trained on these topics, that knows how to treat a trans person in a way that doesn’t make them feel all that anxiety when going to a doctor. That’s really needed.”“… (FG #1)To alleviate gender policing and stigma in communal waiting rooms, some participants described strategies they had used when accessing gynecological care. For example, one strategy was going with their female partners, sisters, or their mothers to avoid situational discomfort with front desk staff, nurses, and providers. As one participant reported:I took advantage when I was in a relationship to go and get checked together. then [my girlfriend] would say to me ’we are going to get checked. We are not going so that they will also check you’, and I would go and talked to the doctor. I would always look for a female doctor, for different reasons, and then we both got checked. But when I don’t have a girlfriend, I don’t go.”“(FG #2)And then I said ‘I have something, something is going on with me, I mean, I don’t have to be like that [trans],’ I mean, I felt guilty, right?” (FG #4) In many cases, participants reported social isolation and feeling alone, as if they were the only person in the world who was transgender.Daily experiences of psychological distress and anxiety were reported by all participants. Many described struggling with self-acceptance and reported feelings of self-blame, guilt, and shame about being transgender. One participant linked his transgender identity to feelings of guilt: “I felt like Pinocchio, I could never truly become myself, I felt as though I was always going to stay this way [in between two genders].” (Interview #1)Participants commonly described the internal conflict resulting from the clash between their felt gender identity as men and the social expectations and gender norms associated with their female sex assigned at birth. One participant described experiencing this as a betrayal of his transgender identity because he felt he had been living a lie: “Several participants reported suicidal ideation and attempts associated with feelings of loneliness. One participant described social isolation due to bullying he experienced based on not conforming to gender norms in childhood and highlighted the toll this took on his mental health:I was isolated and ridiculed…. I only went between school and my room. As a result, I was super depressed and tried to kill myself two times.”“(Interview #1)Participants described the lack of available mental health services, particularly the lack of publicly funded mental health services. Participants relayed difficulties finding mental health providers who were knowledgeable about the mental health concerns of transgender people and trained in working with trans men specifically.Social, economic, and legal contexts emerged as important situational factors in the health and healthcare of trans men. Themes coalesced around seven primary topics: (1) family, (2) school, (3), employment, (4) legal identity recognition, (5) discrimination in public spaces, (6) societal conflation of sexual orientation and gender identity, and (7) peer support. Everyday stressors experienced in relation to participants’ gender identities within these domains were described as sources of anguish detrimental to their health and well-being.Participants commonly described rigid and conservative gender norms in their family growing up as confining and stifling. They described frustration, anger, and ultimately sadness at not being able to express their masculinity visibly and outwardly in childhood, and the long-term negative mental health effects of this hiding. The act of “coming out” was recounted by many participants as an abrupt turning point in their lives. For most, the first disclosure of their transgender identity was to family members, in particular to their mothers. One participant shared:I felt I just couldn’t go on and I told my mother everything…My hair had been long since I had been 14 and I said, ‘No, I just can’t take any more’ and I grabbed and one day I left the house, I went to a party and got drunk and cut my hair [laughs]. And like that I went home, and my mother started to cry.”“(FG #2)what is most difficult to change are the names when of calling us because, it’s been like, twenty years that they have called you one way, and to change overnight, I understand it can be confusing for them” (FG#1)Participants narrated variable experiences with their families and familial acceptance of their being transgender. While some reported maintaining relationships with their family, others were no longer able to. Participants with conservative or religious families described the greatest family difficulties. Even in families that were accepting, participants reported common struggles, particularly the harms associated with being misgendered: “My mom sent with me my nice little hairdo, with my little skirt, and in the middle of the street I took everything off and put on my track pants. -Yeah, I also had my track pants in my backpack.” (FG #4) Participants described how transgressing gender norms in school was generally not accepted by peers or school faculty and resulted in harassment and bullying victimization. Participants explained how others refer to them using pejorative terms such as “bicho raro”  (FG #4) and “la rara” (the strange one) (Interview #8). Others recounted harassment and bullying experiences beyond name-calling:Participants described educational institutions as challenging due to experiences of gender policing related to the sex-segregated dress code at school, as well as moments of resisting these: “They (my peers) would take photos of me on their cell phones while I was in the bathroom. They would mock me and talk about me as though I wasn’t there. I was isolated, never included.”“(Interview #10)Participants explained that schools have little or no information on issues related to gender identity or gender diversity. Participants also reported varying experiences of acceptance or rejection and discrimination at the institutional level according to the type of school attended. Numerous participants reported attending a religious school and described how religious beliefs and teachings on “homosexuality as sin” fueled rejection by family and peers, as well as inhibited their own self-acceptance. As one participant described:I went to an evangelical school and in those years…We were taught that homosexuality was a sin and that homosexuals would go to hell, and at that age I believed it. Psychologically, I couldn’t accept myself because I thought I would go to hell… I tried to remind myself that I wanted God to love me and forced myself to dress like a woman and to try and forget how I felt.”“(Interview #1).true selves.” However, participants reported that the challenging experiences they had in school settings remained with them, including resultant feelings of internalized shame and poor mental health.Trans men often reported that finishing school marked the turning point in their lives when they openly began to transition and express their “Participant narratives about employment were varied and differ according to job type. Approximately 70% reported some form of employment, yet participants pointed to difficulties finding employment. One participant described his challenges:…but unfortunately in questions of being able to apply my capabilities, I have applied, I have (submitted) more than 105 applications…they do not give me the option. And there are people who, I do not want to say that they are bad either, but (who are less capable)…they enter positions that I have been seeking for 3 years…”“(FG #4)I was working cleaning offices and they got rid of me in a month for being like this (trans)” (FG #2).Participants also discussed difficulties of precarious employment: “Trans men reported ongoing complications carrying out their workplace responsibilities because of their transgender identity. These challenges included threats of being “outed”, having their identity questioned, and being discriminated against because of it. Participants commonly alluded to limitations accessing and exercising their right to work due to the incongruence between their gender identity and their legal identity. Participants described how they were misrepresented on the DNI, which legally designates sex assigned at birth rather than current gender identity, and the ongoing difficulties that caused for employment.All participants reported difficulty changing their name and gender markers on official forms of identification. They highlighted this lack of legal recognition as a chronic stressor affecting their health and as a structural barrier to everyday living. Participants viewed the DNI as the primary barrier to accessing healthcare services, employment, and other resources . All participants associated discrimination, fear, mental health distress and anxiety, and social exclusion with the need to present a DNI which was not concordant with their gender identity.It´s always tedious to do any procedure that involves the DNI.”“(FG#3)they call you by your name and stare at you like a weirdo (bicho raro), and they you- it´s that you? And you blush because its embarrasing, right?”“(FG#1)Trans men reported widespread experiences of discrimination, often in public spaces , including in healthcare settings. These experiences were often attributed to their physical appearance  and/or to their transgression of gender norms . Participants reported public restroom use as an unavoidable and challenging situational context in their daily lives. As one participant described:I always have issues entering a bathroom. Honestly, I am scared to enter a public bathroom. Because in the women’s bathroom, I am not enough of a woman to enter and for the men’s bathroom, I am not masculine enough.”“(FG #4)Participants perceived that medical gender affirmation  was not only important to their self-perception and self-actualization as men, but also necessary for easier day-to-day navigation of public spaces such as restrooms and public healthcare settings.[their] true self”  in late adolescence or young adulthood. They highlighted the need for social support during that process.Many participants reported being unaware of the concept of transgender identity until the late stages of adolescence or adulthood. However, they often described in their narratives an early identification with the masculine through their choices of clothing, toys, or identification with a male close to them such as a sibling or father. Participants recounted common questions of ‘who am I’ and ‘what am I’ when searching for “activa”, “chito”) and confusing gender identity with sexual orientation. Participants emphasized the need for greater societal awareness of and access to information about the distinction between sexual orientation and gender identity and expression. Further, they described an absence of role models as transgender boys, and lack of cultural references (“invisibility”) in society as transgender men.Trans men commonly recalled perceiving and naming themselves as butch lesbians Trans men reported resistance and self-care strategies rooted in peer social support, often obtained virtually online. Participants frequently described Facebook, chats, and other online platforms as crucial to circumnavigating feelings of isolation, learning about trans men identity, and understanding medical gender affirmation needs. One participant conveyed his experience:I started to find out about the meaning of the word [trans]. I started to look on the Internet and I began to see that there were other people. I started to see a group of more people who were trans and I felt identified and I said I am like that. And as I felt identified somewhere and started to find out, I started to inform myself, I found other trans people through the internet, who guided me and helped me.”“(FG #3)trans manhood existed. They reported how the Internet was instrumental to becoming aware of peers, especially others living in their city, and how it boosted self-acceptance of their own transgender identity.Participants described the Internet as a resource for health, and a safe space to access needed information and seek social support. The Internet was described as enabling them to understand they were not alone and that This study presents a first-hand perspective of the health and healthcare needs of trans men in Lima, Peru. Trans men exist and narratives described herein highlight the ways that the invisibility of trans men within healthcare and public health contexts adversely impact their health and well-being. Several unmet healthcare needs were identified in this study, particularly those pertaining to lack of publicly available medical gender affirmation interventions and mental healthcare services. Findings demonstrate that the physical and mental health of trans men, as well as their unmet needs for healthcare services, are influenced by a complex set of social, economic, and legal challenges due to the social exclusion of transgender people in Peruvian society . MultileCorroborating research from other parts of the world –23, thisConsistent with prior research , 7, tranMedical gender affirmation emerged as a high-priority area of unmet need for trans men in this study. Prior research has demonstrated the positive health impacts of medical gender affirmation, including improved mental health and psychosocial functioning –29. PartTrans men in the current study commonly reported experiences of depression, suicidal ideation, anxiety, guilt, fear, isolation, and shame, consistent with research demonstrating high rates of mental health morbidity for transgender people globally , 7. GendTrans men described how social entities and institutions punitively reinforce traditional gender norms and expectations through stigma and social exclusion, and highlighted healthcare settings and publicly funded services, work or employment contexts, and public spaces  as constant sources of stress and strain in their lives. These findings are aligned with structural developmental life course frameworks which theorize that poor health results from chronic and cumulative stress and strain across the lifespan due to occupying a stigmatized or marginalized position in society –34. FurtSeveral limitations need to be considered in interpreting study findings. The study population was young, educated, and largely employed at least part-time. We cannot be sure if this demographic is specific to the methods utilized to recruit the sample, such as through community groups, networks, and online social media, or indicative of the trans men population in Lima. This study is exploratory and has a small sample size, though saturation was reached in focus group discussions and interviews. This work is intended as a first step. We recognize the value of considering a larger and more diverse study sample, including for a future quantitative needs assessment study. Given that our study inclusion criteria were broad in defining trans men, study findings were not stratified nor explicitly analyzed for gender diversity. Thus, we did not explore the degree to which study participants’ personal expression of gender conformed or did not conform to social norms of gender in Lima, Peru, or whether they “passed” (were “read” by others) as male or trans. Future research with larger samples is recommended to allow for comparisons of health, social characteristics, and needs of trans men by gender diversity and conformity or nonconformity to culturally-specific gender norms in Lima.Gathering data on the health and social needs of populations is vital to inform public health efforts to ensure the wellness of underserved populations. Results highlight the range of social issues impacting the health and wellbeing of transgender men. Though further assessment of social determinants of health and social resistance and resiliency strategies adopted by trans men in Lima is still needed, results of this study should be taken as a call to action for stakeholders in Peru to guarantee the rights and wellbeing of this community.These results underscore the critical gap in basic knowledge about transgender identity and expression, the unmet health needs of trans men, the need for knowledge and sensitivity training for healthcare providers, and the lack of existing protocols specific to providing competent and compassionate care to them. Transgender health in Peru needs to be addressed as a right in and of itself. To date, the only existing public services offering hormones to transgender people are for transgender women as a way to increase access to HIV prevention services . As tranAs described by participants, the lack of legal protections and rights for trans men in Peru play a critical role in shaping and enabling a social environment which poses multi-layered threats to the mental and physical health of trans men. Most notably, the lack of right to legally change gender designation on the birth certificate to reflect felt gender identity, lack of rights and protections regarding public restroom use, and lack of access to gender-affirming procedures (hormone treatment and chest surgery) emerged in the findings as critical barriers to the social inclusion of trans men in Peru. These issues can be eliminated by rights-forward changes in the law . Advanci