Persistent psychosocial stress is endemic in the modern workplace, including among midcareer high school (secondary comprehensive) teachers in England. Understanding contextual influences on teachers' self-management of stress along with their use of digital health technologies could provide important insights into creating more usable and accessible stress support interventions.The aim of this study was to investigate the constraints on stress management and prevention among teachers in the school environment and how this shapes the use of digitally enabled stress management tools.Semistructured interviews were conducted with 14 teachers from southern England. The interviews were analyzed using thematic analysis.Teachers were unanimous in their recognition of workplace stress, describing physical (such as isolation and scheduling) and cultural  aspects in the workplace context, which influence their ability to manage stress. A total of 12 participants engaged with technology to self-manage their physical or psychological well-being, with more than half of the participants using consumer wearables, but Web-based or smartphone apps were rarely accessed in school. However, digital well-being interventions recommended by school leaders could potentially be trusted and adopted.The findings from this study bring together both the important cultural and physical contextual constraints on the ability of midcareer high school teachers to manage workplace stress. This study highlights correlates of stress and offers initial insight into how digital health interventions are currently being used to help with stress, both within and outside high schools. The findings add another step toward designing tailored digital stress support for teachers. I think we're quite secretive by nature. I think it's such a stigma. As teachers I think we've all got a character trait that we like to do well and I think if you admit you're stressed it's like admitting you're failing.Quote 4, P10, F, 22 yearsI say it’s for research purposes, but actually it’s for me as well that I access these things. I use Pacifica.Quote 5, P12, F, 32 yearsMany participants’ concerns reflected a fear of peer perception that they might not be coping well, highlighting a culture where weaknesses were seen as having their origin in the individual rather than in the system.Added to this fear of an unsympathetic social culture was the inference, from recent national policy, that the focus was solely on prioritizing student well-being, as well as the growing emphasis in the education sector on teachers meeting the mental health needs of students with little provision for their own:You’ve really got to look after yourself because nobody else is going to look after you here. They're not because they can't...nobody’s got time to look after their staff.Quote 6, P7, F, 16 yearsSo you’ve got stressed teachers trying to un-stress children which doesn’t make much sense.Quote 7, P9, F, 9 yearsDespite the rhetoric on well-being, the message that it is “ok to not be ok” reported by a few participants has not yet been normalized.Sometimes participants spoke about feeling isolated, but this was often implied through descriptions of trying to manage stressful times on their own. Others, notably within the smaller setting of subject departments, had been very upfront about struggles and had shared simple advice with colleagues, such as walking more slowly between lessons, or had already suggested technology solutions to stressful scenarios.Sometimes, teachers described scenarios where stress had been overwhelming and the early warning symptoms of insomnia or nervous tics were ignored. These participants were frequently conscious of work dominating their lives, but in their isolation, they saw the ability to cope as an individual responsibility. Subsequently, their well-being suffered with occasionally devastating consequences such as nervous or marriage breakdown:I went down to my staff base. I moved myself away from the door so nobody could look in, went to one of the last compartments, and I cried and I cried and I cried. There's nobody you can go to. When you're in this environment there's nobody. There's nobody to be able to download to. There's nobody to say are you alright. You're just completely by yourself. So the feeling of isolation...and actually...quite powerless to do things.Quote 8, P7, F, 16 yearsI used to bring three bottles of water to school and I could tell if I’d had a bad day because...I’ve had a sip out of each when I got home and I didn’t need to go to the loo. And there’d have been no space.Quote 9, P10, F, 22 yearsDescriptions of subject departments were usually very warm, with heads of department describing camaraderie among colleagues, which led to a more supportive culture:Yes, I'm known for emailing [my department] and saying use this app, I find it really useful. And I did some work looking at reducing workload and marking and being really sort of honest with staff and saying I'm really struggling with this. I struggle with workload and I want to try and make it better. So I share quite a lot.Quote 10, P6, F, 20 yearsI set up a support programme for [my colleague], based on my experience. What would really suit you? What are you happy to do? In terms of the aspects that I could control, I came to an agreement and a balance with her, just making sure to check up on her.Quote 11, P14, F, 15 yearsA majority of participants believed that the wider leadership sincerely wanted to support staff well-being, some referencing an annual staff well-being survey as well as some responses that had been acted upon.All the staff members interviewed were or had been in a position of leadership themselves, and some were involved in their schools’ plans to raise the profile and provision of well-being for the staff. Participants were wary about gimmicks; some had noticed mental health posters appearing in their school but without an accompanying narrative. However, the suggestion that leadership could proactively recommend solutions raised genuine interest:My job at the minute in terms of staff wellbeing and staff development is partly because there are changes that I wish to make because I've been here for a long time...I've listened to people, I've got a sense of what people say and wish to do and actually avoiding helplessness, this is something I can actually do and make that happen.Quote 12, P11, F, 22 yearsNo, I would love . I like stuff like that. No, that is fine.Quote 13, P3, F, 28 yearsDespite expressions of a constricting culture in which stress management was seen as an individual and not an institutional responsibility, there was still a strong sense of trust in the leadership. Most of the staff members had worked at more than one school, and many had changed schools to find a culture in which they felt more supported or valued.Across the participants interviewed, 12 out of 14 participants already used digital tools for stress management or well-being, with 17 apps, 5 different brands of wearables, and 1 desktop program named.Smartphones were taken to school by teachers, but time, signal, and privacy constraints meant that phones remained in the teacher’s bag or coat pocket; just one teacher accessed a calming app in the privacy of her office during the day, and another accessed the Headspace app via her iPad. Over half of those interviewed used wearable technology  and real-time data to manage their stress and well-being:I used [Headspace] when I was in the bath last night...just focusing on breathing and meditation. And I did it the previous night in bed, I just did like five minutes and even just after five minutes I felt quite relaxed and I thought wow, I should just do five minutes a day because it's nothing really...I think if I didn't have that app I wouldn't do it and it now sends me reminders.Quote 14, P2, M, 17 yearsAnyway, back to the Fitbit. I just love all the features of it. It’s got relax as well. Sometimes if I wake up in the middle of the night, I put the relax on. Quick, two-minute session to find a bit of calm.Quote 15, P3, F, 28 yearsWhen asked about their response to the school leadership promoting a digital health innovation for well-being, interviewees voiced near unanimous enthusiasm and a belief that this would only happen if due diligence had been already done to conclude that such a tool was tried and trusted. They might not feel it was for them, but it could be for a colleague:I'd look at that [stress app]. I'd look at anything because it doesn’t have to help me does it? It becomes part of a toolkit of stuff that you signpost to people...This is stuff I'm prepared to recommend. Actually this becomes our provision. This becomes what we do.Quote 16, P11, F, 22 yearsIn terms of meeting their own needs, teachers managed stress using strategies that included the setting of boundaries, focusing on holistic well-being, keeping a diary, or intentional reflection on experiences. Sequelae of stress, such as elevated heart rate, shallow breathing, or racing thoughts, were often the target of conscious self-management strategies, including via digital health tools. Mindfulness was the most frequently cited stress reduction technique, both with and without digital support. Those who had wearable technology all expressed an interest in observing their patterns of behavior and activity, although they did not always welcome the attendants’ prompts. One interviewee had collated data from the wearable to successfully demonstrate to a line manager the need to change her schedule because of the potential exacerbation of a health condition. Many wearers did not share their data or advocate for their wearable despite liking the personal feedback. However, they did appreciate the data captured by technology tools, which was frequently mentioned as valuable and confirmatory.The data gathered were used to aid reflection on reactions or responses to stress, and participants expressed the value of seeing patterns of behavior through tracking and mapping:So it’s about patterns...My wonderful days. It's a diary [app]. And I am supposed to write down every day what I am feeling but it tends to be just what I have done that day whether it's longer or shorter or...I can look back at last year. You can see how far you've come - oh my goodness that was how I was feeling this time last year!Quote 17, P1, M, 34 yearsThe only thing I’ve started, and I’m wearing it at the moment, is a heart rate monitor. That’s more for when I exercise, but I’ve been conscious that it comes up with a sleep pattern. Every morning, it’s less than the desired amount of sleep achieved, poor quality of sleep. So, it’s really interesting to see that, on a regular basis, I’m not getting the right amount of sleep.Quote 18, P13, M, 11 yearsParticipants used apps to access stress management techniques at home, such as dealing with anxiety or relaxing through mindfulness or meditation. Wearables were able to afford real-time intervention or information, such as helping them get back to sleep at night or bringing down their heart rate through managed breathing during a class in school:And again, often if I feel myself getting a bit stressed [in class] I will look at my Fitbit and if I can see that my heartrate is above 80, which for me is very high, again, I will either do a breathing exercise or I'll just do something to change what I've got myself into and then just check again in a few minutes.Quote 19, P6, F, 20 yearsCurrently, I like Insight Timer. I like it because I can adapt it to whatever I'm doing...At the end of the day...if I’m wound up about something, there is [a programme I can chose for example] for resentment or anxiety. It’s very, very adaptable.Quote 20, P10, F, 22 yearsSome teachers described indirect ways of reducing stress, managing their time better to impact workload or build self-efficacy. An example of this was seen through the use of the research tool TeacherTapp. This app has been designed to capture data from teachers at the end of their working day by asking them 3 research questions. By taking part, teachers themselves can review the findings and read associated articles:It [TeacherTapp]) also links each day to some kind of educational research...and it also tells me how long it takes to read...it kind of makes me feel more professional and that kind of feeds into the stress and the workload thing doesn’t it. So although it's not a wellbeing tool I think it does work as one.Quote 21, P6, F, 20 yearsThis study used a qualitative approach across several real-world settings to develop an understanding of the contextual influences on English midcareer high school teachers’ self-management of workplace stress and of their use of digital health tools for well-being. Consequently, we explored each in the following sections.local privacy—this absence of refuge results in inhibition, stifling of expression, or no opportunity to destress [The findings from the data analysis formed a detailed narrative of how self-management of workplace stress by senior teachers is subject to constraining contextual and organizational factors. Although the concept of constraints has often been cited in teaching literature , with wodestress . Some scdestress  work thainferior ability if they ask for help [Stigma of help seeking was a third constraining factor. This related to teachers’ fear of being perceived to be of for help , as wellIt was more often seen as ironic that the recent national policy’s emphasis on mental health in schools was almost exclusively aimed at students and not the education workforce , despite“Feeling lonely in a crowded room” was how one teacher described one symptom of burnout, and it was poignant how symptoms such as isolation, dehydration, hunger, and insomnia were frequently described alongside the assumption that it was purely down to the individual to manage the causes and manifestations of stress. This individualized responsibility can place a profound burden on a teacher as such an approach fails to acknowledge the complexity of the origins of stress . AspiratOur second organizing theme extends previous research on the use of health technology for workplace well-being. Smartphones  were rarely accessed during the working day by teachers. Among the 23 mental eHealth (Web-based) at-work studies reviewed by Stratton  in 2017,However, the participants were nearly unanimous in their willingness to give a particular stress-relieving or prevention technology a try should the school ever promote such a technology. This could partly be a reflection of the high rate of participant use of well-being technology, which was already present in our sample (12 out of 14 participants), but it was also a clear expression of their trust in the school leadership. Most participants believed that the school leadership would only endorse a stress-relieving technology that could be valuable and reliable. This could reflect the fact that the staff members worked at schools that acknowledged staff well-being or that the staff members had chosen to work in a school where they felt valued, which engendered their trust in the leadership.Current use of technology by teachers demonstrated the potential for combining self-management of stress and organizational promotion of well-being. However, the proportion of teachers who did  cannot be extrapolated to the whole population as they self-selected for the interview and were not a random sample. Of Nunes’ description of 5 modus operandi (MO) of technology for self-care, 2 of the 5 were found to be individually oriented: (1) fostering reflection and (2) suggesting treatment. The 3 other MO’s were communal: (3) sharing care activity, (4) enhancing collaboration, and (5) peer-to-peer support . This stAmong participants, methods that fostered reflection, MO (1), were the most widely used both with and without technology. In fact, 2 participants revealed how technology had become embedded, realizing during the interview that it was their apps that aided reflection. Of the 12 participants who reported using technology to support their well-being, 8 participants reported having a wearable band or watch. The real-time feedback and actionable insights of the wearables (2) were felt to be useful and empowering, enabling positive decisions to be taken to manage stress indicators. These included undertaking a breathing exercise to lower an elevated heart rate or planning more exercise. Feedback on and insight into sleep quality were mentioned by several people as provoking a change in behavior. These examples correlate with the approach of empowerment through meaningful data, facilitating participants to make changes in a way that also respects their autonomy as described by Tengland . This auMost teachers did not promote their wearable to colleagues, but 2 participants did mention enjoying comparing activity with other teachers as per the peer-to-peer MO (5) noted above. A recent systematic review of workplace studies utilizing mobile health, including wearable interventions to promote physical activity, has shown reasonable evidence for workplace eHealth in a workplace context as “a feasible, acceptable and effective tool” . This stMany of the apps used facilitated immediate therapeutic access, most commonly to mindfulness, breathing, or meditative tools, combining Nunes’ (1) and (2) MO descriptions. Only one teacher claimed to use Web-based CBT, but some of the apps mentioned by the staff used CBT principles. The staff also engaged with both mindfulness and social support  technologies. All 3 strategies aligned with the evidence for stress reduction efficacy among teachers , and theMost tools were adopted serendipitously, discovered through advertising, friends and family, or social media, or just occasionally through peer recommendation. Both the inclination of the staff and availability of technology suggest opportunities for technology-enhanced stress self-management that both reflect current strategies and could possibly work around the described constraints.tailored support.The UK government’s 2017 Farmer-Stevenson report included recommending public sector employers to “Ensure provision of tailored in-house mental health support and signposting to clinical help” . It is hThis was a small-scale study, and the participant sample cannot be claimed to be representative of all midcareer high school teachers. In particular, as the sample was self-selecting, it is likely that there were a higher proportion of staff members who had experienced crises and time out of teaching than the average population. Beyond the confirmation of the school’s recognition of staff well-being, this study did not investigate the influence of the school’s organizational or leadership attitude on how teachers managed their stress. The participants knew in advance that they were going to be asked about their use of health technology; therefore, although 2 participants did not use any, the proportion of those who did cannot be generalized to the whole teaching population. In addition, this study was limited by a lack of ethnic or racial diversity.All the staff members were interviewed during term time after at least five weeks back at school after the summer holidays. It was intentional that participants were interviewed while in the thick of school activity, and all of them were very much immersed in the demands of school life. Owing to their busy schedules, we are immensely grateful to the participants who gave their time, courageously talked about stressful situations, and who without exception demonstrated commitment and determination. Their pride in their students was tangible.As a former clinician, JM was trained to look for symptoms and think diagnostically. Inevitably, although this can aid insight, it could mean a more medical bias to the analysis. However, the coauthors were from nonclinical backgrounds, and all the findings were reviewed with them.The aim of this study was to elicit the details of the contextual influences on midcareer high school teachers’ management of stress. This study’s findings are consistent with previous research among education and health care professionals on how context shapes their stress management. Distinctively, we described both the cultural and physical contextual reasons, including endless demands, lack of local privacy, stigma, inferiority, and individualism, which are constraining teachers’ workplace stress management. This study also indicated important signs or correlates of stress for teachers, including dehydration, feelings of isolation, and insomnia.This research has provided distinct insights into how DHIs are being used for stress management and noted that mobile apps have the most potential for stress support outside the workplace, although wearable technologies can provide easy access to data within the workplace.The important directions indicated for future teacher studies are to explore contextual changes to improve stress management, examine the correlates of stress that could be addressed by technology support, identify how and why stress symptoms can be helped using digital tools, and determine how such tools can be designed to provide enhanced, tailored support.


Utilizing the Chinese Family Panel Studies (CFPS) dataset and the structural equation model, this paper examines the direct and indirect influences of family income on children’s emotional wellbeing as a function of parents’ life satisfaction and parents’ emotional wellbeing. Firstly, the empirical analysis of this paper shows that family income exerts a positive influence on children’s emotional wellbeing outcomes, including depressed, hopeless, helpless, and meaningless feelings. Secondly, the findings show that family income is significantly associated with parents’ emotional wellbeing, through which children’s wellbeing is affected. The intergenerational emotional transmission mechanism is validated. The ability to control personal emotions is an important skill, related not only to personal health but also to children’s health and wellbeing. Furthermore, parents’ life satisfaction serves as the mediator between family income and parents’ emotional wellbeing. If parents are more satisfied with their own lives, they are less likely to experience emotional problems. Policy implications are discussed in the end. Recently, there has been an increasing number of reports in the media related to suicide and extreme behaviors by children who are left behind by parents in rural China. For example, in 2015, four children committed suicide by drinking poison in Bijie in the Guizhou province, hurting many people. These events attracted wide public attention regarding the healthy development of children’s psychological or emotional health. Subsequently, children’s emotional wellbeing was highlighted by the central government. In 2016, the State Council of China issued notices on strengthening the care and protection for rural left-behind children, which stress the importance of strengthening the protection for left-behind children in rural areas of China, as they are more likely to be affected by psychological or emotional problems due to a lack of adequate care and the absence of parents  [Children’s wellbeing involves their development in multiple domains, which not only refer to the promotion of children’s lives in the aspect of material living conditions, but also their subjective wellbeing and emotional development Despite the importance of children’s emotional wellbeing, there is little evidence demonstrating the relationship between family income and children’s emotional wellbeing in China. The mediation mechanism is also not well explained. This paper examines the mediational role of parents’ life satisfaction and emotional wellbeing. The following questions are addressed: (1) What is the relationship between family income and children’s emotional wellbeing? (2) To what extent do parents’ life satisfaction and emotional wellbeing play a mediational role? (3) To what extent does family income explain children’s emotional wellbeing, controlling for mediators?Some studies argued that a family’s limited financial resources may generate adverse impacts on children’s development outcomes . ThrFurthermore, some evidence showed that wealth is positively related to an individual’s life satisfaction . A highFurthermore, after a comprehensive review, most studies were found to be based in a Western context, whereas research focusing on Chinese children is scarce. Some studies examined adults’ wellbeing; for example, Lin (2016 ) analyzeiY denotes the dependent variable, i.e., the emotional wellbeing of child i, iX indicates the independent variable of interest, i.e., the family income of child i, and β represents the coefficient of interest that interprets their causal relationship. In addition, this model controls for a vector of children’s individual characteristics, iZ. Furthermore, sμ and tλ are the fixed effects of province and year respectively.Empirical methods were designed to investigate the relationship between family income and children’s emotional wellbeing. On the basis of the discussion of previous literature, this study proposes the following hypothesis: a higher family income results in better children’s emotional wellbeing. In order to test this proposed hypothesis and to empirically estimate the relationship, this paper firstly used the multivariate regression method, with the model specification shown below.However, the mechanism behind this relationship remains a black box, and the influence of income may not be straightforwardly linked to children’s emotion, especially for young children. According to the conclusions and findings of previous research, parents’ own emotional wellbeing may impact children’s emotional wellbeing, i.e., intergenerational transmission of emotional wellbeing; thus, it may play a mediational role in the connection between both ends of the hypothetical relationship. Therefore, this paper further proposes the following hypothesis to illustrate the mediation mechanism: a higher family income is linked to better parents’ emotional wellbeing, which then translates to better children’s emotional wellbeing.In order to test this proposed hypothesis and to empirically explain the mediation effect of parents’ emotional wellbeing, this paper next employed a structural equation model with the graphical illustration shown in Furthermore, although this mediation mechanism may help explain the causal relationship between family income and children’s emotional wellbeing to some extent, a higher family income may not necessarily lead to better parents’ emotional wellbeing; on the contrary, it may lead to upset and nervous feelings. One of the innovative contributions of this paper to the academic field is the establishment of a linkage via another mediator. Previous studies found wealth to significantly benefit life satisfaction, which may be highly related to a healthier emotional status. Therefore, this study employed parents’ life satisfaction as the mediator of the connection between family income and parents’ emotional wellbeing, finally proposing the following hypothesis: a higher family income is linked to higher parents’ life satisfaction, which leads to better parents’ emotional wellbeing, and, subsequently, better children’s emotional wellbeing.Finally, in order to test this proposed hypothesis and to clarify the mediation effects, the empirical estimation was once again established using a structural equation model, but with a more complicated relationship, as shown in This study used Chinese Family Panel Studies (CFPS) as the main data source for the empirical analysis. The Institute of Social Science Survey at Peking University conducted the base survey of CFPS in 2010. The survey was originally designed to collect the socioeconomic information of Chinese families and individuals, as well as children’s characteristics such as health, education, and wellbeing. The CFPS investigation was carried out with a stratified sampling method including three levels: counties, communities, and households; each household was then selected according to the probability proportion to size (PPS). The main strength of this database is its national representativeness, as it investigated 25 provinces of China. Thus, this study used CFPS datasets in the wave of 2014, with a sample of 8616 children aged from 0 to 15 years old, to examine how children’s family income affects their emotional wellbeing. All types of households were covered in the sample, such as two-parent and one-parent families; thus, the data are adequately representative of Chinese households.The dependent variable of this study was children’s emotional wellbeing, containing six specific indicators from the CFPS dataset. The independent variable of interest was family income or, more specifically, the household’s annual income per person, reflecting the family’s economic and material living conditions; this study took the natural logarithm of income. In addition, three control variables were used to further depict children’s individual characteristics: age, gender, and urban/rural residence.Moreover, in terms of the two mediators, the indicators of parents’ emotional wellbeing used the exact same variables as for children, with fathers and mothers questioned separately (M101–M106) to reflect their frequency of suffering each emotional problem on a scale from 1 (“nearly every day”) to 5 (“never”). Secondly, the indicators of parents’ life satisfaction contained three dimensions: the satisfaction degrees of their interpersonal relationship, marriage, and life, with each dimension consisting of three individual questions, whereby fathers and mothers were questioned separately (M201–M209). This study aimed to examine the relationship between family income and children’s emotional wellbeing, and Furthermore, the individual characteristics of children also affected their emotional wellbeing. Firstly, as shown in As discussed above, in order to describe the impact mechanism of family income on children’s emotional wellbeing, the reduced form of the regression model was not enough. Hence, to test the hypothesis of certain mediation effects, this paper employed a structural equation model to estimate the direct and indirect influences. The structural equation model allows successfully dealing with a certain number of latent and observed variables/indicators. According to the standardized coefficients in Furthermore, as discussed above, the indirect effect of family income on children’s emotional wellbeing through parents’ emotional wellbeing may be incomplete, and an additional mediator may be required to link family income to parents’ emotional wellbeing. Hence, this study added the mediator of parents’ life satisfaction to complete the linkage, as illustrated in As shown in Wellbeing refers to the realization of children’s rights and the fulfilment of an opportunity for every child to realize their ability and potential . Monitoring and measuring children’s wellbeing status is critical for better promoting children’s basic rights, as ratified in the United Nations Convention on Children’s Rights . As regOther psychological scales have also been developed and applied internationally in different countries for assessing children’s subjective wellbeing or psychological health in both a positive and a negative way. For example, the Brief Multidimensional Students’ Life Satisfaction Scale (BMSLSS) . Beyond this group, a wider coverage of lower-income families and children is necessary.


In the near future, developments in non-invasive prenatal testing (NIPT) may offer couples the opportunity to expand the range of genetic conditions tested with this technology. This possibility raises a host of ethical and social concerns, such as the type of information  that couples might be exposed to and how this might complicate their informed decision-making. Currently, only limited research, mainly carried out in western countries, was conducted on women’s and partners’ views regarding the potential expansion of NIPT.This study used semi-structured interviews with pregnant women and their partners to explore their views on future potential NIPT applications such as non-medical sex selection and non-medical traits, paternity testing, and NIPT use for fetal whole genome sequencing (FWGS). It was conducted in Lebanon and Quebec, as case studies to explore the impact of cultural differences on these views.We found no differences and many similarities when comparing the perceptions of participants in both contexts. While couples in both settings disapproved of the use of NIPT for non-medical sex selection and non-medical traits such as physical characteristics, they were near-unanimous about their support for its use for paternity testing in specific cases, such as legal doubts or conflicts related to the identity of the father. Participants were more ambivalent about NIPT for Fetal Whole Genome Sequencing. They supported this use to detect conditions that would express at birth or early childhood, while objecting to testing for adult-onset conditions.These results can further inform the debate on the future uses of NIPT and future policy related its implementation.The online version contains supplementary material available at 10.1186/s12884-020-03538-y. Introduced into clinical practice in 2011, cell-free DNA (cfDNA)-based noninvasive prenatal testing (NIPT) is a screening tool that analyzes cfDNA circulating in maternal blood to test for fetal aneuploidies. NIPT has created a shift in the practice of prenatal screening and diagnosis due to its non-invasive nature (the test does not carry a risk of miscarriage), its ability to be performed as early as 9 weeks of pregnancy, and its reliability in detecting fetal aneuploidies such as trisomy 21 , 4 and iThe “next frontier” in prenatal testing would be sequencing the entire genome of a fetus through NIPT   and Lebanon. We chose these locations as case studies to investigate whether and how cultural contexts might impact participants’ views about future applications of NIPT. Table In both Quebec and Lebanon, potential participants included pregnant women at low and high risk of having a child with trisomy 21, who were identified by recruiters through their medical records.Women were classified as high risk because of either their maternal age or their medical history with previous pregnancies, or because their MSS result was positive for Down syndrome.In Montreal , participants were approached by the study coordinator or a nurse following their clinical consultation about prenatal testing at the obstetrics/gynecology and medical genetic clinics at a large university center. In Beirut (Lebanon), participants were recruited by a nurse or a physician at a Women’s Health Center within a Department of Obstetrics and Gynecology at a large Medical Center.We conducted one-on-one or one-on-two semi-structured interviews with pregnant women or couples . Women chose whether or not they wished to include their partner in the interview. To ensure the feasibility of the study and to have a homogeneous sample in both cultural contexts, only heterosexual couples were recruited. Interviews were audiotaped, transcribed verbatim, and anonymized. In both Montreal and in Beirut, the semi-structured interview guides explored the same topics, including general attitudes regarding NIPT, informed consent for NIPT, NIPT coverage by the health care system and insurance companies, current and future NIPT uses, and social impact of NIPT. The interviews relied on participants’ knowledge of NIPT. However, the question about the use of NIPT for FWGS included a definition of FWGS.The interview guide is provided as a supplementary file to the manuscript  independently coded the Arabic transcripts. Researchers then compared the coded transcripts and discussed discrepancies until they reached consensus. H.H. translated all themes to English, so authors were able to discuss the developing analysis and prepare the manuscript. G.B. validated the French-English translations and C.H. validated the Arabic-English translations. H.H. selected quotes from the interviews to illustrate the findings.In total, we approached 61 individuals: 11 Quebecois couples, 12 Quebecoise women, 8 Lebanese couples, and 11 Lebanese women. Forty-three individuals accepted to participate in the interviews: 7 Quebecois couples, 8 Quebecoise women, 6 Lebanese couples, and 9 Lebanese women  methodology enabled us to attain this objective . QD offeWhen asked about their views regarding future uses of NIPT, including for non-medical sex-selection, non-medical traits, paternity testing, and FWGS, participants in both settings expressed a variety of opinions and concerns. No striking differences were found between women and their partners. Moreover, remarkable similarities and agreement were found between participants in the two different cultural contexts.“playing God” (Qc 9 Cp F) and being“against nature” (Qc 1 F). Moreover, they feared that some women or couples would request a pregnancy termination because the fetus is of the unwanted sex without stating the real reason behind their request.No. It's just because in my eyes it's playing God when we decide whether or not to keep a child based on sex. I am well aware that there are surely women who are having abortions by citing some other [reason], it might be the same case there. Qc 9 Cp FQuebecois participants were enthusiastic about knowing the sex of the fetus through NIPT. However, when they were asked what they thought about using the test to select the sex of the fetus for non-medical reasons, none of them agreed. Participants mentioned different reasons for thi objection, such as such selection expressingIf NIPT was offered to me saying we will not divulge the result of the [fetus’] sex before x weeks, like after viability, because we do not want people to select based on it. We do not want the test to be used for selections based on that, it would not bother me, I don’t care. Qc 8 Cp FOne Quebecois woman noted that she would not mind if NIPT were offered with a restriction to not reveal the sex before the point in pregnancy after which the fetus would be viable outside the womb, to prevent terminations for sex selection:“out of interest and curiosity”, whereas the majority rejected such use. Some were convinced that one should allow nature to run its course and should reserve such “surprises” until the delivery of the child. In addition, while some participants were convinced that in a very advanced future there might be a potential tendency to use NIPT to test for physical traits, they argued that one has to “accept what God gives you” (Qc 1 F) and “should not change the natural” (Qc 1 F). Participants also feared a “slippery-slope” towards eugenics, which could lead to people starting to test, terminate and “try again” (Qc 4 Cp H) in order to have a baby with desired characteristics.Two Quebecois participants (2/15) did not object to using NIPT to test for cosmetic traits such as physical characteristics - among others, eye and hair colors - Oh yes, my child has eyes that are brown, I wanted them blue, oh yes, we go ahead and we start over! In China, what happens is that no one wants a girl. So, with the science, they check quickly, they see that it’s a girl, they terminate. It actually changes the ratio of women to men. And what will happen there? It’s hard to determine all that! Science is good, but there will be abuse on that front. That’s it actually, there will be abuse. They will say; o.k. I want to have a child with blue eyes with long hair. They will terminate, terminate, terminate. That is the not so cool side of this thing. Qc 4 Cp M“I accept whatever God gives me” (Lb 1 F), “it’s against religion”(Lb 8 Cp H), and “it is an ethical issue before a religious one” (Lb 10 Cp F):As for Lebanese participants, they were also enthusiastic about knowing the sex of the fetus through NIPT. However, they totally disapproved of its use for non-medical sex selection. They mentioned different rationales, such asOf course not. It is related to religion and it’s about culture. Whatever God gives me I will accept it, being healthy is more than just a blessing. Be it five girls or ten boys! Lb 9 Cp FNo, I already don’t like that because for me it’s against nature, what will happen will happen, you don’t have to choose, it’s weird. And it’s a luxury but I wouldn’t feel comfortable doing that. Lb 7 FHowever, one Lebanese woman stated that if NIPT becomes commercially available people might consider it for such use:Personally, I am against it and I wouldn’t do it. However, people might consider it for such purpose if it becomes commercially available. Lb 15 FWhen asked about the use of NIPT for non-medical traits, all other participants rejected such use, except for one Lebanese couple who approved of using it to test for cosmetic traits such as physical characteristics (such as eye and hair colors) out of interest and curiosity:There is no problem in using it for this purpose. I am not against it. Lb 10 Cp FWhy not. It would be of interest for me. Just to know for example if his hair is like his mother’s or his father’s. Lb 10 Cp MLb 3 Cp F) until the delivery of your child. Many other participants argued that you have to accept what God gives you and you should not let humans control such things:Some were convinced that you should allow nature to take its course and you should reserve such “surprises” .Most participants agreed that if it would be possible to test for more conditions or diseases, those that are life-threatening or related to the quality of life of the future child should be targeted. Moreover, they emphasized the need to “God’s hands” and be “God’s will” (Lb 3 Cp F).We noticed Quebecois participants and Lebanese participants shared similar views. For instance, some Lebanese participants completely disapproved of using NIPT for FWGS because they considered it to create anxiety for both parents and the future child, or based on the notion that what happens in the future should remain only in “No, I am against it because it’s all about God’s will. Even if the fetus has a problem, in the end I think that by terminating a pregnancy we will be killing a soul. This is why I am against it. I accept God’s will because no one can predict what will happen tomorrow. Lb 3 Cp FAnd other than that, we might know that our child will develop cancer in 15 years. It is bad for him even bad for us to know such information because we will be anxious and waiting for the disease to develop, so let it be as it is. Lb 3 Cp MSeveral Lebanese participants approved of the use of NIPT for FWGS to detect conditions that might develop at birth or during childhood in order to prevent or treat them or to manage their pregnancy (prepare for the child’s birth or terminate the pregnancy), nevertheless they disapproved of its use to obtain information related to conditions with onset in adulthood.Honestly, I would be interested if it will give me results related to conditions that develop at birth. Because for instance, if, God forbid, my child will have any problem when he is born, I might be able to help him. But I will not go for it to know about the risk of conditions that might or might not develop later on because I do not want to be anxious throughout my whole life, thinking and waiting for the disease to appear at a certain age. Lb 11 FMoreover, some stated that they would perform NIPT for FWGS out of curiosity while deciding not to do anything about the pregnancy:This is controversial because you never know what will happen. Maybe he will develop Alzheimer’s but after many years there will be a cure for Alzheimer’s. However, for curiosity’s sake, I will certainly go for it. But will I be doing anything about my pregnancy? No, I will not. Lb 9 Cp FIf I can know what is waiting for me, and what is the baby’s risk to develop a disease at birth or even later on during his life, I would definitely go for it. Maybe we can prevent or treat and if not, at least I will know what to expect and I will be prepared. Lb 12 FThis study provides an insight into the opinions and views of participants regarding potential future uses of NIPT from two different cultural contexts: Quebec and Lebanon. The most interesting finding is the striking similarities between the views of participants from both settings. We expected to find differences because of the specific cultural and social backgrounds characterizing each context. We also expected differences due to findings we published previously, based on our analysis of different themes, showing how these backgrounds shape and influence pregnant women and couples’ decision-making surrounding NIPT .Most participants from both settings were enthusiastic about knowing the sex of the fetus through NIPT. However, they were unanimously against considering it for non-medical sex selection. Objections to the use of NIPT for sex selection were also reported by other studies, where diverse stakeholders including the public , pregnanNIPT may facilitate couples and pregnant women’s choice by offering them information regarding the fetus’s health and hence, allowing them either to prepare for the birth of a child with a certain genetic condition or to consider the option of pregnancy termination.It is worthy to note that our study considers future uses of NIPT that may be medical or not . The concerns expressed by Canadian participants regarding non-medical sex selection through selective termination, need to be understood on the backdrop of the decriminalisation of abortion in Canada and its availability, in principle, throughout the pregnancy . In CanaThis is clearly not the case in Lebanon, where reproductive rights are more restrained by law, since termination of pregnancy is illegal, except to save the mother’s life , 29. On Expanding the use of NIPT use for non-medical traits, such as eye colour, was rejected by the vast majority of participants from both contexts. Rationales put forward by participants were that doing so was against God’s will and/or against nature’s course. These justifications have been raised and explored in other studies. For instance, religion and accepting what God gives you was a pronounced theme in a study that surveyed and interviewed Latina women deciding whether to accept or reject NIPT . In anotInvoking God and God’s will to discuss NIPT use for non-medical reasons by Lebanese participants reflects the social and cultural nature of the Lebanese context. In Lebanon, religion is integrated in state affairs – “personal matters including inheritance, marriage, divorce, custody, and support are dealt with in religious courts”  (p.2), aHowever, it was a surprising finding that religious reasons were brought forward by Quebecois participants given that religion is not embedded in everyday or political life especially when compared to Lebanon. In Quebec, since 1960, the State and the Church have been separated, with no involvement of the Catholic church in state affairs . One posThe majority of participants from Lebanon and Quebec were favourable towards the use of NIPT for paternity testing in specific cases, such as the existence of doubts or conflicts with regards to the identity of the father. This finding does not align with the one in Farrimond & Kelly’s study, where participants mostly did not support paternity testing through NIPT  out of fParticipants from both countries also shared similar views concerning the use of NIPT for FWGS. Contrary to the other uses explored, participants were more ambivalent when it came to this use. They were interested in FWGS for diseases that develop shortly after birth or during childhood and that are preventable or treatable. Our findings resonate with those from other studies showing that participants were favorable towards testing for childhood-onset conditions, whether or not performed through FWGS , 34–36.However, our participants disapproved of receiving information about adult-onset conditions. Attitudes towards testing adult-onset conditions in the literature are more varied compared to childhood-onset conditions. In the Kalynchuck et al. study (2015), although the acceptability of testing for adult-onset conditions was not as strong as for childhood-onset conditions, 76% of pregnant women and their partners going through first-trimester screening sated they would want to receive fetal whole-exome sequencing (FWES) results for treatable adult-onset conditions, and 74.3% for untreatable adult-onset conditions. Similar results were reported in Sullivan et al.’s study (2019), where 81.2% of pregnant women (≥ 8 weeks) receiving prenatal care stated they would want to receive, following FWGS through NIPT, information about common treatable conditions, 76.3% for serious treatable adult-conditions, 68.9% for fatal non-treatable adult-onset conditions, and 65.5% for common untreatable conditions.Conversely, participants from other studies were not as interested in testing for adult-onset conditions. In Bowman-Smart et al. (2019), 37.6% of pregnant women who had already undergone NIPT in the past supported the availability of NIPT for non-preventable adult-onset conditions, and 45.0% for preventable adult-onset conditions . MoreoveIn sum, our participants seemed to accept NIPT uses for detecting diseases in order to treat or prevent them if possible. However, whenever the discussion stepped into the domain of non-medical uses, they referred to God, religion and nature as justifications for their objections. One possible explanation of this finding could be that referring to God and nature reflects participants’ fear of over control and treating children like products.Some Quebecois participants spontaneously mentioned that it was the child’s right not to know about adult-onset conditions. This is in line with the Canadian Paediatric Society’s position statement on testing of minors, which states that “for genetic conditions that will not present until adulthood (susceptibility or predictive testing), testing should be deferred until the child is competent to decide whether they want the information”  (p.45), However, the child’s right not to know was not addressed by Lebanese participants. This might be explained by the social and cultural contexts in place, where children have little to no autonomy over their decisions, including medical decisions , and parThe comparative nature of our study provides insight into non-Western views, perspectives, and attitudes towards future uses of NIPT, which, to our knowledge, is not yet explored in the literature. In addition, comparative studies allow to shed light on differences, but also similarities between populations. While cross-cultural differences had important implications for NIPT decision-making , in thisThe description of FWGS provided to participants had been simplified to make it easier to understand. We did not offer a detailed description of conditions that might be detected. For instance, we did not differentiate between preventable and non-preventable adult-onset conditions, which might have affected participants’ responses. Considering that some of the future uses explored in our study were not feasible or not offered at the time the interviews were conducted, participants had to reflect on hypothetical scenarios. It is possible that their reasoning would have been different if they had to make actual decisions.Further, we noted that in our study, one Lebanese and two Quebecoise women chose NIPT testing. This might be explained by the fact that at the time of the interviews, the cost of NIPT was a barrier to access . NotwithIn addition, our study participants did not include women with a confirmed diagnosis of aneuploidy. The views of women post-diagnosis may be different, as the diagnosis of their fetus may influence their perceptions regarding the potential future uses of NIPT.NIPT is a fast-moving technology, and its uses have expanded since its first introduction. With the introduction of FWGS, its ability to detect a growing number of genetic conditions will expand. The findings of this study suggest that women and their partners, in Quebec and in Lebanon, support the use of NIPT for several traits and conditions that might be available in the future. However, participants still raise concerns about non-medical uses of the test. Moving forward and with future NIPT applications coming closer, it is important to explore users’ views and the acceptability of this potential expansion prior to its implementation, to promote evidence-informed, ethically sound, and culturally sensitive policy decisions.Additional file 1. Interview guide for pregnant women and couples in Lebanon and Quebec. Interview guide used to collect data from pregnant women and couples in Lebanon and in Quebec.


Dear Madam/SirTrehalose is a disaccharide composed of 2 glucose units connected by an α-1,1 linkage, compared to maltose that has a similar disaccharide composition but differs in the saccharide bond α-1,4). In humans, trehalose consumed at typical dietary rates is known to be digested in the small intestine by membrane bound trehalase, which splits the disaccharide into free glucose, which is available for subsequent absorption. The specific bond between the 2 glucose molecules of trehalose, however, impacts on its digestion rate, compared to maltose (a disaccharide of starch digestion), resulting in a slightly reduced absorption rate and consequently reduced glycemia, insulinemia and oxidation rate in energy metabolism, as we have shown in humans at rest and during exercise . In huma entitledNeither a clear hypothesis nor a discussion is presented about why free glucose, derived from trehalose, would lead to a different response compared to glucose absorbed from other carbohydrate sources.The authors failed to present a plausible mechanism explaining why glucose from trehalose is able to contribute to the prevention of pathologies that are predisposed to by postprandial hyperglycemia.The dose ingested, 3,3 g /day, along with the normal daily food intake, is so small that a measurable effect on blood glucose, hormones, metabolic fate and energy deposition can neither be expected, nor can be measured. . We are concerned about this choice and ask why not maltose, a comparative disaccharide also composed to 2 glucose molecules, has been given, ruling out chances that any difference between TRE and SUC may be due to fructose rather than properties of trehalose.A potentially lower glycemic response, due to a lower digestion rate, is possible after ingestion of a larger dose of trehalose. That this would translate in a lower diabetes risk is hypothetical. A problem with the current study, in this respect, is that dose ingested is negligable.The study was financed and carried out by the company Hayashibara Co. Ltd, the producer of Trehalose, using its own employees as study participants, which causes the work to be subject to bias and to potentially driving for a favorable outcome.Careful evaluation of the digestion, absorption and metabolism of trehalose substantiates that well controlled independent research is required before any conclusion can be drawn that the glucose absorbed from digested trehalose is able to impact on glucose homeostasis in favor of diabetes risk reduction. At present there are no data from well controlled independent studies that would allow to support the conclusions presented here by Chiyo Yoshizane et al. (2020).


Improving surgical interventions is key to improving outcomes. Ensuring the safe and transparent translation of such improvements is essential. Evaluation and governance initiatives, including the IDEAL framework and the Macquarie Surgical Innovation Identification Tool have begun to address this. Yet without a definition of innovation that allows non-surgeons to identify when it is occurring, these initiatives are of limited value. A definition seems elusive, so we undertook a conceptual study of surgical innovation. This indicated common conceptual areas in discussions of  innovation, that we categorised alliteratively under the themes of “purpose” (about drivers of innovation), “place” (about contexts of innovation), “process” (about differentiating innovation), “product” (about tangible and intangible results of innovation) and “person” . These conceptual areas are used in varying—sometimes contradictory—ways in different discussions. Highlighting these conceptual areas of surgical innovation may be useful in clarifying what should be reported in registries of innovation. However our wider conclusion was that the term “innovation” carries too much conceptual baggage to inform normative inquiry about surgical practice. Instead, we propose elimination of the term “innovation” from serious discourse aimed at evaluation and regulation of surgery. In our view researchers, philosophers and policy-makers should consider what it is about surgical activity that needs attention and develop robust definitions to identify these areas: for our own focus on transparency and safety, this means finding criteria that can objectively identify certain risk profiles during the development of surgery. Evaluation of innovation needs to be properly designed, conducted and reported to produce reliable high-quality evidence. “Governance” can take various forms, including legal regulation or monitoring arrangements. These aim at ensuring that innovation appropriately balances benefits and harms, to which patient information and consent for receiving an innovative (rather than a tried and tested) treatment can be calibrated. Although they are separate, evaluation and governance have been linked through guidance, notably the IDEAL framework, which sets down ways of evaluating innovation and specifies the types of studies required at different points in the innovation process for evaluating the innovation in question [Innovation in surgery is not always a good thing. Surgical innovation (SI) can produce harms as well as benefits. There is, therefore, a moral imperative to ensure that SI brings optimal benefit with minimal harm. There is widespread agreement that mechanisms providing greater oversight of SI should be developed . This imquestion . Yet, evis  addresses this limitation by operationalising a definition of innovation based on ‘newness’ . MSIIT egovernance. While MSIIT seeks to clarify newness with examples, this obscures the question of whether newness is an effective criteria for line drawing. We suggest it is easy to circumvent. Third, subjective newness is intentionally broad, so the tool measures many false positives and relies on the surgeon to identify which cases are mistaken. This passes the burden of identifying innovation to the surgeon (by asking them instead to identify what is new), thus undermining MSIIT’s aim of aiding practitioners. Finally, and importantly, it is questionable whether surgeons are the most appropriate people to judge innovation in their own practice. Research identifies surgeons as subject to various conflicts of interest [That MSIIT is based on valuable conceptual research that sets it apart from previous ad hoc definitions. Nevertheless, the tool itself is open to four criticisms. First, using ‘new’ to define innovation appears to swap one indefinite term for a related indefinite term, since ‘Innovation’ is etymologically closely related to ‘new’.interest , 44, 69.interest , 70. Oneinterest  to mitig—to objectively identify innovation. For this reason, although indebted to the conceptual work that underlay MSIIT, we wished to step back from the MSIIT definition. We intended a conceptualisation of SI that transcended specific aims and agendas, to uncover the possibilities and commitments involved in formulating a variety of definitions to meet a variety of aims. Our approach to conceptualisation is discussed now.Helping surgeons to identify innovation in their own practice appears laudable, as this could encourage the safe translation of innovation to practice by encouraging effective evaluation studies. However, MSIIT is an incomplete response as, practically, we still require definitions—for effective governance and beyond7While sometimes considered the foundation of philosophy, conceptualisation is a contested field . Classic8qua SI, and draw on these features when developing future definitions for specific purposes. Our idea was that such a conceptualisation should contribute some underpinning structure to the different definitions of different policy-makers, researchers and practitioners. By undertaking a study of the ways SI, and innovation more broadly, is discussed by commentators in the literature, we intended to provide such a conceptualisation.While concepts are not definitions, conceptualisation can inform the development of definitions. Current paradigms, derived from psychology, suggest that concepts comprise hazy and overlapping features, none of which inevitably embody universally necessary and sufficient features.Our investigation began by synthesising the ways innovation is discussed in surgery and a range of other disciplines. A conceptualisation so derived elucidates conceptual areas of SI, but we reiterate that this was not to furnish a definition by providing the necessary and sufficient features of SI. Instead, our intention was to detect an undergirding conceptual structure.Primary sources in the study of innovation are found in agricultural sociology and economics. Application of the concept to surgery brings in literature from not only surgery, but also bioethics, health policy and medical history in which SI features. As such, our method needed to sample literature from numerous fields of inquiry. We adopted Dixon-Woods et al.’s  CriticalUsing keyword searches derived from the initial research question “How is innovation and its phases  conceptualised and articulated, as they pertain to surgical innovation/innovation in invasive interventions?” we derived a sample frame of 220 sources. Our initial searches excluded clinical research articles reporting surgical outcomes, reasoning these would not allude to the concept of innovation in a form amenable to analysis. Excepting this criteria, any sources that offered reasoned discussion of what innovation is were included see Fig. .12Fig. 112Analysis followed the principles of theoretical sampling. A total of 72 sourcesOur study suggests 5 conceptual areas pertaining to SI Table . For claStudies explored the drivers of SI, suggesting that SI may be undertaken due to patient, surgeon or industry needs or desires. This category also raises the question of whether demand is created by innovations or vice versa.Responding to Patient Needs or Wants The interests of patients, surgeons and industry may to some extent overlap, making clear distinctions about what drives innovation is problematic. Nevertheless, the literature identifies a number of different drivers. Some suggests that patient wants and needs are drivers of SI [rs of SI . These mrs of SI . Others rs of SI . Likewisrs of SI , a motivrs of SI . Meyersors of SI , which srs of SI .14 Outsirs of SI , 51. McKrs of SI . On thisSurgeon and Industry Demand In surgery, demands may come from patients, industry, or arise from surgeons. Surgeons may want to perform a procedure more efficiently or quickly in order to meet their own or institutional need, or they may want to build their career as an ‘innovator’—and this may or may not coincide with responding to patients’ needs. The introduction of innovative devices appears largely driven by industry, based on a desire for market share, and can be imitative of existing devices [ devices , 59. Suc devices ,15 whichIn summary, the role of wants and needs of various parties suggests that “Purpose” is a conceptual area of SI. Definitions of SI may thus take a position on how—if at all—the drivers of an activity feeds into whether it is treated as innovation or not, and why this is the case.where—contextually and geographically—innovation is held to take place. Debates about context largely turn on the relationship between innovation and research, with a subsidiary debate about whether premeditated variations constitute innovation or research.The concept of SI also pertains to Geographical Place Discussion of geographical place is limited to whether diffusion of a SI to a new a location should [n should  or shouln should  play a pn should .16 A lean should . The lean should . A new gDifferent to Research? As a contextual feature, whether innovation is or is not distinct to research is extremely important. If it is indistinct, then the label of innovation is a mere flag of convenience to avoid scrutiny. If it is not, then it represents a lacuna that is insufficiently considered by current governance structures. The literature is divided on whether innovation is equivalent to, or distinct from, research. While acknowledging that research may follow innovation, many distinguish research activity from SI [ from SI , 16, 21. from SI , 52, 65. from SI , 44.vis research is ambiguous, whether an activity is labelled by a surgeon as innovation or research is merely a choice of terminology and may be driven by a desire to avoid the burdens accompanying research [all surgery research [If the status of innovation research  or accesresearch ,19 whileresearch .20 Some research , 45. Indresearch . Extendiresearch , 73. Howresearch . Spontanresearch , 73. Somresearch . These aresearch , suggestresearch .The relationship of SI to research, routine variation and standard practice remains contested. If safety issues inform whether something is defined as innovative, then that definition may need to attend to many other aspects, such as the learning curve, and thus geographical place. Definitions may also consider ‘place’ in terms of context and, depending on the aim of the definition, either choose a definition that disentangles innovation from research or a definition that makes innovation part of a research process. Any of these options might be justified but will imply different kinds of governance.how innovation is achieved, which may be characterised as a process, a discrete event, or combinations thereof. SI may, therefore, involve a one-off event or a series of events (and revisions), with the latter resembling a process. However it is achieved, if the process/event of SI is to be distinguished, it must have features, like impact or newness, that mark it as different from the process/event of normal surgical practice.The concept of SI includes consideration of Nature: Process or Distinct Event? Perhaps due to their differing aims, the MSIIT and IDEAL implicitly take different approaches to the development of SI. MSIIT, in searching for criteria that can prospectively distinguish routine variations and introduction of new procedures to new geographical locations from SI [—existing innovations whose dissemination allows further innovations to arise [ from SI , presupp from SI , 38, whi from SI . While u from SI . Similar from SI . Rogers’ from SI . Descrip from SI , suggest from SI . Iteratito arise . Iteratito arise . Moreoveto arise .Features: Departing from Existing Standards The literature generally argues that SI must differ from what occurs in surgery on an everyday basis. The 1978 Belmont report on research ethics suggests that medical innovation occurs “when a clinician departs in a significant way from standard or accepted practice” [21ractice” . This tyOne frequent way this difference is characterised is as ‘newness’, or similes such as ‘novel’ or ‘first’ , 48, 73.Within this conceptual area, thought must be given to whether a definition aims at breadth or precision, and to which compromises to accuracy are acceptable. Defining SI as a process may exclude details to increase intelligibility and simplicity, while a definition that favours a distinct event must be clear about how iteration is explained and/or excluded.The concept of SI includes any products of SI. Narrowly construed this product may simply be the surgical procedure or instrument itself. However, commonly the products of an SI include  the consequences of the innovation. Consequences might be tangible, like patents, or intangible, like risk. To some degree a discussion of consequences may overlap a discussion of the drivers of innovation (our theme of “Purpose”) as particular consequences may be assumed in embarking on innovation. Nevertheless, we feel that consequences are more coherently considered as a theme in their own right,Tangible Products Tangible products, such as patent or the prospect of publication have been associated with SI [ with SI , 29, inc with SI . Since p with SI . Moreove with SI , Socio-e with SI , 30, 67.Uncertainty Intangible products such as risk are commonly associated with SI [—of some magnitude—may be a persistent feature of SI. Discussions often view risks as proxies of harm, however the flip-side of this is to argue that benefit is the defining product of SI. This benefit may be characterised abstractly or indirectly—such as in terms of producing knowledge [ with SI , 40, 73. with SI , new occnowledge .24 Alternowledge . While bnowledge , and bennowledge . Similarnowledge .25 Arguaexpected outcomes are markers of innovation [While consequences are by their nature unpredictable, some observe that risks and benefits of SI cannot be known prospectively;  indeed, novation . A definThe identity of the innovator in SI is conceptually significant given the prevailing model of innovation (on which IDEAL is based), and the frequency with which surgery and surgeons are identified as innovative. Further, the conceptual area of ‘person’ includes questions of intention central to whether definitions identify SI as subjectively or objectively determined.Personal Characteristics Rogers’ influential sociological theory of the spread of technological innovation explicitly categorises innovators and adopters according to personal characteristics. These include those related to socioeconomic status and “personality variables” including empathy, rationality, and intelligence that Rogers collectively terms ‘innovativeness’ [iveness’ . Rogers’iveness’ . Rogers’iveness’ . Emphasiiveness’ , howeveriveness’ . Others iveness’  includiniveness’ , compassiveness’ , conscieiveness’  and dediiveness’ . Surgicaiveness’ . SI alsoiveness’ , or at liveness’ , 73.26 Niveness’ .27 Histoiveness’ , and somiveness’ .Intention The intention of the surgeon is also, often, noted in discussions of SI, underlining the connection of innovation to debates about what constitutes research, where intention is also considered important [mportant . Some almportant , 73. A dmportant  who implmportant . Difficumportant .28 Subjemportant , 62, 73.mportant  and defiAs with the preceding areas, the approach to this conceptual area will be guided by the aims of a definition. Definitions aimed at sociological studies of surgeons may concentrate on personological descriptions of surgeon innovators, while definitions aimed at safety may seek define innovation objectively and independently of the person.The analysis we have presented from our Critical Interpretive Synthesis has two distinct uses that we will consider in two main sections in this discussion. In the first we offer a conceptual structure for future definitions of SI. The second section discusses our increasing scepticism about the usefulness of SI as a concept, that has led us to question the salience of a definition that claims to identify every instance of SI. Thus, the second section of our discussion presents our analysis as evidence that future studies should take an eliminativist approach to identifying SI. By this we mean that, in inquiries that investigators intuit to be about SI, rather than attempting to define SI, the more important and useful task is to determine what role the term ‘innovation’ would play in one’s inquiry, and then to devise specific definitions that identify the surgical activity pertaining to that area. Our broad motivation for this conclusion is that the term SI appears to carry a great deal of ambiguous conceptual baggage that can only serve to obfuscate and avoid scrutiny of the development of surgical practice.There will never be one single definition of SI, but rather numerous definitions designed for numerous purposes. The five themes of purpose, place, process, product and person relate to conceptual areas that constitute a conceptual toolkit to help ensure a definition is justifiable at a structural level, and carefully considers what it needs from each conceptual area. Each of these conceptual areas require consideration when devising a definition of innovation. A collection of non-exclusive ways that these elements could be resolved into a definition is given below. For clarity we reiterate that these are not intended to be examples of necessary and sufficient features, and we are not proposing a definition. Indeed, some of the elements would be contradictory if taken together. Rather, in Fig. 30Potentially such a toolkit could inform what ought to be reported when information about surgical techniques or equipment is shared. Numerous commentators have proposed (sometimes compulsory) formal registries of SI , 59, 61.32external oversight and regulation of SI to ensure patient safety. It is also notable that not all of these conceptual areas had discriminatory power. Despite them being common themes that run through the discussions of innovation we examined, many had much in common with other types of healthcare interventions. We reasoned that such lack of distinction may be because innovation itself is not distinguishable from much of healthcare. Since so much that was needed to conceptualise SI was either not needed for our purposes, seemed to obfuscate the activity we had intended to identify, or was common to healthcare practice, our conclusion is that an eliminativist approach to SI would be more effective. By effective, we mean that an eliminativist approach would reduce the chances that regulation could be misinterpreted (willfully or otherwise) or misunderstood, thus ensuring a more stringent approach to evaluation and regulation focused where (we argue) it is most needed. This approach stemmed from the view that SI was too hopelessly laden with conceptual baggage to be useful in bioethical discourse. By ‘eliminativist’ we do not mean erasing innovation from language altogether—we agree this would be undesirable and likely impossible given such language is entrenched in surgery. “Innovation” will retain some, primarily rhetorical, uses. But we should call out the essential meaninglessness of the term in serious discourse aimed at evaluation and regulation. In these areas, we should consider what it is about surgical activity that needs attention and develop robust definitions to identify these areas. For example, our own concern is that some surgical activity needs to be safer and more transparent. Given that focus, what seems important to us is both the need for surgical activity to be transparent to third-parties, and (lack of) knowledge about the safety and efficacy of a subset of surgical activities (that may otherwise be labelled as SI). This focus suggested our definition should therefore be objective and should not rely on the probity of individual surgeons to self-report. Rather, it should concentrate on identifying how much is prospectively known about the safety and efficacy of a procedure.As we stated at the outset of this article, our primary purpose is improving the evaluation and regulation of surgical practice. While a conceptual toolkit of the sort presented above was our original intention, we were unprepared for the breadth of potential definitions a conceptualisation would support, and this might impact on our primary purposes. The nature of each conceptual category allows diametrically opposing interpretations, and our analysis shows that at least some of these opposing interpretations are apparent in the literature. Further, many of the conceptual areas would not be needed for our own, regulatory, purposes. This again underscored the scope for dissimilar definitions of a putatively similar phenomenon in different disciplines. For instance, the “Purpose” of a SI might be of interest to social scientists, but be of little help in identifying innovation for regulatory purposes. The context variability was particularly true of the fifth conceptual area, “Person”. The frequency with which the various claims of the affinity of surgeons and surgery to innovation and the regularity of commentary that claimed that intention was a key feature of innovation meant that the person-centred conceptual area appeared important to SI. Nevertheless, a focus on the innovator, and the implications this has for the subjective determination of SI by the surgeon, seemed to work against the (to us compelling) arguments for the need for SI raises numerous ethical and practical questions that suggest it requires greater oversight. Despite the progress that has been achieved in this field, the absence of robust definitions frustrates this purpose. We observe that the definition formulated by the MSIIT study serves specific purposes that make specific (and questionable) assumptions about the probity of surgeons and the nature of innovation. A prospective definition to be used by surgeons is only one of many types of definition that may be useful to the aim of the safe translation of SI into everyday practice. Our conceptual study synthesises a range of sources, concluding that the concept of SI includes information about these conceptual areas; the drivers and purpose for which innovation is undertaken; the contextual and geographical place where the innovation is undertaken; attempts to differentiate innovation from other processes; its tangible and intangible products and consequences, and; the viewpoint and personal traits of the person who innovates. While potentially elucidating definitional criteria, these are so broad as to allow numerous dissimilar definitions of SI. These may further obfuscate and complicate oversight of SI. We therefore, for the purpose of evaluation and governance of surgery, propose an eliminativist approach. Instead of seeking to formulate a universal definition of SI, this approach focuses on the features of the surgical activity that we consider to be in need of scrutiny and develops robust definitions to identify these. Such an approach is both simple and effective, and ultimately will benefit both patients and surgeons.