The live chat technology was well received by both groups, especially for its ability to provide instant, real-time, and convenient help. Live chat was particularly well received by online learners, who were more satisfied, felt more cared about by the teaching team, and would be more likely to recommend it to others than blended learners. Further, online learners reported that live chat gave them better access to staff, and felt that this feature was a good approximation for more traditional face-to-face conversations. As an online, synchronous, private help-seeking tool between student and teacher, these findings provide a strong endorsement for the use of live chat in higher education, particularly for online learners.Help-seeking is an essential self-regulatory and metacognitive skill. In the online learning environment, much of the learning is self-directed and there are generally less opportunities to receive help in real time. The uses of email and discussion boards are the most common method of seeking help in these environments. The current study explored students’ perceptions of the use of live chat technology for online academic help-seeking within higher education, with a focus on comparing online and blended learners’ perspectives. Participants were 246 students who were studying psychology online ( With much of the learning in higher education now occurring online, with stay at home restrictions of COVID-19 as an extreme example, there are reduced opportunities for traditional student-to-teacher and student-to-student interactions . These modes of communication allow one-on-one or one-to-many interactions. However, reports suggest that phone calls continue to have reduced popularity as a mode of communication as they are seen as disruptive, inconsiderate, and overly time-consuming  and client  and the customer (e.g. student), is not attached to any social media platform, and does not allow customers (e.g. students) interact with one another  were more likely to be female (90%) and were undertaking a Bachelor’s degree in Psychology (57%), and had a mean age of 21.68 (SD = 5.93) years. Online learners (n = 91) were also more likely to be female (88%), had a mean age of 31.66 (SD = 10.09) years, and currently undertaking a Bachelor’s degree in Psychology (69%). Age differences between groups were significant; t(125.70) = 8.546, p < 0.001. Gender composition did not significantly differ across groups. All participants were enrolled in one or more of eight psychology subjects spread over years 1–3 of an undergraduate bachelor degree  that were using live chat as a help-seeking tool during one or more trimesters. Most participants were taking only one subject using live chat (n = 123), followed by two (n = 66), four (n = 18), or three subjects (n = 15). Twenty-four participants did not specify how many subjects they experienced live chat in, though they were retained as their responses indicated exposure to live chat in their studies. Please note too that blended learning students in this study have a face-to-face component to their studies, whereas online students have no face-to-face requirements and all studies are conducted online.Participants were 246 students currently attending [anonymous] University in Australia, and aged between 18 and 60 years of age. Blended learners (https://www.livechatinc.com). LiveChat® is a service-based helpdesk software that allows online chat between the service provider and client . Live chat is different from instant messenger services which provide a communication service between friends. The LiveChat® platform allows staff to talk one-on-one with multiple students at a time. The chat is private between teacher and student, such that the chat with one student is not visible to any other student. The platform allows students and staff to share files, save transcripts, and chat in real time. Students can locate the LiveChat® software on each Learning Management Systems (LMS) homepage as a pop-up widget. LiveChat® was monitored by the subject coordinators and by senior tutors, and the widget was only visible to students in a subject when the corresponding subject staff were available. If staff were not available, e.g. outside their virtual office hours, LiveChat was not available to learners. Figure The live chat software was developed by LiveChat®  plus a did not use/not applicable option. The four rating scale questions asked participants (a) how useful live chat was for ‘just-in-time support’, (b) whether using live chat made them feel like the teaching team cared about supporting their learning, (c) how satisfied they were with live chat as a communication tool, and (d) whether they would recommend live chat to other students.Open-ended questions asked participants about (a) what questions they asked, (b) what questions they did not want to ask, (c) what they found most useful about live chat, (d) what they liked, and (e) how it could be improved. Participants were then asked about how they seek help and were prompted to give reasons why they would use (a) live chat, (b) email, and (c) discussion boards to seek help.Ethics was approved by the University’s ethics committee. Participants were enrolled in one or more subjects that were using live chat. Subjects ran in dual mode with blended and online students enrolled together. Live chat was used as the communication channel during virtual office hours. The first author ran one of the subjects that used live chat. Students were alerted to the staff virtual office hours on live chat through announcements on the subject homepage. Each subject used live chat in different ways and at different times of the day that fit with the availability of staff. Most subjects had a set virtual office hours each week. During assessment weeks, additional virtual meeting hours were to facilitate the extra communication needs of students. At the end of the trimester, an announcement on the learning management system alerted students to the study. Data were collected via an online survey provided as a link on announcements on the LMS. Participation was voluntary. Participants went into the draw for 2 × $50 gift vouchers.This is a cross-sectional study using mixed methods. An inductive thematic analysis was conducted to draw themes from responses for each question for the group as a whole. Braun and Clarke’s  six-phasn = 11), or (b) completed both surveys within different trimesters, and there was some overlap of subjects (n = 2). From the 25 participants who completed the survey twice, both responses were included if they (a) occurred in different trimesters with different subjects (n = 9), or (b) occurred in the same trimesters but with different subjects (n = 3). One person was excluded because they were not enrolled in any psychology subjects with live chat. Three participants were excluded for being under the age of 18, and three participants were excluded for giving unreliable data, e.g. humorous responses. A total of 246 participants remained (details in participants section).Three hundred and sixty-seven participants started the survey. One hundred and one participants were excluded as they did not complete any, or only completed the demographic portion, of the survey. Twenty-five participants completed the survey twice. Participants’ first survey was kept and the second survey excluded if they (a) completed both surveys within the same trimester and named the same subject both times  e.g. “private questions personal to me….” “Questions which required confidentiality or a timeline”. However, from the comments provided, it seems some students did not know that other students could not see their questions “such as some private question since it is public”.A small portion of students felt uncomfortable asking private / personal questions  pertained to time of use. A large proportion of students found live chat was “…most useful, during the assignment period towards the due date” and “When I was completing assessment tasks, usually week leading up to deadlines.”A similar number of students said it was useful when they needed a fast response “When I needed an assignment question answered quick while I was working on it and not have to wait several days” and “The fact that it was live and I got answers almost straight away. That’s where the discussion boards can lack because you can wait almost a day for an answer to your question when you need to know right away most times.” This theme also included it being available just-in-time for them, that is, “anytime”, “all the time” and “every time I needed it”. This theme was particularly important for online students who mentioned it significantly more often than blended learning students.A small amount of both blended and online learners preferred to use live chat during the day or before or after class. Significantly more online learners indicated they preferred the evening and significantly more blended learners preferred using live chat when they are at home.Table More than three-quarters of learners mentioned that they liked the instant / real time / convenience of using live chat. They felt it was a good use of their time, helped continue with the flow when they were studying, and they liked the real time responses. For example, “I love that it's an instant response i.e. my questions were answered within a minute or two and I could then move on and keep working on my assignment” and “…..the instant nature of it. Emails usually have a lag and for example right before a deadline time is of the essence! Made me feel more relaxed knowing id be more likely to get a response”.Relationships with and accessibility to staff were also important to learners, particularly online learners, who mentioned this significantly more often than blended learners and in nearly 50% of comments. For example, “……It feels more personal—almost like talking directly to someone, rather than sending an email. It actually makes being an online student feel less isolating. You are aware that being off-campus, that you miss out on one to one contact with tutors and lecturers, but this allows for one to one contact in a different way.”One fifth of learners mentioned they liked live chat because of how easy it was to use or that its good design features (such as that it popped-up or that it could send transcripts of conversations) made it an easy and useful mode of communication. For example, “easy to use and very familiar with the function ”, and “Easy to use, and helpful. Visibility—good that it pops up when you log on”.Lastly, learners liked how helpful live chat was. For example, “It didn't seem like I was annoying them with questions and it felt a little bit more personal ”.For a smaller proportion of learners, they used email if they wanted to keep a record of the conversation “for traceability (evidence), that the exchange took place”, or if it was not urgent or live chat was not available.Table The common reason for using the discussion boards was for collaborative learning. Students used this method when they thought the question and responses would benefit others, or that they would benefit from calibrating their understanding against their peers. For example, “posting questions which are likely to be concerns of others as well—so teaching staff only have to respond once” or “for questions that I would like other students’ opinions on e.g. other ways of seeing the same information to gain a better understanding” or “to obtain differing viewpoints on a topic where multiple opinions are useful or valid”.The types of questions students asked were related general questions e.g. “general questions regarding content, referencing, assignments, classes etc.” Again this often related to anyone being able to respond and being useful to others. Students mentioned that these questions were unlikely to require privacy, or that the students were “not embarrassed asking”. Students also mentioned that they used the discussion boards when live chat was not available or help was not urgently needed.The current study aimed to explore the use of live chat technology for online academic help-seeking within higher education subjects, with a particular interest in exploring any differences related to study mode as an online or blended learning student. Both blended learning students and online students were overwhelmingly satisfied with the use of live chat as a tool for online academic help-seeking. Notably, they felt that by using live chat, the teaching team cared about supporting their learning, and students found it useful for just-in-time support, and would recommend it to other learners. These findings align with other studies that have found that students have high levels of student satisfaction (e.g. Luo et al. As predicted, online learners at times did significantly differ in their perceptions of live chat compared from blended learners. While all learners endorsed the use of live chat as a help-seeking tool, online learners were significantly more positive than blended learners, highlighting the importance of such a tool for these students. This is a particularly critical issue for online students, who can feel isolated from peers and the institution given they are not on campus. From the thematic analysis, two reasons that were mentioned significantly more often by online students stand out as to why online learners may have preferred live chat more than blended learners. The first is the ability to access teaching staff, and to be able to approximate face-to-face interaction they miss out on as an online student; and second the ability to get a quick response and just-in-time help from staff. As the usual modes of communication for online students in this context were online discussion boards and email, it is unsurprising that these are two important themes for them. These comments demonstrate the importance of real-time connection with teaching staff, teacher presence, and being able to get help in-the-moment rather than waiting for a delayed response for online students. These findings also contribute further understanding of help-seeking behaviours of different students groups. Previous research has found that help-seeking is often an underutilised SRL strategy for online learners (Broadbent, Overall, all students liked that live chat was an instant, real-time help-seeking tool that was convenient to use. They said that they found live chat most useful when they needed an urgent response, particularly around assessment time and mostly asked questions—unsurprisingly—about their assignments. Interestingly, while all students found live chat useful to get clarification around assessment, the blended learning students were significantly less likely to ask questions related to asking for extra time to complete assessment, discussing the grade and feedback on their assessment or asking for the assessment piece to be re-marked. This did not appear to be problematic for online students, perhaps because of their limited means for help-seeking, but online students did often mention this was a reason they would preference the use of email. Overall, however, both groups of students said they were comfortable asking anything on live chat, they thought no improvements were needed, except that it should be available more often and in more subjects.When asked about alternative help-seeking methods, all students said they were likely to use email for more formal personal and private matters. While live chat was private, from the students’ responses, it appears that email was thought to be more private, perhaps because the student understood who would be responding to their question and could direct their question more specifically to a single person. Also, email was preferred, as previously mentioned, when students wanted to dispute a grade, feedback or get a remark, which may have required some thought about how to put together the question. This finding aligns with another theme that email was preferred if they had a long and detailed question, aligning with previous studies looking at student communication preferences Lodge, . When asThe current study used live chat in eight psychology subjects where the bulk of the students were female psychology students, live chat may be particularly suitable for this segment of the broader higher education population. Exploration of other courses, particularly male-dominated courses, would be useful in future research. Further, it is not known what was discussed between teachers and students on live chat, only what students reported in the survey, which may have been different if transcripts had been analysed. Gathering this information may give some useful insights into what types of questions, time of day live chat was most frequently used, and time required to use the tool.Lastly, this study did not acquire perceptions of using live chat from teaching staff; this, would be useful to explore in future research. While this study utilised live chat during pre-arranged office hours chosen by the teaching staff, Li and Pitts  have shoThe implications of this study is that it has demonstrated the efficacy of live chat as an online help-seeking tool in higher education between teacher and student. The tool was well received by both online and blended learners, particularly its ability to provide instant, real-time, and convenient help. Live chat was particularly well received by online learners, who were more satisfied, felt more cared about by the teaching team and would recommend it to others. Further, online learners mentioned that they like that it gave them better access to staff and gave them the ability to have their version of face-to-face conversations. As online, synchronous, private help-seeking tool between student and teacher, these findings provide a strong recommendation for the use of live chat in higher education.


Given the global trends toward an aging society and the increased desire for healthy aging in late life, this study examines older adults’ perceptions of aging and their physical identity through their engagement in physical activities. Adopting a grounded theory, we interviewed 15 individuals aged 65 years and older, who were involved in physical activities on a regular basis. This study provided a final model depicting (a) divergent and convergent modes of strategies and socioemotional aspects of physical identity development in later life and (b) different strategies employed between younger-old versus older-old age groups and between participants who have underlying health conditions and those who do not. These findings add a contextual explanation of identity development in later life and stress the recurring process of physical identity development. Most people in later life go through major life events, including retirement, children leaving home, loss of a near one, the onset of physical illness or injury, and changes in physical ability; thus, they experience signals that the end stage of life is approaching ,2. Such Some of the most influential life circumstances that older adults grapple with are health-related issues . ParticuWhen engaging in physical activity, older adults may experience a transformation of “feelings of control and autonomy and the development of an identity as an exerciser”  p. 186)618,19].Extant studies on physical identity among older adults have examined relationships or associations between older individuals’ physical identity and their physical activity or health behaviors. For instance, Strachan et al.  showed tWe adopted Strauss and Corbin’s ,25 versi®, Mountain View, CA, USA) for the initial transcripts, listened again to each interview, and proofread it. All recorded data were coded by using pseudonyms and de-identified. Following the theoretical sampling method, we collected and analyzed data simultaneously that informed us to decide what data needed to be collected next for illuminating the emergent theory ”.The seventh divergent phase, self-cognizance, (2) reconciliation, (3) moderation, (4) adaptation, and (5) transcendence. In the convergent process, the participants found commonalities based on multiple pragmatic knowledge of life to resolve issues they were confronted with. The convergent process includes the categories of (1) self-cognizance. Ten participants emphasized self-cognizance by analyzing self in terms of their exercise/body as they get older. For example, Meghan stated, “Sometimes I have to realize that I have my own limitations physically. And I have to honor those or suffer the consequences. And depending on how much I’ve had to suffer the consequences and how much it hurt, I either listen or don’t”. The first convergent phase begins with the realization of one’s own physical and mental conditions and abilities, which is identified as the category of being cognizant of their body’s threshold. Ten participants emphasized the importance of understanding their physical limitations by reconciliation in which the participants find ways between seemingly opposite things in which they could be successful. When asked to describe their current physical activity and future intention, 11 participants described their intention to maintain current exercise without challenges or a new exercise. For instance, Elvin said, “I really haven’t thought about any new things. I’ve been doing the same exercise”. Eight participants mentioned how they compromise between the ideal or younger and their present self. For example, Stanley said, “Now, it’s a matter of endurance … So, I don’t work out with the intensity that I used to work at. I work with more longevity in mind”.The second phase of the convergent process is identified as a moderation. Ten participants showed an unpretentious attitude toward other older people by trying not to boast of their exercise ability or preach. For example, Nicole said, “My friends from high school that I’m still close to, don’t have the advantages that I do. So, I don’t like to say to them, it’s almost like bragging”. Eight participants described their measured attitude when seeing age-related body changes by giving themselves permission to not be perfect. Tacey said, “I don’t necessarily look better than they do… I don’t think everybody needs to try to be perfect, you know, I just don’t think that’s that important”.In the third phase of the convergent process, participants tended to make sure their activities were not too extreme, demonstrating adaptation. This category can be divided into three subcategories of (a) assimilation, accommodation, and integration. Assimilation can be defined as a process where individuals maintain or protect a sense of self-consistency to circumvent negative feelings when facing an unpleasant situation. When asked to describe how they think about what they look like with age, six participants expressed that they managed their age-related changes in physical ability by accentuating things they still can do. Karolyn said, “I am trying to ignore that because if you start thinking about a problem, it’s likely to get worse”. Accommodation is defined as a process where individuals adjust their identity to better fit the new situation when facing an unpleasant situation. Ten participants acknowledged human mortality and the finitude of life that comes with age. Emilia described her modified exercise motive as she experienced her physical decline, “I don’t expect to live much longer … how much, 93? But I want it to be as healthy as possible. If I’m going to live for a long time, I want to be healthy. Yeah, I don’t want to be living like vegetating”.The fourth phase of the convergent process, which is a participant’s act of changing their personal behaviors or beliefs to make it suitable for a new situation or purpose, could be identified as an Integration can be defined as an act or process of uniting segments to a mature and holistic state by becoming closely linked to a new and existing self. Thirteen participants responded to age-related physical changes by living with them. Diane said, “I just accept it. There’s no point in fighting it, you can’t do anything about it. You’ve got arthritis in your knees … just live with it and adapt”.transcendence. Eleven participants emphasized a sense of humor or they joked and laughed when they talked about something unpleasant but irresistible. When asked to describe the participants’ perception of their body image with age, many participants gave a witty answer. For example, Meghan said, “I wear looser tops [laughing]… Just realize it’s, it is what it is. And I can either accept it, or I can find it and be miserable. And I don’t want to do this. Life’s too short”. Six participants mentioned that there was something they did not know at a younger age but realized in later life, which can be called wisdom-related knowledge from their years of life experiences. For example, Elvin advised the younger generation, including me, to make a habit of exercise earlier in adulthood.The final phase of the convergent process, which is the participants’ insight or way of behaving that lies beyond the practical experience of ordinary people that cannot be understood by ordinary reasoning, could be identified as social interaction and retrospection occurred throughout both divergent and convergent processes as the participants’ socio-emotional aspects. The participants’ belief based on the notion that meanings are shared and constructed between people was characterized as the category of social interaction. Thirteen participants had people who they regularly talked with, and they valued social interaction. The participants’ act of recalling things past, especially in their personal experience related to physical activities and people, was characterized to be the category of retrospection. Thirteen participants expressed their feelings of nostalgia by reminiscing about activities or situations. For example, the participants reminisced about enjoyable moments of particular activities and simultaneously described the memories of their family members and friends with whom they enjoyed the activities. The categories of The participants’ strategies to respond to the core category could be characterized by their age subgroup and underlying health conditions. In the following section, the categories are written in italics and the properties of the categories are written in underlined italics.extroversion, (2) individual orientation, (3) divergent thinking, (4) enthusiasm, and (5) vitality. Participants aged between 67 and 77 years were categorized into the “younger-old” group in this study based on our coding and theoretical sampling processes. The prominent categories among the younger group had the properties—“characteristic of a category”  (p. 101)extroversion were identified 83 times within the younger group, whereas the frequency in the older group was only 40 times. For example, one participant mentioned that he felt full of energy in his everyday exercise and carved out time for physical activity out of a busy schedule. Stanley (76 years old) stated the following:Codes related to the property of “Every day, every, every day, and most of the time I feel like I should be doing more. But the business has eaten up my time. We can be in the office all day. So, we’re making a concerted effort both my wife and myself making a concerted effort to try to carve out time each day for us to do that”.Another participant mentioned that she tried to act energetically to exhibit a positive image to her grandchildren. Aritie (72 years old) said, “I don’t want to be a grandmother in a wheelchair. That’s just my motivation to be active and to be with my family, active. That’s why I do the exercise”.individual orientation appeared 81 times within the younger group whereas it occurred only 44 times in the older group. For example, the following two quotations depict participants’ individual-oriented, self-initiated physical activity: “I call, I work alone. I would like to go with somebody, but the other people, the other ladies, they have another schedule, but I like to do it alone” ; “I find myself being very comfortable being alone, dealing with the issues myself, the treadmill or the workout I don’t need somebody there to encourage me” .Codes relating to the property of Most of the participants in the younger group emphasized that they did not mind engaging in the social type of exercise but preferred solitary exercise.divergent thinking appeared as a code 39 times within the younger group, whereas the frequency in the older group was only 14 times. For example, Sean (69 years old) highlighted how he adapted new knowledge and tips for muscle-strengthening exercises from his son:The property of “He (my son) has now gotten me, we are working on different sections to give those muscles a chance to recuperate, where I would work on chest and arms over and over again, and what he is teaching me is that when I do that, I tear the muscle down, but I don’t give the muscles the chance to recover”.enthusiasm appeared 36 times within the younger group, whereas the frequency in the older group was only 11 times. For example, one participant highlighted that she eagerly goes for a walk to relieve her stress. Artie (72 years old) said, “When I’m, when I get angry or upset or something, I go on a walk and I walk, and I walk. And after that, I feel better. They help me all the ways in, mentally, physically, emotionally”. Annika (67 years old) mentioned how she ardently engaged in her physical activity aided by an electronic fitness device. Codes related to the property of vitality were identified seven times within the younger group, while it appeared only two times in the older group. The participants in the younger group tended to do exercise that exceeds their physical limitations and recognized over-exercise. Stanley (76 years old) noted the following:Codes related to the property of “My biggest concern is that I am energetic enough and enthusiastic enough that I find it very, very easy to overdo it. I can go too far. And I feel like I’m not doing enough again, need to do more … And my wife is constantly reminding me that I’m doing too much I’m trying to do too much. That’s the biggest issue”.precaution, (2) reliance on experts, (3) convergent thinking, and (4) resignation. Codes related to the property of precaution appeared 32 times within the older group, whereas it appeared in the younger group only seven times. One participant, who had heart failure, emphasized the need for preventative behaviors in the pandemic. Emilia (83 years old) noted the following:Participants aged between 81 and 89 were categorized into the “older-old” group in this study. The prominent categories among the older group had the properties of (1) “I am more careful because I’m in that very dangerous age group. And I do have heart failure, so I’m aware that atrial fibrillation… I’m aware that I’m vulnerable. So, I’m very cautious. When they tell me to stay at home, I stay at home. They want us to wear the mask, I wear a mask”.The participants in the older group highlighted the importance of fall risk prevention. Kayla (89 years old) noted, “Particularly, I go a little slower because I have to be careful that I don’t slip and I don’t fall”. reliance on experts occurred 27 times within the older group, and but only six times in the younger group. When asked to describe the participants’ experience of when they were able to improve exercise skills and participate in the activity over a long period of time, most of the participants in the older group referred to taking an exercise class. For example, the participants demonstrated a tendency to rely on the instructor, “Just with the instructor. She demonstrates it and tells us what she wants us to do” ; “I do whatever they [instructors] asked me to do. And whenever it gets better weather and they allow us, we will go to the pool, not that I swim. But I will do the exercise” .Codes related to the property of convergent thinking appeared 25 times within the older group, whereas it occurred only three times in the younger group. For example, the participants in the older group mentioned that they came to acknowledge their own mortality, which was based on their accumulative experiences and knowledge, “I realize when I play golf with my peer group… We talked about how many of our teammates for the football or golf, they’re passed away, and that they were much better athletes than I was” . Nicole (84 years old) described how she eased unpleasant feelings about her own age-related physical decline and became used to the physical changes by self-evaluation. Codes related to the property of resignation were identified 23 times within the older group, whereas it occurred only four times in the younger group. When asked to describe their experience of new physical activities in the last few years and their intention to pursue new physical activities, all participants of the older group agreed that they would maintain their same current physical activity without adding challenges or new exercises. For example, the participants showed their intention not to explore new exercises, “No, I don’t do that very much. I kind of stick to the same things” ; “I don’t think it’s necessary [to do new exercise]” ; “I haven’t really added. I wouldn’t” ; “I tend to be more repetitive. I stick with what I know” .Codes related to the property of enthusiasm, (2) divergent thinking, and (3) extroversion. The prominent categories among the participants without underlying health conditions had the properties of (1) enthusiasm appeared 68 times among the participants without underlying conditions, whereas it was represented by 43 codes among the participants with underlying conditions. For example, Clifford (84 years old) stated the following:Codes related to the property of “Just to be active and play regularly … And I go to tournaments every once in a while. I play two, three, couple, three tournaments a year that come up, where you’re playing against people from other states or other towns. Some of those are goals to keep yourself ready, capable to participate in those events”.Elvin (81 years old) also mentioned how he set the specific exercise goal and tried to reach that goal:“Now it’s got to be sort of a challenge to be able to hit that 33 separate times in the morning. Someday will be a day in the future, whether that’s going to be tomorrow, or when it’s going to be a year or two years from now three years from now, I will be able to hit that”.divergent thinking appeared 33 times amongst participants without underlying conditions, and 20 times for the participants who had underlying conditions. Annika (67 years old), who had no underlying conditions, said, “Just try to do as much as you can and still feel good about what you’re doing. Because you’re still getting those endorphins, you’re still feeling good about what it is that you’re doing because you’re working out”. Sean (69 years old) highlighted how he has engaged in his exercise by actively exploring the physiological mechanism:Codes related to the property of “Also doing things and then not keeping them up is also painful. You go through the process of exercising and go through that soreness period, and then you stop. And then you have to start all over again and go through that whole process again”.extroversion appeared 27 times among the participants without underlying conditions, but appeared only three times for participants with underlying conditions. For example, Sean (69 years old) mentioned how he intentionally set aside time for his practice out of his working schedule. The other participant actively adopted new technology for exercise, thereby enhancing his exercise effect. Clifford (84 years old) said, “It’s a golf GPS… If you are going to shoot par… you want to know how far it is. So which club you can use. So, it’s essential to playing the game very competitively”.Codes related to the property of convergent thinking, (2) communion, (3) reliance on experts, (4) resignation, and (5) wistfulness.The prominent categories among the participants with underlying health conditions had the properties of (1) convergent thinking appeared 89 times for participants who have underlying conditions, but it appeared only five times for participants without underlying conditions. The participants who have one or multiple underlying health conditions tried not to be critical of their age-related physical changes and accepted their current physical conditions by continuing what they can do, “I try not to be critical. Just try to take care of it” ; “I do the best I can with the exercises. So far so good” .Codes related to the property of The other participant tried to think positively when it comes to their health and physical activity. For example, when Emilia (83 years old) delineated her story of how she was cured from cancer, she positively attributed her illness and treatment.communion were identified 49 times among the participants with underlying conditions, but only five times for participants without underlying conditions. For example, the participants with underlying health conditions emphasized their empathic feelings with the other peers in the exercise class or sports club and valued the social effect of exercise. Tacey (88 years old) said, “I just enjoy being with the people that I’m exercising with because we still need to socialize as we get older”. They also emphasized the importance of building camaraderie with peers who have physical and psychological commonalities. Nicole (84 years old) said, “We’re all encouraging and we enjoy each other’s company”.Codes that were related to the property of reliance on experts appeared 33 times among the participants with underlying conditions, whereas no codes were identified for the participants without underlying conditions. When asked to describe their experience of learning new skills or knowledge about the physical activity that they engaged in, 10 participants with underlying conditions tended to rely on an instructor-led class. For example, Artie (72 years old) considered the fitness instructor was the primary source of getting knowledge in terms of exercise. Kayla (89 years old) also mentioned her sole reliance on the fitness class without any self-initiation regarding physical activity.Codes related to the property of resignation appeared 29 times among the participants with underlying conditions, whereas the frequency for the participants without underlying conditions was only five times. When asked to describe their goals of physical activity, five participants with underlying conditions mentioned maintaining physical functioning or independence, rather than the advancement of physical ability. They expressed their resigned attitude in exercise, “To just do it, so that I’m staying. I don’t know that I have any particular goal, I’m not trying to get better at it. I’m just trying to keep myself in good shape” ; “I’m doing exercise, so it could be much worse. It is, it is not painful, but it’s not completely fine, but I’m doing okay. That is the only thing I could say that bothers me” .Codes that were related to the property of wistfulness appeared 22 times among the participants with underlying conditions, and four times for participants without underlying conditions. The participants with underlying conditions expressed their feelings of longing for varied physical activities they had actively engaged in in the past. Artie (72 years old) who has a back issue said, “I must say, at my age… Yes, sometimes it is hard. It’s hard for me when I cannot do things like before”. While the participants expressed their feelings of missing the past when they more freely performed various movements, they also acknowledged their physical changes. Meghan (77 years old) stated, “We did some mountain climbing and things like that. I can’t do that kind of thing anymore. But it was fun! Yeah, we did it … [I have] been there done that. I don’t need to do it again. I’m not gonna go climbing a mountain anymore”.Codes related to the property of All the categories described in the open, axial, and selective codes contributed to the core category, which is depicted as a diagram. We used diagramming as a tool for integrating the categories and presenting the final theory . The schThe participants’ physical identity shift  to better adjust to their aging bodies and physical changes may be caused by the physical signs of aging, pain or distress from chronic disease, a higher probability of injury, and life-changing events . The contextual conditions within the process of physical identity shift were each individual’s different personal trajectory in the physical domain, personal inclination for exercise or body image, affordability, and life responsibility . The conditions of physical aspiration, social exerciser, positive physical outcome, dutifulness, competence, empathy, support, driving mobility, younger subjective age, public self-consciousness, resilience, and longingness  acted to promote the participants’ strategies for how they processed their physical identity development and learned to adjust. In contrast, the conditions of emotional distress, age-related stereotype, private self-consciousness, activity restriction  hindered the participants from effectively processing their physical identity development. The participants managed the phenomenon through determination, self-discipline, deliberation, achievement striving, active experimentation, immersion, and routinization (divergent process); self-cognizance, reconciliation, moderation, adaptation, and transcendence (convergent process); and social interaction and retrospection. Consequently, they may end up reaching states of satisfaction with their own physical identity or ambivalent emotions regarding their physical identity and pursuing a more transcendental view.Our findings addressed that a convergent phase started when the participants began to realize their age-related changes in physical or mental conditions and abilities. While engaging in physical activities, they were attentive to bodily sensations and appropriated multiple pragmatic forms of knowledge from their life experiences to relieve the discrepant feelings originating in their aging bodies. This finding is supported by the prior studies regarding the relationships between involvement in physical activity, bodily awareness, and perception of aging ,43. FougThis finding can also be explained to some extent by an active aging model  that sugThe findings also challenge the rhetoric in the broader context of aging in a society that suggests exercise is a means to fight against biological aging. Consistent with the literature arguing with the notion of the anti-aging purpose of the exercise ,49, the Our findings addressed the dichotomous processes of physical identity development among older adults. These divergent and convergent modes of coping strategies correspond to the notions of exploration and commitment respectively in traditional identity development theories . IdentitOur findings, particularly the category of adaptation within the convergent process, addressed the process of how older adults cope with age-related physical changes. This finding regarding the category of adaptation can be explained by Baltes’s  theory oThe finding regarding the assimilation and accommodation processes is explained by identity process theory that explains the process of how people negotiate discrepant feelings when facing unwanted new experiences ,54. SuchFindings from this study have implications for identity process theory and aging studies. The existing identity process theory accounted for the process of identity shift to be assimilation, accommodation, and a plateau-like stage of integrated balance ,54. We cThe next emerging categories showed older adults’ coping strategies for dealing with the physical changes that come with age, as varied by their age grouping and the severity of underlying health conditions. This finding of different characteristics within an older population can be explained, to some extent, by previous studies’ subgrouping older people into young-old (65 to 74 years), middle-old (75 to 84 years), and old-old (85 years and older) groups such as different psychological aspects , biologiThis finding related to older adults’ severity of underlying conditions somewhat contributed to demonstrating the contrasting characteristics among the participants. This discovery of different effects related to one’s underlying health conditions on their perceptions of aging can be explained by previous studies regarding the relationship between fatigue qualities and underlying conditions among older adults , and theThe present findings also highlight older adults’ heterogeneity. In much previous aging research, older adults were seen as homogenous in terms of age, race, class, ethnicity, and able-bodiedness . This stThis finding has practical implications for instructors, program coordinators, and directors of senior institutes. Our findings regarding different characteristics based on younger- and older-old adults can inform practitioners in senior centers to better understand the significant variability among the senior clients. An older population can be characterized as heterogeneous because of their variability in the aging experience, which also implies varied directions of development across individuals or groups ,68. ThusParticipants in this study were active or highly active in terms of levels of physical activity and that they are regularly engaged in a physically active lifestyle. However, 28% of adults aged 50 and older in the United States are still categorized as physically inactive ,10. TherOlder adults become more attentive to the condition of their health and physical functions than they were in their younger years, considering the major perspectives on adult development of biological, psychological, and sociocultural aspects. However, developing one’s physical sense of self in later life may be a challenging endeavor that requires constant evaluation and adaptation of one’s own physical changes and identity. The primary findings of the analysis were a final model depicting (a) divergent and convergent modes of strategies and socioemotional aspects of physical identity development in later life and (b) different strategies employed between younger-old versus older-old age groups and between participants who have underlying health conditions and those who do not. Future research may take different levels of physical activeness and various demographics into account.


The purpose of this study was to analyze the mediating role of life satisfaction in the relationship between fourteen coping strategies and depressive symptoms in the Portuguese population. To undertake this work, 313 Portuguese adults aged 18 to 70 years  were invited to participate in this study. Their participation was completely voluntary, and participants granted and signed informed consent previously to the filling of the validated Portuguese questionnaires. These questionnaires measured depressive symptoms, coping, and life satisfaction. The results revealed that life satisfaction displayed a mediating role in the relationship between adaptive coping mechanisms, specifically between active coping, planning, reinterpretation, and acceptance and depressive symptoms, showing a negative and significant indirect effect. Maladaptive coping mechanisms of self-blame, denial, self-distraction, disengagement, and substance use had a significant positive association with depressive symptoms, considering the mediating role of satisfaction with life. Current investigation provides initial evidence of how each coping mechanism is associated with satisfaction with life and depressive symptoms. This study clearly demonstrates that not all coping strategies are capable of influencing well-being indicators and that health professionals should focus on endorsing those that are significantly associated with lowering depressive symptoms and increasing overall satisfaction with life. In 2015, the World Health Organization [WHO]  to make me feel better.”), and participants answered each question using a Likert scale going from 1 (Never did this) to 5 (Always do this).[i] Brief Cope, Portuguese version . This waI’m happy with my life.”) to which participants answered using a Likert scale going from 1 (Strongly disagree) to 5 (Strongly agree).[ii] Satisfaction with Life Scale, Portuguese version . This waI don’t feel sad”; “I feel sad.”; “I’m always sad and I can’t avoid it.”; “I’m so sad or miserable that I can’t take this anymore.”).[iii] Beck Depression Inventory , PortuguInitially, a descriptive analysis of the variables was done using the software IBM SPSS Statistics v23 to obtain the average and standard deviation, followed by an analysis of the normal distribution (skewness and kurtosis). The following data for normal distribution were considered: skewness between −2 and +2 and kurtosis values between −7 and +7. Additionally, an analysis of bivariate correlations was done, specifically Pearson correlations.2) and corresponding degrees of freedom (df) are reported for transparency, but were not examined to assess model adequacy, as they are subject to the size of the sample and model specifications  and “self-blame”, “venting emotions”, “denial”, “self-distraction”, “disengagement”, and “substance use” .When looking at the results of direct effects, these results are in line with statements of previous theoretical and empirical studies ,26,27. SThe more an individual uses adaptive coping mechanisms, the less depressive symptoms they exhibit as well as depression, anxiety, and stress; opposite to that, those who tend to use maladaptive coping reveal higher levels of depressive symptoms, depression, anxiety, and stress ,27,36. TRegarding indirect effects, the coefficients indicate that adaptive coping mechanisms have a significant negative and indirect relationship with depressive symptoms when looking at satisfaction with life as a mediator, specifically the mechanisms “active coping”, “planning”, reinterpretation”, and “acceptance”. The maladaptive coping mechanisms “self-blame”, “denial”, “self-distraction”, “disengagement”, and “substance use” present a significant positive and indirect association with depressive symptoms via satisfaction with life.Indeed, when looking at the analysis of the data referring to indirect effects, these results are in accordance with those of McKnight et al.  and MoksThe perception of satisfaction with life seems to be adjusted according to the applied coping mechanisms. In particular, the results show that “active coping”, “planning”, “reinterpretation”, and “acceptance” are variables with a significant negative relation with depressive symptoms via satisfaction with life. The use of adaptive coping allows for recovery of well-being and health, thus improving the level of satisfaction with life. Activities that involve planning the future in a way that helps individuals to feel in control of their lives is a way to obtain adaptive coping that leads to higher levels of satisfaction with life and, consequently, less depressive symptoms. The use of appropriate strategies in daily activities allows one to deal with the problems and accept them, either by forgiveness, by controlling hostile thoughts, or managing relationships with others. These behaviors are also associated with the resilience capacity that each individual has in the face of adverse situations in which one does not give into the pressure of the problem regardless of what it is. As for maladaptive coping, it was observed that maladaptive mechanisms that potentiate depressive symptoms are the use of drugs , denial of what is taking place, blaming oneself for the situation in cause, and constant disengagement day after day. Therefore, “self-blame”, “denial”, “self-distraction”, “disengagement”, and “drug use” are the variables showcasing a significant positive relation with depressive symptoms via satisfaction with life. The higher the persistence of these maladaptive coping mechanisms, the lower the satisfaction with life, as these are behaviors that lead to inner discomfort, and consequently, there is a higher probability of suffering from depressive symptoms or, if they are already present, potential for their worsening.In general, satisfaction with life mediates the relationship between coping mechanisms and depressive symptoms. The adaptive coping mechanisms and problem-focused mechanisms are positive predictive factors in an increase of the level of satisfaction with life, as they can indicate lower depressive symptoms. Contrary to that, maladaptive coping mechanisms, which are emotion-focused, are negative predictive factors in the reduction of satisfaction with life, as they can indicate higher depressive symptoms. Therefore, the type of coping mechanism typically used by one individual can give an indication of the presence of depressive symptoms.This study showcases important results when it comes to the determinants of the mediating role of satisfaction with life in the relationship between coping mechanisms and depressive symptoms. However, some limitations must be taken into consideration. First, this study had a cross-sectional design, which limits the ability to draw conclusions regarding the causality of the relationships in study. As such, it is pertinent that future studies test the relation between these variables using a longitudinal methodology and, ideally, also experimental in order to verify if the results are consistent. Also, within the sphere of the study methodology, it is also important to note that this study was performed using data from a Portuguese sample. Socio-demographic parameters, such as culture and age, may influence the results .Despite these limitations, this research is highlighted by the empiric study it includes which, up to date, was non-existent in general nor with a representative sample of the Portuguese population. As a suggestion, it would be interesting to analyze the results taking into consideration the age of the participants, as the sample incorporates individuals from 18 to 70 years of age, as well as gender in order to compare male and female results, since literature supports a higher prevalence of depressive symptoms in women .According to Batista and Oliveira , includiThere are certain determinants in the quality of life that can influence the promotion of coping mechanisms, such as mindfulness, which encompasses focusing on the present moment without external or internal judgement . MindfulIt appears essential that health professionals interested in behavior modification  are able to promote the use of adaptive coping mechanisms that are effective in the management of potentially harmful symptoms in the quality of life of the individual . Both miThe study was based on the fact that Portugal is one of the countries with higher prevalence of mental disorders and that, although there are suggestions that coping mechanisms may act as an adaptive tool to depressive state, there are not many studies that analyze the mediating role of satisfaction with life between these and depressive symptoms. To date, no study has analyzed this relationship in the Portuguese population, making this a relevant study useful to assess the relationship between satisfaction with life, the fourteen coping mechanisms, and depressive symptoms.This study shows that the deeper analysis of the link between different coping mechanisms, satisfaction with life, and depressive symptoms may provide essential knowledge to develop tools to promote more well-being and less negative psychologic indicators . Based on currently available evidence and the analysis in this study, the results demonstrate that, indeed, satisfaction with life is a mediator in the relationship between coping mechanisms used to manage stressful events in one’s life and depressive symptoms.The current study allows for a deeper understanding of the mediating role of satisfaction with life in the relationship between adaptive and maladaptive coping mechanisms and depressive symptoms. This is also the first study that does so in the Portuguese population, making it more relevant. It therefore suggests that it is important to develop and apply tools to promote the use of adaptive coping mechanisms and reduce maladaptive coping mechanisms. The use of these tools is supported by this study, as with them, health professionals can develop prevention and control strategies using the coping mechanisms investigated on this study and do so in an individual and tailored way.


Women living with HIV (WLH) lack evidence-based information about reproductive options while managing pressures from family, clinicians, and communities to give up the idea of having children. As the reproduction intentions of WLH are not well understood, stigmatizing behaviors force them to hide their disease to avoid rejection by their family, partner, and social networks. Compliance with social norms, fear of stigma, and discrimination influence their experience. Current research is individual qualitative studies lacking the synthesis perspective necessary to guide intervention development. The purpose of this study was to synthesize the evidence to explain the reproductive decision-making process for WLH in developed countries.A systematic review with qualitative research synthesis was conducted through searches in 10 electronic databases . Studies published in journals from 1995 to 2019 with qualitative data about reproductive decision-making among WLH in developed countries were eligible for inclusion. Developed country was operationalized by membership in the OECD for comparative conditions of social wellbeing and economic stability. The CASP and JBI checklists for qualitative research were used to assess study quality and methodological integrity. Thematic analysis and qualitative meta-summary techniques were used for the synthesis.Twenty studies from 12 developed countries were included in the synthesis. Findings were organized into 3 meta-themes from 15 themes and 45 subthemes, including: (1) Shattered identity, (2) Barriers, inequities, and misinformation, (3) Coping, resiliency, and support. Reproductive decision-making was perceived as a complex process influenced by facilitators and barriers. The facilitators helped WLH cope with their new situation to become more resilient, while the barriers made their situation more difficult to manage.WLH encounter reproductive decision-making with knowledge deficits and limited social support. An integrated approach to holistic care with comprehensive multidisciplinary counseling is needed to support WLH. Clinicians could benefit from professional development to learn how to be authentically present for WLH, including engaging in conversations, demonstrating compassion, and understanding situations. Evidence-based clinical practice guidelines need to be tailored for the family planning and sexual health needs of WLH. Globally there are nearly 40 million people living with HIV, more than half are women . In 2018Motherhood is an important role that gives meaning to life for many women; however, decisions about pregnancy and childbearing are often complex as HIV impacts many aspects of daily living . The facAlthough cesarean section was the recommended mode for delivery prior to HAART , 16 EuroWLH lack evidence-based information about reproductive options while managing pressures from family, clinicians, and communities to give up the idea of having children , 21. SinMisinformation and prejudice continue in clinical practice  as WLH dCompared to developed countries, longstanding variations in human rights, socioeconomic conditions, public policies, and health systems in developing countries differentially restrict women from accessing quality health services, achieving sexual health, and making reproductive decisions –31, espeQualitative research synthesis (QRS) , or the Studies published in peer-reviewed journals between January 1995 (the year HAART appeared) and December 2019 using qualitative methods to address reproductive decision-making in WLH were included in this study. The term ‘developed country’ was operationalized by membership in the Organization for Economic Co-operation and Development (OECD). In this regard, the 35 OECD  member cMultiple electronic databases were searched including CINAHL, EMBASE, MEDLINE (through PubMed), Scopus, Social Science Citation Index, Web of Science, Google Scholar, and the Spanish databases Cuidatge, Cuiden Enfispo, and SciELO from January 1995 to December 2019. Although most qualitative research articles for this review were anticipated to be indexed in the MEDLINE database , all resKeywords, defined by the research team and informed by systematic reviews in related areas, were joined by Boolean operators for the database searches. Keywords were used to avoid problems with the unique thesaurus terms for each database with varied meanings between disciplines , 76. TheThe search strategies were tested in November 2017. An example of the algorithm used for the PubMed search strategy is provided in Table The study screening was completed with a structured process ; first bThe research team included the appropriate methods and content experts  to develThe primary focus for the data extraction was the results and the conclusions sections of each article. General data extracted from the articles, line-by-line, were assembled in an Excel spreadsheet, including study setting, aim, participants, study design, direct quotes, and key findings. Then, the data were imported into Nvivo® to digitally record the codes that emerged as themes from the coding . The levFollowing the recommendations of Sandelowski and Barroso , the datIn a staged process , two resThe protocol for this QRS was designed to maximize descriptive validity , interpretive validity , theoretical validity (credibility of researcher interpretations), and pragmatic validity (utility and transferability of knowledge) , 92, 93.Ethics approval was not necessary as the searches were conducted in public databases. There were no human subjects involved in this study. However, the included studies were evaluated for ethical standards with the JBI Checklist. Each of these studies was approved by an ethics committee or institutional review board.A total of 4,519 articles were identified through the systematic literature searches and reduced to a sample of 20 qualitative articles for analysis  Shattered identity, (2) Barriers, inequities, and misinformation, 3) Coping, resiliency, and support . It was horrible because I was disgusted by myself. I looked at myself in the mirror and I could see around me, literally, a grey shadow ... And I thought “this is the virus.” WLH described a shattered identity, referring to two main areas: their womanhood and their motherhood experiences. When they learned of their positive status, they were devastated, and they no longer felt like a woman , 99. The“It [pregnancy] is sort of like a completion of myself as a woman.” Sexual and reproductive decisions were modified; their desire for intimacy reduced, sexual life changed, and breastfeeding prohibited . They fe“I just want one. I don’t want a whole house full… I just want one baby, something that’s me, a part of me. That’s something that I can develop and it’s still great too.” Motherhood was one of the most important social identities for women. WLH felt recognized by their community when had a child , 105 bec“When I was twenty-six, and I’m now forty-four, I didn’t see my life going that far, so I would have made different choices. I think my main thing would have been my choice of having children. I was caught in the middle of the epidemic then. I regretted not having that child. And, you know, as life went on, I still regret it.” Some WLH felt pushed by their families and others to become mothers . Many wo"When you have certain insurances, it doesn’t cover the places you want to go where you feel comfortable. You have to go outside and go to another person you don’t even have a background on. With my oldest all my prenatal care was at Hospital X; with my youngest I had a private doctor. It’s not always easy." When making reproductive decisions, WLH encountered barriers to accessing health services , includi“My doctor was really insensitive […]. I really felt trapped.” WLH generally felt clinicians were not supportive, reporting HIV-related stigma , 110. Th"The people had pretty much brainwashed me . . . they just reared into me, telling me . . . “Right now it’s not a good time . . ., you ain’t got a place to live, you ain’t got no food, you ain’t got no job, you ain’t got this, you ain’t got that.” So, I took a look at all that and just decided to have an abortion … [I]t hurt, you know, because I wanted to keep it but I had to take a look at the situation and say, oh okay, that, that was right, yeah, okay. That’s true, though, but let me make that decision, you know, it was just like a rushed thing and . . . and I said okay, I’ll have an abortion, I can’t do anything else." The physicians never asked about their desire to have children . As a re“I look for things that are safe 100%. There have not been recorded cases of anyone becoming infected , so I thought that’s 100% safe. So like a month later I was reading another one of these small leaflets and it says although the risk is small there is some risk and I started to become a bit paranoid.” WLH wanted more information about contraception methods and approaches to safe sex. They wanted to learn about their disease, including more discussions with clinicians; something they were unable to find in the health system , 111.“I "Like most women, I always wanted to have a baby, but thought it wasn’t an option anymore when I was diagnosed with HIV." Their general knowledge about HIV, varied; however. WLH commonly believed they cannot be mothers. They had the wrong beliefs about the impact of HIV on their ability to become pregnant , 106."Li"My other fear is that my baby will come out positive.” In terms of becoming pregnant, WLH feared the transmission risk for their child and partner, worried about possible health complications, and anticipated adverse effects from HAART , 107. Ye“Am I going to get sick? Am I going to die, and the baby is going to live? I think about all of this.” In contrast, other women considered HIV to be a death sentence. They considered the psychological impact of their health and their longevity for their children when making decisions about pregnancy , 103.“Am“My last daughter was also born tox-positive for cocaine... and I want to change that... I want to make sure it doesn’t happen again.” WLH also confronted overwhelming guilt about their HIV negative partner, past mistakes such as drug abuse, or previous decisions to give up their children for adoption , 108. Ye“My mom told me to erase it out of my head... And it was always the same thing: I was selfish.” .Generally, WLH did not feel supported by family members as they did not want to hear about their pregnancy. As family members assumed WLH cannot have babies, the women experienced stigmatizing behaviors and comments , 112.“My"Stigma …makes that person not want to talk about it [pregnancy]. So, you have already labeled me, you already said how you feel about it. If we are talking, and you already said something bad about someone who has the virus -- why would I open up to you? You’re going to talk about me. And see my feelings are going to get hurt.” This stigma was also present in interactions with partners and clinicians , 109. As"I was always the one pushing him to use condoms, and he didn’t want to. Eventually when we were living together, I just stopped. It’s not always going to be my responsibility to push that." WLH want to be loved and to have an intimate partner . But occ“It’s not an irresponsible thing to have a child. It’s an irresponsible thing to have a child without a father, without a decent income, without a place to live and without the ability to take care of this child…while dealing with your own stuff.” Finally, WLH sometimes experienced homelessness, poverty, domestic violence, drug abuse, and other marginalizing situations. Instability in their lives made reproductive decisions difficult to manage, including whether or not to continue with unplanned pregnancies , 109. So“I just told them it was because you don’t know where I come from, I don’t know where you come from, so it is good to be careful and at the same time I don’t want to get pregnant.” Sexuality and reproduction overlap with love, intimacy, and commitment but all are disturbed by HIV. As the WLH did not want to harm others by transmitting their HIV, they searched for approaches for safe sex or chose celibacy . WLH rep“It’s not really a planning thing, they just talk about it if they want to have a baby, and if it happens then it happens.” WLH considered pregnancy planning to protect their health, as well as their partner, prior to trying to conceive . Nonethe“When you find a guy and you feel comfortable with them and they accept what is going on with you, you cannot use condoms, even though you know you can get re-infected…when you are blinded by that person you take risks, I take risks, and say ain’t nothing going to happen to me, ain’t nothing happened to me so far so what the hell.” Other WLH preferred to conceive without medical intervention so they engaged in unprotected sex. For these women, love and commitment with their partners was more important than the risk because childbirth should not be medicalized , 106.“Wh“Surrounding myself around people that’s HIV… It helps me a lot, it chills me down.” Sharing their status with others was a coping strategy identified by WLH to accept their diagnosis. Creating empowering environments such as support groups for people to understand their situation appeared to be helpful .“Surroun"He’s [partner] with me, he’s got my back 110%. So, anything I decide I want to do he supports me -- there’s not a lot of men that do that. When I met and let him know what my status was, he told me “and what?” He didn’t see my status he saw that person that I was, that I am, he knows that I am a good person and that’s what." However, intimate partners were the most important person for reproductive decision-making as they offered the women the self-confidence they needed to make a decision , 106. In"I really don’t care for…what family has to say, because …as a grown individual you have to be grown enough… to make your own decisions." “Being a mother makes me grow on a personal level, but the doctor doesn’t think of motherhood as medicine for the soul, a morale booster that affects me psychologically.” Despite the challenges when seeking advice about pregnancy from clinicians and family, the women wanted to make a good decision. They were not discouraged from wanting children by negative input from family members or their clinicians , 110."I "But basically, it’s a decision I made with my higher power. I just ask God to show me what to do." “And if I take care of myself, I think maybe God will give me a lot more time of life. Because I pray to God everyday: “God, give me life, I want see my daughters to grow up with me, I want them to see me well, I want myself being able to work" .However, WLH shared their decision with God as they believed their situation was the plan God had for them , 110. Go"However, over the years, with improvements in treatment and people with HIV living longer, it started to feel possible. The doctors told us that the risk of the baby having HIV has gone down to 1%" .When WLH were aware of medical advancements related to pregnancy, the possibility of becoming a mother was real . MotheriOnce a woman is diagnosed with HIV, life changes and identity alters. Many WLH cancel motherhood plans due to knowledge deficits, misinformation, stigma, and judgment. Being a mother is defined by their feminine identity as well as social expectations defined by the cultural context. As such, WLH seek to salvage their role as "good mothers" to stabilize their identity and to maintain their social value threatened by HIV . In geneIn consonance with available evidence, this study found a lack of knowledge about the relationship between living with HIV, sexual health, and reproductive decision-making , 117. ThThe WLH wanted the support of their clinicians as they tried to understand the possibility of safely having a child . Their rFrom this qualitative synthesis, stigma was evidenced in the interactions WLH reported with friends, families, partners, and clinicians , 26. StiReproductive decision-making for each WLH is unique, as they use their repertoire of coping mechanisms to stay alive. When entering a support group for example, they can become part of a larger reality with peer support that provides collective strength . Also, pGenerally, WLH wanted to make their own reproductive decisions despite many barriers while recognizing they needed more support. The women frequently noted spiritual forces protected them, as well as planned their lives. As such, these women felt a strong duty to care for their babies in a way that facilitated self-care. The risk of transmitting their infection to their fetus, or their partner, is their most pressing concern , 18. TheThere are several limitations to consider. First, the synthesis relied on the analyzed data from each article that might not reflect the meaning from the raw data. Second, to synthesize studies from countries with comparable social wellbeing and economic conditions, the search was limited to OECD member countries. As such, the review may not be generalizable to developing countries. In addition, almost half the included studies were conducted in urban areas of the United States which may further limit the generalizability of the findings within the target countries. Despite these limitations, the search included multiple languages due to the multinational team, extensive database searches, and comparable environments. Third, the studies spanned almost three decades, defined by the period of HAART. Despite the wide span, there was data consistency across the decades. Fourth, the systematic review was completed from 1995 to 2018 with an update in 2019 introducing an increased possibility for search bias. However, the broad search strategy minimized the impact of this concern. Finally, the search might have excluded studies not published in non-indexed journals or in different contexts, such as thesis or dissertations. However, the search strategy and the database selection were based on published recommended practices.For WLH, reproductive decision-making is a complex process based upon incomplete information and inaccurate perspectives. In developed countries, WLH engage in reproductive decision-making more frequently due to advances in pharmaceuticals and better evidence-based practices while receiving limited assistance from family, friends, partners, and clinicians. Decisions regarding reproduction are individual but women are not able to make an informed decision without guidance and medical consultation. Clinicians need to be authentically present for discussions and open to the new possibilities for WLH in the context of the modern person-centered health system. An integrated approach with comprehensive multidisciplinary counseling is necessary to address reproductive decision-making and sexual health as a right. Clinicians need to initiate discussions for WLH in the same way as other women.In clinical practice, WLH should be engaged with a human caring approach to identify personal preferences, consider individual situations, and provide person-centered care. Clinicians should learn to collaborate with WLH in reproductive decision-making through regular family planning conversations and routine sexual health assessments. For more effective relationships with WLH, clinicians need to be authentically present, including demonstrating compassion and understanding to minimize the stigma associated with sexual health. Finally, evidence-based practice guidelines for sexual health and family planning need to be developed for WLH to consistently deliver culturally competent, integrated, and holistic person-centered care.


Patients living with cancer often experience serious adverse events due to their condition or its treatments. Those events may lead to a critical care unit admission or even result in death. One of the most important but challenging parts of care is to build a care plan according to the patient’s wishes, meeting their goals and values. Advance directives (ADs) allow everyone to give their preferences in advance regarding life sustaining treatments, continuation, and withdrawal or withholding of treatments in case one is not able to speak their mind anymore. While the absence of ADs is associated with a greater probability of receiving unwanted intensive care around the end of their life, their existence correlates with the respect of the patient’s desires and their greater satisfaction. Although progress has been made to promote ADs’ completion, they are still scarcely used among cancer patients in many countries. Several limitations to their acceptance and use can be detected. Efforts should be made to provide tailored solutions for the identified hindrances. This narrative review aims to depict the situation of ADs in the oncology context, and to highlight the future areas of improvement. Cancer is becoming more frequent as the population ages. An increase of 60% of the incidence between now and 2040 is foreseen ,2,3. AltWhen ICU admission is debatable, the patient’s opinion on life sustaining treatments, invasive care, possible alteration in autonomy and quality of life should be at the center of the decision-making process. Whether the expected benefits of intensive care are certain or not, this information should be obtained beforehand as patients should be given the possibility to accept the burden and possible consequences coming with invasive treatments.Unfortunately, the severity of conditions requiring an ICU admission often goes along with consciousness’ alterations and usually prevents patients from expressing their preferences and wishes. In such circumstances, physicians turn to relatives to gather as much information as possible regarding the patient’s wishes. However, correlation with patients’ thoughts is surprisingly poor ,15.Lack of certainty about patients’ outcome and preferences leads to wide variability in the assessment of critical care relevance between physicians . This unPatients’ preferences regarding care intensification and invasive treatments, as well as their beliefs, life- and end-of-life goals, perceived health-related quality of life, along with medical reasoning, may help the physician find the right balance between diagnostic or therapeutic procedures and patient comfort-oriented care.In response to this imperative necessity, the concept of Advanced Directives or Advance Care Planning (ACP) in English speaking countries was developed in the middle of the 20th century in the USA by Luis Kutner . Since 1In several studies around the world, patients reported a strong interest for advance directives (AD) or ACP ,23,24,25The aim of this review is to look at factors associated with the presence or absence of Advance Directives. We will look at factors depending on patients, the disease itself, physicians, as well as fears and misconceptions from both stakeholders  databases until December 2019 by two independents authors (KS and AC). The following keywords were used: (“advance care planning” or “advance directive”) AND AND “cancer” OR “cancer patient” OR “patient with cancer” OR “malignant tumor” OR “neoplasia” OR “malignant hemopathy” OR “hematological malignancy” OR “leukemia” OR “lymphoma”). Article relevance was refined by using the advance search builder tool of PubMed restricting to keywords presents in “title or abstract”. The final selection of paper was made by the authors, function of relevance to the addressed question. Additional articles, cited in the selected ones were included function when considered of major importance in the field.Parameters associated with knowledge of AD by patients are synthetized in In multiple occidental studies, older age seemed to be directly correlated with the redaction of AD ,34,37,38Socio-economic and educational background are highlighted as independent influencing factors in multiple works ,39,40,41In a study conducted in an outpatient cancer clinic in Ohio, the authors suggested that people with low income and low educational background may have other concerns than discussing their preferences for treatment or end of life care, or that they may have less access to assistance or education programs on ACP ,42. HoweThe discordance between those different studies may be explained by the fact that the study populations come from very different cultures.Religious beliefs may also impact AD. It is interesting to note that their influence varies depending on the countries and creeds .In a Chinese study, having religious beliefs was associated with having AD , mostly On the same note, a patient’s culture also plays an important role . In EastNonetheless, end-of-life care discussions between patients and their family, with or without counselling by a health-care worker, could improve AD’s acceptance ,51. FurtFamily plays a central role both during the process of writing AD and at the time of end-of-life decisions . In an AIn a survey conducted in the USA, 63% of patients reported that completing AD avoided placing responsibility for end-of-life decision-making on their loved ones, even though all participants believed that their family or friend would be able to make adequate decisions by themselves . Lack of awareness regarding AD by patients is obviously a major obstacle. It ranges from complete ignorance of their existence or their usefulness, to redaction difficulties due to a lack of knowledge regarding their practical use or how to implement them.Six years after AD’s legal apparition, a French survey including 367 hospitalized patients revealed that only 34.8% of them were aware of the possibility to have some . HoweverPeople may also have trouble figuring out how their AD can specifically relate to their disease. In a survey conducted in Germany in 2014, half of the patients were in favour of AD consultations. However, only 20% reported that their interest for those consultations was associated with their cancer diagnosis whereas the link between a severe chronic disease and the benefit of expressing themselves about their preferences concerning therapeutic intervention in case of acute and critical situation remains seems not to be obvious . This woSuffering from a deadly disease compels patients to think about their end of life. Unsurprisingly, a new diagnosis of cancer and duration of the illness turn out to be favouring factors towards AD’s writing ,30,56.Both the ongoing disease and the patient’s past history play a role in the perception of AD. Sahm et al. noted in 2005 that patients having a previous experience of serious illness increasingly reported their intention to write AD . In the Realizing the severity of one’s condition seems to be a trigger to AD’s drafting . A longeHowever, even when prognosis is discussed with patients, it may not be well understood. A multicentre study including nearly six hundred metastatic cancer patients, revealed that even when informed of their prognosis by their physician, nearly a third of patients overestimated their life expectancy by more than 2 years. Correct recall of prognostic disclosure was associated with a more realistic assessment of their life expectancy .When information about the disease, its treatment and its prognosis is delivered during the cancer clinic visit, patients may be stunned, impairing their ability to process and understand those details . Some maEncouraging early communication between physicians and patients regarding the prognosis of the disease could help patients to better prepare for possible complications or tragic outcomes, and to refine their goal of care . Many paGanti et al. retrospectively explored the relation between engagement in ACP amongst patients receiving a hematopoietic stem-cell transplantation (HSCT) and adverse outcomes, as well as overall survival. They found that patients who engaged in ACP before HSCT had a better one-year and overall survival compared with patients without ACP . Though As previously addressed, the absence of AD in the cancer patient population is partly due to the absence of information on this legal disposition. This lack of knowledge is partly due to the reluctance of clinicians to discuss patients’ wishes .In a study analyzing discussions during medical appointments between advanced cancer patients and their oncologists, treatment was mentioned in 94.3% of visits whereas prognosis was only disclosed in 50.4% of them . Lower pMany physicians feel inappropriately trained or prepared to talk about AD ,70. HoweQualitative studies report that oncologists feel that discussing end-of-life issues is emotionally difficult both for them and patients . Indeed,Several studies suggest that it is possible to talk about end-of-life preferences and write AD without interfering with the patient’s hope ,79,80,81Despite a general agreement on the necessity of AD , the besDelaying the discussion may not ease the process: when there is no curative option left, the change in goal of care is even more abrupt and causes more distress . PostponPatients themselves reported that AD completion or dedicated consultations should take place early in the illness . Indeed,Lack of time during oncology consultations is an identified barrier to end-of-life care discussion and AD’s completion ,67. In aDistilling prognosis and end-of-life information throughout the follow-up may be less time-consuming, could favor discussion, and may strengthen the patient–physician relationship, therefore giving patients a better chance to express their desires regarding their care .Some obstacles to the realization of AD are due to physicians’ and patients’ misbeliefs or fears . Some paOther patients worry that their wishes may not be respected , as it wAnother barrier to AD is the fear of coercion. Sahm et al. explored this concern amongst patients, healthy controls, nursing staff and physicians . They foADs are effective tools to improve the quality of terminally ill patients’ end-of-life. In a systematic review, Arianne Brinckman-Stoppelenburg highlighted an improvement in quality of life for both patients and their family, a higher compliance with patients’ preferences, and a decreased use of aggressive care at the benefit of palliative care when AD were redacted .Overall, despites multiple attempts to identify favourable or unfavourable factors to the completion of AD, it is difficult to recognize patients who would most benefit from AD’s drafting.First, we ought to understand that patients may not want to choose in advance which treatments they will seek or reject in the future, and that they may prefer to rely on their relatives or caregivers. This ultimate expression of autonomy is summarized by Megan-Jane Johnstone as “the choice to not have to choose” .As stated by Stephanie Johnson, “individual autonomy is socially dependent” (page 384) . The priIf patients are strongly opposed to writing AD, both having named a health care surrogate and having previously collected information about their wishes are valuable. Discussing AD does not necessarily mean writing AD, but it launches the reflexion process and favours the discussions.The vast majority of patients seem to hope that such a topic will be discussed by the physician rather than initiated by them ,71,78,96In an American study amongst cancer patients, 77% had discussed AD with their relatives and only 41% with a physician . MoreoveIn many studies, patients would rather talk about AD with their general practitioner ,34,78. IAs previously mentioned, another pragmatic issue is the available time during oncological appointments. Thus, having other opportunities to discuss their goal of care may enhance patients’ participation in AD. Trained nurses can sensitize patients, either through question prompt lists or during non-scripted interviews they can handle in dedicated consultation ,88. ClinIt is easy to realize how complex it could be for a patient to write their AD: they ignore what specific situation they will have to face, or how their document will be construed. Adding to the complexity of the exercise, patients can have difficulties understanding limitations and consequences of life-sustaining therapies .The different information and wishes expressed by patients will probably not fit a restrictive questionnaire: a standardized form may be impersonal thus inappropriate. In a study involving general practitioners, they underlined how AD is about life and death and figuring out the patient’s wants and needs, and “that can’t be too calculated or tick boxed” (page e452) .Contrary to DNR orders, AD should allow a great freedom of thought. There, patients can express all the complexity of the personal, material, spiritual and social aspects of their plan of care. Moreover, AD still enable the expression of hope while preparing for the end-of-life, whereas DNR are deemed “blunt” or “without any empathy” by patients . It is tAD and, more broadly, ACP are arrangements that allow patients to express their preferences regarding their therapeutic management, particularly in situations of chronic pathology where acute deterioration is always possible. Beyond choices regarding care, organ support or specific procedures, these arrangements can define the patient’s life values. More than just a written record of the specific elements that the person is likely to accept or refuse, AD and ACP should be a tool for reflection and an opportunity for a physician–patient exchange regarding the patient’s philosophy in order to improve the personalization of care. In spite of the steps taken, the use of AD remains very insufficient, especially in Europe, and this fact should encourage us to continue our efforts to both increase their application and to extend their scope of use.