Health rumors often mislead people and cause adverse health behaviors. Especially during a public health emergency, health rumors may result in severe consequences for people’s health and risk governance. Insight into how these rumors form and harm people’s health behavior is critical for assisting people in establishing scientific health cognition and to enhance public health emergency responses. Using the case study with interview data of a salient purchase craze led by a health rumor during the COVID-19 outbreak in China, this article aimed to illustrate the process of how a piece of information becomes a health rumor. Furthermore, we identify factors that cause people to believe rumors and conduct behavior that leads to a purchase craze. Results show that a public misunderstanding of the unique psychology of uncertainty, cultural and social cognition, and conformity behavior jointly informs people’s beliefs in rumors and further causes purchase craze behavior. We developed a simplified model to demonstrate how an ordinary news report can lead to a rumor. Based on this model, some implications of effective health communication are suggested for managing rumors. In the public health field, the public is prone to learning about health and investigating their own health conditions by obtaining massive amounts of health information. However, if many pieces of such widespread information are inaccurate or even totally wrong, people can easily become misinformed and conduct wrongful health behaviors ,2. In thAcademics have reached a consensus that the study of rumors associated with public health contributes to the sociology, management, and communication science of health by enhancing our understanding of lay health knowledge and beliefs, as well as the situated basis of health-relevant actions. Academics also recommend some communication methods for tackling and correcting health rumors ,12,13,14This article mainly analyses the formation of health rumor and how the rumor impacts people’s perception and behavior in a public health emergency. We utilized a case with interview data from interviewees (N = 30) that focuses on a salient purchase craze of Shuanghuanglian (SHL), a traditional Chinese medicine (TCM), led by a health rumor during the COVID-19 outbreak in China. The reason why we selected China’s case is dependent on that COVID-19 outbreak firstly occurred in China, which means China had severely insufficient knowledge about the novel coronavirus in this specific period. In such situation, the public could be misled by health rumor easily ,15. TherIn order to mention effective health communication for preventing and managing rumors, this article also analyzes the formation mechanism of the rumor. This article is dedicated to offering a holistic process involving the formation, dissemination, and management of rumors during a public health emergency.The rumor has become an enduring feature of social and organizational landscapes . As a coIn the public health domain, commonly used concepts concerning inaccurate or false information are “misinformation” and “disinformation”. Generally, health misinformation is contrary to the epistemic consensus of the scientific community regarding a phenomenon. However, what is considered true and false is constantly changing as new evidence comes to light and as techniques and methods are advanced ,17. TherAn example of existing classical research specifically focusing on rumors is Allport and Postman’s paper. They indicated that the rumor thrives on a lack of news. It is a proposition or belief, passed along from person-to-person, usually by word-of-mouth, without secure standards of evidence ,24. AdmiThe controversial discussion around rumors include the containment relation of rumor and misinformation, even though some scholars use them as interchangeable concepts . The relTherefore, we tend to use the concept of rumors to illustrate a process of information distortion in transmission ,29. AllpIt is common knowledge that a specific perception will lead to specific health behavior. However, the factors that impact the perception and behavior are complex ,33. TherFor an individual, health literacy is the main factor for shaping personal health perception. Health literacy focuses on increasing responsibility of individuals and groups to be able to understand and act on the health information. It represents an ability to identify and use health information and to make the decision for improving healthy life ,35,36. FIn the perspective of rational choice economics, people’s perceptions and related behavior are dependent on expected value, which means a person will identify and calculate all possible positive and negative outcomes of the decision/behavior, and select a best one amongst all potential outcomes ,38. SchoCulture, broadly defined as what is learned, shared, transmitted intergenerationally, and reflected in a group’s values, beliefs, norms, behaviors, communication, and social roles, can affect health-related behaviors both directly and indirectly as well ,43. For Health communication is critical to helping people reduce their health risks, as well as to receiving more significant benefits in return for risks they take. It can ensure that information receivers establish an accurate perception and conduct rational behavior. When resorting to risk communications, messages should be shared openly and timely, aiming to bridge the knowledge gap between the originators of information and those receiving the information, and should adjust the public’s behavior to cope with the risk ,47,48.In this paper, we will bridge the health rumor, personal perception, and health behavior, to illustrate how a rumor misleads people’s perception and further impacts health behavior. We also discuss strategies of effective health communication for forming or correcting people’s perceptions. Focusing on the specific COVID-19 era, we aimed to offer the implication of health communication for combating the “infodemic” during this COVID-19 outbreak. From China’s context, we can also realize the specialty in health behavior, which enables us to broaden our knowledge about the character of health perception and behavior in the cross-cultural or cross-national situation.People News, China Central Television, China News, Sohu News, Sina News and Tencent News. Some dissemination contents related to SHL came from Chinese social media outlets, including Weibo and WeChat.The internet has become a primary channel through which people obtain health information. Especially considering social media, it is becoming a reliable platform for health communication to target audiences due to its promptness, multi-sources and diverse contents . In ChinIn detail, the case was derived from a salient phenomenon during the COVID-19 outbreak in China, which was people’s purchase craze towards SHL, a TCM against influenza with symptoms such as fever, coughing, and a sore throat. At midnight on 31 January 2020, eight days after the 23 January 2000, which is the date of Wuhan’s lockdown, a social media affiliated with Chinese central official media, namely Xinhua Shidian, reported that SHL had an inhibiting effect on the novel coronavirus. Because this information came from the central official media, it was then massively reposted or transmitted by other central and local official social media and the public’s social media outlets . This inAlthough the authority made an emergent fact-checking and clarified the information, the public still persisted in purchasing SHL through different channels. However, this craze also led to tragedy. For instance, the media released news that a COVID-19 patient received the virus by being a part of a cluster of people waiting to purchase SHL . This phIn order to investigate why people irrationally purchased SHL on 1 February 2020, we conducted random interviews with people at pharmacies who wanted to purchase the medicine in three Chinese cities where the authors live in. In total, we validly interviewed 30 people. ♦The media reported that SHL has inhibiting effects on the novel coronavirus. How do you understand the authentic meaning of this dissemination?♦Do you think that the concept of inhibition is similar to remedy?♦How do you understand the so-called inhibition?♦Many experts say that quarantining at home or keeping social distance is crucial. Do you fear the risk of being infected when you go outside to purchase SHL?♦Why do you believe SHL has a positive effect?♦Will you purchase other medicines if the media reports that another specific medicine has the same effect?During the interview, we mainly asked the six following questions:The intention of these six questions can be divided into three aspects: (1) to inspire people to talk as much as possible about what they think about COVID-19; (2) to realize how people clarify and understand medicine related to SHL research and COVID-19; and (3) to understand what factors stimulate people’s purchase craze behavior. In order to avoid a specific question framework that may mislead and restrict people’s real thoughts, based on the abovementioned basic questions, the interviews combined a semi-structured approach with open-ended conversations in which the interviewees were encouraged to speak freely and pose questions on the topics considered. The semi-structured component meant that certain key questions were asked in the same way in all interviews. The open-ended component was intended to capture each interviewee’s actual understanding associated with the outbreak and to uncover the real factors that influenced people’s behavior from interviewees’ discourse ,57.We used the ground theory to code interview materials. According to the three-phase coding framework suggested by Corbin and Strauss, the first step was open coding, followed by axial and selective coding . To starIn our interviews, every question was clearly answered by interviewees. Based on our analysis of the interview materials, the results showed four interrelated facets that influenced people’s belief in the rumors that led to irrational purchases: (1) layperson’s misunderstanding; (2) special psychology in risk; (3) social and cultural cognition; and (4) conformity behavior. Following interviewee’s answers, layperson’s misunderstanding and social and cultural cognition were the prominent factors, because almost all of the interviewees mentioned these two facets.During the SHL purchase craze, misunderstandings were an important element of forming and disseminating the rumor, which reflects people’s insufficient health literacy. Buyers were attracted by the news but misunderstood its authentic content. Thus, they thought that SHL was useful for curing COVID-19. The origin of the report’s title is “A research finding of the Chinese Academy of Sciences: SHL oral liquid can inhibit the novel coronavirus” . HoweverIn total, 20 interviewees expressed that they only focused on the headlines and do not read full articles. One interviewee said, “The media told us good news. Our country is so strong and concludes an exciting finding. The pneumonia will be conquered soon” (S1A3). Another said, “Why do I buy SHL? The news said it can remedy the coronavirus. That is it” (S1A5). Even more, another interviewee said, “The official media states that SHL can inhibit the novel coronavirus. As for other contents, I do not care” (S3A3). Although seven people indicated that they indeed browsed entire articles rather than skimming headlines, they nonetheless failed to understand the complex and professional medical expressions being used in the articles. For example, one interviewee stated: “I went through this news, but I really have no idea what it means. In my opinion, it wants to convey that SHL can remedy the pneumonia” (S2A1). Another interviewee said, “I am not a scientist and I cannot understand what [the news] said. Take a joke, I know every [Chinese] character in this news, but I know nothing of how these [Chinese] characters connect into a sentence” (S2A2).Among the 30 interviewees, all of them used “prevent” or “treatment” to express their understanding of the effect of SHL. Moreover, 23 interviewees failed to distinguish between the concepts of remedy and inhibition, and did not possess the knowledge to understand the medical expressions and terms that the news conveyed. With respect to the distinction between “inhibition” and “prevention”, for instance, some interviewees said: “Inhibition certainly means prevention” (S1A1); “I do not understand so-called inhibition, but I think SHL can prevent the coronavirus” (S1A9); “Inhibition, semantically, naturally means restriction. If you drink SHL, you can keep away from the virus” (S3A6); “I think [inhibition and prevention] are different. However, in essence, no matter what meanings they are, it is the same for curing the disease” (S2A9). Furthermore, five interviewees said that the inhibition meant that SHL could defeat the virus, but they were unable to explain why they held that belief. People were inclined to regard inhibition in its daily usage form instead of considering the medical expression. Some of them said: “Inhibition? Inhibition is defeat and SHL can kill the virus” (S1A10); “Perhaps, inhibition means that the ingredient of SHL can eliminate the virus under a specific chemical reaction, but I have no knowledge about this actually” (S2A7); “[Inhibition] may result in a cure. Sorry, I do not know” (S3A5); “I am not a scientist and I cannot tell the meaning [of inhibition]. Perhaps, it means therapy” (S1A8); and “Inhibition is just effective. SHL kills the coronavirus” (S1A3).Following the framework of rumor spreading, four variables jointly shape people’s belief in a rumor: uncertainty, importance, lack of control, and anxiety. The uncertainty about issues of personal importance engenders feelings, such as a lack of control and anxiety .19 interviewees mentioned their anxiety about COVID-19. For example, they said: “This pneumonia is too scary. If there is any hope, I want to have a try” (S1A5); “I am anxious when I saw the increasing number of deaths on TV. I think we ought to try anything we can get. The media said that SHL is effective and it is really a lifesaver” (S2A9); “Too many people died! This outbreak is more severe than SARS. The hard-working scientists give us hope and why not buy SHL to keep safe?” (S2A8) Among these interviewees, five of them expressed their fear repeatedly and emphasized that SHL was a “savior”.Not all interviewees totally believed that SHL had a positive impact. A Chinese proverb says that “it is better to believe that it exists than not to believe”. Six interviewees stressed the importance of “hope”, even though some of them doubted whether SHL had real effectiveness. For example, an interviewee said: “Quarantine at home is so boring. In fact, I do not know if SHL has any effect, but it is a hope for us. If it is indeed effective, we can end this boring quarantine quickly and return to normal life” (S2A6). Another interviewee said: “I do not care about SHL and other medicines. I will try any medicine if it presents hope” (S2A10).Cultural factors play a vital role in this purchase craze. The public’s belief in SHL stems from the fact that Chinese people trust the TCM. A similar story happened during the SARS outbreak in China in 2003, wherein a purchase craze of Banlangen occurred, which is another widely-used TCM . A natioIn our interviews, 27 interviewees expressed their beliefs in TCM: “TCM is a precious legacy from our Chinese ancestors. TCM even cured my rheumatism, so I think SHL is definitely effective for fighting the coronavirus” (S1A5); “TCM is miraculous and it should be effective” (S3A6); “I have no prejudice towards Western medicine, but I still believe TCM’s effect on remedying influenza. Of course, I may buy other sorts of medicine if they have an effect as well. However, TCM is always my priority” (S3A7); “SHL’s effect is common knowledge. Although it cannot defeat the virus, it may prevent infection. After all, treatment before getting illness is a rationale of TCM” (S1A9).We also found that experts played a role in amplifying people’s perceptions. Some leading experts of China’s official expert team emphasized the advantages of TCM, which increased people’s beliefs in their effectiveness against COVID-19 . In totaWe find that conformity is another important variable for stimulating panic purchases. Referring to the existent literature, we define conformity as a modification of an individual’s previous behavior in the direction of a norm, stated or implied. The individual tendency of conformity behavior is higher during an emergency situation ,66. ConfBased on the present observed purchase craze, we summarized three sorts of conformity behavior. The first type was under the family’s pressure or neighbors’ influence. In this situation, an individual’s perception is either ambiguous or precise. Two interviewees showed conformity behavior with certain perceptions. Their attitudes to SHL were negative, but they still stood in the queue to respect the desires of their family members. For example: “Actually I highly doubt SHL’s effect, but I also have to follow my mom’s orders. She firmly believes in it” (S2A4); “Personally, I do not believe SHL. You can see that much information on social media and lots of people transmit. Elders have insufficient capacity to distinguish between information and they tend to believe it. I have no choice but to satisfy them” (S2A2).The second type is blind conformity, which means that curiosity is the driver of purchase. In this situation, individuals have no actual perception, but the purchase process formed their initial perceptions. Six interviewees admitted that they were curious when they saw the queue in front of the pharmacy and joined the queue as a result of others’ persuasion. For example: “I just passed by this pharmacy and was attracted by the line. Many people told us that SHL may have an effect, so I wanted to have a try”; “I have no idea. Other people buy it, so I will buy it” (S3A4).The third type is the conformity of rational choice. Individuals may have normal perceptions and the purchase behavior is motivated by the rational balance among potential medical effect, time cost, and money cost. Four interviewees said the purchase was better than doing nothing, because SHL could have a potential positive effect and there was little time or money cost associated with purchasing it. For example: “Quarantine is completely effective. But the media reported that SHL had a certain effect and my family also hopes to try it. I think going outside is okay. After all, everyone needs their temperature tested when they go out. So, it is no risk if I come to buy SHL” (S3A10); “Isolation at home is so boring. If SHL is potentially effective, why would I not buy it? SHL is a cheap medicine for us. You see me, I am wearing a mask. It is no problem if I use full protections when I buy the medicine” (S1A4).Rumors form via particular mechanisms. In this section, we discuss why news about SHL became a health rumor. In addition, based on the case study, targeted communication methods are given in order to manage rumors.The purchase craze of SHL showed a process where an ordinary news report became a rumor. Following Allport and Postman’s framework, three factors can distort a piece of information and turn it into a rumor: leveling, sharpening, and assimilating. For leveling, a rumor tends to grow shorter and more concise, more easily grasped and told. Fewer words and fewer details are characteristics of a rumor. For sharpening, it is defined as the selective perception, retention, and reporting of a limited number of details from a broader context. Assimilation suggests that perception is, in no small extent, a question of psychology and attitude associated with habits, interests, and sentiments existing in the listener’s mind . Based oFrom Stage one: This stage shows how media processes and distorts information. As mentioned, the media tends to retransmit complicated news into a brief and sketchy version. Such a process then levels and sharpens. From the media’s report, the media is prone to utilize attractive titles and sketchy content, which matches the most crucial issue that the public is concerned about and grasps the public’s attention. Although the media retransmits the whole content, an attractive title can be used, such as “Good news” and “Big news”. For instance, social media used a title inconsistent with the facts for attracting attention, such as “Big news! Tell the people around you ASAP: Here comes the medicine that can cure COVID-19” . TherefoStage two: This stage illustrates how a piece of processed information finally becomes a rumor. There are two key variables responsible for the variation of information and forming the final version of the rumor. The information distortion in the model represents people’s subjective attitudes and inaccurate decoding of the information. Two concepts of misunderstanding and assimilation are used to generalize the cause of information distortion, showing that people tend to systematically favor information that is consistent with their beliefs and preferences . AccordiBased on this purchase craze, we suggest some implications for managing rumors following principles of effective health communication.Communication is a central human process that enables individual and collective adaptation to health risks at many different levels . During Effective health communication during a public health emergency is a pre-informed procedure with credible, professional, and authoritative information sources. Experts ought to play a vital role in communication instead of the media. What a health communication should contain depends on what audience members intend to do with it. In other words, people always need advice about what they should do rather than a post-explanation. In the SHL case, after the purchase craze, experts were asked to refute the rumor and explain the real meaning of the information . If comm♦Maintaining the intelligibility of information: There should be unitized alternatives of medical terms to inform the public, such as plain language and vocabularies. Due to the different health literacy of people, it is appropriate to use simple and straight language for health communication. When communicating public health information, equivocal expressions are most effective for avoiding overly certain predictions [dictions . If popudictions . In addidictions .♦Keeping the accuracy of information: Factual information is a key factor for preventative rumor management. Thus, never level and sharpen a piece of information into a sentence that may mislead people [d people . Accordid people .♦Enhancing the credibility of information: Expert dissemination ought to parallel with media reports when the contents are linked to professional issues, such as epidemiological investigation and advances in medicine research, by direct and plain expressions. In order to correct people’s health perceptions and behaviors, experts should suggest the strength of the recommendation and the quality of the evidence that supports the recommendation, which refers to the practice of the National Institutes of Health, so that they can offer a numerical and hierarchical cognition about probability and effectiveness and help people make a scientific judgment and rational decision [decision . Additiodecision .Following the above analysis, three principles can help conduct effective health communication and health rumor management:Integrating our research findings and three principles of health communication, we propose a simplified tree diagram to illustrate how health communications influence the public’s perception on health information .Rumors always occur during public health emergencies and often mislead people’s health perceptions and behaviors. Taken together, this article details what factors influence people’s perceptions and behaviors regarding health rumors, specifically regarding the SHL purchase craze during the COVID-19 outbreak in China. Following theoretical and empirical analysis, we argued that expertise in a medical issue, psychology for dealing with uncertainty, social and cultural factors, and conformity jointly reinforces people’s belief in rumors. In addition, official media and experts’ suggestions amplify people’s perception.For managing health rumors during a public health emergency, we firstly described how a piece of information becomes a rumor via leveling, sharpening, and assimilation. Furthermore, we indicated that an effective health communication for rumor management depends on prior prevention and thus recommended three main strategies of health communication: withholding information intelligibility, ensuring information accuracy, and enhancing information credibility. These three strategies aim to lead people to establish accurate health perceptions and perform scientific health behaviors step-by-step, thereby enhancing the effectiveness of risk management. The specialty of this case is that cultural factors profoundly impact people’s perceptions and behavior. Therefore, health communication should use the advantage of cultural factor to enhance people’s accurate perception. Moreover, this case shows that the perception divergence amongst different people may mislead or change people’s health behavior due to specific pressures from acquaintances or families. Thus, an individual ought to be responsible for correcting other people’s perception at the level of family and community.Our findings are not without limitations. In this article, we utilized too few samples to analyze the whole process of a health rumor, which also reflects the explanatory power of cases or interview data. In addition, managing health rumors by using effective health communication is a practical issue with implications in the real world. Therefore, our recommendations for health rumor management communication should be tested through related empirical research in the future. For future research, we will consider if demographic characters will influence people’s perception and health behavior, and comparative study should be conducted based on the same phenomenon in different countries.


Adherence to inaccurate rules has been viewed as a characteristic of human rule-following  and has been thought to be exacerbated in individuals suffering from clinical conditions. This review intended to systematically examine these claims in adult populations.We screened 1464 records which resulted in 21 studies that were deemed eligible for inclusion. Each of these studies was examined to determine: (1) if there is evidence for the RBIE in adults and (2) if this effect is larger in those suffering from psychological problems compared to their non-suffering counterparts. In addition, we investigated how (3) different operationalizations of the RBIE, and (4) the external validity and risks of bias of the experimental work investigating this effect, might influence the conclusions that can be drawn from the current systematic review.(1) Out of the 20 studies that were relevant for examining if evidence exists for the RBIE in adults, only 11 were eligible for vote counting. Results showed that after the contingency change, the rule groups were more inclined to demonstrate behavior that was reinforced before the change, compared to their non-instructed counterparts. Critically, however, none of these studies examined if their no-instructions group was an adequate comparison group. As a result, this made it difficult to determine whether the effects that were observed in the rule groups could be attributed to the rules or instructions that were manipulated in those experiments. (2) The single study that was relevant for examining if adults suffering from psychological problems demonstrated larger levels of the RBIE, compared to their non-clinical counterparts, was not eligible for vote counting. As a result, no conclusions could be drawn about the extent to which psychological problems moderated the RBIE in that study. (3) Similar procedures and tasks have been used to examine the RBIE, but their precise parameters differ across studies; and (4) most studies report insufficient information to evaluate all relevant aspects affecting their external validity and risks of bias.Despite the widespread appeal that the RBIE has enjoyed, this systematic review indicates that, at present, only preliminary evidence exists for the idea that adults demonstrate the RBIE and no evidence is available to assume that psychological problems exacerbate the RBIE in adults.The systematic review was registered in PROSPERO (CRD42018088210). Yet it is important to note that they are descriptive and not functional-analytical terms, given that they did not emerge from inductive, functional-analytic research. As such, in the current manuscript we will use them interchangeably as a way to orient the reader toward a specific class of verbal stimuli.constitute a set of statements that can govern behavior in various domains such as personal, professional, social, and legal contexts. In most cases adherence to rules like “eat healthily if you want to live long,” “do not offend your boss,” “do not gossip about your friends,” and “do not drink and drive” is beneficial, in so far as doing so allows the individual to more readily obtain positive consequences  or avoid negative ones . Yet despite the consequences of rule-following, rules can also continue to exert control over behavior even when they are no longer accurate. Within the behavioral-analytic literature, this pattern of behavior has been referred to as the “rule-based insensitivity effect” (RBIE) and has been defined as “an insensitivity of behavior to other contingencies2These contingencies can refer to other contingencies in the environment as well as those specified by a rule.due to rule-following” . The no-instructions group, however, is not informed about these contingencies and thus has to figure out how to earn points via trial-and-error. About half way through the task, the task-contingencies are changed so that participants now have to press the spacebar slowly in order to earn points. Under such circumstances, it would be assumed that there is evidence for the RBIE if participants who were initially provided with accurate instructions, earned fewer points after the task-contingency change compared to those that did not receive such instructions  there is sufficient empirical support for this effect in adults, and (2) adults suffering from psychological problems display larger levels of this effect compared to those that do not suffer from these problems. We also investigated how (3) different operationalizations of the RBIE, and (4) the external validity and risks of bias of the experimental work investigating this effect, might influence the conclusions that can be drawn from the current systematic review.The review protocol was designed in line with the PRISMA guidelines  and regi“rule governed behavior”, “rule-governed behavior”, “rule governed behaviour”, “rule-governed behaviour”, “verbal regulation”, “instructional control”, “verbal rule”, “instructed behavior”, “instructed behaviour”, “instructed learning”, “instruction following”, “instruction-following”, “rule following”, and “rule-following.” These search terms were iteratively developed with experts on systematic reviews and rule-governed behavior, and were subsequently presented to other experts on systematic reviews and rule-governed behavior who were not associated with the project. All searches were conducted on 4∕10∕2017 by the first author  and yielded 1459 records. Five novel records were additionally retrieved by contacting experts in the field, which resulted in a final set of 1464 records that were assessed for eligibility.To identify as many relevant records as possible, multiple electronic databases were searched  using the search terms: There were several general criteria that a record had to meet before being included in the current review: (1) it had to be a peer-reviewed journal article, (2) it had to be written in English, (3) it had to include a study that examined the RBIE by first asking participants to follow socially -or self-generated rules that initially corresponded with a set of contingencies but then became inaccurate after a contingency change, and (4) this study had to have an overall sample age of at least 18 years, (5) and at least 10 participants within each experimental group (see Is there evidence for the rule-based insensitivity effect in adults?”), we only included studies that did not focus upon individuals with clinical problems. That is, only studies which used convenience samples , samples taken from the general population, or those that were not diagnosed with clinical problems, or reported sub-clinical problems were included. Studies were deemed eligible for answering our second research question , if they used the following samples: individuals diagnosed with psychological problems  or those who scored high on instruments measuring psychological problems but were not formally diagnosed with a clinical problem , and a comparison group consisting of individuals that did not suffer from the above problems or were recruited via convenience sampling.Furthermore, depending on the research objective under scrutiny, the individual studies reported in these records had to meet an additional number of criteria to be deemed eligible for inclusion. For instance, when addressing our first research question (“n = 123), were not peer-reviewed journal articles (n = 207)  or dealt with a topic that did not meet our inclusion criteria (n = 1044). Three journal articles were, furthermore, omitted because they did not provide sufficient information to assess their eligibility. An additional 69 journal articles were excluded that were on the RBIE but were non-experimental (n = 6), relied on non-adult samples (n = 14), used samples with less than 10 participants per experimental condition (n = 41), or did not include a contingency change or manipulate accurate rules (n = 8). This resulted in a remaining total of 18 records consisting of 22 individual studies. One of these studies was subsequently omitted because it did not have at least 10 participants within each experimental group. As such, 21 studies were finally included in the systematic review. The eligibility of all studies were independently assessed by the first two reviewers  initial agreement = 99% [kappa = .98], agreement after discussion = 100% [kappa = 1.00]). See Out of the 1,464 records that were assessed for eligibility, 1,446 were excluded because they were not published in English  . These characteristics involved the source, study, task, and sample characteristics. The source characteristics entailed the year in which the first author published the study and the country where s/he worked in when the paper was published. The study characteristics referred to the type of task, experimental design, procedure, and analytic method that were used to examine the RBIE. Furthermore, the task characteristics entailed whether a study reported the exact instructions or rules that were used, how these instructions or rules were delivered  or generated , the reinforcement schedules that were used, the required behavioral responses, the type of consequential stimuli that were used, whether the contingency change was (un)signaled, whether a description was provided of who the experimenter was, and whether the experimenter was present. Finally, the sample characteristics that were evaluated were the size and mean age of the sample, the ratio of males:females, and whether the sample was selected  or non-selected . These characteristics were evaluated for each experimental group.positive” or “negative” effects (see Positive effects refer to results that are in favor of the predicted relationship between the independent and dependent variable(s), whereas negative effects refer to outcomes that are in the opposite direction of what is expected. We only judged (or voted) whether a study had positive or negative effects if it included a comparison group . That is, a group that received the same treatment as the rule groups but was not asked to follow the instructions or rules that these groups had to follow. We applied this restriction because we argued that such a comparison group is necessary if a study wishes to draw conclusions about the extent to which certain rules or instructions are responsible for the observed effects. In doing so, performances in the comparison group would serve as a baseline of how people behave in the absence of these types of rules or instructions. As such, if a study did not include such a comparison group, we argued that its effects were unclear .To synthesize the quantitative results of the included studies, we used the vote-counting method. This method was chosen because not all studies reported effect sizes or information that could be used to calculate such estimates. According to the Cochrane Collaboration guidelines for systematic reviews, the best way to use the vote-counting method is by assessing whether the results of the empirical studies fall into one of two categories: “ects see . Positivfirst change. This was, specifically, done to prevent carry-over effects from influencing the interpretation of the results.The outcome data that were preferably used to cast votes were measures of the central tendency  of participants’ responses, during all blocks after the contingency change. If a study, however, did not report participants’ performances during all blocks following the contingency change, but only during a fraction of the trials after this change, we limited our analysis to that data. In the unfortunate event that no data was provided that could be used to draw conclusions about the central tendency of participants’ responding after the contingency change, we relied on the conclusions that the authors formulated themselves  , Canada [k = 4], France [k = 2], Norway [k = 2], Switzerland [k = 1], USA [k = 9]) and most studies were published in the 2000s (k = 12).The majority of the studies were written by a first author who did not work in the USA at the time of publication . In all of the studies, participants were allocated to one of the experimental groups, and conclusions about the RBIE were drawn by comparing the performances between these groups after a contingency change. Most of these studies examined the RBIE by examining how rules affected adaptation to changes (k = 11) or reversals (k = 6) in the non-instructed task-contingencies. See In the majority of the included studies, participants completed a conditional discrimination task , intermittent reinforcement schedules  and tasks that required simple discrete responses . In 18 out of the 21 studies, points were used as consequential stimuli which were often exchangeable for a monetary reward (k = 10 out of 18). Of those studies that specified the contingency change (k = 9), seven of them stated that it was unannounced. Only one of the studies provided a description of the experimenter. Seven studies provided information about the presence of the experimenter. Of those studies, five stated that s/he was not present during the experiment. See In each of the 21 included studies, a description was provided of the precise instructions or rules that were used. Seventeen of these studies reported how they manipulated their rules or instructions. In 16 of these cases, this was via written text . The majority of the studies used socially-generated rules (SD = 33 and range: 21–150). The mean age of participants was 20 (SD = .16) and the average number of females was 34 (SD = 25). Note, however, that these values were based on the two and six studies that reported the mean age and gender proportions of the samples that were included for analyses, respectively. Twenty out of the 21 studies used convenience samples, whereas only one study used students that were selected based on the presence or absence of sub-depressive symptomatology  votes were only cast for the 11 out of the 20 studies that included a no-instructions group as a comparison group. These votes indicated that the results of each of these 11 studies were positive. No judgments could, however, be made for the one study that was relevant for addressing Research Question 2 , because this study did not include a no-instructions group. For an overview of the vote-counting results for both research questions see To address Research Question 1 . We also argued that there was a low probability that the methods that were used to assess the study outcomes were invalid or unreliable, and that the experimental groups differed with respect to how these outcomes were assessed (detection bias). See Is there evidence for the rule-based insensitivity effect in adults?”) (k = 20) did not report all relevant demographics  of their samples (k = 13) nor their recruitment procedure (k = 13). Most of these studies (k = 16), however, explicitly described the setting in which the experiment took place, and all of them provided a detailed description of the experimental manipulations per group. The one study that was relevant for examining our second research question , selected participants based on the presence or absence of sub-clinical symptoms of depression, reported the eligibility criteria that they used, the demographics of their sample, and the experimental manipulations per group. Nevertheless, this study did not provide information about the experimental setting nor the procedure used to recruit participants.The majority of those included studies that were relevant for examining our first research question  and can lead to a wide range of clinical problems. Despite the presumed importance of this effect for our understanding of human behavior in general and human suffering in particular, to date, no systematic review has been carried out of the experimental work that has examined these claims. To this end, the present study systematically reviewed the RBIE literature to determine: (1) if there is evidence for the RBIE in adults and (2) if this effect is larger in adults suffering from psychological problems compared to their non-suffering counterparts. In addition, we investigated how (3) different operationalizations of the RBIE, and (4) the external validity and risks of bias of the experimental work investigating this effect, might influence the conclusions that can be drawn from the current systematic review.Our results can be summarized as follows: (1) there is preliminary evidence for the idea that adults demonstrate the RBIE; (2) at present, there is no evidence to support the claim that psychological problems moderate the RBIE in adults; (3) similar procedures and tasks have been used to examine the RBIE, however, their precise parameters differed across studies; and (4) most studies did not report sufficient information to evaluate all relevant aspects concerning their external validity and risks of bias. In the following sections, we will elaborate on each of the above-described points and their implications for our understanding of this effect.Is there evidence for the rule-based insensitivity effect in adults?”) were eligible for vote-counting, because they included a no-instructions group (as a comparison group). Of these studies, the results showed that after the contingency change, the rule groups were more inclined to demonstrate behavior that was reinforced before the change, compared to their non-instructed counterparts. At first glance, this seems to suggest that when adults are asked to follow initially accurate rules, they experience more difficulties adapting to changes in contingencies (compared to when they are not asked to follow such rules). Nevertheless, the risk of bias assessments showed that such a conclusion may be premature because none of the 11 included studies assessed whether their no-instructions groups functioned as adequate comparison groups. That is, none of these studies examined if, during the experiment, participants in their comparison group did not follow rules about the task-contingencies that were similar to those followed by the rule groups. As a result, this made it difficult to determine whether the effects that were observed in the rule groups could be attributed to the rules or instructions that were manipulated in those experiments.Remarkably, only 11 out of the 20 studies that were deemed relevant for addressing our first research question  which examined the RBIE but were omitted because they: (a) used samples smaller than 10, (b) samples from non-adult populations, (c) used non-experimental designs, and/or (d) did not manipulate rules or include a contingency change, we still failed to identify many relevant studies. Indeed, such a revised search only resulted in an additional four studies: two studies that investigated the impact of sub-clinical depressive symptoms in adolescents  but not pathology-irrelevant rules . Likewise, it is possible that different clinical groups  demonstrate different levels of the RBIE because of differences in the origins (generated by imaginary agents vs. self-generated) of the rules they follow. Another possibility is that variations in the elements of the rules , might contribute to differences in how people suffering from similar conditions  adapt to contingency changes. We believe that such an endeavor would be useful because it could aid clinicians in developing more targeted treatments.When carrying out such work, researchers should also explore certain variables that could moderate this effect in clinical groups. For instance, it might be that clinical groups  are more insensitive to contingency changes if they follow pathology-relevant  that were used, the point in time in which the contingency change occurred , and the study outcomes  often differed between studies. Generally speaking, if reliable evidence is found for a phenomenon, such variations are often viewed as a potential advantage because they enhance the generalizability of a study’s findings. Yet given that, in our opinion, it is unclear whether the RBIE was adequately assessed in any of the included studies in this review, we believe that this idea cannot be applied to our findings .The results revealed that many studies did not report all relevant demographics of their samples, how they were recruited, if the contingency changes were announced, and if the experimenter was present during the experiment. In addition, no study provided sufficient information to assess all domains of potential risks of bias. Taken together, this suggests that the reports of the included studies did not provide sufficient information to evaluate all coding items assessing their external and internal validity. The lack of such information is particularly problematic in the context of systematic reviews because it limits the conclusions that can be drawn from it. As such, we strongly recommend that, in future work, researchers report all information about their study that may enable readers to more readily draw conclusions about its external and internal validity  experiences in that context .If the latter possibility is valid as well as the possibility that rules governed the behavior of the no-instructions groups, then this might suggest that comparisons between instructed and non-instructed groups might not inform us about the effects of rule-governed vs. contingency-shaped behavior Finally, to the best of our knowledge, there is currently no consensus about how contingency insensitive and sensitive behavior should be measured. Indeed, if anything, the implicit assumption is that behavior is contingency insensitive if it is not in line with a contingency, whereas it is contingency sensitive if it corresponds with a contingency. We believe that although such operational definitions can be useful in some respects, they lack the precision that is needed to measure these behaviors in a uniform and unambiguous manner. Indeed, given the broad and descriptive nature of these definitions, much variation can exist between studies in how they measure contingency sensitive and insensitive behavior. We believe that, although this is not an issue per se, it can become problematic when one wants to draw general conclusions across studies. We, therefore, recommend that future work offers more precise operational definitions of contingency sensitive and insensitive behavior.d for independent samples; 95% CI [.41–1.12]; p < .001) indicating that participants had far more difficulties adapting to a contingency change if, prior to the change, they received a rule as opposed to no rule. Third, across all studies that were deemed eligible for vote-counting, preliminary evidence was found for the RBIE. This was surprising, given that, in general, the likelihood of observing the same effect across all studies in a systematic review is rather low  with a previously effective rule if they demonstrated behavior that corresponded with this rule on at least a few trials, and (2) with a novel contingency and/or rule if they always behaved in line with this contingency and/or rule. As a consequence, it possible that if a different criterion were used, other findings would have emerged. Second, we opted for vote-counting for our quantitative research synthesis, which unlike the standard meta-analytic approach does not provide information about the magnitude of the observed effects . Neverthther low . Usuallyther low . PublicaFor several decades now, the RBIE has been argued to play an important role in human behavior in general and psychological suffering in particular. Yet despite its widespread appeal, the results of this systematic review suggest that strong claims about its existence and role in psychological suffering are currently unsupported and thus far unwarranted. Indeed, at present, only preliminary evidence exists concerning the RBIE in adults and no strong evidence is available to draw conclusions about its role in the development and maintaince of psychological suffering in adults. We, therefore, recommend that more systematic research is conducted on the RBIE so that future work can better evaluate the relevance of this effect for our understanding of human behavior and psychological suffering.10.7717/peerj.9496/supp-1Supplemental Information 1Click here for additional data file.10.7717/peerj.9496/supp-2Supplemental Information 2Click here for additional data file.10.7717/peerj.9496/supp-3Supplemental Information 3Click here for additional data file.10.7717/peerj.9496/supp-4Supplemental Information 4Click here for additional data file.10.7717/peerj.9496/supp-5Supplemental Information 5Click here for additional data file.


Breaking bad news about life-threatening and possibly terminal conditions is a crucial part of paediatric care for children in this situation. Little is known about how the parents of children with life-threatening conditions experience communication of bad news. The objective of this study is to analyse parents’ experiences (barriers and facilitators) of communication of bad news.A qualitative study consisting of a constant comparative analysis of in-depth interviews conducted with parents.The Netherlands.Sixty-four parents—bereaved and non-bereaved—of 44 children  with a life-threatening condition.None.Based on parents’ experiences, the following 10 barriers to the communication of bad news were identified: (1) a lack of (timely) communication, (2) physicians’ failure to ask parents for input, (3) parents feel unprepared during and after the conversation, (4) a lack of clarity about future treatment, (5) physicians’ failure to voice uncertainties, (6) physicians’ failure to schedule follow-up conversations, (7) presence of too many or unknown healthcare professionals, (8) parental concerns in breaking bad news to children, (9) managing indications of bad news in non-conversational contexts, and (10) parents’ misunderstanding of medical terminology.This study shows healthcare professionals how parents experience barriers in bad news conversations. This mainly concerns practical aspects of communication. The results provide practical pointers on how the communication of bad news can be improved to better suit the needs of parents. From the parents’ perspective, the timing of conversations in which they were informed that their child might not survive was far too late. Sometimes, no such conversations ever took place. Communication of bad news receives insufficient attention in medical training.Physicians often feel uncomfortable in delivering bad news.Current studies—mostly limited to palliative care—show that parents are often not satisfied with the communication about their child’s life-threatening prognosis.This study shows 10 themes (barriers and facilitators) perceived by parents with regard to bad news conversations.From the experiences of parents we deduced practical advice on how to improve bad news conversations.The most important message: talk with parents, even when prognosis is uncertain.During their years of medical training, physicians are instructed about how to deliver bad news to patients and their families.The few studies that have focused on parents’ experiences found a general lack of satisfaction with the way in which bad news is communicated.In a large-scale, nationwide qualitative study, we interviewed parents on care and decision-making for young children (aged 1–12 years). The themes on communication of bad news presented in this paper are the results of a focused analysis of parents’ experiences.We recruited bereaved and non-bereaved parents of children (aged 1–12 years) with a life-threatening condition. Life-threatening conditions are here defined as all medical conditions that are potentially lethal and/or life limiting. Parents were excluded when their child had died more than 5 years prior to the interview. Recruitment was tailored to yield maximum variety in terms of condition, age, cultural background, level of education and place of residence. Recruitment continued until data saturation was achieved. First indications of thematic saturation were observed after 30 interviews,Study participants were recruited in the period from November 2016 to October 2018. Parent support groups used their online platforms to reach potential participants, and paediatricians and paediatric palliative care teams were contacted to invite potential participants. All potential participants received full information about the study, were given an opportunity to ask questions before participation and gave their written consent.A single face-to-face, in-depth interview was held with parents, usually at their place of residence (average duration: 2 hours). The topic guide is added as an 10.1136/archdischild-2019-318398.supp1Supplementary dataThe aim of the analysis was to provide a qualitative description of barriers in communication of bad news as perceived by parents.Atlas.ti, a software program for coding qualitative texts.The first author coded the transcripts in terms of communication-related content. All of the authors read the selected material to familiarise themselves with the content. Themes were identified by a reiterative process of comparing and contrasting interview sections, which were further specified using 10.1136/archdischild-2019-318398.supp2Supplementary dataRegular meetings with an advisory group of parents, researchers and paediatricians were held to discuss the results and translate them into recommendations of care.We held interviews (n=42) with 64 parents of 44 children with a life-threatening condition, 24 of them bereaved. All of the children involved suffered from a variety of life-threatening conditions. Parents were recruited from all parts of the Netherlands. Every Dutch academic medical centre, as well as over 20 local hospitals, was represented. Details of participants’ characteristics are shown in The experiences of parents included both facilitators and barriers, but parents were most explicit about the barriers to good communication of bad news. Conversations about the (possible) death of their child were most prominent in their narratives, but their experiences on bad news conversations included other information (such as the severity or treatability of the condition) as well. We identified 10 themes: (1) a lack of (timely) communication, (2) physicians’ failure to ask parents for input, (3) parents feel unprepared during and after the conversation, (4) a lack of clarity about future treatment, (5) physicians’ failure to voice uncertainties, (6) physicians’ failure to schedule follow-up conversations, (7) presence of too many or unknown healthcare professionals, (8) parental concerns in breaking bad news to children, (9) managing indications of bad news in non-conversational contexts, and (10) parents’ misunderstanding of medical terminology.During the illness of their child, some parents seemed to be unaware that their child might not survive during treatment. We identified four types of prognosis: (1) conditions with a terminal prognosis, (2) conditions with a gradually changing prognosis , (3) conditions with an all-or-nothing prognosis (such as cardiac surgeries) and, finally, (4) conditions where no precise diagnosis could be made . Especially in the last two categories, there was little or no discussion of the possibility of death.You just don’t know what you are getting into. And looking back, I do think physicians knew, I think they realized quite quickly what was happening. But we did not. Because they never told us. Maybe they didn’t withhold the information on purpose, I don’t know, but… (M37)Interviewer: Looking back, do you think you would have wanted to know?Mother: Yes, when I look at that entire period, I would have wanted to know it. Maybe not on day 1, but at least a lot sooner. Then we might have done things differently that final year.Several parents recalled retrospectively that they had never been explicitly told that their child’s future was uncertain or that their child might die, until shortly before the moment of death.I went to the doctor, and asked, ‘Is he going to be okay?’ He replied, ‘well, with the right…’ And then I said, ‘No, I really want to know. I’m asking you.’ And it turned out that there was no chance at all. That’s when I said, ‘Then I don’t want all this treatment for him any more. We should take him home.’ After that it went quickly: he died the following day. (M20)In some cases, a conversation never took place because parents were referred to another hospital and physicians assumed that the conversation had taken place. Parents felt that it was important to have open conversations about the child’s uncertain prognosis. They said that parents would be thinking about this anyway, and not mentioning it created a taboo. They felt that it should not be up to parents to take the initiative in such matters, as that would make them feel that they were giving up on their child.You have to have the courage to [talk about the possibility of death]. And we were lucky to have one doctor who had that courage. I think a lot of doctors find that really difficult, because of who they are, and because of their training. (…) But it helps to talk, or philosophize together about death. And of course there are limits to what is possible, but there are possibilities as well, and it helps to be open about how you feel towards those. (F09)The failure to hold such conversations leaves parents unprepared when the message is finally delivered, and deprives them of any opportunity to make decisions about their future.If they had told me, I would have taken him home instead, to give him a dignified end of life. (M20)Parents appreciated conversations in which they were treated as equals. They emphasised that, in conversations of this kind, they wanted physicians to take them seriously when they signalled symptoms or evaluated the child’s quality of life. Physicians only see small snippets of a child’s life. This makes their evaluation incomplete and serves to underline the importance of a parental perspective.They only see [our daughter] during check-ups in the hospital. But she behaves completely differently there. And then they draw all kinds of conclusions about how she is doing, and I always feel, yes, but when we get home, everything will be different again. (M38)Recognising that some people might want more information than others, some parents advised physicians to ‘ask parents how they wish to be informed—Whether they want all medical information or not’ (M04).Parents stated that they often felt overwhelmed by the conversation, because they were not sufficiently prepared for the conversation. One mother explained that she was given the news that her daughter’s tumour was terminal while she was lying in a hospital bed, recovering from a caesarean. She had been given no prior notification of this conversation, and felt overwhelmed and bereft of autonomy.The feeling of lying there, in your pyjamas, looking up to all these doctors, has left such a bad taste in my mouth. And I remember wondering, does it really need to be done like this? (M01)The importance of facilities to support parents following conversations was also emphasised. Several participants remember walking out of the bad news conversation and being unable to find a quiet space where they could calm down and call their family, and with no idea of how to get home safely in that distressed state of mind.Suddenly we were in the main hall again, and we said to each other, ‘What are we supposed to do now? I think we should call some people?’ We had come to the hospital by car, so I said, ‘I don’t think I can drive home right now.’ My husband said, ‘I think I can drive…’ But having to do that, that’s just irresponsible! (M23)The parents emphasised that, when people are informed that their child’s illness is incurable, they should be told what to expect in terms of care and support.[After the bad news conversation] we went home, [with the message] ‘go and make good memories with her.’ But how? I don’t think we had another appointment, or anything. For two weeks after that conversation, we had no idea what to do: Where should we go now? Who should we call? What should we do? We had to find out all those things ourselves. (M21)Other parents had more positive experiences, appreciating that physicians promised to be there for them.What I really appreciated was that besides the information about prognosis, they also said, this is what we can do for you. (…) We are going to support you through what is to come. (M15)Parents felt that physicians often found it difficult to talk freely in situations involving uncertainty. Conversations were postponed until the details had been confirmed; in others, information that was presented as factual later turned out to be incorrect.Just tell us that you don’t know. (F01)Honesty about physicians’ lack of certainty was appreciated.[The doctor] said: ‘Are you okay with a second opinion? Because I really don’t know how to proceed at the moment.’ And I said, ‘I’m just happy that you honestly admit not knowing it, even as an expert on this.’ (M03)Several parents said that, after receiving bad news, they were immediately expected to ask questions and make decisions. This gave them no time to process the news.We were sitting there, in front of 14 white coats, and they said, ‘We have seen a cerebrovascular accident, what do you want?’ That was the first thing they asked. Without any context. (M07)Several parents recommended that bad news conversations be carried out in two stages. The first stage would involve delivering the bad news, while the second stage would give parents an opportunity to ask questions, or to discuss decisions. A few parents had experienced such two-stage bad news conversations and appreciated this approach.[A physician can] check during the second meeting, ‘did they hear everything I told them?’ Because maybe they only absorbed part of the message. (F31)In several cases, bad news conversations included a group of physicians, many of whom were complete strangers to the parents. Parents would have preferred a more intimate setting.Six or seven people came in (…) and then they told us the news. And I just thought, ‘Why are all these people here? What is the value of that? How am I supposed to react?’ Everyone is looking at you, and of them, we only knew the neurologist. It was really uncomfortable and overwhelming. (M01)In cases where presence of several healthcare professionals was required, parents advised to introduce them and explain their presence at the conversation.Most of the parents in the study were positive about the way in which bad news had been broken to their child. However, some parents disagreed with physicians about how much children should be told about their illness. Others felt abandoned when it came to discussing illness and death with a young child. Several participants remarked that much of the information provided was targeted at children with terminal oncological conditions. Children themselves also had an impact on communication: some flatly refused to talk about their illness, while others were actively involved.She would always know when the results of the MRI would come back, and would pick up the phone when the doctor called. She would say, ‘Oh, you can tell me!’ And the doctor would have a conversation with her about it. (F25)During the treatment, important messages were sometimes inadvertently conveyed by other means: notes on a hospital bed, the waiting time before the results arrived or overheard conversations. Parents stressed that healthcare professionals need to be aware of the impact of such messages.We were notified that the MRI had been rescheduled because the neurologist was hesitant to wait so long. The planners just make a schedule and notify you. But for us it was an all-important message. So it would have been nice to have a little more… compassion there. (M15)Parents often felt that they understood what had been explained to them by healthcare professionals, but not always. An example of the latter is provided by a couple explaining that they had never realised that the brain tumour of their daughter was in fact, a cancer… Medical terminology may not carry the same meaning for healthcare professionals as for parents, creating misunderstandings.The aim of this study was to investigate parents’ experiences (barriers and facilitators) in communication of bad news. We studied this on a uniquely broad scale, with a large number of participants, nationwide, and a representation of various life-threatening conditions.The narratives of parents gave insight in the various experiences of parents during communication of bad news. Some of the experiences of this group corroborate findings from earlier studies, such as the need for empathic communication,The study adds insight in how lack of conversation impedes decision-making. Decisions that influence life expectancy occur long before the illness is terminal. Parents expressed that they would have made different decisions if more information about the child’s prognosis had been provided. This finding underlines the urgency to hold timely conversations about decision-making in line with parental needs for individualised care planning.Parents specifically mentioned the need for honesty regarding their child’s prognosis, as an opportunity to discuss the proportionality of treatment and possible end-of-life decisions. A lack of information could limit parents’ ability to make well-informed decisions about their child’s quality of life (including end-of-life decisions). In some instances, the healthcare professionals involved may feel that the parents are not ready to hear the prognosis.Parents’ wish to be seen as an equal partner in communication about bad news ties in with ongoing changes in physician–patient relationships, in which the classic paternalistic model is giving way to models of shared decision-making.Our study does have some limitations. First, it focused on young children (aged 1–12), so the results may not be generalisable to adolescents or neonates. Second, cultural differences in decision-making may mean that the experiences of Dutch parents differ from parents in other countries. Third, we focused on the issues involved from the parents’ perspective, which means that we cannot be certain how the bad news was delivered. However, people’s experiences are central to their lives, and improving communication is, in the end, about how communication is understood.This study shows how parents perceive the communication of bad news. Their experiences highlight two main points. First, the experiences of parents mainly concern very ‘practical’ aspects of communication: where conversations happen, who is present, how they are scheduled. Second, from the parents’ perspective, communication of bad news often took place far too late. Indeed, in some cases, no such conversations ever took place.This study shows that parents experience a significant number of barriers in the communication of bad news. Their experiences, however, provide an opportunity to improve communication about life-threatening conditions, for example, by being aware that adequate information is disclosed to parents, especially in circumstances of uncertain knowledge. Parents express a need to be informed, even if their child’s situation is uncertain. This may be anticipated by having conversations shortly after a condition is classified as life threatening or by asking parents how much they want to know. Second, parents may be better prepared for the conversation by creating circumstances that empower, rather than overwhelm them—for example, by having regular one-to-one conversations. Together with our advisory group we translated the themes into a list of advises to improve communication of bad news. This list is presented in Good communication matters. It influences good care,


In the future, artificial intelligence (AI) is likely to substantially change both the tourism industry and tourist behavior. At present, research on artificial intelligence and tourism is receiving widespread attention, but most of them focus on a certain subject or a specific aspect of the tourism industry. For example, artificial intelligence influences the behavior of tourists and tourism enterprises. The analysis of the impact of artificial intelligence on the tourism industry as a system is still insufficient. Therefore, this research proposes a multi-dimensional framework from an industry perspective based on the existing definition of artificial intelligence. The framework involves three aspects: the level of intelligence, task types, and whether artificial intelligence is embedded in robots. The authors use a large number of Chinese practice cases to investigate how AI affects the tourism industry, then put forward a research agenda to analyze how destination government, tourism enterprises and tourist experience will change in the future. Finally, they highlight important issues related to privacy, prejudice and ethics. The industry .Artificial intelligence plays a key role in a series of innovations and applications in the tourism industry, and is deeply changing the experience of tourism and service . The gloIn real life, artificial intelligence has been widely used in tourism and service industry. However, in the academic field, most of the existing research is concentrated on the field of information science, exploring the artificial intelligence technology itself  and the Existing studies rarely systematically explain how artificial intelligence will affect the tourism industry and how artificial intelligence will develop in the future. Out of practical and theoretical demands, this article attempted to put forward a research framework on how AI influences and changes the tourism industry. Based on insights from marketing , social sciences  and computer science/robotics, we proposed a framework which can help tourists, tourism enterprises, governments and destinations foresee how artificial intelligence will develop and evolve.. Since the emergence of artificial intelligence technology is inseparable from the rapid development of computer technology, some scholars tend to define it from the perspective of computer science, believing that it is “the scientific study of the computational principles behind the ideology and intelligent behavior” [Most definitions of artificial intelligence focus on it as a subfield of computer science or in terms of how machines can mimichuman intelligence . Since tehavior” . Others ehavior” .Another way to describe artificial intelligence does not depend on its underlying technology, but on its marketing and commercial applications . For conSome researchers try to use the knowledge of network science to understand it. They believe that tourism is a dynamic and complex system . A centrGunn  first prIn this article, the research object is regarded as a tourism system composed of dynamic and interdependent tourism elements, including governments of tourism destinations, tourism enterprises, and tourists.From the perspective of tourism enterprises as the supply side, artificial intelligence is in the stage of growth from Weak AI to Strong AI, and its impact on employment is continuously increasing . The serFrom the perspective of tourists, artificial intelligence has a great impact on consumers and their experience. In the Web of science database, searching with Artificial Intelligence and Consume/Consumption/Consumer as the subject keywords, a total of 5216 related documents were retrieved, of which the number of studies from 2011 to 2014 was relatively small. Since 2015, there has been an upward trend in the number of studies focused on computer science, communications science, and engineering, but there has been less research in the fields of social science, economics, and management science. At present, smart customer service, accurate information push, robot sensing services and other methods have had a great impact on consumer needs, preferences, decision-making and experience . For exaBased on the insights of marketing, social science and computer science/robotics, Davenport T et al.  proposedThis research is aimed to help destination management organization and tourism companies predict how artificial intelligence may develop. We considered three perspectives: governments, tourism enterprises, and tourists. In each perspective, there are three dimensions related to artificial intelligence: the level of intelligence, task types, and forms of AI. We extracted topics and questions from real cases, and integrated them to form the framework of the impact of AI on governments, tourism enterprises, tourists and future issues.Task automation. In China, the instrumental value of artificial intelligence and “intelligence” as an important direction of social governance in destinations have been highly valued by governments at all levels [l levels . A serieThe application of “City Brain” has improved the quality and efficiency of tourism emergency rescue and tourism services. The “One-click escort” system of “City Brain” can automatically control signal lights to clear the queues in advance through video and real-time information of vehicle trajectory. In this way, it opens up a “green channel” for rescue traffic. The government also lays more emphasis on some “pain spots” of tourism governance. Based on data analysis results, the authorities can provide services such as “find vacancies within 10 s”, “enter the scenic spots within 20 s”, and “annual card for cultural tourism in the Yangtze River Delta” now. Taking the “enter the scenic spots within 20 s” as an example, tourists go to the attraction and open Alipay, scan the payment code and enter the park directly, reducing time spent in queue for ticket purchase.Numbers. The “City Brain” cultural and tourism system focuses on the construction of Hangzhou cultural and tourism big data decision-making system. Firstly, build a unified data standard, and a data sharing mechanism to promote the integration of the “city-county-street” three-level data platform. Secondly, rely on the government affairs data sharing and the exchange platform, promote the integration of travel-related data from public security, transportation, urban management and other departments to the “City Brain” cultural tourism system to provide first-hand data support for travel tasks. Finally, in order to accelerate the construction of a tourism data network for vertical and horizontal communication, actively guide tourism companies and other market entities to participate in cultural tourism data production and results sharing.Hangzhou “City Brain” also analyzed sentiment tendencies on text data such as tourist reviews. For example, the system conducted data mining on hotel reviews from six categories: health, location, service, price, facilities, price, and organized the overall ranking of Hangzhou hotel praise rate and the favorable rate ranking of each individual item.Digital form. WeChat applet, APP and other methods have innovated the service process. The WeChat applet of “Hangzhou Digital Tourism Line” relies on various data such as tourist trajectories, railway reservations, and bus operations to plan dedicated lines scientifically and schedule shift times dynamically. At present, 35 special lines have been opened, serving more than 1.2 million tourists. In response to the difficulty of accommodation during holidays, the Hangzhou government has launched a WeChat applet called “Find vacancies”. The front-end vacancy display platform displays the hotel vacancy status; the back-end inventory management system docks with platforms such as PMS and OTA. Tourists can find suitable nearby vacancies based on real-time positioning and price preferences through the applet.In order to solve the problem of cumbersome check-in and check-out procedures for tourists, the Hangzhou government started from the front desk of the hotel and launched a “hotel check-in in 30 s” service. Tourists can check in and check out quickly by themselves with only three steps: scan and compare ID card, find order and confirm check-in, make room card. Both the check-in experience of tourists and the efficiency of service are improved. At present, “hotel check-in in 30 s” has been connected to 246 hotels, serving more than 284,000 tourists.Task automation. Automation does not simply mean replacing manpower with machines, but integrating machines into an autonomous system that can complete a process without manpower assistance [“The process of customized tours should be automated. ‘Mioji Travel’ hopes to automate customized tours through the route planning supported by artificial intelligence.” (2) Intelligent customer service system: Chinese OTA platforms represented by “Ctrip” and “Qunr” have set up customer service robot systems, which are responsible for answering basic customer service questions.sistance . Many to“When passengers need to ask for flight information or directions, they can talk with foreigners as long as they wear the headset.” In travel activities such as shopping or dining, this kind of communication will make travel more interesting.Shenzhen timekettle.Co., Ltd. Has developed the world’s first real-time translation headset WT2, which realizes the effect that two people in a conversation do not need to repeatedly pass the device, and do not require the person receiving the conversation to download the program. Its co-founder Qin Zi’ang said, Numbers. The big data group “Vpon” accurately locates passport holders and high-spending groups by analyzing more than 600 million mobile devices in China. “Vpon” uses AI to research various algorithms to understand the data, and then classify different types of passengers. Since purchase transactions may occur at different stages of travel, people use AI to analyze consumers’ preference during a trip based on the historical data, predict the behavior of passengers, and finally locate advertisements accurately.The text of customer reviews often contains words of emotional value, such as “thank you”, “sorry”, and “not satisfied”. Some Chinese companies use robots which can detect how many words containing negative emotions the customer has used to collect information about preferences, satisfaction through customer posts on social media platforms.Digital form. In July 2019, the “In-depth enjoyment of the Forbidden City tour” applet launched by the Forbidden City was upgraded. The AI tour guide “Mr. Fu” became the biggest highlight. As a cabinet bachelor, “Mr. Fu” can not only chat with tourists, but also recommend personalized tour routes and explain the cultural relics of scenic spots. Especially in this epidemic, a series of “vertical tourism” products represented by the Forbidden City applet played an important role in promoting the recovery of the tourism industry. People can enjoy the beautiful scenery at home.With technical support, the robot continuously adapts and evaluates application scenarios. In 2018, Alibaba’s first unmanned hotel “Fly Zoo Hotel” landed in Hangzhou. Although full-robot hotels like this may still be rare today, hotels around the world have implemented intelligent automation in some customer-oriented operations, such as automatic check-in, virtual personal assistants, and meal delivery robots.Task automation. In the expectation stage before a trip, there are two main difficulties for tourists in decision-making: First, tourism data is large in volume and diverse in types. The decision-making process consumes energy and requires great ability. Second, the travel process is continuous, so it is difficult to achieve the best time, distance and price at the same time. To solve these problems, the online travel website “Qyer” designed an itinerary planning tool called “Itinerary Assistant”. Tourists input their own needs, and directly perform one-key intelligent optimization to obtain the most reasonable arrangement. In this way, tourists have an increased sense of expectation towards the destination.“Admiring modern technology and ancient technology, I often wonder whether the humans who created modern electronic intelligent technology are smarter, or those who created ancient extinctions are smarter. Traveling in the history and imagining the future, this is the surprise and fun brought by cultural relics.” It can be seen that context awareness technology makes tourists deeply integrate into the scene, breaking their stereotype of the museum. They no longer stay in the sensory aesthetic stage of “skimming the surface”, but develop to a stage of both appreciating the scenery and reflecting on themselves.Image recognition, voice recognition, and face recognition technology is widely used in museum tourism in the stage of on-site experience. This article takes the Hunan Provincial Museum, and sorted out 100 key comments with a total of 3507 words. The keywords “technology”, “experience”, “interaction”, and “explanation” appeared 51 times, 21 times, 17 times, and 13 times respectively. Numbers. The entire process of tourism decision-making, experience, and recall constitutes a closed loop. Before the journey, tourists are usually not clear about their travel preferences, but after in-depth analysis of their previous travel data, they can more clearly recognize their habits and make better decisions.Still take “Qyer” as an example, it has formed a “Qyer Community” that attracts a large number of experienced tourists. User-produced content (UGC) is its greatest feature. People discover some niche attractions through vivid language and photos. After a trip, they are also willing to share what they have seen and heard. A social community gives tourists a more personalized and memorable experience. Meanwhile, artificial intelligence analyzes the non-numeric data and gains insight into consumer behavior.Digital form. In the on-site experience stage, tourists obtain personalized support services through digital products. In Hunan Provincial Museum, tourists can directly scan the QR code on WeChat to get the voice explanation for free, which provides tourists with opportunities to observe cultural relics more closely and experience culture more deeply.“The kindergarten children are not very interested in the museum, but are attracted by the Xiaodu robot at the entrance.” For tourists, robots in travel scenes can not only provide more detailed and convenient services, but robots themselves are also an attraction.A tourist who has been to the Hunan Provincial Museum commented, In the field of tourism, research similar to artificial intelligence is found in “wisdom tourism” (originating from “smart cities”), and has become an independent research field with the development of “smart cities” . GretzelWe can see the impact of different abilities of artificial intelligence on tourism companies in different dimensions in the following aspects: (1) Economic benefits: the use of artificial intelligence robots may bring economic development and various other benefits. Artificial intelligence systems or robots can work 24 h a day. Its low error rate saves costs for enterprises. (2) Internal and external customer service: the impact of this aspect mainly includes two parts: one is forecasting customer needs, conduct customer portraits based on customer past data, and make recommendations based on customer preferences, the other is simplifying repetitive tasks for employees so they can focus on more meaningful things. (3) Tourist satisfaction: a lot of technical research is to improve tourist experience, thereby improving customer satisfaction. (4) Artificial intelligence technology requires enterprises to innovate business models. Companies can understand the preferences of tourists through the analysis of historical data, and even “tailor-made” travel experiences for them.How does the tourism destination management structure under the influence of AI technology move from fragmentation to synergy? How will the highly circulated data sharing mode and disintermediated service organization boundaries that accompany the emergence of AI technology help improve the existing power structure? The inefficiency of the market-oriented supply of tourism public services is basically due to the fact that it is difficult to reconcile the contradictions and conflicts between the profit-seeking nature of marketization and the public nature of public services. Promoted by AI technology, how to make the marketized supply of tourism public services move from concealment to transparency, and finally realize the effective supply of tourism public services is worthy of further exploration. How to realize the socialized supply of tourism public services from amateur to professional? It is also a new topic for the development of tourism public services under the background of AI technology to promote the standardization and professionalism of tourism service socialization.AI transforms the traditional seller’s market to a buyer’s market. The complex needs of tourists are met, but at the same time privacy issues are encountered. Intelligent systems capture information about tourists on platforms, such as their location. The entire analysis process is a “black box” operation, tourists do not know who uses their information and what channels it is used for.A kind, patient, and knowledgeable virtual tour guide makes tourists more likely to have a desire to communicate. This kind of interactivity changes the mindset of users. In the future, it is necessary to focus on the social interaction between tourists and virtual people, and to deeply explore its social value and the value of shaping IP.When talking about the erosion and threat of artificial intelligence to people, some researchers will use the term “human-centric” to describe the loss of intrinsic value. Intrinsic value does not serve any purpose, so its influence on moral judgments is crucial. Although the current level of technology is still at the stage of weak artificial intelligence, and only stays at simple technical support, it is still necessary to maintain a rational attitude and make preparations for research on robot ethics related systems.All in all, this research focuses more on the analysis and summary of the overall research framework, and lacks a quantitative analysis of each case. In the future, we will conduct in-depth analysis on the key cases mentioned.