Standard mindfulness-based interventions have significant at-home assignments of formal mindfulness practice as a key component. Engagement with formal home practice has been correlated with treatment outcomes, but participants often complete less than the assigned amounts. Here, we explore the requirements for technology tools that can support and encourage home practice, in a way that is appropriate and consistent with the core principles of mindfulness-based interventions. Interviews were held with a group of five highly experienced mindfulness teachers and a group of five participants who had previously completed an eight-week course. Data was subjected to thematic analysis. A key finding was that providing teachers with information on how students practice could support communication around difficulties with home practice. We also identified questions around the appropriateness of adapting the course in response to participant difficulties and participant preferences. Both teachers and students made numerous suggestions for ways to augment their training using technology, such as via practice reminders and provision of teacher-specific content. Finally, a major design issue for technology developers is how to support participants in reflecting on their experiences of mindfulness practice, and subsequent learning, but not to critically evaluate their practice. Formal practice includes the Body Scan , yoga, and sitting meditations, generally supported by audio guides, and consists of around 45 minutes per day over the eight-week course. Along with shorter ‘informal’ practice , the longer formal practice is presented as a core part of the course. Practice is emphasised as one of the key means for people to become aware of, and relate differently, to mental habits.2Standard eight-week mindfulness courses, as for other psychological therapies, require participants to complete at-home assignments, in addition to group sessions. At-home assignments provide opportunities to practice new skills, test new ideas, and generalise learning outside of sessions with the therapist.3 Home practice requires participants to expose themselves to difficult subjective experiences, which they may have previously avoided.2 Practice has been described as ‘the slow, disciplined work of digging trenches, of working in the vineyards, of bucketing out a pond. [As] the work of moments and the work of a lifetime, all wrapped into one’4 (p. 111). Mindfulness-based interventions strongly emphasise experiential learning: participants are encouraged to ‘try it out’.Completion of home practice is often a challenge for participants, similar to home assignments in other psychological therapies.5 and like MBSR and MBCT, it has home assignments as a central component. Home assignments can take many formats in CBT, including symptom logs, self-reflective journals, and specific, structured activities like exposure and other behavioural experiments. For example, a patient might be asked to schedule an activity associated with enjoyment or accomplishment . The extent to which patients complete their CBT home assignments is related to the benefit they receive from treatment . These meta-analyses indicate that there is a small to moderate association between home assignment completion and treatment outcomes. That is, completing more home assignments is associated with better outcomes. The positive associations between home assignment completion and outcome hold, even when attendance at CBT treatment is taken into account, along with initial symptom severity.8Cognitive behaviour therapy (CBT) is the most studied psychological treatment,9 There was a small to moderate association between home assignment completion and treatment benefit. Furthermore, the amount of practices that participants reported doing was highly variable: some reported practising even more than the assigned amounts and some did far less.10For MBSR and MBCT, a recent meta-analysis of 48 studies found that participants reported completing a significant amount of home practice , but less than the recommended 45 min.11 For instance, in one feasibility study of MBCT, finding a time during the day, particularly among those with external employment, was the main challenge described.12 A second study reported that being unemployed predicted greater engagement with home practice.11 The authors argued that participants with unrestricted time during the day were better able to complete their practices. Other work has described additional barriers to practice including impatience, boredom and fatigue; scepticism regarding the value of mindfulness training; the notion that mindfulness is ‘self-indulgent’; negative affective states  and the requirement for forced breaks from routine.13 Finally, a study of participants 12–18 months after completing an MBCT course found that participants required reminders of the practices they had completed, and indeed reminders of the benefits of practice.14Given the importance of practice, it is crucial to understand the obstacles that participants face in its completion. A number of qualitative studies have emerged that describe some of the obstacles. Lack of time is perhaps the most frequently discussed issue.9 Studies to date have relied almost entirely on participants’ retrospective, subjective, one-time self-report ratings of home practice completion. The problems with retrospective self-report are numerous, and include memory lapses, socially desirable responding, and inaccurate recall, as well as loss of paper diaries.15 These problems may be compounded where participants face mental health difficulties (e.g. conditions such as depression can negatively impact memory16), which is often the case in mindfulness-based interventions.One major issue in our understanding of how participants practice at home, and how this impacts on outcomes, relates to the way in which practice is typically recorded.17 Another study used an iPad app to record listening time during a six-week mindfulness course, again with reduced home practice requirements compared to MBSR or MBCT.18 Participants listened to around 23 min per day according to the app, with a drop to 16 min per day after the end of the six-week course.Technology provides a means to address this practice measurement limitation. For example, participants’ home practice guides can be played via a website or app on a mobile device, which can then log listening time. This could enable monitoring of formal home practice completion by both the participant and teacher in real time over the course of a mindfulness-based intervention. Several recent studies have used technology-based methods, such as app usage data, or web portals, to record participants’ practice time (a measure of the use of audio guides for practice) during mindfulness training. However, these studies have delivered their own mindfulness training courses, rather than using the two standardised formats, MBSR or MBCT. Often these training courses do not include a face-to-face group and have no human teacher, relying instead on automated and self-guided standalone programmes, which differ substantially from standard formats. For instance, one study using a mindfulness app with cancer patients, assigned 15 min of home practice to participants, substantially less than the 45 min assigned in MBCT or MBSR. Just over half of the patients continued to use the mindfulness app consistently until week 10, completing a median number of exercises of four at week 1, dropping to a median of two at week 10.19 Commercial mindfulness apps typically provide meditation guides, rather than full, evidence-based standardised training programmes. For instance, one review of the available ‘mindfulness’ apps identified more than 700 apps on the iTunes store. However, the majority offered standalone guided meditations, timers, or reminders only.20 A small minority provided actual mindfulness training content or education, and only one was supported by empirical evidence. Consistent with this, a recent review of the 16 most popular iPhone meditation apps reported that the primary function of most was to provide guided meditations. None of these were based explicitly on MBSR or MBCT.21Mindfulness apps are now widely available, and are popular among the general population. However, there has been substantially less empirical testing of mindfulness apps compared to CBT-based apps.In this study, we hope to clarify the necessary features for mobile technology tools designed to support formal home practice for participants in MBSR and MBCT courses. Specifically, we aim to understand the requirements of participants and teachers for mobile technology tools that can support participants in face-to-face MBSR and MBCT courses. While studies to date have focused on the experiences of course participants, we also sought the perspectives of experienced mindfulness teachers, who bring a wealth of understanding about the course principles and participant challenges. We therefore interviewed mindfulness teachers and past course participants about i) their experiences with home practice and ii) how technology should be designed to support engagement with the course.22 and the two courses are closely related. The interview with course participants (students) took place in March, and the teacher interview in June 2017.Two semi-structured group interviews were conducted with individuals who had completed MBSR courses previously, and with experienced MBSR teachers. While we focused on MBSR course teachers and participants, we note that MBCT has the same schedule of home practice,14 The sample selected is typical of the age range and gender breakdown of those who attend courses at this centre.23Five participants  who had previously taken part in an eight-week standard format MBSR courses at the Danish Center for Mindfulness, Aarhus University took part in the interviews. Participants attended these MBSR courses for a range of physical and psychological health issues . Participants were selected from those attending ‘booster’ class sessions at the centre and who were available to attend on the scheduled day. Booster sessions are offered as a means to support ongoing mindfulness practice, and people attend for a variety of reasons. For example, some students want to ‘deepen’ their practice further. Other students notice a drop-off in their practice and want to re-start.Five teachers participated , all affiliated with the Danish Center for Mindfulness. All were trained to international standards in delivering MBSR. Each teacher had extensive experience delivering MBSR courses . The teachers also reported extensive experience practising mindfulness meditation themselves .24 Within this framework, finding useful technological solutions requires us to better understand the participants’ values and experiences in engaging in the target activity more generally. Interviews are not only about technology and attitudes to technology, but more broadly consider participant experiences. Therefore, the interview schedules asked different questions of the two groups, but both were designed to encourage participants to reflect upon and discuss their experiences either in completing or teaching MBSR courses. Both groups were told that we were interested in designing technology tools to support participants in engaging with the MBSR course. Teachers were asked what they currently do to encourage practices, whether there is information that would be helpful in their teaching but which is currently inaccessible, and whether they see any conflicts between the goals and processes of mindfulness training and the idea of technological monitoring. Students were asked about how they approached their mindfulness practices, any issues they encountered, whether they used any technological tools or other support for their practice, and how they might feel about monitoring approaches.Semi-structured interview schedules were used to guide discussion in both participant groups. The composition of these sessions was influenced by the Experience-Centered Design framework.The same moderator ran both interview groups. The interview time was approximately 2.5 h for each group. Interviews were conducted in a room at Aarhus University, and were video-recorded and transcribed fully before coding.25 was used to identify key themes and subthemes within the data. An exploratory inductive approach was considered appropriate because of the novelty of the area being investigated. Initial sets of codes were produced independently by the first and senior author, each going through the open coding process twice. Initial codes were refined through discussion between the coders and a consensus code book was established. The new set of codes was then reapplied to the data by both coders, again refining as appropriate. At this point, a meeting was held in which codes were collapsed into themes. One coder then double-checked the fit of the themes to the data through close reading. Figures of the themes and codes were merged to a single graphic model .Results suggest four overarching themes that describe the experiences of teachers and students in relation to home practices in MBSR, as well as their thoughts and concerns regarding how technology can support those experiences. The four themes were adapting the MBSR programme when home practice is difficult, reflecting but not evaluating, supporting communication and understanding between teachers and students, and augmenting the course with mobile technology see . ParticiThe first theme describes both the difficulties that students experience in completing a demanding schedule of daily exercises during the MBSR course, and the various ways that teachers respond upon identifying student difficulties.Both teachers and students spent large portions of the interviews discussing the difficulties with engaging regularly in home practice. Students in MBSR are expected to engage in a set of regular exercises in order to achieve benefit, and teachers (e.g. T1) advise students to set one regular time slot in which to practices every day. S1, S2 and S3 stated that they did not practice every day and that they should have. Two students (S2 and S3) regularly practiced at the same time slot each day (or at least each day that they practiced). S1 did not have a set time slot, but felt that, in hindsight, she would have liked to. S4 suggested that a set time would have been negative for her, and that she enjoyed the freedom to fit the exercises within her day. Given these reports, a question remains as to whether flexibly scheduling exercises would increase or decrease engagement in MBSR home activities.One of the teachers (T1) suggested that a significant problem may lie in the length of home practice sessions, which last 45 min to 1 h per day. However, this did not emerge consistently from the students’ discussions. Indeed, S2 and S3 suggested that the length of each practice time was a fine positive aspect of the course. S2 suggested that it took at least 20 min at the beginning of a session for her to engage fully with the practice, while S3 felt he needed practice, and regularly extended the sessions beyond 1 h. S4 reported that it was difficult to engage in long sessions, but this was due to the emotional difficulties involved in the task, rather than scheduling time.Participants suggested that many of the assigned activities are inherently difficult or uncomfortable to do, either physically or emotionally, especially at the beginning of the programme. Participants reported an increased awareness of ‘my suffering, my pain, my nausea’ (S2), when undertaking meditation; ‘sometimes I think I’m in a good state but when I lie down I can feel I’m not’ (S4). Indeed, participants rarely described the home exercises as enjoyable, with a number of students suggesting that they ‘hate’ (S2) doing them, at least some days, although they often felt better afterwards.One of the main difficulties highlighted by participants is the experience of uncertainty over whether they were doing the exercise correctly. Indeed, the teachers discussed moving students away from an initial tendency of evaluating their own performance. One teacher noted that with MBSR, improvements in well-being may take a while to be apparent, regardless of how much daily practice is undertaken (T1). It also takes time to gain an understanding of what is, and is not, appropriate during meditation; ‘If people report back for instance, “Oh, it doesn’t work for me because my mind is wandering all the time,” that is not an obstacle – that is just … “Well, so you are becoming aware of the present moment”’ (T2). Compounding this difficulty is the fact that trying hard to do the exercise ‘correctly’ is often self-defeating in mindfulness practices, ‘I focused on to do it right, instead of doing it with mindfulness’ (S1).Home practice in MBSR comprises a number of different activities: yoga, sitting meditation and the body scan. Participants reported very different experiences across the different types of exercises. For example, S1 and S3 found the yoga exercises much easier, as they were less likely to be interrupted by others in the house. Yoga exercises look like ‘working out’ and signal ‘do not interrupt’, in a way that the other exercises do not. For instance, one participant described the misunderstanding from others in her household when she completed the non-yoga exercises, ‘my husband said “Was it a good rest?” No, it was not a good rest’ (S3). Conversely, S2 reported that the yoga was most challenging. Thus, ‘home practice’ is not one homogenous activity, but a number of different activities that may be experienced as enjoyable or aversive by different students.Teachers spent considerable interview time discussing how they respond when they learn that a student on their course is not engaging in the prescribed amount of home practice. Student problems with engagement are typically addressed within weekly classes, ‘you use what the participants are sharing, to sort of normalise also, to say out loud [that] the others in this group have the same experiences’ (T4). In smaller classes (<20 students), teachers often begin the session by going around the room asking each student about their practices during the week. In larger classes (up to 30 students), teachers offer some time at the beginning of class when students can volunteer to discuss their challenges. When students report problems, teachers engage in a dialogue with students, for instance to encourage reflection on their motivation for starting the course, ‘I put it in a larger perspective, about your life’ (T3). Teachers also discussed using a structured enquiry process to understand the barriers disrupting engagement, which involves ‘going into dialogue and actually asking questions like, “So you've only been practising 1 day of these 7 days; would you wish that it was different? Would you like to practice every day?” “Yeah, yeah I would, but I just can't find the time”. “Okay, so you can't find the time; what is in the way of you practising?”’ (T2).In discussing their responses to problems, all teachers first emphasised the importance of setting expectations regarding home practice before starting the programme. Teachers make it clear that benefits are achieved if students engage in the daily activities: ‘telling people that “if you are not sure that you are motivated, you are not sure that this is the right time, better not start”’ (T1), and this generally works as a motivator for students (T2). When problems arise, students are reminded of their previous commitment to doing the work of home practice, ‘like heightening their awareness. Why are they not doing the home practice? Because they signed up for the programmes and knew this would be required’ (T2).One of the most interesting tensions to emerge from interviews was the question of whether, and when, it is appropriate to adapt the home practice for students who are experiencing challenges. Three of the teachers  suggested that they often tune home practices recommendations to the abilities and situations of students, ‘I say, “just do a little”. And I have personal talk with them. I think that’s very helpful’ (T3); ‘we work with the programme for each class, each course and each person. We will make it suitable’ (T4); ‘also if people are very uncomfortable sitting still, you can do the practice walking. Or if you have chronic pain, you can do the practice laying down with your feet up’ (T3).Students also said that they often adapted home practices to suit themselves, rather than strictly following the assigned exercises. This included doing shorter sessions when they were having difficulties (S2), lying down when they became tired of doing sitting meditations , and picking and choosing the exercises that they preferred (e.g. yoga over body scan).sic] But it didn't help them. It was like more talking about nothing (T1).I have just been in the group where people talked a lot about why they didn’t do the home practices and it was so much talk and nobody came to do the home practices! There was a lot of talk about ‘I didn’t do it because of this and this’, it was like a confession round, and we were just two people doing the homeworks!, but to me’ (T3). Students also noted that they wanted to hear their own teacher’s voice , rather than a generic teacher’s voice, as a way of connecting back to the class experience.Many concerns were also raised over how the introduction of new technology might interfere with or undermine the programme. For example, teachers were concerned with students becoming competitive (T3), or diligently trying to report good practice times rather than engaging honestly with the exercises . One teacher emphasised the importance of students’ autonomy, ‘And also it is up to the person themselves to do the practice so … we don’t check it’ (T1). While there may be opportunities to support participants using technology, teachers did not want to encourage inappropriate evaluation, or a shift in responsibility for undertaking the home practices. Finally, there were also teacher concerns about the implications of being able to view what participants did outside of class time. One suggested that it could add to their workload, ‘it would require more work and things to think about’ (T1). They also identified more complex difficulties that this could raise: could the teacher respond fairly to those who they knew were not practising? ‘And then … how can we as teachers go into the class not having an agenda’ (T4), and ‘it might create a bias beforehand now I have to pay attention to these people’ (T2).The aim of this work was to understand the requirements for technology that can support participants in undertaking the at-home practice recommended within standard mindfulness-based interventions. To this end, we interviewed experienced mindfulness teachers and past course participants about a) their experiences of home practice and b) their beliefs about technology usage in these courses. We outline how teachers and participants address challenges in completing the assigned home practice. We reflect on several considerations for technology design for mindfulness interventions .28 while patients with Obsessive–Compulsive Disorder more frequently rated the body scan as more helpful than yoga.29 While the students reported adapting the practice schedule to best fit their own needs and preferences, there was no clear consensus among teachers as to whether this should be supported. Some teachers valued considering the needs of the individual students, while others more strongly emphasised that the programme is a standardised, validated treatment.The students often reported adapting the schedule of at-home practice sessions to suit their needs. A number of the students reported preferring some types of practice over others (e.g. yoga to sitting meditations) and did more of their preferred practices. A number of qualitative studies have reported similar differences in participant preferences across the formal exercises. For instance, patients with breast cancer preferred and engaged in more yoga than other exercises,31 There is balance between maintaining the integrity of the intervention, and ensuring its acceptability and accessibility, especially in a non-research community sample. For a mobile tool, an appropriate adaptation or personalisation for students may lie in allowing them to choose the frequency and timing of reminders to practice. However, other work testing a stress-management app suggested that daily notifications, compared to occasional notifications, promoted greater exposure to the intervention content.32 This would require testing in relation to MBSR. Another technology-based solution might be in showing participants the number and frequency of practices types (e.g. yoga) that they completed, to increase their own awareness of their preferences, and also if they are ‘missing’ one of the assigned practice.One solution might be to provide teachers with the flexibility to make decisions on whether students’ practices schedules should be adaptable on an individual or class basis (e.g. in providing shorter practices to those students who need them). Indeed, several recent reviews have discussed how adaptations to mindfulness-based interventions can be helpfully formatted to fit the population and context in question.To be consistent with the principles of MBSR, technology solutions should help students to become aware of their own behaviour patterns, but not in evaluating these as either ‘good’ or ‘bad’. For instance, typical monitoring approaches  present rewards  for goal achievement. This type of approach conflicts with the fundamentals of mindfulness-based interventions. Both teachers and students cautioned against the use of metrics-based systems that might promote evaluation of behaviour or competition. It is appropriate to increase awareness of behaviour patterns, but not to introduce any design elements that might push students towards critical evaluation. Teachers identified an opportunity to support participants in reflecting on their experiences with home practice, for instance through the use of diaries.33), and different methods of providing home practice guides (via email or other websites). We suggest that providing a streamlined, integrated solution to teachers and students may support communication beyond face-face sessions. It was also unclear whether teachers were aware of the students’ adaptations (e.g. choice of one mindfulness practice over another). Again, technology solutions could allow students to communicate the adaptations that they make more readily. Finally, another type of communication that technology might support is peer-to-peer communication between class participants. Peer-to-peer support was noted as an important component of the in-class experience, consistent with other qualitative studies.34 Since our intention is to improve engagement with home practice, there may be potential in facilitating a social connection during at-home sessions , to replicate some of the rewarding features of group practice.We identified a clear opportunity to facilitate communication between teachers and students through technology. Teachers outlined differing methods used to communicate with their students, such as email and phone calls, consistent with implementation guidelines, , which should be considered in any technological design.Teachers reported that the midway evaluation in MBSR (a part of the curriculum) was a valuable opportunity to understand student progress and challenges with practice. This led to the suggestion that was broadly agreed upon, that midway evaluations could be integrated with a mobile application. Teachers suggested that this would be of benefit, as it could save class time.Finally, there are questions as to how teachers will deal with new potential information on participants’ listening time behaviour, and how this might change student/teacher interactions and student expectations. Design of teacher tools should avoid adding significantly to their clinical workload. Ultimately, teachers agreed that it would be of use to ‘test out’ what it is like to have access to information on participants’ practice time, especially if they can have control over whether or not to use it.35 but we believe we heard contrasting opinions from participants here. Our focus was limited to understanding formal home practice, but participants also undertake informal practices during mindfulness-based interventions, like bringing awareness to everyday activities . Finally, most of the research on home practice in MBSR and MBCT has focused on formal practice, and this is arguably more amenable to technology-based measurement and support.We acknowledge that our sample size was small. However, the teachers that we interviewed were highly experienced mental health professionals, with substantial clinical workloads. The teachers were a difficult group of participants to access, and we believe that the length of the interviews allowed us to reach a saturation point in our data. We also interviewed participants who had completed MBSR courses for a variety of significant health concerns. Additional participant samples should be recruited to examine the requirements of specific subsamples, for instance those participating in MBSR for sleep problems or pain, and those participating for psychological distress. There are inherent issues with focus groups, such as the tendency for certain types of socially acceptable opinions to emerge,9 As with other psychological interventions such as CBT, these home assignments can be challenging for participants to complete.37 We suggest that there is potential for technology to support participants in engaging with their mindfulness practice. However, to fully realise this potential, there must be careful consideration of how technology can be used in a way that is complementary to the fundamental principles of mindfulness-based interventions. To this end, we explored how to design technology tools to support home practice in mindfulness-based interventions, through interviews with experienced teachers and students. These discussions highlighted important ideologies in mindfulness training for software and digital developers to consider.At-home formal practice is a key component of mindfulness-based interventions and their completion is linked to intervention effectiveness.There are clear opportunities to support communication between teachers and students, and to provide teachers and indeed researchers, with information as to how their students are engaging with home practice. Other helpful tools could support students in reflecting on their experiences and in providing reminders of their motivation for undertaking the course. There are questions as to whether and how the course might be adapted in the face of student difficulties, and whether technology should support participants’ adaptations . Finally, we should not encourage students to evaluate their practice as good or bad , as this would be counter to the course aims. Rather, we should aim to promote non-judgemental awareness of behaviour patterns, as development of awareness is a core focus of mindfulness training.


A large survey of visitors at a science museum about the perception of biotechnology shows that names matter and that gender has an influence on people's attitude towards new technologies. The fast development of new research fields, such as genetic engineering or synthetic biology, is often met with public concerns or even resistance, the fate of genetically modified crops being a prime example. There are many factors at play that determine how laypeople perceive new technologies and a better understanding of these can help to inform debate. Foremost, however, it is necessary to obtain reliable information on public opinion of emerging technologies that have the potential to affect their lives. To this end, we conducted a survey to gauge public opinion on genetic engineering and biotechnology as part of a special exhibition at the CosmoCaixa Museum in Barcelona, Spain. The large sample size of 38,113 respondents allowed us to assess the effect of age, gender or education on the perception of three related terms: “biotechnology”, “genetic engineering” and “synthetic biology”. In addition, by randomly associating these terms with the image of either a male or a female scientist, we looked at the effect of gender on people's perception of these technologies. In short, two conclusions can be reached: the terms “biotechnology” and “genetic engineering” were preferred to “synthetic biology”. Second, terms associated with an image of a female scientist were better rated compared to the same terms associated with a male researcher. These results show an interesting gender dimension of public perception of new technologies.Synthetic biology, genetic engineering and biotechnology are interrelated terms with blurred boundaries. Biotechnology uses living organisms, cells or cellular components to synthesize products for agriculture, medicine, industry and research and has been used for centuries, albeit unconsciously. Genetic engineering is one of the subdisciplines of biotechnology: it involves the manipulation of an organism's DNA sequence by addition, deletion or modification in order to expand the product range of biotechnology. While both generally are based on using organisms, genes or metabolic pathways from nature, synthetic biology aims to design novel artificial systems. Synthetic biology can thus be seen as both an extension of genetic engineering, as well as a new view on biotechnology by using engineering principles such as standardization, modularity or orthogonality There are many factors at play that determine how laypeople perceive new technologies and a better understanding of these can help to inform debate.http://ec.europa.eu/commfrontoffice/publicopinion/index.cfm/Survey/index#p=1&instruments=SPECIAL&search=341). Indeed, genetic engineering is perceived with a higher degree of concern compared to other scientific fields In the public eye, however, biotechnology, genetic engineering and synthetic biology are often reduced to genetically modified organisms (GMOs). This, combined with a critical perception of GMOs, has fuelled a generally negative attitude of biotechnology. The last Eurobarometer survey 2010) on GM food showed that only 5% of Europeans completely support it, 18% “tend to agree”, but as much as 61% totally disagree, that is, are against GM food. Moreover, 83% of Europeans had not heard about synthetic biology before. The main concerns were the possible risks rather than potential benefits from these technologies (010 on GM… Generation T (2011–present), also known as Generation Alpha, is growing up with an iPad or a smartphone in their hand in front of a screen.In relation to perceptions of gender, a number of recent studies have shown biases of how men and women are evaluated and perceived at work https://blog.caixaciencia.com/ca/-/biologia-sintetica-que-vienen-las-biomaquinas). It included videos in which researchers explained synthetic biology; a display of the E. chromi suitcase designed by Alexandra Daisy Ginsberg featuring plastic replicas of human stool (https://www.daisyginsberg.com/work/echromi-living-colour-from-bacteria); and a set of interactive screens to further explain synthetic biology. One of these screens was used for our survey.The survey was carried out in the CosmoCaixa museum, a flagship science museum in Barcelona that is sponsored by La Caixa Banking Foundation. Entry is free for students younger than 18 and for CaixaBank customers; visitors can explore a variety of permanent and temporary exhibitions, including “Top Ciència” (Top Science), which features emerging technologies and research areas. It is a small part of the museum with a few stands, mainly screen‐based. From November 2016 to April 2018, Top Ciència hosted an exhibition on biotechnology, coordinated by one of the authors (MP)  to totally favourable 10). The term displayed was either “synthetic biology”, “genetic engineering” or “biotechnology”, and it was always associated with an image of either a female or a male scientist . Their age ranged from 1 to 110 years old—both extremes being dubious for obvious reasons, and the reason why Generation T answers were not taken into account for the analysis. A total of 11,979 respondents had a university education; 3,221 had professional training; 9,276 had secondary school studies; and 13,637 had finished primary school.Almost half of the responses (49.43%) came from the centennial generation born between 1997 and 2010. The highest average value was given by Generation X, followed by millennials and baby boomers. The lowest average values came from the Silent Generation  than men 7.148; Fig 8; Fig 4.There are two main conclusions related to the terminology and to gender perceptions. The survey indicates that the sample population clearly prefers the terms “biotechnology” or “genetic engineering” over “synthetic biology”. This is unexpected, since the context in which the survey was carried out—a science museum with a temporary exhibition describing synthetic biology—was expected to induce a more positive view of synthetic biology. The results suggest that either the exhibition did not succeed in changing people's views of synthetic biology or that the public's negative views cannot easily be swayed. Interestingly, there was no significant difference in public attitudes between biotechnology and genetic engineering although the latter more easily invokes notions of GMOs.Similarly interesting and somewhat unexpected is the finding that disciplines associated with a female researcher were better rated than disciplines associated with a male researcher, and that this trend is particularly strong for female respondents. Since the images were displayed randomly and since only one image was shown to each respondent, the differences in rating could be explained by an unconscious preference by women for female scientists, whereas men are strikingly indifferent to the gender displayed when it comes to rating a scientific discipline associated with an image. Alternatively, it might be explained by a bias in favour of female scientists at least among the women attending a scientific museum; in other words, the sample population might have been enriched for women who are interested in and motivated by science. Lastly, given that the vast majority of visitors and respondents were young—born before 1997—the bias of women in favour of female scientists could also be linked to a more positive identification with the depicted character after years of outreach efforts to promote women in science. Whatever, the reason(s), we think that this is a solid effect given the size and design of our survey, which would warrant more studies and analysis of gender‐based perceptions of scientists.Nature Human BehaviorIn addition, we found a difference in perceptions of both gender and discipline depending on education. The higher the level of education, the higher the appreciation of synthetic biology, biotechnology or genetic engineering. This observation matches with a recent paper in Finally, the survey clearly demonstrates the influence of age on the perception of synthetic biology and related disciplines. The youngest and oldest respondents generally gave the lowest evaluations. The ones belonging to Generation X showed the most positive attitude towards these technologies.This was the first large survey on the public's perception of synthetic biology. Given the sample size, it shows a significant difference in how these terms are perceived along with a robust difference in how women perceive female versus male scientists. These results would warrant further studies and analysis to explain these rather unexpected observations. Moreover, they can help to inform educational and outreach campaigns to address people's concerns over modern biotechnologies or to raise the interest in science, in particular among young women and girls.


In this paper, we investigated two subjects with superior memory, or hyper memory: Solomon Shereshevsky, who was followed clinically for years by A. R. Luria, and Funes the Memorious, a fictional character created by J. L. Borges. The subjects possessed hyper memory, synaesthesia and symptoms of what we now call autistic spectrum disorder (ASD). We will discuss interactions of these characteristics and their possible role in hyper memory. Our study suggests that the hyper memory in our synaesthetes may have been due to their ASD-savant syndrome characteristics. However, this talent was markedly diminished by their severe deficit in categorization, abstraction and metaphorical functions. As investigated by previous studies, we suggest that there is altered connectivity between the medial temporal lobe and its connections to the prefrontal cingulate and amygdala, either due to lack of specific neurons or to a more general neuronal dysfunction. The study of persons with exceptional memory abilities that are not reliant on mnemonic techniques or other memory aids has been less explored, with few exceptions,,In addition to hyper memory, these two subjects also experienced synaesthesia, defined as an event in which stimulation of one sensory modality elicits an involuntary sensation in another sensory modality.Our aim is to discuss whether Shereshevsky and Funes, besides being synaesthetic, experienced autistic spectrum disorder (ASD) symptoms of the savant type. This idea is supported by a recent reviewNew York Times and subsequently as a novel titled “The Mind of a Mnemonist.”This remarkable man with superior memory was followed by the eminent Soviet neuropsychologist A. R. Luria for more than 30 years and whose story was first published in a brief note in the He was able to recall autobiographical information since one year of age. As an adult in Luria’s laboratory, he would recall a long list of words and a lengthy mathematic equation with the same accuracy 12 and 16 years later. The way in which he described his excellent memory was as using a kind of grouping of the words, like the “distribution of houses in a street.”He describes his remarkable hyper memory and all of his recollections with a variety of multimodal synaesthesia. In his case, noise was creating colours, touch, taste, and smell. Sometimes sounds would appear as visual, tactile, or olfactory synaesthesia. He experienced a confluence of sensory impressions such as, “if I read when I eat, I have a hard time understanding what I am reading, the taste of food floods out other senses.”Interestingly, Shereshevsky had important deficits in executive functions. He could not understand poetry or metaphors and he was unable to understand abstractions. In his own recollection he states, “I can only understand what I can visualize” and, “In order for me to grasp the meaning of something, I have to see it.” His memory for faces was also impaired. He saw faces as “changing patterns of light and shade” and commonly became confused.Ireneo Funes is a fictional character and a Uruguayan gaucho, created by the Argentinian writer J. L. Borges and published in 1942 by a Buenos Aires newspaper La Nación and later in a book named “Fictions.”This young man suffered a severe traumatic brain injury at the age of 19. He found that the accident had rendered him able to perceive everything in full detail. He was able to remember and have full recollection of the shapes of the clouds on a certain date. He kept these images in his visual memory in the form of a persistent image. He was able to reconstruct a full day’s worth of past memory and spend a full day for the recollection of the memory in an automatic and constant way. As a result of these flooding of memories, it was very difficult for him to sleep. He stated, “To sleep is to be abstracted from the world.”Funes also experienced synaesthesia, and his hyper memory was associated with somatic perceptions that are described as being all over his body and in his words as “muscular sensations, thermal sensations.”Borges expressed that previously, since he was young, before the traumatic brain injury, he had characteristics of ASD like a “chronometer”, had exceptional memory for proper names and that he was poor at social interaction. After the accident, it was impossible to eliminate irrelevant memory. He described, “I have more memories in myself alone than all men have had since the world was a world” and, “my memory … is like a garbage dump.” Funes was incapable of platonic ideas or generalities or abstraction, but he was talented in the acquisition and registration of information. For example, he learned to speak English, French, Portuguese and Latin without effort. As his creator Borges suggested, “I suspect, nevertheless, that he was not very capable of thought. To think is to forget differences, to generalize, to abstract. In the overly replete world of Funes there was nothing but details, almost contiguous details.”Shereshevsky and Funes both experienced synaesthesia associated with hyper memory. We hypothesize that what we now call ASD has contributed to these individual’s superior memory abilities along with their synaesthesia. We suggest this after it was proposed that individuals with hyper memory and synaesthesia should be tested for undiagnosed autismFirst, we will explore the possibility that Shereshevsky and Funes had ASD. Both experienced a deficit in executive functions, categorization and generalization, much like individuals with ASD.,,While both ASD and synaesthesia are typically conditions involving functional connectivity, ASD is likely characterized by local over-connectivity and long range under-connectivity,-,Single case studies of patients with medial temporal lobe (MTL) lesions involving both hippocampi were the origin of the discovery of various memory systems in humans.-As discussed above, ASD has been associated with dysfunctions among many neural systems including brain areas such as the MTL, parietal lobe, amygdala and cingulate cortex


The self-efficacy of educators plays a crucial role in their professional competence and subsequent provision of care. The present study aims to explain the main sources contributing to the development of self-efficacy beliefs among healthcare providers in delivering health education.This qualitative study was conducted from 2015 to 2016 in various settings of Isfahan such as hospitals, doctor’s offices, and healthcare centers. Twenty three health educators with an average of 10-year work experience in healthcare participated in the study. Data were collected using semi-structured in-depth individual interviews and were analyzed through conventional content analysis. Prolonged engagement with the participants, maximum variation in the participants’ characteristics, sampling, and member check were among the factors enriching the research.The six main categories extracted during data analysis included: 1) Quantity and quality of their experience; 2) Encountering unexpected events; 3) Client trust; 4) Self-concept; 5) Professional knowledge and skill; 6) Vicarious experiences.The study results show two new findings, including “encountering unexpected events” and “client trust”, affecting professional self-efficacy beliefs among healthcare providers in the delivery of health education. The other main findings were extremely similar to Bandura’s theory. These results can be used as a basis in planning and implementing health development educational models for human resources. Through designing learning experiences, health education helps to increase the knowledge or influence the attitudes of individuals and communities in order to improve their health . It encoAs some of the most important elements of health promotion, health care providers, particularly nurses and family health experts, can play a significant role in health education owing to their greater access to individuals and families and the considerable time they spend with them to take care of them. As a result, they have numerous opportunities to educate them , 10. HowThe results of previous studies have shown that excessive workload and insufficient force, inadequate qualifications of health educators, failure to integrate patient education into the rehabilitation process, lack of job satisfaction, regarding education as unimportant, education by non-professionals, ignoring patients’ rights in education, inappropriate communication skills, physician-oriented atmosphere, conflict and lack of coherence in education, lack of motivation, lack of a rewarding system in the organization, and poor supervision and control, problems in planning the time and space for the program, nurses’ belief in not considering patient education as their duties, insufficient facilities in hospitals and lack of enough time are the most important causes of insufficiency of client education –18. ThisSome studies have indicated that educators’ self-efficacy (i.e. their perception of their abilities) plays an important role in the performance of their educational and training duties , 25. In This qualitative study, which was conducted using conventional content analysis methods, considers the reality based on the context, and investigates various structures of the phenomenon under study , 33.This qualitative study was conducted on 23 health educators from 2015 to 2016 in various settings of Isfahan’s hospitals, doctor’s offices and healthcare centers. The participants included 3 nurses, 6 individuals with M.Sc. degrees in health education, 11 public health workers, 2 social pathologists , and 1 individual with a Ph.D. degree in health education and promotion  who on average had 10-year work experience in healthcare. At the beginning of each interview, the willingness and ability of the participant to transfer experiences were examined. Purposive sampling was used: Those who had at least 3 years of health education practice were included in the study. Health education services that offered care to the general public were selected as the study settings.The Ethics Committee of Isfahan University of Medical Sciences approved the study (No.IR.MUI.REC.1395.1.O95). The necessary explanations were presented to the participants concerning the significance, objectives, methodology, the consent process, and the maintenance of confidentiality at all stages of the study. In addition, the participants were informed about the characteristics of the study team and how the results were achieved. The decision on determining the time and place of the interviews was made with the participants’ consent. In a qualitative study, obtaining informed consent from the participants for their voluntary participation in the study is a process; thus, in the whole period of data collection, this issue should be considered and checked. In the current study, the participants’ consent was continuously verified. Although the initial consent forms were obtained at the beginning of the interviews, the participants’ were asked about their consent and convenience to participate in the study during the study. The participants were also assured that they could freely leave the study at any stage.Data collection was conducted using semi-structured, in-depth individual interviews. The participants were interested in precisely and clearly explaining and expressing their experiences to the researcher; the data were collected by recording the participants’ voices, but recording interviews seemed to raise concerns in the participants and most participants seemed to be unwilling to talk while their interviews were being recorded. In this regard, they were assured of the confidentiality of their data, and the researchers pledged to delete the recordings after transcribing the interviews. This issue facilitated communication with health educators and gained their trust, resulting in obtaining enriched data and experiencing a more efficient data collection process. Open-ended and general questions were initially employed in the interviews. The participants were requested to freely talk about their experiences as health educators. The interviews began with a general question concerning barriers and facilitators to health education. Afterward, the interviews were continued by asking exploratory questions like “Please explain how you held that session?” The time of each interview varied from 20 to 60 min, depending on the participants’ views, and the interview situation and process. The researcher continued the interviews up to the point where no new data could be obtained. After conducting and recording each interview, it was fully transcribed verbatim. Data analysis was concurrently conducted with data collection using the qualitative method of conventional content analysis in three phases: preparation, organization and reporting.All interviews were analyzed. In preparing the interviews, a complete interview, which could be regarded as a meaningful unit, was chosen as the most suitable analysis unit. Each interview was reviewed several times to achieve data immersion. To organize the data, open-coding was utilized. Then, the coded data were recorded in coding sheets for further reference, and grouping was carried out after several interviews. By repeating the mentioned process for each new interview, some topics were added until the final pattern emerged. Merging and comparing groups reduced the number of categories. Sub-categories were formed based on similar characteristics, and the category names showed their contents .Spending sufficient time to communicate and collect data and prolonged engagement helped to achieve in-depth data collection and build trust and rapport with the participants. Maximum-variation sampling was employed based on the health educators’ age, gender, job, number of years of work experience and place of residence. To insure that the analysis reflected the participants’ experiences accurately, member check was carried out with several participants, and a number of changes were applied to the data based on this procedure .Quantity and quality of their experience; 2) Encountering unexpected events causing self-efficacy reduction; 3) Vicarious experiences; 4) Self-concept; 5) Self-efficacy as a reciprocally interacting influence on the client’s perception of trust; 6) Professional knowledge and skill as a factor enhancing self-efficacy.Based on the obtained results, the main sources of self-efficacy beliefs in health educators could be divided into 6 categories, including: 1) Because this was my first work experience, I was anxious and worried all night long, as I might not have been able to organize the session well, speak well, or be unable to answer some questions.”“The study results showed that inexperienced educators initially had low self-efficacy regarding the holding of educational sessions. A participant told the researcher about his first experience with educating others as follows:When I started the educational session, I felt I was hot and even flushed, and everyone knew I was inexperienced, .”: “… “This experience helped me understand that I have the ability to educate others. Because before the educational session, I did not have that much belief in my own ability…But at the end of the session, my self-confidence increased, and I understood that if an educational program was delegated to me, I would be able to deal with it.” .The findings of the study showed that if the educational programs were successfully performed, and relevant successful and satisfactory experiences were obtained, self-efficacy would increase. This increase in self-efficacy occurred not only in future programs, but also in the same session. As one of the participants said: “When addicts who quit see me, they express their gratitude by saying that whatever we have achieved was due to you. This helps me believe in my ability to offer education and counseling to these people.” .A participant expressed his experience of oral feedback received from the clients as follows: I have educated and advised drug addicts for four years now. I am proud of myself because I can perform my duty well. Because I see previously-referred individuals who are now healthy and drug-free as a result of training and counseling.” .A participant who worked in substance abuse treatment centers described his/her experience of observing changes in the target group: “Another factor affecting the enhancement of self-efficacy among health educators is official feedback:When your boss gives you a low evaluation score, this does not affect your salary, and only your morale suffers, and you think that you do not want to educate people any longer.” .““Each month, I recommend 10 health educators who are active and work well for a pay raise, because I have noticed that this is really effective and helps them believe in their own capabilities.” .“In the morning, when I went to conduct the educational program, I thought the audience consisted of 20-30 individuals. However, 150 individuals were present. Because of stress, I became confused. I had not thought there would be so many attendants. I felt I couldn’t handle it. At first, I was nervous….”)Public health worker, 4 years of work experience).Based on the experiences of educators, sometimes they faced unexpected events such as a large number of clients, which reduced their self-efficacy in conducting the health education program. For example, a participant who was invited to hold an educational session at the cultural center of the municipality said: . “... especially half of those present were men (I didn’t expect men to participate). It took me a moment to reclaim my self-confidence. I was sure that I could work with the women, but not men … I became anxious ….” . This participant added, “Men asked me more questions and also acknowledged and praised me more.”Additionally, if it is unexpected by the educator, the clients’ gender can affect the educator’s self-efficacyand you need to pay more attention to the tone of the word so that they don’t feel affronted ..... How you communicate is important to them. Particularly illiterate or poorly educated men do not want to learn from female health educators.” She said “Older men interact better and ask for training but young men are rebellious and ridicule everything ... If the nurse is unable to control the situation, she cannot provide effective education .... We often send male nurses to male patients because they are more accepted by male patients” .There is no common view in this regard, and the experience is different for educators with different backgrounds, such as work experience and the culture of the health educator’s place of residence. A female health educator said “Men show more pride “[Because I didn’t know them] it took me a while to feel normal again. While the audiovisual equipment operator was preparing, the slides for display, with a quick evaluation, I learned about the class personality types and the educational levels of the audience. And I was able to hold the educational session based on this and I gradually felt normal again.” .Inadequate knowledge of the clients, and their characteristics can reduce educators’ self-efficacy. One of the participants said about holding a session in a public hall, “Once in the spring, my colleague and I went to visit an agricultural field. There were 7 or 8 women farmers there. After greetings, my colleague taught them contraception methods for one hour. He taught them so well that the next day some of them referred to the health center for the TL operation. As a result of this experience, I understood that I could be an effective educator too…” .Spending time with other colleagues in the health and treatment system with the same health education context can positively affect health educators’ self-efficacy, and when individuals possess limited previous experience, they are more sensitive to this issue. A participant who was the health educator of a province explained his/her vicarious experience in relation to other colleagues working in the field of health education: For example, when I go somewhere for giving a lecture, while I am waiting for the earlier speaker to finish his/her speech, I get anxious especially in cases where the speaker is not successful, or on the contrary, when he/she has an excellent lecture. Also, I may think that my topic is not as interesting as his/her topic, and, I become nervous whether I can give a good lecture or not.” .A participant described the experience of his M.Sc. studies regarding the effect of vicarious experience on self-efficacy, ““I behave in a manner that children admire me, and admit that I am an authority or a role model to be followed on this issue. Because I feel that they are searching for a role model at this age.” .Participants’ feelings, emotions, ideas, mentality, and images play an important role in understanding their abilities in health education. A participant explained that “I am relaxed in contact with others. I have good interpersonal skills. I am popular among children, so I can influence and educate them and give them advice.” .Another participant said that My instructional creativity has resulted in having an educational program with an effectiveness of 70% and has led to client satisfaction.” .The results of this study indicate that considering yourself creative is an enhancing factor for self-efficacy. For example, a participant said: “The clients admire me more. Because they expect a midwife to be tall and have wide shoulders, they assume me more suitable for this job. Since I am married, I can educate sex and midwifery issues better. People do not accept my colleague who is single and has a small body well.” .Another one expressed her self-concept beliefs by the following statement: “I don’t talk much about a healthy lifestyle (nutrition and exercise) because I feel I am not a good role model (I am overweight). I think this belief about myself can lead to anxiety and feelings of helplessness in every educator.” .One of the participants described his/her self-concept: ““Here, trust is very important, and the client should trust the educator, especially in our field, that is, midwifery and sexual issues. If the clients don’t have confidence in us, we can’t…When the trust and confidence is formed, the counseling could be offered well.” .The self-efficacy of the educator is largely affected by clients’ trust and assurance such that if he/she believes that the clients trust him/her, his/her self-efficacy will increase. A participant who worked in a doctor’s office stated that: I started to speak. I tried to earn their trust by telling them that I have the same problem and I take care of my mother who has the same problem. I was aware of the details of the disease clinically and in terms of the awareness and attitudes of the family members regarding the disease.” .Another participant who had held an educational session for the caregivers of Alzheimer’s patients’ said, ““We should be able to communicate, not only with words, but also with the type of eye contact we make, so that we can earn their trust, and educate and offer them counseling.” .Not only can earning the trust of the clients increase health educators’ self-efficacy, but also their self-efficacy can help to earn the clients’ trust and confidence. A participant said, “Sometimes, when I am invited to educate healthcare personnel, if they do not trust me and if I feel that I can’t teach acceptable issues, I become nervous and anxious. First, I try to earn their trust…For example, there were clients in my class that I felt that did not feel any need for what I taught. They thought my speech was not relevant to them, so they did not trust me adequately. I conducted a research study in this regard, and for the next session, I started my educational session by presenting a review study in my chosen field which was conducted by one of the prominent people in their field. Thus they understood that some people who outshone in their field used these methods, and in this way, their trust and confidence increased, and I succeeded.” .One of the participants described his/her experience in earning the trust of the clients and its effects on his/her self-efficacy thus: “I am familiar with the PEN-3 model and its use, I can successfully educate women about the pap-smear test.” . Another participant said, “I am familiar with the practical skills for health education. For instance, I can describe the self-care program very tangibly. For example, if you want to go walking, when do you have the time, and how do you like to do it.” .Professional knowledge and skill are one of the factors enhancing educators’ self-efficacy. A participant said, In that session, the clients talked about issues that made me feel that they were more up-to-date than me. That is because they were constantly in contact with their doctors, and the things that I knew were fossilized in the books, and that is why I could not educate them well.” .A participant suggests that lack of knowledge about up-to-date information is a factor reducing professional self-efficacy: “...“For example, I go to a school to teach children a fertility health program. The first thing I need to know is needs assessment to learn what necessities they have, at what level their awareness is on this specific topic, what needs they have in mind, so that I can conduct a good educational program …” .A participant pointed out that, “If at the time of the educational program you are constantly worried that you have not mastered what you are teaching, then you will be stressed and will feel that you can’t control the class.” .Another one described the effect of professional knowledge and skill like this: The present study aimed to explain the factors contributing to the formation of health educational self-efficacy among health care providers. The results indicated existence of a new classification with 6 categories of factors affecting health educational self-efficacy. Based on the participants’ statements, self-efficacy means the educator’s faith in his/her own abilities to hold educational programs and sessions, which were considered an important factor in their success and in performing their duties. In one study conducted by Haghbaghery and Salsali , the parThe first factor presented in this study was “the quantity and quality of their experience”. In previous studies , 37, 38,Additionally, the present study showed that, in addition to individual perceptions of failure and success, other people’s perceptions, especially those of officials and clients, play an important role in increasing self-efficacy. According to Bandura’s theory and the results obtained by the present study and other studies , 40, it The second factor affecting self-efficacy was “encountering unexpected events”. This factor was not reported in previous studies and was not directly in line with the sources proposed by Bandura , 26, 27.According to Bandura, emotional and physiologic states such as anxiety, stress and tiredness are sources conveying self-efficacy beliefs to individuals , 40. TheThe forth factor affecting self-efficacy in this study was “vicarious experiences”, which is consistent with the fourth source of self-efficacy according to Bandura , 37, 38.Health educators’ “self-concept” is the fifth factor affecting their perception of self-efficacy in successful educational sessions. For example, if this self-image is not positive, it can lead to anxiety and reduce his/her self-efficacy. The question is “How can self-concept help the health educator, and what benefits its understanding would have?” Self-concept can predict future behaviors. Self-concept is able to form behavioral motivations and direct them toward specific behaviors . The resIn the present study, the participants stated that if healthcare personnel did not have “professional skills and knowledge”, they would become anxious; this feeling negatively affects their self-efficacy. According to the study by Haghbaghery and Salsali, self-efficacy originates from personal characteristics, but the level of knowledge and work-related social relationships affects individuals’ professional self-efficacy. In this study, the participants mention factors such as the use of inappropriate methods of education, casting doubt on the scientific and technical competence of the healthcare personnel, thereby affecting their self-efficacy . In the Some factors associated with self-efficacy as extracted by the present study are largely in line with the sources proposed by Bandura but in a more extensive sense. Some new categories such as “encountering unexpected events” and “clients’ trust”, which affected the healthcare providers’ professional self-efficacy beliefs in health education practice, emerged from the study. According to the results of our study, it seems that it is necessary to develop educational programs based on the extracted factors to increase health educators’ self-efficacy.One of the strengths of the study was participation of people from diverse backgrounds in the study, for example from both health and treatment fields. In addition, the emergence of the concept of sexuality as affecting the self-efficacy of health educators in the Iranian culture was among the strengths of the present study. Furthermore, the results of this research can be used to provide more precise instruments to measure these factors or design empowerment interventions.In the present study, although the nature and quiddity of the self-efficacy sources were clearly explained and comparisons and contrasts with Bandura’s sources were made, no findings were offered about how these sources were affected, particularly in cases where this leads to reduced self-efficacy in health education. Moreover, no findings were presented about how these sources could be measured and what their relationship with self-efficacy was. Thus, it is suggested that further studies devise appropriate instruments to measure the self-efficacy sources in health education and subject the devise instruments to psychometric methods so that the effects of different interventions on the improvement of self-efficacy in health education could be studied.


Despite growing evidence of the impact of smoking on diabetes complications, people with type 2 diabetes still smoke at high rates and little is known about the specific barriers to quit smoking in this group. The purpose of this article is to explore the perception of smoking, and motivation and barriers to quit among smokers with type 2 diabetes. This exploratory study will help designing a smoking cessation intervention tailored to the needs of people with type 2 diabetes. We hypothesize both that living with diabetes and gender may raise additional difficulties to quit smoking.The qualitative exploratory research included ten in-depth semi-structured individual interviews and five focus groups conducted in an Ambulatory Care University Hospital in Switzerland. The thematic analysis was conducted with a gender-sensitive focus.Both current and former smokers recruited from the ambulatory clinic and the community took part in the qualitative interviews. We restricted the analysis to 21 current smokers only.The sample included 12 men and 9 women with type 2 diabetes, having a mean age of 59.4 years, who had diabetes for an average of 9 years with a mean HbA1c of 7.4%. We found that harmful effects of tobacco were superficially understood, and participants used several patterns of thinking to minimize the risks. The relation between tobacco and diabetes was poorly known. Readiness to change was related to personal self-image and meaningful engagement in life and social relationships. Barriers could be organized into three groups: dependence, psychological habits and social barriers. Barriers were markedly shaped by gender and living with diabetes.Results suggest that “one -fits-all” smoking cessation interventions do not satisfy the needs of type 2 diabetic smokers. Personalized smoking cessation interventions should be preferred and should pursue positive psychological outcomes addressing contextual factors. Smoking and diabetes act synergistically on morbidity and mortality, 2. PeopDespite increasing evidence of the metabolic risks caused by the interplay between smoking and diabetes, prevalence of smoking remains high among people with diabetes. In a country such as Switzerland, it is estimated that 20.8% of people with diabetes are current smokers , 14.Previous research suggests that people with diabetes have specific behaviors and needs towards smoking –20. In aThe purpose of this qualitative study is to gain a better insight into the interconnection of diabetes, smoking and gender to be able to design a more effective smoking cessation program. This study specifically explores the way people with type 2 diabetes related to smoking cessation in a Swiss sample of smokers with type 2 diabetes and explores specific needs and beliefs towards smoking cessation.The current research is an exploratory qualitative study. Our approach is rooted in a realist social constructionism perspective, 33 and We conducted ten in-depth semi-structured individual interviews with current and former smokers with type 2 diabetes. Interviews were used to get a deep insight into the relationship of participants with tobacco in the context of their daily experience. We then conducted five focus groups including 3 to 5 participants who were current and former smokers, in order to compare and contrast the relation to smoking and smoking cessation and to discuss emerging findings as a group. We stopped the individual interviews and focus groups after 21 participants, as we considered that saturation was achieved. We had specified in the protocol that data collection would continue until saturation point had been reached and no new domains or themes were generated.We carried out sampling purposively, in a way that ensured even distribution of smoking status , gender, diabetes duration and educational level. These characteristics were the most crucial regarding our research interest.We conducted interviews and focus groups in the conference rooms of the Ambulatory Care University Hospital, from August 2015 to February 2016. The interview team was formed of two investigators: the principal investigator (PI) of the study, a 39-year-old white woman, trained as a general internist and a research collaborator, of 29 years, white male, trained as a sociologist. To reduce influential bias, status, function and hierarchical position were not introduced to participants and visual indication of status was purposely removed (for example lab coat and signs of grade). No participants were under the care of the PI and it was explicitly mentioned that participation in the study was disconnected with care.http://www.cer-vd.ch) approved this study (CER-VD protocol n°302/15). Written and oral consetn were obtained from participants to this study.We sent a complete study description to the participants prior to the interview and researchers made sure that the participation conditions were well understood by repeating the most important conditions at the beginning of the interviews. Informed consents were signed before interviews started. The Cantonal Ethics committee  d’éthique de la recherche sur l’être humain (CER-VD) Interviews and focus groups were based on interview grids. For individual interviews, the first part of the interview aimed at understanding the participant’s daily life, context and perception of life with diabetes, enabling the second part of the interview to focus on the knowledge and perception about smoking and living with diabetes, motivation to smoke and quit smoking and potential impediments to smoking cessation in the context of their everyday experience. For the whole sample we addressed questions about how gender impacts smoking, quitting smoking and managing diabetes. At the end of the interview, we gathered socio-demographic information as well as information regarding diabetes and smoking history using a short quantitative questionnaire.verbatim. Transcriptions and analyses were done using MaxQDA software. We checked the accuracy of the transcript during the first coding phase by the research team. We anonymized the transcript material and stored it on a secured drive.Interviews were integrally audio-recorded and transcribed Information-Motivation-Behavioral Skills Model by Fisher and collegues I don’t feel bad from diabetes, every year my kidneys are checked, or my eyes or sensation is checked, my foot sensitivity hasn’t changed, and my eyes haven’t changed, the kidneys have had a bit of tinkering, but well… In eighteen years, I think if I had an 18-year-old car, it would be more run-down than me! (Laughter)”“No, ID08 manThese participants were likely to dismiss the relationship by arguing that diabetes would develop anyway without smoking, based on examples of family members and friends.More than half the participants considered that smoking was not a problem since they were not experiencing serious lung problems. They portrayed themselves as being “fairly” fit. In particular, three participants (2 men and 1 woman) considered themselves strong enough to contain and cancel out the potential health problems caused by tobacco.that we all have our strong and weak points. One of us might have to stop smoking one might not need to. In the end it depended on our good and bad points. Well … I stopped at that, because it suited me to”"The doctor, who operated my heart, told me, ID22 manMany participants mentioned that the manner in which they smoked significantly reduced the harmful effects of smoking.Both men and women participants described that they did not smoke many cigarettes a day, or currently less than previously. Some participants of both genders claimed they were not dependent on tobacco, or that they were able to take a temporary break from tobacco smoking.Another strategy to reduce perceived harm of tobacco was typically expressed by women. They described their way of smoking as “soft”, not or less harmful and not problematic; for example, never smoking in the morning, not smoking the whole cigarette or not inhaling deeply cigarette smoke.Misconceptions on harmful effects of tobacco were reinforced through positive comparisons. This comparison could be made either to other people, or to other risky behaviors perceived as “worse”. While these kinds of comparisons concerned both genders, a higher proportion of men tended to use these comparisons. The analogy was always made to men at higher risk.I’m not addicted like my son, well, him, in the morning he’s already at it, I tell him " you’re ridiculous! ""ID05 manWe categorized major quitting motivation elements into five groups, organized in ascending order of scope.Participants expressed displeasure or even disgust towards tobacco smoke and smell, based on personal taste. These preferences were more likely to be expressed by women. Smell, smoke and effects of smoke were found to be incompatible with the participant’s conceptions of cleanness or desired personal smell.per se.Among men, discomfort about the smell or tobacco smoke was most frequently found related to a state of illness and/or respiratory distress and not Cost of smoking was also mentioned as a motivation to quit smoking but to a lesser extent. Heavy smokers or smokers who were planning to quit smoking particularly expressed this concern.At first participants expressed their concerns in a vague manner, for example by stating that smoking was “not good” or “bad”. However, subjects with these kinds of narratives rarely had a high level of preparedness to change.Both men and women were more likely to raise concerns about actual tobacco-related health problems if they directly experienced negative impact on their body in everyday life. Men and women were both sensitive to susceptibility to respiratory and cardiovascular disorders caused by tobacco.With respect to diabetes, men and women did not perceive a need to change their smoking habits due to diabetes if they did not perceive an impact of smoking on their diabetes management.Only three male participants explained that living with diabetes might motivate them to quit smoking and this motivation was significantly related to negative impacts of diabetes, including erectile dysfunction.Among women, a general concern about health was raised by the experience of living with several chronic diseases:"No, no, I think that … It’s bad, very bad … Anyway, with diabetes, we’re already at risk for our veins clogging up, if we add another risk … when there’s already a chance, so no, I get it … […] [I know] very well that, having diseases, like for everyone, our disease, or my diseases, it’s not good, I know that. "ID14 womanWomen also expressed particular concerns about adverse health problems due to tobacco, such as preserving a feminine voice.Finally, we noticed that male participants became markedly motivated to quit tobacco if they witnessed harmful effects on others, especially family and friends.In the group motivated to reduce or quit smoking, participants thought that smoking conflicted with their values, aspirations or expectations about themselves.Three female smokers expressed that smoking did not align with their personal values, considering it “stupid”, “ridiculous”, “silly”.Almost half the participants at some point expressed having a problem with their dependence on tobacco. Dependence was experienced as a lack of liberty and both men and women shared a desire for independence often heard in narratives of a strong motivation to quit smoking."I don’t have a great opinion of myself, I try to do my best. What people expect of me at work, I work really well, and I think I’m worth it, owe it to myself, to make this gesture (quit smoking), and … I can’t manage, that’s the thing. It’s hard … No it’s terribly hard, isn’t it. "ID04 womanSport-related metaphors were found among men:It’s like someone who scored, a goal, for me, it’s a cigarette I say, look; I ‘let in’ a cigarette. "“Just before smoking I think I should justify it because it’s a failure. Yes, smoking a cigarette is a failure for me. I mean I do it, I poison myself and that’s the first thing I tell myself. ID01 manMen also mentioned experiencing embarrassment or feeling shame at the idea that smoking damages their image, typically if they were sportsmen.Smoking was sometimes perceived as conflicting with important plans or desires for social engagement. Participants purposefully chose to reduce, hide or attempt to quit smoking to get involved or to maintain engagement in meaningful relationships. The kind of dialogue was very often related to an actual plan to quit or actual attempt to quit.Professional activity deters smoking: Participants reported that some work activity dissuades them from smoking, even if smoking is permitted in the workplace.This was particularly evident in physically active professions, typically among men.Female-dominated professions, such as a health care provider, particularly seem to influence women to quit smoking to avoid inconveniencing patients.I thought it was awful, caregivers who bent over you, smelling of tobacco, I said to myself, OK, how about one day, I go back to school and stop smoking.""[While she was studying nursing:] ID43 womanSmoking is a barrier to positive engagements with others: About one third of participants of both genders felt uncomfortable about smoking in front of non-smokers. They would delay or stop smoking that then triggered them to realize that their smoking was problematic.Women tended to pay greater attention to avoiding smoking in front of non-smokers than men. However, certain men showed more concern if smoking increased health problems for their partner, for example an asthmatic partner.Parenting and Grand-parenting roles: Taking on parenting and grand-parenting roles was critical for smoking attitude. This was mentioned by a large majority of participants as strong motivation to reduce or attempt to quit smoking.R1: Well maybe if I had a grandson or granddaughter to look after at home from time to time … Well, then I think I would stop entirely "ID03 womanThis particular motivation to reduce smoking stems also from the desire to preserve their health to benefit from the joy of being (grand-) parents as long as possible.We could not find a clear gender difference for this motivation, although men more often reported smoking at home in front of their children compared to women.In this section, we identified discourses that described direct influence or incentive from a relationship(s) to quit smoking.Take-up challenges: A challenge to quit launched between two male friends was very effective for inducing attempts to quit:fighter, a bull , and you better not tell me “You can’t do it! " If someone says that to me, it provokes me, I rise to the challenge… ""So for me it’s exactly the opposite, because all my life everyone thought of me as a male ID10 manFor women, challenges rather come from the broader context of social influences:it was a bit of a joke at the office, I was in a large, open space office, and the only smoker … ""I started to [referring to quitting smoking the first time] because ID15 womanSocial support and encouragements to quit smoking: Participants reported that they wanted to reduce or quit smoking especially if their partners or close relations encouraged them to do so.An effective motivation was to quit with one’s partner, if both partners smoked.It is notable that a few single or divorced male heavy-smokers pointed out that finding a non-smoking woman was the only convincing way they could imagine to quit smoking.Close friendships and the broader family also played a role in encouraging stopping smoking.Smoking is not allowed: About two thirds of the participants noticed in that a public ban on smoking or agreement on smoke-free areas at home, encouraged them to reduce or quit smoking.We ordered the perceived barriers to quitting smoking into 3 broad categories: physiological effects of tobacco and nicotine, habits and psychological barriers and social barriers.Out of twenty-one participants nineteen, both genders, talked about the physiological effects of tobacco on their bodies.Tobacco dependence: Two thirds of the smoker participants described themselves as dependent on tobacco and dependence was used to explain why they kept smoking.For example, for the large majority, dependence was used to express a lack of capacity to quit smoking, a state of powerlessness, most frequently experienced by women."Even though I don’t smoke a lot, I’m still an addict, since I smoke every day, worse though, I’d really have trouble stopping”ID41 womanHeavy smokers reported tobacco withdrawal symptoms when trying to quit smoking."If I don’t have a cigarette, I act like a drug addict, I don’t take drugs but I’m addicted, I look in all the drawers, I feel awful, it’s … You can’t imagine how addicted I am "ID09 woman« Stopping smoking makes me too nervous »: Some participants experienced increased nervousness after stopping smoking. This behavior might lead to negative social consequences, which deters motivation to quit smoking. Anger behavior was found to be different for men and women.Men reported aggressiveness if they could not smoke. In some cases, this temperament gave rise to potential expression of violence towards others, including subordinates.Among women, expression of aggressiveness from tobacco withdrawal was less socially accepted.Diabetes as a barrier: In our sample a significant part of the participants suggested that diabetes might interfere with attempts to quit smoking.First, smoking might be perceived as a way to manage glycemia. Smoking was also described as a mean to manage physical suffering caused by diabetes and its complications:"When you wake up in the morning with a very high diabetes rate, you feel like your head doesn’t belong on your body! Because when my diabetes is high, I feel it in my head, for example, I’m dizzy, and then the only way to get my head back to normal is to smoke. And then have my morning coffee, isn’t it? "ID08 womanFemale participants in particular expressed that living with diabetes was an additional stressor that prevented them from succeeding to quit smoking.Yes, I really think, now, I have to stop because I have diabetes as well as a progressive rheumatoid arthritis […] but I’m having trouble, its difficult, so difficult, our diseases take a lot out of us on a daily basis, make physical activities hard, which is bad for diabetics who need to walk. Everything requires effort, there’s continual doubt, checking yourself 6 times a day, in the end it’s trying. For me it gets difficult to bear. So stopping smoking, I know, I saw the doctor again today, but … Even though I know I have to stop, I just can’t do it »ID19 womanWeight control after smoking cessation was not described as a barrier to quit smoking, even in the context of diabetes, despite participants knowing the risk of gaining weight and experiencing it after quitting. Participants who felt ready to quit were prepared to accept weight gain and deal with potential impacts on diabetes.Almost all participants reported that smoking was encompassed in some form of ritual or habits. Participants talked about the difficulties of doing without smoking."All day-long and at night, if I wake up at night, I smoke … I smoke a cigarette with my medicine in the morning, between my injections, doing anything and everything, I smoke one. But, it’s, it’s becoming a ritual with everything … Totally useless connections, but it’s like that. "ID 22 manHalf of participants both men and women mentioned that refraining from smoking after meals, especially after lunch and dinner, was the most difficult part of an attempt to quit or reduce smoking. These specific cigarettes were perceived as the most important and pleasant.Social barriers: Almost all participants mentioned that quitting smoking was difficult if smoking is entangled in significant relationships. Participants reported difficulties to quit if their partners kept on smoking."I tried twenty years ago, and stopped for six months, and I was married, to a woman who smoked, Gauloises too! But then, after 6 months, I went home one day and inhaled the scent of Gauloises, I said to myself, why on earth did I stop, and then just like that started again "ID08 manFamily members, close friends or colleagues also had an impact on smoking behavior.Peer relationships were a third social context group, especially difficult to manage for people who tried to quit. Among men, the male peer group was identified as a major cause of smoking relapse among current smokers. The activities associated with smoking were typically masculine such as partying with male friends or joining the army.Women who attempted to reduce or quit smoking experienced difficulties in avoiding smoking during festive events attended by men and women, especially when drinking alcohol:"Sometimes, it happens without thinking, usually in a group, where, maybe, we’re drinking, well, I don’t drink much alcohol, but from time to time an aperitif, and I noticed, then, I want to smoke straight away. "ID04 womanPeople living with type 2 diabetes have a certain degree of awareness and information about the general harmful effects of tobacco. However, accurate information was rarely available, even among those with the highest motivation to quit. The relationship between tobacco and diabetes was poorly understood and often denied. Most patterns of thinking discarding the risk of smoking on health seemed to be influenced by gender, with patterns of perception fitting more one gender than the other. Schematically, men supposed themselves stronger than the harmful effects or used social comparison to maintain a positive image on their tobacco intake, whereas women developed “soft” patterns of smoking.We noticed that desire to quit related to positive self-image and meaningful engagement provided the strongest impetus for the actual quit attempts reported. Among attempts, deep gender structures can be at work. The motivations found most often among women were consistent with the traditional feminine role of caring about themselves and others. Conversely, when men engaged in reflexive thinking, it encompassed themes central to masculine gender identity . Gender relationships were found to be relevant in shaping reason, especially for smoking challenges or reinforcing gender roles.Most of the barriers we found for quitting smoking have been previously described in other studies, such as tobacco dependence, 47, strThe interpretation of our results is limited due to the very small number of in-depth interviews and focus groups. Data generalization needs further research using quantitative methods. However, our results suggest directions for improving smoking cessation interventions.Smoking cessation interventions should take into account that information on the relationship between tobacco and diabetes could be better communicated. In this vein, our findings suggest that personal experience of participants on tobacco effect is more influential than transfer of information by health professionals. Motivation analysis suggests that the major catalyst to help participants quit smoking is to assimilate their sense of positive self-image and meaningful engagement to life, which are both highly individual and gender structured. Both aspects could benefit from a personalized intervention approach  and positive psychology from the growing body of literature (e.g. Seligman ), which Gender in its three dimensions, i.e. as a structure , hierarchy (submission to passive smoke at home or work) and identity  might impact smoking and smoking cessation. Therefore healthcare providers have to take gender better into account when counseling for smoking cessation and integrating contextual, relational and structural factors influencing smoking might increase its efficacy.This research shows thatthere are gender specificities in beliefs, needs and barriers to quit smoking among type 2 diabetic smokers. However but not every aspect reveals gender patterns. In addition, typically gendered perceptions tend to be shared by participants for the other sex also . This observation accounts for changes in social roles in the current society. We also