Drawing on ethnographic research with radical right-wing activists in Italy and Poland, my article reflects on the ways in which the Gramscian framework may enhance our understanding of the present-day political landscape. Gramsci’s role in the article is threefold. First, since he was a keen observer of fascist developments, I relate his observations on fascism and inquire into their relevance for understanding the rise of the far right today. Second, I explore the agendas of the movements I studied through the Gramscian lens. Inspired by the special issue’s editors, I examine the extent to which Gramsci’s concept of “common sense” is helpful for analyzing contemporary far-right activism. Third, I relate my own ethnographic observation to analyses of a broader terrain of far-right politics to shed light on the phenomenon of “far-right Gramscianism.” Bringing together all these observations on the radical right, “common sense” and Gramsci’s legacy, I reflect on the complex interrelationship between the radical right and the radical left. I believe that living means taking sides.Those who really live cannot help being a citizen and a partisan.Indifference and apathy are parasitism, perversion, not life.”Antonio Gramsci, August 1916“You need to read Gramsci,” Ula exclaimed with a smile, interrupting Krystian, who was in the midst of a heated political debate.“I know his theory, but I don’t buy it,” Krystian replied, annoyed by her interruption.“From the perspective of your research, this area is the most fascinating.”“You mean: the question would be ‘How to close the circle’?” I asked.“No, the question is rather whether it should be closed,” he replied.I was with Krystian, the founder of a nationalist-socialist movement, and Ula, a sympathizer with the far-right scene in Poland. We were sitting in a Warsaw café, talking about the aims of Krystian’s movement. The main arguments that Krystian and Ula advanced were concerned with the errors in contemporary attempts to categorize present-day movements as right- or left-wing. Ula claimed that the classic division of political struggles along two axes — economic and cultural — was insufficient. It was not enough, she claimed, to say that a movement or a party could be economically liberal but morally conservative. This two-dimensional picture no longer captures the diversity of socio-political phenomena. Krystian did not share her emphasis on culture, precisely for the reason that he rejected the Gramscian interpretation of Marxism that, in his view, also approaches culture as an autonomous sphere. But he did agree that the two-axes model is insufficient and suggested that, precisely for this reason, he found a “horseshoe” model of the political landscape much more convincing. According to this model, the radical right and the radical left occupy the ends of the horseshoe — and, consequently, are close to each other. Listening to him, I drew a picture of a horseshoe, asking him to place Polish political parties along the arc. He did so and, pointing to the area between the two ends of the horseshoe — that is, between the radical right and the radical left — he observed:Anthropological wisdom suggests that ethnographers ought to follow their research participants. It is a conviction that informs my various research projects. In this article, I follow Krystian’s advice and attempt to investigate the political terrain between radical right-wing and radical left-wing ideologies by analyzing the activities of two youth movements that I have been studying in recent years. In depicting their activism, I demonstrate why Gramscian thought may help us to better understand the often surprising affinities between ideas professed by the actors occupying different sides of the political spectrum. Or, to paraphrase the above comment by Ula, I show why we should read Gramsci to better understand the increasing appeal of certain “left-wing” ideas among activists who increasingly reject the label “right-wing.”1I want to make it clear, however, that it is not my aim to argue about the “increasingly blurred boundaries” between left and right, echoing numerous observers who use this argument to explain the contemporary political vacuum. On the contrary, what the movements I study reveal is a clear re-articulation of specific ideological positions that inspire their own projects. I also want to note that, although I use the adjective “far-right” when describing my research participants, I do so with reservation, recognizing that the term does not precisely render the agenda(s) that combine radical nationalism with socialist thought. On the other hand, these kinds of movements have a long history when we consider historical instantiations of the variously far, radical, and extreme right, first of foremost fascism and national socialism.Bringing in history is important when we consider Antonio Gramsci as a companion in our discussion. Gramsci’s role in my article is threefold. First, since he was a keen observer of fascist developments , I relate his observations on fascism and inquire into their relevance for understanding present-day developments. I am particularly interested in Gramsci’s reflections not about fascism per se, but about the reasons behind its success and the role of the left in this process. Second, I explain why I find it helpful to explore the agendas of the movements in question through the Gramscian lens. Inspired by the special issue’s editors, I examine the extent to which his concept of “common sense” is helpful for analyzing contemporary far-right activism. I consider how a “far-right” common sense emerges through heterogeneous experiences and understandings and I relate it to Gramsci’s reflections on culture. Third, I relate my own ethnographic observation to analyses of the broader terrain of far-right politics to shed light on the phenomenon of “far-right Gramscianism.” As my discussion demonstrates, Gramsci has had a profound impact on far-right milieus. For all these reasons, he is a particularly apt guide for investigating the “fascinating area” between the radical left and the radical right.s of our time” . He further demonstrates that Mussolini saw communist Russia as the only political system where revolutionary and ideological counterparts to fascism could be found. Importantly, such views remained prevalent among fascists, even after their defeat during the Second World War, an attitude made evident in declarations suggesting that “the truest fascists” would welcome Stalin’s communism rather than Churchill’s and Roosevelt’s “plutocracy” Parlato : 7–8. ThThis latter approach, amplified by the events of the Second World War, became dominant as a result of Cold War dynamics, when both left and right tried to purge their ranks of “fascism,” or, even better, to cast the term at their political opponents. While Marxist scholars described fascism as reactionary rather than revolutionary, particularly for safeguarding capitalist interests, their opponents on the right promoted the idea that totalitarianism was a common denominator for both fascism and communism. In one way or another, fascism was perceived as a sort of political aberration and treated as a monolithic phenomenon.want to see it, even if they may completely differ from Gramsci in their evaluation. That is, they aim to see it as a peculiar sociopolitical “project under construction,” which has had its worse and better phases. It is not my aim to summarize Gramsci’s thought here, which is a task that has already been pursued by scholars who have traced the evolution of Gramsci’s thinking on fascism, from viewing it as a transient phenomenon to granting it a revolutionary status . As is well known, Gramsci developed most of his theories during his stay in prison; ironically, fascism created the conditions of possibility that produced a great Marxist theorist. Gramsci’s notebooks and letters demonstrate that imprisonment led him to re-evaluate the force of fascism, which he had initially underestimated. However, given that he died in 1937, Gramsci did not witness the end of fascism. As such, his outlook does help us to understand fascism in the way that many of my research participants In identifying the sources of fascism’s success, Gramsci saw it as a response to a series of interrelated crises. He talked about an “unresolved national crisis” and claimed that “fascism is the name for a profound decomposition of Italian society which could not but accompany the profound decomposition of the state”  and the political (ideology). Unable to provide a new hegemony, fascism is an example of “Caesarism.” Gramsci understood this as a force (whether a person or a collectivity) capable of asserting domination and temporarily restoring equilibrium, yet unable to bring about profound social change: a passive revolution or a “revolution without revolution” Gramsci : 250.4 “While scholarly assessments regarding the accuracy of Gramsci’s take on fascism vary, he clearly provides an original framework that enables us to understand both the failures and successes of fascism and communism/socialism, which, more broadly, makes evident his influential role as a scholar — observer and analyst — of state transformations Mangoni . Some obon fascism/communism, but the ideas that arose from his analyses of fascism and communism. I mean here his reflections on common sense and the role of organic intellectuals, including politicians, in recovering “good sense” from chaotic common sense; the related question of language as a medium; and the (de)naturalization of social order, through the transformation of culture, as a condition of social change. In what follows, I illustrate different ways in which we can use these Gramscian ideas in the analysis of contemporary far-right milieus. More specifically, I aim to show that an emerging “new” far-right common sense is made of very heterogeneous influences (including “heretic” Marxist ideas). Furthermore, I demonstrate that that we can use Gramsci’s reflections on organic intellectuals and revolution to investigate two aspects of far-right activism: how activists interpret their own action through what they take to be a Gramscian lens and in what way the Gramscian framework helps us to interpret their activism.However, equally important for understanding this kind of radical politics, whether in the present or in the past, are not Gramsci’s specific comments Since 2016, I have been conducting a research project on transnational cooperation between youth far-right movements, with a special focus on Italy and Poland (Pasieka forth.). What connects the studied movements is that they are critical of liberal democracy, argue in favor of national autarchy, and link the defense of “traditional family” with the “national/patriotic cause.” All of them are youth movements and place a strong emphasis on the communitarian aspects of their activism, presenting themselves as diametrically different from political parties, even though, as I show below, they engage in political agitation for far-right parties. As for social backgrounds, members — predominantly male — come from all walks of life, with manual workers and unemployed young people engaging in militancy along graduate students and well-off entrepreneurs. In this article, the protagonists of my ethnographic material are two movements. Although they do not work together, they offer a good representation of a set of concerns and forms of activism that characterized all the studied milieus and, simultaneously, make evident the importance of Gramscian reflection for the understanding of the far-right scene.Lealtà Azione, hereinafter: LA) has been active in Italy for over a decade and has been very successful in developing all across Italy, even if its stronghold is still the north of the country. The number of core members in the respective chapters varies from several people to several dozen; among them are numerous sympathizers who join LA activities occasionally. Hierarchical and clearly structured, LA is divided into sections — branches — responsible for specific tasks: social assistance , care for the environment and animals, actions raising awareness about persecuted Christians, martial arts and sport, and historical politics. LA considers “cultural work” to be crucial and frequently organizes discussions, conferences, and guest lectures by “cause”-friendly journalists and scholars. Although proudly identifying itself as a “community” and “movement,” in recent years it has lent support to several Lega  politicians.The Italian association Loyalty Action  has been active since 2017 and is much less numerous and widespread than LA, while the latter has dozens of members in each region, PL has dozens of members in total, and contrary to the wide range of activities LA offers, PL focuses predominantly on economic aspects and develops and promotes the agenda for a new Polish nation-state, based on social economy, social solidarity, and ethnonationalism. It does so through publications, online and offline conferences, as well as social assistentialism. The following two sections shed light on all these aspects.The Polish movement, Polish Labor Reno, one of the founders of LA, was one of the first activists I got to know in Italy. In his sneakers, jeans, and sweatshirt, he looked like my university friend rather than a “typical” right-winger. Reno graduated in foreign relations and his collaborators joke that he performs the role of “minister of foreign affairs” in the movement. He also works for his father’s company, meaning that he travels a lot, and is responsible for the mountain section of the movement, which promotes a “reconnection with nature” and the “valorization of the national cultural-natural landscape.” Generally, the movement’s key aim, as Reno explained to me, is to lead to “national rebirth” before Italy “gets totally destroyed by immigration.”Unsurprisingly, immigration was one of the key themes of our conversations. Reno would always emphasize that he and his movement are not against immigrants, but against immigration policies. “It’s not that we don’t want them, they simply can’t be happy in Italy” as “their roots are elsewhere” was the leitmotiv of our discussions. He stressed the inhuman conditions in which migrants often worked, which constituted an “offense to human dignity.” The biggest problem with labor migration, in his view, is the fact that it leads to uprootedness which, in turn, prevents “human flourishing.” As he explained to me, human dignity flourishes thanks to the use of one’s resources — through one’s labor — for which people receive fair pay; thanks to the possibility of living with family and community; and through rootedness in a culture and a territory, one’s natural environment. Labor immigration precludes all of this, and thus is to be limited and controlled.While we can read such a statement as providing sophisticated cover for xenophobic rhetoric, characteristic of the increasingly common discourse on “autochthony” . Apart from being a member of LA, Sandro is also a Lega representative and member of the local council. For him, walking through the rundown building is an opportunity to learn about urgent problems and to gain electoral support.Sono-una-persona-di-sinistra). Sandro seemed inattentive and scrolled through his phone, as if he already knew what she was going to say. His attention was piqued when the host praised the support provided by “good lads” (bravi ragazzi). When we were about to leave, the journalist asked her: “Don’t you mind that the people who are helping you are from a far-right organization?” The woman looked at her, amazed: “Are they?”.One of the inhabitants, a Romanian immigrant, served as our guide. She led us through the dirty, rubbish-filled corridors, illuminated only by a single bulb dangling from the ceiling. Some people agreed to talk to us, while others refused: those who did complained about “abusive” Roma people, about their own neighbors, about the inhabitants who had managed — “God only knows how” — to buy one of the municipal apartments. Some of them begin shouting at the Romanian lady and shut the door. The entire tour made it clear that the building was tormented by conflicts, grievances, and mutual accusations. Towards the end, we arrived at the apartment of an elderly lady whom Sandro already knew, and who was supposed to “tell her story” to the journalist. She invited us in and sat down with us while her husband remained in the kitchen; the apartment was perhaps 20 square meters in size. She recounted in detail the problems that she and the other inhabitants faced. The negligence of public authorities featured prominently in her account, including their disregard of Italians’ needs, low pensions, and drug dealers taking over a nearby park. She explained that her family had always voted left and that they were concerned with social justice. She clearly accentuated each word in a key statement: “I am a left-wing person” . My Polish case study further supports this point.How unique is the LA agenda? Most far-right movements and parties of the fascist type have drawn extensively, even if inconsistently, on left-wing ideas. While the currently observed increasing popularity of “nationalist”-cum- “socialist” agendas may constitute an argument in a debate on the disappearing distinction between far left and right, the evidence that I present here suggests that something else is occurring. It seems that young people from LA, and numerous other kindred organizations, both in Italy and abroad, achieve more than simply attracting voters (for the far-right parties that they more or less openly support) or otherwise converting people to their political views. They are, no doubt, representatives of a new, “contentious European fascism,” whom Douglas Holmes recently  describeCapital, which he quoted in one of his first statements to me, asking if I remembered the story of the privatization of the Renault factory. He noticed that I felt embarrassed, and in order to cheer me up, said something like, “Oh, don’t worry, you specialize in ethnic minorities and religious pluralism,” which made me realize how well he was prepared for our conversation.. Within the last four years, Krystian has managed to gather several dozen activists and establish organizational structures in several Polish cities. Krystian and his girlfriend, Maria, are the leading figures in the new organization. Both are in their early twenties and combine their studies with work.10When I first met Krystian, I quickly realized that I was unprepared: I had not read Thomas Piketty’s PP shares with many other radical nationalist organizations the belief in sovereign nation-states, criticisms of the E.U. and the U.S., and the rejection of foreign capital. The nation, in their view, has an ethnic basis, and they believe that migration to Poland and Europe ought to be stopped. What makes them stand out from similar organizations is their very detailed social economy program, which includes advocating for progressive taxation, availability of social housing, widespread worker unions, and a reformed labor code. Although PP members do not remember the time of the Polish People’s Republic, they call for correcting the mistakes of the postsocialist transformation. For example, they consider it vital to address problems of regional marginalization by restoring bus and train connections, which were removed in the post-socialist era due to their presumed unprofitability, and to support the mining industry. Some of their claims appear contradictory if one considers, for instance, their emphasis on environmentally friendly policies and care for nature together with their emphasis on the necessity of building nuclear energy and bringing back heavy industry. Other policies, by contrast, may appear progressive in comparison with other far-right groups in Poland, as PP promotes religiously neutral policies and widely available nurseries and daycares that would allow both parents — mothers and fathers — to work.PP promotes its ideas and puts them into practice through three forms of activism: “social campaigns” — which in fact mean “information campaigns”; “events” — usually one-day long conferences and fund-raising events; and “library” — publication and promotion of contemporary and historical works by authors who address national and social questions. Tech-savvy, PP activists successfully use social media to promote their activities. They stream most of their conferences and lectures online. They place a strong emphasis on design and aesthetics, making sure that the materials produced are high quality, eye-catching, and different from what they describe as “typical” nationalist propaganda materials — full of martyrological content and national-religious symbolism. Their logo includes a simple graphic of an ant, and they rarely use national symbols in their promotional materials.capitalists bring immigrants.”Similarly to Reno, Krystian and his collaborators point to the problem of migration as one of the driving forces behind their activism. Krystian openly states his opposition to foreign laborers, whose numbers have increased in Poland in recent years .He justifies his objection on several grounds. The first is a recognition that he shares with numerous other people in Europe and beyond: migrants mean competition and wages drops, and thus are not beneficial to the local (Polish) populations. The second is the fact that migration to Poland is not beneficial for Ukrainians: they are underpaid in Poland, and often work in scandalous conditions. He states that “Ukrainians are less and less satisfied with the work in Poland. Poles treat them as serfs.” The employers are eager to employ them because they are more subordinate and dependent on them. Similarly to LA activists, he sees the underpaid migrants in his home country as a local expression of a global phenomenon: the dominance of market logic. In order to raise Ukrainians’ awareness of this issue, PP created a poster targeting Ukrainian workers and informing them about the minimum wage in Poland to help them realize that they are underpaid and exploited. The third reason for his objection is that, by leaving Ukraine, migrants — usually young and skilled people — are slowing the process of change in and transformation of their own society. As a consequence, they are also undermining the process of global anti-capitalist change.The Russian invasion of Ukraine in February 2022 did not alter Krystian’s approach. Contrary to other Polish nationalist movements which expressed solidarity with Ukraine, he continues to argue about the potential threat that the waves of Ukrainian newcomers pose to Polish society and the Polish economy. He presents a similar take on the ongoing protests in Belarus, strongly opposing the anti-Lukashenko protests, claiming that the worst possible fate for Belarus is to become “yet another Western colony.” Generally, ethnic/national diversity does not go hand-in-hand with working-class solidarity, Krystian claims. “Anti-capitalism needs to be global,” he says, but “Ukrainians [and Belarusians] need to do it [act against capitalism] at home.”economize nationalism.” Although the organ ization aims to express the interests of the working class, this is why it is mostly represented by students. He describes the organization’s member profile as “inteligencko-pracowniczy” (worker-intelligentsia) — a notion that calls to mind the discourse that was prominent in discussions on Polish anti-communist activism . In emphasizing the desire to cooperate with local party members, the speakers assumed that they were less corrupt than high-level politicians and genuinely concerned about everyday matters. Some activists objected, however, emphasizing that cooperation could be difficult due to the clerical outlook of PiS politicians. Others challenged these claims, meanwhile, suggesting that PP members should not exaggerate the role of religious matters when it comes to cooperation in non-religious fields.Taking the floor, Krystian emphasized that what matters more is PiS’s views on “social questions.” In concluding, he stated that he hopes their agenda will evoke more and more interest among left-leaning people, especially those who do not feel represented by those parties dubbed left-wing, but mainly preoccupied with “sexuality.” One of his companions added that anti-fascism is yet another obsession of such groups. Instead of tackling economic issues and real problems, they sit at university conferences and ponder whether or not something counts as fascism. He proposed, however, that they at least try to establish cooperation with students of economics. Yet another activist drew attention to a potential alliance with football fans, in what appeared to be an inclusive gesture towards some of the conference guests. In trying to engage them in discussion, Krystian asked these guests to recount something about the social and class background of football fans. They confirmed that most of them were working class. However, they did not seem eager to engage in discussion; instead, they were happy to take part in the martial arts training that concluded the conference.these people every day,” he says, and by “these people” he is referring to underpaid construction workers (Ukrainian and Polish) and industrial laborers. He thus claims to know how to speak “people’s language” — the aspect strongly emphasized by Gramsci. As Crehan notes , one may be tempted to ask him to comment on the contemporary far-right scene. Would Gramsci see in Krystian, Reno and other LA and PP militants “monsters” who come into being in a moment of instability, or would he rather see them as “organic intellectuals” who try to reach out to contemporary “subalterns”? Quixotic as it may be to try to provide a definite answer to this question, I dare to suggest that even if Gramsci rejected the LA and PP programs, even if he considered them too meshed up and contradictory (as he considered fascism to be), he would approach them in a less dogmatic manner than numerous present-day commentators, including his heirs, tend to do. “We are in the process of losing our foremost thinker of and on concrete historical scenarios, Antonio Gramsci, to a reactionary right-wing cause,” reads the opening line of the International Gramsci Society Newsletter from 1999. Right-wing Gramscianism, the note suggests, misunderstands and misappropriates Gramsci’s thought, especially his notion of hegemony: “a productive concept – ‘hegemony’—is being abandoned by progressive positions and revitalised by reactionary forces” , finding inspiration in their thoughts on societal becoming and unity . Similarly, one might imply that it tries to attract young generations by presenting itself as a truly radical force opposing “the hated ‘bourgeois system’” and open to “unconventional counter-cultural lifestyles”.La France Insoumise, a left-wing populist political party in France. More generally, we may read the Gramscian approach as appreciative of “attempts at change” and condemning indifference more than condemning political adversaries.All the above interpretations feature prominently in current debates on the far right. Inspired by Gramsci’s thoughts on fascism, I would like to propose one more: to approach the political agendas of movements such as LA or PP as “projects under construction,” a sort of political experimentation and a search for an answer to the problems here and now  has been dropped from the rhetorical vocabulary, and the political horizon is now filled by what is there, by what is given, which is capitalism (…) What is the point of theoretical anti-capitalism, if political anti-capitalism cannot be taken seriously?”  and to consider change possible. Criticism of such a deliberate lack of engagement and of an aborted political imagination is something Gramsci, Reno and Krystian could likely discuss over dinner .The latter points bring to mind G. M. Tamás’s essay ?” Tamás . What I grassroots anti-capitalism, if political anti-capitalism cannot be taken seriously?” Movements such as LA and PP claim to perceive the globalized economic order as the key enemy and neoliberal capitalism as a morally and culturally destructive system. Yet to be able to act and spread their agenda, they establish alliances with political parties, and end up cooperating and campaigning in the name of the political agendas they claim to challenge. Therefore, in concluding our conversation with Gramsci, it is plausible to assume that while appreciating their political experimentation, he might observe that — similarly to the fascist movements from whom they claim inspiration — they simply pursue a “revolution without a revolution.”At the same time, in light of the evidence presented in this article, Tamás’s reflections provoke yet another question. In paraphrasing his query, we could ask “What is the point of Inspired by my ethnographic research, in this article I have argued that Gramsci’s ideas may help us to better understand the “fascinating arena” between left-wing and right-wing ideologies, a territory that the far-right movements I have described seem to be fighting for. What are the implications of this observation? I find it important to distinguish two kinds: those for social theory and those for understanding present-day political developments.As to the first, I suggest that the “theft” of Gramsci by the far right, the debates about whom his ideas “belong to,” or what kind of phenomena we can explain using his scientific apparatus provoke an important question: what makes a good social theory? Is it its capacity to explain concrete socio-political phenomena, in a given time and place, or is it the possibility to stretch it and adapt it to new contexts, carving from it some categories that are “good to think with”? Gramsci’s thought has inspired numerous scholars and fields of studies, including postcolonial, subaltern and globalization studies. This multiplicity is no doubt owed to the heterogenous nature of Gramsci’s writings, which make them open to a variety of, often contradictory, interpretations. It is therefore no surprise that it has also inspired people on the right, and it is far from surprising that the most inspiring concept was that of common sense and its relationship with  hegemony. Due to the emphasis Gramsci puts on its heterogeneous nature, on the fact it constitutes an aggregate of disparate, contradictory conceptions, the concept of common sense sheds light on both the reasons for the far-right success and its potential defeat.However, I have also been suggesting that the “common sense” that left-wing and right-wing activists and ideologues refer to is not necessarily as different as we might think. This leads to the second point, that of the implications for our analyses of the present day. Whether they want to admit it or not, the radical left and radical right share important features, among them strong anti-Americanism, rejection of market economy and condemnation of the neoliberal model (in very broad terms), anti-Zionism, protectionist policies and the autarchy model. Recent responses to the Russian invasion of Ukraine illustrate the similarity of certain political standpoints well. If the left does not want to recognize it, it is because of “the fear of contamination,” as suggested by Giacomo Loperfido  who drawCrucially, the realization of these affinities ought not to lead to some sort of “domestication” of the far right simply because they embrace some “progressive” ideas, because they have learned to talk about social justice and because some of them are genuinely concerned with the plight of their neighbors. Scholars conducting the ethnography of the far right have long warned about the danger of mistaking empathy for sympathy (Gingrich and Banks Rather, then, a recognition of these affinities should foster a more critical stance towards our own positions which we like to see as progressive, open-minded, and critical. To correspond with this portrait, such a position must entail an engagement with the ideas and practices we might consider despicable, to dare to ask uncomfortable questions and, to paraphrase Tamás , to rest


Current efforts to integrate reproductive health care into primary care in the United States involve assessing pregnancy intentions and reproductive goals, which are often not meaningful or attainable for some. Alternatively, we designed a reproductive health services-based screening question: “Can I help you with any reproductive health services today, such as preventing pregnancy or planning a healthy pregnancy?” In this study, we describe women's interpretations of this question as part of a larger study, exploring perspectives on reproductive health care quality in primary care.N = 30). Semistructured guides queried participants on interpretations of the screening question and preferences for raising reproductive health concerns during a primary care visit. We employed inductive thematic analysis.We utilized a third-party research firm to recruit New York women of reproductive age (18–45), who visited a primary care provider in the past year. We conducted five focus groups and eight interviews (Participants interpreted the question as offering contraception or pregnancy counseling and care, although younger participants also understood it as offering sexual and reproductive health services broadly. Participants also connected the question with discussions about their ability to conceive. Some participants described experiences with provider assumptions and implicit bias. Tensions emerged around accepting primary care as a setting for reproductive health due to a perceived lack of specialized training.Participants interpreted the screening question as intended, indicating face validity. Primary care settings should increase patients' awareness of reproductive health service availability, such as by routinely introducing a services-based screening question. To this end, screening initiatives using pregnancy intention and reproductive life planning frameworks to enhance preconception and contraception care have been adopted by many primary care practices and endorsed by US public health and professional organizations.8–11 Pregnancy attitudes, plans, and emotions tend to inform patients' service needs. Current approaches rely on time- and goal-oriented questions regarding pregnancy intention and plans.12 A planning-based paradigm may portray implicit assumptions about mistimed or unwanted pregnancies being inherently negative and causing adverse outcomes.10 Multiple articles describe these conceptual flaws in measuring and utilizing “unintended” pregnancy as a public health indicator, including both abortions and unintended births as equivalent outcomes and categorizing both as inherently adverse; contradictions in how survey respondents answer questions on unintended pregnancy; differences in intention, wantedness, and timing of pregnancy; and its oversimplification of complexities surrounding pregnancy decisions and unique social contexts in which pregnancies occur.14While both frameworks are designed to increase access to SRH services, they are not always salient, as many women do not possess unequivocal, binary pregnancy intentions and may have complex, ambivalent feelings that fall along a spectrum.15–19 Taken together, discussing pregnancy “intentions” and reproductive life “plans” in the clinical setting is often not meaningful and may be perceived as disrespectful by some patients.In addition, systematic reviews and studies have found an inconclusive effect of intentions screening on contraceptive use and pregnancy-related health outcomes.20 We found utilizing this question in primary care was considered feasible, acceptable, and preferable over other questions by patients and providers in New York, due to its inclusiveness, open-endedness, and promotion of reproductive autonomy.21–23 Patients reported feeling comfortable with this question and that it demonstrated providers cared about them.23 Providers also perceived it as an easy way to start a conversation on SRH.22To move away from the “planning” paradigm, our group developed a services-based screening question born out of key informant interviews with diverse stakeholders, including family physicians, obstetrician/gynecologists (Ob/Gyns), health educators, advocates, and public health professionals: “Can I help you with any reproductive health services today, such as preventing pregnancy or planning a healthy pregnancy?”25 By asking broadly about service need, rather than pregnancy intentions, the question can be asked to patients of all ages, genders, sexual orientations, and backgrounds, without preconceived notions of who may be “at risk” for pregnancy. Therefore, this question embodies principles of patient-centeredness in that it is respectful of and responsive to individual patient preferences, needs, and values.26 This screening question was integrated into practice and tested for feasibility and outcomes within a large Federally Qualified Health Center network in New York City and resulted in a modest 3.4% average adjusted increase in the documentation of family planning services, including counseling, across seven sites, with more work needed to improve implementation equally across sites.28Studies have found that many primary care providers (PCPs) do not routinely screen for SRH needs, provide preconception or contraceptive counseling, or discuss sexual health.23 Understanding how patients interpret this question is critical before widespread implementation in US primary care systems. To deepen our understanding, we queried New York State women on their interpretation of this question as part of a larger study on metrics for measuring quality of reproductive health care in primary care settings.Although many patients find this question acceptable and preferable to other reproductive health screenings, how they interpret this question remains unknown.29We conducted a qualitative study involving semistructured virtual focus groups and interviews with a purposive sample of women of reproductive age between October and December 2021. Eligibility criteria included women 18–45 years of age, currently living in New York State, who spoke and read English, self-identified as women, and had seen a PCP in the past year. We only recruited women of reproductive age; separate studies with people of other genders and ages are needed to understand their unique experiences and perceptions. We utilized a third-party research firm to recruit. They administered our survey screener, which queried on the above eligibility criteria, described the study, and invited participants to share their contact information.The firm established quotas to recruit 80 respondents within each age group: 18–25, 26–35, and 36–45. We contacted survey respondents in waves within each age group to invite them to prescheduled virtual focus groups. We aimed to conduct six focus groups, two per age group, with 5–6 participants per group. We planned to schedule 8–10 participants per group to allow for attrition. We emailed those who expressed interest in informed consent document describing the study, videoconferencing log-in information, and guidance on changing display names to chosen pseudonyms.30 The semistructured guide included questions on experiences and perceptions of optimal primary care visits for reproductive health care, as the principal study aim explored patient perspectives on measurement of reproductive health care quality.We conducted focus groups to allow group interactions to reveal how participants perceive and experience SRH. Group interaction enables participants to present their own views, hear, question, and comment on others’, and engage in continued discussion.As a secondary aim, we asked them to describe what they thought their PCP would mean if they were asked during their next primary care visit, “can I help you with any reproductive health services today, such as preventing pregnancy or planning for a healthy pregnancy?” We further probed participants on their preferences for raising SRH concerns during an appointment with their PCP, even if the appointment was for another health issue. In this study, we focus our analysis on these secondary aims.31Focus groups lasted 50 minutes to 2 hours. We discussed the informed consent document and obtained verbal consent from each participant before audio-recording. Immediately after each focus group, the co-moderators (M.G.M. and S.S.) and principal investigator (H.E.J.) practiced reflexivity by discussing emergent themes and patterns, group dynamics, strategies to improve moderation, potential revisions to the focus group guide, and personal reflections. Reflecting on ideas, processes, and experiences as they occur allows researchers to improve data collection, uncover more about themselves and their topic, including how assumptions may impact qualitative inquiry, and deepen analysis.Due to scheduling and participation challenges with age groups 18–25 and 26–35, we transitioned to in-depth interviews with these age groups to alleviate scheduling challenges and the potential discomfort participants may have in discussing SRH with strangers. We adapted the focus group guide for interviews, and we followed the same procedures for scheduling, informed consent, and data collection for interviews as we did focus groups. Interviews lasted from 25 to 60 minutes.Immediately after each focus group and interview, we emailed participants a brief demographic survey. Participants received $30 for participating within 24 hours of completing the survey. We also captured concurrent field notes, reflecting on methodological considerations, subjectivities, and emergent patterns. Audio recordings were transcribed by a third-party professional service; only participant-selected pseudonyms were used for on-screen names, in transcriptions, and reported here. The Institutional Review Board of the City University of New York approved this study (Protocol No. 2021-2006-PHHP).32 The analysts (M.G.M. and S.S.) identify as cis women and reproductive health researchers, one with and one without a child. Both believe SRH services should be accessible in primary care. We independently read the first three focus group transcripts (one from each age group), took margin notes, employed block coding, and reviewed field notes. We created an initial codebook through this process. We reviewed coding, reconciled discrepancies, and refined the codebook. One analyst (S.S.) coded all remaining transcripts and reviewed coding questions with the team. M.G.M. served as a second coder for interviews she did not conduct to ensure familiarity with all data.We employed inductive thematic analysis to explore participants' interpretations of the screening question and preferences for SRH discussions with PCPs.Throughout the coding process, we practiced reflexivity and wrote memos to document patterns, connections to literature, and emerging constructs. We used field notes and memos first to identify themes and generate initial theory with respect to the research question. Then, we sorted excerpts with specific codes related to provider types, the screening question, and reproductive health history using a data display to deepen analysis. We utilized Dedoose version 9.0.17  to manage data. We did not find differences in findings between focus group and interview respondents, so we present combined results.We collected data from 22 participants in five focus groups and from 8 participants through in-depth interviews, for a total of 30 women of reproductive age . We presOverall, participants interpreted this question as asking about contraception or help with preparing for a healthy pregnancy. Most described contraception as simply, “birth control” : “just birth control, nothing else really comes to mind” . They also included abstinence and abortion in their understanding of preventing pregnancy: “everything on the spectrum…from abstinence to birth control options, to abortion” .Participants conceptualized preparing for a healthy pregnancy in two ways: being healthy for pregnancy and fertility in terms of conception challenges and how to increase the likelihood for conception. They described service providers could offer as “folic acid”  and “routine checkup[s] to make sure…the physical aspect is okay and [the pregnant person's] healthy enough to go through [their] pregnancy” .Participants also expressed interest in discussing information about and options for getting pregnant. For example, “showing me dates of when I'm maybe ovulating. When is the best time to get pregnant for me… enough eggs and stuff like that” . Another described, “I was thinking maybe helping to track your ovulation cycle to know the sign of the best time for your body, maybe give you some tips or…reference material” . Others asked for services and referrals like “in vitro”  and “a test on fertility, and maybe a referral to a reproductive specialist” .Participants of all age groups interpreted the screening question as including fertility counseling, information, and services, although, younger participants discussed trying to get pregnant with respect to their own “family history”  and demystifying the unknowns and myths around the ability to conceive. One described wanting to talk to their provider about “things that would help my chances to have kids… My family, actually, has genetic things going on that doesn't necessarily work before kids” .When you have a child at certain age, you might have a child that's autistic or some other development disabilities, and we prepare for that as well. But having understand the risk you're taking and what is it that you can do, again, what tests I can take and be prepared. Have the discussion… “because you're getting pregnant that late, these are the problems you can have”… make sure that you understand the risks, and what are the tests that you can do if that becomes your concern. The older age group more frequently discussed fertility regarding how older maternal age could impact one's ability to conceive and potential health consequences:One, would I still be fertile? Number two, then you get into your IVF, and surrogacy, and the whole other realm of options that may be available to me… We would have to do a rundown of what my options would be… I would have to go in for a fertility test to see if it was even possible for me to get pregnant at this point. And if it turned out that it wasn't, then we would have to do a deep dive into what other options were available… [If] it was determined that I was still able to have my own child, that would be my preference, but I wouldn't be opposed to adoption or fertility, surrogacy, fostering. Another described wanting their PCP to explain all options available:While the youngest age group did not differ significantly in their understanding of the screening question, they interpreted it as slightly more expansive compared to older groups. Beyond family planning, they perceived the screening question to refer to “test[ing] for any STDs…also cancer”  and “maybe even mammograms” .I would assume that they're referring to planning a pregnancy. I mean, at the time of my life right now, being that I'm a little bit older and stuff, and I'm in a stable relationship, I would assume they would be talking about planning the pregnancy. Although participants interpreted the reproductive health services screening question as referring to a variety of SRH services, one assumed the provider would only refer to one type of service—preventing or planning a pregnancy—depending on where patients are in their lives and how they present to the provider. She explained:It did feel rushed as we weren't talking about [contraception]. And it felt more of like a push toward a specific option… I just feel like as far as women in reproductive health, certain birth control, or certain measures might be pushed toward certain demographics… There have been women I've spoken to…that have mentioned the adverse effects of birth control. But then when you bring that up to your provider, instead of them being more relatable – reassure you that those are rare occurrences…go through different birth control options before you find the one that better suits you… – [the provider was] more information-based and provide statistics… You have your provider saying, “Oh, well, you know IUDs are the best option or…the pills might be the best option”… So, they don't bridge that gap. While only one person discussed provider assumptions in the context of being asked the screening question, others across age groups raised concerns and experiences with provider bias in reproductive health care generally. For example, one Black young adult described her personal experiences with bias in contraceptive counseling where providers focused on efficacy and encouraged some options over others, rather than tailoring counseling and listening to her concerns:Some respondents relayed that they were not bothered by these types of interactions, and instead focused their narratives on how they are the ultimate decision-makers regarding contraceptive use and method choice.Regards to primary care doctors, you want to feel comfortable, and you want to feel non-judgmental. Sometimes if you're too young, they look at you like, “oh my gosh, you're so young, you have a kid already,” or “you're so old…you're at that stage.” You don't want them to judge you, because not everyone wants to have a kid.” Beyond contraception, several discussed providers expressing assumptions and gender role stereotypes about getting pregnant versus “being childless by choice” . One reflected: “I didn't want to have kids when I was younger…but then they just push like… ‘you're going to want kids, you are.’ I mean…that's always what I heard… [The PCP] didn't really give you any option” . Another described:One respondent in the older group was made to feel uncomfortable by their provider for expressing interest in getting pregnant again later into adulthood: “The question that I get, “Are you done having kids?” After having three kids, it's like, “Are you done? Are you done?” I think that's a common question that makes me uncomfortable” .I feel like that's not her specialty, the gynecologist is. That's what she does…. anything that I had that I thought was even remotely related to reproductive health, I would contact my gynecologist, make an appointment, or bring it up when I'm already there at an appointment. Despite participants understanding that the screening question would be asked during a primary care visit, there was tension and pushback in accepting their PCP as the provider of reproductive health services. Some viewed Ob/Gyns as the appropriate specialists for this care, not PCPs:If you talk to a PCP and tell them about that, they just gonna refer you to a Gyn, they're going to say they don't know that or like, I can't help you with that, because it has happened before with me like several times and my sister too, and it's kind of like, not annoying, but I understand that they're not in that field. Those who felt this way related their attitudes to their own experiences in primary care. For instance, in past visits, their PCPs did not have enough information to help them with their reproductive health needs and referred them to an Ob/Gyn or specialist clinic. One described:I never had a primary doctor that asked me about my reproductive system… The one I have just asked me if I'm having babies or taking precaution, it was just very simple question. And I'm just like, “Yep, yep.” And he was like, “Okay, you're good.” And then he go on and getting my physical. So, for me, I still think the best way to ask for questions about my reproductive system were to go to my Ob/Gyn because she does my pap smear, she does the invasive internal checks. My primary doctor doesn't. (FG 3. age 36–45)In real and hypothetical scenarios, these participants would prefer to go straight to an Ob/Gyn for their reproductive health needs because they assumed that they would ultimately be referred there. Some participants never had a PCP ask them about their reproductive health needs and would prefer to see the Ob/Gyn because they have historically filled those gaps:Only her. If I was to change my primary care to another person, I wouldn't feel that connection to be able to do that, really, or maybe I would, it depends on how bad the issue is. But with her in particular, I've been seeing her as my primary care since I was in middle school… I've grown up with her. My mom sees her, my grandmother sees her. So, it's like a family primary care doctor…That's the only reason why [I would receive SRH care from my PCP]. When discussing how PCPs can be trained to provide reproductive health care, participants were open to the possibility of receiving this care in primary care, “all in one” . Some preferred primary care over Ob/Gyn because of being able to get the care they need “done in one sitting” and “avoid paying another copay and having another appointment” . They also already had positive relationships with their PCPs, and cited trust and comfort as enablers for allowing them to open up about reproductive health care:[If] he or she is making me feel comfortable, I wouldn't mind opening up to the doctor about reproductive health. And I wouldn't mind asking [them] questions. Versus if I felt rushed and felt like, okay, [they're] just trying to hurry me and rush through the visit. I probably would not feel comfortable asking any questions about reproductive health. Furthermore, some participants did not have a preference over a PCP or Ob/Gyn. Rather, what mattered was how the provider made you feel:Participants in our qualitative study seemed to correctly understand the open-ended reproductive health services screening question to refer to contraception and preconception care, demonstrating face validity. They also interpreted it with an expansive understanding of SRH services, including fertility and STI testing. This illustrates patients' interests in a spectrum of services they may need beyond contraception and preconception care. They are also interested in fertility, cervical and breast cancer screenings, and STI care as part of SRH services in primary care.34 Significant disparities in access to fertility services exist, with women of color and of lower incomes least likely to have access.35 Ensuring broad conversations about family planning in primary care may begin to reduce these inequities. In addition, introducing this open-ended question in primary care may enhance patient-centered care as it may allow patients to raise their SRH needs and concerns to providers when, if, and how they prefer. Given the comprehensive and holistic nature of primary care, incorporating broader SRH discussions, counseling, and services may also increase access to and continuity of care, especially for those with the greatest barriers to health care.36Although fertility can be highly complex and expensive, incorporating fertility counseling, options, and referrals in primary care may better promote reproductive justice and autonomy.37–40 Most literature discusses contraceptive coercion, such as overpromoting and even forcibly providing sterilization and long-acting reversible contraception for adolescents, gender minorities, disabled communities, and people of color compared to white, middle- and upper-class women. However, participants in this study also highlighted providers' implicit assumptions that women will want to have children.Participants described similar experiences with implicit bias in reproductive health care, as previously identified.41–43 For example, gender role stereotypes about women as mothers may implicitly influence providers' language when discussing pregnancy. Rather than being told what to do, judged for their decisions, or having assumptions made about them, ultimately, patients want their providers to listen to them and collaborate when it comes to SRH care.44Provider bias in reproductive health may emerge due to internally held stereotypes about certain social identities and reproduction, which are also perpetuated by society, on which a provider may implicitly act.Our group designed this open-ended screening question to increase patient-centeredness and to reduce risks of implicit bias by enabling patients to identify services they want. However, it is impossible to prevent internalized biases entirely, as evidenced by some participants' experiences, and thus, training on how to manage SRH conversations holistically is needed. To enhance autonomy and provide respectful, responsive, nonjudgmental care, health centers and medical education must incorporate initiatives to prevent implicit bias and improve patient-centered care by strengthening PCPs' skills and willingness to listen to patients' concerns and expertise and provide care tailored to individuals' needs and preferences.46 Family medicine providers are often trained in SRH care, although other PCPs, like internists and physician assistants, may receive less exposure.47While studies demonstrate that patients find receiving reproductive health services acceptable in primary care, participants in our study highlighted concerns around PCPs' SRH training and expertise, which impacted their views of primary care as an appropriate setting for reproductive health care.48–50 For example, some clinicians display badges, mugs, and other items in examination rooms with prompts like “Ask me about abortion care,” “pro-choice,” or “she/her pronouns” to subtly convey to patients a safe space to talk about abortion options and needs for gender expansive populations.51As such, it is critical to enhance training for all PCPs in SRH care, and to inform patients that their PCPs are trained to increase their trust and willingness to receive such services from their PCP. Integrating a routine screening question on SRH needs, such as our proposed question, may increase awareness of the availability of these services in primary care settings, which can effectively offer SRH services. In addition, SRH-themed patient education, artwork, and promotional materials in waiting and examination rooms may facilitate a safe environment for patients to raise these concerns.29 They may be a group who are interested and knowledgeable in SRH, which may have prompted their self-selected participation in this study. We did not explore the perspectives of non-English speakers, or individuals who did not self-identify as women; additional research is needed to understand a wider range of perspectives.These findings should be interpreted within the study limitations. Our sample includes those who self-identify as women, live in New York State, and are part of an online survey panel used for research recruitment; thus, findings may differ among other distinct populations.Furthermore, as we transitioned from focus groups to in-depth interviews to address scheduling and participation challenges for two age groups, these distinct methods may have generated different data. However, we did not find differences during analysis. The strengths of this study include the ability to recruit and engage a diverse group of women of various ages, race/ethnicities, and geographic locations within New York State, the flexible nature of our qualitative study design to respond to focus group challenges, and our rigorous iterative analysis process.28 Our findings indicate face validity, in that women of reproductive age interpreted the question as it was intended. Implementing a routine, open-ended services-based screening question in primary care, such as our proposed question, may increase patients' awareness of SRH service availability, enable providers to respond to patients' SRH needs directly in primary care, and enhance patient-centered care overall. They also suggest key considerations for strengthening provider education and practice to improve patient satisfaction, awareness, and acceptability of SRH in primary care. Future research should consider testing this screening question in primary care settings to explore its effect on patient-centered SRH outcomes.This study adds to the literature evaluating a reproductive health service screening question in primary care by exploring New York women's interpretations.


This study examined the significant differences in Chinese college students’ learning perceptions and outcomes between the “quasi smart” and smart classrooms under the perspective of the community of inquiry (CoI) framework.The participants were 275 freshmen students who took the “college physics” hybrid course in the spring of 2022 at a four-year university in central China. Data were collected from the CoI survey, a follow-up focus group interview with ten randomly selected student participants, and a semi-structured interview with the instructor.The results indicated that the students’ perceptions of the teaching, social, and cognitive presences were significantly higher in the smart classroom than in the “quasi smart” classroom; further, students in the smart classroom achieved significantly higher course marks than those in the “quasi smart” classroom. The pros and cons of these two different classroom environments were identified by the participating students and their course instructor. The classroom environment plays an important role in creating the best educational experience for students . DiffereThe smart and traditional multimedia classrooms are two different learning environments . The smaThe disadvantages of the traditional multimedia classrooms were overcome to some extent in the “quasi smart” classrooms; and some key advantages of the smart classrooms were also introduced into the “quasi smart” classrooms . The “quA typical smart classroom always incorporate digital cameras, recording or casting equipments, multiple interactive whiteboards or touch screen televisions, mobile devices , the wireless Internet, and the educational management software . Such edPrevious research has indicated that smart classrooms provide opportunities for students to use digital learning resources and tools in their self-regulated learning and collaborative inquiry learning activities . ObviousIn addition, To sum up, research on the effect of classroom settings on teacher-student interaction indicated that students’ autonomy could be more strengthened in the smart classroom than the “quasi smart” classroom; further, students would be more active in face-to-face communication and more likely to collaborate with each other in the smart classroom than the “quasi smart” classroom.Research also indicated that students’ preferences for the learning environments could affect their learning outcomes  framework to structure the process of learning in an online environment was proposed by The CoI framework suggests that the profound and meaningful online learning is caused by the interaction of the teaching, social, and cognitive presences perceived by students in the online learning community . It provSince the framework was proposed, it had been largely used, discussed, and examined by researchers in the field e.g., . ArbaughSome instructors used the framework to guide course designs and make educational decisions e.g., . Fiock . These rThe CoI framework has been widely discussed in the MOOC (massive open online course) context and it was found to be a helpful instrument for designing and delivering the MOOCs e.g., . For exaThe purpose of this study was to examine the significant differences in Chinese college students’ learning perceptions and outcomes between the “quasi smart” and smart classrooms under the perspective of the CoI framework. Specifically, the following three research questions were asked: (a) are there significant differences in students’ perceptions of the teaching, cognitive, and social presences between the “quasi smart” and smart classrooms? (b) Are there significant differences in students’ learning outcomes between the “quasi smart” and smart classrooms? And (c) what are the pros and cons of these two different classroom environments?t-test was then performed to investigate the significant score difference between the two groups. In addition, interviews with the instructor and students were conducted to examine their environment preferences.The flowchart of the quasi-experimental research was shown in The participants of this study included 275 freshmen students who took the “college physics” course in the spring of 2022 at a four-year university in central China. This was a hybrid course. For the face-to-face section, students were placed in either a smart classroom or a “quasi smart” classroom. Among the 275 freshmen students, 147 students were placed in the smart classroom, and 128 students in the “quasi smart” classroom. For the online section, students in both classrooms were using Chaoxing, a popular online learning platform in Chinese higher education. It is important to mention that these two classes were taught by the same professor.The instrument for data collection was a five-point Likert survey ranging from 1 (strongly disagree) to 5 (strongly agree). It consisted of 26 items which were selected from the previous literature  to measuIn addition, a follow-up focus group interview with ten randomly selected participants and a semi-structured interview with the course professor were conducted. Questions about the pros and cons of the “quasi-smart” and smart classroom environments were asked during these interviews. The purpose of these interviews was to answer the last research question. To elicit more in-depth information from the interviewees, the interviews were conducted in Chinese. Furthermore, to ensure the reliability, integrity, and validity of the interview data, the interviews were transcribed and then translated into English by the two joint first authors.Using IBM SPSS, the survey data were analyzed at the following levels. First, the construct validity and internal consistency reliability of the five-point Likert survey were examined. The exploratory factor analysis (EFA) was performed to identify the three latent constructs as originally hypothesized in the CoI framework. After the correct number of latent constructs was identified, the internal consistency reliability of CoI survey was then calculated.t-test were conducted. The purpose of the MANOVA was to examine the significant differences in participants’ perceptions of the teaching, cognitive, and social presences between the “quasi smart” and smart classrooms. The purpose of the independent samples t-test was to investigate the significant differences in students’ learning outcomes between the “quasi smart” and smart classrooms.Further, a one factor multivariate ANOVA analysis (MANOVA) and an independent samples Finally, the interview data were coded and analyzed by the two joint first authors who have rich experience in qualitative data analysis. Specifically, responses under each interview question were color-coded and sorted into different categories by two of them independently, and then organized collaboratively based on content; and finally, conceptually similar responses were discussed, grouped together, and then categorized according to the recurring themes. To enhance its validity, direct quotes from the interviewees were also incorporated .A principal component with promax rotation EFA was conducted to examine the construct validity of the CoI survey. The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy was 0.94. Eigenvalues for three factors were >1; further, the scree plot suggested a three-factor model which explained 63.5% of the total variance see . All iteAs shown in A one-factor MANOVA was conducted to examine the significant differences in Chinese college students’ perceptions of the teaching, cognitive, and social presences within the CoI framework between the “quasi smart” and smart classrooms. The results are presented in F-value. Also the significant p-value of less than 0.01 (effect size = 0.44) indicated individual between-group differences. Follow-up univariate ANOVAs indicated that there were significant differences for all three dependent variables of the teaching , social , and cognitive presences . Specifically, the students’ perception of the teaching presence were significantly higher in the smart classroom (mean = 4.69) than in the “quasi smart” classroom(mean = 4.06) ;similarly, their perception of the social presence were significantly higher in the smart classroom (mean = 4.36) than in the “quasi smart” classroom (mean = 3.76) ; finally, their perception of the cognitive presence were also significantly higher in the smart classroom (mean = 4.48) than in the “quasi smart” classroom (mean = 3.78) .As shown in t-test was conducted. The results are presented in In order to examine significant differences in students’ learning outcomes between the “quasi smart” and smart classrooms, an independent samples p < 0.05, effect size = 0.31).As shown in The follow-up focus group interview with the ten randomly selected students and semi-structured interview with the course instructor generated the following findings see .The student participants commented on the pros and cons of these two classroom learning environments  from the following three aspects: (a) physical environment, (b) accessibility of resources and availability of supporting tools, and (c) convenience of learning see .the flexible desks and chairs in the smart classroom are convenient for group discussions and learning cooperation in smart classroom,” as mentioned by one participant. By contrast, as many of them mentioned that the tables and chairs are fixed in the “quasi smart” classroom, and it is not convenient to organize group activities in the “quasi smart” classroom.First, the ten student participants commented positively on the physical environment  in the smart classroom. Also, “the intelligent classroom with automatic screen recording can be played back for us to check the missing content at any time… the technology supports our learning before, during, and after class., “…especially there are computers and tablets for us to search information conveniently; and we could try our experiments immediately when we have new ideas in the smart classroom… however, the ‘quasi smart’ classroom does not have these features,” as argued by one participant.Second, the student participants argued that the educational technology matters. The accessibility of intelligent devices in the smart classroom could increase the chances of self-learning; and “Multi-screen display is good for showing results and receiving information in the smart classroom;” “everyone can see what is on the screen;” “it is the same wherever you sit;” “students can easily interact with each other” and “it is good for cooperative learning.” However, in the “quasi smart” classroom, the students did usually lack such convenience of learning, as agreed by all of the student participants.Finally, the student participant made the following positive comments on the convenience of learning in the smart classroom. “According to students’ perspective, the pros and cons of these two different classroom environments are summarized in Unlike the student participants, the course instructor commented the pros and cons of these two classroom learning environments from different three aspects: (a) technical support and guidance, (b) teaching methods, and (c) student engagement and interaction see .the multi-screen display in the smart classroom is conducive to me walking around the class at any time to explain, and answer questions… it shortens the distance between me and my students… it enhances the interaction between me and my students.” In the quasi smart classroom, however, “there is only one screen in the front of the classroom, so my walking space is limited. moreover, there is a space distance between the instructor[me] and students, which can naturally separate me from my students.”First, the instructor commented that “…the mode of teaching in the smart classroom is basically the same as in quasi smart classroom, with no significant change.” He continued to explain that “… many students enrolled in this course …classroom interaction can adopt the way of asking questions and casting screens through the learning APP or the classroom response system and all students can participate in.”Second, the instructor commented that “they [students] can search information at any time, explore knowledge independently, and communicate with classmates freely in the smart classroom in contrast to the “quasi smart” classroom.”Finally, the instructor mentioned that students in the smart classroom are more learning autonomous and feeling more comfortable than in the “quasi smart” classroom. He further commented that “According to instructor’s perspective, the pros and cons of these two different classroom environments are summarized in This study examined the significant differences in Chinese college students’ learning perceptions and outcomes between the “quasi smart” and smart classrooms under the perspective of the CoI framework. The findings of this study were significant. Specifically, the students’ perception of the teaching presence were significantly higher in the smart classroom than in the “quasi smart” classroom; similarly, their perception of the social presence were significantly higher in the smart classroom than in the “quasi smart” classroom; further, their perception of the cognitive presence were also significantly higher in the smart classroom than in the “quasi smart” classroom; finally, students in the smart classroom achieved significantly higher course marks than those in the “quasi smart” classroom.The results confirmed the difference of the teaching, social, and cognitive presences existed significantly between the smart and quasi smart classrooms. Previous research found that the profound and meaningful online learning was caused by the interaction of such three elements as the teaching, social, and cognitive presences perceived by students in the learning community . Smart tPrevious study showed that the effective interaction such as the interpersonal interaction between the instructor and students, peer to peer interaction, human–tech interaction supporting instructor’s presentation and management were enhanced in the smart classroom, and the classroom atmosphere was also more harmonious . IntelliFurthermore, instructors in the smart classroom could more accurately and quickly analyze students’ learning status through the smart terminals and learning analytics technology , accordiIn addition, students liked the smart classroom better than the quasi smart classroom because the atmosphere in the smart classroom was more harmonious, which could explain why the social presence in the smart classroom was better than in the quasi smart classroom. The social presence was beneficial for the cognitive presence through motivating the learners, increasing the active community atmosphere, promoting learners’ engagement, and facilitating interaction e.g., . In addiFinally, previous studies have shown that the classroom interaction could affect the classroom atmosphere, students’ behavior, and the level of engagement , which cFurthermore, no steps between lecture desk and students desks. The instructor also stated that no step between the lecture desk and students’ desks is convenient for him to walk around in the classroom; it also bring him much closer to his students for emotional support; it guarantees much more interaction between him and his students; and makes the learning atmosphere in the smart classroom much more harmonious and joyful.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Research Ethic Review Committee of the Evidence-based Research Center for Educational Assessment at Jiangsu University. The patients/participants provided their written informed consent to participate in this study.All authors listed have made a substantial, direct, and intellectual contribution to the work, and approved it for publication.


Error in medicine and medical liability has a long history dating back to Antiquity. During the 19th Century, most lawsuits related to errors in treating surgical problems were settled. However, in the first half of the 20th Century, lawsuits claimed that mistakes were related to the doctor's action: the doctor made something wrong (errors of commission). In Brazil, medical error is defined as inappropriate conduct, including negligence and recklessness, that causes harm to the patient. The physician's fear of being suited is the reason for some practice named defensive Medicine (D.M.), defined as ordering unnecessary tests and procedures or avoiding treatments for patients considered at high-risk. Thus, this narrative review aims to analyze and describe the relationship between medical errors, medical negligence, and the practice of D.M. So, the authors propose procedures and attitudes to avoid medical errors and the approach of D.M.: a national focus to create leadership and research tools to enhance the knowledge base about patient safety; a reporting system that would help to identify and learn from errors; the use of a computer-based protocol reminder; some technological devices to help the medical practice (electronic prescribing and information technology systems); creating risk management programs in hospitals. Therefore, the authors conclude that the most critical attitude to avoid medical liability is a good and ethical medical practice with the proper use of technology, based on knowledge of scientific evidence and ethical principles of medicine - for the benefit of patients. Error in medicine and questions about medical liability has a long history dating back to Antiquity. In Mesopotamia, there was already the Code of Hammurabi (1792‒1750 BC). This code dealt with the mistakes made by doctors in the exercise of their profession. One of the first reports of errors in medicine was made by British legal scholar Sir William Blackstone. In 1765, he published a compendium of legal principles entitled Commentaries on the Laws of England. He refers to “Mala Praxis”, which he defines as “neglect or unskillful management of a physician or surgeon”. The modern word “malpractice” is derivedth Century through lawyers who acted aggressively, with most lawsuits related to errors in treating fractures, dislocations, and amputations.The problem evolved during the 19th Century. Most of them claimed that mistakes were related to the doctor's action: the doctor made something wrong, so-called errors of commission, “such as causing injuries due to too much radiation (during radiographs examination), complications of surgical treatment, and diagnostic failures”.,Lawsuits for alleged medical errors continued during the first half of the 20At this point, someone can argue: what really is a medical error?Some authors define a medical error as “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim”.In summary, allegations of negligence against physicians suffered a transformation over the last decades: in the beginning, patients sued them for doing something wrong; now, the doctors began being sued for failing to do something right.,,As a result, contingency plans “often arise within a clinician when faced with thoughts of shame, or embarrassment”Thus, this narrative review aims to analyze and describe the relationship between medical errors, medical negligence, and defensive medicine and propose some procedures and attitudes to avoid the mistakes and the practice of defensive medicine.An extensive search query was utilized, analyzing results from journal articles regarding medical error, medical negligence, and defensive medicine. A MEDLINE, PubMed, and Cochrane Library literature search were conducted with search terms “defensive medicine” AND “medical malpractice” OR “medical errors”. All articles were analyzed for this narrative review, but the authors chose 34 of them that we believed were essential to explaining the authors’ point of view.Physicians are accustomed to operating within multi-level guidelines, but errors can arise in planning actions or executing them. According to Oyebode,It is important to note that “there are two models of human error causation, namely the person approach and the systems approach”.,Oyebodest Century. First, they began to use a type of conduct called “Defensive Medicine” (D.M.). As stated by Hellinger and Encinosa,In this scenario, some pathways are intended to prevent error by negligence, primarily by surgeons, in the 21The American Medical Association (AMA) has defined defensive medicine as the “performance of diagnostic tests and treatments which, but for the treat of a malpractice action would not have been done”.,In the last decades, the culture of practice of D.M. spread worldwide due to an increasing number of lawsuits against physicians in all medical specialties. As a result, the physicians used D.M. “to lessen their exposure to medical malpractice litigation” or “by fear of malpractice litigation”.,The specialties most affected by claims are in the U.S and Brazil. were Plastic Surgery, General Surgery, Gynecology, and Dermatology.Otherwise, Frati P et al.As far as the authors know, D.M. has two primary forms. An active form, also called “positive”, is when the physician orders extra tests and procedures. The other is “passive or negative” when avoiding high-risk patients and methods. Someone can also categorize defensive practices into two distinct patterns: “assurance practices that unnecessary over-investigate lower-risk patients, and avoidance practices that aim to avoid intervention in the care of higher-risk patients”.In this perspective, exposure to lawsuits has made physicians more careful in their actions and procedures to prevent medical claims, “rather than to promote the patient's best interest”, disregarding medical ethics.Another problem is that D.M. is not innocuous or harmless. As physicians involved in any surgery may be sued when executing surgical treatment or preoperative activities, the result is the request for unnecessary tests before the procedures with consequent enhancement of the entire process.In a universal public health system, as in England or Brazil, this means considerable resources, burdening the whole system and harming many other patients who may be left without care. Furthermore, Garattini, Padula & MannucciThe essential principle of ethical behavior in medical practice is to act to the patient's benefit. But it also includes the use of all communities, that is, public health ethics focusing on collective aspects, such as sharing risks and benefits.KappThe legal culture in each country towards medical errors and medical responsibility affects how and how D.M. is practiced. In Brazil, for example, it must be clear that medical responsibility is subjective; the doctor should care for the patient but not cure. Moreover, the cure depends on several other individual and collective factors, not just on the doctor's performance. Therefore, it is necessary to characterize the existence of fault on the part of the professional to confirm the presence of an error in medical practice. And guilt, in turn, is manifested by inappropriate medical conduct based on negligence, recklessness, or malpractice. The proof of error is made through the expert examination requested by the judge, who will decide based on this expert analysis.But, as far as the authors know, in the U.S. and other countries, the medical responsibility is objective; there is a compromise with cure and with a good result – independently of any factor strange to the doctor-patient relationship. Moreover, their legal system “is based on the premise of trial advocacy, which relies on the adversarial arrangement of opposing parties, a judge, and potentially a jury. The jury serves as the decider of fact, whereas the judges decide all questions of law”.In Brazilian Criminal Law, the doctor can also be called upon in articles 129 (bodily injury) and 121 (to kill someone if the patient dies) of the Penal Code. Whether the doctor has a “non-observance of the professional technical rule” in both cases will be observed. If so, the penalty will be increased. It is essential to point out that “non-observance of professional technical rule” means that the doctor did not follow the protocols and guidelines recommended for each case. Of course, the procedures and protocols are built on the best available scientific evidence.Defensive medicine is a medical, legal, and moral problem.However, somebody should view bioethical principles in a relational way.It is important to note that D.M. in positive  or negative (when high-risk patients and methods are avoided) form is firmly questioned morally and ethically. Frierson and Joshi,,The authors pointed out above that physicians in the U.S. and other countries, in the past decades, “have long believed that they must practice defensive medicine to diminish litigation risk”.Besides, the practice of D.M. does not have the strength to prevent a lawsuit. For example, since defensive medicine became part of medical malpractice 45-years ago, medical errors have increased1; D.M. is not a solution for posterior medical litigation. As stated by Williams et al.,Committing an error has devastating consequences for the physician, personally and professionally. To be suspended from practice, convicted, or increased surveillance about his professional performance are some of the worst effects. Colleagues may regard him as incompetent or careless. Hospitals may suspend him to practice. Thus, the fear of being perceived “as a lesser-quality physician” supports the survival of D.M.First of all, to answer this question, the authors have to pay attention to other correlated questions, such as individual motivation to perform at the best level of his capacity, professional culture, and social constraints within the workplace. The staff and gestures are really committed to making changes that could prevent errors? If so, are they interested in proscribing procedures of D.M. in their environment? Are they committed to improving health care quality?OyebodeSince McDonaldIt is essential to note that many studies of malpractice deterrence suggest that a “higher risk of malpractice liability is not significantly associated with improved health care quality”.,In turn, the authors think that some actions must be taken. As the authors pointed out above, we must act to improve technologies to avoid risks to the patients or build strategies to improve the doctor-patient relationship. It is important to note that “some errors involve momentary or inadvertent lapses at the individual clinician level”.The authors must invest in creating risk management programs in the study's hospitals. As Kohn et al.On the other hand, two problems can be avoided in preventing to use of D.M. First: as Mello et al.Kohn et al.Kohn et al.In the case of adverse events or errors, Morris et al.Another necessary action regarding avoiding medical liability is the performance of an autopsy in the cases of the suspect of medical error. In Brazil, that procedure is made by the Medico-Legal Institute (IML), and they are called “suspicious death”. Kohn et al.Finally, from the authors’ point of view, the most important solution to prevent medical litigation and the use of D.M. is a good and ethical medical practice with the proper use of technology. A medical practice based on knowledge of scientific evidence and ethical principles of medicine ‒ for the benefit of patients. Nonetheless, “the factors that predict that a patient will resort to litigation include a prior poor relationship with the clinician and the feeling that the patient is not being kept informed”.Medical errors have several causes, mainly disregarding guidelines and protocols of safety, failures in the dissemination of drug knowledge and inadequate availability of patient information, unavailability of equipment, production pressure and hectic schedules, and physician fatigue. These errors are capable of leading a medical liability. On the other hand, the fear of penalties induces the use of procedures of defensive medicine, which are, by nature, unethical and increase the costs of medical practice. Besides, its use does not prevent future litigation.Therefore, the authors conclude that the essential attitude to avoid medical liability is a good and ethical medical practice with the proper use of technology, based on knowledge of scientific evidence and ethical principles of medicine ‒ for the benefit of patients.Ivan Dieb Miziara and Carmen Silvia Molleis Galego Miziara: These authors contributed equally to this work.The authors declare no conflicts of interest.


The intersection between bipolar disorders and creativity has been investigated in western literature. Although psychopathology has been proposed for famous artists in painting, writing, music and other forms of art, there is no systematic study examining bipolar disorders and music production in composers.The aim of this review is to investigate this relationship by providing an overview of published studies.The search included papers published in English as abstracts as well as in full length until October 2020. The literature search was conducted using the MEDLINE, EMBASE, PUBMED and GOOGLE SCHOLAR databases. For all the searches, the terms/key words that were used were “bipolar disorder”, “music”, “creativity”, and “composers”.Search results for composers from different music genres and musical periods indicated that the proposed origin of the overall bipolar pattern is attributed to several stressful environmental factors which are taking the form of interpersonal problems regarding the expressed emotion, life events, and paucity of stress-management skills. In addition to that, bipolar psychopathological patterns seem to influence the quantity of music composing activity indirectly due to changes in everyday functional abilities.Published reports, although based on biographical research, do provide evidence in support of a strong bipolarity-music creativity/production link for famous composers. Further well-designed studies in living music professionals engaged in music composition are needed.