As COVID-19 has plagued our world, the term “social distancing” has been widely used with the aim to encourage the general population to physically distance themselves from others in order to reduce the spread of the virus. However, this term can have unintended but detrimental effects, as it evokes negative feelings of being ignored, unwelcome, left alone with one's own fears, and even excluded from society. These feelings may be stronger in people with mental illnesses and in socio-economically disadvantaged groups, such as stigmatized minorities, migrants, and homeless persons [1], many of them also having high risk for suicidal behaviors [2]. Mental health disorders are pervasive worldwide; the global burden accounting for approximately 21.2–32.4% of years lived with disability—more than any other group of illnesses [3]. So, the vulnerable group of people with mental health disorders represents a considerable share of the total global population. As COVID-19 has plagued our world, the term “social distancing” has been widely used with the aim to encourage the general population to physically distance themselves from others in order to reduce the spread of the virus. However, this term can have unintended but detrimental effects, as it evokes negative feelings of being ignored, unwelcome, left alone with one's own fears, and even excluded from society. These feelings may be stronger in people with mental illnesses and in socio-economically disadvantaged groups, such as stigmatized minorities, migrants, and homeless persons Suicidal ideation is common among a broad group of patients with mental problems, including affective, psychotic and anxiety disorders. People with suicidal ideation have a pessimistic and dark outlook on life, and may be very sensitive to any signs of rejection. The suicidal process may be accelerated due to an interplay between the receivers’ desperate and chaotic feelings and the communication that “social distancing is necessary” circulating throughout every level of society. The inner psychological entrapment of persons close to suicide In times of crisis, there are centrifugal movements among the general public. On one side, we see solidarity and more care for each other; on the other side, sadly prejudice reigns. The term social distancing may enhance latent racism or xenophobia, especially against migrant groups and refugees The notion of “social distancing” affords neither comfort nor help to vulnerable people. They are often reliant on social connection and relations, so a sudden break in those, perceived or real, has devastating consequences. Therefore, we advocate to use the term “physical distancing”—as a physical distance of 2 m will prevent and diminish the spread of COVID-19—rather than the term “social distancing” While the large majority of the general population are unlikely to react negatively to the term of social distancing, it is important that the majority is informed and aware of how vulnerable groups in society perceive and react to this term. The literacy of the general population about mental health is unfortunately still very low, as well as the knowledge about how it is possible for lay people to support persons with mental health problems As psychiatrists, along with other mental health professionals, we must embrace, alongside our daily tasks of early detection, treatment, and rehabilitation of persons with mental disorders, the job of increasing public mental health awareness and collaborating with public health institutions by giving information, advice, and guidelines Now, as the world begins to reduce the restrictions in place and return to some sense of normality during the ongoing COVID-19 pandemic, daily social interactions will increase. However, also during this time, everyone should be careful about maintaining a physical distance to avoid a second wave of COVID-19 infections—yet at the same time remain social, supportive, and empathetic toward one another. Let us be inclusive, in both our words and our actions, so that no one feels excluded or isolated from their wider community.After one of the authors who is also the Chair of the EPA Ethics Committee (D.W.) alerted the WHO Mental Health and Substance Abuse division that the term “social distancing” was adversely influencing vulnerable groups, the WHO’s COVID-19 response team on March 23 addressedthe media stating that the term “physical distancing” will replace “social distancing” for the sake of mentally ill persons.Policy makers, media, governments, and the general public should be encouraged to use the more neutral term of “physical distancing” rather than “social distancing” during the COVID-19 pandemic on the basis of the negative connotations of this term.


However, there is a strict link between distributed/distributional representations and discrete symbols, being the first an approximation of the second. A clearer understanding of the strict link between distributed/distributional representations and symbols may certainly lead to radically new deep learning networks. In this paper we make a survey that aims to renew the link between symbolic representations and distributed/distributional representations. This is the right time to revitalize the area of interpreting how discrete symbols are represented inside neural networks.Natural language is inherently a discrete symbolic representation of human knowledge. Recent advances in machine learning (ML) and in natural language processing (NLP) seem to contradict the above intuition: discrete symbols are fading away, erased by vectors or tensors called  Natural language is inherently a discrete symbolic representation of human knowledge. Sounds are transformed in letters or ideograms and these discrete symbols are composed to obtain words. Words then form sentences and sentences form texts, discourses, dialogs, which ultimately convey knowledge, emotions, and so on. This composition of symbols in words and of words in sentences follow rules that both the hearer and the speaker know Chomsky, . Hence, distributed and distributional representations. In ML applied to NLP, distributed representations are pushing deep learning models  applied to natural language processing (NLP) seem to contradict the above intuition: discrete symbols are fading away, erased by vectors or tensors called The success of distributed and distributional representations over symbolic approaches is mainly due to the advent of new parallel paradigms that pushed neural networks  number of words in common; (2) realization of the pattern “ANIMAL EATS FOOD.” The key point is to decide or to let an algorithm decide which is the best representation for a specific task.Distributed representations are then replacing long-lasting, successful discrete symbolic representations in representing knowledge for learning machines but these representations are less human interpretable. Hence, discussing about basic, obvious properties of discrete symbolic representations is not useless as these properties may guarantee success to distributed representations similar to the one of discrete symbolic representations.interpretable as symbols are not altered in expressions. This is one of the most important, obvious feature of these representations. Infinite sets of expressions, which are sequences of symbols, can be interpreted as these expressions are obtained by concatenating a finite set of basic symbols according to some concatenative rules. During concatenation, symbols are not altered and, then, can be recognized. By using the principle of semantic compositionality, the meaning of expressions can be obtained by combining the meaning of the parts and, hence, recursively, by combining the meaning of the finite set of basic symbols. For example, given the set of basic symbols mouse, cat, a, swallows, }, expressions like:Discrete symbolic representations are human are totally plausible and interpretable given rules for producing natural language utterances or for producing tree structured representations in parenthetical form, respectively. This strongly depends on the fact that individual symbols can be recognized.alter symbols when applied to symbolic inputs and, thus, are less interpretable. In fact, symbols as well as expressions are represented as vectors in these metric spaces. Observing distributed representations, symbols and expressions do not immediately emerge. Moreover, these distributed representations may be transformed by using matrix multiplication or by using non-linear functions. Hence, it is generally unclear: (1) what is the relation between the initial symbols or expressions and their distributed representations and (2) how these expressions are manipulated during matrix multiplication or when applying non-linear functions. In other words, it is unclear whether symbols can be recognized in distributed representations.Distributed representations instead seem to altering symbols. The debate dates back in the late 80s. For Fodor and Pylyshyn . By using the operator for concatenation, the two above examples s1 and t1 can be represented as the following:that represents a sequence with the infix notation andthat represents a tree with the prefix notation.Functional compositionality explains compositionality in distributed representations and in semantics. In functional compositionality, the mode of combination is a function Φ that gives a reliable, general process for producing expressions given its constituents. Within this perspective, semantic compositionality is a special case of functional compositionality where the target of the composition is a way for meaning representation  can be useful to describe functional compositionality. The set mouse, cat, a, swallows, eats, some, cheese, } may be represented with the base vectors e1 is the base vector for mouse, e2 for cat, e3 for a, e4 for swallaws, e5 for eats, e6 for some, e7 for cheese, e8 for . The additive functional composition of the expression s1 = a cat swallows a mouse is then:the derived vector is the classical bag-of-word vector space model Salton, . Whereass Plate,  to matris Plate,  or in nes Plate, . ExampleΣ(s1)func, symbols are still visible but the sequence is lost. In fact, it is difficult to reproduce the initial discrete symbolic expression. However, for example, the additive composition function gives the possibility to compare two expressions. Given the expression s1 and s2 = a mouse eats some cheese, the dot product between Σ(s1)func and s1 may become Φ(s1)func = Φ, 4e), 3e), 1e) by following the concatenative compositionality of the discrete symbolic expression. The same functional compositional principle can be applied to discrete symbolic trees as t1 by producing this distributed representation Φ, Φ)). Finally, in the functional composition with a generic recursive function Φ(s1)func, the function Φ will be crucial to determine whether symbols can be recognized and sequence is preserved.where the concatenative operator ∘ has been substituted with the sum +. Just to observe, in the additive functional composition Distributed representations in their general form are more ambitious than distributed local representations and tend to encode basic symbols of d where d < < n. These vectors generally alter symbols as there is not a direct link between symbols and dimensions of the space. Given a distributed local representation ew of a symbol w, the encoder for a distributed representation is a matrix d×nW that transforms ew in yw = d×neWw. As an example, the encoding matrix d×nW can be build by modeling words in 3 ×9W for the example is :distributed representation. In a distributed representation  for additive functional compositionality becomes:Even for distributed representations in the general form, it is possible to define s1 in Example 1 is:In the running example, the additive functional compositionality of sentence s1 that has generated the final distributed representation.Clearly, in this case, it is extremely difficult to derive back the discrete symbolic sequence interpretability of distributed representations can be framed as the following question:Hence, how much the underlying functional composition of distributed representations isconcatenative?interpretable as their composition is concatenative. Then, in order to be interpretable, distributed representations, and the related functional composition, should have some concatenative properties.In fact, discrete symbolic representations are ys of discrete symbolic expressions s are obtained by using an encoder d×nW and a composition function, assessing interpretability becomes:Then, since a distributed representation Symbol-level Interpretability - The question “Can discrete symbols be recognized?” becomes “to which degree the embedding matrix W is invertible?”Sequence-level Interpretability - The question “Can symbols and their relations be recognized in sequences of symbols?” becomes “how much functional composition models are concatenative?”Symbol-level Interpretability and Sequence-level Interpretability will be used to describe the presented distributed representations. In fact, we are interested in understanding whether distributed representations can be used to encode discrete symbolic structures and whether it is possible to decode the underlying discrete symbolic structure given a distributed representation. For example, it is clear that a local distributed representation is more interpretable at symbol level than the distributed representation presented in Equation (4). Yet, both representations lack in concatenative compositionality when sequences are collapsed in vectors. In fact, the sum as composition function builds bag-of-word local and distributed representation, which neglect the order of symbols in sequences. In the rest of the paper, we analyze whether other representations, such as holographic reduced representations )?Can we decode an encoded symbolic representation? In other words, assuming a decoding function δ : ℝSequence-level interpretability of the resulting representations will be analyzed in section 5.Random projection (RP)  are interpretable at symbol level as these functions can be inverted. The inverted function, that is, the decoding function, is:These vectors η encoding/decoding functions may not be linear; (2) learning can optimize functions that are different with respect to the target of Principal Component Analysis (see section 4.2); and, (3) solutions are not derived in a closed form but are obtained using optimization techniques such as Learned representation can be further classified into:Task-independent representations learned with a standalone algorithm , usually the first layer of a deep neural network. In this case the new representation is driven by the task.n → ℝd by using local representations of a set of examples  that are in ℝd. Given η : ℝn → ℝd and δ : ℝd → ℝn as the encoder and the decoder, respectively, an autoencoder aims to maximize the following function:An autoencoder is a neural network that aims to reproduce an input vector in ℝwhereThe encoding and decoding module are two neural networks, which means that they are functions depending on a set of parameters θ of the formW, b, W′, b′} with W, W′ matrices, b, b′ vectors and s is a function that can be either a non-linearity sigmoid shaped function, or in some cases the identity function. In some variants the matrices W and W′ are constrained to WT = W′. This model is different with respect to PCA due to the target loss function and the use of non-linear functions.where the parameters of the entire model are θ, θ′ = {denoising autoencoders  input:and then one minimizes again the reconstruction error, but with regard to the g can be either:Usually g(x) = x + ε, where Adding Gaussian noise: Masking noise: where a given a fraction ν of the components of the input gets set to 0.symbol-level interpretability, as for random projection, distributed representations η(v) obtained with encoders from autoencoders and denoising autoencoders are invertible, that is decodable, as this is the nature of autoencoders.For what concerns Embedding layers are generally the first layers of more complex neural networks which are responsible to transform an initial local representation in the first internal distributed representation. The main difference with autoencoders is that these layers are shaped by the entire overall learning process. The learning process is generally task dependent. Hence, these first embedding layers depend on the final task.It is argued that each layers learn a higher-level representation of its input. This is particularly visible with convolutional network  and the similarity between cat and dog is higher than the similarity between cat and mouse as the cosine similarity cos is higher than the cosine similarity cos.Hence, the word The research on distributional semantics focuses on two aspects: (1) the best features to represent contexts; (2) the best correlation measure among target words and features.How to represent contexts is a crucial problem in distributional semantics. This problem is strictly correlated to the classical question of feature definition and feature selection in machine learning. A wide variety of features have been tried. Contexts have been represented as set of relevant words, sets of relevant syntactic triples involving target words  . These, among other measures, are used to better capture the importance of contextual features for representing distributional semantic of words.Finding the best correlation measure among target words and their contextual features is the other issue. Many correlation measures have been tried. The classical measures are  Salton,  and poinhuman-interpretable. In fact, features represent contextual information which is a proxy for semantic attributes of target words  is largely applied in compacting distributional representations: Latent Semantic Analysis (LSA) is a prominent example  Pearson,  is a linX ∈ ℝm×n where each row As a probabilistic method, PCA finds an orthogonal projection matrix 1w, which maps an element of the dataset x into a single number 〈x, 1w〉. Maximizing the variance means that w is such that:More specifically, let's consider the first weight vector w is the eigenvector of XTX with largest eigenvalue. This then produces a projected dataset:and it can be shown that the optimal value is achieved when X:The algorithm can then compute iteratively the second and further components by first subtracting the components already computed from XTX, that is, the d-th weight vector is the eigenvector of XTX with the d-th largest corresponding eigenvalue.and then proceed as before. However, it turns out that all subsequent components are related to the eigenvectors of the matrix The encoding matrix for distributed representations derived with a PCA method is the matrix:wi are eigenvectors with eigenvalues decreasing with i. Hence, local representations v ∈ ℝn are represented in distributed representations in ℝd as:where v) are human-interpretable as their dimensions represent linear combinations of dimensions in the original local representation and these dimensions are ordered according to their importance in the dataset, that is, their variance. Moreover, each dimension is a linear combination of the original symbols. Then, the matrix Wd reports on which combination of the original symbols is more important to distinguish data points in the set.Hence, vectors η(v) are decodable. The decoding function is:Moreover, vectors η. Both methods are neural networks, the former takes input a word and try to predict its context, while the latter does the reverse process, predicting a word from the words surrounding it. With this technique there is no explicitly computed co-occurrence matrix, and neither there is an explicit association feature between pairs of words, instead, the regularities and distribution of the words are learned implicitly by the network.The name word2Vec comprises two similar techniques, called W1n×k and W2k×n plus a softmax layer to reconstruct the final vector representing the word. In the learning phase, the input and the output of the network are local representation for words. In CBOW, the network aims to predict a target word given context words. For example, given the sentence s1 of the corpus in catches given its context , these networks are not trained to be invertible.Clearly, CBOW distributional vectors are not easily human and machine interpretable. In this section, we want to investigate a second and important aspect of these representations, that is, have these representations Concatenative Compositionality as symbolic representations? And, if these representations are composed, are still interpretable?In the previous sections, we described how one symbol or a bag-of-symbols can be transformed in distributed representations focusing on whether these distributed representations are Concatenative Compositionality is the ability of a symbolic representation to describe sequences or structures by composing symbols with specific rules. In this process, symbols remain distinct and composing rules are clear. Hence, final sequences and structures can be used for subsequent steps as knowledge repositories.Concatenative Compositionality is an important aspect for any representation and, then, for a distributed representation. Understanding to what extent a distributed representation has concatenative compositionality and how information can be recovered is then a critical issue. In fact, this issue has been strongly posed by Plate   where Ci is the i-th subtree of the node rT and R is the relation that links the node rT with Ci. The dependency trees of two example sentences are reported in Before investigating if these models are interpretable, let introduce a recursive formulation of additive models which can be applied to structural representations of sentences. For this purpose, we use dependency trees. A dependency tree can be defined as a tree whose nodes are words and the typed links are the relations between two words. The root of the tree represents the word that governs the meaning of the sentence. A dependency tree fr(T) results in a linear combination of elements Msws where Ms is a product of matrices that represents the structure and ws is the distributional meaning of one word in this structure, that is:According to the recursive definition of the additive model, the function S(T) are the relevant substructures of T. In this case, S(T) contains the link chains. For example, the first sentence in where Each term of the sum has a part that represents the structure and a part that represents the meaning, for example:model-that-composes which, in principle, can be highly interpretable. By selecting matrices Ms such that:Hence, this recursive additive model for compositional semantics is a it is possible to recover distributional semantic vectors related to words that are in specific parts of the structure. For example, the main verb of the sample sentence in In general, matrices derived for compositional distributional semantic models Guevara,  do not hinterpreted.Lexical Functional Models are compositional distributional semantic models where words are tensors and each type of word is represented by tensors of different order. Composing meaning is then composing these tensors to obtain vectors. These models have solid mathematical background linking Lambek pregroup theory, formal semantics and distributional semantics  and one word that is represented by a vector. For example, BLACK and WHITE are matrices representing the two adjectives and cat and dog are the two vectors representing the two nouns.where partially interpretable: knowing the adjective it is possible to extract the noun but not vice-versa. In fact, if matrices for adjectives are invertible, there is the possibility of extracting which nouns has been related to particular adjectives. For example, if BLACK is invertible, the inverse matrix BLACK−1 can be used to extract the vector of cat from the vector f(black cat):These two words models are interpretability of this model. Moreover, if matrices for adjectives are built using Jonson-Lindestrauss Transforms . In this case, each atomic element has an associated vector and the vector for the compound is obtained by combining these vectors. The major concern here is to build encoding functions that can be decoded, that is, it should be possible to retrieve composing elements from final distributed vectors such as the vector of eat.Holographic reduced representations (HRRs) are e Plate, . In factnearly orthogonal unit vectors  to structures. Hence, symbols are represented with vectors sampled from a multivariate normal distribution In HRRs, d. Circular convolution is commutative and bilinear. This operation can be also computed using circulant matrices:where subscripts are modulo A∘ and B∘ are circulant matrices of the vectors a and b. Given the properties of vectors a and b, matrices A∘ and B∘ have the property in Equation (8). Hence, circular convolution is approximately invertible with the circular correlation function (⊕) defined as follows:where d. Circular correlation is related to inverse matrices of circulant matrices, that is where again subscripts are modulo e, J, and a for eat, John and apple, respectively, the following encoding and decoding produces a vector that approximates the original vector for John:Hence, circular convolution ⊗ and circular correlation ⊕ allow to build interpretable representations. For example, having the vectors The “invertibility” of these representations is important because it allow us not to consider these representations as black boxes.However, holographic representations have severe limitations as these can encode and decode simple, flat structures. In fact, these representations are based on the circular convolution, which is a commutative function; this implies that the representation cannot keep track of composition of objects where the order matters and this phenomenon is particularly important when encoding nested structures.shuffled circular convolution function as the composition operator. Distributed trees are encoding functions that transform trees into low-dimensional vectors that also contain the encoding of every substructures of the tree. Thus, these distributed trees are particularly attractive as they can be used to represent structures in linear learning machines which are computationally efficient.Distributed trees . The output are distributed vectors derived for specific tasks. Hence, these models-that-compose are not interpretable in our sense for their final aim and for the fact that non linear functions are adopted in the specification of the neural networks.When neural networks are applied to sequences or structured data, these networks are in fact models-that-compose: the recurrent neural networks  of complex objects. At its core a recurrent neural network (RNN) is a network which takes in input the current element in the sequence and processes it based on an internal state which depends on previous inputs. At the moment the most powerful network architectures are convolutional neural networks  and produce as output a single vector y ∈ ℝn which is a representation of the entire sequence. At each step t the network takes as input the current element tx, the previous output t−1h and performs the following operation to produce the current output thA recurrent neural network takes as input a sequence t−1 xth] denotes the concatenation of the vectors t−1h and tx. The parameters of the model are the matrix W and the bias vector b.where σ is a non-linear function such as the logistic function or the hyperbolic tangent and [Hence, a recurrent neural network is effectively a learned composition function, which dynamically depends on its current input, all of its previous inputs and also on the dataset on which is trained. However, this learned composition function is basically impossible to analyze or interpret in any way. Sometime an “intuitive” explanation is given about what the learned weights represent: with some weights representing information that must be remembered or forgotten.x = (1x … nx) and produce as output a single vector y ∈ ℝn which is a representation of the entire sequence. At each step t the network takes as input the current element tx, the previous output t−1h and performs the following operation to produce the current output th and update the internal state tc.Even more complex recurrent neural networks as long-short term memory (LSTM) ;it is the input gate: it decides which position in the internal state will be updated, and by how much;ot is the output gate: it decides how to modulate the internal state to produce the outputmodels-that-compose have high performance on final tasks but are definitely not interpretable.These models-that-compose that we present is the class of recursive neural networks  and fUV is obtained. Then, the network is applied to the result and eat and fUV) is obtained and so on.This method deals naturally with recursion: given a binary parse tree of a sentence compositional distributional semantic models as those presented in section 5.1.1. In fact, the non-linear function g is the one that makes final vectors less interpretable.Recursive neural networks are not easily interpretable even if quite similar to the additive Attention neural networks (Vaswani et al., only an implementation of discrete symbolic representations. The question behind this debate is in fact crucial to understand if neural networks may exploit something more that systems strictly based on discrete symbolic representations. The question is again becoming extremely relevant since natural language is by construction a discrete symbolic representations and, nowadays, deep neural networks are solving many tasks.In the ‘90, the hot debate on neural networks was whether or not distribute representations are We made this survey to revitalize the debate. In fact, this is the right time to focus on this fundamental question. As we show, distributed representations have a the not-surprising link with discrete symbolic representations. In our opinion, by shading a light on this debate, this survey will help to devise new deep neural networks that can exploit existing and novel symbolic models of classical natural language processing tasks. We believe that a clearer understanding of the strict link between distributed/distributional representations and symbols may lead to radically new deep learning networks.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The primary aim was to describe the similarities and differences among the general health, physical health, psychological health, social trust, and financial situations of people with Usher syndrome (USH) types 1, 2, and 3. A second aim was to explore whether age, gender, clinical diagnosis, visual field, visual acuity, and degree of hearing impairment were associated with the general health, physical health, psychological health, social trust, and financial situations of people with USH.2-tests and Kruskal-Wallis tests for group comparison were used. To examine the effect of independent variables on poor health outcomes, a logistic regression analysis was conducted.In this study, 162 people with USH living in Sweden were included, and all three types of the disease were represented. Data concerning vision, hearing, and genetics were retrieved from the Swedish Usher database. Group comparison using frequencies, χProblems with poor health, social trust, and finances were found for all three types; however, more similarities than differences were found. The results of the regression model were ambiguous; it is not clear which independent measures contributed the most to poor outcomes. People with USH3 tended to report the most problems regarding the dependent outcome measures.The observations of the associations between the independent variables and poor health, social trust and finances made in the present study are important to bear in mind in a rehabilitation setting; however, they do not fully explain how people with USH actually feel or rate their health. More research is needed to confirm the knowledge that exists within the clinical setting and the life stories told by the people with USH to merge existing knowledge into a rehabilitation setting based on evidence. Thus, deafblindness is a distinct disability. To varying degrees, deafblindness limits activities and restricts full participation in society”   and the All 171 included persons had a clinical diagnosis of USH based on their HI, vision impairment, balance, family histories, and other clinical observations; 90 of these participants had a genetic diagnosis. Data concerning HI, visual impairment  and genetics are retrieved from the Swedish Usher Register and collected at approximately the same time as the questionnaires. The two questionnaires were sent to 87 persons with USH1, 122 persons with USH2, and 21 persons with USH3. The questionnaires were returned by 60 persons with USH1, 96 persons with USH2, and 15 persons with USH3. However, of these, two persons with USH1, and seven persons with USH2 were excluded because they failed to complete the HAD-scale, see Analyses were conducted with regard to how different health outcomes varied as a function of numerous factors such as USH category, gender, age, degree of HI, visual field, and visual acuity.The three sub-categories of USH are described above. Overall, 58 persons with USH1, 89 persons with USH2, and 15 persons with USH3 were included in the study see . The thrIn total, 91 women and 71 men were included in the study. The gender distribution for each group was 24 men and 34 women (USH1), 43 men and 46 women (USH2), and 11 women and 4 men (USH3). The mean overall age was 51 years old, and the age range was 18–84 years old see .Hearing impairment was assessed. The average pure tone for 0.5, 1, 2, and 4 kHz (PTA4) was used. Thresholds were classified according to the European standard from mild hearing loss to profound hearing loss  . The degVisual acuity was measured using Snellen chart-based standard test . The besThe visual field test (Goldman perimetry) was measured and categorized into five phenotypes (1–5), where 1 denoted normal vision, 2 denoted visual field of partial or complete ring scotoma, 3 denoted a concentric central field loss with remaining peripheral island, 4 denoted a concentric loss and a visual field of ≤10°, and 5 denoted blindness . The valThe Swedish Public Health Agency’s questionnaire HET  was usedThe HET is a comprehensive questionnaire that contains numerous questions split across the following domains: health, living habits, tobacco and snuff, gambling, alcohol, financial situation, social relationships, and demographics  . The preThe HET measures general health via four questions. The first question is “How do you rate your general health?” and is to be answered on a five-point scale ranging from “very good” to “very poor.” Three questions concerning healthy days and activities of daily living were asked . The perHealth on equal terms questions referring to diabetes, asthma, allergy, or high blood pressure were “Have you any of the following diseases?” Answers were given using a four-point scale ranging from “no” to “yes, great distress.” Furthermore, eight questions were related to shoulder and neck pain, back pain/backache/hip pain or ischia, and hand/elbow/leg or knee pains , headache, eczema, incontinence, bowel trouble, and obesity . These qPsychological health as assessed by the HET includes questions related to fatigue, sleeping problems, and anxiety/worry or anguish. These questions are answered using a three-point scale from “no,” to “yes, great discomfort.” The psychological health outcomes also included 12 questions regarding abilities over the last few weeks. These questions included topics such as being unable to concentrate, having feelings of worthlessness, and being unable to appreciate the day. Answers were given using a four-point scale ranging from “not at all” to “much more than usual.” A question about stress “Do you feel stressed at present?,” was answered using four-point scale ranging from “not at all” to “very much.” Two questions concerning suicidal behaviors were also included: “Have you at any time found yourself in a situation in which you seriously considered taking your own life?” and “Have you ever tried to take your own life?” Possible answers were “no,” “yes, once” and “yes, several times” .Within the HET social relationship domain, questions associated with social trust were asked. These questions were “Do you ever refrain from going out alone for fear of being attacked, robbed or otherwise molested?,” the question could be answered on a three-point scale from “no” to “yes often”; “Have you been subjected to physical violence over the past 12 months?”; and “Have you been subjected to threats of physical violence so that you became frightened over the past 12 months?,” the answer could be “yes” or “no.” Finally, “Have you been treated or received in such a way that you have felt wronged over the past three months?,” the answerer could be given on a three-point scale from “no” to “yes, several times.” Additional questions concerns having someone to share one’s innermost feelings and whom to confide, the possibility to obtaining help if needed and believing that most people can be trusted .The respondents answered questions about their financial situation. The questions were “in case of an unforeseen situation in which you had to get hold of 15,000 Swedish Crowns in a week, could you manage this?” The answer could be “yes” or “no.” The other question asked was “if during the past 12 months that you have had difficulty in managing your expenditure for food, rent, bills and so on?” Answers were on a three-point scale ranging from “no” to “yes, on several occasions” .The HAD-scale was developed by Zigmond and Snaith in early 80s. It consists of 14 questions, seven of which refer to anxiety or depression. The HAD-scale has been widely used in both clinical settings and among the general population to identify cases of anxiety and depression. Summation indices for each subscale are calculated, and a cut-off for anxiety and depression is set as 7/8 for probable cases .In addition to descriptive statistics, the Kruskal–Wallis test was used to examine the differences among the USH groups with regard to health  and social trust/financial situation outcomes. A logistic regression analysis was used to determine whether the independent variables associated with health, social trust and financial situations remained significant after adjustment. Independent variables such as demographics and, clinical diagnosis as well as visual field, visual acuity and HI were used to examine general health, physical health, psychological health, and social trust and financial outcomes). A reference category was determined for each independent variable.The Ethics Committee of Linköping University Hospital, and the Institutional Review Board of the Boys Town National Research Hospital in Omaha, United States, in 1990 and 1997 approved the use of the material in the Usher Register for research. In 2012, the Ethics Committee of Uppsala approved the translation of the HET and HAD-scale and to send these forms to persons with USH1 to collect data on their health and wellbeing (Dnr 2012/515). All persons with USH signed informed consent documents to participate in the clinical and genetic research on USH.The results described the similarities and differences among persons with USH1, 2, or 3 with regard to general health, physical health, psychological health, social trust, and finances. The results also present the analysis of which dependent health outcomes were associated with the controlled independent variables demographics, clinical diagnosis, degree of HI, visual field and visual acuity, and the extent to which the variables affected the health outcome.As Having 15 or more poor psychological health days was equally reported within the USH1, 2, and 3 groups. Persons with USH2 reported fewer problems with a lowered capacity for work and activities of daily living due to poor physical and psychological health than did those with USH1 or USH3. However, this difference was not significant. Persons with USH3 most frequently reported problems with lowered capacity for work and activities of daily living .The regression model regarding how the independent variables were associated with the general dependent outcomes revealed that age had a significantly high OR  with regard to the dependent outcome poor health . This reSignificant differences were observed in three of thirteen physical health outcomes: tinnitus; hand, elbow, knee, and leg pain; bowel problems . When inThe logistic regression model regarding how different independent variables contributed to poor physical health outcomes did not reveal a clear tendency, where only one variable contributed to poor physical health outcomes. Usher syndrome category or gender was associated with a higher risk for poor outcome on six of the physical outcomes controlled. These findings show that if belonging to a “higher” USH category  was associated with a higher risk of tinnitus; hand, knee or leg pain; and bowel trouble (table 6). Women were at higher risk for having problems with headache, shoulder and neck pain, and incontinence . Older pTwenty psychological health outcomes were measured, of which two were significant: fatigue and suicidal thoughts . The groA non-significant pattern was identified with regard to psychological health outcomes in which persons with USH3 reported the most problems for ten of the outcomes. Persons with USH2 reported the most problems for five outcomes; and persons with USH1reported the most problems for four outcomes .p-value 0.02, Exp B 0.19, CI 0.05–2.10); thus, those who had better visual fields were at a higher risk for poor problem management. A negative association was found between visual acuity and being incapable of making decisions .The logistic regression model regarding how different independent variables contributed to poor psychological health outcomes did not reveal a clear predictor of poor psychological outcomes. Of the seven psychological health outcomes included in the model age was associated with a significant OR for three of the outcomes. However, both age and USH category had significant ORs with regard to sleeping problems. Other independent variables were associated with different psychological outcomes . InteresSix of nine social trust and financial situation outcomes presented with significant differences . Regardlp-value 0.04, Exp B 0.57, CI 0.33–0.96; The regression model performed for the social trust and financial situation outcomes did not reveal a significant predictor of poor outcomes . Differen = 15) these results should be interpreted with caution, and more research  are needed to examine the variables that contribute to the complexity of living with a progressive condition such as USH further.Both similarities and differences were identified among the USH groups with regard to general health, physical health, psychological health, social trust, and financial situation. Persons with USH3 tended to have poor outcomes such as headaches; hand, knee, leg, and elbow pain; fatigue; sleeping problems; and suicidal thoughts. These participants also tended to refrain from going out and did not trust most people in general. Persons with USH1 presented with a shifting of problems, primarily concerning psychological health and problems with social trust and finances. Persons with USH2 had problems that were more evenly distributed across physical health, psychological health, and social trust see . LikewisThe current results are ambiguous as to which variables contributed the most to the poor health, social trust and financial outcomes; each outcome was associated with a different predictor . These fDeafblindness such as that found in USH is a complex phenomenon. We empirically examined numerous independent variables to determine how they are associated with different health outcomes. The results did not reveal connections in terms of linear causality; thus, the risk of a poor health, social and finance outcome depended on the independent variable. Concluding that persons with USH automatically have poor health outcomes or more problems with social trust or finances as their vision deteriorates is not possible based on the results of the present study. The same reasoning can be made with regard to the degree of HI. However, vision and hearing are highly complementary senses  used to This study and previous studies both from the current research group , 2016b aDeafblindness such as that observed in USH is described as a disability that affects communication, giving and receiving information and orientation . HearingBecause USH is a rare syndrome, healthcare and rehabilitation setting professionals seldom come in contact with people with USH, and previous research has found that the healthcare and support that is offered does not meet the needs of the people with deafblindness or USH because it is fragmented, lacks coordination and is time consuming . TherefoDuring rehabilitation or in other healthcare settings, the whole person must be taken into account; hence, a bio-psychosocial perspective is necessary to understand the general, physical, psychological, and social health of persons with USH. To focus on a single impairment  in the rehabilitation or healthcare setting reduces a complex living situation and does not consider deafblindness as a distinct disability with special consequences for the individual or the adjustments that must be made by society.None of the independent variables examined in the current study fully explain the poor health of persons with USH. The independent variables that contributed the most to poor health outcomes were ambiguous. Additional research is needed to examine the consequences for health and other variables or mechanisms regarding persons with USH. An evidence-based rehabilitation setting that provides help and support for people with USH should rely on the individual’s knowledge about their life situation and challenges, research and professional knowledge. The observations of the associations between the independent variables and poor health, social trust and finances made in the present study are important to bear in mind in a rehabilitation setting; however, they, do not fully explain how people with USH actually feel or rate their health. More research is needed to confirm the knowledge that exists within the clinical setting and the life stories told by the people with USH to merge existing knowledge into a rehabilitation setting based on evidence.Due to privacy concerns, the data will not be made publicly available.The studies involving human participants were reviewed and approved by the Ethics Committee of Linköping University Hospital, and the Institutional Review Board of the Boys Town National Research Hospital in Omaha, United States, in 1990 and 1997 approved the use of the material in the Usher Register for research. The Ethics Committee of Uppsala approved the translation of the HET and HAD-scale and to send these forms to persons with USH1 to collect data on their health and wellbeing (Dnr 2012/515). The patients/participants provided their written informed consent to participate in this study.MW was responsible for the data collection, statistical analysis, and writing. CM, BD, and KM contributed for the discussions of analysis, results, and writing. All authors have contributed to the design, analysis, and writing of the manuscript and the study.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


N = 20, M = 40.4 years old, 60% female) participated in nominal group technique focus groups. The Ecologic Model of Obesity grounded stimulus questions asked about barriers to obtaining and preparing healthy food. Participants emphasized common barriers across everyday settings—focusing, for example, on the ability to reach shelved food inside the home, navigating to and inside stores and restaurants, and using delivery services. Home environments often did not afford suitable spaces for food preparation and storage. Participants reported inadequate transportation and numerous additional barriers in many settings to be able to eat healthfully. Participants reported lack of accessible transportation and architectural barriers inside stores, restaurants, and their own homes, highlighting the need for efforts aimed at improving accessibility and usability. Findings support the use of the Ecologic Model of Obesity to guide research and suggest the need for improvement in assessment practices and policies that enhance access to healthy food.Almost 1 in every 8 adults in the U.S. have a physical disability that impairs mobility. This participatory project aimed to identify and describe environmental and personal barriers to healthy eating among people with mobility impairments using a rigorous, structured mixed methodology. Community-dwelling adults with a self-reported mobility impairment ( Almost 43 million (about 1 in every 8) adults in the U.S. have a physical disability that impairs mobility . People Poor dietary habits are attributed, in part, to environmental and social barriers, such as lack of access to grocery stores and lack of support for healthy eating ,10. ThesMacro-level policies can influence multiple settings and people. For example, the Americans with Disabilities Act (ADA) .”Most (4 of 6) groups who discussed barriers inside of grocery stores also identified In summary, participants identified transportation-related challenges and weather as important barriers to shopping. They also identified physical barriers inside stores, limits on what one could carry while shopping, and various features of checkout lanes as challenging during grocery shopping.navigation, inadequate seating and lack of accessible restrooms. The majority in all groups that were asked this question (n = 5) mentioned and endorsed these three issues. Navigation within restaurants seemed problematic for all participants, regardless of whether they used wheelchairs or some other assistive device . For example, one participant stated, “Maneuvering the tables/chairs very difficult with my cane. Constantly getting it caught and tripping on it”. A person in another group stated that, “There might not be enough space between tables and chairs, I have to ask customers to move, possibly ask them twice”. “Large crowds and limited space”, were universal barriers for eating in restaurants for those with mobility impairments.Reflections on experiences in restaurants tended to yield three consistent considerations of In addition to posing challenges with navigation, the internal seating arrangement of many restaurants does not sufficiently accommodate people with mobility impairments, especially those using wheelchairs and other assistive equipment. All groups indicated that the table height was too high or too low. All groups also discussed seating options that were never quite adequate, whether the issue was chairs being too low or too high, too small or simply not having enough. Inadequate seating is another universal barrier experienced in most restaurants.Perhaps the most distressing finding was that all but one group raised the issue of “Lack of accessible restrooms once inside of the restaurant,” as one participant stated. Every group endorsed this as an important barrier to restaurant dining. A participant in one group emphasized, “Sometimes the bathrooms are inaccessible, I might not be able to close the stall door, the hallway might be blocked”. As well as the entrance to the restroom itself being a concern, a participant in another group stated that, “Sometimes the bathrooms in the restaurants are difficult to move around in”, suggesting that the interior of the restroom is also often problematic.Perhaps reflecting ADA regulations implemented some three decades ago, only two of the groups mentioned, “Lack of an accessible entrance”, to the restaurant itself as one participant succinctly stated. A participant in a different group noted, “There might be a step to get in, or a damaged old ramp to get in”. The restaurant entrance was not highly endorsed, even when it was mentioned, suggesting that this may be a less commonly experienced barrier by people with mobility impairments.In summary, participants noted challenges inside restaurants, especially with navigation around tables, chairs and other obstacles; seating arrangements and options that were not adequate for people using assistive devices; and lack of accessible restrooms.storage space or issues related to a lack of access to storage. For example, one participant told us, “I don’t have as much storage room as other people, because I use a wheel chair, so I can’t use any storage that is up high. So, I run out of storage room”. Five out of six groups mentioned the specific issue of, “Not enough storage space…”, and all participants in those groups endorsed this as a top barrier. An issue connected to insufficient storage was the inability to reach things in the storage space that was available. One participant told us, “I can’t reach a lot of things in cupboards or on the shelf.” Every group that discussed this question mentioned this barrier and a range of unreachable storage spaces including shelves, cabinets, refrigerators, and freezers.An overarching theme that emerged across several groups was that kitchens were often not designed with accessibility in mind. When asked about storing and retrieving food in the home, many participants noted insufficient limits to what one could carry or the ability to manage more than one thing at a time serving as a barrier, “Moving items, I can only carry one item at a time, difficult to carry multiple things at one time”. In some cases, this may have been related to the issue of products being too heavy to lift or carry. Three groups specifically discussed the weight of objects, for example, “Canned foods are sometimes too heavy to bring down from the shelves.” A third commonly mentioned problem was the fact that opening and closing containers could be challenging. For example, one participant stated, “Tupperware containers and anything with a lid could be difficult to open”.Participants in two groups mentioned In summary, research participants discussed how most home kitchens were not designed with accessibility in mind, with insufficient storage space that was often not accessible. They also noted that food was often stored in ways that were awkward or too heavy to carry and hard to open.Inability to reach things was again a commonly identified issue, with four of the groups mentioning that items needed for a meal or snack were “out of reach”. This was a top issue in three of these four groups. One participant stated that it was difficult to plan without, “Knowing what I have in inventory at home already or do I need to get it. I can’t access the cupboard to determine what is in the cupboard”. Other groups echoed this sentiment, particularly in the context of having housemates who put things out of reach and out of sight for the person with the mobility impairment.Six groups responded to the question about planning meals or snacks. limited inventory altogether. This was a top choice in three of the four groups who mentioned it. Two subthemes of this construct emerged. The first, “getting the groceries”, was the biggest barrier to planning mentioned in one group. A member of another group explained, “You might have a recipe that calls for ingredients that you don’t typically use. Items may expire before you can use them again”, which narrowed her ability to plan more interesting healthy foods. A second subtheme was cost of inventory, and this was mentioned in three groups and a top choice in two of them. A participant in one group said that, “Healthy options are more expensive, so financially it may not be feasible to purchase what’s good for you”.Beyond the barrier of not being able to reach inventory, participants mentioned the problem with general planning is difficult, for a variety of reasons, although this was not a top barrier for any of them. One participant simply stated, “Planning meals takes a lot of effort. It’s tiring”. One participant in another group acknowledged that, “It is hard to stay disciplined enough to focus on planning what I need to do”.Given the barriers already cited, it was not surprising that four groups acknowledged that appropriately designed cooking space also came out of the responses to this question in about half of the groups, but the ranking was not consistent. For example, one participant stated that, “mobility around obstacles in the kitchen, having enough room to maneuver around the kitchen”, impeded planning. A member of another group mentioned that, “I only have a hot plate, and a size small refrigerator, and minimal cooking appliances”, which limited the kind of meal planning that was possible. Another participant in a different group added, “lack of room or space is a barrier. I have to be very specific in planning, because things don’t fit”.Mobility in the kitchen, and lack of an In summary, participants mentioned that having difficulty reaching or seeing food inventory inhibited their ability to plan meals and snacks. Participants also mentioned having limited inventory kept in house as well as the complexities of planning being overwhelming and tiring.appropriately designed cooking space was a consistent and pervasive theme with all participants agreeing unanimously that their kitchens were just not designed for them to cook easily. All cited a lack of space, with one participant stating that, “it is difficult to move around in the kitchen”. Kitchens also didn’t seem to be the correct size, with things at the wrong height for easy access, such as, “the counters might be too high up.” A participant in another group poignantly illustrated this concern, by telling the group, “I have an average size stove but a lower chair, which means I burn my wrist on the edge of the pan when trying to stir using spatula. I get burned from the front burner”.Four groups answered the question about barriers to preparing foods. Across the board, not having inability to reach things, in particular with stove cook tops, and this was one of the most commonly endorsed items for each of these groups. For example, one participant noted, “Sometimes pots are too high up or too deep to see if the food is actually cooking”. A participant in another group raised the same issue, stating, “I can’t see the pots on top of the stove, can’t monitor the pan ingredients.”Three groups mentioned the common issue of kitchen as the center of hearth and home, with cooking viewed as an activity done with other household members. For example, one participant mentioned, “Cooking together in a small space is fun, get to spend time together”. In contrast, another participant in another group seemed to bemoan the limitations of the available cooking space in stating, “It is difficult to cook with other people, chair is in the way, cook alone or prep food outside of the kitchen”. Cooking time seemed to be an activity that is undertaken collectively perhaps as part of tradition and ritual.A final thread that emerged in three of the groups and endorsed as a top choice two out of the three times it emerged, seemed to harken to the notion of the In summary, participants discussed how their kitchen cooking space was not designed well for cooking for them, and that they perceived cooking as an activity often undertaken with family or housemates.receiving the delivery. One participant noted, and all in that group endorsed, that merely, “Signing for your purchase at the door”, was a significant barrier. A participant in another group noted, “I can’t get to the door quickly, so sometimes the delivery people don’t think I am going to come to answer the door”. This may seem to remedy these issues, but the lack of personal attention may also be more challenging, as one participant in another group stated, “Accepting the food at the door is difficult, because of the weight and quantity”. This might also be challenging in cases, when “…delivery services leave it out front where I’m unable to get it in time and the food might go bad.”Five groups answered the question about food delivery services. Perhaps the most commonly mentioned issue in all five groups had to do with simply food packaging, either being unwieldly or otherwise hard to manage or open. Delivered food typically comes in secure packages to minimize the number of parcels and to withstand transport from the store or restaurant. Thus, as alluded to above in the concerns about receiving the delivery at the door, a participant in one group noted a similar issue of, “The groceries bags and boxes might be too heavy”. Other groups discussed this same issue. One participant noted that, “Ordering food from restaurants, the type of containers might be hard to open or access the food”, suggesting that packaging for ease of delivery did not lead to ease of consumption.Another commonly mentioned barrier in four of the five groups, and endorsed as most important by two of them, focused on supply-and demand-related logistics that affect all users, regardless of mobility impairments. Concerns about cost were cited in three groups and ranked highest in all three. One participant noted, “For people that are on fixed incomes, some places add a premium; it is more expensive to have it delivered than just to go to the store”. Availability of service was noted in four groups, but usually endorsed by only one participant in the group. Issues about the availability of specific items such as, “the order is sometimes wrong”, or “unable to return items if they are wrong”, came up in three groups and was the highest endorsed item in two. Respondents in two groups, one rating it most highly, noted that time to delivery was slow, “Not quick turn-around for online orders, it could take possibly 24 h to a few hours”. These common complaints about food delivery may be resolved as availability of these services becomes more widespread.Other issues mentioned by the groups included concerns about cost, lack of service availability, unavailability of specific items, and slowness or timing of deliveries, which are all In summary, participants discussed challenges with food delivery such as the difficulty in taking receipt of delivered food, carrying and opening packages, and logistical issues such as cost, availability and incomplete or incorrect items in the delivery.The purpose of this study was to identify and describe barriers to healthy eating among people with mobility impairments by applying a mixed methods approach, guided by the Ecologic Model of Obesity . We founConsidered within the Ecologic Model of Obesity, commonly frequented neighborhood micro-level environments such as stores and restaurants often posed challenges related to navigation . ParticiThe home environment, the micro-level environment where people spend most of their time, also received generally poor marks from our participants. Participants focused on barriers related to things being out of their reach, having poorly designed cooking spaces in which to cook easily and safely, and many considerations focused on inventory and storage. Developing or modifying homes that are universally accessible may be an unattainable luxury for many people with disabilities who often have fewer financial resources compared to the general population ,27. SomeIn discussing barriers, most groups mentioned situations that served as barriers, where having help might have helped to overcome them. If this were the case, this would be consistent with our hypothesized meso- and exo-level environmental linkages from the Ecologic Model of Obesity . For exaReliable transportation was another important exo-level environmental linkage between people and places. Given the regulations of the ADA and other policies to improve transportation, it is disconcerting that a lack of reliable transportation was mentioned so frequently. Other studies have reported that public transit is often an unreliable transportation strategy for this population, particularly in rural settings . People Having personal control over one’s circumstances is an individual-level factor that can mediate or moderate environmental factors in the Ecologic Model of Obesity . For exaResponses suggested that participants perceived an inability to exercise the discipline needed to make healthy dietary choices, as evidenced in the responses to planning meals or snacks. They also suggested that cooking meals was part of a family or household endeavor. Perceived lack of personal discipline or “willpower” is often reported by all people trying to establish or maintain healthy habits that require exerting extra effort, particularly when there are others sharing meal planning, food shopping, and cooking responsibilities ,24. It mAnother commonly cited barrier was bad weather, which operates as a macro-level factor, affecting all settings and residents in an area, not solely those with mobility impairments. However, using an assistive device may add to the complication beyond merely donning a jacket and heading out to accomplish one’s daily activities. Although bad weather can pose challenges to everyone, the challenges for people using wheelchairs or other assistive equipment to get from place to place can be exponentially worse, especially during winter, e.g., when snow and ice bring community participation to a standstill.The findings from the current study provide rich information that authenticates theorized ecologic barriers to healthy eating from the perspective of people with mobility impairments. Strengths of the study include the use of a carefully constructed, theoretically-informed, a priori question guide; a robust systematic qualitative strategy and protocol for generating information; multiple well-trained group moderators; and experienced and well trained coders. Coders were able to compare and discuss themes with the community advisory board to improve reliability further . ParticiFindings from this study support the use of the Ecologic Model of Obesity to guide research in the promotion of healthy eating among people with mobility impairments . As presImproved implementation and enforcement of existing macro-level policy is also needed. Additional research is indicated to test these findings systematically in larger samples using rigorous methodologies and analyses. Moreover, future research is needed to develop and implement training programs for grocery stores and other entities to reach compliance with existing disability regulations and to increase their sensitivity to people with disabilities . Multiple efforts are needed to improve the profound lack of access that participants reported when trying to navigate the built environment in their own homes or inside grocery stores and restaurants. Full compliance with the ADA could eliminate many of the barriers that people with mobility impairments experience in accessing healthy food.


Workforce development for implementation practice has been identified as a grand challenge in health services. This is due to the embryonic nature of the existing research in this area, few available training programs and a general shortage of frontline service staff trained and prepared for practicing implementation in the field. The interest in the role of “implementation support” as a way to effectively build the implementation capacities of the human service sector has therefore increased. However, while frequently used, little is known about the skills and competencies required to effectively provide such support.To progress the debate and the research agenda on implementation support competencies, we propose the role of the “implementation support practitioner” as a concept unifying the multiple streams of research focused on e.g. consultation, facilitation, or knowledge brokering. Implementation support practitioners are professionals supporting others in implementing evidence-informed practices, policies and programs, and in sustaining and scaling evidence for population impact. They are not involved in direct service delivery or management and work closely with the leadership and staff needed to effectively deliver direct clinical, therapeutic or educational services to individuals, families and communities. They may be specialists or generalists and be located within and/or outside the delivery system they serve. To effectively support the implementation practice of others, implementation support practitioners require an ability to activate implementation-relevant knowledge, skills and attitudes, and to operationalize and apply these in the context of their support activities. In doing so, they aim to trigger both relational and behavioral outcomes. This thinking is reflected in an overarching logic outlined in this article.The development of implementation support practitioners as a profession necessitates improved conceptual thinking about their role and work and how they enable the uptake and integration of evidence in real world settings. This article introduces a preliminary logic conceptualizing the role of implementation support practitioners informing research in progress aimed at increasing our knowledge about implementation support and the competencies needed to provide this support. The applied discipline of implementation science includes both implementation research and implementation practice. It aims to integrate research and practice in ways that improve the outcomes of those being served by human services . Implemeembedded researchers” or “researchers-in-residence” as a potential strategy for ensuring a collaborative and participatory implementation research production that is informed by and relevant to local contexts  implementation after training” . Thiaining”  has been defined as involving “tcomes” ( p109). Ttcomes” , andWe suggest conceptualizing implementation support practitioners as professionals not involved in direct service delivery or management. Instead, they work closely with the leadership and staff needed to effectively deliver direct clinical, therapeutic or educational services to individuals, families and communities and support them in implementing evidence-informed practices, policies and programs, and in sustaining and scaling evidence for population impact.provider implementation capacity, the ability to select and apply appropriate and contextually informed implementation frameworks, strategies or other concepts and tools and to tailor these to different interventions, contexts, populations, and settings in real world health services. The educational and professional backgrounds of implementation support practitioners therefore vary. They include specialists such as clinical psychologists, social workers or nurses and generalists trained in sociology, organizational change and other fields. What connects these professionals is their knowledge and experience in supporting implementation efforts in service systems to achieve outcomes. We therefore refer to them as implementation support practitioners.A key focus of the work of implementation support practitioners is to build evidence synthesis and translation system and a delivery system, assisted by a support system. This support system specializes in providing implementation support and building general and intervention-specific capacity to adopt and integrate research evidence into day-to-day practice. It is this support system that implementation support practitioners are part of.An explicit recognition of the need to actively build the capacities of evidence users and their organizations first occurred with the development of the ‘Interactive Systems Framework’ , which dexternally situated intermediary organization established for the explicit purpose of providing technical assistance to service providers implementing specific evidence-informed programs or interventions commissioned by government organizations [within and between provider organizations – in the form of distinct individual or team roles with knowledge translation and implementation support responsibilities. Examples include practice facilitators used in health [Multiple studies report on how the idea of a support system can be operationalized in routine service settings –53. In mizations –57. Simun health , 21, or n health –60 and in health –63 used These examples illustrate that a support system can lie within or outside of the delivery system, with implementation support practitioners being situated within the delivery system, outside, or both. They also highlight that implementation support practitioners can and should move flexibly across the different systems that form the Interactive Systems Framework, thereby ensuring that knowledge from one system is transported to and meaningfully applied in another system.To do this work, implementation support practitioners require specific competencies.more than a set of skills” and instead a “mix of aptitudes, attitudes and personal attributes” . Tontext” ( p2). Thiontext”  Department of Veterans Affairs [The formal position – implementation support practitioners can be fully embedded into the organizations and systems they support; they can be part of an intermediary organization; or they can belong to academic research settings. At times projects and initiatives may also rely on the parallel provision of services from internal as well as external implementation support practitioners. This “ Affairs –79.Professional background – i.e. training in specialist disciplines such as psychology, nursing or psychiatry or generalist education in e.g., ethnography or sociology. For example, a review of practice facilitators operating in healthcare showed that in most cases facilitators were individuals with an educational background in healthcare .Knowledge – i.e. the factual information implementation support practitioners bring to and acquire about the contexts in which they work, e.g. about the evidence-based practice or policy in focus, individual and organizational change processes or implementation concepts. As an example, in a realist review of studies examining characteristics of effective change agents operating in healthcare both practice, academic and local knowledge together with practical experience was highlighted as crucial for successful knowledge translation .self-awareness, self-management and social awareness [Attitudes – the predispositions that influence implementation support practitioners’ work-related actions and responses, e.g. a positive attitude towards evidence-based practice, a collaborative mindset or flexibility. Among the key characteristics of effective facilitators identified through a recent systematic review were for example wareness .goal setting”, “assessing progress and outcomes”, and “providing tools and resources” [Skills – the ability to activate attitudes, utilize resources and apply knowledge in ways conducive to achieving goals, e.g. the ability to engender trusting relationships, facilitate interpersonal processes or select and utilize relevant implementation strategies. For example, “sources”  emerged sources” .Using this realist approach, we view an implementation support practitioner – who may be a facilitator, knowledge broker, consultant or some other similar role – as a resource with a unique mix of qualities, includingWe anticipate that when this resource – a unique combination of the above qualities represented in a single or multiple implementation support practitioners – unfolds as intended and required, implementation stakeholders – be it individuals, groups or entire systems – will respond positively.trust, which we view as foundational for implementation support practitioners to be successful. Two types of trust are important [Intrapersonal trust is represented by the belief that the implementation support practitioner is reliable, competent, and committed to the change effort on behalf of the organization they are supporting. Interpersonal trust is represented by the perception of both implementation support practitioners and their stakeholders that they are in a collaborative and reciprocal relationship focused on achieving identical aims. Hence, trust describes a quality of relationships in implementation partnerships that affects information exchange and opportunities for learning [In the first instance, this response will primarily be demonstrated by mportant . Intrapelearning . While slearning , 86, truCapability – the psychological and physical capacity to initiate behavior change – may show in changed stakeholder intentions to use research evidence, support inquiry driven service improvement, or implement an evidence-informed intervention; motivation in improved attitudes towards using evidenced implementation concepts; and opportunity – factors enabling or prompting an intended implementation behavior – in changes to the organizational climate surrounding an implementation effort.Taking on board the concepts from the Capability-Opportunity-Motivation-Behavior (COM-B) system , we alsogeneral capacities – e.g. improved organizational structures, implementation leadership, infrastructure for continuous improvement, or more evidence-focused policies – and innovation-specific capacities, related to the intervention in focus of the implementation support practitioners’ assistance [We suggest that the consequence, or output, of this process of “reasoning” (i.e. stakeholders’ response to working with an implementation support practitioner) is two-fold. In the first instance, it will result in enhanced stakeholder implementation capacities. At the individual level, this will be demonstrated by an increase in implementation knowledge, skill and competency. Organizations and systems, on the other hand, should experience increased sistance . Ultimatsistance  and its Finally, successful implementation also requires enabling contexts, i.e. constructive adaptive system behavior  that supRecent literature illustrates that implementation support is frequently institutionalized in complex human services systems , 54, 55.A more unified understanding of implementation support practitioners’ role could be achieved by specifying what these actors do, the skills they need to execute their roles, and the ways in which the stakeholders they assist might respond to their offering. This should permit better analysis of implementation support practitioners’ impact on implementation processes and outcomes. It should also address recent calls for a classification system specifying the implementation actor and the implementation target to examine how specific strategies delivered by certain actors can facilitate an effective use of evidence in practice .An analysis of data gathered from an international sample of implementation support practitioners, reflecting on the competencies they require in their day-to-day work to support implementation efforts in different service settings. This analysis will facilitate the integration of practice-based knowledge potentially not reflected in the literature.A systematic integrative review of the vast and diverse literature on implementation support roles to examine our thinking through this lens, enabling the improvement of our logic. This review will build on the many studies – some of which have been highlighted in this article – that examine different aspects of the work of facilitators, knowledge brokers, consultants and others and allow for the extraction of data on e.g. the knowledge, skills, or attitudes these implementation support practitioners require, and on the contextual factors influencing their efforts.The proposed logic presented here is of preliminary nature and requires critical review and refinement. This will be part of an ongoing program of work by the authors, involving two parallel activities:The goal of this work is to (a) integrate this knowledge into the joint program logic, (b) describe the competencies that can be derived from this model as being potentially important for implementation support practitioners, and (c) discuss how these competencies can be developed, built and researched within real world practice settings. This last and final step will also imply to compare findings with already existing work focused on competencies as they relate to implementation science and practice. Multiple studies exist describing the curricula used with and results achieved from different types of implementation research training , 90, 91,Hence, additional research activities will be necessary to enhance the knowledge base on implementation support practitioners, and to critically examine whether their support is adding value in practice contexts, and how this translates into positive client outcomes. First then, will it be possible to evaluate to what degree the substantial investment made in this support by local, state, and federal institutions  is justiAdditionally, rigorous qualitative studies should be prioritized to more deeply explore the mechanisms of change, together with the contextual influences affecting implementation support practitioners and their work. Relational and behavior changes build on more than a simple link between stimulus (i.e. implementation strategy use) and response (i.e. implementation behavior). It is a complex process involving the relationships, motives, identities, self-regulation, habits and rituals of individuals and groups . How impThe development of implementation support practitioners as a profession necessitates improved conceptual thinking about their role and work and how they enable the uptake and integration of evidence in real world settings. Such enhancement is possible by synthesizing the diverse literature on different implementation support roles aimed at not only consolidating what implementation support practitioners know, display, do and achieve but, importantly, also the potential mechanisms of change unfolding between their offering and the responses of their stakeholders. The logic proposed in this article will be refined as future research and practice insights deepen our understanding of the relationships between implementation support practitioners, capacity development, frontline implementation practice, and population outcomes. As such, this article introduces preliminary thinking to stimulate further research and invite input, challenge and critique from others.


In this study, we qualitatively analyze the Chinese ETS through the lens of three interconnected themes—equity, innovation, and awareness—which are disaggregated into six specific dimensions. We then explore these themes and dimensions with a mixed methods and original research design involving a survey of 68 Chinese experts as well as 34 semi-structured research interviews with respondents from local governments, financial institutions, technology service companies, universities, industries, and civil society groups. We find that uneven economic and social growth could exacerbate any initial permits allocation scheme that could be a cornerstone for an ETS. Substantial technological and institutional uncertainties exist that could also hamper development and enforcement. Low or negative awareness among the public and private sector were identified as also being significant barriers for ETS implementation.How can the Chinese emissions trading scheme (ETS) be redesigned or improved to better address issues of fairness and equity, innovation and learning, and awareness and social acceptance? In order to meet its 2030 carbon emission reduction pledges, the Chinese government has announced plans for a fully implementable national carbon ETS after 2020. This scheme is set to become the world’s most significant carbon trading market and it could cover half of all Chinese CO Emissions Trading Schemes (ETS) are expected to become one of the most cost-effective, or at least popular, mechanisms for mitigating carbon emissions in the future WGEA . CurrentAs the world’s largest developing country, China is facing a monumental series of interconnected energy and climate challenges, including rising energy demand, deteriorating environmental quality, and eroding energy security , it is crucial that various Chinese enterprises need to be persuaded for accepting their reduction targets and permits.” R1 suggested that, “Undeveloped Western areas should be compensated by the optimization of initial permit allocation and appropriate use of the revenues raised.” R25 elaborated by saying, “Most of the Western regions with lower marginal abatement costs have weak economic endurance, and also bear the responsibility for ecological environment protection. However, these situations are not typically included in the abatement costs nor reflected in the policies. Therefore, indirect costs within Western regions should be considered in the system design.” R11 pointed out, “As China’s ETS has decided to adopt the free distribution method, it must fully consider historical emission levels and the metric of GDP per capita so that more permits can be allocated to underdeveloped regions.” However, R23 suggested that permit allocation should move closer toward auctioning, “If the auction method is adopted, the underdeveloped areas will be more likely to be compensated by the revenue from an auction, thereby alleviating distortions.”This leads to concerns over how permits are allocated. R19 pointed out that, “There is a game of interests between the state-owned enterprises as well as between higher and lower levels of governments, because different allocation schemes might favour different interest groups,” as R5 stated. Furthermore, due to a lack of historical emissions-related data, it is difficult to unify a baseline between existing enterprises and new enterprises  system as well as the poor transparency of information. In this regard, R11 mentioned that, anything innovative about the ETS, with one respondent marking that “There is no innovation existing in Chinese pilot systems, it is still at the stage of imitation.” Other respondents, however, discussed how they felt that China has implemented an innovative layered decomposition of binding indicators to form a relatively mature assessment mechanism, an issue also mentioned by  by stating, “It is generally acknowledged that technology will lead to a decline in carbon emissions, but the technological uncertainty would cause the less predictable carbon price in future trading process.” In addition, R22 explained that, “With the utilization of renewables, the contribution of China’s ETS to reducing emissions will be very small.” R28 also estimated that, “With the breakthrough of abatement technologies, the volume of emissions reduction for industries and regions will increase accordingly, assuming economic development is stable. If emission cap standards are not able to be adjusted aptly, it would jeopardize China’s ETS. Therefore, along with such uncertainties, the national ETS will inevitably need to be updated”. By contrast, R14 positively pointed out that, “Innovative abatement technologies will enable China’s ETS to enter a new state in which total volume for emissions reduction will decrease but the carbon price will increase.”However, although 42.9% of respondents demonstrated positive attitudes toward the innovative abatement technologies, other respondents held either neutral or negative attitudes . R3 noted that, per se but very specific technologies, such as solar energy  as well as semi-structured expert research interviews (n=34), our data do give rise to a set of policy recommendations.First, adjustments to the allocation schemes and permit process within the ETS may be warranted. Our data strongly suggests that uneven economic and social growth could exacerbate any initial permits allocation scheme that would be a cornerstone for an ETS. In this regard, our respondents expressed a preference for allocation schemes that provide a lower emission-reduction burden on Western provinces and a relatively more significant one on the Eastern provinces. In addition, several experts also suggested that it is more equitable for China’s ETS to adopt an auction method instead of free distribution because as doing so will achieve an appropriate use of carbon revenues, which is likely to assist with alleviating distortions. Furthermore, a reliable and effective monitoring and verification system was stated as critical to create trust and confidence in the trading scheme. Figure Second, policy is needed to help hedge the substantial technological and institutional uncertainties that exist, which could potentially hamper the development of an ETS. Due to the development and utilization of renewables, some experts believe that the contribution of China’s ETS to emission reduction will be insignificant. Many other respondents questioned the strength and innovativeness of the institutions that would be involved in emissions trading. Although China’s ETS pilots have been ongoing for almost a decade now, respondents were still skeptical that sufficient learning had taken place. Stronger incentives for learning, as well as directed subsidies for low-carbon sources of energy including renewables but also efficiency, could promote this type of innovation, as could more government support for industrial-scale climate mitigation options, including carbon capture and storage or process optimization  or negative awareness  among the public and private sector were identified as being significant barriers for ETS implementation. Although increased public awareness of climate issues does not necessarily lead to changes in individual behavior DfT , greaterBecause China leads the world in its total amount of carbon emissions, it is imperative that it designs an emissions trading scheme that is as equitable, innovative, and socially acceptable as possible. In order to meet the Copenhagen and Paris Accords, China has demonstrated a seemingly significant intention to establish a unified national ETS after 2020. The near-term future may very well be critical for China’s carbon emissions to peak, and also a formative but critical period for eventual low-carbon transformation.At this stage, Chinese climate policy objectives are at a rare state of flux. The country has sought to implement measures to decarbonize its economy, constrain emissions, and meet its international pledges under the Paris Accord. At the same time, it is recovering from a global pandemic, managing growth in manufacturing and employment, and seeking to appease diverse stakeholder interests. Our results suggest that the road to an effective future ETS in China will likely be long and winding, with barriers that cut across many environmental, economic, and institutional dimensions. These must be proactively managed if the ETS is to get travelers to their ultimate and vital destination of emissions reduction—for China’s sake, and the world’s.