Exacerbated by the COVID-19 pandemic and the proliferation of fentanyl and fentanyl analogs, overdose deaths have surged in the United States, making it important to understand how individuals who use drugs experience and perceive the risks of fentanyl use and how it has changed during the COVID-19 pandemic.Twenty clients from a Philadelphia syringe services program completed a questionnaire and in-depth interview about their fentanyl experiences from January to March 2021. These interviews were transcribed and analyzed using thematic analysis methods.Sixty percent of participants were female and racial/ethnic minority. Participants indicated they believed fentanyl use accounted for most Philadelphia opioid-related overdoses and understood that fentanyl was different from other opioids. Fentanyl use was characterized as “all-consuming” by taking over lives and inescapable. While most perceived their risk of fentanyl overdose as high, there was low interest in and reported use of harm reduction strategies such as fentanyl test strips. The COVID-19 pandemic was noted to have negative effects on fentanyl availability, use and overdose risk, as well as mental health effects that increase drug use.The divide between perceived risk and uptake of protective strategies could be driven by diminished self-efficacy as it relates to acting on and engaging with resources available at the syringe services program and represents a potential intervention target for harm reduction intervention uptake. But the COVID-19 pandemic has exacerbated risks due to fentanyl use, making an effective, accessible, and well-timed intervention important to address the disconnect between perceived overdose risk and use of preventive behaviors. Opioid overdose is the most common cause of accidental death in American adults ages 18-50, and deaths involving synthetic opioids were nearly 12 times higher in 2019 than 2013  and an aThe prevalence of fentanyl use, especially when used in combination with other drugs such as stimulants , has also increased overdose rates, contributing to significant mortality increases in all types of drug use , 11. WhiA number of community-based studies demonstrate there is awareness among people who use opioids that fentanyl use increases overdose risk , 24, andvia SSPs  were approached by study staff  while they were onsite to access services, such as syringes, case work, mail or medical services. This occurred on different days and times to correspond to when services were provided to ensure a cross-section of different types of clients. Clients were asked if they were interested in participating and 21 provided informed consent. One participant was interviewed twice, but only their first interview was retained for analysis. When available, SSP staff facilitated introductions between clients and study staff. Eligible participants included clients 18 years of age or older who self-reported current drug use.In-depth interviews were conducted with clients of Prevention Point Philadelphia in Kensington. Prevention Point Philadelphia distributed nearly 6 million syringes between 2019 and 2020–making this organization the largest syringe services program in the United States and an appropriate study site to address the research questions, according to the organization's Executive Director (2021). Clients  who have significant experience working with people who use drugs, audio recorded, and transcribed verbatim. Data were collected January through March 2021. Participants provided informed consent and received a $25 gift card at interview completion. The Temple University Institutional Review Board approved this research (27637), and Prevention Point Philadelphia approved the study taking place at their location.Summary thematic analysis determined that thematic saturation had been reached after 20 interviews, so no further interviews were completed. Descriptive statistics for categorical  and continuous  data are presented for sociodemographic variables . InferenSixty percent of participants were female and identified as racial/ethnic minority. The mean age was 43.3 (SD 10.7). Most (90%) were homeless and earned < $1,000 monthly. Participants were aware of differences between fentanyl and other opiates, and that substances like cocaine could also be adulterated with fentanyl . Fentanyl use was believed to cause hospitalization, overdose, and death  and account for most Philadelphia opioid-related overdoses . Slightly fewer reported thinking that more than one dose of naloxone would need to be used to reverse an overdose due to fentanyl .Participants stated they were aware that fentanyl was a different substance from heroin and other opioids. They conveyed that fentanyl was stronger, that they became more easily dependent on it compared to heroin, and that fentanyl was distinguishable from heroin by the “different high” experienced with fentanyl use. Personal experiences with fentanyl were characterized as a struggle between awareness of its dangers and not liking the sensation of tiredness after use but needing to continue due to severe withdrawal symptoms. Participants also shared being unable to stop fentanyl use despite negative experiences of overdose, cravings, and fear of death. One participant described how quickly she became dependent on fentanyl and the negative physical effects of its use:And before I knew I was addicted, and now my life revolves around it...I can't (stay away from it)…This is what it does to your body. You never know your hands swell up, your feet swell up. You know, you can't sleep, restless syndrome, you're throwing up, your stomach hurts. You can't eat.” (Participant 4) “It's like yo, it's the devil. Like those blue bags are like it's the devil himself on earth. I swear. I swear. People will kill their own love for that little blue bag.” (Participant 6)Another participant said, “It picked me up when I'm down, but it put me down more. It's the only person that was ever there for me. When I cry it pat me on my back, but when I'm down [it's] pushing me down more. It took everything from me.” She went on to say, “I like got a relationship with it. And then I tried to leave it. And I can't. And now I'm just out here by myself and I can't stop.” (Participant 6) Most participants expressed the belief that substances such as cocaine and heroin can be adulterated with fentanyl and reported a belief that fentanyl in Philadelphia was increasingly cut with xylazine  since the beginning of the COVID-19 pandemic. Additionally, participants stated they knew naloxone was typically used to help with opioid/heroin overdoses, but believed it was not as effective for fentanyl overdoses.Some participants personified their relationship to fentanyl. One participant called fentanyl her “frenemy”. She said, “It's like, it's dangerous. If you misuse it you can die,” (Participant 3) and “It's [fentanyl] bad for you” (Participant 7) indicated knowledge of the dangers of fentanyl; however, these were often followed by a lack of concern about personal adverse effects from use with statements such as “Not (concerns about fentanyl) for the most part.” (Participant 7)For some participants, there appeared to be a disconnect between understanding of the adverse effects and personal concerns about actual use. Statements such as “I just wish I wasn't doing it” (Participant 1) and “I'm concerned what it's doing my body,” (Participant 5) while expressing a lack of knowledge about consequences of long-term use. Most of these participants said they wished they had known more about fentanyl's effects on the body both in the short and the long term before they started using it. For example, one participant said: “I didn't originally use fentanyl, and no one explained to me that when I went from a regular heroin to fentanyl how bad and hard fentanyl is to get off .” (Participant 3) Another participant indicated that despite long term substance use, fentanyl was different. They said:Conversely, other participants shared their personal concerns about fentanyl use in statements such as “That was my first time I've ever, ever overdosing off anything. I've been using drugs for years, you know, and I know this drug is different. I ain't never seen no shit that killed you like this. It's mind numbing, certainly.” (Participant 8) “Participants said that access to concrete information that could be seen and read might result in people taking the risks of fentanyl use more seriously. Participants suggested sharing information based on studies about what really happens in the body and consequent symptoms of fentanyl use, why it began to be circulated, how long it takes to wear off, and the severity of withdrawal as ways to increase awareness about fentanyl. Once participant said:I don't even know all the symptoms, like if I can get any more informative information, meaning something that I can read and see. Or speak to doctors and nurses or even, you know, students… anyone that can give me facts, not just the drug aspect of it. The real thing. Yeah. Well, what the studies have shown and what's really happened, you know what I mean, it'd be way more helpful to people because they would take it more seriously. See, the fact of everything is not word of mouth.” (Participant 4) “I know you can take the drugs if you use the test strips to see if fentanyl's in it. I don't use test strips. I just don't.” (Participant 1) Only 20% of the participants interviewed expressed either an interest in and/or experience with using the test strips including knowing where to obtain them and using them as a safety measure: “I just got ‘em last week and used it (test strips) and it was good.” (Participant 8). One participant (16) learned about test strips from people at Prevention Point and felt strips could help them “be more safer”, yet this participant indicated they did not use them. Another said they had some in their purse but did not use them. Not all participants responded directly to this question and one participant shared that they identified fentanyl by smell based on experience from long term use, making test strips unimportant: “Once you do it all the time and you've been doing it for a while you know you can smell it. You can smell it. You put the water on there. It's got a certain smell.” (Participant 3) Another indicated that they did not use them because they take too long. They said: “No, they'd (fentanyl test strips) be a pain in the ass…Because as soon as I get the bag of dope, I want to snort that before the cops come.” (Participant 17). Similarly, another participant indicated they knew about test strips and acknowledged that having test strips was good but felt that the need to use fentanyl made them irrelevant: “They're good to have. But at this point, I need fentanyl.” (Participant 10).Most participants shared knowing that fentanyl test strips could identify the presence of fentanyl in substances but did not use them. For example, one participant said, “Finally, many participants discussed substance use, fentanyl use, and overdose in the context of what was happening during the COVID-19 pandemic and why overdose risk and substance use changed. Some discussed the economic hardships people were facing, especially those who were trying to get money through hustling, sex work or other means, and how these financial pressures increased substance use. One participant shared a belief that COVID-19 mitigation strategies fostered a dangerous environment for people with existing drug use dependencies because of the mental distress brought about by the crisis. They said:Now you can't go to work. Now you have to stay inside your house. Now you're stuck with your thoughts. Well, you know, it's a scary place to be, especially for people that were already addicts...That's why I think there's more overdoses during the pandemic.”  “The results of this study provided insight into the lived experiences about the risks associated with fentanyl use in a high overdose-risk population from a large SSP during the COVID-19 pandemic. Our sample characterized fentanyl use as “all-consuming” and nearly inescapable from daily life. But a chasm between high perceived risks of fentanyl and low interest in and reported use of harm reduction strategies, such as fentanyl test strips, was identified. Given that this sample drew from a well-resourced syringe services program, it is noteworthy that participants reported underutilization of overdose prevention strategies despite the collective recognition that fentanyl posed life-threatening risk. The divide between perceived risk and uptake of protective strategies could be driven by myriad interrelated factors. If thought of in a risk environment framework, as proposed by Rhodes, there are individual factors that must be considered but also social and physical factors from the environment in which drug use occurs that increase or decrease the chances of harm during drug use.  Given paImportantly, most knowledge of fentanyl, including its effects and dangers, appeared to be from participants' personal and peer experiences with use rather than reliance on public health information or resources despite participants having proximity to the vast educational and prevention infrastructure of the SSP. Participants shared what they believed to be personal adverse consequences of fentanyl use, but many demonstrated a lack of understanding of why/how those consequences occurred and expressed a desire to have more information available to know the effects of fentanyl on the body, especially before they started use. Although public health information resources such as the Centers for Disease Control and Prevention website exist,  the easeOur results also indicate diminished agency to act on health-protective behaviors, like using fentanyl test strips. These attitudes are consistent with current literature which identifies a higher perceived risk of fentanyl overdose among individuals who use fentanyl or other opioids but aligns with a sense of hopelessness about personal use and a lack of interest in fentanyl test strips to decrease risk of lethal overdose or significant harm/injury –23. HoweThe COVID-19 pandemic has also certainly exacerbated the proliferation of fentanyl-adulterated products and created new mental health challenges. The social and psychological risks of the pandemic have been shown to potentially intensify drug use and increase feelings of hopelessness . Our resAnother escalating problem exacerbated by the COVID-19 pandemic is the presence of fentanyl not only in opioids such as heroin, but also stimulants such as cocaine and methamphetamine , 13, 50.Finally, it should be noted that there are significant limitations to the availability of effective treatment for fentanyl's toxic effects . While nAlthough these interviews provided us with new information about the perceptions and experiences of fentanyl use in a population that used drugs, the interviews were intentionally narrow in scope, and may not have reflected all harm reduction strategies the sample practiced. We asked these questions to this population of SSP participants because they had better access to fentanyl and services for overdose prevention than many other groups, making their perspectives informative for future intervention efforts. A limitation may have been the sample size. However, a systematic review suggests that data adequacy and saturation are the primary factors to be considered and that a sample size of 20 is adequate;  This samIn addition to gathering preliminary data to assess the perceptions and experiences of fentanyl use risks during the COVID-19 pandemic, utilizing a participatory approach to develop, implement, and evaluate an opioid education intervention that incorporates information about fentanyl could be an effective and novel step to increase awareness about its risks and adverse consequences of use. For now, creating greater awareness of fentanyl toxicity effects and increasing self-efficacy in being able to protect from overdose and death could be a proactive step in saving lives.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Temple University Institutional Review Board. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.SB: conceptualization, methodology, resources, writing–original draft, writing–review and editing, visualization, supervision, and funding acquisition. PK: conceptualization, formal analysis, data curation, writing–review and editing, and project administration. SP-K: data curation and writing–original draft. JP: data curation. KM: formal analysis and writing–original draft. EL: conceptualization. JW: conceptualization, writing–review and editing, and supervision. PT: conceptualization and writing–review and editing. All authors read and approved the final manuscript.This work was funded by the National Institute on Drug Abuse . The funding body played no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.SP-K, KM, EL, JW, and PT were employed by CODA, Inc. The remaining 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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Assess the feasibility of using goal attainment scaling (GAS) in care planning for older adults with complex needs. GAS is an individualized approach to goal setting and follow up using a quantified scale. To date, little is known about the feasibility of GAS among this population.We conducted a qualitative study with a sample of 28 older adults and 23 providers from diverse settings to evaluate the value and challenges of this approach. We conducted semi-structured interviews and iteratively coded and analyzed interview transcripts for themes related to value, challenges, and implementation.Most older adults and providers reported that the GAS approach added value to the care encounter. GAS supported collaboration and patient accountability for their goals, though it could be demotivating to some patients. Some older adults and providers noted that GAS could be confusing and that it was uncomfortable to talk about negative outcomes . Factors that facilitated implementation included using visual copies of the GAS forms, having an established patient-provider relationship, practicing the approach, and having previous goal-related clinical training.GAS was feasible to implement across diverse settings, and, despite challenges, both older adults and providers reported that it added value to care planning encounters with the potential to improve delivery of person-centered care. Further efforts to demonstrate the applicability and benefit of this method for older adults are warranted, particularly to address implementation of the approach. There is broad agreement that patient goals and priorities should guide care and quality measures used to evaluate care –3. For oDespite agreement on its importance, there is wide variation in approaches to eliciting and documenting goals , 10. WitGoal attainment scaling (GAS) offers a structured approach for goal setting and measuring goal progress that could support measurement and monitoring. In addition to facilitating patient-centered goals, a key feature of GAS is that goals can be customized to the individual, but their progress can be tracked in a standardized way resulting in a quantitative score comparable across individuals . The GASAt follow-up, the patient and their provider discuss the individual’s progress and determine which outcome most closely matches what the individual achieved in the time since their previous visit.GAS has been used in various settings, including hospital –14, primDespite its promise, studies using GAS with older adults have often been limited in sample size or to single site evaluation , 20–22,mTo address this gap, we conducted a pilot study to understand the feasibility of implementing GAS in routine clinical care across seven clinical sites in the United States . In thisSeven sites participated in a learning collaborative designed to improve the quality of care for older adults with complex conditions by incorporating GAS into routine care Table . Three oThe learning collaborative occurred from July 2016 through July 2017. Providers at each site participated in an in-person training (1.5 days) on GAS and implemented GAS in their practice as a quality improvement activity. The learning collaborative included knowledge sharing across the participating organizations in monthly hour-long telephone meetings and an in-person conference at the end of collaborative.Between March and July 2017, we conducted qualitative interviews with patients and providers to understand their perspectives on setting goals, measuring progress, and achievement of outcomes using the GAS approach. The Advarra Institutional Review Board  approved this study.For the qualitative interviews with patients, we recruited 28 individuals from 184 older adults who participated in the larger study  based onWe conducted qualitative interviews with 23 providers. At three of the sites, we interviewed all providers participating in the pilot and at the remaining 4 sites a smaller subset of providers based on their willingness to be interviewed and availability during the site visit.Separate semi-structured interview guides were developed for older adults and providers. The guides included questions related to the process of using GAS and the overall experience with the approach.Prior to the interview, all participants (older adults and providers) were provided with an information sheet describing the study and the interview. At the beginning of the interview, the researchers reviewed the information sheet and obtained informed consent prior to conducting the interview. All participants provided verbal consent to participate in our study.At each site, two researchers trained in qualitative methods conducted interviews with older adults. Both researchers were present for each interview. Interviews lasted an average of 30 min and were conducted in the older adult’s usual care setting: in-clinic (n = 8) or at home, either in person (n = 11) or by telephone (n = 9). All older adults interviewed received a $50 gift card for their time and participation.At each site, two researchers trained in qualitative methods conducted interviews with providers. Both researchers were present for each interview. Interviews lasted an average of 60 min, and generally took place in a clinic.Interviews were digitally recorded and transcribed verbatim by a professional transcriptionist.Data analysis began in June and continued through September 2017. Although there was one-month overlap between data collection and analysis, our analysis did not inform the subsequent interviews (n = 3). We used an iterative approach in our analyses, allowing for emerging themes to shape subsequent analysis. To improve methodologic rigor and validity, the team conducted analysis utilizing three methodological principles: constant comparison (p. 210), negative cases (p. 89), and rival thinking (p. 211) .The data analysis began with preliminary review of a sub-sample of interviews (N = 5) by the primary coder (CAC). An initial codebook was developed based on the interview guides and initial review of interviews. The coding team included two additional researchers. Inter-coder reliability for the coders was established with the same sub-sample of interviews. Inter-coder reliability was defined as applying the same code to a similar section or passage of the text.The team independently coded the remaining transcripts using NVivo 11 Pro, a qualitative data management and organization software. The team met weekly to share observations, add new codes, and reach consensus on complex interview passages. The three methodological principles listed above informed these meetings: Team members were instructed and encouraged to compare that week’s coding to findings from previous weeks , to highlight instances in which data differed from the main themes , and to acknowledge alternative interpretations .The final codebook was developed after all transcripts were coded. Previously coded transcripts were reviewed with the final codebook to ensure that all codes were appropriately represented in the final analysis.On average, the older adult participants (N = 28) were 74 years of age (SD 8.81) with multiple chronic conditions (mean 3.71) and multiple activities of daily living (ADL) limitations (mean 2.79). The majority of older adults were female (67.9%), white (71.4%), and non-Hispanic (92.9%).p > 0.05)  Table . Two intThe 23 providers interviewed, comprised of registered nurses (10), nurse practitioners (4), social workers (6), physicians (2), and 1 patient navigator. Fourteen (60.9%) had more than 3 years of work experience at the participating sites. Of those with more than 3 years of experience, the average length of tenure was 5.4 years. Length of tenure was missing for 1 provider .Overall, most older adults and providers reported that using GAS added value to the care planning encounter, although some expressed challenges. Table we both had some input in it. That’s what was nice about it” . Participants described goal setting in the care visit as a joint venture with their provider where both parties had a voice. A 77-year-old man said: “I’ve compromised a little, she’s compromised a little” .Many older adults said they liked the collaborative nature of the process of working with their provider on setting a goal and using GAS to follow progress. For example, a 64-year-old woman described the goal-setting process as a process where “This is the [goal] that they are focused on because this is the one that they’ve had so much input on...this involves them having to have a discussion in what they want and how they hope to achieve it. Another provider said, "It solidified the relationship. It solidified the transparency as far as what we were working towards, and what I heard" .Generally, providers viewed the process of goal setting and the GAS approach as supporting collaboration with their patients in the care visits. A social worker explained the positives of this collaborative effort, saying,"more opportunities now to go after [her] goals" when using the GAS approach . Participants also explained that the GAS approach was easier to understand as compared to the standard goal setting offered by the site. A 64-year-old man said,Well, it’s a little easier for us. And well, you know, I don’t really -- I wasn’t really motivated, have the ambition, you know, to really say I know I should, but I didn’t. But with her and this program here, because she is like, “Well, OK, well...” And I do find out -- I have found out that in doing some of the things that we put down, there’s strength in me .Several providers commented that the GAS was a useful method even when the older adult did not meet the goal they had set. In fact, some providers said that re-scaling the goal during follow-up encounters after challenges or setbacks was the most meaningful part of the GAS work. As a social worker explained, even when an older adult does not meet their goal,It allows for a good conversation about…what the challenges were, and what kind of things can we help you to overcome those .Several providers found that using GAS with their patients uncovered new goals and concerns. As one nurse described it:So you go in and you’re like, ‘OK.’ In my head I think I kind of know what they’re going to pick. And they pick something completely different. That’s cool. I would have never pegged that .A social worker commented that the GAS method “opened the door for discussion [of] things that they hadn’t even mentioned before” .Older adults also explained how using the GAS approach differed from their usual process of working with their providers. One 75-year-old woman felt that she had I was made more aware of the time spent at the bedside, how much you can gain from that conversation, how much information you can gain to make the right referrals and to set that patient up for even a greater success post-discharge .Providers also described the utility of the GAS method to inform patients' care plans. One nurse who visited older adults in a rehabilitation facility commented,Because it kind of gives you incentive, you know, and a person being home all the time gets in a rut, you know, and do the same things every day, every day. And this kind of gives you a goal to do something .A 58-year-old woman said,Well, it’s [goal-setting] very important for me, because that’s -- that’s what makes me -- that’s what keeps me going .Several older adults said they thought that other individuals could find the process to be motivating as well.Many older adults described the process of goal setting as motivating. When asked why she wanted to continue with setting goals, a 68-year-old woman explained,It helps you focus because you’ve got the paper right there, and then you want to be able to write down that you walked and that you made some improvement, and it’s -- It reinforces -- It’s a positive reinforcement and I think that would help keep anybody just a -- you know, more motivated .Despite their general positive feelings about the process, a few providers did express concern that patients might feel sad or guilty when they did not make expected progress. For example, when asked to compare the GAS method to usual practice, one social worker said,I think maybe because this was like this process where it was documented, and it was this whole thing, it felt like she had somehow let us down by not achieving the goal .Furthermore, some older adults said they felt bad when they did not meet the goal they had set for themselves. A 63-year-old woman commented that she did not like this method of working with her provider because,I feel like I’m expected to do this, you know, after I say this is what I want to do…It makes me feel guilty when I can’t do what I said I wanted to do .Another participant, a 67-year-old woman, worried prospectively about the potential outcomes of not reaching her goal and feeling negatively. She said, "And then if my goal come, and I haven’t reached that goal, then I will feel bad" .A 67-year-old woman described the GAS method this way:I feel like the one thing that was a little bit confusing was the goal, and the starting at zero and the plus and the minus was slightly confusing to some people .Some older adults also noted confusion with the GAS method for goal setting. A 63-year-old woman commented,The whole thing is difficult...the questions, you know, making the goals and stuff. It’s always been hard for me to understand it since it came out, you know, and I really don’t like it .Another example was mentioned by an 86-year-old man who described his confusion with understanding the direction he was supposed to be working towards with the scaling, which was resolved by a conversation with his provider.86-year-old male: Sometimes I get confused on which way we’re going…but then when he tells me, I understand where we’re going. Interviewer: OK. So, it’s a little unclear -- so, it’s about how you’re scaling the goal to be better than expected but Dr. [Name] helps you kind of understand?86-year-old male: Right. He explains it a little better and then I understand. Providers also worried about confusing patients with the process and the standardized scales involved with the GAS method. The 5-point GAS scale is a set of possible outcomes ranging from “worse than expected” to “better than expected”, with a numerical weight from − 2 to + 2 is assigned to each possible outcome. One nurse said,If you got somebody that's really gung-ho... [and] you're bringing up, 'Well, what if you didn't do it?' [They] say, 'No, but I am going to...You're supposed to have confidence in me. You're supposed to think I can do this. Why are you asking me what it would look like if I don't do it?' So that was an interesting thing. That didn't happen all the time, but I think it happened a couple times .Some providers commented on the issue of discussing negative outcomes  with patients and worried about confusing or upsetting them. One nurse practitioner relayed an encounter to the interviewer:Across and within the seven sites, there were slight variations in how GAS was implemented. Providers noted several steps that made GAS easier to implement.“it gave me something definite that I could see in black and white” . In other interviews, older adults mentioned keeping the form in a visible place in their home—such as putting it on the refrigerator, in their calendar or appointment book, or by their bedside—in order to help them stay focused on meeting their goal.At four of the seven sites, providers gave older adults a physical copy of their scaled goal. Several older adults at sites who provided a physical copy commented that they liked seeing their goal written out, and that the paper copy served as a physical reminder to focus them. As a 67-year-old woman said, A 63-year-older woman mentioned that had she been able to see the worksheet (which was present in the interview), it would have made more sense and she would have preferred to fill it out herself.Interviewer: What do you think makes it easy to talk to her?82-year-old woman: Because I’ve developed trust, she’s developed trust. .Patients and providers said GAS was easier when they already had a relationship of rapport and trust.I became more comfortable with it. I mean, obviously, those first couple of times, I probably sounded like I was fumbling. But, towards the end...I was -- yeah, overall felt comfortable with it .Providers explained that the initial visit where the goal and the scaling was established was the longest and least comfortable as the GAS method was a new process to them. As providers continued to implement the GAS approach and became more comfortable, the time added to the length of the encounter decreased. A nurse described the experience, saying,Social worker: I mean this is where I kind of just tried to like weave it in because we normally have conversations with our patients about goals usually. So, you know, it would just kind of -- it didn’t feel that uncomfortable because I just sort of had the conversation that I would usually have around setting the goal .Providers who had experience with goal setting or motivational interviewing expressed that GAS was more a continuation of their usual care.This study suggests that that the use of GAS was feasible with older adults with multiple chronic conditions and functional limitations in various clinical settings, and older adults and providers found value in the process. Still, the GAS approach can be challenging, and participants identified key facilitators that may help to overcome these issues, such as using physical copies of the GAS form as a visual reminder, developing rapport in the patient-provider relationship, repeatedly using the method, and capitalizing on previous training like motivational interviewing. As with all qualitative research, the researchers bring their own experiences to data collection and data analysis. We acknowledge that the gender , race (White), ethnicity (non-Hispanic or Latino) and professional dynamics of our researchers may have influenced data collection. For example, our non-clinical backgrounds may have influenced how the providers tailored their responses . In response, during data analysis, we attempted to maximize methodologic rigor in our research process .Our qualitative findings expand upon and provide context for the findings of Giovannetti et al. . GiovannIt is important to note, due to the study design and implementation of Giovannetti et al. , we cannThe health care system often misses the opportunity to involve patients in their care, even less so to account for their diverse care preferences and goals . The GASOur findings suggest that the GAS method may offer accountability, which was expressed by both older adults and providers. Accountability is a foundational aspect of patient activation and engagement, which is described as the patient’s “motivation, knowledge, skills, and confidence to make effective decisions to manage their health” . Our stuGAS is a tool that may offer value for both patient care and for evaluating quality of care. Using GAS, providers can have collaborative discussions with patients to identify the patient’s ideal outcome. By understanding and responding to the preferences and goals of the patient, providers may be better able to engage patients and caregivers, identify problems, and prescribe or recommend care more aligned with what matters most to them. With GAS, providers can measure these prioritized outcomes on a standardized scale and track progress over time. The standardized, yet personalized, methodology helps illustrate how well a provider or care team is helping individuals achieve the outcomes that matter most to them, a key pillar in The John A. Hartford Foundation and Institute for Healthcare Improvement Age-Friendly Health System initiative .This study highlights areas of future research, particularly for integrating GAS into clinical care. Implementing GAS on a large scale  magnifieThis study has a number of limitations. First, our findings were based on a small, convenience sample of older adults with multiple chronic conditions and functional limitations enrolled in care management programs. This sampling strategy was chosen to ensure availability and willingness to participate, as well as an adequate ability to communicate , 35. DesOverall, the GAS method is promising and requires training and preparation for all parties, including providers, patients, and family members. Given the potential benefit and the implementation learnings from this study, further efforts to demonstrate the applicability and benefit of the GAS approach for older adults are warranted. Such work should specifically address implementation issues on a larger scale.


The emergence of opinion polarization within human communities—the phenomenon that individuals within a society tend to develop conflicting attitudes related to the greatest diversity of topics—has been a focus of interest for decades, both from theoretical and modelling points of view. Regarding modelling attempts, an entire scientific field—opinion dynamics—has emerged in order to study this and related phenomena. Within this framework, agents’ opinions are usually represented by a scalar value which undergoes modification due to interaction with other agents. Under certain conditions, these models are able to reproduce polarization—a state increasingly familiar to our everyday experience. In the present paper, an alternative explanation is suggested along with its corresponding model. More specifically, we demonstrate that by incorporating the following two well-known human characteristics into the representation of agents: (1) in the human brain beliefs are interconnected, and (2) people strive to maintain a coherent belief system; polarization immediately occurs under exposure to news and information. Furthermore, the model accounts for the proliferation of fake news, and shows how opinion polarization is related to various cognitive biases. As Evan Williams, co-founder of Twitter, famously said in a 2017 interview, “I thought once everybody could speak freely and exchange information and ideas, the world is automatically going to be a better place. I was wrong about that” , insteadopinion dynamics , has emerged in order to study the way opinions, information, views and beliefs propagate in human communities [consensus refers to the state in which all social actors share the same opinion, polarization to the condition when each agent accepts one of two opposing opinions, while fragmentation refers to a transitory phase, in which a finite number of distinct “opinion islands” appear.The quest for finding a valid explanation—and a practicable model—for the phenomena of the above mentioned polarization and fragmentation has been underway for decades. Specifically, regarding computational models, an entire field, munities ,14,15,16munities ,12,17. Wevents often have a polarization effect [A key concept related to continuous opinion dynamics models—models representing opinions as scalars taken from a continuous interval usually between under it ,14,15,17under it ,20,21,22under it . Lately,under it  or by inunder it  definingn effect ,26, the n effect —in a wayn effect . Other mn effect  or hydron effect  perspectIn the present paper, an alternative, or complementary, explanation is suggested, by showing that in case some “basic” human characteristics are incorporated, polarization immediately appears once agents are exposed to new information—even without direct communication. These almost trivial human characteristics are that (i) human beliefs are interrelated rather then evolving independently of each other, and (ii) people strive to maintain a coherent, contradiction-free belief-system. The fundamental difference between “classical” opinion dynamics models and the ones incorporating such features is that while in the first case agents are represented with a single scalar value in the second case the model of the social actors has some kind of inner structure. This difference gives rise to an entirely different dynamic ,31.never occur alone, that is, no concept or belief can exist in isolation.  which has well-defined features [First and fore-most, it seek to be consistent. This means that people try to maintain a belief system in which the elements mutually support each other, or are independent [conflicting beliefs, people experience discomfort called cognitive dissonance [ependent ,52. In tssonance ,54 whichssonance ,56.Secondly, beliefs are not equally important: those that are more personal, closer to the “self”, “identity” or “ego”, trigger more intense feelings and are more difficult to change [hierarchical property: the ones that are higher in rank define or constrain the ones that are lower in rank [o change ,46,54,57 in rank . For exa in rank . FurtherFinally, beliefs belonging to the same broader topic  are more strongly interrelated than beliefs belonging to different topics. For example, attitudes towards “freedom of speech”, “religious freedom” and “freedom to choose spouse” are more closely related than beliefs regarding “freedom of speech” and, say, homeopathic treatments. In mathematical  terms, belief systems are “modular” or “compartmentalized” [talized” ,50.During the last decades, a vast amount of knowledge has accumulated in scientific fields on the ways humans perceive the world, make decisions and structure their beliefs. Despite the fact that obtaining a detailed understanding of these processes still require further work, some scientific fields, such as neurobiology ,34,35,36aningful .) Ratherfeatures ,47,48,52modular, hierarchical network (graph) in which the nodes are connected by supportive (positive) or invalidating (negative) relations [As a first approximation, such a structure can be represented as a elations ,49,50,59elations ,61. Theslevel of consistency can be defined [relatedness of beliefs—captured by graph representation—while the hierarchical and modular characteristics do not gain special importance , whether they be simple or complex, that can be transmitted with the use of language from one person’s mind to another’s [In these models, a node is “an element of a person’s belief system” , which tnother’s ,43. Accoincrease the system’s consistency—while others—the ones decreasing the system’s consistency—will not [biases in the field of psychology and sociology [The fact that beliefs (attitudes/concepts) are in functional relation with each other  is crucial, because it implies that some “new” belief will fit into an already existing system—the ones that will not . These lociology ,65,66,67ociology ,41,65,66marketing campaign failed, so it is actually a miracle that the product was sold at all [merits of the product, not its failure, and as such, serves as a basis for the pleasant feeling of reassurance. This mechanism is analyzed in Furthermore, these cognitive dissonance avoiding mechanisms are in close relation with the proliferation of fake news and the circulation of various types of questionable information as well. In case the well-fitting of a piece of information into the already existing belief system weights more than its credibility, people will adopt it—simply because it provides the pleasant feeling of reassurance. This mechanism is applied in all aspects of life, not only in case of political issues. For example, in the field of economics, it has been observed that managers, whose sales fall short of expectations, rather than rethinking the qualities of the product, tend to identify the cause of the failure elsewhere, for example in the marketing campaign. In such cases, they state that the d at all . By findN agents. At this point, only their attitudes towards two concepts are important  and, say, a certain public figure (Concept 2)). People can hold any kind of attitudes towards these concepts, from total condemnation (marked by We assume a population of epts see b.in favor of vaccination (concept 1)”  will give rise to the comforting feeling of ssurance . In thiseduce it ,54.Turning back to the basic scenarios, an agent can hold negative attitude towards one of the concepts, and a positive one towards the other—say, for example, a negative attitude towards the public figure and positive attitude towards vaccination. In this case, a negative relation will give rise to reassurance, i.e., “XY politician, whom I anyway hold very low, talked out against vaccination, a cause so important for me ... No surprise here, a fool is known by his conversation” and so on. All scenarios can be analyzed with the same train of thought.i will experience at time-step t, can be formulated as:i towards concept 1 and 2, respectively, at time-step t , and C is positive, it is called reassurance, while in case it is negative, it is usually referred to as cognitive dissonance. Anyhow, in both cases, C denotes the value by which the information alters the coherence or consistency level of agent i’s belief system. Note that Accordingly, from a mathematical point of view, the cognitive dissonance (or reassurance), see also b. In cas(i)Rejecting new information that conflicts with the already existing ones;(ii)Re-evaluating the attitudes;(iii)A tendency of “explaining things away”, that is, finding alternative explanations (developing new beliefs) which supplement the original information in a way that the primordial contradiction is dissolved.According to the literature ,41,65,66From a modeling point of view, the first strategy—rejecting the information—simply leaves the belief system unaltered. In this case, in the framework of the model, the network—nodes, edges and weights—remain unchanged. The second and third strategies do modify the belief system, due to the new connection between the originally unconnected concepts. In the following section, we will focus on modelling these strategies.The constant re-evaluation of our already existing beliefs is an inevitable part of the process of learning and development . New infIn the context of a formal model, the most simple and plausible way to grasp these attitudes is to use numbers between how these values might change, consider for example the following case: Paul believes that, say, genetically modified food is harmful. He has already heard it from his friends, and now he reads it in his favorite blog as well. This gives him a feeling of reassurance, due to which he will be convinced about the verity of this belief even more, and will be more attached to his favorite blog as well. In other words, the "embeddedness" of the original attitudes will increase. Mathematically speaking, his already positive attitudes towards these concepts (his belief and the blog) will increase even more due to the positive connection. Now consider a situation where he learns the opposite from his favorite blog, namely that there is nothing at all that could be harmful in genetically modified food . In this case, he will experience some level of cognitive dissonance, whose extent depends on his original commitments towards the two concepts [cognitive dissonance , while reassurance  increases it. Consider the following formula:i at time-step t towards attitude k, cognitive dissonance, in case it is negative, and reassurance in case it is positive). Finally, the In order to see concepts ,53,56. T(2)ai,kt+=sign, some people are detached, while others are convinced that they are just evil-minded hoaxes. The more extreme an attitude is, the more difficult is to change it ,46,54,57"more difficult to change" can be introduced into the model in two ways:a is, the lower the probability that it will change. Equation —to 1. In other words, in Equation , then they interact with each other. In contrast, if the source of the information is something else  then agents do not interact directly with each other. In reality, information usually circulates in both ways. The reason why entire populations are considered is twofold. Firstly, because one single agent cannot “polarize”; they can develop extreme attitudes under certain circumstances. Polarization is an emergent, statistical property of communities, a phenomenon which does not have an interpretation on the level of individuals. The larger the statistics, the more apparent the phenomenon. The second reason is that after studying the elementary process of attitude-update in detail (which is the topic of the present paper), an immediate next step is to study the way by which agents manipulate and organize their social ties (links) assuming similar motivations (avoiding cognitive dissonance and enjoying reassurance).Note that in all the equations, the updated attitude values depend only on the agents’ previous attitude values  is proportional to the relief its adoption provides. Since only positive The most simple assumption is that the probability i towards concept 1 and the new belief at time-step t, respectively, and As shown before, Let us consider a population in which the agents’ initial attitudes towards two arbitrarily chosen concepts are distributed uniformly, taking values from the t, a randomly chosen agent i acquires the information, and updates his/her attitudes according to Equation (t), the attitudes tend to move towards the two extreme values, distribution of the attitude values within the population evolves very similarly in case of the two attitudes, since both are governed by Equation . The diEquation .  in order to avoid cognitive dissonance. This phenomenon is highlighted in Note the small peaks around near-zero values in Equation ) pushes Equation .As has already been mentioned, the other “basic strategy” applied by people in order to reduce the unpleasant feeling of cognitive dissonance is to reinterpret the incoming information by placing it into a context in which the contradiction vanishes, or even better, serves as a basis for reassurance . For exaIn the context of the present framework, this scenario can be represented by supplementing the original graph . In contrast, those for whom the approval of the new belief would create cognitive dissonance, simply reject its adoption. In terms of the model, in their case, the edge The detailed methods by which humans perceive and make sense of the world—despite some eminent achievements ,34,38,39Accordingly, the novelty of the present model lies not in “assuming” the above-mentioned two human characteristics—since they are well-studied and widely accepted by main-stream science ,53,55—ra(i)entire system. From a physicist’s point of view, this process is in close relation to physical structures aiming to reach an energy minimum. In this approach, “different realities” [elementary relation between two elements of the system before considering the entire structure. The present manuscript focuses on this elementary relation. Graph representation is important because, and only because, it serves as a mathematical tool for handling interrelated entities (which are the “beliefs” or “concepts” in our case). Since in the human mind a vast amount of concepts and beliefs are interrelated densely and intricately, any of its graph representations must also assume a vast amount of intricately interrelated (linked) nodes. However, from the viewpoint of the present study, the specific type of the graph does not play any role, because we focus on the elementary process altering the characteristics of two nodes  due to a newly appearing link between them. . The nodes whose values alter are selected by the link (representing a piece of information).Real belief systems have a tremendous amount of elements (instead of two or three), that are interconnected and embedded into each other in a complicated manner ,43, and,alities”  can be d(ii)exactly the same, only that the type of connection between two concepts  is tenaciously either positive or negative. Hence, it also explains how attitudes can become extreme due to the continuous repetition of information, and as such, it serves as a complementary explanation [The present model does not assume that the repeated information is lanation  for the There are two more further points worthy of consideration related to the model:intensity of the exposure. More precisely, in case of limited exposure, people tend to develop a centralist attitude first (which is an unstable equilibrium point), which, in case of persistent news-circulation, give way to extreme stances. The dynamics under limited exposure to news was not studied extensively in the present manuscript.Furthermore, the present model has some additional results as well, which are yet to be studied. Specifically, according to the results, the attitudes a certain type of news or information triggers depend on the The ambition of the paper was to call attention to certain human traits that have not yet been incorporated into current computational models aiming to simulate opinion dynamics in human communities. From this perspective, the main point is the naturalness by which polarization can emerge, despite the fact that the model incorporates only minimal assumptions which are considered to be part of well-established, main-stream scientific results.


People with aphasia need high-intensive language training to significantly improve their language skills, however practical barriers arise. Socially assistive robots have been proposed as a possibility to provide additional language training. However, it is yet unknown how people with aphasia perceive interacting with a social robot, and which factors influence this interaction. The aim of this study was to gain insight in how people with mild to moderate chronic expressive aphasia perceived interacting with the social robot NAO, and to explore what needs and requisites emerged. A total of 11 participants took part in a single online semi-structured interaction, which was analysed using observational analysis, thematic analysis, and post-interaction questionnaire. The findings show that participants overall felt positive towards using the social robot NAO. Moreover, they perceived NAO as enjoyable, useful, and to a lesser extent easy to use. This exploratory study provides a tentative direction for the intention of people with mild to moderate chronic expressive aphasia to use social robots. Design implications and directions for future research are proposed. Aphasia is a language disorder caused by acquired brain injury mostly as a result of a stroke )A potential alternative, which could address the limitation of screen-based treatments, is the use of social robots. Although not studied with PwA, extensive research has been conducted on interacting with SAR. Like asynchronous screen-based practice programs, robots are—in principle—always available, unlike human therapists, and can be utilised in the home environment of PwA, allowing them to practise language independently, whenever they want. Yet, contrary to screen-based practice programs, SAR were found to have three major advantages in social interaction. These advantages are: (1) physical embodiment, (2) the ability to tailor the interaction, and (3) the ability to use multimodal communication.The first advantage of SAR is its physical embodiment in social interaction that is absent in screen-based systems –25). Bai. Bai25])The second advantage of SAR in social interaction is the robot’s ability to personalise therapy to its user, and additionally, use motivational strategies to increase engagement. Van Minkelen et al.  researchThe third advantage of SAR in social interaction is its ability to use multimodal communication, i.e., they can simultaneously use speech, gestures, and facial expressions. Various research demonstrates that PwA benefit from multimodal communication –34. EggeBesides the ability of SAR to use gestures, SAR can recognize gestures made by humans . This caSo, while SAR have the potential to provide PwA additional language training effectively and acceptably, little research has been done to investigate how this could be achieved. We present an exploratory study on how PwA perceive an interaction with a NAO robot with the aim to provide guidelines to develop such robots.A mixed method approach was applied by combining a semi-structured interaction and observations  with questionnaires (quantitative). This approach allowed for observation and analysis of participants’ interaction with the robot, as well as assessment of participants’ perception of the interaction, to answer the research questions. Due to the Covid-19 pandemic, the interaction took place online, which means that participants had a conversation with the robot via a video call. One participant interacted with the robot in real live as a case study. This study received ethical approval from the Research Ethics and Data Management committee of Tilburg University.M = 52.09, SD = 13.61) were recruited using purposive sampling. This entailed contacting all aphasia centres in the Netherlands via email, placing a call on the website http: www.afasienet.com , and by the first author, a former aphasia therapist, approaching PwA personally. Participants were included if they were Dutch native speaking adults with a mild to moderate chronic expressive aphasia who were able to speak intelligibly without any help from anyone. Participants were excluded if they suffered from severe language comprehension problems, psychiatric problems, encountered problems in maintaining attention for thirty minutes, suffered from a progressive disorder, and suffered from severe hearing impairment. All participants received an information letter and a consent form. These two forms contained simplified language to ensure participants understood the content. All participants gave written consent and additional consent on video. Table A sample of 11 participants  with an age range from 21 to 68 years old (N = 7), Zoom (N = 1), Microsoft Teams (N = 1), and Cisco WebEx (N = 1). Participant #11 interacted in real live with the robot. The robot, participant, and researcher all sat in the same room.Participants #1 through #10 interacted online with the robot, so participants and the robot were not in the same room, whereas the researcher and the robot were in the same room. Participants used different platforms for accessing the robot remotely: Skype ('online participants') were contacted at an agreed time via a video call using a laptop. The NAO robot and the researcher sat side by side in front of the laptop. The researcher asked participants if they could see and hear her properly, after which instructions were given to improve image and / or sound quality if necessary. The interaction between the robot and participant #11 (henceforth 'live participant') took place at the home of this participant.Participants #1 through #10 . First, the robot explained the setup of the conversation. Second, questions about participants' holidays were asked. Third, the robot announced a change of topic into 'work’ and asked if the participant currently has a job, so questions about 'work' could be asked in the present or past tense. Fourth, participants were asked if they normally use alternative and augmentative communication (AAC) forms when they had not used AAC up until that point of the conversation. The robot then encouraged them to use AAC during the remaining of the conversation. Fifth, questions about participants' work were asked, and finally, the robot ended the conversation with thanking the participant. The number and order of the questions asked about 'holidays' and 'work' depended on participants' responses. For instance, if the participant disclosed in one answer where and with whom he went on holidays with, questions regarding this were passed over. The robot used conversational fillers and clarifying questions to continue the conversation. Importantly, this research focused on how people with aphasia perceived interacting with the robot, therefore, the conversation in itself is the focus of this study and not so much which questions were asked or what answers were given.Next, the robot introduced itself by saying 'online participants. The online participants were asked if they preferred to name the number of their choice, or to make the number clear by raising their fingers. They were also informed that the researcher was going to share her screen so they could see the question and then end the screen sharing, so the researcher appeared full screen. In this full screen mode, the researcher asked them to provide an explanation about their answer. The questionnaire was presented on a tablet to the live participant.After the interaction with the robot ended, the researcher re-appeared besides NAO in front of the laptop camera to introduce the questionnaire to the After participants finished the questionnaire, they were debriefed about the used WoZ during the interaction, after which the recording was ended.This study used the 58 cm tall humanoid robot NAO  with 25 degrees of freedom, produced by Softbank RoboticsThe interaction, which was in Dutch, was designed using Choregraphe version 2.8.6.23 , on the Furthermore, to ensure consistent robot behaviour across participants, autonomous life was switched off, since this setting causes the robot trying to make and maintain eye-contact by moving its head, besides making breathing movements and subtly moving back and forth. The threshold for automatic speed recognition was also adjusted to avoid unintentional triggering of behaviour by unintentionally naming a user rule. A preliminary assessment of the clarity of the interaction as well as the appropriateness of the questionnaire regarding the aimed constructs was performed by two experienced researchers in the field of social robotics. As a result, some minor adjustments were made to the interaction and the questionnaire.online participants compared to the live participant. For the online participants, the duration of the interaction ranged from 6 min and 28 s to 8 min and 57 s, with an average interaction duration of 7 min and 7 s, whereas the interaction duration of the live participant was 5 min and 14 s.The duration of the interaction was noticeably longer for the online participants, due to the distance between NAO and the laptop microphone, an external microphone was used which was connected to an Alecto PAS-210 speaker set with a mixer, built-in amplifier, and two speakers. This microphone and speaker set was not used for the live participant.To bridge the sound loss for the online participants via a shared screen on the laptop, and on a Microsoft Surface Pro 13-inch laptop with a touchscreen to the live participant. Figures online participants.The questionnaire see 3.2.2) was presented to the .2 was prTo explore how participants interacted and communicated with the NAO robot, participants’ interaction with the robot was manually coded on four general categories that might influence the interaction: (1) simultaneously turn-taking  communication break-down  that hindered the interaction; (3) participants’ mood during the interaction; and (4) participants’ involvement in the interaction. “Appendix B” shows the coding scheme with general categories and subcategories. To this aim, 2-min video clips were created, starting at question two from the topic ‘holidays’ for one minute, followed by question two from the topic ‘work’ also for the duration of one minute. We started at the second question of both topics , so participants could get familiar with the topics and the conversation would be well underway at that point. Clips from both topics were included to reduce possible preferences of participants in terms of the topic.online participants (40%), as well as on the single live participant. The inter-rater reliability was assessed using a two-way mixed effect model based on the mean-rating (k = 3) and consistency , t(10) = 2.96, p = 0.014, d = 0.89, indicating that participants enjoyed interacting with NAO above the middle value. Participants' Mean PU  was also significantly higher than 3.0, Mdiff = 0.77, 95% CI , t(10) = 2.32, p = 0.043, d = 0.70, indicating that participants perceived NAO as useful Participants' Mean ATT  was also significantly higher than 3.0, Mdiff = 0.77, 95% CI , t(10) = 2.48, p = 0.033, d = 0.75, indicating that participants believe NAO could be of practical use However, participants' Mean PEOU  was not significantly higher than 3.0, Mdiff = 0.36, 95% CI , t(10) = 1.90, p = 0.087, which means that participants did not perceive NAO as easy to use. Figure Next, four one-sample  1.59], t = 2.96, Three major themes were identified from the transcripts of the open-ended questions, as Table Well, uh then [participant moves arms alternately up and down] also there [participant makes ssss-sound], don’t do that. Just [participant moves arms alternately up and down + pp makes rrrr- sound]. Is difficult for me to talk with [participant makes rrrr-sound] so.Participant 4: Are you saying that if the robot makes a lot of gestures, it is difficult to understand?Researcher: Yes, exactly. [The participant moves arms alternately up and down + pp makes zzzz-sound]. Researcher: Do you hear him move?Participant 4: For me then uh yes [participant makes a circular movement next to the temple].Participant 4: Uh, sound, and he does all kinds of things [participant makes big arm movements], and that a little bit, and that uh, that doesn’t go so well than uh.Participant 2: Well, uh the robot that, that talk uh that’s nice but moving the arms of this that thing, it’s almost impossible to follow.Participant 3: The first theme that emerged from the open-ended questions was the intelligibility of the robot. Six participants (55%) mentioned that the robot’s gesturing negatively affected its intelligibility, as Fig. First, I got a bit difficult. It is a bit better, later it is a bit better.Participant 5: Okay, so you had to get used to it?Researcher: Yes.Participant 5: To the sound that the robot made, is that what you mean?Researcher: Yes, yesParticipant 5: And then when you get used to it, then ...Researcher: Yes, that is going better.Participant 5: Uh, wait a while, uh. What did you say? What did you say? What did you say?Participant 10: Are you saying that you couldn’t always understand the robot properly?Researcher: Right, yes.Participant 10: A subtheme that emerged from the data was that participants (45%) needed to familiarise themselves with the sound of the robot’s speech to understand it properly.Well. Don’t you uh don’t you have say shame.Participant 11: So, you mean it’s okay to make a mistake because it’s just a robot?Researcher: Yes, correct.Participant 11: That robot has no emotion and there you have no embarrassment because then it is safe, eh, because then it is safe, eh.Participant 6: The second theme that emerged was that participants (73%) highlighted that the robot was nice and was easy to talk to, due to the robot’s slow speech rate and delayed response timing see Fig. . This enIt would be nice if he uh if you can respond to what you say. More uh today’s newspaper or uh whatever, if he that robot can have something unpredictable, can have something predictable. [...] Yes, slightly more variety and is more on random, give it a newspaper headline. What are you doing today? Well, I have to pass an exam today. Then I hope he knows and a somewhat larger repertoire, that he knows what an exam is so to say. Because that I can pick up on that. Or uh I’m going to a party. Nice who’s birthday? Sort of.Participant 9: If uh I had a story and then and then it has a uh conclusion a summary and uh was not the correct description of the story uh uh an example uh holiday. I had, he said, what uh was the nicest or nicest. I wanted the story of uh restaurant I made up completely uh well. But uh, his answer was” oh nice”.Participant 6: And what else could the robot have done there?Researcher: Yes uh, even better interaction.Participant 6: So that the response would have been more appropriate?Researcher: Yes, right yes.Participant 6: The third theme that emerged was that participants (64%) indicated that they would have liked more dialogue with the robot, in the sense that the robot would have responded to their answer in a more content wise manner  appreciated that the robot talked slowly, which provided them more time to process language.I can’t uh, not uh [participant moves hands alternately between himself and the robot], no uh, he’s not helping.Participant 11: He doesn’t help?Researcher: No.Participant 11: And how could he help? What could he do to make it easier?Researcher: Questions, something else, let’s say. How do you want that uh? Something else again ask so to say. Researcher: You mean he could repeat the question in a different way?Participant 11: Yes, something like that. Another time. Deeper again. Still question.Participant 11: Some additional questions?Researcher: Yes yes.Participant 11: So, it would have been easier if he had asked more questions?Researcher: Yes, deeper so to say. That it uh that it, he helps with uh you can more uh questions answered so to say.Participant 11: Because then you could have told some more?Researcher: Yes yes.Participant 11: Well, uh I uh I, now I have it again. Sometimes I can’t find the words and if that robot gives me a boost of uh, could it be this or could it be this, then he could help me, I think.Participant 3: A third subtheme that emerged from the data was that participants indicated that the robot did not sufficiently cue them during word retrieval difficulties. They mentioned that the robot could have asked additional questions and more in-depth questions to assist them formulating their responses.My uh I am furthermore uh good but uh, the first start of practise with aphasia then the robot was a uh added value in the sense of uh, then you can uh why do I say that, that exercises are limited in time. If you go to a rehabilitation centre, for example, you have 20 minutes of exercises with a speech therapist a day. Yes, that is limited. And that robot has all the time.Participant 6: Well, uh, look uh, if you have aphasia you should be able to talk continuously because. Actually, you should also continuously have exercises.Participant 6: You can practise. Practise, practise, practise. And if an alone here, all day. You cannot talk. And now [pp gestures to robot and herself] you can talk.Participant 11: Well if no one is home, yes then you can uh without making an appointment, I think, have a small conversation with the robot.Participant 3: The fourth theme that emerged was that participants (73%) indicated that they would like to increase the frequency in which they can practise language use in addition to language therapy see Fig. . They emApart from the three themes that emerged, it is also important to highlight that six participants (55%) used different kinds of nonverbal communication forms to express themselves. The nonverbal communication forms that participants used were (1) writing something down on a piece of paper or on a mobile device and then held it in front of their laptop camera; (2) gesturing; (3) gesturing accompanied by sound; and (4) showing an image on the telephone to the laptop camera. Participants used this augmentative communication when referring to the gestures the robot made, as well as when answering demographic questions about ‘year of birth’ and / or ‘highest degree of education’.This study aimed to present a first-effort view on how PwA interact with the social robot NAO and how they perceived this interaction by observing, analysing, and assessing PwA’s interaction. In this section, findings are discussed along three factors underlying the success of self-administered technology-based treatment of PwA, as proposed by Macoir et al. . These fintelligibility of the robot (55% perceived the gestures made by NAO as noisy), and in the observations regarding communication break-down due to not hearing the robot properly. In contrast, participants mentioned that NAO was nice and easy to talk to, had a good speech rate.The analyses suggest that participants did not perceive NAO as easy to use, which echoes in the theme Based on these data, it appears that gestures made by NAO complicated the communication for participants instead of facilitating it. This contradicts previous studies, which demonstrated that PwA benefit from multimodal communication –34, becaAn alternative explanation for the perceived low intelligibility of NAO would be that the robot’s speech combined with gesturing increased the cognitive load of participants to such an extent that they experienced increased language comprehension problems. This is in line with the findings of Murray , who foulive participant it is striking that this participant did perceive NAO as well intelligible, and in addition, did not encounter communication breakdowns.Another possible explanation for the perceived low intelligibility of NAO as a result of gesturing would be that the interaction took place online. During video calling all sounds, i.e., the speech of the robot but also the sound of the robot’s motors while making gestures, were evenly amplified. As a result, the robot’s speech may have been perceived as less intelligible. This effect could have been reduced by advising participants to wear a headset, yet none of them did spontaneously. Alternatively, participants may have adjusted their audio settings after the initial question of the researcher whether they could hear the researcher properly. Unfortunately, the online setting made it infeasible to verify this repeatedly without disrupting the flow of the interaction. When examining the data of the Perceived ease of use is the simultaneous turn-taking, where the participant and the robot interrupted one another, or started talking at the same time. There are three possible explanations for these findings. First, the internet bandwidth of participants may have been too low causing the connection to hamper. This delay in signal reception may have caused participants to assume that the robot finished its turn, when in fact the robot was still taking its turn. This possible explanation, moreover, may explain why no simultaneously turn-taking was observed in the live participant, although this concerned only one participant. Second, comprehension problems of participants may have affected their turn-taking, i.e., if they did not understand or only partially understood what the robot said, they may not have expected the robot to continue its turn. Third, the researcher –who was a former aphasia therapist– acted as wizard during the interaction. She observed the nonverbal communication signals of participants indicating the process of word retrieval [Another factor that may have affected the etrieval  before tPerceived ease of use, participants perceived NAO as easy to talk to. They indicated that NAO was nice and decent, although most participants were unable to explain in detail why they felt this way. This was most likely caused by cognitive problems, specifically problems in executive function skills, which may have complicated explaining their thought in more detail [easy to talk to, may be that  people who experience anxiety to talk to people, feel less anxiety when talking to a social robot compared to a human [Despite the aforementioned factors that may have negatively affected the e detail , 57. Fut a human , howevereasy to talk to. Moreover, the findings that participants denoted NAO as easy to talk to, are in line with Khosla et al. [Perceived ease of use in interacting with social robots.Participants, furthermore, mentioned they appreciate the robot’s lowered speech rate, which may be an underlying factor that positively impacted their perception of NAO as a et al. , who foua et al.  demonstrautonomy in practising language use, brought to light how they thought the robot could be useful to them in practising language use.The analyses suggest that participants perceived NAO as useful, which emerges from the quantitative analysis of the questionnaire. Additionally, the theme Seventy-three percent of the participants would like to increase the frequency of practising language use, which might allow them to have a minimum of five to ten hours language training per week. This minimum is required to achieve improvement in language skills in everyday life , 5, 7. PFurthermore, 64% of the participants indicated that they were less satisfied with how the dialogue with NAO went during the interaction. They indicated that the robot did not seem to understand what they were saying, and that the robot, as a result, did not continue the conversation based on their responses. In other words, participants indicated that they would like the robot to adapt its behaviour in real-time based on their responses. As a result, the interaction would most likely mimic real live interaction, and would therefore be more useful for PwA to practise language. Cruz-Maya and Tapus  proposedThe analyses suggest that participants enjoyed interacting with NAO, which is consistent with the literature showing the advantages of social robots over computer-based agents. For instance, Matarić et al.  found grPerceived Enjoyment may have been negatively affected by the level of language comprehension problems participants experienced due to their aphasia. In other words, it may be that not fully understanding what the robot said resulting in a less enjoyable interaction with the robot.Participants’ Attitude refers to participants’ beliefs if NAO could be of practical use, i.e., the cognitive component of attitude [The analyses, furthermore, revealed that participants felt positive toward using NAO. The construct attitude . This coautonomy in practising language use. PwA’s feeling of autonomy seem to be important factors in users’ engagement and motivation in using social robots [The analyses, furthermore, suggest that participants specifically believed the robot could assist them practise language use independently of others, allowing them to personalise training frequency and duration , 55. Alml robots , 29.Involvement [communication break-down and simultaneously turn-taking which are likely causes of lowered involvement. Winkle et al. [Perceived enjoyment in the current study which align with participants’ Involvement. It is possible that the level of participants’ engagement, is positively affected by the robot’s embodiment, in accordance with the findings by Okamura et al. [Mood, i.e., the affective component of Attitude [Mood nor Involvement between the participants who interacted with NAO online vs. the participant who interacted with NAO live. So, future research could determine the effect and relevant factors of physical embodiment in a live setting vs. in an online setting on PwA’s engagement during an interaction with a social robot.When examining participants’ engagement in the current study, which emerges from the observational category olvement , most ofe et al.  revealeda et al. . They foAttitude . The anaBased on the results of this exploratory study, the following preliminary recommendations for robot designers emerge t in researching and developping social robots in providing additional language training to PwA.The social robot should personalise its approach to the user by adapting its speech rate, volume, and pauses in real-time based on users’ language abilities and users’ responses. The robot should, in addition, detect when the user is no longer engaged and adapting its approach in real-time so that PwA’s autonomy in language practice remains preserved .PwA often use alternative and augmentative communication forms to support their language production, e.g., writing a single letter or word, drawing, showing a picture on a mobile device, or gesturing. Importantly, these forms of communication are influenced by the physical and cognitive constraints that PwA face because of their acquired brain injury. For example, a gesture is often made with one hand and drawing occurs with their non-preferred hand. As a result, these forms of communication are difficult to recognize but they nevertheless complement the spoken language production of PwA. Thus, for a social robot to provide language training to PwA, it should be able to recognize and adequately interpret various alternative and augmentative communication forms PwA could use to support their language production.The main strengths of this study are that (1) the results are based on a single online semi-structured interaction between 11 adults with mild to moderate chronic expressive aphasia and a NAO robot. To our knowledge, this is the first study to explore how PwA interact with a social robot; (2) the interaction as well as the questionnaire was designed by a researcher who was a former speech-language therapist and who has had almost 20 years of experience in working with PwA. This ensured the interaction as well as the questionnaire to be feasible and comprehensible to PwA; (3) the current study provides useful and novel evidence that PwA overall felt positive towards using a social robot.There are limitations of this study that should be considered. First, given the small and specific sample of this study, generalisation should be treated with caution. We suggest a controlled follow-up study with a larger sample size to provide more conclusive findings. Since people with severe language comprehension problems  were not included in this study, it is important to note than one should not draw conclusions beyond adults with mild to moderate chronic expressive aphasia. We suggest that future research will explore how people with other types of aphasia experience interacting with NAO.Second, the qualitative component of the questionnaire may have been influenced by researcher bias, since the researcher used additional and clarifying questions to capture participants' opinion. However, the researcher recognized the pitfall of using leading questions beforehand and therefore always verified if the answer was indeed correctly interpreted. Moreover, the qualitative data should be interpreted with care since the robot was controlled using Wizard-fo Oz by the researcher who was a former aphasia therapist. The findings can therefore not be generalized across the population of people with mild to moderate chronic expressive aphasia.Third, all participants voluntarily participated in this study, which may have affected their perception of the robot, although it is unlikely to assume that PwA will involuntarily use a robot for language training in the future.Finally, the study took place online, except for one participant, due to the Covid-19 pandemic. As a result, participants could not experience a shared space with NAO, restraining the advantage of the physical presence of NAO. The findings of this exploratory study can therefore not be generalized to a real-live setting. A follow-up study in a real-live setting is therefore important to investigate how people with mild to moderate chronic expressive aphasia experience NAO.So, it is desirable to conduct further research in real life with a larger sample of people with various types of aphasia to generalise the findings of this study. Moreover, this study should be replicated in real life, instead of online, to determine in more detail the relation between the robot’s gesturing and its intelligibility.This study contributed to the literature on deploying social robots to provide additional language training to PwA , 10, by The findings of this study provide initial recommendations for the research and development of social robots for people with mild to moderate chronic expressive aphasia. These recommendations aim to enable PwA to practise language use independently of others by using a social robot, to increase practice intensity and frequency. This enables them to meet the required short-term high-intensive dose of five to ten hours language practice per week to enable significant improvements in language skills , 7.