Physical activity is a major component of treatment for adolescents with obesity and prediabetes or type 2 diabetes; however, sedentary behavior remains pervasive. An SMS text message–based intervention paired with financial incentives may be an effective way to promote physical activity in this population.This study aims to obtain end-user feedback on SMS text message content and assess the acceptability of a planned SMS text messaging intervention with financial incentives to motivate youth with prediabetes or type 2 diabetes to increase physical activity.Adolescents with overweight or obesity and prediabetes or type 2 diabetes who attended a large academic pediatric endocrinology clinic were recruited to participate in group interviews (2-4/group) via videoconferencing. Participants were asked to share their thoughts on the use of SMS text messages and financial incentives to remind and motivate them to be more physically active. They rated and provided feedback on specific messages to be used in clinical trials. Participants were also asked about their personal experience with rewards to motivate behavior change and their anticipated reactions to rewards provided for goal attainment (gain-framing) versus those provided and then taken away if a goal was not met (loss-framing). The interviews were conducted by 2 trained interviewers and a note-taker. Content analysis was used to explore themes.2 . Most participants were non-Hispanic Black  and 10% (2/20) were Hispanics. Participants frequently cited near-continuous smartphone use and agreed that SMS text messages would serve as good reminders to be physically active, but the consensus about the need for short messages was strong. Favorable content included references to what they were likely to be doing when messages were sent  and messages that were upbeat or informative. Specific physical activity suggestions were rated favorably. Attitudes toward financial incentives varied, with differing opinions about whether loss-framed incentives would be motivating or discouraging. Many participants highlighted the role of intrinsic, rather than extrinsic, motivation in achieving and sustaining behavior change.Group interviews were completed with 20 participants  with a mean age of 15  years and a mean BMI of 41 (SD 5) kg/mThe engagement of adolescents with obesity and diabetes or prediabetes allowed for the refinement of SMS text messages for our planned intervention, with an emphasis on short, upbeat, relatable, and informative messages. Although an SMS text messaging intervention using financial incentives to motivate youth with prediabetes or type 2 diabetes to be more physically active is theoretically acceptable, the impact on actual activity levels in this population requires prospective evaluation in a clinical trial. Once a disease of adulthood, type 2 diabetes is now becoming increasingly common among youth . Among iApproximately 95% of teenagers in the United States now report ownership or access to a smartphone . SmartphAnother potentially effective strategy to motivate youth to be more physically active is the provision of financial incentives. In adults, incentives framed as losses  rather than gains  are more effective at inducing physical activity-related behavior change . FinanciTo prepare for the trial, we conducted group interviews with adolescents from the target population. We sought insights into message content and financial incentive strategies, including financial incentive preferences and the anticipated impact on one’s motivation to be physically active.1c 5.7%-6.4%, fasting glucose 100-125 mg/dL, and 2-hour oral glucose tolerance test glucose 140-199 mg/dL) or type 2 diabetes  were recruited from the pediatric endocrinology clinic at the Children’s Hospital of Philadelphia, a large academic children’s hospital in Philadelphia, Pennsylvania, United States, from December 2020 to April 2021. Potentially eligible participants were approached about the study at clinic visits or by phone within 2 weeks after a clinic visit by the study research coordinator or principal investigator. Individuals with limited English proficiency were excluded from this study. Eligible individuals were invited to participate in a 1-hour group interview. Electronic consent and assent (for participants aged <18 years) were obtained via REDCap . Group interviews were roughly segmented by age when possible (13 to 15 or 16 to 18 years) to promote more open dialogue among similarly aged peers but not by other demographic or clinical characteristics. Participants were compensated with US $30 for their time. Limited medical record reviews to include demographic information and pertinent medical history were performed by the study team with the permission of the participants.A convenience sample of individuals from the target population of the BEAM trial, adolescents aged 13 to 18 years with overweight or obesity (BMI ≥85th percentile for age and sex) and prediabetes .The text messages were developed by the investigators with the assistance of one high-school student  and one college student . Both students became involved after approaching the primary investigator regarding temporary research opportunities in pediatrics, independent of any school-required research experience. Messages were designed with the target population in mind; limited financial resources and transportation barriers are common, so physical activity suggestions included only those that were free or low-cost, as well as many that could be performed at home. Initial message development was guided by common barriers to being more physically active, including feeling too tired, lack of interest, lack of peer or family support, lack of equipment, lack of space indoors or outdoors, lack of motivation, preference to avoid sweating, embarrassment, lack of confidence in skills, and lack of knowledge about how to do so . MessageGroup interviews were chosen rather than individual interviews to promote an atmosphere of engagement and the sharing of ideas among peers. Smaller group interviews  were chosen over larger group interviews or focus groups  because of the virtual nature of the interviews, which was necessitated by the COVID-19 pandemic. Although the original study design included the use of focus groups, the richness of the data gathered from focus groups is heavily dependent on the ability to promote and maintain dynamic group discussions. It is possible to conduct focus groups in a virtual setting, but potential challenges include technological difficulties and the inability to control each individual’s environment, which may lead to distractions and interruptions . TherefoA semistructured interview guide was designed to elicit open-ended feedback on text messages for physical activity motivation , experience with and motivation for behavior change, and experience with and attitudes toward the use of financial incentives for behavior change. The interview guides were piloted with nonmedically trained adults and revised as needed for clarity. The interviews were rehearsed by the interviewers with oversight by the study principal investigator (MEV), who had formal training in qualitative research methods. Interviewers practiced neutral, nondirective responses to participant answers and the use of open-ended probing questions to elicit more detailed responses. Before the start of the interview, interviewers informed participants that there were no correct answers and that all feedback, including critical feedback, was welcomed.screenshare function and read aloud. Participants were asked to rate the messages as great, OK, or bad; these specific rating words were chosen to maximize the ability to identify message outliers—those that truly resonated (great) and those that were strongly disliked (bad)—so that themes relating to message success or failure could more easily be identified. Participants were invited to type their initial ratings in the platform’s chat or respond aloud. After all initial ratings were shared, the participants were asked to explain their ratings, including why they liked or disliked the message and how it could be improved.In addition to specific questions, 8 messages were reviewed during each interview. The number of messages was restricted to 8 to optimize the amount of time available for discussion, with the goal of understanding what aspects of the message were engaging or not rather than simply rating the specific message. Messages were selected to include a variety of barriers addressed and tones used  such that all combinations were tested at least once throughout the study. The messages were not repeated across groups; in total, 64 representative messages were reviewed. The remaining 20 messages were not substantially different in tone or content and thus were not reviewed by the study participants. During the interviews, message content was shared with participants via the videoconferencing platform’s All interviews were conducted via the videoconferencing platform BlueJeans (Verizon), accessed by participants using their preferred personal internet-connected device (smartphone or computer). Participants were asked to keep their camera on if comfortable doing so and to remain unmuted in a quiet setting if possible. If participants wrote in the chat rather than speaking, the interviewers reread the typed content, stating which participants responded.Text messages acceptability and Text messages: preferred content. Next, two of the study team members with experience and training in qualitative study methods (TAH and MEV) reviewed the transcripts, identified emergent themes, and then refined the initial codebook. For example, an additional code for pandemic was considered owing to the frequent mention of how the COVID-19 pandemic impacted behavior and motivation but ultimately not included as an independent code but rather incorporated as a subcode to motivation for behavior change. After independently coding the 3 transcripts, the 2 reviewers compared the coding and clarified the codebook as needed. NVivo  was used for qualitative analysis.Participant characteristics were presented using summary statistics, including means and SDs for continuous variables and proportions for categorical variables. All interviews were recorded securely on a videoconferencing platform, and audio was transcribed using a professional transcription service. Transcripts were reviewed by the study staff, corrected as needed, and supplemented by observer notes. Transcripts were deidentified before analysis. Content analysis was conducted to explore these themes. An a priori set of codes was created based on the semistructured interview guide; for example, 1c level was 6.1% (IQR 5.9%-6.2%) among participants with prediabetes and 7.3% (IQR 6.5%-10.4%) among participants with diabetes (Participants (N=20) had a mean age of 15.7 (SD 1.3) years; 75% (15/20) had type 2 diabetes, and 25% (5/20) had prediabetes. The majority  of participants were non-Hispanic Black, and the remainder were non-Hispanic White , Asian , or mixed race ; of the 20 participants, 2 (10%) participants were of Hispanic ethnicity. Among the participants with diabetes, 53% (8/15) were prescribed insulin, 93% (14/15) were prescribed metformin, and 13% (2/15) were prescribed liraglutide. The median most recent hemoglobin Adiabetes .In all, 8 group interviews, each consisting of 2-4 adolescents, were conducted from December 2020 to April 2021. Each group interview lasted for approximately 30 to 45 minutes. The participants had variable degrees of engagement, with many leaving their cameras off. However, all  participants responded to the entire set of interview questions and rated all text messages per session. Many used the chat feature in the videoconferencing platform to respond but spoke aloud when asked to do so.κ=0.92). Several themes and subthemes emerged from focus group discussions that pertained to the development of text messaging content as well as the use of financial incentives in an intervention designed to motivate youth with overweight or obesity and prediabetes or type 2 diabetes to be more physically active.Thematic saturation was achieved with no new themes generated from later interview groups. Instead, previously identified themes were also present in the later groups. The interrater reliability of the 8 transcripts was high  participant had smartphones and felt that text messaging was a good way to remind teens to be more active:We always on our phone, so we gonna see it [and] texting is a really good way to sort of spread words. I mean, I know that I, personally, spend probably way too much time on my phone.Participant 19, group 8; female, aged 14 yearsThe interruption via text message was felt to be a useful prompt to move more:I feel like if you - if we got manual reminders, it could implant something in our head, and like an idea in our head to do it instead of forgetting about it throughout the day.Participant 19, group 8; female, aged 14 yearsParticipants varied in the acceptable frequency of text message reminders, with a participant suggesting that messages as frequently as once per hour would be appropriate. However, most participants preferred 1-2 messages per day, either at noon or after school. They emphasized the need to know from whom the text was sent, so they did not mistake it for spam. Most felt that they used their phone more during the summer but had it with them at nearly all times, regardless of the time of year or day of the week.upbeat characteristics such as exclamation points, smiley faces, or encouraging words were felt to be most motivational. However, even if brief and encouraging, those stating a generally known fact  resulted in mixed responses. Importantly, a participant highlighted the need for caution when discussing self-esteem. Reflecting on the message ,Did you know that being physically active can improve your self-esteem? Why not start right now? You got this  she stated that this comment would cause her to question her own self-esteem:Short and upbeat messages were strongly preferred. While self-esteem is a great thing to focus on and have, I think if you point it out, it makes us feel a little bit insecure...If I got this sent to me and I was like - and I looked at it, I’d be like do I have low self-esteem?Participant 1, group 1; female, aged 16 yearsFeel like you’re tight on time? Maybe it’s in your head. A brisk walk actually changes the chemicals in your brain to make you feel more relaxed and less anxious was felt to explain a bit of the science and to be memorable.Participants reported satisfaction with texts that reported facts or specific suggestions on how to overcome barriers: Physical activity that gets your heart rate up releases endorphins that raise your energy level. Ready for your energy boost?)  was appreciated for providing a specific reason for exercising. Messages that gave examples of how to overcome specific barriers were also well-rated. For example, in response to a message that identified the common barrier of feeling embarrassed to exercise in front of others and suggested a solution , a participant rated the message highly:Another informative message , and not everyone has room to or enjoys dancing at home. Suggestions about how to be physically active at home were appreciated, but participants differed in the perceived utility of including a link to a video or description of activities, with many stating that they would click the link, but others suggesting that clicking the link is “just kind of another thing to do.”Messages that mentioned school or sitting on the couch and watching television were highly relatable. A message that emphasized that being active can help with school performance resonated with a participant:I like how it ties in the school thing. I know that I would like to do better in school. And I think that it’s the same for a lot of people my age. So, I think that this one could really capture a lot of people.Participant 10, group 4; male, aged 18 yearsbeing lazy, then felt motivated to stand up and walk around or even exercise during commercial breaks. A participant reflected as follows:Participants imagined themselves receiving messages while sitting on the couch and ...Think about like if we were all sitting on the couch or whatever being lazy, then someone got this text message, they could maybe motivate everybody else, like let’s just go on a walk together.Participant 11, group 5; female, aged 16 yearsAnother participant agreed:I think that when you get this, let’s say, you’re watching a movie. Everybody’s on the couch and eating chips or whatever, and you see this emoji or you see this message. It’s like a reminder to like go out, and it’s like motivational...Participant 12, group 5; female, aged 13 yearsParticipants frequently reported that they had a goal to exercise more, but they differed in their sources of motivation or encouragement to do so. Parents and physicians were often cited as the person setting physical activity goals for participants, and frequent reminders were felt to be particularly frustrating. A participant noted that “a lot of adults tell kids to exercise and that they need to get out more” by quoting the following:And I get it. Not helpful when I’m in the middle of doing something, and then someone comes into my room and just like get outside. I’m just like why? I also tend to not exercise when there is no immediate goal...It needs to have a sensical purpose.Participant 1, group 1; female, aged 16 yearsAnother participant expressed frustration about being reminded to exercise:When I’m told over and over again to exercise and what will happen if I don’t, it’s – because I make sure that I’m exercising as frequent as possible...So when people...say why aren’t you exercising or you need to exercise more, it can get annoying and it can make me not want to do it.Participant 12, group 5; female, aged 13 yearsA participant emphasized the value of a parent taking time to show concern when encouraging him to be more physically active:It’s like she actually sat down with me, instead of just telling me. She actually sat down. Actually, had a nice conversation about it, instead of just coming to my door and telling me what to do.Participant 8, group 2; male, aged 14 yearsPersonal and family history of type 2 diabetes were major motivators for several participants to engage in a healthy lifestyle. A participant shared the following:...My motivation is so I can get off of these pills I take, the metformin and whatnot...I’ve been doing absolutely everything I can because I have family members who have the severe type two diabetes, and I don’t want that to be me...I don’t want to lose my life due to health issues...I don’t want to pass away when I’m 40 because I have serious health issues, so I want to live my life the right way and be normal for once.Participant 15, group 7; male, aged 16 yearsAnother reflected by quoting the following:Saw kind of the direction that my health was going in, and it was kind of like concerning, so I wanted to turn that around so that before it got too permanent or too bad or anything like that, so that was something that motivated me for sure.Participant 19, group 8; female, aged 14 years“...When I started getting - becoming like older and more slightly anarchist, it was a bit of why am I doing this for capital reasons? I don’t like this” .Nearly all participants reported that their parents had offered rewards for behavior change, most commonly money or a desired item such as a video game or clothes. However, the perceived effectiveness and acceptability of this approach varied. Some reported that a monetary reward or desired object “kind of pushes you more and gives you a good boost of energy and motivates you a lot”  and that “I like the idea of getting something out of doing things” . On the other hand, another participant questioned the use of financial incentives when discussing her experience with an allowance: good” for themselves or others, but if “[T]hey weren’t helping people that much...I really saw no point in doing it” . Being physically active was categorized by some respondents as “just the right thing to do,” which negated the use of financial incentives. In addition, the end goal was emphasized:The perceived importance of the underlying behavior to change was a major factor in the persistence of behavior change. Participants reported feeling motivated to continue the behavior if habits were “It’s a good chance that you’re going to meet your goal when you have the motivation, like something that you’re working hard towards. Like for example, if I was - I know that I’m trying to work hard toward being healthy mentally and physically. Well, I know that we - all this hard work is eventually going to pay off. So, sometimes you’ve just got to - sometimes you ’ve just got to think and have that mindset. If I work hard, eventually it’s going to pay off in the end.Participant 11, group 5; female, aged 16 yearsFinancial rewards were also seen as a way to overcome barriers even for goals that were previously intrinsically motivated:...Last year before, pre-coronavirus, I was all-A student...And I didn’t need any money to motivate me...when I saw the honor roll in my hand, that was my motivation...But this year, I did not get all As and all Bs...as motivation [my dad] said at the end of the year, if I was to bring home an...all As and Bs honor roll, that I would get a shopping spree or money or stuff like that...but that is kind of the motivation that I do need to keep my grades up.Participant 11, group 5; female, aged 16 yearsonly extrinsically motivated by money may not be achieved when additional barriers arise:However, participants identified that goals that are ...My parents used to give me a prize if I got like 100 on a test or something like that, and it always motivated me to study and do well in school...it pretty much worked until COVID hit because my grades started going down because I wasn’t that motivated.Participant 12, group 5; female, aged 13 yearsWhen asked about loss-framed incentives, using either money or physical objects, participants gave examples of times that their parents had threatened or actually removed objects for poor behavior. Most participants expressed frustration, stating that this approach would make them “sad,” “mad,” and “defeated or upset” and that it would be “unmotivating.” However, some also acknowledged that this approach could be viewed as fair:...I would understand why that got taken away from me. I know that it would be because I didn’t do whatever I was supposed to do, so I personally wouldn’t be angry because I know why that would get taken away from me.Participant 11, group 5; female, aged 16 yearsAnother participant, speaking about her father’s threat of not allowing her to participate in an activity anymore if her grades fell, reflected the following:...I felt neutral about the whole situation, but I was always - I think it helped me because I knew that that could be taken away because one thing about my dad’s ultimatums is that he means business...So I felt - not scared, but I was like okay. I know what I need to do.Participant 12, group 5; female, ages 13 yearsWhen evaluating preferences, perceived fairness, and effectiveness of loss- versus gain-framed incentives, opinions varied, with some participants reporting that either approach could work. Several participants acknowledged that the perception of loss would likely be highly motivating despite, or because of, the frustration it causes. A participant reflected the following:...It is nice to have something earned but there should be some sort of consequence so you don’t become lazy. Earning something would be more successful because you can see your accomplishment.Participant 6, group 2; female, aged 17 yearsSome noted that they would feel highly motivated by the possibility of having something taken away, stating the following:What motivates me more is like having something taken away, so then I would know that...I would get that back in the end after I work hard [and] the threat of having something taken away motivates me to do better, just so I could have it with me the whole time.Participant 11, group 5; female, aged 16 yearsHowever, participants felt that the effectiveness of loss- versus gain-framed rewards would depend on the reward itself:It depends on what the reward is and it depends on what’s being taken away. So like if you took - personally, like if you took my [video game system] away, I’d be like yeah, I’d choose that one.Participant 1, group 1; female, aged 16 yearsSeveral others felt the following:Positive reinforcement would be more effective and that the threat almost makes me want to revolt, because I don’t like threats...that promise, like that shopping spree promise, it motivates me. I’m like I’m almost there. I can see the finish line. But threats, no. So the promise of having a reward, because the threat is too much for me and it does not make me want to do my best. It makes me want to do worse just to prove that person - I don’t know, because it’s a really catty thing with me if I’m threatened...Participant 12, group 5; female, aged 13 yearsImportantly, although the behavior may change in the desired way because of the incentive, a participant questioned whether it would result in true motivation:I think it’s the [threat of having something taken that works better] because you’re scared of doing it or not doing it, so you keep on doing it. And it’s not necessarily motivation, but it’s just like at the end of the day, you’re still doing it, so it’s good.Participant 20, group 8; male, aged 14 yearsbad by even a participant were edited to omit unfavorable content or discarded entirely if the overall concept was disfavored. For example, the message Did you know that being physically active improve your self-esteem? Why not start right now? You got this was omitted, and messages that were supportive of self-confidence and self-efficacy but that did not unintentionally imply that the individual had poor self-esteem, were substituted instead . On the basis of the favorable response to messages referencing feeling lazy or describing how being physically active may help with school performance, more messages with these themes were created. Messages with mixed responses were edited based on specific negative feedback or included if responses were positive and neutral. Additional encouraging messages were created to address problem solving to overcome barriers to being more physically active and to remind the value of a support person to help achieve activity goals; for example, Does your step count goal seem like a stretch? Break it up! Every minute counts! and Who will be your workout buddy today? Bring a friend or family member with you on a walk or to the gym (blame us if you need to!). Messages were also shortened and adapted to fit the preferred timing in mid-day or afternoon , and additional encouraging messages were created . Additional specific lessons learned are summarized in On the basis of the participant feedback, messages were refined by study team members for use in the BEAM trial. Those rated as Acceptable message frequency1-2 texts per dayAcceptable message timingMid-day or afternoon (after school)Ways to minimize the risk of messages being ignoredSave the study’s or team’s phone number in contacts so that it is not identified as spamShorten messages or put most important text in beginning of messageUse exclamation points and emojisFinancial incentives for behavior changePotentially motivating in theoryFamiliar concept to adolescentsLoss-framing to promote behavior changeAcceptability divisive: motivating but possibly too frustratingThrough virtual group interviews of adolescents with obesity and prediabetes or type 2 diabetes, we obtained end-user feedback to refine a bank of text messages for an mHealth-based physical activity intervention and identified several themes related to the use of text messaging and financial incentives to motivate youth to be more physically active. The participants’ responses highlighted the challenge of developing message content that appeals to all end users , as wellperson-based, in which qualitative research is used to inform design by gaining insight into the perspective and psychosocial context of individuals who will use the intervention [Our approach to intervention development is rvention . This qurvention , but to rvention ,27. One rvention ,29.The likelihood of limited financial resources or safe spaces to engage in physical activity shaped our physical activity suggestions, which were intentionally free or low-cost and included in-home options. In addition, our population also likely differs from otherwise healthy adolescents in terms of overall stress and depressive symptoms; youth with type 2 diabetes report high levels of life stressors, which correlate with poor psychosocial functioning and impaired treatment adherence . Thus, fOur finding that adolescents preferred messages that were brief, upbeat, and informative was similar to previous reports ,31. In tTo our knowledge, ours is the first study to evaluate the acceptability of a text message–based intervention to increase physical activity in adolescents with obesity and prediabetes or type 2 diabetes. Because of the critical importance of lifestyle changes in improving health outcomes, youth with prediabetes or type 2 diabetes are likely to have already been instructed by multiple health care providers and their caregivers to be more physically active. It is notable that despite this commonly heard advice, adolescents still reported that daily or twice-daily text messages encouraging and reminding them about physical activity would be acceptable and potentially motivating.exercise may also be perceived in this light. Our revised text message bank now places greater emphasis on being more physically active in any activity of their choice, rather than structured and repetitive exercise. Indeed, distinguishing between exercise  and more general physical activity may help clarify expectations for patients, as increased nonexercise physical activity may be an acceptable goal for both patients and providers [In addition to specific feedback about the reviewed text messages, participants shared valuable insights about experiences when encouraged to exercise by caregivers and health care providers. Their responses highlighted the fine line required when showing concern about an adolescent’s health and health behaviors. Although expressing genuine concern may be encouraging for some, repeated reminders may be perceived negatively by others. There is a danger that repeated text message reminders to roviders . As partroviders  on healtroviders .Because of the challenges of maintaining engagement in mHealth and physical activity interventions as well as motivating adolescents to be more physically active, we also tested the impact of different financial incentive strategies in our BEAM trials. Specifically, we evaluated loss- versus gain-framed financial incentives to achieve step-count goals. Although the comparative efficacy of these financial incentive approaches has been evaluated in physical activity interventions in adults, it has not been assessed in youth , who mayAlthough not initially planned, owing to the COVID-19 pandemic, we conducted group interviews using a virtual format using videoconferencing technology. Virtual interviews had several benefits: (1) ease of recruitment, particularly for adolescents with financial or transportation barriers; (2) efficient and high-quality audio recording via the platform; and (3) availability of the chat feature, which allowed participants who may not otherwise have interrupted someone speaking to share their thoughts and engage in the discussion. The virtual format allowed participants to mute video or audio, which was done at times the strain discussion progressed. However, the ability to retain control of their privacy, which is not practical in most traditional focus groups , may havtranscreation process, in which the text messages are not simply translated but adapted in a way that is linguistically and culturally appropriate [Attitudes and perspectives about text message content and financial incentives may vary across populations; therefore, our findings may not be generalizable to other adolescent subgroups, such as those with obesity but without comorbidities, or to individuals of different age groups or at different neurodevelopmental stages . Howeverropriate . Thus, aThe focus of this study was on the perspectives and preferences regarding text messages and financial incentives to motivate behavior change, which may not perfectly correlate with objectively measured behavior change; objective measurement will occur as part of the BEAM trial. Because of our study’s sample size, we were unable to reliably characterize differences in attitudes and perceptions across patient characteristics, such as age, gender, or prediabetes versus diabetes; however, we will do so when evaluating the acceptability of the intervention in the BEAM trial. The use of virtual interviews made engaging participants challenging at times; this limited engagement often contributed to more limited discussion than may have occurred in face-to-face interviews and thus to the shorter actual duration of interviews than originally planned (30-45 vs 60 minutes). Finally, although participants reported that they found even frequent text messaging acceptable, their actual behavior may differ, as additional interruptions from push notifications and text messages from friends also occur. The BEAM trial will also evaluate the impact of message frequency.In summary, among the participants in our study, all adolescents with obesity and prediabetes or type 2 diabetes preferred text messages that were short, upbeat, informative, and relatable. Through virtual group interviews, participants’ feedback allowed for the creation of an end-user–refined bank of text messages that will be used in an mHealth physical activity intervention targeting the same population . The perceived acceptability of loss-framed incentives was mixed, but the effect of incentive framing will be objectively measured in the BEAM trial. Overall, the ability to elicit end-user feedback increased the likelihood of acceptability of our intervention among the target population, and we will continue to engage participants throughout the trial to further refine our approach to intervention development.


VPEs are directional by drawing attention either to an outcome’s occurrence (“it is possible”) or to its non-occurrence (“it is doubtful”). In this sense they may be more informative than numbers. Uncertainties about outcomes in a distribution (continuous quantities) are alternatively expressed as interval estimates. The width of such intervals can function as a cue to credibility and expertise. Incomplete, one-sided intervals, where only one boundary is stated, imply directionality. “More than 100 people” suggests a crowd, while “less than 200” implies a shortfall. As with VPEs, directionally positive intervals are more frequent, and perhaps more neutral than negative ones. To convey expectancies and uncertainty in a balanced way, communicators may have to alternate between complementary frames.The paper reviews two strands of research on communication of uncertainty that usually have been investigated separately: (1) Probabilities attached to specific outcomes, and (2) Range judgments. Probabilities are sometimes expressed by verbal phrases (“rain is likely”) and at other times in a numeric format (“70% chance of rain”), whereas range judgments describe the potential amounts expected (“1–4 mm of rain”). Examination of previous research shows that both descriptions convey, in addition to the strength of expectations, pragmatic information about the communicative situation. For instance, so-called verbal probability expressions (VPE), as  Past facts and future outcomes are rarely known exactly, and have to be expressed in tentative or approximate ways . We may call this the probabilistic approach. (2) Alternatively, a statement can express a set of potential outcomes (“we will have 0–4 mm of rain”). We may call this the range approach. The two descriptions are complementary by indicating degree of probability, in the first case, and an uncertainty interval, in the second. They can be combined into a confidence interval (“0–4 mm of rain is very likely”).In a context of quantifiable events (magnitudes and amounts), we can distinguish between two approaches: (1) Statements about one specific outcome, for instance a “best guess”, modified by a probabilistic quantifier, which can be numeric or verbal , which may be described as doubtful, likely, or uncertain, but more rarely given numeric estimates.In this section we are concerned with probability expressions of target outcomes that can be conceived as categorical: a patient is infected by the flu (or not infected), we will have rain tomorrow (or no rain). Such outcomes can be assigned numeric probabilities between 0 and 100% or be qualified by so-called by verbal probability expressions (VPE) such as Probabilities of specific target outcomes are ideally expressed in a numeric format. Numbers are precise and unambiguous; they can be derived from statistics and formal computations and can, in turn, be used as input to further calculations. But numeric estimates may also be attached to outcomes that are not calculable in a formal sense but are derived from human judgments. Studies of such judgments have shown that people’s intuitive (estimative) numeric probabilities are poorly calibrated and show “overconfidence” when compared to actual hit rates , adjectives and adverbs  and nouns . These may in turn be modified by intensifiers , comparatives (more likely), and negations . A complete list of alternative ways of expressing expectancies in ordinary language has yet to be attempted. For overviews of approaches and findings, see Budescu and Wallsten , while unlikely outcomes are assumed to occur rarely . Tables of verbal phrases with corresponding numeric probabilities have been constructed by panels of experts in various domains  to simplify and standardise the communication of uncertainty to decision makers and the public at large. Such scales are typically symmetrical and consist of 5–9 standard steps, as illustrated in Table Discussions of verbal phrases presume that their main function is to indicate levels and degrees of probability. A possible makes sense when wedged between likely and unlikely. In addition, several authors have recommended use of verbal-numerical (V–N) combinations, which they think will lead to better understanding than either format taken in isolation. We might for instance learn that temperatures in the future are likely (> 66% chance) to reach 3 degrees, or that the chances of a terrorist attack are remote (< 10%). Such combined expressions give a rough guide to what the phrases mean, as well as offering an informal explanation of the numbers  into corresponding numbers can be obtained by asking people to estimate which probabilities they associate with selected verbal terms, in isolation or in contexts . The meanings of a verbal term will accordingly change in different communication settings. leading to discussions about a “severity effect” and the use of verbal phrases under face-threatening conditions  make sense as reflecting the strength of causal tendencies operating for or against the target outcome. The causal view has been discussed as a dispositional or a propensity account of probabilities  account, high probabilities indicate strong beliefs or high degree of confidence in a proposition, whereas low probabilities express weak beliefs or lack of knowledge.Alternatively, probabilities may be construed to reflect degrees of belief or knowledge (or lack of it). According to this believe, assume, suspect, guess, or doubt describe the speaker’s states of knowledge. Sentences with such verbs require a person as their grammatical or logical subject. It takes somebody to believe, or to doubt, that the pandemic will come to an end in 2022. In contrast, auxiliary verbs, like will and could, describe more “objective”, externally grounded expectancies. The coronavirus can persist regardless of what experts think. Statements of this type take impersonal rather than personal pronouns. It (not I) can happen, I (not it) believe it will.These external or internal sources of expectancies are reflected in the words used to describe them. So-called epistemic verbs, like to chance, likely/likelihood. and probability) primarily describe aleatory probabilities, whose chances depend on objective features of the situation, like frequencies and random variations. In contrast, “confidence terms”  are primarily used to describe the knowledge (epistemic state) of sentient beings. Going through two volumes of New York Times they found that likelihood terms were much more often quantified and based on external evidence, compared to confidence terms. The latter reflected more often subjective judgments and were used more often about knowable events of the past. Participants in an experimental study  also differ by suggesting internal or external attributions of uncertainties. Ülkümen et al.  proposedIn Ülkümen et al.’s  scheme, certainty, can be conceived both as internal or external depending on its appearance in a personal or an impersonal clause. While “I am X% certain” describes the epistemic certainty of the speaker, “it is X% certain” presumably reflect external facts  or a negative prefix (uncertain). The contrast between these two types of terms have been called a difference in directionality . “Unlikely” is directionally negative, suggesting non-occurrence of a target event, but might be positive in an evaluative sense, if it implies negation of an aversive outcome (“it is unlikely that you have been infected”).Directionality is not to be confounded with very likely is more than simply likely) while negative terms are shifted downwards (very unlikely is less than just unlikely), as illustrated by the standard scales in Table The concept of directionality was originally introduced to show that VPEs are not simply informal or imperfect substitutes for numbers, but carry other, distinctive meanings of their own Teigen, . A verbaa chance of winning the tennis match? Because she is a strong and skilful player. Why is it uncertain that she will win? Because of her opponent’s skills. Only propositions that explicitly state that it can go both ways (“It is a fifty-fifty chance”) include both kinds of reasons . The type of reasons people offer can accordingly be used as a directionality criterion. This test reveals that even some low probability expressions  can be directionally positive, as they evoke more reasons in favour of the target outcome than against it. Directionality can alternatively be determined by asking speakers about consequences. If NN has a chance of winning, she is entitled to be hopeful. If it is uncertain, she should be prepared for a loss.Directionality can also be revealed by asking people for explanations. It seems that people typically add reasons supporting either an outcome’s presence or its absence, but not both . The authors conclude that “verbal probabilities convey implicit recommendations more clearly than probability information, whereas numeric probabilities do the opposite”  terms, as defined in linguistics  and associated degree of confidence (low vs. high). Formally, these measures are inversely related, so a narrow interval that contains, for instance, 60% of the distribution could be compatible with a 90% interval that is perhaps twice as large.Lay people seem often to mix up these two indicators of uncertainty. Some people realize (correctly) that narrow intervals entail less confidence, whereas less numerate participants believe that narrow intervals and high probabilities go together  may reflect accurate knowledge of the domain in question, whereas wide interval estimates for a stable quantity  indicates lack of knowledge. Such judgments will, in turn, affect judgments of expertise and interpretations of lower and upper interval bounds, as discussed in the next two sections.sceptical about, they chose again the narrow estimate, which now appeared overly precise.An early study of the “preciseness paradox” Teigen,  found thThus, the credibility of preciseness depends on the question asked, together with the assumed predictability of different domains  $100, or, alternatively, less than $150. These statements are not neutral. The first suggests that the product is expensive, the second that it is affordable. So even if the lower limit estimate is the smaller of the two, it functions as a reference point and implies largeness, whereas the upper limit calls attention to the target object’s relative smallness. Thus, choice of lower versus upper limit estimates can reveal the speaker’s attitudes, recommendations and concerns  than 50 percent is particularly frequent. Figure more or less than X percent (not limited to probabilities). While more than-statements are numerous throughout the range, less then-statements are more specific by being limited to low percentage values. Similar counts of probability expressions show that “More than X percent chance” is applicable to both likely and unlikely outcomes, whereas “Less than X percent chance” is reserved for chances of 50% or below  duration for a battery even if the occurrence frequency of this specific outcome may be much less than 50%; in other words, they answer as if “probable” and “average” or “most likely” mean the same. This way of asking people to describe VPE usage rather than probabilistic meaning, was introduced in an investigation of will and can , and the top value, 3.5 h, was selected to illustrate a possible outcome (like can), even if as few as 5–10% of all the batteries lasted that long  and the extremity effect (for other VPEs) are quite robust and appear to persist even when participants are given graphs displaying probability distributions or receive numerical explanations of what the terms are supposed to mean. Jenkins et al.  outcomes, and from research on complete or incomplete outcome ranges of continuous (multiple outcomes) distributions. In both domains, uncertainties can be expressed by means of words and numbers, or by a combination of both. Strictly speaking, directionality, that is, complementary ways of directing listeners’ or readers’ attention towards occurrences or non-occurrences of single outcomes, or towards the largeness or smallness of quantities measured on a continuous scale. We find in both settings evidence for positive/negative asymmetries but also disclose some paradoxical shifts in meanings for common verbal probability expressions. The challenge of uncertainty for practitioners is to be aware of such non-probabilistic features and not believe that they are permanently solved by prescriptive definitions of what verbal or numerical expressions should technically mean.The two settings compared in this review are similar not just in addressing probabilities and uncertainties in factual, explicit and descriptive ways, but also, and more indirectly, by including hints about the speakers’ attitudes, their communicative intentions, and their persuasiveness and credibility. They also suggest the origin of the uncertainty, the valence of the target outcome, implicit reference points, and the direction of potential trends. We have in this article especially emphasized and explored Risk analysts and other experts are often required to be “neutral” in their communication to decision-makers and in statements intended for the general public. The research reviewed in the present paper shows that ideals of objectivity and neutrality may be hard to achieve. A probabilistic message must be framed in one way or another and will accordingly convey a corresponding emphasis on probability or uncertainty. The way it is phrased will further suggest implicit comparisons, and reveal evaluative attitudes, like reassurances, recommendations, and reasons for concern. Narrow uncertainty intervals may be chosen to maximize informativity, but at the risk of being inaccurate.We think it is important for communicators to be aware of the pragmatic connotations that surround all estimates, as surveyed in the present paper. For instance, defining “likely” as corresponding to probabilities above 2/3 might look like a rough and handy approximation, whereas p > 66%  rise with 60–90 cm, but a lower or a higher rise cannot be ruled out”.For proper understanding, it is essential to know the conversational setting under which the estimates have been produced. Is the frame and format freely chosen, or does the estimate come in response to an issue raised by someone else than the speaker? In a discussion about implausible estimates . In general, one should make clear when phrases are used in a technical, predefined sense, and when it is just used as part of everyday language. To avoid that these usages are not mixed up one might as well replace the verbal terms that form a part of ordinary conversations with a schematic display of risks of different levels (or colours).Similarly, phrases from a standard scale, like those displayed in Table probability being a positive and uncertainty a negative term. Second, probabilities typically refer to specific outcomes (or a class of outcomes), whereas uncertainties suggest a plurality of alternative options, or multiple outcomes, like the intervals discussed in the range section of this present manuscript. While probabilities are assumed to reflect the strength or frequencies of outcomes, uncertainties indicate which or how many outcomes to expect. Thirdly, they are not co-extensive in the sense that they span a full scale defined by polar opposites. The upper endpoint of a probability scale is often defined as 100% certain, whereas the lower endpoint, zero probability, is not equivalent to full uncertainty. Instead it is explained as impossible – suggesting yet another concept. Perhaps expectancies would be a better and more comprehensive term for capturing all three dimensions, with uncertain indicating p < 1 and possible p > 0. To date, few studies have been conducted to compare estimates of probability and certainty. One study showed a gambling wheel with sectors occupying different proportions  participants answered by reporting (correctly) the proportion. When participants in a different condition were asked to estimate how certain they were, the frequency of normative answers was much lower (57%). Further studies should compare probability estimates and range estimates in a more systematic way, for instance whether Kahneman and Tversky’s (Presenting verbal probabilities and outcome ranges side by side, as attempted in this paper, reveals some common themes but also differences and lacunae in our knowledge. It seems that many authors have struggled with coming up with umbrella term for what these modes convey. Many overviews of verbal and numerical expressions are titled “communication of uncertainty” (e.g., Dhami & Mandel,  Teigen, . When asversky’s  four-fol


How we research eating disorder (ED) recovery impacts what we know (perceive as fact) about it. Traditionally, research has focused more on the “what” of recovery  than the “how” of recovery research . In this paper we aim to provide an overview of the ED field’s current perspectives on recovery, discuss how our methodologies shape what is known about recovery, and suggest a broadening of our methodological “toolkits” in order to form a more complete picture of recovery.This paper examines commonly used methodologies in research, and explores how incorporating different perspectives can add to our understanding of the recovery process. To do this, we (1) provide an overview of commonly used methodologies , (2) consider their benefits and limitations, (3) explore newer approaches, including mixed-methods, creative methods , and multi-methods , and (4) suggest that broadening our methodological “toolkits” could spur more nuanced and specific insights about ED recoveries. We propose a potential future research model that would ideally have a multi-methods design, incorporate different perspectives , and a longitudinal course . In this way, we hope to move the field towards different, more comprehensive, perspectives on ED recovery.Our current perspectives on studying ED recovery leave critical gaps in our knowledge about the process. The traditional research methodologies impact our conceptualization of recovery definitions, and in turn limit our understanding of the phenomenon. We suggest that we expand our range of methodologies, perspectives, and timeframes in research, in order to form a more complete picture of what is possible in recovery; the multiple aspects of an individual’s life that can improve, the greater number of people who can recover than previously believed, and the reaffirmation of hope that, even after decades, individuals can begin, and successfully continue, their ED recovery process. How we research eating disorder (ED) recovery impacts what we know (perceive as fact) about it. In this paper we aim to provide an overview of the ED field’s current perspectives on recovery, discuss how our methodologies shape what is known about recovery, and suggest a broadening of our methodological “toolkits” in order to form a more complete picture of recovery. To do this, we (1) provide an overview of commonly used methodologies , (2) consider their benefits and limitations, (3) explore newer approaches, including mixed-methods, creative methods , and multi-methods , and (4) propose a potential future research model with a multi-methods design, incorporating different perspectives , and a longitudinal course . In this way, we seek to expand our picture of what is possible in recovery; the multiple aspects of an individual’s life that can improve, the greater number of people who can recover than previously believed, and the reaffirmation of hope that, even after decades, individuals can begin and continue their ED recovery process. These paths are sometimes polarized, indicating that research aiming for  consensus is incompatible with research pushing into new areas. We suggest that both can be simultaneously pursued, acknowledging that one does not discount the other.The belief that there is a need for a singular definition is one way of understanding the utility of recovery and may be useful for some groups. The intent of our paper, though, is not to provide a statement about what a consensus definition might be. Rather, we are offering a more diverse view of methodological perspectives  and ideas that might allow for forward movement in the field. In a dialectal format, this can involve both movement toward Quantitative research stemming from (post)positivist perspectives has tended to emphasize “objective” illness and recovery criteria that can be measured and compared in the lab/treatment, such as body mass index (BMI) , and beIn a systematic review of 126 studies looking at predictors of ED outcomes )The majority of the studies thus far on ED recovery definitions are therefore composed predominantly of non-diverse participant samples who have the means to overcome the barriers to treatment access . Indeed, there has been comparatively little research on other populations with EDs , as these groups often do not have access to the diagnoses and treatments that are the gateway to research study participation. These limitations determine whose recoveries we can learn about, and excludes other experiences , 53, 54.Traditionally, those with lived experience have not been invited to co-design recovery research, limiting study participation and the diversity of representation. Even when recovery research includes non-clinical samples, methodology choices impact who is selected for participation. For example, studies that exclude potential participants with BMIs above certain levels  exclude many ED recovery experiences automatically, limiting the view of what “recovery” looks like.Additionally, the specific terminology of “recovery” may not resonate with all people experiencing life beyond an ED , causingGiven that “recovery” as a term does not resonate with all , 63–65, We come into this work from various vantage points; we name our positionalities here, since researchers’ subjectivity inevitably shapes their research and interpretations . EngaginBelow we provide an overview of the commonly used quantitative and qualitative research methods, along with tables that illustrate examples of the different types of analyses that fit within these broader methodological categories. We also analyze the benefits and limitations of each method, focusing on what we can learn from them and identifying relevant gaps in the literature.As noted above, quantitative methods typically stem from a (post)positivist ontological/epistemological stance, which inherently affects how data are interpreted and understood. This is a core consideration of how we in turn can view the findings. This approach aims to provide “objective” results ; in thisDifferent types of quantitative methods have been employed in ED recovery research (see Table According to (post)positivist stances, these quantitative methods have the anticipated or theoretical benefits of enabling researchers to reach higher sample sizes , randomize participants (reduces bias), and replicate results . In practice, though, generalizability extends only to the sample that is recruited , and randomization within that sample thus does not increase the diversity of results. The relative focus on “novel” research means that replication studies are not conducted to the degree we would hope or expect.In addition, quantitative methods limit what can be known about any particular individual. For example, numbers can tell us a person’s standardized assessment scores, but they do not include the detailed descriptions of the individual’s experiences. They also reduce recovery to a single experience which may overlook the tremendous diversity in lived experiences. Similarly, while statistical analyses can account for contextual confounding variables, they cannot tell us the broader factors which influence the delivery and the function of interventions.Overall, qualitative methods offer the potential to engage deeply with phenomenon of interest, often stemming from non-positivist epistemological stances . While qualitative methods are commonly critiqued for small sample sizes, in a qualitative paradigm, small samples allow researchers to dig into the nuances illustrated in participants’ stories, strengthening study findings. The aim of qualitative research is in-depth, contextualized analysis, rather than generalizations. Qualitative methods often, but not always, involve interacting directly with participants in the form of interviews or focus groups. However, qualitative research can also involve analyses of existing textual or image data, such as blog or social media posts, or news articles. A core feature of qualitative research is the researchers’ focus on exploring meaning in voiced or textual data, vs. using only quantitative measures.possible to achieve. Some  draw one  studies, describe their methods as “qualitative,” without specifying the exact type(s) of analysis. The differences between these various types of methods are at times subtle.Some of the qualitative methods that have been commonly used to explore ED recovery experiences are summarized in Table Discourse Analysis (DA) focuses on language not as just a route to content, but as powerful in and of itself  , 78. Wittheorizing what ED recovery processes are occurring for this particular group )ht alone . Given tht alone , and insht alone .Similarly, standardized assessments  have been the “go-to” for assessing recovery outcomes in comparison to statistical norms. However, these measures are often developed by clinicians/researchers (thus reflecting what they feel is important in recovery) and in line with particular therapeutic modalities . Thus, scores on these measures may not always match the person’s particular recovery aims and goals, nor the relative importance of particular behaviors in their lives. Employing these measures as a part of multi-methods designs with other types of assessments for comparison may offer the potential to think differently about these measures, and their role in assessing outcomes. We also suggest the need for measures co-designed with folks with lived experience and which reflect the diverse recovery elements described in qualitative studies .Future research could compile more comprehensive lived experience narratives of changes in thought patterns through the recovery journeys , which could provide a more realistic timeline of this portion of the process for individuals and their “supports.” To begin to employ these kinds of measures in a way that opens up new possibilities, it would also be important to explore whether the ED-related ideas being measured resonate with the person whose recovery is being explored. Co-design processes may also be particularly relevant here, inviting people in recovery to be a part of research teams and take a role in determining the kinds of measures that could be used to assess recovery.As years of ED behaviors and thoughts tend to impair different areas of psychosocial functioning , improvement in these areas, along with related QOL, tends to also lag behind physical recovery . FutureSeveral studies  have successfully employed recovered mentors, providing hope in recovery . FutureAnother area of study has developed around online  use among those who are at risk for developing an ED, struggling with an ED, and those who are on the path to ED recovery. Analyses of online websites, blogs, and social media posts, along with their related potentially triggering content, have been conducted . Howeveand away from a consensus, including perspectives which do not seek to identify a single recovery definition. We believe that both can be simultaneously pursued, acknowledging that one does not discount the other. We have outlined several potential areas to explore which do not necessarily depend upon a consensus definition. Here, for balance, we would like to propose a future research model that could guide us in a direction that may eventually lead to a consensus definition–or definitions. In effect, we are advocating for: (1) transparency in researchers’ epistemological stances; (2) more varied approaches to research in order to “see” different aspects of recovery experiences; and (3) collaboration between researchers and other stakeholders to generate new methodological approaches and insights about recovery.The aim of this paper is to offer a more diverse view of methodological perspectives  and ideas that might allow for forward movement in the field. As noted above, in a dialectal format, this can involve both movement toward Our proposed future research model is detailed in Table will necessarily leave out some people and experiences. This is especially the case for those who have not been meaningfully included in the research we have conducted to reach this consensus . Since there are so many different facets of recovery experiences, using different methodologies is imperative to develop a more complete understanding.In conclusion, we would like to encourage a creative, transparent, and thoughtful approach to ED recovery methodology, that considers what each of the methods allows us to engage with, or not, as the case may be. What we can (and do) know about recovery is intricately tied to our methodological and study design choices, which all have limits. Within this context, while there is a benefit to current pushes in the field to “come to consensus,“ these consensus definitions Indeed, it is important to acknowledge how the centrality of the method that is chosen to define ED recovery in turn influences how researchers and clinicians understand recovery, and how one moves towards it. New insights into recovery processes may depend on new methods of investigation. Thus, we suggest that some potential areas for future research ideally employ multi-method designs , incorporate different perspectives  and extend the duration of studies to provide a more longitudinal outlook . In this way, we hope to move the field towards different, more nuanced, and comprehensive perspectives on ED recovery.


Chronic illnesses and multi-morbidity can threaten competence and independence, particularly in old age. Autonomy becomes increasingly important in the context of sedation, as in this case medication leads to (further) changes of consciousness. The study aimed to identify possible age-related differences in the perspectives of healthcare professionals on patients’ autonomy, in the context of sedation in specialised palliative care.Secondary analysis of interviews with healthcare professionals, analysed by qualitative content and linguistic conversation analysis. The interviews analysed span 51 healthcare professionals in specialised palliative care across 17 centres  in Germany.The study shows that the perspectives of healthcare professionals on patients’ autonomy differs according to the age of the patient in the context of sedation in specialised palliative care. The different perspectives may lead to different ways of treating the patients, for example a greater space of autonomy and decision-making for younger patients.In particular, measures that may restrict consciousness (e.g. sedation) and thus influence patients’ ability to fully exercise their autonomy and fully participate in decision-making require special attention by healthcare professionals with respect to possible influences on treatment, such as different perceptions by healthcare professionals based on the patient’s age or age-related stereotypes.DRKS00015047).The study “SedPall” is registered in the German Clinical Trials Register (ID: The online version contains supplementary material available at 10.1186/s12904-022-00963-y. The worldwide average life expectancy is continuously rising, leading to a growing proportion of older people in society. With this trend, possible age-related factors and special needs of older people become more important.In end-of-life care, communication, autonomy and decision-making are becoming particularly important. Multi-morbidity and/or need for care can restrict a person’s autonomy, especially when not compensated for by supporting environmental factors. This becomes even more important in the context of sedation as this can lead to changes in consciousness and consequently to restrictions patient’s expression of autonomy - for example in decision-making.In the context of the preferences and conditions for older people with co-morbidities to participate in medical decision-making the preferred role for older patients was for the doctor to make the final decision after considering the patient’s opinion (32.7%), and the most common actual role was that the patient was not asked for their opinion (27.5%). Thereby, the reason for the most common barrier for communication was the patient’s illness and not their age.In the study, two complementary qualitative analysis methods were combined  in an innovative and exploratory approach.The paper identifies age-related differences in perspectives on patients’ autonomy of healthcare professionals and the influence of those professionals on the autonomy and decision-making of younger and older patients in the context of sedation in specialised palliative careIn addition to medical factors, it is important to sensitively consider other implicit factors that influence decisions and the involvement of patients in the decision-making process.To avoid age-discrimination it is important to encourage and support healthcare professionals’ self-reflection, and to raise awareness of it through training and education. Critical questioning of stereotypes can contribute to effective erosion of stereotypical patterns and instead to lead to the development of alternative mental structures.Intensified collaboration of geriatricians and gerontologists within palliative care may be instrumentalIn future, it has to be clarified where and how age discrimination comes into effect, and how it can be avoided. This requires further intersectional research.Currently, the worldwide average life expectancy at birth lies at 73 years  and it iUp until now, only two studies could be found on aspects of communication, autonomy and decision-making in the context of sedation at the end of life with a focus on age; however, neither refer specifically to specialised palliative care , 4. De GA Swedish study showed that the “most common preferred role [for the patient] was for the doctor to make the final decision after considering the patient’s opinion 32.7%), and the most common actual role was that the patient was not asked their opinion (27.5%)”  o examine the presumed tension between care and concern for particular patients, and impartiality and equal concern for all patients also with regard to care for the elderly”  SkirbekkEspecially in the context of the patients’ health condition and ability to assert autonomy and participation in decision-making becoming more limited, it seems really important to identify possible factors of influence for decision-making on the side of healthcare professionals, loved-ones and the patients’ legal representatives.Therefore, this study aims to identify possible differences in the perspectives of healthcare professionals and their influence on the autonomy and decision-making of younger and older patients in the context of sedation in specialised palliative care. The study focuses on all forms of sedation in the context of specialised palliative care which are reducing the consciousness of the patients. A special category in the range of sedation is “continuous deep sedation”. “Palliative sedation” is defined by the European Association for Palliative Care as “the monitored use of medications intended to induce a state of decreased or absent awareness (unconsciousness) in order to relieve the burden of otherwise intractable suffering in a manner that is ethically acceptable to the patient, family and health-care providers” .Answering the research question required an explorative design and the use of qualitative methods, since the constructs and concepts to be investigated are not yet sufficiently known in their combination and therefore a particular openness and flexibility towards the research object was required . The intThe qualitative interview topic guide was developed by two research associates , with support from a senior researcher  and the multi-professional research consortium, based on available literature and the researchers’ working experience. Both VH and JB were trained and experienced in the development of topic guides as well as conducting and analysing interviews. Qualitative researchers in the department and a qualitative expert group at LMU university were also consulted for feedback and to facilitate self-reflection. The final topic guide  was named and involved in identifying and establishing contact with potential interview candidates. Potential candidates were contacted by either JB or VH, informed of the study’s aims, the interviewer’s experience and credentials and the interview setting. The participants had the opportunity to ask questions regarding the study and gave their oral and written informed consent prior to the interview. The inclusion criteria were experience with at least one case of sedation and sufficient command of the German language. Purposeful sampling was implemented to ensure a varied sample regarding profession, position, age, gender and working experience.The interviews were conducted by VH and JB face-to-face in the participants’ workplaces between July 2018 and September 2019, often in blocks of 2–4 interviews per recruitment centre. During the interview, no other personnel was present. Field notes were written and compared after each interview or block, in which personal observations and possible reactions or biases were also included. Four scheduled interviews had to be cancelled because of illness or unexpected scheduling conflicts. The interviews’ duration ranged from 45 to 90 minutes. No repeat interviews were conducted. During the interview process, the researchers engaged in constant self-reflection and discussed whether new and important themes had emerged that made changes to the topic guide necessary and whether data saturation had been achieved, which constituted the end of the interview period.All interviews were audio-recorded and transcribed verbatim, including anonymisation. Data on sociodemographic and professional background were collected using an anonymised questionnaire. The participants did not receive the anonymised transcripts. Ethical approval was given by local ethics committee  and the study was performed in accordance with the relevant guidelines and regulations (Declaration of Helsinki). The COREQ checklist was followed to ensure methodological rigour  were between 25 and 64 years old (on average: 48 years) and mainly female . They worked in specialised inpatient palliative care (n = 32), specialised palliative home care services (n = 18) or both settings (n = 1). They were physicians (n = 23), nurses (n = 20) or other professionals . Their working experience in general ranges between 2 and 40 years and lies on average in 21 years. In the field of palliative care their working experience ranges between 0,75 and 23 years and lies on average in 8 years.The database for the secondary analysis is 51 interviews on sedation with healthcare professionals in the field of specialised palliative care  in Germany. Interviewees  were analysed with regard to formal aspects  he primary care physician stated: ‚I won’t draw any blood from him, he’s palliative anyway and besides, what’s up with these transfusions?‘ So I said: ‘This man is of clear mind, born in ‘72, yes, he’ll tell you exactly what he does and doesn’t want.’ ( … ) And that’s what the rest of the procedure is based on, it doesn’t work any other way” (P1).‘Regarding possible age-related differences in healthcare professionals’ perspectives on patients’ autonomy a difference can be seen between younger and older patients. While patient autonomy is emphasised in cases of younger patients, and even advocated for –in this case by the specialised palliative care physician towards the primary care physician– the data set shows a tendency of devaluation of older patients’ autonomy, consequently restricting their range of decision-making and action. Thus, for younger patients:“[H] e always wanted to be sedated, wanted to get the injection, so that he could fall asleep and not wake up, was 80 years old. (...) It was only the loss of autonomy, in the end, that was left as an indication, because he didn’t have much pain or nausea. So really he didn’t have anything, aside from, yeah, not being able to deal with the situation. And it was exhausting, every day, because every day he wanted to have the lethal injection, and it was very difficult to get him away from that. But then I decided not to sedate him” (P2).On the other hand, for older patients, the following example shows attempts to minimise the patient’s expressed symptoms. The patient’s insistence is viewed negatively, until in this case, a doctor decides to refuse the patient’s treatment – in a more paternalistic than advocatory way:“[W] hen it’s just end-of-life care, when they’re 95, where everyone can, I think, follow along relatively well. And you don’t take it home with you” (P4).“And I think, others in palliative medicine will see it the same way, particularly when you have a young person in front of you, you have a pit in your stomach and the decision [sedation], leaves an impression before and long after” (P1).Beyond that, the description of the stress experienced in attending to an older patient and the perceived emotional burden seems to be lower, where on the other hand the attending to a younger patient is described as emotionally more burdensome, as it is illustrated in the following expressions:This difference in perception and evaluation of patient autonomy between younger and older patients by healthcare professionals was also seen on a semantic level.“And then she still wanted to, because she already knew, if she gets sedated now, that she wouldn’t see her parents again. And then we just had one more week for them to really have a proper farewell, to take all of it in, even with all the downsides, but then we accept that, because it’s just how they want it” (P5), “then in the end we offered to bring her to the ward with us. That’s where she was finally palliatively sedated” (P7) or “in fact, we agreed on it together, that we would sedate her, yes” (P8).Regarding the attribution of autonomy, it is important to take the semantic roles into consideration that healthcare professionals ascribe to younger as well as older patients. Although sedation is a medical treatment that cannot be done by the patients themselves actively, the active and passive formulations of sentences show a different degree of involvement of the patients. Thereby, younger patients are assigned an active role in sentence structures and are given an acting role. For example, a healthcare professional describes in the case of a younger patient:“Now, in the other case, with Mr. [name], he was already diapered” (P3) or phrases in connection with pressure, force, or manipulation such as: “[W] e got it so far, that she (...) accepted the syringe driver” (P1). In other cases, the passive role of the patient was also applied to relatives: “[B] ut then the carers or relatives are told: ‚Now we would sedate.” (P5) or “they will get the patient ready and sedated from us” (P6).In contrast, the tendency for older patients in the sense of a speech act analysis is to put them in a passive role with a lower degree of involvement: “But it was very clear that she didn’t want that at all and (...) then we initially just discontinued use of pain medication at home” (P9), “and then (...) we considered a palliative sedation” (P10) or “that she was then brought into a sedation” (P11).This shift of communication from patient to relatives can also happen in younger patients’ cases, but without the pejorative use of language commonly used with older patients and the resulting constraints on their autonomy. In connection with pressure or force, the chosen phrases for younger patients are more lenient or attenuated, such as:„He just said: ‚I gotta go, I need some deep sleep, I can’t take it anymore, (...) “(P6) or „he even said that he wanted, he wanted to be sedated “(P12), whereby patients can speak for themselves and are somewhat literally quoted. There are also differences in the choice of how reassurance is phrased between the age groups. For younger patients, the tendency is towards choosing phrases carefully while at the same time weakening the negative connotations of them: „[H] ow shall I say? “(P8), „to exaggerate a bit “(P12) or „this is kind of a stupid way of putting it, but (...) “(P13). In contrast, the tendency in phrases for older patients is more absolute in nature with a more justifying claim, such as: „to be honest “(P5), „I have to say “(P14) or „as one may say “(P15).In accordance with younger patients’ autonomy, passages with active or reported speech can be found in this context: “[S] he was such a shrivelled old granny “(P5) versus “Even just seeing that, I mean, he was in his mid-thirties and to see himself in the mirror, disfigured by his tracheostomy tube, (...). Well that’s pretty tough “(P12).In addition to the results of the qualitative content analysis, the linguistic conversation analysis also shows the differences in the perceived emotional burden in attending to younger and older patients. Healthcare professionals are found to use normalising expressions in relation to the dying process of older patients, in contrast to the emphasised tragedy and burden of the dying process of younger patients, or in their contrasting youth with frailty, such as:Aside from an uneven distribution of semantic roles – demonstrating a tendency of passive roles for older patients the interviews showed differences in the perspectives of healthcare professionals of older patients and younger patients.To the best of the authors’ knowledge, this is the first study that focuses on possible age-related differences in healthcare professionals’ perspectives on younger and older patients’ autonomy and decision-making in the context of sedation in specialised palliative care. For this purpose, an innovative study design was developed in multi-professional and interdisciplinary collaboration, combining various qualitative evaluation methods.The results of the qualitative data analysis shows that healthcare professionals describe more deficit-oriented perspectives of older patients, whereas a focus on resources and aspects of vitality and youthfulness was found toward younger patients. Also a report published by Denninger describes that with older patients, aspects of dependency, need for help and care are particularly emphasised, while with younger patients, their desired or actual independence is emphasised . Ideas op = 0.017) [p = 0.003) [In relation to autonomy, the results of the analyses show that there are age-related differences in the perspectives of healthcare professionals on patients’ autonomy. For example, healthcare professionals tended to perceive demanding, loud and strong-willed behaviour in younger patients as rather positive in the sense of ‘standing up for oneself and one’s loved-ones’, whereas in older patients this is perceived as rather negatively and is classified as rebellious. These results are consistent with the findings of Mayer and Rothermund, according to whom observed behaviour can be explained by activated age stereotypes and their prescriptive character, but can also lead to misattributions . This co= 0.017) . MedicalWith regard to an over-adaptation and a protective, paternalistic attitude, which is, however, based on a deficit conception of ‘old age’, this can be named as a form of positive ageism, as this also undermines the independence and self-worth of older people in the long run through overprotective behaviour . KitwoodAnother reason for the rather early informing of younger patients about the possibilities of  sedation, instead of their age and thus a bias, could be due to the presence of certain diseases, such as COPD (Chronic Obstructive Pulmonary Disease) or ALS . These diseases are described as particularly uncertain and difficult to predict with regard to possible courses and symptom exacerbations , 31. ThiAlmost regardless of age, the interviews reveal challenges with psycho-socially related symptoms for the indication of  sedation. Overall, the literature reveals a controversial discussion on the implementation of palliative sedation in cases of predominantly to exclusively present psychosocial symptom burden –35. ChalDue to the explorative character of this study as well as the study design of secondary analysis the results should be confirmed by further research, with particular focus on the connection between stereotypes and images of aging. Furthermore, it has to be clarified where and how exactly age discrimination comes into effect, and how, in the future, it can be avoided.An essential strength of this study is the innovative approach of combining the methods of qualitative content analysis and linguistic conversation analysis. In the case of sedation of older patients, it is evident that the description of decision-making processes corresponds to the semantic level. Another strength can be found in the large number of interviews with healthcare professionals in specialised palliative care which were analysed for this study. In addition to this, not having a specifically gerontological focus during the interviews uncovers in which contexts the calendar age of the patients is taken into consideration and becomes meaningful for the healthcare professionals. To analyse and contextualise the results, it is important to disclose the epistemological positions of the main researchers involved. On the part of the doctoral candidate (first author), these were from a background of social science  as well as from gerontology and palliative care. The backgrounds of the other researchers intensively involved were: nursing science, sociology, medicine and linguistics. Through this interdisciplinary exchange, it was possible to discuss the results and their interpretative uncertainties throughout the entire research process.On the other hand, this project faces the limitation of selection bias, as it was easier for interviewees to remember younger patients. This led to the availability of more data on younger patients for this secondary analysis. In addition, using interviews with remembered cases the likelihood of examples or cases responding to stereotypes is greater than in observations. Using secondary analysis also precludes asking further questions and exploring respondents’ statements from the perspective of the research question. In this study it would have been necessary to ask questions about the intentions and influencing factors behind the statements of the healthcare professionals. Thus, this study can only speak of tendencies and no causal connections can be made. Another limitation is the age limit of 60 years, which was set and derived from literature as well as the respective attributions of the healthcare professionals in age groups (e.g. ‘younger patient’ into the group ‘younger patient’). This has to be further investigated in detail in another study design (primary study design) with a special focus on gerontological issues, differences and concepts. Also, the average of age of the healthcare professionals seems to be rather high at 48 years. This also could point to a selection bias. Looking at the generalisability of the results, there are limitations due to the care context being specialised palliative care and the small number of interviewees within specialised groups of healthcare professionals. Specific limitations in the linguistic analysis are due to the fact that aspects of emotionality in the language were considered and analysed, however without being able to connect these results with the underlying intention of the statements. Therefore, the results of this study are to be regarded cautiously and should be examined and confirmed by further in-depth research, with particular focus on the connection between stereotypes, self-images, and portrayals of aging.The results of this study indicate that healthcare professionals have different perceptions of younger and older patients’ autonomy. This becomes important in the context of sedation as administering sedative medications can lead to (further) restrictions of consciousness and consequently to restrictions of communication, the ability to express one’s autonomy and to take part in decision-making. Therefore, in addition to medical factors, it is important to sensitively consider other implicit factors that influence decisions and the involvement of patients in the process of decision-making. It is possible that a permanent critical questioning of stereotypes can contribute to an effective erosion of stereotypical patterns and instead to lead to the development of alternative mental structures. Furthermore, it has to be clarified where and how exactly age discrimination comes into effect, and how, in the future, it can be avoided and healthcare professionals can be supported. This requires further, and particularly, intersectional research.Additional file 1.Additional file 2.