Most female patients with lung cancer experience sexual dysfunction. This narrative describes one patient’s experience, focusing on how tobetter address issues related to toxicities stemming from long term treatment on targeted therapies. I got lucky on the trifecta of precarious conditions that provide a temporary reprieve. When I hit one year of stability, I began to hope to eke out a few more purposeful, and dare I dream, pleasurable years?Diagnosed in 2020 at stage IV, I was single, with an incurable cancer, and along with the likelihood of a shortened life span, I mourned the loss of intimacy this portended. Lung cancer inevitably evades treatment, but After reconnecting with an old crush undeterred by my prognosis, I came down with a UTI. At the appointment with my gynecologist, I was doubled over with discomfort, but smiling, nonetheless. “You have honeymoon cystitis,” was how he put it. I am deeply fond of this doctor, whom I have seen for 2 decades, but it is baffling that this term, informed by Victorian era notions of chastity, assuming that the first time a woman would have sexual intercourse would be on her honeymoon, is regularly invoked by medical professionals.“Cancer is my bad boyfriend and I’m cheating on him with joy!” I giggled like a teenager.“Just give it a rest for a few days.”I threw back a round of antibiotics, stockpiled cranberry juice and a trifecta of pro-, pre-, and post-biotics. But when I came down with another UTI, and then another, I asked my cancer care team if there might be a connection between my targeted therapy and the infections. They maintained that they were unaware of any correlation. After 6 months of averaging 2 UTIs a month, the relationship had blossomed, but I began to worry that my partner and I might have some sort of bacterial incompatibility that recommended breaking it off. Again, I asked my oncologist about a possible connection. “Stop having so much sex” I was advised with a dismissive shrug. The implication was as demoralizing as it was clear—just be happy you are still alive.Then, in August 2022, after giving a patient advocate address at the International Association for the Study of Lung Cancer conference in Vienna, I attended a presentation recommended by Dr. Brandon Stiles, a thoracic surgeon at Montefiore, Albert Einstein College of Medicine. Dr. Narjust Florez, Associate Director of The Cancer Care Equity Program and thoracic oncologist at Dana- Farber Brigham Cancer Center presented data from the Sexual Health Assessment in Women with Lung Cancer, SHAWL Study, for which she was the lead author. Scheduled at 7:30 AM, a decidedly unsexy time, I was the person punctuating her talk with fist bumps, weeping, and barking, “Yes!” as I learned that 77% of female lung cancer patients experience moderate to severe sexual dysfunction. When the call came for questions and comments, there were no takers. I stood up, as though at a 12-step meeting, and introduced myself. “I’m Annabelle Gurwitch, and I have a very, very dry vagina. Thank you for bringing attention to this issue, I thought I was alone.”As to why our symptoms go unaddressed, the study points to numerous reasons, including a cultural taboo surrounding discussions of sexual health. Florez, herself, was unaware that female patients with lung cancer were experiencing UTIs and painful intercourse (it was not brought up in training), until in 2019, she noticed a patient’s armpit rash. The patient, in her early 30s, and her partner had been having intercourse in her armpit because vaginal penetration caused extreme discomfit. The patient had been embarrassed to bring the topic up, in addition to conditioning to the well-documented history of female patients’ complaints falling on deaf ears. Can you imagine a man in treatment for prostate cancer being told, like I was, to just stop having sex? You cannot, because it does not happen; monitoring sexual health is standard protocol in prostate cancer management.“We’re trained to pay attention to the effects of therapies on patients’ other organs,” Dr. Florez told me, “And, it’s tragic because a vagina is not only an important organ, but provides our patients with pleasure. You can’t say that about a spleen.”Female sexual health, understandably, presents a relatively new set of issues for both patients and long-time practitioners in lung cancer as City of Hope thoracic oncologist Jack West recently reminded me. Prior to 2017, when targeted therapies became standard first line treatment, the 5-year survival rate was 4%-7%, compared to 23%-40% which it hovers around presently. As the only treatments carried high toxicities, “sexual activity wasn’t top of mind” for most of his patients, and if side effects didn’t send someone to the ER at 1 AM, he was not focused on them either. In this new era, he noted, “Chronic, non-emergent side effects should be the focus of more of our attention—as we have treatments that are effective enough for people to be living much longer, they really affect quality of life.”Also, in the past, patients were overwhelmingly male. For the first time in history, more younger women in the US will get diagnosed than young males. In patients less than 50 years old, 2/3 are young women. Preserving fertility and sexual dysfunction are top of mind for this population but the SHAWL study finds that for almost 80% of us, our providers have not yet registered this new reality.E. coli bacteria, a by-product of chronic diarrhea, another TKI side effect, and you have got the perfect climate for persistent UTIs. Granted, it is possible that a contributing factor to my doctor’s not recognizing the relationship between my side effects was due to widespread underreporting by patients. A common topic of discussion within the patient community is the fear of being taken off of our medications.As Florez explained to me, 2 of my side effects (considered low-level toxicities) were conspiring with my canoodling to produce the UTIs. Introducing friction causes small tears in the delicate lining of the vagina, which was already compromised due to the tyrosine kinase inhibitors blocking collagen production. Add in I can testify to my own reluctance to disclose the severity of side effects at the onset of treatment. At the 3-month mark, the first assessment of the targeted therapy I was receiving, CT scans of my lungs showed shrinkage of the main tumors and the trace areas were diminished as well. The oncologist was pleased. I was miserable. Fatigue was possible, I’d been warned, but nothing prepared me for the level of enervation I was experiencing. If I got up in the morning and made coffee, the exertion of operating the machine sent me back to bed. If I sat down at my desk, by the time I powered up my computer, I’d need another nap. There were days when I had a good 6 or 7 hours of wakefulness, unfortunately, none of those hours were consecutive.One day, I summoned the strength for an afternoon walk. I was less than 3 blocks from home when I could not take another step. I crumpled like a wet potato chip onto a grassy meridian. I lay there, inert, and unable to rouse myself, for maybe 30 minutes, until I managed a form of locomotion, something akin to an injured racoon. Not a single car that passed stopped to inquire if I was OK. “Women in Los Angeles will do anything to stay fit, I saw a woman crawling on all fours on the sidewalk today!”Admitting to the severity of the fatigue might risk burning off my first-line treatment; on the other hand, I was not sure that the way I was surviving qualified as living. After confiding in my doctor, each day of a 3-month trial period at a lower dosage was a nail biter. Thankfully, the stability held.With a new care team and through mitigations suggested by Florez, I have halved my frequency of UTIs, lessening my risk of becoming antibiotic resistant, while still getting my sexy on.Intimacy, of course, can be fostered in many forms. Jill Feldman, co-founder of EGFR Resisters, a lung cancer advocacy group, and a co-sponsor of the SHAWL study, reminded me, “Emotional intimacy is important too! Initially, after I was diagnosed, my husband and I were focused on the well-being of our four kids. We also share a love of the Kansas Jayhawks, so we started doing date nights to the Final Four. It was so liberating and brought us back to us, fun, adventure, and far away from cancer.” Me? I am with Marvin Gaye. I’d like some of that “sexual healing.”It’s widely recognized in the oncology community that it was breast cancer survivors who pushed for improvements in survivorship issues like insurance coverage of breast reconstruction and conversely the normalization of the “going flat” movement by medical practitioners who were initially reluctant to endorse this choice. Our pink warrior sisters are providing leadership in another area as well: rethinking methodologies used in toxicity level reporting during clinical trials. In 2021, the Patient Centered Dosing Initiative, founded by breast cancer survivor Anne Loeser, conducted surveys confirming that disparities in language used in patient surveys and clinician reports during clinical trial data collection contributed to “oncologists somewhat underestimate(ing) the prevalence and severity of their patients’ side effects.” Since the results were presented at ASCO in 2021, the FDA has launched an initiative, Project Optimus, that holds promise for improving patient-provider communication.I am coming up on 3 years in treatment and any indifference I have experienced in Cancerland has been off-set by the calamity of kindness I have received from members of the medical establishment. Dr. Florez is an extraordinary evangelizer for our vaginal health and has earned a Swifty-like following in the female lung cancer patient community, but I am resolutely hopeful that once we gain wider acknowledgement of the issue, our care teams will respond, as well, and introduce sexual health into regular consultations. Modalities like the Ex-Plissit Model, which offers guidance for the introduction of topics related to sexual health, are currently in use in medical settings. However, this training was not included in any curriculum of the oncologists I spoke with.In her presentations, Florez often gesticulates with an intimate accessory or tube of favorite lubricant, props she regularly offers to her audiences with assurances that though we live in a share economy, these are virginal—so to speak. “So, are there always takers?” I asked Florez. “Always.” “And, what’s the ratio of patients and clinicians?” “One hundred percent patients,” she answered definitively, no need to consult her notes on that data point. Perhaps the day that clinicians leave her presentations toting unmarked brown paper bags will signal a small bit of progress.


Older people have been disproportionately affected by the COVID-19 pandemic and are often portrayed as passive victims of this global health crisis. However, older adults do take responsibility for their own health and that of others in large part through social network dynamics. The purpose of this study was to understand the processes whereby older adults’ social networks shape their own health behaviors, and vice versa, in the context of COVID-19 vaccination and other mitigation efforts. Qualitative data from 77 older adults between ages 65 and 94 obtained through focus groups or individual interview participants were analyzed. Participant narratives demonstrated the reciprocal nature of social support and health behaviors and provided evidence that COVID-19-related health behaviors in this population were motivated by social support, altruism, and life experience. These findings emphasize older adults’ active role as health promoters in their families and communities, keeping themselves and their significant others safe from COVID infection. Implications for the role of older adults in community health promotion efforts are discussed. Since the beginning of the COVID-19 pandemic, people have been talking about aging and older people in terms of risk of infection, disease severity, hospitalization, and risk of death. Some have pointed to age as a risk for severe COVID outcomes . More acWithout question, the COVID-19 pandemic disproportionately impacted older adults in terms of greater disease severity and mortality ,4. OlderAgeism, namely negative stereotyping and discrimination related to chronological age, is fundamental to understanding how older people were affected by and responded to the COVID-19 pandemic. Our society largely focuses on the negative age stereotypes about growing older such as poor health creating a drain on healthcare resources, a lack of meaningful social contributions after retirement, and old age being a life stage of loneliness, dependency, and decline ,6,7,8. AHowever, were these perceptions congruent with the actual lived experience of older adults during the pandemic? The unthinking adoption of such ageist and paternalistic attitudes ignores the reality that older people are those in our society with the most lived experience and are sources of generational knowledge and wisdom while continuing to make positive social contributions in numerous ways ,12. One Health locus of control (HLoC) refers to how individuals perceive that their life and health are under their own control  versus controlled by external forces  . People In theory, external HLoC might prompt older adults to listen to healthcare professionals and other authority figures and to comply with government-mandated COVID mitigation measures, ultimately resulting in better health outcomes. However, external HLoC is positively associated with symptoms of depression and anxiety, while internal HLoC is found to be associated with adherence to COVID mitigation measures ,20,21. TResearch also finds associations between LoC and social support resources. Individuals with greater internal LoC also tend to have more sources of social support that promote positive health behaviors . Older people do not consume health information or make decisions about COVID-related health behaviors in a vacuum, but rather in the context of close social ties. Social relationships affect health across the lifespan ,26,27 reFamilies are an important source for developing, adopting, and changing health beliefs and behaviors as well. Older adults are just as often the promoters of positive health behaviors as they are recipients of health encouragement from same-age and younger relatives. There is an extensive body of work documenting the influence that older spouses have on each other’s health and health behaviors, such as chronic disease management and care engagement, e.g., . IntergeThe ability of older adults to successfully weather the COVID-19 pandemic was associated in part with their ability to activate social network resources. However, our understanding of health behaviors and social network dynamics in older populations suggests that older adults take responsibility for their own health as well as shaping the health behaviors of others by acting as sources of information, advice, and generational wisdom. In the current study, we sought to understand these processes in the context of COVID-19 vaccination and mitigation efforts and efforts to cope with the impact of the pandemic.Data were obtained from a larger qualitative study of how race and ethnicity were associated with older adult attitudes toward COVID-19 vaccination, mitigation efforts, and sources of trusted health information in partnership with one of the largest senior service providers in New York City. Since we were interested in better understanding how people were thinking about a novel and emerging phenomenon—the COVID pandemic and its influences on their decision-making—a qualitative approach was the most appropriate method to understand these complex phenomena.While our preferred data collection method was using focus groups in order to obtain additional information gained by group interaction, we designed the study with the flexibility to employ individual interviews as necessary due to COVID restrictions or recruitment complexities. In line with the aims of the larger study, we recruited from six prominent linguistic/demographic groups of older adults in New York City, namely, U.S.-born Black/African Americans, West Indian-born Blacks, Spanish-speakers, Chinese-speakers, U.S.-born Whites, and Russian-speakers. Recruitment flyers in the languages most commonly spoken at specific program sites  were posted by staff at the senior service sites . We also worked with the organization’s vaccine coordinator to organize and conduct thirteen tabling events at service sites to screen and schedule potential participants. Recruitment and data collection occurred from October 2021 to January 2022. Older adults interested in participating were screened for eligibility: (1) age 65 or older; (2) able to participate in a 90-min in-person focus group discussion or telephone interview; (3) willing to discuss COVID-19 vaccination; and (4) able to converse in English, Spanish, Russian, or Mandarin Chinese. Eligible older adults were scheduled into focus groups or individual phone interviews. Interviews were conducted when a person was eligible but the focus group time/place was not convenient or COVID mitigation protocols precluded in-person gatherings. Participants provided informed consent. Research materials, including informed consent, were available in English, Russian, Spanish, and Mandarin Chinese. Non-English language focus groups and interviews were conducted by research staff who were either native speakers or fluent in those languages. Focus groups and telephone interviews were audio recorded, with permission. We developed a discussion and interview guide that covered general sources of health information, experiences with vaccination, COVID-19-vaccine-specific concerns and motivators, the vaccination process, and overall experiences during the COVID-19 pandemic. The study protocol was approved by the City University of New York Integrated Institutional Review Board. The participants received a USD 20 gift card as compensation for their time.n = 62) or interviews (n = 15). The largest group was the U.S.-born Blacks (n = 22), followed by Hispanic/Latinx older adults (n = 21), Russian speakers (n = 11), Chinese speakers (n = 9), U.S.-born Whites (n = 8), and West Indians (n = 6) (Seventy-seven older adults participated in focus groups ( (n = 6) . Most pahttps://www.descript.com/, accessed on 24 January 2023). Audio recordings in Chinese, Russian, and Spanish were translated and transcribed either in-house or via a third-party vendor. The ranscriptions were analyzed using the Atlas.ti 22 qualitative software package . The research team developed and finalized a project codebook via an iterative process. The initial codebook was developed deductively from the interview guide. This codebook was then refined inductively, from the data, after an initial coding round of each of the focus groups. Memos were used extensively to document impressions of the data, the adequacy of the coding framework, and emergent themes. The research team met regularly throughout the coding process to discuss the preliminary findings, coding modifications, and interpretation of the narrative data. Each transcript was coded independently by two members of the research team using the final codebook. Disagreements were resolved by discussion.Audio recordings were uploaded onto secured, password-protected network drives and encrypted. English-language audio recordings were transcribed using Descript software  had access to COVID vaccines earlier than younger people, including their own family members. Many of our participants became vaccine advocates within their own networks based upon their experience as early adopters, their constant exposure to the stream of vaccine information and misinformation, their personal stake in needing others to get vaccinated to protect them, and their role as trusted advisers within their social networks. This role, which came through strongly in almost every group and interview, stands in sharp contrast to the dominant ageist image of older adults as confused victims of COVID. Meanwhile, these older people were exceptional in building trust in a pandemic of distrust, enabling effective and selective information dissemination and helping shape social norms within their networks and communities. However, some participants shared that their children and other younger family members were unwilling to get vaccinated due to concerns about vaccine safety and efficacy at the time they became eligible for the shot. In response to such hesitancy, our older participants shared vivid stories about how they took the role of health advisors for their families and advocated for the COVID vaccine. My youngest son wasn’t going to do it. And I remind him, “you have asthma, baby, you know. That virus hit your lungs, you don’t know what happened to you. Do you know, your asthma, baby, you used to smoke, you don’t know the condition of your lungs. Now don’t do that to yourself. You know?”Some participants use their own experiences with vaccination and COVID as examples to facilitate their families’ decisions: My son has not taken the vaccine up until now… Everybody’s took it [sic], but he refused to take it. [He said] “Oh mommy, you took it and you got COVID twice” and I say, “Okay, well maybe if you take it, you will get it three times. I got it twice, if you take it, you will get it three times. But as I said it worked in a great way and because I’m still alive today. I got it twice and I survived it. And here I am, and it was because of the vaccine”.Another participant told us:We guided my son so that he could take the vaccine. He’s, he’s not that old, but he’s not that young either, 30-something, 37. Uh, and he was pretty reluctant, right? But when we got vaccinated and we told him that the vaccine is just like giving you get a vaccine like, like any other. He got vaccinated a few months ago.Some participants convinced their family members by making vaccination a vital personal matter. One woman shared this story: And when I asked him [her son] whether he was going to take the vaccine or not, his thing was to me, he said, “Mom, I don’t think so.” And I said, “Why not?” And he gave me some crazy excuse, and I said, “Wait a minute… listen, that does not make sense to me. Think about it… because God forbid that you should contract the virus. I would not be able even to come and see you. It wouldn’t be even worth me coming to where you live to call me because I couldn’t see you. They’re not going to let me come in upstairs. And the same thing with myself.” And I said, “I will not want anything to ever separate us from not being able to be together”.Sometimes these conversations spanned many generations:My grandson, he’s in college, down in Alabama. He made me so angry with him. And he did contract COVID while he was in college, you know? So I made him promise me that he would take the vaccine. So what does he do? He said, “Grandma, I’ll always keep my promises with you, but this was one I’m not going to do.” So I said this to him. “Then if you get sick don’t come nowhere near me, you know?” And he said, “Grandma”, I said, “No, no.” I said, “I really mean that, you know?” And so now he told me to go, “Grandma, I’ll think about it”.In addition, participants’ active engagement in health promotion was not limited to vaccine advocacy. Since many of them lived in senior apartments, some also stepped forward to reinforce the mask mandate in the shared common area to ensure the safety of themselves and many other older residents:I went the other day in the elevator and came to the other floor. A young fellow did not wear a mask. I ask[ed] if he was a worker from here. He said yes... I told him you have to use masks in the hallway, in the elevator. “Okay, for you.” I offered him masks. He opened the package and he took the mask.As mentioned before, many participants shared altruistic motivations to get vaccinated because they highly valued the safety and lives of the younger generation and other community members. Some of them also transmitted these values to younger members of the community: It was one person I asked her and she said, “I’m not going. I’m not going.” I said, “Well, if you was still working at the nursing home, you would have to take it or you lose your job! You’ve got to protect the residents there”.In addition, as described earlier, peers played an important role in the decision-making process for many by delivering effective, tailored, and relatable COVID-related information. Many of our participants who once obtained support from peers paid it forward by becoming peer support for many others. Do the best we can. Those who are our friends, we let them know that this is a safe way, that’s the way to go.There were still some that were hesitant, it was quite a few then was waiting to see. They weren’t all jumping to get it and I said, I explained to them that I already took it and that I’m feeling fine and, and some of them were convinced to go ahead and, you know, take the vaccine.Some expressed their vaccine advocacy among members of their faith communities:I have been to the Middle East, India, Pakistan, the Holy Land. I always had to take shots. And I am telling all the people—I am telling my Muslim counterparts—when you go to the Holy Land, you need to take shotsOther participants’ advocacy specifically targeted the spread of misinformation:I’m going to tell you if I come across anybody who’s talking nonsense about the vaccine “Shut your mouth go take your vaccine and protect yourself.” I’ve heard concerns about people talking about turning monkey and donkey at this one and nonsense, you know, all over the place. Why? Take a vaccine, take the vaccine if it’s, if it’s beneficial to you. They wouldn’t call me to tell me nonsense like that because I won’t entertain it, you know? I wouldn’t, I would come meet with you at [the] door. Go to you, have to take a vaccine.Our participants shared that such messaging was often extraordinarily effective. This is because they were often well-respected and established members of their families and communities.Moreover, the participants also described helping one another to find vaccination sites when vaccines were scarce and available appointments were hard to identify by providing information and logistical support. One participant described helping his friend with limited computer literacy to schedule an online appointment:Well, I have a friend who said that he really wanted to get vaccinated, but where they live is not as good as we are here. They asked me to help them register on the website and get vaccinated… They don’t know how to use the Internet. I taught them.As with the rest of the population, older adults experienced disruptions to all aspects of their lives due to COVID-19, including social interactions, physical activity, and accessing healthcare. Consistent with other studies ,34 partiThe bidirectional nature of social support among older adults and members of their social networks is evident in the participants’ reports that they actively engaged in conversations about the vaccine. Several studies have documented changes in family and friend contact and support exchanges that older adults experienced during the pandemic ,36, notiImportantly, we observed that older adults served as key sources of information and health behavior encouragement for their families, peers, and communities during the pandemic. Specifically, they shared information about vaccination procedures in their communities, encouraged younger family members to get vaccinated, and endorsed other COVID-19 prevention behaviors, such as social distancing. There is a long tradition of utilizing older adults as peer educators in health promotion programs , includiThe leadership of older adults too often goes unrecognized. However, our findings exemplified the role that older adults take in influencing others in their social networks. However, the strategies employed to persuade older adults to adopt risk mitigation and vaccination relied heavily on public authorities  or recognized community leaders (ministers and leaders of community organizations). Neglected was amplifying the voices of people just like those the messages were trying to reach. Older adults could be effective messengers for public health campaigns and consult in the development of such campaigns. For example, it may have been helpful for senior serving organizations to include COVID-prevention messages recorded by their own members to play at the beginning of virtual classes. Similarly, ads depicting an older woman speaking directly to her peers about her decision-making process about taking the booster could be particularly salient for older adults, especially when considering the powerful tendencies towards behavioral homophily in peer networks . Peers are widely recognized as effective public health messengers. Despite programs attempting to capitalize on older women’s role as keepers of wisdom , interestingly, it is quite unusual for public health programs to identify older people as leaders among their peers. The present findings suggest they are effective in that role and that public health programs should include them as communicators in person, virtually, and in scripted campaigns. Despite some recognition of the value of leveraging older adults’ unique perspectives, experiences, and roles in society , there aThis study is not without limitations that could be addressed in future research. The study took place in New York City, where the general political and sociocultural norms towards vaccination are more positive than in many other parts of the U.S. and limit the generalizability of these findings. Although anyone over 65 and affiliated with the service organization at any level was eligible to participate in the research, due to the implication of the research topic in the recruitment flyers, recruitment might have been biased toward individuals who had more positive attitudes towards the COVID vaccine. For example, those who had not been vaccinated and/or strongly opposed vaccination might feel less inclined to participate, knowing that their opinions were less likely to be approved by others. Future research should examine the effects of social participation and network engagement on health decisions among older adults who had not been vaccinated or living in areas with low vaccination rates. Despite these limitations, this study provides unique insight into older adults’ roles in their families, peer groups, and communities during the pandemic. A key strength of the research is the diversity of the research sample, which encompasses a broad range of experiences by race, ethnicity, immigration experience, and age. Importantly, this study uniquely focused on older adults’ social support dynamics, proactive crisis management, and their critical role in health communication and advocacy during the COVID pandemic. More gerontological research is needed that centers on older adults’ social engagement and explores more ways for older adults to provide leadership in community public health initiatives. The findings in this study present a counter-narrative to the ageist stereotypes of older adults as helpless, vulnerable burdens to society during the COVID-19 pandemic. Older adults reported taking charge of their own health and that of their loved ones, motivated by both internal LoC, life experiences, and self-determination and external LoC, operating in social contexts. Importantly, the narratives presented in this research serve as compelling evidence against the prevailing political discourse that treats the growing aging population as a catastrophe rather than an opportunity.


The SARS-CoV2 pandemic as well as the implementation of public health measures to decrease the spread of the virus re-sparked the call for “virtual” health or “distance” treatments. This paper aimed to assess the use of video consultations, the up-to-dateness of practice websites, and the views of GPs on whether eHealth is a positive aspect for the future of their practices in publicly -funded primary healthcare facilities in Austria.The cross-sectional online questionnaire, part of the PRICOV-19 study, was conducted from December 2020 until July 2021. We randomly recruited 176 GP practices across Austria. Descriptive statistics as well as binary logistic regression models were applied to examine the associations between telemedicine use and practice factors.Compared with before the pandemic (3.8%), 7.6% of publicly funded GP practices have been using video consultations since the pandemic. In line with this, 93.9% of the practices had no increase in video consultation use. Fewer than half (44.3%) had an up-to-date webpage, and 27.8% assumed that the pandemic might have been a positive driver for eHealth in their practices. Positive associations with video consultation use could be found in practices with fewer patients aged 70 years and over than the average and more patients with chronic diseases than the average.The use of video consultations in general practice and the readiness for other telemedicine approaches are both very low in Austria. Austria has to urgently follow the example of countries with a transparent and comprehensive national digital health strategy that includes video consultation. Without a proper payment system, patient inclusion, and support with regard to administrative and organizational aspects, no substantial change will occur in spite of an increase in need due to the pandemic and changes in the patient population. Since January 2020, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has had the world within its grasp. The pressure on health-care systems worldwide has resulted in major challenges and the fragmentation of provision and support processes .Fast policy response has been vital, as threats throughout the systems have demanded sustainable solutions that guarantee planning security . As primThe use of digital technologies to improve sustainable care routines, however, have in many countries not yet adapted to the needs or the capacity of patient populations because of widespread skepticism regarding telemedicine . HoweverThe implementation of public health measures to decrease the spread of the virus, such as quarantine, isolation, and physical distancing, once again sparked the call for “virtual” health or “distance” treatments. For example, teleconsultations were remembered as having provided good support in previous pandemics, such as those of Ebola or SARS , 6.Thus, for several countries, it became during the SARS-CoV-2 pandemic an additional strategy for serving primary healthcare demand . Where iHowever, organizational case studies have shown that VC can disrupt, for example, the routines and processes of GP practices, leading to additional consultation times. Moreover, many physicians have expressed concerns about technical as well as privacy, safety, and accountability issues that hinder the use of telemedicine –11.Additionally, VC needs sustainable implementation solutions, but weak broadband connection, lack of or outdated equipment, and lack of training for caregivers and patients make it impossible to guarantee comprehensive and permanent implementation, leading to an increase in overall costs to the health-care system and to GPs –12. AnotMoreover, an important issue to consider when it comes to using telemedicine concerns financing. Whether the widespread implementation of telemedicine will create an economic burden or an economic opportunity for health-care providers is as yet still under debate. While VC has the potential to improve efficiency and, after an initial phase, save time and therefore money for physicians, studies that have investigated the economic consequences of telemedicine suffer from poor quality and considerable heterogeneity, making comparisons or meta-analyses of their data impossible. This was the conclusion of a systematic review published in 2017 .In Austria, efforts to promote telemedicine applications have been underway for some time in both the public and private sectors, and the SARS-CoV-2 pandemic resulted in an unexpected upswing and new developments in this field.Nevertheless, until recently, payment for Austrian physicians accommodating their patients by offering VC was not guaranteed. This means that the new tariff plan was introduced nine months after COVID-19 breakout and included a reimbursement for the use of VC equivalent to face-to-face appointments. However, those GPs who already provided VC were not paid for these nine months .This is important because Austria is a Bismarck-system country without gatekeeping or a list-system. GPs are generally self-employed and remunerated by a mixed payment model that is predominantly fee for service . The firAdditionally, guidelines addressing the legal questions with regard to telemedicine in Austria are usually based on solutions from foreign legal systems that might not fit well into local regulations and/or be applicable only to one specialty medical field. Previously, the formulation of telemedicine guidelines based on local Austrian conditions and applicable to all medical fields was created in 2005 , but theThe consequences of the use of telemedicine on patients’ health-care outcomes and on medical practitioners are still not well understood, and there is little to no data available on the status in Austria specifically. Therefore, the research results at hand include data from GP practices to create an overarching understanding of the situation before and since the pandemic.Against this background, this paper aims to assess the use of VC, the up-to-dateness of practice websites and GPs’ views on whether eHealth is a positive aspect for the future of their practices in publicly funded primary health-care in Austria.The data were collected as part of the PRICOV-19 study, a cross-sectional study using an online questionnaire sent to GPs in 37 European countries and Israel. In total, more than 4700 practices participated in this study. The PRICOV-19 study investigated how GP practices were organized during the COVID-19 pandemic to guarantee safe, effective, patient-centered, and equitable care. Also, the shift in roles and tasks and the wellbeing of staff members were researched [The study was designed in accordance with the STROBE statement for cross-sectional studies  and was www.randomizer.org) from a list provided by the Austrian Chamber of Physicians. However, with regards to Austrian data protection law this list did not contain any e-mail addresses, therefore we had to search for 500 email-addresses via official GP search engines (i.e. DocSearch.at etc.). Of the selected 500 GPs, only 300 had a publicly available e-mail address . For this reason, we selected 400 GPs additionally with the same procedure and inclusion criteria as before and searched for their e-mail addresses in the list again. This way, we succeeded in collecting 500 e-mail addresses and invited these GPs accordingly to participate between December 2020 and July 2021. The invitation included a short description of the study and a link to the online survey, and four reminders were given. The Research Electronic Data Capture (REDCap) platform was used to host the questionnaire in all languages, to send out invitations to the national samples of GP practices, and to securely store the answers from the participants. A total 195 GPs began with the online questionnaire, and the relevant question for this analysis were completed by 176 (return rate 35.2%). This was higher than the median value of the response rate across all the PRICOV-countries (22.0%) [In Austria, the aim was to invite 500 GPs to participate. Therefore, we stratified all GPs with a contract with social health insurance companies according to the county they work in and their sex . Considering the GP and sex distribution within each county, we selected randomly 500 GPs via the platform Research Randomizer , infection prevention, information processing, communication, collaboration and self-care, and practice and participant characteristics [It was translated into the languages of the participating countries by the national coordinators. In Austria, the readability and feasibility of the translated questionnaire was checked by a group of GPs and colleagues (see acknowledgments), and the questionnaire was back-translated into English.Video consultations: “To what extent did this practice use VC before the pandemic?” and “To what extent has this practice used VC since the pandemic?” The answer options were “never,” “less than once a week,” “weekly,” “daily,” and “multiple times a day.”Up-to-dateness of practice websites: “In the 12 months since the pandemic, how often has the information on the website of this practice been updated?” The answer options were “not at all,” “1 or 2 times,” “less than monthly,” “monthly,” “weekly,” “daily,” and “this practice does not have a website.”GPs’ views on whether eHealth is a positive aspect for the future of their practice: “What positive aspects for the future can you gain from the COVID-19 pandemic for your practice in terms of innovations in eHealth (e.g. video consultations)?” The answer options were “yes” and “no.”Most important for this analysis were the questions regarding the dependent variables, which were as follows:Work experience: “How many years of work experience do you have in general practice?”Number of GPs at the practice: “How many GPs and GP trainees are working at this practice? Count every GP and GP trainee as one, irrespective of whether they are full-time or not. Do not forget to include yourself.”Location of the practice: “How would you characterize the location of this practice?” The answer options were “big (inner)city,” “suburbs,” “ town,” “mixed urban–rural,” and “rural.”Size of the patient population: “We would like to get an idea of the size of this practice. How many patients are registered at this practice? If there are no registrations, please indicate the total practice population.”Patient population composition: “Compared to the average PC practice in your country, would you say that this practice on average treats more/fewer patients from the following categories: patients with a migration background with difficulty speaking the local language, patients with limited health literacy or low literacy, patients with financial problems, patients with a psychiatric vulnerability, patients over the age of 70, patients with chronic conditions?” The answer options were “above average,” “approximately the average,” and “below average.”Furthermore, the following background questions regarding the practice were relevant for the independent, exploratory variables:For this analysis, the answer options regarding the number of video consultations were clustered into “never or less than once per week” (category 0), “once per week” (category 1), and “daily or multiple times per day” (category 2) for both before and since the pandemic. For the binary regression model, only two categories were created, namely “never or less than once per week” (no video consultation) and “once per week, daily, or multiple times per day” (video consultation).An additional variable was then built and named “increase in video consultations.” For this purpose, the given category for video consultations before the pandemic was subtracted from the given category for video consultations since the pandemic. Every positive result was counted as an increase.Regarding up-to-datedness of the practice website, we clustered the answer options into no website, no up-to-date website , and up-to-date website . For the binary regression model alone, two categories were built with “no website, 1 or 2 times, less than once per month” (not up-to-date) and “once per month, weekly, daily” (up-to-date). The views of GPs on whether eHeath is a positive aspect for the future of their practices stayed with the two answer categories, namely “yes” and “no.”The work experience variable was clustered into three categories, namely 0 years to 4 years 11 months, 5 years to 14 years 11 months, and 15 years and more. The number of GPs working was also grouped into three categories, single-handed (1 GP), 2–3 GPs, and 4 or more GPs. The practice location was clustered into big cities, medium-sized locations , and rural areas. The size of the patient population was clustered into four groups: 0–1999 patients, 2000–4,999 patients, and 5000 patients or more. The patient population composition stayed with their answer options "above average,” “approximately the average,” and “below average.”First, all independent and dependent variables were described by descriptive statistical methods (frequencies and percentages). Subgroup analyses were then conducted by means of cross-table and Fisher’s exact tests because of the small numbers in several subgroups.2 was presented as a measure of model fit.Binary logistic regression models were additionally used. In them, video consultations since the pandemic, up-to-date websites, and views on eHealth as the future were defined as dependent variables consecutively. In each regression model, all explanatory variables were taken into the model simultaneously. The results of all the regression models are presented as odds ratios with 95% confidence intervals. Nagelkerke’s RThe study was seen as safe by the ethics committee of the Medical University of Vienna (EC N°2200/2020). All participants were classified as experts, and the survey was designed to be completely anonymous. All participants had to read the informed consent at the beginning of the questionnaire and could only fill out the questionnaire if they clicked the “I agree” button.Table Of the practices, 44.3% had an up-to-date webpage, and 27.8% assumed that the pandemic might have been a positive driver for eHealth in their practices.Table The results of the cross-table and Fisher’s exact tests showed that only a few significant associations could be reported Table . PracticRegarding up-to-date websites, only possible financial problems of the patient population showed a difference. More specifically, practices with below-average related populations had an up-to-date website significantly less often than practices in or over the average.Regarding the assumption that eHealth might be a positive aspect for the future, practices with a practice population with fewer patients over the age of 70 than average more often answered “yes” than practices on or above the average. In addition, contrary to VC, practices with an above average number of patients with chronic diseases viewed that eHealth was a positive aspect for the future significantly less often. A positive trend towards future eHealth can be seen for practices with 5000 patients and more.Table Altogether, the use of VC was observed to be extremely low in Austria. Even since the pandemic, which required safer forms of consultation, the use of VC has remained very low and has not increased substantially across all the groups analyzed Tables  and 3. IThis leads to speculation that the general preparedness and readiness for VC and eHealth among Austrian general practices is not yet certain. Greenhalgh et al. stated in 2020 , 11, 22 Moreover, a major issue in this regard is the complicated funding structure of VC pilot projects in Austria. There is an unavoidable funding barrier between the private and public sectors that does not allow the instant implementation of promising solutions from start-ups to be used in the insurance-funded public health-care system.On the other hand, there also might still be skepticism and fear of change on the physicians’ side regarding digitalization processes. Evaluating the acceptance of the need for electronic health-care records, for example, was the main goal of a study conducted by Hackl et al. . The autAlso, from the patient’s side, an Austrian study showed that patients mainly used the telephone instead of video calling when contacting their doctors during the pandemic .Despite the overall low use of video consultations, we could find a significant difference among practices with a below-average population of elderly patients over the age of 70 and those with an above-average number of patients with chronic diseases, in that they used VC more often. Practices with fewer patients over the age of 70 than the average also tended to see eHealth as a positive aspect for the future of their practice Tables  and 4. TA paradoxical finding in this study was that while practices with an above average number of patients with chronic diseases used VC significantly more often, they less frequently saw eHealth as a positive future aspect for their practices than practices did on average. It could be speculated that this might relate to how VCs are conducted and because they are time consuming, in particular with patients with complex and/or chronic diseases. Therefore, these patients might not be the best suited for VC in the Austrian healthcare system with its established incentives.Additionally, we could see a trend for bigger facilities with more GPs in bigger cities using VC more often and also viewing eHealth more often as the future for their practices.The main strength of the paper is that it is the first of its kind in Austria. This study was part of an international project and succeeded in recruiting a random sample in Austria. However, the rather low return rate could imply that only highly motivated GPs participated. This means that our results might be an overestimation. On the other hand, it also could be that GPs who were massively involved with the pandemic and had no time available to answer the questionnaire were not represented. This might lead to speculation that particularly motivated GPs did not answer the questionnaire, which could have led to an underestimation of our results.Moreover, our recruitment procedure led to the exclusion of GPs without a working e-mail address. Assuming that these GPs are generally uninterested in digitization processes, this could again lead to the assumption that our findings are overestimations. Additionally, recall bias is a general problem in surveys .Additional qualitative research is urgently needed to get a deeper insight into the major causes for our findings.The use of VC in general practice and readiness for other telemedicine approaches is very low in Austria. Austria has to urgently take the example of countries with a transparent and comprehensive national digital health strategy, including VC. Without proper payment, patient and physician inclusion, and support with regard to administrative and organizational aspects, no substantial change will occur in spite of there being an increase in need due to the pandemic and changes in the patient population.VC and other eHealth technologies will be a key resource in patient treatment in the future, but without proper research and implementation strategies, it will be a usage lottery for patients and general practitioners alike. The lack of an international implementation framework adapted to Austria’s unique funding system and legal requirements will be a major barrier to adequate knowledge transfer. The question is not whether VC will find its way to GP practices or primary healthcare facilities but rather when and how.


The present time is characterized by the instability of society, the authoritarian state, social insecurity, and the events of the global pandemic. One of the main properties of modernity is the continuous nature of the social changes taking place in it. Social uncertainty, instability and social insecurity complicate the usual strategy for constructing ideas about the world around us. In connection with certain factors, events in a person’s life can be defined as significant.The purpose of this study was to ckeck the fact that important life events are something associated with stress and have a negative emotional connotation.The methodological basis of the research was the qualitative study: semi-structured interviews, including projective techniques  were carried out. N = 50 residents of Russia and Austria, age 16-65.The hypothesis about important life events was completely confirmed. It turned out that important life events were described by the respondents mainly as negative, that is, in most cases , important events were associated as something associated with stress, having a negative emotional connotation. It is interesting that mentions of joyful and happy events were much less frequent than negative ones, while there were practically no descriptions of the experience of vivid emotions accompanying any long-awaited events. At the same time, important events are quite extensively associated with stress and critical emotional experiences, often with mental problems: “shock”, “crisis”, “debts”, “severe depression”, “complete collapse”, “everything goes to hell”.Important life events for a person are rather negatively assessed events, as well as events associated with stress, rather than positively assessed events.None Declared


Although China and South Korea share a similar East Asian culture, owing to major social and cultural differences, international students encounter several difficulties, which can lead to various psychological problems.To explore the experiences of eight Chinese doctoral students in South Korea participating in mandala-based art therapy.Data for this phenomenological study were gathered through individual interviews and visual art from April 5 to 20, 2022. The MAXQDA software program was used for data analysis.The data analysis results yielded 355 codes, 53 subcategories, and 17 categories. Five final themes emerged: (a) sealed lips by others’ eyes, (b) inner exploration and outward expression, (c) healing power of the mandala, (d) filling the inner space together, and (e) opportunities to understand art therapy.The researchers hope that completing this intervention will enable participants to complete their studies more effectively and achieve their ideals as well as future career goals, helping them ultimately return home safely with both personal and academic growth. There aEven though China and South Korea share a similar East Asian culture, major social and cultural differences exist. These differences cause several difficulties for international students; the pressure they experience can lead to various psychological problems . PsychosArt therapy helps express emotions and explore needs through visual art work . With anRegarding existing research on MBAT, some studies have noted its positive impact on adolescent mental health, allowing teenagers in crisis to express their inner repression and maintain psychological stability, so as to develop and show their inner potential . Other s1.1.In recent years, the number of foreign students in South Korea has continued to grow along with the globalization trend of the education field. At the same time, the number of Chinese students studying abroad has also increased , with ChStudies show that Chinese students in South Korea often experience stress owing to key differences in communication and interpersonal relationships . In term1.2.Art therapy is a way of using the fine arts, a nonverbal medium, to express personal growth, insight, and change. The special process of creating art works can help visually express human images and become an appropriate means to express individual minds. Participants can then go on to recognize their inner experiences and perceptions, connect their inner world with the external world, and work with the inner self to help discover and confirm relationships with the environment, society, and others .The purpose of group art therapy is to collectively create iconic art works, share feelings, and establish a sense of intimacy. The goal is to enable participants to easily express emotions, problems, and conflicts in a nonverbal manner, harmoniously resolving psychological and emotional issues and thus alleviating painful emotions or experiences . Such a mandala originates from Sanskrit in ancient India, referring to all round objects with centers in nature; it implies a “round wheel” and “round phase.” A mandala can thus be defined as the center and essence of perfection  was meant for the participants to release tension and form a sense of intimacy; the middle stage (sessions 3–6) was geared toward self-expression and exploration; the final stage (sessions 7–8) was for self-integration and concluding the activities. Each session of the treatment plan lasted 120 min (this length was based on interpretation time and group size) and consisted of three stages: introduction (20 min), task and activity (60 min), and organizational and verbal sharing (40 min). Activities included enhancing the sense of collective belonging and cohesion, exploration and expression of safe areas, exploring identity through past and present life, expressing the core themes and emotions of life in the present, exploring and expressing current life stress and coping methods, expressing and integrating their own resources and shadows, identifying new identities through life goals and achievement process, and the internalization and integration of the overall treatment process . No part2.4.Data were gathered via individual semi-structured interviews, visual art works, and researcher notes. The researchers conducted 90-min individual semi-structured interviews with each participant after they completed eight sessions . This in2.5.Member-checking was conducted to ensure an accurate understanding of interview data . The pri2.6.The researchers have studied expressive arts therapy abroad, equipping them with great sensitivity regarding this topic. However, to prevent previous experience from influencing data interpretation, the primary researcher bracketed her own bias and preconceived knowledge on this topic to ensure that one was explicitly aware of the influence this would have on the data analysis process and results. It brought me to a bias that art therapy students have a deeper internal reflection. As a student majoring in art therapy. As the interviews were conducted in Chinese as the native language by a researcher, translated into Korean, and then translated into English for journal publication, the researchers were meticulous in verifying their translations.2.7.MAXQDA for qualitative data analysis was used to analyze data. The analysis process was as follows: (1) organize data to access files easily; (2) read data to get familiar with the content; (3) transfer data into the MAXQDA program, with all meaningful statements being coded; (4) conduct peer debriefing with two experienced qualitative researchers; (5) combine similar and repeated semantic units, reviewing and modifying them through peer reports; (6) repeatedly confirm the original data and ensure proposed analytical feasibility, with the subcomponents being obtained through combining semantic units, and components obtained through combining subcomponents; and (7) obtain saturated final themes, categories, and subcategories.2.8.This study is part of the author’s doctoral dissertation conducted with the approval of the Jeonju University Institutional Review Board (jjIRB-220421-HR-2022-0408). All participants were given details of the research project, informed of their rights, and provided written informed consent. Participants were told they had the right to refuse or withdraw from the study at any time without fear of penalty. All information was collected with the participants’ consent, and the answers were processed anonymously.3.The researchers analyzed the interview transcripts, yielding 355 codes related to the research topic. As a result, five themes, 17 categories, and 53 subcategory codes were identified: (a) sealed lips by others’ eyes, (b) inner exploration and outward expression, (c) healing power of the mandala, (d) filling the inner space together, and (e) opportunities to understand art therapy. Each topic contained its own unique categories, derived from the data analysis. 3.1.3.1.1.In any psychotherapeutic group, participants need time to get comfortable with openly sharing their true selves. This was evident in this group, with Han sharing that, at the beginning of the activity, “the members of the group were not familiar with each other” and that this fed “a sense of conflict.” Shi “regarded inner things as private” and was unwilling to share. When speaking during group activities, he could not “let go of the fear that others do not understand” and could not open up his heart.While participant defensiveness is common in the early stages of any psychotherapeutic group , privacy3.1.2.Participants spoke about their fears of self-expression and openness in the group, as follows:The challenge is to express what you do not want decisively. This is my biggest challenge and it is difficult for me. […] I refuse to share my heart with others very much. It is a big challenge to open myself up in activities. The tension when communicating with others makes the sharing process difficult. (Liu)While it is natural for participants to avoid the pain of sharing, they must eventually overcome this obstacle to obtain a wholesome therapeutic experience and enable the same outcome for the rest of the group.3.2.3.2.1.Participants discovered the value of paying attention to the present, focusing on themselves, and improving concentration through MBAT activities. Gong believed that the greatest significance of therapeutic activities was to focus on the present moment:I think, rather than worrying too much about the future, I find it more important to enjoy the process and live in the present, which is my greatest gain in this activity. Therapy has given me a way of thinking, that is, to face my problems, not to worry about the future, not to be overwhelmed by the trauma of the past. I learned to appreciate the present.Wang made similar observations about concentration, saying “I also lived unconsciously and became more focused on myself.” Xie found that drawing in a circle improved his focus and attention :I draw my tree of life in a circle. Without this circle, the sky part will become bigger, I might add other factors, some other embellishment. But in that case, the tree would not be so big… Based on this circle, it is visually easier for me to focus and allows me to be more focused.3.2.2.Participants acquired the tools to understand their hearts, learning how to objectively review and organize themselves while exploring and improving their shortcomings. This gave them a deeper understanding of themselves and allowed them to master new methods of self-understanding. For instance, Liu learned how to examine himself objectively :The best part is that I learned to look at myself. I use purple to indicate anxiety, depression, and escape. The blue part is the positive part, which represents rationality. I learned to look at myself dialectically.Shi “combs his past step by step, which is a very meaningful thing.” While adjusting himself, he “gives himself some strength.” Xie said that his mentality and thinking mode changed, and he was able to recognize problems and improve them. Wang developed a better understanding of herself through her art work, saying that “It can make me know myself better.” Li shared that he “discovered me and dug into myself” by painting. “This is a good way of (gaining) self-insight.” Liu liked talking with the therapist and learning about himself through the therapist’s analysis :The therapist analyzed it, and his understanding of me was very accurate and magical. Drawing a paper airplane, the therapist said, “you are not a paper airplane; in fact, you have a lot of strength and resources, so you should make good use of it.” After the therapist dissected my work, I found that it virtually expressed my thoughts.3.2.3.Participants found a channel for self-expression, learning to express themselves actively and openly during the sessions. Xie learned to “learn from other people’s experiences” to help their self-expression in English when their oral skills were insufficient. Shi said that he adjusted his mentality in time, admitted that “his works are inner expressions worth seeing,” and realized that he should focus on artistic expression and symbolism, rather than on the aesthetics of his works. Shi learned a new and safe way of expressing himself. Wang talked about her experience of learning to express herself: “I learned to express myself and open myself up. I will share my thoughts, opinions, and experiences with my friends.” Liu said that he experienced “a new and safe way of self-expression” through the therapeutic activities.3.3.3.3.1.Participants learned how mandalas could be a new tool to reduce stress, anxiety, and depression. Wang found that her inner repressed emotions were relieved: “Activities can not only relieve academic pressure but also relieve language pressure.” Li learned how new ways of mandala painting could allow him to vent his repressed emotions and “decompress himself.” Gong noticed group members becoming more comfortable and saw the mandala’s power to “get rid of the uneasy state” and “eliminate negative emotions.” Li said, “Depression is eliminated through activities.”3.3.2.Participants, like Liu, gained a sense of security. Gong experienced reduced anxiety, saying that the “therapist shields me without prejudice, protects me, and makes me feel safe.” She also mentioned that “in Chinese culture, the circle is a symbol of balance”; thus, painting in the form of a mandala felt particularly comfortable to this group. Wang felt “the tolerance and warmth of the circle and felt a sense of security” during mandala painting. She said that painting in the circular form of a mandala made her feel warm, stable, and secure :I like to draw in the circle. If you give me an empty piece of paper, I do not know what to do. In this circular range of the creation, I feel very practical, very safe. In the Chinese view, the circle is a symbol of safety and warmth. This circle is just like my home, giving me a sense of security.3.3.3.Participants found relaxation, which helped them release their negative emotions into art work. Liu said that “MBAT makes me feel more at ease and more gentle than other treatments, so I feel more acceptable. This kind of relaxation cannot be experienced by other treatment activities.” Xie said that he “no longer insists on things that cannot be changed, but is willing to accept other people’s voices” and “has a relaxed mood.” Li said that through treatment activities, “understanding the way of art creation is helpful to get psychological relaxation.”3.3.4.Participants gained satisfaction by completing the art activities. Gong said that MBAT was a “compensation for the past,” satisfying her unfulfilled childhood wishes. Gong also talked about the satisfaction brought by the integrated works in the session .This is the most perfect bike, guzheng , music, food, beach seagulls; everything I want. Particularly satisfactory. Finally, I returned, and I felt that the arrangement of heaven had come to an end for my mandala art activities.Han experienced satisfaction when painting in the circle of a mandala .Because my name means “the stars,” this starry sky can be combined into my name. And I like Van Gogh as a painter very much, and I am honored to express myself with his paintings. At that time, my companions all praised my good painting, and I felt very satisfied.Participants found satisfaction through the demonstration, self-expression, and completion of their art works. Painting in a circular space gave participants a stronger feeling of completion. For many, this activity also met an unfulfilled childhood desire to love art.3.3.5.Participants gained confidence through the mandala group activities. Han said that he “accumulated a lot of energy” and “gained confidence and strength” in his work. Wang said that the activities were “of great help to confidence,” changing the mentality of self-distrust and helping her gain confidence in overcoming difficulties.3.3.6.Participants gained the courage and strength to face pain and overcome difficulties through sessions. Gong said that she gained the courage to face the trauma of her past. Liu noticed that he developed a better attitude, and that new ways of thinking gave him the strength to face and overcome difficulties. This was also reflected in his work :I drew a circle of yellow light around me, something like lightning. This yellow light represents my courage to face difficulties, and it is a kind of power to help me achieve success. This work has given me the strength to face and overcome difficulties, and will play a positive role in my study abroad life and my future study and life.3.3.7.Participants found that the group activities stimulated their longing for the future. Liu was able to clarify his future direction, and Gong was able to look forward to the future once again.The most important thing about the whole activity is to have a little expectation for the future. I did not before, but now I seem to have a little expectation for the future. There are moments of harvest, healing brought by therapeutic activities, and my own reflection, which make me understand a lot. I do not worry about the past anymore. (Gong)3.4.3.4.1.Participants communicated with their group members sincerely, deepening their mutual understanding. They felt a sense of understanding and support and were sincerely moved when they received notes of encouragement and blessing from group members during the event. Yun said that “mutual understanding among group members” was improved through sharing experiences. Gong was healed by the understanding and resonance of the members:I used to think I was alone on the road, but now I know that there may be countless people like me around the dark. They got my signal. I feel that I have been understood by everyone, and I really want to cry. It is bringing me to tears.Xie shared finding “solutions to difficulties” within the group through communication, “learning the views on things,” and receiving help through various experiences provided by group members. When Wang received letters from the group members, she felt “warm and moved” and “cured” by everyone’s encouragement. Gong communicated with the therapists by sharing his works, finding a new understanding of these works, and discovering a new way of detecting problems :I was particularly impressed by a painting, which was the time when I described my life. When sharing, the therapist said, my portrait is to cover my past wounds with quilts; at that moment, I thought, “Oh, I can look at my life like this.” When I face this pain again, I look at past problems not from the perspective of the past, but from the perspective of the present.Through sincere communication with others, the participants found a new understanding of their own works, gained new perspectives on problems, discovered new strength, and developed a better understanding of themselves. Mutual understanding among the group members was deepened through sincere exchange and communication.3.4.2.Participants found emotional support through the group. Xie confessed that “when you find yourself to be similar in the paintings of group members, you will resonate and influence each other.” The group members felt recognition and mutual support, which enhanced the trust between them. Gong was recognized and supported by group members through participation in group activities, feeling “that their creation is very meaningful.” Wang said that, through the sharing and unfolding of works, participants “trust each other more” and develop mutual understanding. It is this kind of support and trust that makes participants’ relationships closer.3.4.3.Interpersonal relationships within the group improved across the sessions, creating a positive impact on interpersonal relationships in life outside the group. Gong said, “In the process of treatment, we can understand others and be more tolerant of other people’s phenomena and voices.” Through group activities, Gong learned to abandon prejudice, understand others, change his attitude toward others, and tolerate others. Shi described his experience of trying to open himself up in group activities by saying, “it is very important to actively communicate with each other in group activities” and “enhance openness” in group therapy. Li said that “the skills of communication and interpersonal communication have improved [and] the fear of social life has been alleviated”; he learned how to “actively make friends.” This indicated that the desire to establish and maintain harmonious relations with others increased through MBAT. Overall, an improvement in interpersonal relationships was seen across the participants.3.5.3.5.1.There had been some psychological discomfort with painting as an unfamiliar tool during the early days of the MBAT. In the process of the fine art of mandala, owing to a lack of painting skills and difficulty with image performance, participants experienced psychological anxiety and an inferiority complex. In addition, participants indicated that they felt bound when painting within the circle of the mandala. Although they felt psychological discomfort while painting, their techniques of art and imagery performance improved through the MBAT.Gong felt that “painting is the biggest challenge” owing to his lack of skills, so it was “difficult to express his inner thoughts accurately.” Shi felt “confused” when he encountered “difficulties in expressing an image of paintings” in his work. Li said that “it was difficult to draw and caused anxiety.” Yun talked about feeling an “inferiority complex caused by insufficient painting skills” and even “discrimination by members in groups” in the creative process, owing to a lack of artistic ability. Shi also mentioned the sense of confinement or restriction created by the constraints of the mandala form .In China, ants symbolize diligence and bustle. Shi expressed the tremendous pressure he felt in his busy life as an ant carrying a heavy burden. Shi believed that ants are trapped in circular rules, expressing his state of being bound and not free in life:In the process of drawing, I thought of my current state. I have a lot of pressure; I feel like an ant, with a big burden on my back, leaving me out of breath. Drawing in the circular rule makes me feel bound and unable to move freely…there are many rules binding me.Gong said that through the work process, his painting skills improved. Wang also mentioned the experience of improving her painting skills, “After MBAT, I feel that my drawing skills have been improved.” Most of the participants said that during the process of MBAT, they felt the difficulty of art creation, but through the mandala activity, they gained a new experience of improvement in their art ability.3.5.2.Through the new experiences gained from MBAT, participants reported growing academically by participating in a group, especially as many of them were pursuing degrees related to expressive therapy. Han reported a deeper understanding of MBAT, which was of great help to his professional knowledge. This was an added benefit for participants in the physical education major, beyond personal growth. Wang shared that “in the art therapy activities, I have a certain understanding of art therapy and mandala.”4.We explored the experiences of Chinese students studying in South Korea, who participated in a group MBAT. The participants were challenged during the early stages of group activities, as they worked to build trust and overcome their fear of being vulnerable, alongside exposing their shortcomings in front of people they did not know. This was consistent with findings by Through the intervention, participants focused on themselves, uncovering a better self-understanding and channel for self-expression. The participants enjoyed the process of painting in the mandala style, and experienced the value of focusing on the here and now. MBAT enables participants to understand the beauty of the painting process itself and find value in focusing on the present and self. The mandala’s circular form invites an obvious center, creating a point of focus . It is tThe intervention helped participants understand their hearts. The participants agreed that the mandala functioned as a channel for self-expression, consistent with Stress, anxiety, and depression were relieved through the sessions, and the participants came to consider mandala work as a new decompression method to promote mental peace and stability. A previous study  showed cThe participants experienced the pleasure of creation and psychological relaxation. They gained satisfaction through the completion of their art works, improving their self-confidence, gaining the courage to face difficulties, building a sense of security, and clarifying future goals and expectations. The creative process can create an overall comfortable environment that brings positive emotional experiences. The mandala’s constrained form is special in that it creates both a safe haven for spiritual reconciliation and identity  and protCreating a mandala also helped the participants change their mentality and be more relaxed, while accepting the difficulties in their lives. This is consistent with The participants had the opportunity to gain insight into other group members’ hearts and visualize their unconscious world; the art works they created promoted feelings of self-satisfaction and pride of achievement. When drawing the mandala patterns, participants felt a strong sense of perfection, consistent with Moreover, the participants improved their confidence in overcoming difficulties and gained a high degree of self-confidence through sessions. This was consistent with Creating complete mandala art works helped participants gain the courage to face difficulties and strength to overcome them. This was in line with the findings by Through the treatment activities, participants’ direction for the future was clearly defined, their soul was cured, and their expectations for the future were raised. This aligns with The participants had an expectation of healing when they joined the group. While they encountered emotional difficulties in this process, they also found courage and strength in facing difficulties. Participants expressed increased confidence, confirmed their inner strength, and reported having a better attitude toward overcoming difficulties in life.The participants also reported receiving emotional support from group members through sincere communication, and interpersonal relationships improved through the group activities. This aligned with previous findings, whereby group mandala activities helped participants gain insight into distorted emotional and behavioral patterns, helping them become more energetic . These pThe participants in this study were all Chinese students with similar cultural backgrounds, going through the similar experience of pursuing a doctoral degree abroad. This enhanced their ability to resonate with and support each other, build intimacy and trust, and generate a group identity. Shi shared the following:In this activity, we are all compatriots from China. We have received the same education and culture in the process of growing up, so I have a natural sense of affinity and trust for them. Moreover, our current situation is the same. We all left our families and came to South Korea to study for a doctorate. We are facing the same difficulties, such as language barriers, missing our hometown, academic pressure, and so on. So, we understand each other’s plight, and we are more willing to share our inner feelings, hoping to help each other and grow together.Through the process of drawing together, participants reported a positive emotional experience, which created a supportive atmosphere of belonging. This aligned with earlier findings by Participants in the present study gained supportive relationships and a sense of identity, finding tolerance and understanding with the other group participants. This was consistent with At first, the participants were uncomfortable painting a mandala because it was an unfamiliar skill; however, they ultimately developed the required artistic skills, which benefited them both academically and personally. When participants lacked the necessary artistic skills, they felt nervous, anxious, and inferior painting in front of others, fearing a negative evaluation from other group members. It is natural for people to avoid experiences that provoke anxiety . In learIt is worth noting that in the face of such positive findings, there are potential biases. As six of the participants were international students majoring in art and music, it may be easier for them to receive psychotherapy and be more familiar and open, perhaps making it easier to obtain positive results.5.We found that Chinese doctoral students in South Korea worked through diverse emotional difficulties and built useful strengths through MBAT. They reported relieving their pain, challenging themselves, and expressing themselves better. Sharing pain in a supportive group gave them a sense of security and satisfaction, and improved their self-confidence and interpersonal relationships. MBAT provided a space in which they could paint their anxieties and navigate feelings of inferiority. Through the process of painting a mandala, they were guided to visit their inner self, reconnecting with the sense of order, achieving balance, and strengthening themselves. Drawing the mandala promoted self-awareness, self-expression, inner healing, and social ties. This safe psychological and emotional home gave participants a tool to express negative feelings, gain satisfaction, and build self-confidence, helping them generate the courage and strength they needed to face and look forward to the future.However, this study had some limitations. The researchers were non-native English speakers. Therefore, while translating the direct quotations from the interviews, there is a possibility that the meaning was not captured accurately. Second, no follow-up interviews were conducted after the participants completed the eight art therapy sessions; therefore, the persistence of their meaningful experiences cannot be confirmed.Regarding the future implications of this study, the researchers find huge value in conducting similar studies with pre- and post-assessments of depression, anxiety, and so on. Validating the clinical impact of MBAT could greatly increase the reach of such an intervention. The researchers recommend a subsequent continuous in-depth research protocol to provide various MBAT programs. If a long-term scheme of MBAT is designed and participants can fully experience the program, richer research results can be obtained. It is hoped that concluding this intervention will help participants complete their studies more effectively and achieve their ideal as well as future career goals, enabling them to ultimately return home safely with both personal and academic growth.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving humans were approved by Jeonju University, Korea, IRB was approved. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.YM: Writing – original draft. KK: Supervision, Writing – review & editing.


Performance anxiety is a widespread issue that can affect musicians across their education and career. It can develop in musicians from a young age leading to short-term and long-term impacts on not only their performance, but also their wellbeing. There is potentially a significant role that music educators hold in the development of their students and how they handle performance anxiety, though it is not clear how, or how often, teachers support their students in this way. Through a PRISMA-based systematic review, this paper explores what is known about the strategies used by music educators to help manage their students' performance anxiety. The paper also discusses the role that instrumental/vocal tutors and school classroom teachers might hold in this area. The findings show that music educators are implementing multiple strategies to assist their students with MPA, with the most common being simulated performance, positive outlook, preparation and breathing. It was found that there is a role for teachers to address MPA management with their students. While some students prefer to receive MPA support from experts in the field of psychology, students still expressed a need to have this support come from their teacher. Though many teachers felt a need for additional training for them to help their students cope with MPA, many of the strategies were found to be multifunctional and embedded into the regular teaching practices or teaching styles of the educator. Although these strategies might be implicit rather than explicit, the findings suggest that music educators could represent a valuable source of support for MPA management. Performance anxiety is a widespread area of concern that can impact individuals across a range of endeavors, including public speaking, sport, and performing arts including dancing, acting and music. According to Marchant-Haycox and Wilson , amongstThere are many studies that explore these issues, investigating potential causes, symptoms, and strategies that musicians use to cope with music performance anxiety (MPA) -based systematic review  and ProQuest. The following search terms were applied to the title, abstract and keywords across the databases: “music performance anxiety” AND (“teacher” OR “education” OR “pedagogy”). The search provided a total of 96 articles, excluding duplicates . The absThe full text of the articles that met the research conditions was examined and explicit strategies were noted and coded into relevant themes. For example, articles that mentioned “performance opportunities”, “performance exposure”, “performance practice”, or “playing through repertoire in front of family/friends” were regarded as “simulated performance”; “play for fun”, “mistakes don't matter”, and “you'll be happy you did it” were regarded as “positive outlook”. Coding was completed by author IM and cross-checked with all authors. Information was extracted from each article including: types of studies (questionnaires and/or interviews), aim of the paper, types of participants (types of music educators and/or students), strategies identified and/or viewpoints on the role of addressing MPA. Examining the methods used in the reported studies, it was found that 4 of the studies used questionnaires, while 5 of the studies used semi-structured interviews.We then examined the strategies used by music educators to help manage their students' performance anxiety. Several strategies were identified across the articles including: preparation (in 5 articles), simulated performance (5), positive outlook (5), breathing (5), focused attention (4), open MPA discussions (4), visualization (3), safe environment (2), imagery (2), repertoire (1), physical activity (1), psychological performance skills (1), pre-performance routines (1), self-talk (1), diet (1), and suppression (1) see .The reviewed literature offered a broad discussion of teachers' approaches to MPA management. Interestingly, almost all of the articles included in this review were published in the past two years, suggesting that there is an emerging interest in this topic from a pedagogical perspective. An array of strategies used by teachers to support their students with MPA were identified in the papers. The following strategies appeared most frequently, with each mentioned in five of the studies: preparation, simulated performance, positive outlook and breathing. These strategies overlap with the findings from MacAfee and Comeau , who alsCognitive strategies emerged as less frequent in the present review which focused on common teaching practices, than in the studies reviewed by Blair and van der Sluis , who focIn this review and the literature, the terms “strategies”, “MPA management strategies”, “coping skills”, “coping strategies”, and “coping tools” have been most commonly used to refer to the ways in which educators have supported their students with MPA (Moura and Serra, Similarly, Moura and Serra  made refEmbracing a positive outlook, too, might be regarded more as a teaching style rather than strategy. It includes teachers reacting positively to mistakes and normalizing errors as opportunities for learning Sieger, . One exaPerhaps accordingly, a distinction has been made between focusing on technique and mastery, and addressing the affective aspects of being a musician; thus, Tahirbegi  found a While a range of MPA strategies had been identified across the literature, it seems clear that some educators feel ill-equipped to tackle MPA because of a lack of training or being unqualified in the area (Moura and Serra, The main limitation of this paper is due to the small number of articles that met the inclusion criteria. The inclusion criteria were focused on studies that investigated MPA management strategies that are used commonly in the teaching environment, rather than studies that test the transfer of specific MPA interventions in the teaching setting, of which there are numerous studies. The inclusion criteria were also focused on the role that teachers hold in this area. The small number of articles, and the fact that 6 of the 9 articles date from the last two years, indicates that this is a relatively new area of research, that is proceeding rapidly.The purpose of this review was to investigate strategies used by music educators to support their students with MPA, and to explore their role in addressing MPA management with their students. A total of 96 articles were identified in the initial scoping of the literature. This was reduced to 9 articles that met the inclusion criteria.The literature reviewed suggests that studio and classroom teachers are using multiple strategies in their lessons to support their students with MPA, with the most common being simulated performance, positive outlook, preparation, and breathing. There is evidence from the literature that there is a role for teachers to address MPA management with their students. While some students might prefer support from experts in the field of psychology, there is still demand for this support to come from the teacher. Though some teachers expressed a need for additional training in MPA management, the exploration of the literature showed that many of the strategies may be embedded in regular teaching practices to assist with the affective aspects that come with being a musician. This suggests that some of the strategies to combat MPA can be acquired from the teacher, without onerous additional training. With this understanding, perhaps supported by professional development, music educators may find that tackling the issue of MPA is more manageable under their remit. As multiple assumptions exist on whether it is the role of the teacher to manage their students MPA, this issue calls for further exploration.The original contributions presented in the study are included in the article, further inquiries can be directed to the corresponding author.IM conducted the systematic review, analyzed the data, and wrote the drafts of the manuscript. KB and EM assisted with the analysis and editing of the manuscript. All authors contributed to the article and approved the submitted version.