The perception of illness and health-seeking behaviours, including rabies differ from one culture to another. Depending on the cultural setting of the society in which people live, the definition of the causal factors of illness may range from natural biological causes to supernational causes which greatly influence subsequent health-seeking behaviour. To ensure best health practices and plan effective health interventions for the control of dog-mediated-human rabies, we explored how school children and adult communities perceive and respond to illnesses, including rabies in southern Bhutan.We collected quantitative data related to the causes of illness and health-seeking practices of school children using a questionnaire survey (QS). Qualitative data were collected through focus group discussions (FGDs) and in-depth interviews (IDIs) with older members of communities (≥ 18 years) that work closely with school children. Descriptive analysis was performed for the quantitative data and thematic analysis was performed for the qualitative data.The participants during the FDGsand IDIshave linked the illnesses to past actions, spirits, energy channels, planetary movement, sorcery, black magic, food, physical or environmental factors, individual habits and social factors. The survey of the school children reported microorganisms (75%), past actions (16.8%), spirits (9.6%) and black magic (9.1%) as causal factors for illnesses. Health seeking behaviours reported by the participants included visiting hospitals, performing spiritual or religious rituals and local treatments. Similarly, school children also mentioned that illnesses can be treated by visiting hospitals (98%), performing rituals (59.1%), and seeking traditional treatments practices (18.8%). Both school children and adult members of the communities that we interviewed were well aware on the causes of rabies and need for allopathic treatments rather than seeking spiritual or local treatments.There is a need for the consideration of the socio-cultural context in the planning and implementation of health-related policies, including the rabies prevention programs in Bhutan, by involving traditional healers and religious entities with “One Health” public health sectors. The wesbomohs) . In thesbomohs) , 9, but bomohs) . In recebomohs) . The Worbomohs) . Howeverbomohs) . In casebomohs) , traditibomohs) , 15. In bomohs) . For insbomohs) ), 99% ofbomohs) . Althougbomohs) , 11, 18,bomohs) , 19, 20 The ethical approval for the study was obtained from the Research Ethics Board of Health, Ministry of Health . Administrative approvals were obtained from the city education officers, school principals, and class teachers prior to school children questionnaire interview.The study was conducted in three areas of southern Bhutan - Phuntsholing, Samdrup Jongkhar, and Gelephu - where we previously conducted knowledge and perceptions studies about rabies among school children  see Fig. Cross-bThe study was conducted as part of a larger study looking at knowledge, attitude, and practices of school children on rabies and sociocultural factors that influence their perception and behaviours. The participants included both schoolchildren and adults. The school children participated in a structured questionnaire survey, while adults were included in Focus Group Discussions (FDGs) and In-depth Interviews (IDIs). For a survey, a total of 701 school children studying in class X in three middle secondary schools in southern Bhutan were conveniently chosen. In FGDs, those adults who closely interact with the school children  and those having specific knowledge of culture  were randomly selected. Participants from different occupational groups that are involved in diseases and rabies control programs such as the Department of Livestock (DoL), Department of Forest and Park Services (DoFPS), Bhutan Agriculture and Food Regulatory Authority (BAFRA) were also included for FGDs. Twenty threee individuals who had participated in FGDs that were conducted in three groups - two on the school campus (Samdrup Jongkhar and Phuntsholing) and one outside of the school campus (Phuntsholing). Each FGD comprises of 7–8 participants and included both men and women. The key informants for the IDIs were chosen using snowball sampling method after the FGDs and consisted of local leaders, local healers, astrologers, Buddhist masters, business leaders, and farmers. A details description of the samples was given in Table Quantitative data from the school children were collected using structured questionnaires which were designed as part of a larger study conducted to understand the knowledge, attitudes, and practices on rabies, which has been published elsewhere . Qualitawww.pressure.to/qda). For qualitative analysis, narratives of IDIs and FGDs were transcribed into English, followed by coding into different themes and categories. Development and placement of the coded data under the relevant themes were performed by considering each line, phrase, or paragraph of the transcript. The transcripts were read carefully and cross-checked by listening to the digital voice records to ensure the accuracy of the data. The codes were refined, updated, or removed depending on the significance of the data. Colour shadings, pens, and papers were also used to assist in coding of the data. In each theme or sub-themes, the discussion and probes were conducted to establish the links from which the main conclusions could be drawn.Descriptive analysis of the quantitative data collected from the school children was analyzed using R software . The quaThe results are presented in two broad themes -causation of ill-health and health-seeking behaviours following illnesses and potential exposure to rabies. The results from the survey of the school children were also placed under these two themes. Quotes and conversational trends are presented within inverted comma to support the themes. To maintain the original meaning of the respondents, some of the words were presented in the local language. However, wherever possible, the English translation has been provided in the text.Most of the participants linked the causes of illnesses to the “karmic effect”. A Buddhist teacher or Rinpoche  explained that “karma is the basis of all illnesses” which operates at a very subtle level.“Law of causes and effects does not change, which means bad actions follow bad results, and good action will follow good results. Karmic effects follow like a shadow all the time and never leave. If the illness is the results of ripening of karmic effects, such illnesses cannot be cured using the medicines or rituals”.He explained that –.Once the karmic forces are ripe, there will be arising of the “84,000 obstructive forces”  that can affect the functioning of the physical, mental and subtle body of human beings, which can weaken them and make the body susceptible to afflictions by various kind of illnesses. Another participant reiterated its importance by saying that “karma can affect the state of both the present and future life including the health status”.The strong links between one’s actions with illness were also shared by the school children, with 16.9% reporting that illness can result from bad karma  Fig. .Since the links between illness and ‘karma’’ were found to be widely shared among the participants, we investigated whether our participants also linked the causes of rabies to “karma”. On enquiring about the possible causes of rabies, most of the participants understood that rabies occurs due to a bite from a rabid animal. For example, one of the respondents mentioned that rabies occurred due to a bite from a“mad dog”. However, most participants agreed that “karma” might create an enabling environment for the bites at the subtle level as one respondent said, “everything happens because of karma, including dog bites”.“When our parents or grandparents die, they expect offerings and afflict the living people when they are not offered. For example, if a dead person is a good friend of us or a family member, their soul would expect close people to offer and dedicate good things for them when they are suffering in the intermediate state after death - Bardo”.Spirits and deities are considered another major cause of illness by most of the participants. Some of the names listed by the participants in local languages are “sadak” (Lord of the soil), “Neydak” (the guardian of sacred sites), “Lu” (water spirit /naga spirit that reside in water sources), “Sondre” (spirit of a living person), “Shindre” (spirit of a dead person), “Tshen” , “Deuth” (spirit), “Chesung” (deity entrusted with protection of dharma), “Kasung”(deity entrusted with the protection of dharma by command), “Mamo” (wrathful feminine deities), “Rongthung abi memi” (spirit from Rongthung village in eastern Bhutan), “Phoshing” , “Moshing”  and “Neypo” (owner of a place owned by the spirit). A local astrologer said, “The pain in the body is not necessarily caused by diseases. Some are afflicted by Shindre, some by Tshen, some by Sadak and Lu”. One of the farmers mentioned the spirit’s name in local language as “Mema yin” (the spirit that are formless and not visible to human eyes). “Mema yin is like the wind. We cannot see them, but it afflicts us just by thinking about it”. An astrologer believed that some of the spirits are wandering “consciousness” of dead animals or humans suffering in the intermediate state . Some spirits are guardians of elements like fire, water, tree, and air , while others are deities or dharma (religious) protector . He explained that spirits can affect human beings for different reasons. For instance, when they need food and water or when they need the dedications of good deeds for them (i.e. Shindre), or when human beings disturb their surroundings . One of the KIs explained that:“Yes sure, animals will be also affected. When dog, cow, or horse are sick and if doctors don’t find any diseases, they might be affected by the phosing or moshing”.The spirits can also affect the animals as reported by one respondent as-.From the survey we carried out in three schools, 9.6% mentioned that illness can be caused by the spirits see Fig. .rlung (plainly translated as “life energy”) flows and maintains our life. The teacher said, “there are 3 major channels and 21,000 minor channels” in our body. Any change in the physical environment, body function, and different levels of mental emotions have the ability to affect the flow of rlung inside the body whichcan ultimately result in different types of illnesses.Most participants believed that disturbance in energy channels inside our body can result in illnesses. A spiritual teacher and a local astrologer have explained that there are several energy channels in our body through which The link between illnesses and planetary alignments was shared by some of the participants. They shared that everything in the universe is “interdependent” and any changes in one thing have abilities to affect others. The astrologer explained that there is a period in the life of human beings when the body is not in harmony with the planetary alignments which can result in illnesses. Some of the examples of such periods, as mentioned by astrologers, are called “Chak”, “Loka” and “Cho” in the Buddhist language.“The people along the borders let the pigs freely scavenge without any care. Pigs can feed on human feces/stool and on all types of waste materials”..Food as the cause of illnesses was reported by most of the participants. They mentioned that consuming of “poor quality” and “unhygienic ” food can result in illnesses. Since food is essential for the body to “function normally”, they reported that the food consumed by people needs to be clean and fresh. One representative participating in an FGD explained that “spoiled food can be contaminated with lots of microorganisms which can damage our body”. Moreover, a few of the participants reported that food animals also need to be reared in a clean environment to prevent humans from contracting diseases. One participant felt that imported meats are unhygienic and not fit for human consumption when he said -Some of the KIs participants considered that chemicals in vegetables and fruits are likely causes of various illnesses. They strongly felt that the vegetables that are purchased from outside the country contain high levels of chemicals.Changing in the weather patterns, dirty surroundings and destructions of wildlife habitats due to developmental activities were cited as major physical or environmental factors leading to causes of illnesses in people. All participants mentioned that dirty surroundings attract lots of “microorganisms” and “flies” which then transmit many diseases to human beings, resulting in illnesses. When comparing if the school children from the survey also have similar perceptions, 75% of them reported that microorganisms are responsible for causing illness and 68% of them linking illnesses to poor hygiene and sanitation.Due to developments, we destroy the habitat of wild animals. Wherever there is forest, we construct the houses. As a result, we can see now that wild animals are getting closer to human beings. For example, many monkeys have started to come inside our home. Similarly, wherever we go, there are rats in people’s home. People are not being careful. When we sleep, the rats get into the kitchen and eat the food if the lids of the pots are not closed, and there is a risk of disease transmission to humansSome participants explained that due to developmental activities, the habitat of wild animals was destroyed at unprecedented rates, which brings wild animals closer to human dwellings and transmit diseases.“If wild animals are not taken care at present, there are chances that they can transmit many diseases to humans”.Another participant cautioned on immediate need for some interventions when he said:“I have seen two people from the village coming to hospital complaining of fever, headache and giddiness after being bitten by ticks”..Moreover, increases in the incidence of tick-borne diseases were reported by some participants due to the destruction of environments. When probed whether he had seen any cases of tick-borne infection, one farmer explained that -Some believed that illnesses can be due to “seasonal changes”. For example, “dengue is caused when season changes and when there is lot of mosquitoes” said one respondent.Drinking alcohol, lack of physical exercise, not wearing a facemask, and family problems were reported as some of the important factors responsible for illnesses. “Liver damage” and “Non-Communicable Diseases (NCD)” were mentioned as examples of illnesses by the participants that can results from the consumption of alcohol and lack of exercise respectively. The importance of wearing a facemask to prevent illnesses resulting from diseases like “COVID-19” was shared by most of the participants. Few of the participants felt that wearing the mask should be taken up as “individual responsibility” rather than being enforced by law by the government. Family problems such as divorces and fighting between parents were mostly mentioned by the teachers as one of the important causes of ill health in school children. Similarly, 22.5% of the school children also linked illnesses to social problems including divorce, fighting, and economic hardships.Few respondents reported that illnesses can also result from sorcery and black magic. Although none of them were able to explain how it was done and how it affects people’s health, most of them agreed that it’s done when people have a “conflict with each other’s”. 9% of the school children surveyed also felt that illnesses can result from sorcery and black magic see Fig. .The participants in our survey reported various forms of health-seeking behaviours following an illness. The behaviours and practices were reported under the following sub-themes:-.Seeking medical care from hospitals was the first preference for all participants following illnesses. Irrespective of the causes, all agreed that they would visit hospitals if they, or their family members, are ill. Most of them noted that “allopathic treatments” and “religious/traditional healing” should be used in complementarity to each other and believed that combining these two methods was the “best approach for the treatment of any illness”. The hospital treatments were mostly preferred when they felt that the causes are physical such as food and change in weather conditions.When the causal factors are suspected to be the causes of illness such as “karma” and “spirit”, biomedicines would be of little help, reported as having “little effect” by one of the participants. On exploring the behaviour and practice of the school children, almost all school children (98%) reported that they will visit the hospital for treatment see Fig. .Although hospital treatment was the most preferred treatment by most of the participants following illnesses, they agreed that seeking guidance from spiritual persons was appropriate, particularly for those illnesses that are chronic and can not be treated by modern hospitals. Similarly, more than half of the school children from three survey schools agreed that they would perform rituals in their house whenever they are ill see Fig. . The Bud“Cleaning of the demerits and accumulating the merits is the only way of getting out of such diseases. If ample accumulation of merit is done, there are chances of getting out of the illness, but some can remain as a lifelong illness. Once the demerits are cleaned, medical and rituals will help to cure the illnesses”.Most participants from FGDs and IDIs believed that “rituals would help in improving the overall outcome of ill patients” and agreed that they would even consider performing rituals if their family members are ill due to a dog bite. They believed that performing rituals would help to “clean the karmic effect and brings in the favorable circumstances”.The participants in our survey came up with the names of numerous religious rituals. Commonly mentioned rituals or practices that can help to recover from illnesses included: “Kago” (recitation of prayers and mantras by lamas or rinpoche to the sick person), “Jabthri” (cleaning with blessed holy water performed by lamas (is a title for a teacher of the Dharma in Tibetan Buddhism), recitation of “Sangay menla” (medicine buddha) and “Vajrasattva mantra” (one of Buddhist deity) mantra, and burning of “Duzey” (similar to mustard grain size pills blessed by rinpoches and believed to cure illnesses), and “Dribsang” . For a person suspected of being affected by spirits, local astrologers and healers recommended burning butter lamps and “Sur” (burning of maize/wheat flour). They believed that “if we offer Sur or butter lamp, it will help them”. Few participants believed that hungry ghost spirits can be satisfied by the smell of the Sur offering. Since local astrologers and healers were actively involved in treating illnesses in the community, we sought to understand how they would treat rabies patients. On enquiring, if they had handled any rabies cases during their career, both KIs reported that they had not treated any rabies suspect patients. However, they said that “few patients with Central Nervous System signs” visited them, which would be difficult to treat them, although they indicated that religious rituals would be recommended for a person with such signs. On asking if they would be able to treat rabies patients, both agreed that they would not be able to cure such illness and recommended allopathic medicines as the best option. However, they also strongly believed that “rituals would help improve the outcomes”.vajra’ (‘indestructible thunderbolt instrument’) to treat a patient complaining of leg pain. With this method, the healer invoked the mantra using a rosary, blew on the painful area of the patient’s body, rubbed the area with mustard oil, heated the area with the hot iron plate, and pointed the vajra towards the painful area. He reported that such methods are performed for “illnesses like headaches, pains in legs and hands, and high blood pressure” and mentioned that it should not be used to treat “children and pregnant women”, as it could cause abortion. When we requested a local healer to share some examples of his treatment success, a local healer gave the example of a girl who came to him with a swollen leg. He explained-“Once, there was a girl at Therbam village with a swollen leg. She was taken to the hospital and was given an injection. Blood was also taken from her leg but was not responsive to its treatment. I collected the medicinal leaves from forests, heated it, and applied a paste on her leg, and she was cured”..In addition to modern medical treatment in hospitals and spiritual healings, local medications practices were reported in our study area. 18% of the school children that we survey also reported that they seek local treatment to cure their illness see Fig. . Most ofCarica papaya) mixed with coconut juice would help in curing the disease in human beings, and it was practiced by people during the 2019 dengue outbreak in Phuntsholing”.“Drinking the juice of papaya leaves ” for treating various illnesses. On probing whether participants had performed or will performed any kind of local treatments to the dog bite wound, all respondents were not in favour of performing local treatment of dog bite wound. However, one farmer from the IDIs had reported that he had heard that dog bite victims can be treated by applying clean soil blessed by mantra from local healers after thorough washing.“After thoroughly washing the wound, get soil from a clean area, roll it in the hand, blessed it with the mantra from local healers, and put it on the bite sites. That will also cure the wound”.Other participants talked about the effectiveness of “dried bile of an Asian black bear , the “karmic force” which is mentioned as one of the important causal factors by many participants including school children is linked to three mental poisons  and three humours  [Our study revealed that there are huge influences of core cultural values on how the communities define and respond to illnesses. The influences were not only limited to adult members of the communities but were found to be extended to young school children. They define illnesses not only from biomedical perspectives, but their definition includes complex interactions between physical, social, and supernatural origins. Most of the participants, including school children, mentioned past actions, spirits, sorcery, energy channels, and black magic as some of the causal factors for illnesses. The anecdotes of such religious or supernatural entities responsible for causing illnesses in living beings can be abundantly found in many Buddhist texts , 28). Ac/phlegm)  and many/phlegm) , 29, 30,/phlegm) . But und/phlegm) . Therefo/phlegm) , 33.In terms of rabies, our findings indicated that most of the participants understand that rabies is due to biological causes and not as a result of any supernatural or religious factors. They also understood that rabies can be treated only through washing animal bite wounds with soap and post-exposure prophylaxis, with some participants referring to it as “very necessary”. The local spiritual healers we interviewed confirmed that if they receive any patients with dog bites or suspected rabies cases, they would “immediately refer to hospitals” rather than treating the patients with the local healing methods. The finding indicated that there is a high awareness level of rabies in Bhutanese communities. The high level of knowledge on rabies among Bhutanese communities and school children was reported in a few other studies , 24, 34.Because of COVID-19 pandemic restrictions, schools had to be chosen conveniently depending the approval from the government and school administration. Due to same reason, we were also unable to engage some of the key stakeholders  in FGDs and KIs as initially planned, which could have added more values to our study.Social and cultural values strongly influence the perceptions and health-seeking behaviour of school children and adult communities in our study area. Their definition of illnesses and subsequent behaviours are not only limited to the biomedical approach but extend to include complex interactions between physical, psychological, and supernatural models. Tostrengthen the health care system, and improve overall health outcomes and well-being of the people, efforts are needed to engage all relevant stakeholders including local or spiritual healers in health intervention measures, including a rabies control program.


Author Contributions Statement appears below:“Zeina Radwan” was not included as an author in the published article. The corrected “ML, MI, DM, ZR, LN, and HI contributed to the writing of the manuscript. All authors contributed to the article and approved the submitted version.”Affiliation 1 was listed incorrectly as Balamand. This has been corrected as the “University of Balamand”.Furthermore, The authors apologize for these errors and state that this does not change the scientific conclusions of the article in any way. The original article has been updated.


The Covid-19 pandemic has stimulated the use of social robots in front-office services. However, some initial applications yielded disappointing results, as managers were unaware of the level of development of the robots’ artificial intelligence systems. This study proposes to adapt the Almere model to estimate the technological acceptance of service robots, which express their gender and personality, whilst assisting consumers. A 2 × 2  between-subjects experiment was conducted with 219 participants. Model estimation with Structural Equation Modelling confirmed seven out of eight hypotheses, and all four scenarios were estimated with Ordinary Least Squares, showing that robot gender and personality affected their technological acceptance. Measures dictated to protect citizens from the Covid-19 pandemic, such as keeping social distance to avoid contact, isolation of people and patients and protective equipment for front-office staff, have contributed to boosting the use of social robots worldwide  software that allows them, on the one hand, to create the appearance of autonomy and, on the other, to exhibit social skills that facilitate human–robot interaction (HRI) , as their physical appearance (non-mechanoid: humanoid or android form) and the possibility of social interaction  makes it possible to engage the customer emotionally  and OLS (ordinary least squares). Fourth, we present the results. Finally, we draw and discuss conclusions, as well as future proposals and limitations.The AI algorithms installed in robots operate through three subsystems: a data collection and storage subsystem, a data processing subsystem  and finally a response subsystem  use additional social intelligence protocols to achieve friendlier interactions with humans  in hospitals, nursing homes, stations and airports, educational centres and universities and hospitality, amongst others, but fewer than half were equipped with social intelligence protocols allowing them to talk to users , but also delivery with high provider–customer interaction  , they need to be programmed autonomously and installed in the robot. If, in addition, it has to greet the customer and say encouraging phrases, etc., this also has to be programmed and added as a social intelligence protocol, complemented by text-to-speech software and gesturing  applications. Finally, all programmes must act in unison in order to appear realistic  in social contexts, service marketing researchers have used models derived from social psychology. One of the pioneers, Davis , proposeThe UTAUT model has been extended to all new technologies  will have a more positive influence on the robot’s technological acceptance than when there is a mismatch .To test and validate the proposed hypotheses and try to answer the research questions, we conducted an experiment with a robot equipped with an AI system and four social intelligence response protocols. On reviewing previous studies, we discovered that, in order to obtain a sufficiently large sample in real establishments, for example, a hotel, we would need an amount of time that was beyond our reach. For example, Nakanishi et al.  needed tA between-subject 2  × 2  experiment was proposed involving the recreation of a scenario in which a robot equipped with an AI system helps customers to complete a difficult task. To recreate the service, we drew on the examples of experiences with self-service machines  proposed by Meuter et al. , where cAs a simulator of a scripting task, we proposed a board game consisting in trying to complete the five-letter name of a Nobel laureate (e.g. “CURIE”) from ten letter tokens Fig. . FurtherA TIAGo robot, equipped with an AI system to manage the game and four responsive subsystems, was used as a service provider, assisting participants as they completed the game. The TIAGo is a highly versatile semi-humanoid robot that combines perception, navigation, manipulation and HRI skills and also has one of the fastest and most efficient processors on the market (NVIDIA® Jetson™ TX2), which allows the programming of functional activities, as well as social communication protocols and the coordination of social functions  and the time between movements were processed and, in turn, activated the response subsystem . And, to recreate personality, we manipulated the tone of the script for the conversation with expressions of praise and support to represent the cooperative role and more challenging expressions to represent the competitive role, in a similar way to what has previously been done in the literature  = 4.45, standard deviation (SD) = 1.03) than feminine  = 66.89, p < 0.01) and, vice versa, when it played a female role, it was said to be less masculine  than feminine  = 43.40, p < 0.01). Although the two personalities were also identified, they did so in a less forceful way. Thus, the cooperative robot was rated as more collaborative  than competitive  = 6.74, p < 0.05) and, vice versa, the competitive robot was seen as more competitive  than collaborative  = 8.86, p < 0.01). And finally, participants judged the competitive robot as more challenging  than flattering  = 7.10, p < 0.05) and, vice versa, the cooperative one was described as more flattering  than challenging  = 19.34, p < 0.01). The manipulation was therefore perceived correctly.A pre-test was conducted to verify whether the manipulation of gender and personality were perceived differently. A sample of 21 Master of Business Administration students  were randomly assigned to one of two experimental conditions , where they evaluated a video showing a TIAGo robot playing a board game with a person. The robot’s perceived gender and personality were measured by rating six items on a five-point scale (1 = “strongly disagree” and 5 = “strongly agree”): “The robot expresses itself as masculine (feminine)”, “The robot seems competitive (collaborative)” and “The robot seems challenging (flattering (you receive praise))”. The results of an analysis of variance (ANOVA) showed that gender manipulation was easily identified. When the robot played a male role, it was described as more masculine . Second, in batches of ten participants per scenario, where we controlled for gender, they completed the board game with the help of one of the TIAGo robot profiles (5 min). Third, the participants answered the questionnaire consisting of 26 statements that had to be evaluated using a five-point Likert-type scale (1 = “strongly disagree” and 5 = “strongly agree”) and the identification data. Given that the scales taken from the literature are in English, the back-translation method proposed by Brislin  was usedBefore testing the model, the descriptive statistics of the collected data were analysed. As the questionnaires were completed in the presence of a researcher, who was available to answer any possible questions, and were followed up in detail, none of questionnaires were incomplete. Furthermore, the values obtained were within the range of acceptability for skewness (between −3 and 3) and kurtosis (between −10 and 10) Brown . Having α above 0.80, composite reliability (CR) higher than 0.80 (ranging from 0.83 to 0.94) and all the items exhibited adequate convergent validity. Each factor load exceeded 0.6 and the t-values for each item were significantly high according to what is recommended by the literature . Their measurements, depicted in Table R2 values for the sample size , but does not provide the R2 obtained with the path analysis of the global model.The intention-to-use model of the robot equipped with an AI system (including the four response subsystems) was fitted using SEM and achieved acceptable k et al.  providedβ = 0.41, p < 0.05), by the Social Influence that the environment generated on participants  and by Perceived Enjoyment, indicating that they had a good time , thus supporting H6, H7 and H8. However, the degree of Ease of Use had a negative effect on Intention to Use. At the same time, Perceived Usefulness was mainly described by Perceived Adaptability to the visitor  and, in this case, also by Ease of Use , thereby supporting H1 and H4. In addition, the feeling that interacting with a robot seems entertaining, i.e. Perceived Enjoyment, was defined by Perceived Adaptability  and, albeit with less intensity, by the perception of being in contact with a sociable being (Perceived Sociability) , thus supporting H2 and H3. Considering that seven of the eight hypotheses have been confirmed and, with the same sign as the original Almere model, most of this parsimonious adaptation of the original model has been validated.From Fig. R2 = 0.62. The main direct drivers of this model were Social Influence  and Perceived Usefulness . Regarding indirect relationships, Perceived Usefulness was explained by Adaptability  and Perceived Enjoyment was also explained by Adaptability  and Perceived Sociability . On the other side of the coin, the totally incoherent scenario S4  explained the model to a lesser extent (R2 = 0.41). Three factors, Perceived Usefulness , Social Influence  and Ease of Use, described the Intention to Use, although negatively in the case of the latter . And, albeit indirectly, Perceived Usefulness was explained by Adaptability  and Ease of Use , whilst Perceived Enjoyment was also explained by Adaptability .To test H9, the sample was divided into the four response subsystems, which configured the combination of gender and personality, giving subsamples of 55 participants in Scenario 1 (S1), 58 participants in S2, 52 participants in S3 and 54 participants in S4. From each subsample, the parsimonious adaptation of the Almere model was estimated using OLS  and Perceived Enjoyment , but negatively in the case of the Ease of Use . Moreover, Perceived Usefulness was explained only by Adaptability  and the fact that it seemed enjoyable was explained by Adaptability  and Perceived Sociability . Finally, in S3  the model explained 50% of the variance in the intention to use a social robot. In this case, it is mainly explained by Social Influence  and Perceived Usefulness . At the same time, Perceived Usefulness was explained by Adaptability  and, furthermore, Perceived Enjoyment was defined by Perceived Sociability  and by Adaptability .As for the rest of the scenarios, S2  achieved an R2 robot S1 – R2 robot S4 = 0.21). When applying the Fisher transformation and estimating the difference in correlations , it was concluded that this difference was significantly higher for the female–cooperative robot than for the male–competitive one. However, although S1  is the one that best fitted the proposed model, according to the Fisher transformation there were no significant differences with the other scenarios, with S2  or with S3 . This difference could be considered as a measure of the moderating effect of gender–personality interaction on the type of task performed and its effect on the intention to use a social robot  and personality (collaborative versus competitive) expressions to the response subsystem may contribute to greater acceptance in tasks consistent with their stereotype. Next, we discuss the theoretical and managerial implications of our findings.A more parsimonious version of the Almere model has been proposed and validated with a sample of visitors to a trade fair, who evaluated a TIAGo robot equipped with an AI system and four response protocols. This adaptation was performed due to both a theoretical controversy, as in the case of the factors Attitude and Social Presence, and context, because of the type of robot used (a humanoid) and the environment in which the experiment was conducted (voluntary participation and a public space) , perceived usefulness is more or less important to explain intention to use, depending on their personality. These results are in line with those obtained by Heerink et al.  in the AFindings suggest that gender and personality stereotypes work for social robots when they perform tasks in line with their profile, i.e. that perceptual fluency is activated and mental shortcuts facilitate this outcome. Nonetheless, further research is needed to corroborate these findings, as well as to address the debate about the social desirability of these results.Companies that use social robots need to know that front-office services produce experiences that involve functional elements as well as socio-emotional and relational elements (Kim et al. In this research, a TIAGo robot was equipped with a social AI system with the three components, namely, a data collection and storage subsystem, an information processing subsystem and a response subsystem (Agrawal et al. This research has some limitations. First, for the sake of convenience, a sample of visitors at a trade fair and a board game have been used, instead of a sample of guests completing some front-office tasks at a hospital or hotel reception. However, this experience has provided us with a lot of information to improve social intelligence protocols. Therefore, future research could examine more gender–personality combinations with different tasks and determine whether the support provided improves robot acceptance and even increases clients’ persistence in completing the task (Gelbrich et al. The model developed in this study captures a short first-time HRI, and the findings reflect that experience. Therefore, we can consider that as familiarity with robots increases, and the model should be adapted to the new reality. Moreover, a convenience sample formed by people who agreed to participate in the study was used, so it is not possible to make any statistical inferences. However, it is worth noting that the sample was fairly balanced between men and women and covered a wide range of ages.


Decision-making in clinical assessment, such as exit-level medical school Objective Structured Clinical Examinations (OSCEs), is complex. This study utilized an empirical phenomenological qualitative approach with thematic analysis to explore OSCE assessors' perceptions of the concept of a “prototypical intern” expressed during focus group discussions. Topics discussed included the concept of a prototypical intern, qualities to be assessed, and approaches to clinical assessment decision-making. The thematic analysis was then applied to a theoretical framework  that explored the complexity of making assessment decisions amidst potentially contradicting pressures from academic and clinical perspectives. Ten Australasian medical schools were involved with 15 experienced and five less experienced assessors participating. Thematic analysis of the data revealed four major themes in relation to how the prototypical intern concept influences clinical assessors' judgements: (a) Suitability of marking rubric based on assessor characteristics and expectations; (b) Competence as final year student vs. performance as a prototypical intern; (c) Safety, trustworthiness and reliability as constructs requiring assessment and (d) Contradictions in decision making process due to assessor differences. These themes mapped well within the interaction between two proposed activity systems in the CHAT model: academic and clinical. More clinically engaged and more experienced assessors tend to fall back on a heuristic, mental construct of a “prototypical intern,” to calibrate judgements, particularly, in difficult situations. Further research is needed to explore whether consensus on desirable intern qualities and their inclusion into OSCE marksheets decreases the cognitive load and increases the validity of assessor decision making. The assessment of clinical, communication, and practical skills is an important component of health professions education for both feedback provision and informing progress decisions. Learners are placed and observed in a variety of settings—teaching facilities, simulation centers, and “real world” practice—to ensure that learning outcomes are achieved. Expectations of learners evolve through programs, with the focus changing from individual components  to more integrated comprehensive tasks that require focus on presentations, diagnostic reasoning, and management plans. Marking sheets may include checklists, rating scales for individual items or competencies, global scores and free-text comments. Assessors are a diverse group, including people in various combinations of academic and clinical roles, in different clinical specialties, and with different levels of experience as clinicians and assessors. Their assessments often rely on relatively brief observations of performance to inform judgements, drawing on both stated learning outcomes and their own experiences and expectations of good clinical performance .Significant variability in clinical assessor judgements has been reported –5. HowevIn educational psychology this construct is known as a heuristic cognitive process, conscious or unconscious, whereby “rule of thumb” judgement decisions are made, possibly neglecting some presented information –15. ThisSo far, exploratory studies on assessor cognition have focused mainly on workplace-based assessments (WBAs), usually involving learners performing authentic tasks in clinical settings , 22–25. This research was informed by the interpretivist paradigm, which is a relativist ontology with a subjectivist epistemology . InterprWe focused on exit-level OSCEs in Australian and New Zealand medical schools within the Australasian Collaboration for Clinical Assessment in Medicine (ACCLAiM) network. Their medical programs are mapped to a national medical graduate competencies framework and have similar integrated, outcomes-based curricula and OSCE processes, including some shared stations –35. ThisAll thirteen ACCLAiM member schools were invited by email in November 2020 to purposefully recruit both experienced and less experienced assessors from their OSCE examiner pools. For consistency, an experienced assessor was defined as having five or more years of post-specialty training clinical practice, experience in assessing senior medical students and/or junior doctors, and a record of consistent and reliable scoring. Ten schools agreed to participate, providing a list of 39 assessors  who were invited by email to participate, supplied with an information sheet and provided written consent.Focus group discussions (FGDs) were conducted to enhance exchange and clarification of participants' viewpoints by exploring how and why they think in a particular way . Semi-stThere were two stages of analysis. The first involved the use of inductive thematic analysis with emerging themes identified, based on the tenets of Braun and Clarke . This waWe chose the third-generation cultural historical activity theory (CHAT) developed by Engeström , 40 becaThe value of CHAT is that it develops “conceptual tools for understanding dialogue, multiple perspectives and voices, and networks of interacting activity systems” , centereTranscribed data were analyzed according to framework elements using NVivo version 12 software . This approach utilizes both inductive and deductive analytical techniques and entails six stages: (1) Reading and re-reading the textual data to familiarize oneself with the content, (2) Identifying, devising, or refining a thematic framework to facilitate data analysis, (3) Indexing the data to corresponding themes, (4) Charting the identified themes (5) Mapping, and (6) Interpreting the themes generated . The codA total of 20 assessors participated in the five FGDs, each with between 3 and 6 participants. The number of participants per group was kept low to foster rich FG discussions. There were 7 females and 13 males with, respectively, 8.4 and 14.8 mean years of clinical experience (range 1–45 years). Fifteen were experienced assessors  and 5 less experienced , almost all in dual roles as academics engaged in medical education as well as clinical practice. Less experienced assessors were all clinicians, although one also held an associate lecturer role. All participants were coded by their level of experience , sex  and an individual participant number. Details of the participants' characteristics are shown in Thematic analysis of the FGD transcripts revealed four major themes in relation to how the prototypical intern concept influences clinical assessors' judgements in senior medical student OSCEs. These themes are (a) Suitability of marking rubric based on assessor characteristics and expectations; (b) Competence as final year student versus performance as a prototypical intern; (c) Safety, trustworthiness and reliability as constructs that require assessment; and (d) Contradictions in decision making process due to assessor differences.Participants demonstrated a good understanding of their roles as OSCE assessors within AS1 and the requirement of compliant use of the marking criteria proforma to assess students' clinical performance.“For the OSCE, from my experience, there's a proforma, there's specific questions and there's marking attached to it, and then there's always a clear description. So essentially, when I'm assessing a student using that proforma, I will follow what's written” Exp-F-P09Participants reported knowing that they had to complete both the checklist and global rating scales of the marking rubric and claimed to understand the rationale for adhering to the criteria, despite sometimes experiencing a personal cognitive dissonance with the rubric.“I feel like my job as an assessor in OSCEs is to follow the assessment sheet and follow the criteria fairly closely. And I have been in situations when I've felt that the assessment criteria didn't necessarily reflect what I would expect an intern to be capable of. And so, have provided feedback after the assessment that I felt that, you know, perhaps the assessment criteria, were more pitched at a fourth-year level rather than a fifth-year level or something like that. But I felt that because their criteria for consistency across examiners that it's really important to stick to them.” Exp-F-P07However, when engaging with the marking criteria to assess the students, participants also believed that the listed criteria did not necessarily reflect all aspects of the expected performance. At this point, they felt that there were relevant elements of subjectivity from their clinical experience, and they had their own personal views about expected standards that related to their clinical work environment.“But even just reflecting on our OSCE about a month ago, yeah, examiners still have different views, personal views about what they think the minimum standards should be, despite how the committees…adjudicate as to what is the minimum standard. So, there's always going to be some difference there.” Exp-M-P05The concept of the “prototypical intern” was applied as the assessors began to critically appraise and compare the final-year medical students' performance to that of their junior doctors/interns in the clinical work environment. For most assessors, the comparison between the final year medical student and the prototypical intern happened intuitively, where the student was mentally placed into the AS2 environment for evaluation.“When we're assessing in that final year in the clinical assessments, to my mind, we are explicitly telling students and other examiners, that the level we are setting the assessment at is: will you in the next few months be able to work as a PGY1 doctor, and be able to give me a reasonable differential diagnosis and some initial management steps?” Exp-M-P13“When I think of how to examine these students, I do also think as to what I expect…a standard intern to be. It's a bit easier because I was an intern two years ago. So, it's quite fresh in my mind as to the standard that I was at, and what my peers were at. And then last year, for six months, I was a tutor for sixth year medical students. So, I had a good grasp as to what level they were at, as they were just reaching the end of their internships. And so, looking at that cohort, and teaching them each week, I was able to know what I thought the average graduate should be at.” Less-F-P15The concept of the prototypical intern was used to make judgements at all levels of performance—excellent, borderline or failing student. Interestingly, the ideal of a prototypical intern has been around for a long time.“My views are pretty similar to Exp-M-P14. And they probably began about 30 years ago, when I was an undergraduate at XXX university. And we were told…as we neared the final examinations, the way we would be assessed is as an intern, and we would not pass if we harmed or killed the patient. Otherwise, we're pretty well, right. And that's something that has probably stuck with me all the way along. I tend to use it, if I'm assessing someone, really for a fail. And I say, “Okay, have they caused harm to that patient, as an intern, or has it been worse?”. And if that is the case, which is rare, but if it is, then I'll give a clear fail. If I think it's something that, you know, can be addressed, and requires some, you know, remedial education or something, then I know that a borderline is going to get them a supplementary exam and they can study harder. So, for me, it's similar. But it's the distinction between a clear failure as regards to pass/fail” Exp-M-P16“So when I mark the student, I would think of an intern that is safe, and minimally competent, at the level, and above expectation, is obviously above the level of intern, a minimally competent intern.” Exp-M-P06However, one assessor did not support the idea of using the prototypical intern as the yardstick, finding it unfair for final year students who had yet to experience the intern year.“The only fair way we can assess them is where they are in the course. I don't think there's any way we can be building into our system, some second guessing about…what they're going to be like in a year's time. That's just not fair. I think the only way it's fair to do that is to say, this is a fifth-year medical student, and you judge them at the level of your expectations of a fifth-year medical student. All sorts of things could happen in the next year.” Exp-M-P2Other assessors agreed that it was unfair to judge final year medical students at the level of an intern but attempted to provide a rationale for doing the comparison and described seeking evidence of foundational learning on which internship performance could be constructed.“And so I think when it comes specifically to final year fifth year XXX University OSCEs, I do have that picture of when they're that first day intern, how will …this intern do? When it comes to final year OSCEs, I feel like I interact with a fair number of interns in ED, and I kind of have this idea of what an intern should know when they first come onto the floor.” Less-F-P18“Yeah. But if you're looking at things that would concern you about a student progressing, okay, I agree with the notion that we're not looking for perfection, but we're looking for evidence, if you like, of something that's already there, rather than something that might need to be added on in turn, and I'm thinking more of a skill rather than content” Exp-M-P01Assessors often looked for the professional behavior characteristics of a good intern in candidates' performances. While most of these qualities are not readily assessable in an OSCE, and thus tend not to feature in marking rubric, they still influenced examiner judgements. The criteria that assessors considered during their judgements included important professional behaviors such as good communication, safe practice, trustworthiness, reliability, and insight into one's own limitations and scope of practice.“We're all wanting that registrar, or that student, or an intern whose knowledge isn't as good. But we'll trust them, we'll be more confident with them. If the knowledge isn't good, then that's easily fixed. If they're not trustworthy…then that's really an issue. But how do you test that in an OSCE?” Exp-F-P03“I tend to be looking at qualities in a student and that hypothetical intern that I have in mind is the one that I would trust, to work for me. And I'd be able to trust the information they were giving me; I'd be able to trust that they got the information that they should have got. And I would be sort of, I'd be able to rely on that. And I'd expect to then go and see the patient with them or separately, and to be able to see something that was consistent with that.” Exp-M-P01It was recognized that unconscious positive bias toward candidates of perceived similarity to self may also influence assessor judgements, as a cognitive overlay to the prototypical intern construct.“I imagine we, even if it's just subconsciously, make judgements on how they dress, how they walk, how they talk, how much they're like us because we will probably favor them positively if we think they're like us. How well they interact with the patients, how polite we feel they are, what it is that makes them safe or what makes them unsafe, how prepared we feel they are all probably goes into whether or not we think that they're a responsible and trustworthy candidate.” Less-F-P18Assessors also acknowledged the role of other health professionals and health service consumers in the AS2 system and integrated these perspectives into their judgements of candidate performances. The assessors expected students to demonstrate an understanding of the professional and interprofessional relationships that exist within the clinical environment. Less experienced assessors, in particular, valued the input of the simulated patients (SP) in making judgement about students' performance.“I always also try to get a gauge of what the SP or the patient felt overall as well to see their thoughts because you know they've been doing this for years and they've seen many different students compared to us, that's also a good gauge I think.” Less-M-P19“Where a lot of their problems come from is, as Less-M-P17 alluded to, [when they think]“Well, I'm the doctor.” They won't listen to the nurse; they won't escalate things.” Exp-M-P16Assessors identified some areas of conflicting views. This mainly related to the conflicting expectations between activity systems. The assessors felt that faculty is focused on performance on the day, while assessors are more concerned with the general character of the final year medical students and their suitability to fit into the medical team in the clinical environment.“One of the things that our [postgraduate specialty] college exam stressed was to avoid the term borderline, because it allowed the examiner to sit on the fence. And so, we tried to make the examiner be a little bit more specific, just below or just above, but don't use the term borderline. And that's something that I've held, personally, in assessing a student's overall competency. Try and work out what it is that makes them safe or what makes them unsafe but avoid borderline.” Exp-M-P05“We use below expectation [and] at expectation. And that's really interesting. I hadn't reflected on this before. But I think that does bring in what's the expectation? So, if you're using that sort of language, it probably does encourage [if] the expectation is intern level or…graduate, ready to graduate into final year. So, I hadn't thought about that before. But now I think about it when I see those words in a marking rubric for the global score, it does point my attention to what's my expectation? So, it probably does encourage the use of the prototypical intern.” Exp-F-P07Participants also flagged possible differences between male and female assessors as well as junior and experienced assessors; assessors marking stations inside or outside of their particular discipline and among postgraduate specialty college assessors.“And one of the things that I've had to do in my [postgraduate specialty] College job, as chair of examiners, is to actually sit with the cohort of examiners as a co-examiner to see what the discrepancy is. And you are absolutely right that the younger examiners, and often the women, the younger women examiners are tougher than the old men. And it really is something I think examinations have to take into account that the old retirees often [have] soft touches. And they will, because of their experience of having seen mistakes made and rectified, they will be a bit more lenient. So, I think we do have to be careful about examiner variability.” Exp-M-P05“But one of the interesting things we're finding is that it's more junior examiners, who might only be three or four years out themselves that seem to have much higher standards of the students. And those of us who've been around for a bit longer seem to be a little bit more willing to tolerate maybe poor performances.” Exp-F-P04“We've got all sorts of examiners and obviously some [postgraduate specialty] colleges and disciplines rely more on OSCE than others. And I do notice that the colleges who do use OSCEs if we have some of their examiners who are familiar with the college exams come to examine, they tend to be a bit more hawkish. So, they do, I think, bring their expectations over. I think it's almost unavoidable.” Exp-M-P10“At medical school level, it's sometimes difficult to get examiners who have enough knowledge of the subject to do a comfortable OSCE. I'm comfortable with general medicine, I'm comfortable with pain medicine. I am a neurologist. And I've noticed that my co-examiners who are not neurologists let some things through that I would object to.” Exp-M-P05“It's difficult to get the examiner line-up the level that we are expecting. So obviously, we have the specialists in that particular discipline doing the examination in that OSCE station, they will expect more as Exp-M-P05 mentioned… because they are the specialists in that discipline. And they will always argue saying, but the student won't be exposed to the same scenario in year four, so, we need to set the bar high enough to be an exit-level." We will then remind them, the student will still improve their communication skills, their history taking skills, examination skills.” Exp-M-P06To improve the examiner decision making process, the participants suggested the use of calibration sessions and well-defined performance descriptors.“Great descriptors are really important. For example, I'm working in intensive care [and] don't have interns. They have to be PGY [postgraduate year] two, three, and have to be good to get to ICU. So, without good descriptors, I probably wouldn't know what the expected level is going to be.” Exp-F-P09“We have a breakout for each station and all the examiners on one station have anywhere from 30 to 40 minutes to discuss that station to go through it in detail. And usually, we have the person leading that as one of the academics who has helped at least quality assure, if not write, the OSCE so that it can be standardized, and you can thrash out some of those questions about what we're actually looking for. And I think that's a useful approach.” Exp-F-P04“Perhaps having kind of explanatory dot points as to what an excellent candidate would be. And then you know what [a] very poor or definite fail is…Then the examiner can …they had a few excellent qualities, but they did miss some, and therefore I'll put them…not quite there. Rather than explaining each individual one, just giving them a bit of a sense as to… what they could do to move them further in one direction than the other.” Less-F-P15The identified themes mapped well within the interaction between two proposed activity systems in the CHAT model: academic and clinical. In relation to how the CHAT can further explain and structure these perceptions, we present OSCE assessor judgements as an interaction within and between two activity systems (AS)—AS1 “academic” and AS2 “clinical,” which function independently but collaborate to produce an outcome. The interactions commenced in AS1 with the Subject (assessor) engaging with the marking rubric (Mediation Tool 1), provided by the academic faculty (Community 1), based on internal interactions with faculty requirements (Rules 1) and the organization of the community (Division of Labor 1), with the aim of facilitating judgement on demonstration of competence (Object 1) by final year medical students. At this point, should the assessor feel there is a misalignment of the marking criteria (Instrument 1) with their expected performance standards from AS2 elements , the subject (assessor) proceeds to mentally adjust Instrument 1 (OSCE marking criteria) to create a shared object—capability of the medical student to transition as a safe, reliable and trustworthy junior member of the clinical team, based on the concept of the “Prototypical Intern” that is better aligned with their expectations. The academic AS1—the medical program—focuses on curriculum development and delivery, specific learning outcomes, assessment tasks, mark sheets and progress decisions, whereas the clinical AS2 focuses on global application of knowledge and skills in authentic clinical practice. The activity system of authentic clinical practice is different in almost every respect to the academic system, but assessor decision-making requires an interaction between two AS because learners are transitioning from one to the other and the assessors work in both systems. The subject in the clinical practice AS is a practitioner whose object is to care for patients. However, when this practitioner is called into the academic AS to serve as an assessor, the object in this AS is to observe and make progression judgement on the level of competence demonstrated by learners. These manifestly divergent goals/ objects in the two activity systems create tensions and contradictions for the subject. While the OSCE is focused on written rules of standardization as indicated in the marking rubric, the assessors prefer to focus on unwritten but fundamental rules and values that are core to authentic, safe and trustworthy clinical patient care.This study uses the CHAT as the theoretical framework to contribute new knowledge to understanding the decision-making processes of assessors during clinical assessment of candidates at a major professional transition point—graduating from a primary medical degree course to entering the workforce. Clinical assessors make judgements that combine, to a varying extent, two interacting sets of roles and experiences that have different origins. The academic construct is the achievement of agreed, expected, graduate learning outcomes; in contrast, the clinical workplace construct is the ability to successfully work within professional settings. The former is reliant on knowledge, skills and behaviors represented in marking sheets in several scheduled, controlled assessment events, one of which is the OSCE. Academic progress decisions are informed by combining assessment data from many assessment events, converting a series of “snapshots” to a “low frame-rate” moving image. The clinical workplace construct is reliant on respect, organization, reliability, teamwork, and trustworthiness exhibited over time. Clinical assessors form impressions of what constitutes a “safe” junior doctor, a “prototypical intern,” through personal clinical experience of working with graduates. These impressions may be shared by close colleagues but different to those in other fields of health care, producing a form of cognitive bias that is likely based on a combination of “signal” and “noise.” This may provide an implicit set of “rules” that reflects “noise” and necessitates adaptation of the academic marksheet. When candidate performance is “borderline,” time is pressured or the assessor is more experienced, this characteristic heuristic, “how would this person fit into my clinical team?” is likely to be relied upon as a benchmark, either consciously or unconsciously, merging rules and influencing resulting judgements. The application of CHAT explained the intricacies and contradictions that may occur within OSCE assessor decision-making.This study explains how assessors in certain circumstances fall back on the clinical workplace experience to influence judgements about candidates. The extent of the influence may depend on the balance of academic and clinical experiences of individual assessors. Predominantly, clinical assessors may respect the academic rules, but over-ride them or merge them with clinically informed rules. This may explain why some assessors add components to checklists, add data points to rating scales and provide negative feedback to faculty on marksheets content. Another position may be that the more academic and less clinically relevant the marksheet, the more assessors may follow clinical logic in making decisions on clinical performance—overriding the marksheet criteria. The dominance of one or other activity system may also explain why examiner training appears not to be effective and why “doves” and “hawks” are difficult to change. “Debiasing” training is becoming popular to improve clinical reasoning, but success may be elusive . It may The relevance of this theory to other forms of clinical assessment, or clinical assessment at course levels other than the graduating cohort, cannot be determined from this study. The analogy may be stronger for exit assessments for other health professionals, where clinicians are assessors in an OSCE-like event. The model may be less relevant to WBA, where the clinical workplace activity system is likely to dominate, even though relatively low failure rates and the “failure to fail” phenomenon have been reported . AlthougThere are implications for both marksheet design and assessor training. Marking rubrics may reflect what learners are “taught” but not necessarily the expectations of their imminent clinical service roles, suggesting a potential disconnect between achieving program learning outcomes and working in the clinical environment. The OSCE may currently present patient care as a set of individual tasks, whereas healthcare is being conceptualized increasingly as a team activity . Would mLess experienced assessors were less represented because they were more difficult to recruit to interview sessions due to less flexible workload in their clinical service and specialty training requirements and a preference by medical schools for utilizing experienced assessors where available. Therefore, the perspectives of less experienced assessors may be under-represented. “Volunteer bias” is also possible, where assessors who follow medical school examiner training guidelines volunteered to be a part of this study—and “rogue examiners” did not volunteer. Hence, the statement that assessors usually followed institutional rules and guidelines for the OSCE may be overrepresented in this work. Additionally, the authors are insider researchers, and this could serve as potential bias, however, trustworthiness and credibility of the findings were enhanced through member checking and analytical group confirmations.Clinical assessment judgements in exit-level medical school OSCEs are complex, with individual assessors balancing perspectives from two different but interacting constructs that overlap and compete. The first is that of the academic system which is more task-oriented, emphasizing knowledge, skills and behaviors, based on achieving agreed graduate outcomes. The second is that of the clinical workplace, where graduates will soon have defined roles and responsibilities within a clinical team. The balance of the influence of these activity systems on judgements varies for individual assessors. Less experienced assessors tend to follow the academic rules listed in marksheets. More clinically engaged and more experienced assessors tend to fall back on a heuristic, mental construct of a “prototypical intern,” to calibrate judgements, particularly, in difficult situations. This heuristic is based on personal clinical experience and discussions with workplace peers, emphasizing professional attributes and trust, and may lead to a form of confirmation bias, that dominates thinking when candidates are “borderline;” time is pressured; or assessors are more experienced. Further research is needed to explore whether designing assessment marksheets and assessor training to more closely align the two systems decreases the cognitive load and increases the validity of assessor decision making. Designing marking frameworks should consider the possible introduction or amplification of unconscious biases. Further, assessor training may benefit from explicit “de-biasing” by aiming to increase awareness of a heuristic that is shared by assessors and caution against over-reliance on this strategy, thereby reducing unconscious bias.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by the James Cook University Human Research Ethics Committee under Permit H6833. In addition, all participating schools obtained ethics approval from their local Ethics Committee. The participants provided their written informed consent to participate in this study.BM-A, RH, and KD'S conceived the study and conducted the focus groups. BM-A, KJ, RH, KD'S, and SS advised on data analysis and interpretation. BM-A, RH, KD'S, SS, AC, and RT contributed to writing the original draft of the manuscript. All authors facilitated collection of data, reviewed, edited, and accepted the final version of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Sir H. Gillies once stated: Occasionally, a routine procedure may end up with a complication of ischemia and tissue loss. This is seen, for example, in rhinoplasty, with nasal skin viability issues, facelift flap compromise, digital ischemia in a hand surgery, or fat necrosis in lipotransfers. In fact, even a filler injection into the face involves an ischemic element with a rare risk of tissue necrosis. When it comes to specific flaps or free tissue transfers, then the focus on the intactness of blood supply becomes much more obvious. Hence, the concern about tissue viability is always there.[Tension ∝ Ischemia]. One generally reverts to undermining and advancement  or other means according to the “reconstructive ladder principle.” This simply means wound tension is inversely proportional to the amount of tissue mobilization, or advancement [Tension ∝ 1/Tissue transfer].Some tension at the site of closure is a normal expectation in all PRS procedures. Nonetheless, when it is significant, “tension” means an invitation to problems and wound edge ischemia, with accompanying risk of dehiscence 4 [Tissue transfer ∝ schemia].Tissue mobilization in attempt to relieve tension could also prove to be potentially detrimental to perfusion when it is miscalculated, depending on the physical factors in locoregional flaps or upon reestablishing the microcirculation in case of free tissue transfers.debt to be paid.” The concept we are conveying here is the fact that any tissue repositioning or a flap procedure does involve a risk to the tissue’s vitality. The three formulas (Fig. Nevertheless, free muscle transfer, for instance, is often indicated to improve blood supply of a certain region; however, when a free flap fails, then one is back to square one, besides a donor tissue loss. The original defect to be reconstructed, therefore, often remains like a “las Fig.  are some5 To elaborate, an example of a microtia reconstruction can be used. To achieve the best possible shape, the skin flap should be optimally thin, and meanwhile, its adequate perfusion is obviously critical. If more skin is recruited from the surrounding areas, it would reduce tension and accommodate a higher profile detailed cartilaginous framework. A perfect balance needs to be achieved for the reconstruction to work (Fig. There is often a thin line that exists between obtaining marvelous results and ending up with complications of tissue necrosis and a possible exposure of implants or other structures. Numerous examples exist: various body lift procedures, augmentation mastopexy, free tissue transfers, etc.ork Fig. .The message from this brief communication is to acknowledge a technical process that characterizes the field of PRS, and to express it in the form of three mathematical formulas.


While many studies address the clinical management of participants with uncomplicated urinary tract infection (uUTI), the emotional impact of uUTIs has been investigated less often. The aim of this qualitative study was to understand the emotional experience of women with uUTIs.This was a qualitative, exploratory, in-depth interview-based study conducted among women in the United States (US) and Germany. Women aged ≥ 18 years with at least one uUTI treated with antibiotics in the past year were recruited through a patient community panel and physician referrals. Participants were recruited using purposive sampling to include an equal split of those with 1 or ≥ 2 antibiotics, and an equal split of those treated for a single or recurrent uUTIs (≥ 2 uUTIs in the past year). A structured telephone interview included questions about symptoms, diagnosis, treatment, and retreatment (if any). Each participant was queried about her emotions and the impact of the uUTI on life activities. Thematic analysis of responses was carried out to identify common themes.A total of 65 participants completed the interview, 40 (61.5%) from the US and 25 (38.5%) from Germany. Major themes that emerged from the analyses included (1) a wide range of negative emotions were experienced due to uUTI symptoms, interference with activities of daily life, and effects on relationships and sleep; (2) varied emotions and understanding related to uUTI treatment and management approaches; (3) treatment failure caused frustration, worry, and anger; and (4) the prospect of recurrent uUTIs provoked dread and helplessness.Our research uncovered emotions of helplessness and dread experienced by women in the context of uUTI clinical treatment failure and recurrent uUTIs. Knowing patients’ perspectives on UTI management will help guide the development of patient education and improve shared decision-making.The online version contains supplementary material available at 10.1186/s12905-022-01757-3. Urinary tract infection (UTI) is the most common bacterial infection presenting in outpatient settings . Most UTWhile many studies address the clinical management of patients with uUTIs, the emotional impact of uUTIs has been investigated less often. Few studies using self-report measures have investigated the impact of uUTIs on patients’ quality of life and emotional and mental health –12. In aEriksson et al.  conducteThis was a qualitative, exploratory, in-depth interview-based study conducted by Adelphi Research between November 26 and December 18, 2019. An interview-based methodology was selected to allow for a more in-depth discussion and to pose a lower threshold for participants to report private or intimate details compared with focus groups. As part of these interviews, a semi-structured narrative self-task component was used, via the SoGoSurvey mobile app platform, as an additional help and source of information to support and engage participants throughout the interview . Three tThe recruitment process included a patient community panel, such as email and social media, and physician referrals. Referring physicians were directed to identify participants according to the following definition of uUTI: “a woman with uncomplicated UTI presents with local signs and symptoms such as dysuria, frequency, urgency, or lower abdominal/suprapubic pain. The patient, otherwise healthy, does not have an anatomical or physiological abnormality of the urinary tract and no systemic signs of infection such as fever (greater than 38 °C) or costovertebral pain.” Women with a fever were excluded as this would indicate complicated UTI (pyelonephritis) . ParticiThe eligibility of interested participants was confirmed via phone. All participants were ≥ 18 years of age, were informed of all rights pertaining to this study, and written informed consent was obtained. Respondents who were recruited via phone were sent a consent to participate form, which was signed and returned to the recruitment agency. This study was non-clinical and was for patient insight purposes only. It was exempt from Institutional Review Board (IRB) requirements per criteria listed in 45 CFR 46.101(b), category 2 for participants from the US, as it used interview procedures recorded in a way that human subjects could not be identified. IRB approval was also not required nor sought for participants from Germany, per the Association of Medical Ethics Committees (AKEK), and the study did not meet the requirements for needing ethical approval, per section 1.3 of the EphMRA guidelines. Respondents were not classified as vulnerable, nor would participation induce undue psychological stress or anxiety.Included participants were required to be female, aged ≥ 18 years, have experienced at least one uUTI in the past year, and have received antibiotic treatment for a uUTI in the past year. Participants must have experienced at least one of the following symptoms during a uUTI episode within the past year: needing to urinate suddenly, needing to urinate more often than usual, or pain or a burning sensation when urinating. We used a purposive sampling approach , 16 and Adelphi Research personnel were responsible for the design of the project, data collection, analysis, and reporting. Adelphi Research are ISO certified and all research was completed in line with ISO20252 . Adelphi was selected through a competitive bidding process. Adelphi’s proposal was deemed the best option for the work as well as having industry experience in completing work used for medical publication. Participants were recruited through independent healthcare fieldwork agencies in the US and Germany, Schlesinger  was conducted by three female external moderators trained in qualitative interviewing in accordance with the interview format developed by Adelphi Research  fully reviewing the interview data, (2) developing codes that best described and represented the data, (3) identifying patterns and common themes among the data, (4) defining themes to best represent the data, and (5) developing the study report to include the thematic story of the findings with detailed and nuanced representation of the data.When quoting specific participants in this paper, an identification number  is used that consists of the participant’s country of residence (US or DE [Germany]) and a unique, anonymized participant number within that country.In the US, 631 people expressed interest in the study. Of these, 564 did not meet inclusion criteria, 15 withdrew from the study after being recruited due to personal reasons, and 12 did not attend the scheduled interview. In Germany, 90 people were contacted, of whom 45 did not meet inclusion criteria, five did not want to download an app required for an associated mobile ethnography exercise, and 15 did not meet quota criteria. A total of 65 participants completed the in-depth telephone interview, 61.5% from the US and 38.5% from Germany.Participant characteristics are summarized in Table Of the women interviewed, 73.8% were between 18 and 49 years of age. Most participants either had a uUTI at the time of the interview or had experienced one within the past 3 months. Similar proportions of participants had experienced either less than three or three or more uUTIs in the past year. Approximately half of the participants had received one course of antibiotic treatment for each uUTI experienced in the past year.Analysis of the interview texts focused on three domains of participants’ statements about their uUTI journey: (1) experience of physical symptoms, diagnosis, and treatment; 2) impact of uUTI on life activities and relationships; and (3) the emotional impact of these experiences . Taking time away from school and work led to high levels of stress and frustration. Impacts on normal routines  led to feelings of helplessness due to lack of control.Regarding experiences at work, participants described frequent toilet visits, vigilance to ensure a bathroom was nearby, and worry about odor associated with the infection. A participant said, “You’re thinking, ‘What are [my coworkers] thinking? They can totally smell this’ … It’s kind of like social uncomfortableness … Sometimes I’ll go to another floor in the building where I think I won’t see anybody I know” (US19).Difficulty in visiting the doctor for treatment also affected daily life and caused stress and anxiety. Some participants expressed irritation at trying to obtain a doctor’s appointment and having to spend time in the waiting room. One participant said, “Going to the doctor makes me very stressed out and irritated, as it is so time consuming” (US14). Many participants expressed a desire for a more efficient treatment process.uUTIs also caused emotional impacts in the context of relationships. Participants often felt unable and unwilling to involve or share their experience with others, reducing contact and intimacy. The need for frequent bathroom stops when seeing friends resulted in the cancellation of plans, and difficulties in socializing led to withdrawal and loneliness. Participants’ low mood also led to negative emotions around interacting with others and again resulted in feelings of isolation. One woman said, “When I have a uUTI it’s like I wake up on the wrong side of the bed every day” (US38).Participants described negative impacts on romantic relationships and intimacy because low mood caused irritation. Abstaining from sex, based on a doctor’s advice or symptoms, led to frustration and anxiety. Some participants also mentioned anxiety or the partner mistakenly feeling they are at fault.Finally, disruption of sleep due to discomfort and getting up during the night resulted in tiredness, irritability, and low motivation, which led to an inability to accomplish day-to-day chores and significant decreases in overall productivity. These impacts on productivity caused feelings of frustration and helplessness. Participants also described irritability due to lack of sleep, which affected relationships with others and led to withdrawal. One participant said, “The sleeplessness is a major problem that affects my ability to function in everyday life” (DE18).Participants compared the severity of uUTI symptoms to that of other common, acute, high-impact conditions that are quickly resolved but may recur, such as a cold or toothache. The experience appeared to be low in severity but high in impact. One participant expressed, “It’s similar to having flu or a cold—a common illness that many of my friends have had and one that is treatable” (DE25). Another participant stated, “You know when you know you have a toothache coming? I know if I don’t do something now about it, in about four to five days it’s going to be killing me. That’s how I can relate to it sometimes: I know it’s coming, and if I don’t do something now, I’m going to really regret it” (US22).Many participants who experienced recurrent uUTIs felt an acute sense of frustration. When symptoms emerged, they quickly recognized they were experiencing a uUTI. These participants were aware of the uUTI process and impact and therefore tended to see the uUTI as an annoyance or frustration. Because of a lack of awareness or expectation of what was happening and what was to come, participants who were newer to uUTIs tended to feel more shock, worry, and fear in response to initial symptoms than participants who had experienced more uUTIs. One participant said, “I woke up because of the pain, and to start with I didn’t know what was wrong because I had never had this before” (US40). However, many participants who had not experienced recurring uUTIs still had past experience or an awareness of uUTIs through talking to friends and family to draw on.Few participants sought medical attention as soon as symptoms started. Barriers to seeking help included the inconvenience or necessity of taking time off work to see a doctor, wanting to avoid the frustration of a doctor’s visit, wanting to solve the problem themselves, hoping the condition would resolve without antibiotics, and reluctance to take antibiotics unless really needed. Some participants in the US referred to cost of care as a barrier to seeking medical attention. One participant said, “I wish I could have a medication on hand, instead of waiting long hours for the doctor” (DE02). A few participants, typically those experiencing their first uUTI, mentioned embarrassment as a barrier to seeking care. Common triggers that ultimately prompted participants to seek help were symptoms that did not go away after a few days, pain that worsened to the point of being unbearable, or actively taking a test strip that came back positive.Based on participants’ accounts, the financial impact of having a uUTI differed for participants in Germany and those in the US. Whilst high levels of consistency were observed between participant responses to the emotional impact of a uUTI, the financial impact upon the participant was the key difference between participants from the US and those from Germany. While out-of-pocket healthcare costs are limited in Germany, multiple participants expressed irritation at having to spend money on a uUTI, particularly when purchasing homeopathic treatments. One participant said, “It is difficult to go the doctor, time-consuming and so on, so sometimes I try to treat it with products that I can buy at a pharmacy, and that can cost quite a lot” (DE19).For some participants in the US, the financial impact was perceived as irritating. One woman explained, “It’s $35–$40 every time you get a uUTI. It’s a little ridiculous for something supposedly one in three women experience multiple times a year” (US36). However, for other participants in the US, the financial burden was much greater. Missing work to attend a doctor’s appointment was sometimes difficult if the participant did not have sick leave. Out-of-pocket payment for a doctor’s visit and treatment, particularly for participants who were uninsured, meant difficulty paying other bills and led to stress and frustration with the financial shortfall. One participant stated, “I end up having to miss out on work [to attend a medical appointment]. Because I am paycheck to paycheck, I fall behind. And it has a snowball effect for me. It’s frustrating … Eventually I will catch up on my bills, but I do fall behind” (US21).Participants with an infrequent history of uUTI were often satisfied with the treatment discussions with their physicians, attaching little to no emotion to the conversation or prescription, with one participant reporting that “I just got it and took it as advised” (DE09). However, participants with a more frequent history of uUTIs felt that their previous experiences allowed them to have more involved treatment discussions with their physicians, with prescribing decisions guided by past experience with antibiotics. One participant reported that “I was aware that it may not work due to my past experiences” (US22). Conversely, some participants with frequent uUTI reported that they did not always feel as though they were being listened to regarding previous treatments and a plan in moving forwards to other treatments, with one reporting that they “asked if we could try something different to see if it worked better—as soon as I finish antibiotics it comes back very soon afterwards” (US27).Most participants reported that they had a dipstick test for confirmation of a uUTI. The majority of participants took a pragmatic approach to the need for testing, with an understanding that the test would determine their suitability for antibiotics. One participant reported that “this is standard practice every time I go to my GP” (DE06). Some participants who took a self-management approach mentioned doing an ‘at-home’ test first to confirm infection and the need for treatment. However, some participants with recurrent uUTI questioned the need for diagnostic tests, when they deemed the diagnosis to be obvious.In addition to frustration in requiring a positive diagnostic test, some participants reported frustration at the burden of time needed for visits to their PCP. Participants with recurrent uUTI felt they knew when they had another uUTI, and therefore felt they should be prescribed treatment without the need for a visit to their physician: “It is frustrating that you cannot call the doctor and get the prescription based on your reporting of symptoms and knowledge that you have a uUTI” (US36).Among participants who experienced treatment failure, most reported going back to the same physician or clinic as they did for initial treatment. In explaining treatment failure, some physicians provided a basic explanation of bacterial resistance. Participants were generally relieved to have an explanation for treatment failure and motivated to receive a second antibiotic to resolve symptoms. One participant said, “Bacteria are too stubborn. I didn’t really ask for much detail, I just took [the antibiotic] because I wanted the UTI to go away as quickly as possible” (DE01). When the physician offered no explanation for the treatment failure, participants sometimes felt responsible and blamed themselves. In the words of one woman, “I was asking myself whether I did something wrong: sitting on a cold surface, not drinking enough…” (DE03).Participants who experienced treatment failure described many feelings, including helplessness that the antibiotic was not working, frustration at “going round in circles,” disappointment that treatment did not work, irritability because nothing seemed to be working, anger at having to go to the doctor again (which was seen as inconvenient), exhaustion with continuing symptoms, and worry (“Is something underlying?” “Is this my fault?”). One participant said, “You’re irritable. You don’t want to be bothered. You’re taking pills and nothing seems to be working. And you’re not sleeping … Sometimes I just feel like I’m going around, and around and around and around” (US22). When offered a second antibiotic, participants described feelings of worry and concern about whether the new treatment would work, as well as frustration and annoyance at having to take another round of antibiotics. A participant said, “I cried in the practice, because I was frustrated and in despair” (DE02).There was substantial overlap in the emotional experience of uUTI recurrence and treatment failure of an acute episode. With both recurrence and treatment failure, participants experienced the same feelings of continual suffering, as well as the same experience of having to continually revisit the doctor. Participants described feelings of frustration at suffering from yet another uUTI impacting their life and routine; helplessness because of a “hamster wheel” effect of continually suffering and visiting the doctor; dread and anxiety because of the expectation of another uUTI, as well as anticipation of the negative symptoms to come; and worry that there was an underlying issue causing treatment failure or recurrence Fig. .After resolution of a uUTI episode, participants continued to experience residual feelings.Anticipation of the next uUTI and the pain and disruption it would bring caused dread and a feeling of helplessness in participants with frequent uUTI. Indeed, one woman described this feeling as, “Here we go again” (US42). Participants who suffered very frequent uUTIs expressed helplessness that the problem kept returning and anxiety at the prospect of another infection being just around the corner. Participants became anxious about suspected triggers of uUTIs, such as a new sexual partner, restarting birth control pills, giving birth, stressful life experiences, and even cool weather. Some participants described feeling helpless that they are in a permanent cycle, waiting for the next uUTI. A participant said, “I felt trapped. Like I couldn’t break free or away from it. I was trapped in a cycle of having these UTIs back to back and I couldn’t seem to break free” (US32).Participants who experienced recurrent uUTIs sometimes raised concerns with the physician, and they expressed a lack of trust in their HCP if requests were not responded to. Women experienced anxiety and anger that treatment was not working or that further problems were not investigated. One participant said, “I asked if we could try something different to see if it would work better. In the past, as soon as I finished the antibiotics, the problem came back very soon afterwards” (US27). Some participants described not feeling they were “heard” regarding previous treatments and their desires for the management plan moving forward, which led to frustration with and distrust in their HCP. Belief in the physician was questioned, and some participants considered changing PCPs or visiting a specialist. One woman said, “I do not have high expectations from medical professionals—doctors have missed things before” (US19).In contrast, a few participants described positive developments after having experienced recurrent uUTIs. Some received specialist referrals after repeated treatment failure or recurrence, and these participants expressed relief at undergoing further investigations. A few participants suffering from recurrent uUTIs mentioned feelings of positivity when they found ways of keeping the problem controlled. A participant said, “I did recover faster because I was drinking more water, so now I feel like I’ve got a little more empowerment every day to prevent them” (US46).In this qualitative, interview-based study of participants who experienced uUTIs (including recurrent uUTIs) in the past year, women described a striking range of emotions related to the burden of symptoms and to their experiences of recurrent infection and apparent treatment failure. Women described frustration as symptoms interfered with typical life activities and relationships, and they felt hopeless and fearful in the context of recurring infections.Our findings have some correlation with previous research on the experiences of participants with uUTIs. Similar to the qualitative interview study by Eriksson et al.  of SwediThe finding that the financial impact of uUTIs is often greater for US than German participants is not surprising. In the US, many patients are uninsured or have high-deductible insurance plans and limited coverage for prescription drugs, so their out-of-pocket expenses for medical visits, urine testing, and antibiotics can be substantial. Additionally, many US workers do not get paid time off for medical appointments and sick leave. In Germany, patients pay only a small copayment for antibiotics, although they do pay out-of-pocket for phytopharmaceuticals and over-the-counter pain relievers. The impact of missed work on earnings is low in Germany because sick leave is routinely paid by employers.Patient education strategies should highlight the need to help patients understand why an office visit and urine testing may be needed, especially for recurrent uUTIs. Patients want greater reassurance around their antibiotic resistance concerns, and they want to be better informed about the possible side effects of antibiotic treatment. Previous research has demonstrated that physicians and patients often have different perceptions of uUTI symptom severity and that improved communication between physicians and patients can improve health outcomes . Shared One limitation of this study is that participants were drawn from a variety of settings in Germany and the US and are not necessarily representative of all women experiencing uUTIs. We cannot exclude a selection bias toward women with a higher symptom load and those who perceive a greater impact of UTI on their quality of life. Another limitation is there is potential for participation bias due to the need to downloading an app, which could exclude participants with older mobile phones or who did not feel technologically capable of completing the exercise. Sociodemographic information about participants  was not collected, which also makes it difficult to assess whether our findings are transferable to larger populations. Differences between the US and German patient samples may have affected study findings. On the other hand, the relatively large number of participants  and inclusion of participants from both Europe and North America provided a broad perspective on participants’ experiences in these geographic regions. A further strength of this study is that it used participants from both the US and Germany, which allowed for the comparison of experiences of women from two different healthcare systems. There was a high degree of consistency in experiences, with financial impact being the key difference between the participants of the two countries.In summary, this analysis points to measures clinicians can take when interacting with participants with uUTIs. Considering patients’ reports of isolation and embarrassment, clinicians can help patients with uUTIs understand how common the condition is. Patient education should focus on explaining key aspects of the pathophysiology of uUTIs; that treatment failure lies with the infecting organism, not the patient; that recurrent uUTIs can happen even without underlying medical or anatomic conditions; and that urine testing is necessary in certain situations.Additional file 1. Text of structured interview, including instructions to the moderator conducting interview.