De Anima, he specifically analyzes three fundamental elements required for visual activities, namely, color, transparent substance, and light. Color moves and limits transparent substance, thereby transforming transparent substance from potentiality to actuality through light. However, there is a debate between Physicalism and Spiritualism as to the specific implementation of the visual activity. Through the intertwined mechanism, Aristotle’s theory of vision can be clarified. The visual activity is neither purely psychological nor purely physical, it is the “psycho-physical” intertwined mechanism. This is why Aristotle’s visual theory is closely related to contemporary visual psychology.Aristotle’s visual theory plays a pivotal role in  De Anima. The rule established by Aristotle for the order is to start with the most fundamental sense, namely touch. Nevertheless, Aristotle places vision at the forefront of his discourse, violating the rule in De Anima. In the view of De Anima. Nonetheless, the question about the exemplary vision is as follows: are we only aware of an object’s color by purely conceptual mind when we see it, or are our eyes physically changed by color? In order to resolve this dilemma, the academia has debated between Physicalism and Spiritualism. Scholars represented by Metaphysics that there is no pure matter in actuality, and it must be a form-involving matter. The form is crucial for the matter, namely “what the process towards health begins from”  Colish eyes .Transparent substance serves as a medium for visual activities. In a broad sense, transparent substance can be referred to as an “ontological medium” because the process of vision relies on transparent substance, not only are our eyes based on transparent substance, but also every visual object has transparency, even if it is a completely solid entity. It can be seen from this that transparent substance is the medium that maintains coherence between the visual organ and the visual object. In a narrow sense, transparent substance should be regarded as a medium between the visual organ and the visual object, such as water or air between our eyes and colored objects. Regardless of the broad sense or the narrow sense, transparent substance is not the purely physical entity outside of specific elements, but rather the entity that possesses the “indwelling nature” of different elements . This inMoving and limiting visual objects through color can only make transparent substance a potential medium, and only through light can the potential medium be transformed into the actual medium. Accordingly, light should be understood as the “transformation” or the “illumination” from potentiality to actuality, and this visual activity is a “psycho-physical” intertwined process. This is because light is not only the activity of activating transparency but also enables color to be seen, “What is seen in light is color, which, accordingly, is not seen without light” . AristotDe Anima II.7. First, De Anima. Nonetheless, he also harbors the idea that the visibility is only an innate attribute of color, not a purely conceptual definition of color. Is there a physical definition of color beyond the purely psychological definition? Second, despite the fact that Aristotle reveals the fundamental difference between color and phosphorescence, he fails to demonstrate the intrinsic meaning of phosphorescence. The explanation for why we could see phosphorescence should be discussed elsewhere  light is the activity of “illumination.” The reason our eyes need light is because we cannot see a color in the dark. Only through the illumination of light can color has visibility, and vision can actualize its ability to “see color.” (2) Aristotle’s concept of light in 3.According to Aristotle, the reason why color is visible is not because of its purely physical characteristics, but because it is the concept relative to vision, so the essence of color is visibility. Put it bluntly, the essential definition of color depends on whether it can be seen, not it’s purely physical attribute. Therefore, we should crystallize color from the perspective of visual psychology. However, the concept of color is not a purely psychological form. The essential meaning of color is a non-purely psychological form, it involves physical substance in the definition. From this, it can be seen that the definition of color is complicated, and its psychological definition is mixed with the non-purely physical definition. In short, we can take an attitude that color is a “psycho-physical” intertwined component in Aristotle’s visual theory.in De Anima, rather than the colored object in a physical sense. Sense and Sensibilia, this is because color only has features of the two-dimensional plane, it does not penetrate the three-dimensional structure of colored objects but rather lies on their surface  Light is a paramount concept of visual theory and it is a key element of the visual activity along with color and transparent substance. The reason why light is necessary for visual activities is because without the “illumination” of light, eyes cannot see the form of the visual object. (2) The “illumination” activity of light is not only in the literal sense, but also in the metaphorical sense. Visual activities are not static, but dynamic behaviors of vision. The light in a metaphorical sense should be understood as a verbal “transformation,” that is, a transformation from potentiality to actuality. (3) Light is a “psycho-physical” intertwined element. It can be seen from (1) and (2) that regardless of whether in terms of literal “illumination” or metaphorical “transformation,” light is an essential component of the visual activity. Now that color is a “psycho-physical” intertwined element, vision is a “psycho-physical” intertwined activity, and we can conclude that light must be a “psycho-physical” intertwined element, otherwise it is impossible to “transform” or “illuminate.”De Anima II.7 easily leads readers to regard the illumination of light as a purely physical activity, but this is a misreading of Aristotle’s visual theory. It can be determined that as light is an actual medium of vision, it cannot be regarded as a purely physical element, but rather a “psycho-physical” intertwined element. Physics and Metaphysics, “time” is a way of measure, excluding the psychological dimension. Nevertheless, light is not a purely physical element in Aristotle’s De Anima, and its illumination is also not a purely physical activity. Owing to light is a necessary condition for visual activities, vision is a “psycho-physical” intertwined activity, we can conclude from this that light must be a “psycho-physical” intertwined element. From a metaphorical perspective, light is timeless because it is only a symbolic or metaphorical description. It can be seen from this that light is timeless, as it does not possess purely physical characteristics. Nevertheless, the literal meaning of “illumination” is still in non-purely physical time.How does light exist? Light does not include purely physical characteristics, how can it trigger physical change in the attributes of transparent substance? Due to the “psycho-physical” intertwined activity of light, illumination is the process of transforming the potential medium into the actual medium, so we should also analyze the light in the sense of metaphorical “transformation.” It should be noted that such a transformation would cause a fundamental change in the attributes of transparent substance. This psychological transformation essentially involves non-purely physical components in its definition, otherwise there would be a lack of efficient cause to actualize psychological activity. Aristotle believes that light is the manifestation of fire, and that light is not a purely physical entity because two physical entities cannot be in the same place. In addition to the potentiality in the dimension of metaphorical transformation, light also serves as a concept of actuality. 6.De Anima II.5. The concept of actuality has double dimensions. First, it is the “first actuality,” which means that vision only has the ability to see color, but not in the process of implementation; Second, it is the “second actuality,” which means that vision not only has the ability to see color, but also in the dynamic process of implementation. Therefore, the discussion of the interrelationship between color, transparent substance, and light is a necessary condition for the second actuality of the visual ability.We have analyzed three fundamental elements of the visual ability in previous sections, namely, color, transparent substance, and light, all of which are “psycho-physical” intertwined elements. Due to the fact that the visual behavior is composed of three fundamental elements, it is a “psycho-physical” intertwined activity. Nonetheless, we should investigate the interrelationship between color, transparent substance, and light, it is a necessary condition for understanding visual activities. This paper has analyzed three constituent elements of color, transparent substance, and light, but this analysis is more from a static dimension and has not yet established a dynamic relationship between the three. Nevertheless, the visual activity is not just concerning potentiality, but more importantly regarding actuality, so we need to further analyze the dynamic process of visual activities. This is why we analyze the dynamic relationship between color, transparent substance, and light. In case that this paper only confines the three elements to conceptual analysis, we cannot establish a dynamic process of vision. Only by establishing a mutual foundation between color, transparent substance, and light, and analyzing the dynamic interrelationships among the three, can the visual behavior shift from the static concept to the dynamic activity. This is in line with Aristotle’s analysis of actuality in Aristotle’s argument on the fundamental elements of vision is not fragmented, but rather constitutes a structural relationship in the sense of dynamicity whereby color, transparent substance, and light are all in a mutually foundational relationship. The first type is the mutual foundational relationship between color and transparent substance. Color moves and limits transparent substance, making it visible and transforming it into a visual medium. It should be noted that color can only move transparent substance, and the “psycho-physical” intertwined process only exists in a non-purely conceptual definition. Color is the form of the colored object. It can only trigger a “non-standard” change rather than a purely physical change. The non-standard change is a “psycho-physical” change in the non-purely conceptual definition, for the transparent substance has no purely physical or purely psychological characteristics. Color and light are also in a mutually foundational relationship. Color makes light possible as a “psycho-physical” illumination, otherwise light would be a purely psychological form. Only through color can light has an actual visibility. Therefore, color is an essential condition for light to actualize transparency. This proves that there is an essential difference between Aristotle’s visual theory and the theory of intention. Aristotle acknowledges the existence of the external physical object, otherwise color would be impossible to actualize a non-purely conceptual activity. A further advantage is that light is a necessary prerequisite for the color to become inherently visible, otherwise color would be a purely physical matter. It is only when color already in the process of implementation that it can be considered as having this potentiality. to krinein.” Therefore, visual activities can be divided into two levels: (a) how to see color, and (b) “how to perceive that we see” (to krinein” as “judgment,” such as Hamlyn’s translation (to krinein” in Aristotle’s De Anima is the behavior of “distinguish.”Light and transparent substance lay the foundation for each other in visual activities. Transparent substance is the foundation for light to carry out visual activities because light acts on transparent substance, otherwise light cannot be actualized; In addition, light is the fundamental premise of transparent substance. Transparent substance has first to be in the process of actualization, to be considered a visual medium in the sense of potentiality. Most scholars regard vision solely as an activity of seeing, while  we see” . Ebert (nslation , which c7.De Anima II.7, the visual organ and its visual ability are inextricable, whereby the visual ability is the form of the visual organ, and the visual organ is the matter of the visual ability. Aristotle’s visual theory can be traced back to the concept of the soul in a macro sense. Animal’s soul has multiple functions, and vision is one of the most crucial functions. For this reason, in Johnston’s view, we should shed light on the soul “in terms of its powers” (Aristotle’s visual theory has caused significant impacts on contemporary Functionalism. According to Aristotle’s visual theory in  powers” . The resDe Anima cannot be reduced to a purely physical activity that are no different from the coloration. However, as a function, vision should be the function of eyes. Therefore, vision cannot exist independently of eyes. Significantly, can contemporary Functionalism really maintain an independent position between Physicalism and Dualism? Green denies the possibility that Functionalism can insist this independent status, believing that it is a transformation of Physicalism, only rising to dominance in the 1960s when Physicalism and Behaviorism lost support (De Anima can be analogized to the relationship between software and hardware: This example has been used by many Functionalists. The function of software must be based on hardware to operate. However, software does not require specific and individualized hardware, so the material requirements for hardware are broad, and the correspondence between software and hardware is not unique. Similarly, the actualization of the visual ability should be based on the visual organ. Nevertheless, the visual ability does not require the specific and individualized visual organ, thus the correspondence between the visual ability and the visual organ is not unique. From this, it can be seen that according to Functionalism, the matter plays a fundamental role in visual activities. Without physical substance, the visual ability cannot be actualized at all. Functionalism is similar to Physicalism, because the two all hold that the matter plays a crucial role in visual activities. It should be emphasized that there is still a fundamental difference between the two: Functionalism believes that physical substance plays a fundamental role in visual activities, but does not negate the existence of the psychological behavior. However, according to Physicalism, when the visual activity occurs, there is no change in our psychological state, so vision is not a psychological behavior. Contrarily, the visual activity is only a physical behavior. For instance, they all hold the view that when we look at red with our eyes, our eyes would be colored red. Apart from this behavior of “coloration,” there would be no psychological activities, such as emotional or conscious changes.Some contemporary scholars aim to connect Aristotle’s visual theory with contemporary Functionalism, represented by scholars such as  support . We shouSecond, Functionalism is an anti-reduction position. To be precise, determining the eye’s essence is the visual activity that cannot be reduced to physical activity, rather than the eye itself, Nussbaum is a representative anti-reductionist . FinallyDe Anima’s Spiritualist interpretation believe that visual behaviors are conscious activities, that is, as Aristotle’s visual theory in De Anima II.7, when we look at the color of something, we are only aware of it. Behaviorism corresponds to the Physicalist interpretation of Aristotle’s visual theory, which states that when we see color, our eyes only engage in physical activities. Therefore, Aristotle believes that when we look at red, our eyes would be colored red. Due to Aristotle’s theory of vision being a “psycho-physical” intertwined mechanism, Behaviorism and Structuralism only consider one side of Aristotle’s visual theory and cannot fully reflect the richness of De Anima II.7. Compared to Behaviorism and Structuralism, Aristotle’s visual theory is more similar to contemporary Gestalt psychology. Gestalt psychologists, represented by Aristotle’s visual theory is closely related to contemporary Structuralism, Behaviorism, and Gestalt Psychology. Contemporary psychology has two influential schools, namely Structuralism and Behaviorism. Contemporary psychologists represented by Aristotle’s visual theory has a certain degree of connection with present visual theory. According to the contemporary theory of vision, the visual activity is the sum of sensation and perception. In essence, visual activities allow us not only to receive the external object and its related sensory experience, but also to systematically integrate sensory experience to form an introspective consciousness. This contemporary perspective is intensely similar to Aristotle’s theory of vision. According to Aristotle, we are not only able to see color, but also aware of the ongoing visual activities, Therefore, we have self-awareness in visual activities . For Ari8.De Anima II.1–2, but also plays an exemplary role in the five individual senses in De Anima II.7–11. The visual object is mediated by transparent substance, which cannot be seen by itself. Transparent substance is moved and limited by color. This behavior can only make transparent substance potential, and only through light, can the potential medium transform itself into the true medium. This study is grounded in the “psycho-physical” intertwined mechanism. Color, transparent substance, and light are in a “psycho-physical” intertwined relationship. However, there are many difficulties in Aristotle’s discourse on three fundamental elements of visual activities. By solving these difficulties, not only can we understand the essential connotations of three elements, but also have a more comprehensive understanding of vision’s implementation, whereby vision is an intertwined activity.Aristotle’s theory of vision not only provides an individualized interpretation of the “potentiality-actuality” in QZ: Visualization, Writing – original draft.


Voicing My CHOiCES is an American booklet which serves as a communication guide to help AYAs have these important discussions with their families and health professionals and document their preferences for care. Our study looked at whether the American guide was suited to young Australians, and what aspects of the guide young people, health professionals, and parents thought caused stress. Overall, participants thought the guide was appropriate and helpful for adolescents and young adults, and they talked about different sources of stress for AYAs attempting to complete it. Our research will inform the adapted Australian Voicing My CHOiCES and support health professionals in how to use this guide to facilitate positive end-of-life outcomes for young people and their families.Adolescents and young adults (AYAs) with life-threatening illnesses want to voice their end-of-life choices. However, these conversations do not happen often. This is in part because of the discomfort that surrounds talking about these issues and because health professionals often have not had enough training in this area. Background: Adolescents and young adults (AYAs) with life-threatening illnesses need support to discuss and voice their end-of-life choices. Voicing My CHOiCES (VMC) is a research-informed American advanced care planning guide designed to help facilitate these difficult discussions. This multi-perspective study aimed to evaluate its appropriateness, acceptability, and clinical considerations for Australian AYAs with cancer. Procedure: Forty-three participants including AYAs who were either undergoing or recently completed cancer treatment, their parents, and multidisciplinary health professionals assessed the acceptability of each VMC section quantitatively  and qualitatively (sources of stress). AYAs also assessed the benefit and burden of completing several sections of the document, to inform clinical considerations. We conducted a mixed-methods analysis to obtain descriptive statistics and to identify prominent themes. Results: In terms of acceptability, almost all participants (96%) rated VMC as appropriate overall. Perceived helpfulness to their situation (to themselves/their child/their patients), to others, and stressfulness were rated, on average, as 4.1, 4.0, and 2.7/5, respectively. Stress was attributed to individual and personal factors, as well as interpersonal worries. All sections were considered more beneficial than burdensome, except for the Spiritual Thoughts section (Section 6). Conclusions: While VMC is an acceptable advance care planning guide for AYAs with cancer, changes to the guide were suggested for the Australian context. Health professionals implementing VMC will need to address and mitigate anticipated sources of stress identified here. Future research evaluating the impact of a new culturally adapted Australian VMC guide is an important next step. Finally, the clinical implications of the present study are suggested. Adolescents and young adults (AYAs) with cancer—a group encompassing varyingly defined age ranges worldwide —are chalAdvanced care planning is a process which aims to improve the quality of patients’ end-of-life period by supporting them to make choices consistent with their values and goals of care ,12. It eAYAs generally want to be involved in end-of-life communication and have preferences for how this happens ,21. HoweVoicing My CHOiCES (VMC), a research-informed AYA advance care planning guide developed in the United States (US)  can be quite overwhelming and just quite negative. … I’d rather focus on [the] positive. It sort of doesn’t give you any hope when you’re confronted with questions like that.”(ii)AYA-related developmental factorsParticipants reflected on how AYAs’ cognitive, social, and emotional development may contribute to stress around end-of-life decision making. They showed that the confronting nature of the topics contained in VMC encountered perhaps for the first time in their lives, could be stressful to consider.“Then at that age when that’s all you can do, when you’re being asked ‘so when you want to die, where do you want to die.’ It’s like—‘but hang on a minute, I want to go to the movies with my friends’.”“Probably the last question ‘when the end of my life is near’, … I think no matter how you frame that it’s going to create some stress for the young person.”Some suggested that the demands of engaging with adult decision making may be challenging for some AYAs and feel that this contrasts with the unequal doctor-patient power dynamic they may have grown up with:“You’re brought up… you go to the doctor, and you do what the doctor tells you. So, to be able to stop previously started treatment, or to ‘hire or fire a healthcare worker’—that’s stuff that’s like, wow—hold on—that’s a bit… [intimidating]”(iii)Concerns around the potential impact on family and friendsParticipants suggested that AYAs’ tendency to consider others in their actions (or not) may be a source of stress for AYAs completing VMC—for example, by worrying about the impact of their responses on family and friends:“It also has the scope to make you feel concerned about how your loved ones are going to be feeling after your death, and that can be really upsetting.”(iv)Interpersonal interactions around the anticipated stress of HCPs using the guideParticipants also thought that broader social issues also influenced the anticipation or stress of completing VMC. Participants noted that stress could arise due to the social complexities within the AYA’s interpersonal network, for example, if the AYA-nominated visitors, medical decision makers, and those to whom online-account access would be granted were in conflict with the family’s preferences.“I’m sure there’s going to be young people who don’t want their default, their parent or guardian, to be making those decisions.”Participants also noted that stress could arise where AYAs and/or their family members were not ready to have these conversations together:“Sometimes because the parents or the siblings can’t get there [to accepting the possibility of death] the child feels… [that] they don’t have permission to get there, and I think that permission to die … and permission to express your feelings before you die is very important.”As one health professional noted, successful engagement with the guide and a reduction in such distress would be “… dependent on you setting the scene and having that person walking you through it, someone else who can give it [VMC] with [an] explanation rather than just throw it [to them] as a questionnaire.”n = 9) completed Medical Decisions and rated it as moderately beneficial  and only a little burdensome , and “It was helpful/relieving to voice my thoughts” (n = 5), while the two most-endorsed reasons for the burden were “Thinking about the topics discussed made me anxious” (n = 3) and “Questions were confusing” (n = 2).All AYAs (n = 4). AYAs found all sections more beneficial than burdensome (SD = 0.29), and the mean burden rating was 0.9 (SD = 0.12). The top three benefits named were “It was helpful/relieving to voice my thoughts” (n = 15), “Helped me think about/decide what I want” (n = 14), and “It provided me the opportunity to discuss my wishes with others” (n = 12). The top three sources of burden were “Thinking about the topics discussed made me anxious” (n = 9), “The questions were difficult to answer” (n = 4), and “The questions were confusing” (n = 4). All sections (aside from the My Voice section) were chosen to be completed by at least one AYA.AYAs subsequently chose a range of other VMC sections to complete, with the Comfort, Life Support, and Being Remembered sections chosen equally frequently .Changes included those surrounding differences in terminology between Australian and US health systems, e.g., the use of the terms “Health care agent”, “DNR”, “Medicaid”, and reference to the option of “hiring and firing” healthcare professionals. One health professional commented on the American language on the Medical Decisions page, ““In my experience with young people, and as technology goes on and things like that, you know, it might be just not as appropriate to use book stories or readings. Readings has a bit of a religious connotation, I guess, to it, so whether that could be changed to maybe the kind of movies, something that’s more technologically related or my favourite podcast.” .Participants also noted the potential for a hypothetical digital, internet-mediated, or app-based version of the guide in the future, as opposed to the current paper-based booklet format. In this context, participants suggested changes including updates for modern technology, the addition of suggestions for photos and videos as part of How I Wish to Be Remembered, and suggesting writing the My Voice content electronically, or as a voice recording on a mobile phone. One healthcare professional suggested the inclusion of podcasts as an option for How I Want to Be Comforted, Participants also commented that aspects of the graphic design of the guide were not especially representative of Australia, for example, the water, reeds, and dragonfly motif.I think again dragonflies are really—I haven’t been to the (United) States a lot. There are a lot dragonflies around. More than you see here, I don’t know why, and so maybe it’s more—it has a connotation for them but I don’t know about it.”“Some participants also expressed that they liked the blue and green colour scheme, while many disliked the mix and arrangement of fonts.Age-appropriate advance care planning communication guides can facilitate best-practice end-of-life communication with AYAs with cancer. This multi-perspective study evaluated the acceptability of the VMC guide for Australian AYAs with cancer to inform the guide’s cultural and linguistic adaptation to local use. This was the first study to evaluate VMC’s acceptability and feasibility in Australia, with diverse health professionals embedded within paediatric and adult hospitals, and the first to include parent feedback. We found that AYAs, parents, and health professionals for the most part considered VMC appropriate and helpful for Australian AYAs with cancer. Our results accord with previous US-based evaluations amongst AYAs with cystic fibrosis and their health professionals , bone maSome nuances around VMC’s perceived helpfulness emerged from our data. Health professionals rated VMC’s appropriateness and helpfulness higher than AYAs and parents, while both AYAs and parents considered VMC more helpful to  others than to themselves. This tendency to consider VMC more helpful in others has been shown before. For example, 85% of health professionals working in cystic fibrosis found VMC useful for their patients, compared to 100% for “someone with cystic fibrosis” . In our Our study is the first to explore VMC’s sources of perceived, or anticipated, stress. Participants in our study considered the VMC Sections on Life Support and Being Remembered most stressful. Our thematic analysis further identified sources of perceived or anticipated stress arising from individual and interpersonal factors. Our findings, therefore, endorse the guide’s helpfulness whilst also acknowledging the potential for some stress (and distress) to arise in the course of these conversations. While distress is always important to manage and mitigate where possible, it is also a natural and understandable element of discussing end-of-life topics, particularly with young patients facing their mortality whilst on the cusp of the rest of their lives.Distress in general (and anxiety in particular) can often be worse in anticipation of difficult events or conversations. The most recent data evaluating the American VMC guide indeed demonstrated that while ~50% of the AYA sample reported moderate/a lot of end-of-life-related anxiety at baseline, this reduced significantly to ~30% immediately after using the guide . AdditioSeveral methodological limitations warrant consideration. Due to purposive sampling and opt-in-based recruitment approaches, we cannot calculate response rates and cannot rule out participant self-selection, resulting in our sample being especially passionate about and/or comfortable with end-of-life discussions. While our sample’s cultural composition was fairly well-matched to the Australian population  , we onlyDeveloping a culturally-tailored, Australian version of VMC is an important next step. Additionally, research needs to determine whether the VMC guide and approach is appropriate for sub-groups of Australians, such as culturally and linguistically diverse groups, and Indigenous AYAs, who experience poorer cancer outcomes compared to the general population of AYAs,  and who From a clinical perspective, excellent communication is a necessary—but not necessarily sufficient—ingredient to support high-quality, patient-centric palliative and end-of-life care. Data are therefore needed to determine whether age and culturally appropriate end-of-life communication guides lead to better end-of-life communication and more consistent delivery of goal-congruent end-of-life care for AYA patients and their families. Recent American data reported that AYA participants were more likely to have had end-of-life conversations after completing VMC ,56—whichFinally, research into the feasibility of integration of an Australian version of VMC into the Australian clinical context should be conducted. Further study into considerations such as the timing of introduction to advance care planning and documents like VMC would be helpful to ensure optimal integration. The variety of responses to the document in our study also suggest that an individualised approach should be taken, which is advocated for in other literature, along with an early approach to the introduction of these topics . FurtherBy having identified sources of stress that most concern AYAs, parents, and health professionals, we can now address how these potential barriers can influence the use of VMC in Australia. For example, health professionals’ descriptions of what they perceive as the biggest source of stress also point to likely reasons why they may not want to introduce the guide. Australian AYAs with cancer, their parents, and health professionals view VMC as appropriate and helpful. Anticipated sources of stress in completing VMC—individual, developmental, and interactional stress—may be mitigated by health professionals taking care to introduce and support the guide’s facilitation in the context of a young person’s history and cancer care. Future research should explore how VMC can be adapted to best meet the needs of Australian AYAs from diverse cultural backgrounds and at different stages of treatment so that all AYAs may have the opportunity to discuss their end-of-life preferences in a well-supported way.


A view that guides the bulk of cancer research and oncology posits that each neoplastic cell in a tumor is a genetic offspring of another neoplastic cell. Yet, analyzing tumors from transplant patients has revealed that some normal migratory cells adopt the phenotype of neoplastic cells without acquiring their genome, thus becoming what I suggest to call adopted neoplastic cells. This commentary reviews the evidence for the existence of adopted neoplastic cells, outlines the consequences of their presence, and discusses what kind of cells can be adopted, how, and why. Cancers, or malignant tumors, are defined and diagnosed as tumors whose cells migrate into normal tissues, while benign tumors as those whose cells fail to do so . Why theThis situation is not due to the want of effort, as attested by at least 3.3 million articles published on cancer  since a prominent researcher concluded a century ago that “despite an immense accumulation of data, the solution of the tumor problem waits upon fresh findings” . That thOne of the models that are still neglected proposes that tumor cells become migratory not by accumulating genomic aberrations, as a century-old view which dominates cancer research and drug development posits –21, but The original hypothesis, also a century old , 23, proThis hypothesis had laid fallow for six decades, until a serendipitous discovery revealed that human cancers grafted into laboratory animals can become metastatic and evade the immune response by forming hybrids with the cells of the host , 26. SinAre these observations relevant to human cancers? This question prompted a search for cell hybrids in human tumors.To find a hybrid in a laboratory animal, the animal is made chimeric, that is, composed of two or more genetically distinct cell populations. For example, to make two populations distinct and their hybrids easier to detect, one population is commonly modified to carry a gene encoding a green fluorescent protein, while the other a gene encoding a red protein. Hybrids are then identified as cells that carry both genes.Chimeric animals are required for two reasons. First, unlike other features that may be specific to parental cells, nuclear genomes cannot be changed by cell fusion beyond recognition, are replicated during each cell cycle, and, consequently, can be identified unambiguously even after numerous cell divisions, which is why genomic analysis is also used in forensics to identify humans and their genealogical relationships. Second, most cells of a laboratory mouse or a human have the same genetic background because they are the progeny of one cell, the fertilized egg. As a result, cell hybrids remain “invisible” to genomic approaches unless the analyzed organism is chimeric.Hence, the search for hybrids in human cancers turned to patients who are chimeric because prior to a cancer diagnosis these individuals received an organ transplant and, as a result, are made of two genetically distinct cell populations: one has the genome of the recipient, the other the genome of the donor. Analyzing patients who received an organ from the donor of the opposite sex, say a female who received a bone marrow transplant from a male , is partThese so called sex-mismatch patients are rare – for example, only four were found among 12,000 transplant patients by one study  – and soThe analysis of tissues from sex-mismatch patients has revealed two groups of tumors .In the first group, which included basal cell carcinomas, skin squamous cell carcinomas, and oral squamous cell carcinomas, all of the analyzed neoplastic cells in each tumor contained the sex chromosomes of either the donor or the recipient –46.This result is consistent with the current view that all neoplastic cells in a tumor are a clone of a single cell, the cell of origin . Indeed,However, in the second group of tumors, which included lung adenocarcinoma, laryngeal squamous cell carcinoma, glioblastoma, Kaposi sarcoma, colon adenomas, esophageal carcinoma, basal cell carcinoma, squamous cell carcinoma, and pancreatic ductal carcinoma, 1% to 40%, or “a proportion” , of neopSeveral additional observations support this conclusion. First, not all tumors analyzed by the same approaches in the same laboratory had detectable neoplastic donor cells –47, 50, The presence of donor-derived neoplastic cells could be explained, as the model which prompted the search for the hybrids had predicted, if some normal donor cells fused to the neoplastic cells of the recipient, yielding hybrids in which the neoplastic phenotype becomes dominant. However, genomic evidence for hybridization has been found only for a fraction of neoplastic donor cells and only in some tumors , 49, 52.If they are not hybrids, then what are they?The lack of evidence for their hybrid origin, the observation that these cells are a minority among neoplastic cells, and the finding that these cells are detected in tumors diagnosed as early as two months after an organ transplant  can be eHow are these cells adopted? Who are the “adoptive parents”? What types of cells can be adopted? What is the fate of adopted cells? What kind of tumors can adopt cells? Are these cells restricted to transplant patients? To see if these questions are worth discussing, let us first consider how the presence of adopted cells would affect tumor development.Adopted neoplastic cells not only look as resident neoplastic cells to expert pathologists, which is by itself remarkable because how tumor cells look is used to diagnose tumors and to predict their clinical course , but at The ability of adopted neoplastic cells to proliferate, migrate, and retain their phenotype prompts a hypothesis that even if the majority of the adopted cells vanish, as adopting a neoplastic phenotype might trigger cell suicide, cell cycle arrest, or an attack by the immune system, some hopeful monsters, to use an evolutionary term  particulIf so, the existence of adopted neoplastic cells would have consequences that might explain some outstanding observations.A model taken by cancer research and oncology as a fact, despite contradicting evidence , 56, posFor example, the notion of genetic continuity underlies the effort to identify and target genomic aberrations that cause the cell of origin to become cancerous and thus are expected to be inherited by all neoplastic cells in a tumor. Hence, the hope is that targeting these aberrations would kill all tumor cells with one arrow. However, if normal cells can acquire a neoplastic phenotype without acquiring the tumor genome and thus its aberrations, targeting these aberrations is bound to fail, as has indeed been the case for reasons that are only partially understood –59.7 of hopeful monsters per each 1 cm3 of the tumor [This unfortunate implication of genetic discontinuity may not require many adopted cells, as a single cancer cell can seed a tumor , cancershe tumor .Genetically discontinuous evolution can also help to explain some observations related to metastasis.All metastases are thought to be genetically continuous with a primary tumor . Yet, soHow are these aberrations lost?The parallel model of metastasis  explainsAdopted neoplastic cells would also seed metastases that “lost” the aberrations of the primary tumor, but for a different reason – because adopted cells do not inherit the tumor genome. This difference also means that adopted cells can seed metastases with “lost” aberrations at any time of tumor development, not only at its early stages, as the parallel model suggests.leap), as they suddenly  enable “profound phenotypic novelties or species” [The failure to find mutations that cause metastasis prompted a search for a “discrete step in tumor evolution that may be independent of specific oncogene pathways or mutations and instead co-opts cellular traits that mitigate immunologic, genotoxic and therapeutic stressors accreted during tumorigenesis.“ . In evolspecies” .For example, the metastasis seed preselection model proposes that neoplastic cells become “bone marrow-like” under the influence of bone marrow-derived cells, which are abundant in tumors, and thus can prosper and proliferate once they reach the bone marrow, a common site for metastasis , 72. TheSeveral properties of neoplastic adoption make it a suitable candidate for the sought after “leap”. First, this phenotypic switch is a discrete step and it happens suddenly on the time scale of tumor development. Second, adopted cells do not inherit the burden of genomic aberrations, and the consequent aberrant antigens targeted by the immune system , becauseCirculating tumor cells (CTC), discovered a century and a half ago , are neoParadoxically, a fraction or, in some cases, most of CTC released by some non-hematological tumors, such as melanoma, breast, ovarian, and pancreatic cancers, were found to carry CD45, a protein whose expression is normally restricted to bone-marrow derived cells , 76–78. The presence of a lymphocyte protein on the cells of non-hematological tumors prompted a hypothesis that CTC-CD45 are hybrids between tumor cells and leukocytes . As a reThe existence of adopted cells suggests another potential explanations: that some CTC-CD45 are bone marrow derived cells that adopted a neoplastic phenotype. This explanation is consistent with a report that only a fraction of CTC-CD45 recovered from a pancreatic cancer patient have a mutation characteristic to this cancer . Given tThe fact that various normal cells are commonly present in tumors means that only some of these cells can be adopted. What type of cells could they be?Adoptable cells should be migratory to enter a tumor, able to adopt the phenotype of surrounding cells, and capable of residing in more than one organ, as adopted cells were detected in patients transplanted with all transplanted organs that were analyzed: bone marrow , 49, 51,This profile matches that of mesenchymal stem cells (MSCs), a group of migratory cell types that are found in bone marrow and some other organs, are capable of assuming a variety of phenotypes, and are prone to home to damaged tissues and tumors –87. SincWhile MSCs are a suitable candidate for a cell type susceptible to adoption, the spectrum of cell types that can be adopted will need to be determined. These studies can be informed by considering potential mechanisms of adoption.The lack of genetic evidence for hybridization prompted a hypothesis that cells derived from bone marrow can adopt the phenotype of resident tumor cells by “subjection to locally released growth factors and cell-cell contact,” a mechanism named developmental mimicry   environmental factors that can result in cell damage.The model that neoplastic adoption is a side effect of cell repair, and the observation that adopted cells are present in colon adenomas , which aThis model would also be consistent with the exponential increase of cancer incidence with aging, a process associated with accumulating cellular damage of various kind , and theFinally, the model that neoplastic adoption is a consequence of repair implies that a treatment that damages cancer cells without killing them can create adopted neoplastic cells. These cells may take revenge even if the “adopting parents” eventually die, reminding us, to rephrase a quote, that if you strike at an emperor, you must kill him , 191.Another possibility is that neoplastic adoption is not a side effect of cell repair but results from the propensity of neoplastic cells to bridge neoplastic and normal cells into the networks using anastomosis tubes and gap junctional channels, as has been documented in glioblastoma , 193.Both the side effect model and the network model imply that neoplastic adoption may affects the “adoptive parents,” for example if the unidirectional transfer of components from the “healer” to the “patient” turns into intercellular exchange. If so, then neoplastic adoption not only would produce adopted neoplastic cells but would also modify resident neoplastic cells. For example, resident cells can become migratory or “invisible” to the immune system. If so, neoplastic adoption would further increase the diversity of cell types in a tumor and thus its ability to preempt our assassination attempts when they are still on the drawing boards of pharmaceutical companies.Adopted cells have been revealed by analyzing tumors from transplant patients. Because these individuals have a medical history that differs from that of most cancer patients, it is reasonable to ask if adopted cells are also present in the tumors of non-transplant patients and how these cells can be detected.A hint that neoplastic adoption is not limited to transplant patients comes from the studies of fetomaternal microchimerism, a condition in which cells exchanged between a woman and her child during pregnancy persist in their bodies, sometimes for decades –196. If This approach has revealed that some fetal cells have properties of migratory progenitors with multilineage differentiation capacity , 198. LiYet, fetal cells that have the features of surrounding tumor cells have not been considered neoplastic because these cells were not found in clusters “even if they expressed antigens that can be found within the adenocarcinoma“ . HoweverThe similarities between fetal progenitors and mesenchymal stromal cells in their ability to home to damaged tissues and adopt the phenotype of the resident cells suggests that fetal cells could be “tracers” of adult cell populations that have similar properties, including the ability to adopt a neoplastic phenotype.The uncertainty about whether fetal cells can be neoplastic, as well as about some of their other properties, stems from their rarity – a few to a hundred are found per million of maternal cells analyzed  – althouPregnancy provides another, yet to be explored, opportunity – to detect adopted neoplastic cells and cell hybrids by analyzing gestational tumors. Gestational tumors, which include moles and gestational choriocarcinoma, arise from the cells of the conceptus and thus are genetically distinct from the cells of the mother . Hence, To look beyond chimeric tumors, the concept of neoplastic adoption predicts that some histologically neoplastic cells of genomically aberrant tumors should have a normal genome, and that the offspring of these cells evolves in parallel with the resident cells of the tumor. This prediction can be tested by comparing the genomes and histopathology of single cells from non-chimeric tumors. Given precedents with cell types, such as CTC-CD45, that were neglected because they were not supposed to exist , it mighFinally, as experiments with humans can go only that far, and fortunately so, testing the hypotheses we have discussed will require experimental systems, such as human tumor explants which have been explored to reveal intercellular bridging , 130 andMeanwhile, I hope that considering and testing the concept of adopted neoplastic cells will prove to be useful in explaining puzzling observations related to neoplasia and would lead to ideas, discoveries, and technologies beneficial to future cancer patients.


Emotional eating is recognized as a potential contributor to weight gain. Emotional eaters often hide their problems because of feelings of shame about their behavior, making it challenging to provide them with the necessary support. The introduction of a virtual coach might offer a potential solution in assisting them. To find out whether emotional eaters are receptive to online personalized coaching, we presented emotional eaters with two essential proto-typical problem situations for emotional eaters: “experiencing cravings” and “after giving in to cravings,” and asked them whether they preferred one of the three coaching strategies presented: Validating, Focus-on-Change and Dialectical.An experimental vignette study (2 × 3 design) was carried out. The vignettes featured two distinct personas, each representing one of the two common problem scenarios experienced by emotional eaters, along with three distinct coaching strategies for each scenario. To identify potential predictors for recognition of problem situations, questionnaires on emotional eating (DEBQ), personality traits (Big-5), well-being (PANAS), and BMI were administrated.A total of 62% of the respondents identified themselves with “after giving in to cravings” and 47% with “experiencing cravings.” BMI, emotional eating and emotional stability appeared to be predictors in recognizing both the problem situations. In “experiencing cravings,” the participating women preferred Dialectical and the Validation coaching strategies. In the “after giving in to cravings” condition, they revealed a preference for the Dialectical and the Focus-on-Change coaching strategies.Using vignettes allowed a less threatening way of bringing up sensitive topics for emotional eaters. The personas representing the problem situations were reasonably well recognized. To further enhance this recognition, it is important for the design and content of the personas to be even more closely related to the typical problem scenarios of emotional eaters, rather than focusing on physical characteristics or social backgrounds. This way, users may be less distracted by these factors. With the knowledge gained about the predictors that may influence recognition of the problem situations, design for coaching can be more customized. The participants represented individuals with high emotional eating levels, enhancing external validity. This viFace-to-face therapy and counseling, such as personal coaching, personal feedback, and education, as provided in behavioral therapies such as Cognitive Behavior Therapy (CBT), and Dialectical Behavior Therapy (DBT), are effective means of helping the emotional eater .However, to prevent or reduce emotional eating behavior and getting adequate help in time to the recipient is not always easy. Firstly, the patient or client is often distanced from health care (because of shame or embarrassment). Emotional eaters will have difficulties contacting care providers on their own initiative. Secondly, therapists are not available when the need is most urgent for the emotional eater. We distinguish two proto-typical problem situations here 1) when experiencing cravings or 2) just after having given in to cravings .Thirdly, health care is overburdened - the waiting lists are very long. There is too little specialist care available for this specific group of patients. And lastly, this patient group should have a greater presence in the public health system as emotional eating is a risk factor for weight gain and obesity.In order to improve right-on-time coaching for emotional eaters, providing ehealth solutions may be a good addition to existing treatments . DigitalNot only the timing and the 24/7 availability of coaching are important, the essence of the message and the tone of voice demand a good fit, adapted to the situation at hand .Successful therapies for treating emotional eating behavior such as Cognitive Behavior Therapy (CBT)  and DialFace-to-face therapy is a fast-paced interaction between therapist and coachee, in which the therapist not only anticipates the coachee’s response, but can already predict, based on his facial expressions, tone of voice, and contextual information, what that response will be. Reality dictates that social intelligence and interaction at such a level are not (yet) possible for a personalized virtual coach .As mentioned earlier a virtual coach can be experienced as impersonal . The perVirtual coaching based on DBT is still something of the future. Since the outbreak of COVID-19, therapists have begun to offer DBT online , but theIn this study, we will assume 3 coaching strategies, inspired by DBT, focussing on two proto-typical problem situations:Validation strategies suggest response from the coach in an empathic way, by hearing another person’s point of view and accepting them (and their emotions) without judging,Focus-on-Change strategies present the receiver with a practical change-oriented focus on problem behavior by providing practical advise,using Dialectical strategies the coach focusses on pairing of Validation and Focus-on-Change. The key here is finding a balance between acceptance of intense feelings and emotions and the need for change by adapting feelings and emotions.To best meet the emotional eaters’ need for right-on-time coaching , we have“experiencing cravings,” when experiencing negative emotions and distress,“after giving in to cravings,” undergoing feelings of disappointment, anger, shame and disgust .The two problem situations are depicted by personas. Personas are created by designers to act as “fictitious, specific and concrete representations of target users”  “PersonaA persona acts as a prototype because it represents a group of users. It is constructed from characteristics of that target group based on data from the literature, and data from research among users . A persona is rich in composition by placing it in a context and by providing it with a personal profile, background, and user needs , 2017.In the literature, the need for, or importance of, validation of personas is mainly associated with User Centered Design - to support the design of applications, for creating user stories, for heuristic evaluations, and to spur creativity among developers .Little has been published about the validation of personas used for experimental or exploratory research.We chose to use personas because they may make the depiction of the proto-typical problem situations more insightful and accessible to the participants than presenting an abstract description, conducting interviews, or presenting mock-ups.It is very important that participants and future users of the personalized virtual coach recognize themselves in one or both problem situations, because these two situations are the most essential situations for emotional eaters . It is eThe personas presented to the participating women in this study, were Anita – representing the problem situation “experiencing cravings,” and Lisanne – representing “after giving in to cravings” see The sections of the personas  were developed based on the literature and data collected . They we1.1.In order to enable the provision of online personalized coaching and the appropriate coaching for any individual, the purpose of this study is firstly to explore whether respondents recognize themselves in the presented proto-typical problem situations “experiencing cravings” and “after giving in to cravings”, to ensure that the coach, yet to be developed, learns to present the right coaching, appropriate to the user’s situation and secondly, whether, or to what extent, that recognition is being affected by specific characteristics, such as a tendency towards emotional eating, personality traits, and the degree of well-being. If we can predict this, we will be able to further tailor the support of the virtual coach.In order to provide with the most appropriate coaching for the given problem situations, it is important to determine which coaching strategy would be preferred by emotional eaters in relation to the two given problem situations.The objective is to gain more knowledge about recognition of the given problem situations so that the virtual coach is enabled to deliver the right coaching based on this information. With this focus in mind, we formulated the following research questions:RQ1: Are there predictors for identification with the typical problem situations for emotional eaters “experiencing cravings” and “after giving in to cravings”?RQ2: What are the preferences for a specific coaching strategy with regards to the two typical problem situations for emotional eating?2.2.1.This study was approved by the ethical committee of the Faculty of Behavioral, Management and Social Sciences at the University of Twente (registration number 18033) on the 27th of February 2018, and was carried out between 13th of April and 13th of May 2018.An information letter introduces the researcher and provides potential study participants with details about the study’s purpose, content, and the specific areas under investigation. The letter outlines the responsibilities expected from the participants, including providing personal information such as height, weight, and age, reading vignettes, answering related questions, and completing three questionnaires.For reading the vignettes and answering the questions one online session is required. The estimated duration of the session is 45 min. Participants are also informed that the scenarios described in the study may be relatable or trigger strong empathetic reactions, which could potentially lead to personal reflection or discomfort. In light of this, informed consent is a critical aspect of the study.2.2.2.2.1.An experimental vignette study (2 × 3 design) was carried out. Vignettes may be used for three main purposes in social research: to allow actions in context to be explored; to clarify people’s judgments; and to provide a less personal and therefore less threatening way of exploring sensitive topics. The vignettes were used as a method of presenting the personas that depicted the two proto-typical problem situations for emotional eaters:“experiencing cravings,” when experiencing negative emotions and distress,“after giving in to cravings,” undergoing feelings of disappointment, anger, shame and disgust.The vignettes subsequently produced one of three pre-defined coaching strategies: Validating, Focus-on-Change, and a Dialectical respons .2.2.2.To recruit participants, an invitation to participate was sent out to all dieticians of a particular franchise organization. They forwarded this request to their group of clients. A hyperlink in the email message directed the participants to an online survey (available on request). The clients were under treatment with the dieticians for weight reduction and lifestyle improvement. The dieticians asked their clients if they wanted to participate in a study on emotional eating. Those who answered affirmatively were forwarded the invitation to this study by e-mail.2.2.3.emo = 3,68; range 1,68-4,92) is highly similar to those of the norm-group of women with ages between 21 and 40 years (DEBQ); .Adult women with self-proclaimed emotional eating difficulties .They were invited to view the vignettes containing the presentation of the personas Lisanne and Anita (text and images as depicted in the 2.2.5.2.2.5.1.2]. The average score of BMI is 30.61 (N = 67) (see N = 78).Participants shared information on their gender , year of birth, length, and weight. Body mass index was calculated by dividing self-reported body weight (in kilogram) by height squared (in meters) . Women with high degrees of self reported emotional eating identified themselves more with both the identification with “experiencing cravings” and the identification with “after giving in to cravings” than women with lower degrees of self reported emotional eating.Emotional eating was positively associated with both the identification with “experiencing cravings” and the identification with “after giving in to cravings” .A likelihood ratio test showed that the differences between the three coaching feedback conditions were statistically significant for both Q-2 and Q-3  were distinct. The probability of a participant giving a positive rating to Validation was higher than to Focus-on-Change. The probability of giving a positive rating to Dialectical was higher than to Focus-on-Change.3.2.1.1.In the “experiencing cravings” condition, the women preferred the Validation and Dialectical coaching strategies. There was no difference in their preference if it was the coach’s feedback in general, or if it was directed to themselves personally.3.2.2.Estimated probabilities of a positive opinion for all three conditions are presented in 2 (2) = 9.62, p = 0.008, and χ2 (2) = 6.61, p = 0.037). Post-hoc pairwise comparisons  indicated that for Q-2 the difference between the Validation and Focus-on-Change conditions [(OR = 6.54) was statistically significant p = 0.013], for and for Q-3 the differnce between Validation and Dialectical (OR = 4.22) was significant (p = 0.045).A likelihood ratio test showed that the differences between the three coaching feedback conditions were statistically significant for both Q-2 and Q-3  were distinct. The probability of a participant giving a positive rating to Validation is smaller than to Focus-on-Change. The probability of giving a positive rating to Dialectical is smaller than to Focus-on-Change.p = 0.078 and p = 0.306). The same held for differences between the Validation and Focus-on-Change conditions (OR = 2.76) and between the Focus-on-Change and Dialectical conditions (OR = 1.53) in Q-3. With, respectively, p = 0.177 and p = 0.481, they both were not statistically significant.The differences between the Validation and Dialectical conditions (OR = 3.64) and between the Focus-on-Change and Dialectical conditions (OR = 0.56) were both not statistically significant , or whether it was directed to themselves personally (Q-3) in Validation and Dialectical .4.RQ1: Are there predictors for identification with the proto-typical problem situations for emotional eaters “experiencing cravings” and “after giving in to cravings”?To be in a position to meet the needs of prospective users of a personalized virtual coach, the present study examined whether respondents would identify with the presented problem situations.It is crucial that participants and future users of the personalized virtual coach recognized themselves in one or both problem situations, because these two situations are the most essential situations, known by emotional eaters . The facThe majority of participants recognized the problem situations and women with a higher BMI and with a higher degree of self-reported Emotional Eating recognized themselves more often in both situations than women with lower BMI and lower self-reported Emotional Eating. This was also found for emotional instability in relation to “experiencing cravings”. Thus, the characteristics BMI, emotional eating and emotional stability can be considered as predictors in recognizing the problem situations “experiencing cravings” and “after giving in to cravings”. The added value of this knowledge may reside in the fact that future users of the virtual coach, who score on these characteristics, are better recognized and accommodated in their need for coaching. By taking such insights into account, coaching can be more tailor-made.Considering the results, we can conclude that the personas were well recognized by the participants. In this context it can be noted that, though not statistically significant, the recognition for the personas was different from one another: 62% of them identified with the persona that represented the problem situation “after giving in to cravings”, compared to the 47% that identified with “experiencing cravings.”The somewhat higher percentage of recognition may have arisen because at least five possible factors may have influenced the participants’ choices:the appearance of the two different personas ;the description of the problem situations “Experiencing cravings” versus “After giving in to cravings”;the described emotions in de problem situations; It is possible that “After giving in to cravings” appealed to more participants because the miserable feeling once the binge is over, the anger, the regret, the disappointment about one’s own behavior, shame may be more universal among emotional eaters than “Experiencing cravings,” because here stress is the described emotion that gives rise to cravings, while there are also other negative emotions such as fear, anger, annoyance and loneliness, which can be the prelude to experiencing and giving in to cravings ;the appearance of the personas in terms of  background, education, and socioeconomic status. Anita, middle-aged, is a poorly educated woman. She has an anxious nature - she suffers from stress because of financial worries and concerns about her family. Lisanne, representing “after giving in to cravings”, is a well educated, good-looking young woman);the order of presentation of the problem situations to the participants .Participants may not have recognized the persona “experiencing cravings” as good as “after giving in to cravings” because the appearance of that persona was possibly less appealing. Participants looked at the picture and perhaps had their thoughts ready. A study by Salminen and colleagues showed that “[…] a smile enhances the perceived similarity with the persona, similar personas are more liked, and that likability increases the willingness to use a persona . In follIn principle, both problem situations should be well recognized because the emotional eater experiences both problem situations. If an emotional eater suffers from cravings and gives in to them, then usually the phase “after giving in to cravings” is also lived through , 2018. AHowever, it is not known which factors weighed more heavily for the participants because they were not surveyed on those aspects. It is therefore quite possible that the difference in appearance and presentation of the two personas could affect the internal validity of the study.To increase the degree of persona recognition, it is important that preferences of participants are not affected by attributes other than those directly related to the specific characteristics of the emotional eater, and the proto-typical problem situations she can encounter.RQ2: What are the preferences for a specific coaching strategy with regards to typical problem situations for emotional eating?The objective of this study was to gain more knowledge about recognition of the given problem situations so that the virtual coach would be enabled to deliver the right coaching based on this information.In the problem situation “experiencing cravings”, the women chose Validation and Dialectical over Focus-on-Change as the most appropriate coaching for them personally and as generally applicable coaching strategies. On the same questions regarding the problem situation “after giving in to cravings”, they preferred Focus-on-Change and Dialectical over Validation.The coaching strategy of Validation seems to align with “experiencing cravings” but not as much for “after giving in to cravings”. A possible explanation for the fact that Validation may cause resentment in a person who just gave in to cravings is that she is ashamed of her behavior (giving in to cravings) and does not want her feelings and behavior to be ‘justified’ or even given a positive annotation.Validation is valued in “experiencing cravings” but an equally large group preferred Dialectical. Validation is appreciated, but in combination with practical advice it has added value, because it could take the user further in her process of enduring cravings .The Focus-on-change strategy seems to have possible interfaces with “after giving in to cravings” but not as much for “experiencing cravings”. A woman who just gave in to cravings needs practical advice. When she is still experiencing those cravings, she should be stopped from giving in to them, with the use of an instantaneous intervention. Perhaps the given advice was not the kind she was hoping for at that moment. She had already decided to leave the cookies in the cookie jar and had picked up her phone to contact the virtual coach. She did not need another confirmation from the coach. An advice might have been better, such as: “Anita, put on your coat and go out for a walk.” That could have helped her to temper the stress she was experiencing.Dialectical feedback seemed appealing for women who were experiencing cravings. For those who already gave in to cravings it was preferred to some extent because they were not susceptible for the validating component of this coaching variety. Apparently they were only interested in practical tips with information on how to get her life back on track or how to prevent this from happening in the future.So it seems that the virtual coach should make it clear to the client that Validation does not involve the act of giving in to cravings itself, but rather hinges on the client’s feelings of regret, or disgust or revulsion after giving in to cravings.The Dialectical coaching strategy seems to get the best marks for both the problem situations. This style of coaching does well in the practitioner’s office , but see4.1.Using personas is an efficient way to provide insights into how respondents relate to matters. They were generous in sharing their opinions on both the personas and the suggested coaching responses from the virtual coach . It mighthe personas differed from one another in terms of socioeconomic status, background and level of education,it is not fully clear why participants did or did not recognize themselves in a persona,the photos shown may have been too determinative.These factors may have affected the study’s internal validity.In future studies it is recommended that personas differ less from each other in person-related data such as socioeconomic status and background, but making the personas more comparable might have impact on the heterogeneity. Systematic methods have since been developed that underpin this problem . By usinWhen developing personas, it is important to strive for uniformity in personal profile and background to prevent participants from letting outward appearances influence their choices.The strength of presenting personas using vignettes lies in the fact that it can be well applied when raising delicate topics. This promotes a sense of comfort among participants and encourages them to be open and approachable. The recognizability of the content with their everyday experiences creates a secure and credible context for them to reflect on the personas presented.It is also important to note that the participants were a representative sample of individuals with heightened levels of emotional eating, which enhances the external validity of the results and suggests that the interpretations could be directly incorporated into virtual coaching practices for people dealing with emotional eating.The percentages of recognition of the problem situations “experiencing cravings” and “after giving in to cravings” did not seem high. The explanation may be that we have imposed a strict standard in converting the 4 answer categories to 2 dichotomous variables. The initial answer categories that participants could choose from, were not articulated clearly enough. The response categories were as follows:1) Yes, I can totally relate to L/A, 2) Yes, I can relate more or less, 3) No, I cannot relate very well, and 4) No, I cannot relate at all.To keep the recoding beyond all reasonable doubt, only the first answer ‘Yes, I can totally relate to L/A’ is recoded to ‘entirely’. The other answers, namely ‘Yes, I can relate more or less’, ‘No, I cannot relate very well’ en ‘No, I cannot relate at all’ are recoded to ‘not entirely’. Working with such strict selections may have had ‘adverse’ effects on the results, but the result is beyond any doubt. Had response categories 1 and 2 been combined, 86.8 and 90.6% of participants, respectively, would have identified themselves “totally,” or “more or less,” in “experiencing cravings” and “after giving in to emotional eating.Finally, a potential limitation may have been that participants were not asked if they knew of any other proto-typical problem situations.5.Possible important predictors of identification with the presented problem situations are BMI, emotional eating and emotional stability. The relationships between these characteristics and the degree to which participants recognize themselves in the problem situations, may offer perspectives for developing a virtual coach application that resonates with the emotional eater’s experience.The Dialectical coaching strategy apparently emerges as the most valued coaching strategy in both the proto-typical problem situations, namely “experiencing cravings” and “after giving in to cravings”. In contrast, Validation is rejected as an appropriate coaching strategy by a significant proportion of participants. The finding that a large proportion of the group rejects Validation as coaching strategy requires more insight into the emotional eater’s state of mind immediately after giving in to cravings.The recognition of the personas provided more insight for the design of the virtual coach, but developing personas with more uniformity in personal profile and background, focussed on the characteristics of the typical problem situations of the emotional eater, could potentially contribute to more robustness of that design.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.This study was approved by the ethics committee of the Faculty of Behavioural, Management and Social Sciences of the University of Twente (registration no. 18033) on 27 February 2018, and was conducted between 13 April and 13 May 2018. Written informed consent was obtained from the individuals for the publication of any potentially identifiable images or data included in this article.AD: Conceptualization, Formal analysis, Methodology, Writing – original draft. TS: Writing – review & editing. HV: Writing – review & editing. LG-P: Writing – review & editing. CB: Writing – review & editing.


Audit and feedback (A&F) is a widely used implementation strategy to influence health professionals’ behavior that is often tested in implementation trials. This study examines how A&F trials describe sustainability, spread, and scale.This is a theory-informed, descriptive, secondary analysis of an update of the Cochrane systematic review of A&F trials, including all trials published since 2011. Keyword searches related to sustainability, spread, and scale were conducted. Trials with at least one keyword, and those identified from a forward citation search, were extracted to examine how they described sustainability, spread, and scale. Results were qualitatively analyzed using the Integrated Sustainability Framework (ISF) and the Framework for Going to Full Scale (FGFS).n = 161 studies met eligibility criteria. Seventy-eight percent (n = 126) of trials included at least one keyword on sustainability, and 49% (n = 62) of those studies  frequently mentioned sustainability based on inclusion of relevant text in multiple sections of the paper. For spread/scale, 62% (n = 100) of trials included at least one relevant keyword and 51% (n = 51) of those studies  frequently mentioned spread/scale. A total of n = 38 studies from the forward citation search were included in the qualitative analysis. Although many studies mentioned the need to consider sustainability, there was limited detail on how this was planned, implemented, or assessed. The most frequent sustainability period duration was 12 months. Qualitative results mapped to the ISF, but not all determinants were represented. Strong alignment was found with the FGFS for phases of scale-up and support systems (infrastructure), but not for adoption mechanisms. New spread/scale themes included (1) aligning affordability and scalability; (2) balancing fidelity and scalability; and (3) balancing effect size and scalability.From the larger review, A&F trials should plan for sustainability, spread, and scale so that if the trial is effective, the benefits can continue. A deeper empirical understanding of the factors impacting A&F sustainability is needed. Scalability planning should go beyond cost and infrastructure to consider other adoption mechanisms, such as leadership, policy, and communication, that may support further scalability.Registered with Prospero in May 2022. CRD42022332606.The online version contains supplementary material available at 10.1186/s13012-023-01312-0. Contributions to the literature• This study explores the understudied area of how sustainability, spread, and scale are discussed in audit and feedback trials.• The need to consider sustainability is mentioned frequently, but little detail is provided on how to plan for audit and feedback to be sustained, if found to be effective.• The time periods used to explore sustainability were relatively short. Twelve months was the most frequently mentioned sustainability period.• When planning for scaling-up, trials most frequently mentioned the need to keep costs low and use existing infrastructure.• Future audit and feedback trials are encouraged to publish follow-up studies that report on sustainability, spread, and scale.In 2012, a Cochrane systematic review found that audit and feedback (A&F) can have a small, yet potentially meaningful impact in professional clinical practice . To exteGiven the potential for beneficial impact and use at a large scale, such as throughout a geographic region or healthcare system, a deeper understanding of how trial teams plan for the A&F to be continued (if effective) in other settings or contexts is needed. In the past 10 years, there has been an influx of A&F trials and an update of the Cochrane review is underway in 2023 . This upThis is a secondary analysis of a Cochrane systematic review using qualitative synthesis methods informed by relevant theory. The focus was on keywords used to describe the three concepts, the timeframe used to claim the impact or overall intervention, including A&F, was sustained, the determinants of sustainability, and the sequence, mechanisms, and underlying factors for spread and scale.after a defined period of time, a program, clinical intervention, and/or implementation strategies continue to be delivered and/or individual behavior change  is maintained; the program and individual behavior change may evolve or adapt while continuing to produce benefits for individuals/systems  consisted of comparable standardized elements, but more strongly involved local professionals in the design and performance of the locally tailored interventions” [The stepped-wedge design did not allow us to anticipate in a flexible manner to all types of circumstances that hindered the implementation. In retrospect, it is fair to say that we expected too much change in a too short time frame” [Allowing participants to develop tailored systems changes to address barriers may have promoted sustainability by building engagement and aligning efforts with existing clinical processes” [Implementation processes consider how the intervention is implemented . Within trials that planned for sustainability, focus was on how to embed the intervention into routine practice. This embedding was thought to be supported by involvement of key decision makers and local staff, mainly in the design process, and connected to ongoing adaptation. “entions” . The abie frame” . In studocesses” .There was little mention regarding team training for A&F. Strategic planning typically focused on recommendations for what should happen next for effective interventions , rather than experience with strategic planning. Program evaluation and access to data focused on the infrastructure for access to audit data, not on data to evaluate the ongoing impact of the A&F strategy.The principal strength of the study is that it met the requirements of systematic reviews calling for large well-designed long-term trials of hand-hygiene interventions which apply behavioural theory to intervention design” [A new factor was the use of implementation theories, models, and frameworks, and behavior change theory, to strengthen the implementation process and support sustainability potential. “ design” .Using existing staff is important for understanding whether a model is feasible and sustainable regardless of externally funded interventionists” [It appeared that large-scale uptake of evidence-based but complex implementation strategies with a minimum of influence of external researchers, but with the stakeholders in healthcare themselves being responsible for the work that comes with integrating this intervention into their own groups, was not feasible” [Specific provider or implementer characteristics, such as roles, benefits, stressors, skills, and expertise, were rarely mentioned. When characteristics were discussed, focus was on embedding with existing staffing models and capacity, as well as motivation of implementers, including champions, to stay involved. Aligning with organizational capacity, the reliance on existing staff was suggested to be beneficial when planning for real-world implementation. “ionists” . Other seasible” .The operational delays in preparing the Dashboard in the latter months left supervisors with less time to perform their duties and may have reduced the quality of supervision. Second, supervisors could have lost motivation over time, which might have reduced the effectiveness of their supervision” [An enthusiastic motivator who used her or his time and energy to provide feedback, encourage competition and energize the staff to keep up the efforts throughout the season” [Motivation to stay involved was described as a barrier and a facilitator to sustainability. If there were multiple delays in the implementation process, and lack of time, these decreased initial implementation effectiveness and sustainability potential. “rvision” . Motivat season” .Population characteristics are typically included in this ISF domain; however, this information would not have been extracted from trials, so it was removed.Delivering a complex intervention into a complex system, … is challenging with many barriers to achieving intended outcomes. There was no simple reality” [Characteristics of the intervention include the ability of the intervention, including A&F, to be adapted (not how it is adapted), fit within the context, perceived benefit, need for this benefit, burden and complexity of the intervention, and the cost. The A&F trials focused on challenges of working with complex interventions and systems. “reality” .Although the added costs of such resource-intensive support can be maintained during research evaluations, it is challenging to incorporate these costs into a business model that enables sustainable, scalable provision of the service” [Cost was mentioned as a key characteristic impacting sustainability, including comparison between research costs and sustained implementation. “service” .The fit with the context, population, or organization, as well as the need for the intervention, was mainly covered in the descriptions of the need for the trial itself, not connected to sustainability. Perceived benefits were mainly covered in the results regarding whether or not the intervention, including A&F, was effective, only speculating on the potential for sustained benefit in the discussion.Most studies made generic statements regarding the need for more studies to consider scale for their specific clinical area and more generally. Within studies that mentioned conducting the trial at scale, many were reported as “first of their kind” and provided some strategies for how they planned for scalability. Strategies were mainly focused on keeping costs low and using existing infrastructure. Many of these same trials recommended that more preparation work was needed and provided suggestions on why the intervention did or did not have the desired effect at scale.Results of the deductive analysis to the FGFS, specific themes related to A&F, definitions of the FGFS determinants, and supporting quotes are included in Table The goal-setting and action-planning worksheet was designed to be readily scalable and was delivered with minimal supports” [For phase 1: set-up, trials discussed how they prepared the groundwork for the trial to scale, including designing materials and training that could be easily scaled. “upports” . Some stpilot test the systems consultation strategy in a small set of primary care clinics to see if the strategy demonstrated feasibility, acceptability, and preliminary effectiveness in improving clinician adherence” [In phase 2: develop the scalable unit, the trials mentioned moving beyond initial design to conduct small pilots to inform what would be taken to the next level. A scalable unit is defined as a small administrative unit  that includes key infrastructural components and relationship architecture that are likely to be encountered in the system at full scale . As an eherence” . If effeconfidence in the wider applicability of trial findings as it replicates guideline implementation activities under standard conditions. We paid close attention to ensuring that the evaluated intervention was embedded in real world practice, and the trial itself involved more than 94% of primary care practices in three geographical areas” [Many of the trials that discussed scale frequently were focused on phase 3: test of scale up, as they conducted the trial across multiple sites/settings with the intention of going to full scale. The main focus was on conducting the trials under usual conditions across a large area. The approach taken in one study was mentioned to increase “l areas” . In thisFor phase 4: going to full scale, there was no standardized way to determine what qualified as “full scale”; however, descriptions such as “across all of Australia,” “across the province,” or “on a national scale” were all treated as “full scale.” Trials at this level typically mentioned work from previous phases first, and although the FGFS suggests less emphasis on learning during this phase, as anticipated for a trial, these trials still focused on learning and results.Within the adoption mechanisms, determinants include better ideas, leadership, communication, policy, and a culture of urgency and persistence. Included trials mentioned use of more scalable, or “better” ideas before phase 1, as the emphasis was on learning from the literature, and a need for simple ideas or principles that could improve scalability. For example, some studies focused on use of “nudges,” as they aim to be low-cost, innovative behavioral approaches that have potential to be scalable and align well with A&F , 62, 64.Within support systems (infrastructure), determinants include human capability for scale-up, infrastructure for scale-up, data collection and reporting systems, learning systems, and design for sustainability. Human capability for scale-up focused on implementing the trial in “usual circumstances,” the benefits of needing as little implementation support as possible, and not to be labor intensive. The focus in this determinant was on how to make it feasible for people to engage with the A&F; however, as with the ISF analysis, there was minimal mention about specific skills to enable scalable A&F processes.Infrastructure for scale-up was the most frequently mentioned determinant, particularly with the emphasis on using existing data structures for audit results, and a standardized way to share feedback. Scaling across sites/settings that have the same systems was seen as a significant facilitator for scaling-up, such as working in systems with the same EMR, or when data was already collected and accessible. However, only embedding the A&F process into the EMR was not enough, and some trials acknowledged they still needed strong design and implementation processes with some adaptation to local settings and processes.Data collection and reporting systems were directly linked to infrastructure for scale-up, as both focused on using existing data collection and reporting systems, including EMRs and open data reporting systems. This overlap is likely unique to A&F as the need for audit data is the intervention or strategy, while different intervention types would use the data for monitoring and evaluation. Some studies mentioned learning systems, mainly focused on the benefits of implementation laboratories, clinical networks, or taking a learning health systems approach. Design for sustainability is the FGFS domain focused on planning for sustainability, so is covered by the ISF results.Brief interventions likely need repeating at regular intervals to achieve sustained improvement, balancing affordability and scalability” [Although it was designed with wide reach and scaling up in mind, our budget for Website development and implementation likely exceeded that available… raising concerns about sponsorship of such programs” [Routinely collected, accumulating data in administrative data sets offers a cost-effective opportunity to implement and evaluate antimicrobial stewardship interventions at scale across large populations” [Aligning affordability and scalability: keeping costs low was a main way trials planned for future scalability. Studies mentioned how the high cost and high resource use common in these trials were barriers to scale, with some studies mentioning strategies to keep costs down. “ability” . How to rograms” . Using elations” .Although an all encompassing intervention is likely to achieve impact, complex interventions can be impractical to scale up” [Balancing fidelity and scalability: there were strong concerns about how to maintain fidelity to previous trials while delivering the intervention at scale, particularly for complex interventions. “cale up” . Some trAlthough this is a small change for an individual prescriber, our study demonstrates how this can lead to large impacts on antibiotic use over a broad jurisdiction” [Scalable and effective systems that require minimal support to implement could make major improvements in primary healthcare system performance and health outcomes globally” [Balancing effect size and scalability: although studies had concerns about smaller effect sizes than anticipated based on a pilot study, some trials acknowledged how this small effect at a large scale led to greater impact overall. “diction” . The reclobally” .Three new themes were identified:A&F trials should plan for sustainability, spread, and scale so that if the trial is effective, the intended benefit can continue and benefit a wider audience, which also reduces research waste and increases trust from the community –8. SustaTwelve months was the most frequent sustainability duration reported, but total study durations and sustainability periods were not clearly reported in many studies. As different terminology was used across studies, with many not explicitly calling it a sustainability period, some of these time periods were included when it may not have been considered by the trial authors to be measuring sustainability. There is currently no recommended time for claiming an intervention is sustained; however, 12 months may not be long enough to truly understand whether or not an intervention, implementation strategy, and/or impact are sustained. Authors are encouraged to report clearer sustainability durations, publish follow-up studies, and indicate if the intervention, including implementation strategies, continued or not during that time.The ISF determinants provided a useful structure to explore what may impact sustainability of A&F-based interventions, although it was difficult to directly connect ISF determinants to A&F, rather than other components of the intervention . Using the ISF is recommended to design suitable and appropriate sustainability strategies for future A&F trials, alongside tools such as the Expert Recommendations for Implementing Change (ERIC) sustainability glossary , which mAs limited work has been conducted regarding sustainability of A&F, this qualitative review was important to conduct before asking questions about sustained effectiveness of A&F. With confusion around the definition and timeline of sustainability (range from 2 to 24 months), lack of clarity on whether the intervention was continued during the sustainability period, and generally inconsistent reporting, clear criteria, informed by this review, will be needed going forward when exploring sustained effectiveness of A&F trials. Trials will likely need to report results for at least three time points , have a minimum amount of time that qualifies as “sustained,” and a clear differentiation between trials that continued the intervention and implementation strategies, including A&F, after the intervention phase and those that did not. Further exploration of scale will also need more consistency regarding the scalability phase of the trial, particularly what is meant by “full scale.” Improved reporting of intervention timelines and increased descriptions of how sustainability and scalability were planned  will help increase our understanding of this impactful topic.We limited eligibility to more recent trials given the more recent focus in the literature on sustainability, spread, and scale, but recognize that in doing so, some insights from older studies would be missed.Results are based on A&F trials designed to look at effectiveness within clear time limits, so the lack of detail regarding sustainability and spread/scale planning was unsurprising. We mitigated this limitation through the forward citation search. As included trials often used multiple intervention components and implementation strategies, not limited to A&F, it is not possible to attribute results solely to A&F. Although our initial inclusion criteria based on keywords aimed to be as inclusive as possible, some studies were excluded due to lack of use of specific words. For example, one study always used “12 months” to refer to continuation of the trial and was excluded . As manyWe also acknowledge that these studies were not necessarily solely or explicitly designed to study sustainability, spread, or scale, and future work could focus on studies with this explicit focus.Our initial aim was to extract text directly to the ISF and FGFS; however, there was a large discrepancy between reviewers during the first pilot due an inability to distinguish between text explaining the initial implementation versus information specific to sustainability/spread/scale. For this reason, the broader strategy for text extraction was used as it had more consistent extraction during the second pilot. This change meant that potentially relevant text for the frameworks may not have been extracted if it was not directly referring to sustainability, spread, or scale. This method may explain why limited information was found for factors of the ISF and adoption mechanisms of the FGFS; however, the general lack of detail regarding these planning strategies indicates that a different extraction process would likely have led to the same results.A&F trials should plan for sustainability, spread, and scale so if effective, the benefit can continue and impact a wider audience. Many studies lacked detail on if or how they planned for any aspect of the intervention, including A&F, to be continued. Scalability planning must go beyond keeping costs low and using existing infrastructure, to considering other strategies that support scalability. Future research should explore if the effect of an A&F trial is continued, for how long, and whether this is with or without continuation of the A&F process. Careful planning for sustainability, spread, and scale is needed to ensure that the changes can have a positive, sustainable, impact for a wide audience across different contexts.Additional file 1: Appendix 1. Full list of keywords used for sustainability, spread, and scale.Additional file 2: Appendix 2. Methods for grouping studies.Additional file 3: Appendix 3. Codebook.