The COVID-19 pandemic and Movement Control Order have restricted learning activities from traditional face-to-face classrooms attendance shifted to full online learning in the student’s environment. The present study is aimed to explore pertaining issues on full online learning among nursing students and offer a contingency solution. Nursing students from one Malaysian public institution were recruited. The sessions were conducted online via teleconference and were recorded. The data were analysed using thematic analysis with the assistance of QDA Miner Lite software. Twenty-one students participated, resulting in four focus group discussions and three in-depth interviews. Three themes with a total of ten sub-themes were generated: (i) Full online learning has ramifications on life , (ii) full online learning is a medium of teaching and learning delivery but with several concerns , and (iii) Foundation in teaching and learning is the key . A model of practice for full online learning was developed, consisting of some modifications to create a conducive and healthy learning environment. This study embarks on a more structured and standard online learning practice for making the Internet of Things and Industrial Revolution 4.0 concept a contemporary and mainstream education practice. The sudden abruption of the Novel Coronavirus COVID-19) global pandemic has disrupted teaching and learning activities. It accelerated the transition from conventional learning to technology-based learning without offering sufficient time and learning space for preparation among higher education institutions, educators, and students. Before the COVID-19, the acceptance of technology-based learning was low, where only blended-learning was accepted in educational practice. In contrast conventional classroom and physical-attendance learning still dominates most of the teaching and learning activities 9 global . When CONursing programmes adopt a semester-based system in Malaysia, whereas medical programmes use a block-based system. The semester-based system is a standard system for higher education, including other health sciences programmes. Nursing students have a similar burden in learning theoretical knowledge compared to other health sciences programmes. However, nursing programmes have the highest workload requirement compared to other health sciences programmes; which requires students to complete 56 weeks (approximately 2000 hours) of clinical attachments . Other hIn addition, nursing programmes requires 60% of its assessments in the form of a final examination ; while oOne major issue for nursing education to take place effectively during the COVID-19 pandemic is because the training relies on precision skills in psychomotor aspects in managing patients, such as performing wound care like cleaning and bandaging. Mastery of psychomotor skills ensures best services and safety are prioritised while reducing errors in performing health interventions. Such training requires close observation and direct experience . Giving and receiving immediate feedback from the educators, supervisors, or preceptors is needed. Compared to other academic programmes such as social sciences or technological sciences, the delivery of health sciences education during the pandemic is majorly impaired by barriers and restrictions of full online learning –14.Nevertheless, higher education, in general, felt the effect of restrictions due to the COVID-19 pandemic. The educators and students faced challenges in negotiating the technology , limited resources , limited facilities and accessibility , and limited ability for effective skill development  . The accA qualitative phenomenological design was used to attempt the research aim. The design is appropriate for investigating human experience in its intact setting and making sense of meaningful interpretations of an event that people bring into it . The focNursing students at one public institution was conveniently invited to participate in this study. The institution offers a single-intake per year of four-years undergraduate nursing programme with a total of 99 students. The invitation was open to all students which was distributed online via social media, emails, and WhatsApp messages with the assistance of the class representatives (one representative for each year of study). The recruitment was opened for one week, and two reminders were made to increase the participation rate. Students were encouraged to convey the invitation to peers. The participants’ eligibility was for nursing students who have had an active status for the past two semesters and have had online learning experiences during the COVID-19 pandemic. Participants who consented to participate filled up an electronic Google Form , informing their personal details and indicating preferences . The study was conducted between July and August 2021.Participants were contacted to attend focus group discussions or individual interviews. Each session was conducted via tele-conference application . Communication technology is feasible, convenient, and cost-effective. It offers a less threatening, natural environment and better referral on interview content . At the The participants were interviewed based on a list of guided questions Table . These gAs the sessions were conducted online, the participants were informed early to be able to sit in a comfortable environment when joining the sessions. Each session consisted of students from the same cohorts . For a cohort with more students, the students were equally divided into several groups. The group’s allocation per cohort allows for homogeneity among the group members. The homogeneity facilitates active discussion due to maximum shared values such as learning experience, classmate relationship, peer-equality (absent of junior-senior relationship), and similar overall study experience . The firhttps://provalisresearch.com/products/qualitative-data-analysis- software/freeware/software/freeware/ ). Coding was conducted in the software, and themes were generated by condensing and summarizing codes under a coherent and meaningful message. The research assistant did the transcribing, and the first and fifth authors validated the transcription. The first author performed the coding in collaboration with the second author and then validated by the third and fifth authors. The fourth author then acted as a member-checking process. The summary of the finding was then sent to participants via email for their feedback.This qualitative study’s data management and analysis were guided by Sutton and Austin’s  frameworn=5; Group B: n=4), Year 2 has one focus group discussion (n=5), Year 3 has one focus group discussion (n=5), and Year 4 has three in-depth interviews (n=3). One participant from Year 1 Group A withdrew at the early stage of the study due being uncomfortable with the topic. The demographic information of the completed participants is shown in Table n=19/21, 90%) of the participants briefly responded that they agreed with the summary findings.Twenty-two nursing students participated in the study. In the expression of interest form, most participants comfortable with any methods or prefer focus group discussion, except one from Year 3 and two (out of three) from Year 4 prefer an in-depth interview. After discussions with the prospective participants, the agreement resulted in four focus group discussions and three in-depth interviews. In specific, Year 1 has two focus group discussions  while requesting for physical learning for any topic that requires skill training – not only the practical  but also soft skills .The participants consider online learning as an alternative for delivering a lecture and learning activities; online learning is not a unique learning technique or approach. Therefore, many learning approaches in physical learning are transferable to online learning with some modifications. However, online learning partially brings the values and meaningful experience reflected in physical learning. The participants perceived that physical and online learning has its strength and limitation.A fine line that divides between the advantages and disadvantages of online learning. Several aspects were identified, such as flexibility in time, setting and activity, communication aspect, availability of back-up material , financial concern, and participation in assessment.[The] good point is, we do not have to be there. We can even [attend the class] in the car. I saw some of my friends do that.” “The participants reported that full online learning had provided them and the educator with flexibility in time, setting, and activity. The flexibility provides an opportunity for the participants to be independent. The class can no longer be made during the day or hassle to reschedule due to lecturer unavailability (such as finding an empty slot or booking the facility). However, it can conveniently be made available at any time, even at night. It also saves time for the participants where minimal effort requires self-care and travelling. Moreover, online learning makes them able to attend the class whenever possible. In addition, the students can do other activities while attending the lecture, such as having a meal or doing house chores.However, in the flexibility, sometimes it is too flexible until it disturbs our rest time… I have experience attending the exam at night." “However, the flexibility given too much freedom has created uncertainty in scheduling and interrupting participants’ time. The participants may compromise on class attendance, such as near-missed incidents of non-attendance. The facility issues such as internet connection may require them to find a place such as a kitchen or uncomfortable corner of the house . There is also a misperception among some educators or family members who underestimate students' burden and availability.Online for me is easier to meet. Even though we cannot do work physically, the communication is easier, like we want to interact just via Google Meet” “…but then on the online learning as we can only rely on the WhatsApp, or maybe a google docs, something like that to share information.” “Communication has become more feasible where the participants can communicate with their classmates using teleconference medium without requiring a place to meet. Communication can be done through various telecommunication methods such as WhatsApp or Telegram. This is not limited to their peers but also to the educators, whom they can email any queries they have rather than immediately meet the educator after the class finish when in traditional physical learning.Right now, we are in the online class, so if we want to ask or chat with our friends, we need to WhatsApp. I am quite lazy to type to… umm… ask my friends. I prefer to meet and directly ask, easier because what we want to know can get it on the spot. So if through WhatsApp, we need to wait for the person. Perhaps the person is doing something else whatsoever, so, after a long wait, like what we want to ask has… is no longer interested." "However, communication using technology has limitations where delay in response is tangible, feels a bit difficult in manoeuvring the technology , missing the intangible message , and lack of authentic relationship . Some participants prefer the conventional communication style of a face-to-face meeting.[D]uring the study week, I will watch back the lecture recordings, you know… Umm, sometimes I think if face-to-face, I do not have a recording. Like me, if I do not understand, I need to meet the lecturer back. However, with the recording [available], I can watch back and understand what I learned previously.” “…Frankly speaking, I feel sleepy watching the recording; I rarely watched it… However, yeah, the recording is also valuable. For example, I can review back lectures of last semesters on statistics and now understand it better for my research project” “Most of the participants feel that the availability of the class recording is beneficial for them to refer for any missed information and revision. They can return to the recording at their convenience. The recording can be a backup if an unwanted event occurs . However, this also creates a latent attitude among the participants where they do not give full attention during the class as they know they can refer to the recordings. Some students admit that hearing the recording is a bit dull and makes them sleepy.…for me, online learning also has its advantages. Like, save time, safe energy… oh yes, save money." “At first, I need to share a laptop with my brother, because… err… I do not have my own laptop at that time. So, it is quite difficult; for example, I have a class that clashes with my brother's class. Then, I knew that Zoom could be installed on the phone. So, I just use the phone afterward. Hmm…” “…students do not have much money. So, difficult to pay… like buying the internet plan…” “Some participants perceived that online learning made them save more money and reduce cost-related expenses such as preparing the assignment materials. However, other costs may increase, such as the subscription to internet service and those students who do not have the proper equipment for learning need to find a way to get the equipment such as laptops. Having proper information technology equipment  and facility  is crucial to ensure comfortable and successful online learning.…and, even sometimes, we… like… Umm… we prepare the script earlier. So, it is easy for our presentation.” “…mostly… [the assignments] need to do video. So, personally, it is one of the biggest constraints for me to do the assignment. It feels like… to prepare, okay, whom we want to make patient, and then the equipment, where to do it. And then, it is not just about shooting the video only. It's like we need to watch back; if not okay… then we need to re-shoot.” “Final exam right, umm… each subject… each course, like, different. Like ours, we need to answer at that time and open the camera [for proctoring]. So, there are other courses I saw, like the lecturer gave them the whole day and it is up to them, they can discuss with friends, seek answers, etc. Umm… so, it is sort of unfair. It is not standardized.” “The students presume that online learning has created liberty in their assessment and makes them more prepared to achieve a better grade. However, some participants consider this has increased the burden on preparing the assignment. In addition, assessment, especially examination conducted online, creates conflict and queries the students’ integrity and ethics when approaching the assessments.However, the participants consider that all these depend on the individuals to decide how they utilize online learning to scaffold its benefits or drown into its affliction.[F]rom what I observe, in an online class, I can focus only 20 to 30 minutes, and after that, even I try to focus, it will be challenging. When the lecturer says [the lecture], I just see and hear but cannot understand what the lecturer says. If compared to a physical class, I can maintain my focus for one to one-and-a-half hours… like that.” “However, online learning identified several challenges, such as a shorter attention span. The participants deemed that they were easily distracted and jeopardized their technical skills.Like before, , we practice in the nursing lab after the theory. Nevertheless, [in online learning] when we finish with the theory, it just ends. It is difficult for us to understand things when watching a video because it is a skill, right. It cannot be like that; when we learn a theory, we can memorize all that; however, when it is a skill, yes, we can memorize, but it is gone when we want to do it. Because it is experiencing, based on experience.” “One significant barrier to full online learning is that it only caters mainly to cognitive purposes, while limited for affective and negligible for developing psychomotor skills . The participants affirmed that the nursing course is technical and requires skill development. However, the full online learning is inadequate to train their nursing skills, especially the new skills. In addition, there are contradictions found between the procedure taught as it uses commercially and publicly available video, which may not be similar or inapplicable in actual local clinical practice. Thus, the participants feel they need to re-learn, which has taken more of their time.…one more, our existing skills are also diminishing. For example, we are now at the senior year, so when we are not going towards, or going to the nursing lab for practice whatever we learned and have done, we like… not remember it [skills]” “Not only that, the participants perceived that their obtained skills were also deteriorating. This is because they have limited opportunities to practice the skills again.for online [learning], make sure, if do not have Wi-Fi, then buy the internet data, all that to smoothly join the class, as worries being disturbed due to connection problem. Like if do not have room (for study), try to find a place like in the kitchen, far from others, to focus on the class.” “The participants reported several strategies to stay alert and sustain their online learning participation and independent learning.…like before the class, I will prepare snacks or something to eat… Umm… during the class. So, I can focus because it is difficult when hungry.” “For me, I will play with the handphone, or otherwise, I lie down, go to the toilet, have a drink, walk a bit, then sit back in front of the computer." "For staying alert and sustain their participation in fully online learning, especially the lecture, the participants implement small interval activities for a quick divert and refresh. The participants may move around, do other activities, or have a small meal when they feel tired or uncomfortable.For their independent study, the participants modified the usual learning approach they had done before online such as group discussion that was previously conducted by meeting outside and gathering in a group physically into meeting virtually via teleconference application.Techniques or strategies in teaching and learning play a pivotal element to ensure the continuity and sustainability of learning. The techniques are general, and not limited to only technology but emphasize educational theories, individual approaches and the conventional concept of teaching.…like some of the lecturers, ermm... that just read the slides, as I said before, and then did not give any explanation. Maybe s/he include all the… all-important points in the slide. We can say that, and then each part s/he just read-only. *laughing*. ermm... I think, ermm... this one also let us feel bored. We do not want to just listen, and go through the slide. Because aaa... if the lecturer just read the slide, we can also read [it] by ourselves.” “…I think that s/he teaches with enthusiasm. Before s/he teaches something, s/he will relate the thing with… current… general issue. So, it makes me like, ‘Wow!’ so interesting on how s/he teaches. S/he likes so eager to make the students understand on what s/he tries to deliver.” “In participants’ opinions, educators need to excite the teaching by avoiding being monotonous in the lecture, not just reading the slide, and applying various activities to make the learning session interactive and engaging.[A lecturer] likes to replace, right. Sometimes, s/he just replaces the class with lots of assignments.” “The participants mentioned that they less appreciate total independent learning, such as replacing the lecture with activity and presentation without validating the information presented. As they feel uncertain about the information they gain and less confident about what they learn, the participants require confirmation from the educator.…more empathetic. Like, sometimes a student says coming a bit late due to an internet problem, please do not respond like "Oh, you can prepare early". The internet, sometimes is beyond our control. Hmm… I found lots of lecturers like that. I feel like they lack empathy. It actually will affect the student's emotion.” “…some likes condemning, like, err… s/he said, "I have told you to study by yourself, right? I have given a task for you to do… to look at" like that. Furthermore, like mad at the students because we cannot answer his/her question. It is not because we do not want to answer the question (correctly), but we do not understand." "Maybe lecturer or the department can do… or request the clinical instructor or anybody to… err… record a procedure video for us to watch. Because when we watched the procedure video on YouTube… err… yes, it can add our knowledge, but the procedure is clashed (not suitable) with the standard checklist we have." "In addition, participants appreciate educators who are empathetic and not condemning. The participants appreciate educators who are enthusiastic about teaching and if the procedure is carried out by the educator rather than showing a video from the internet.Both (students and educators) need… urm… training or courses to improve online learning and teaching skills. Because not all lecturers know how to use this online [learning], even though they have been for a year like this. There are many things to explore, a lot… material, apps, websites that can be used for teaching purposes to make our learning more interesting. Moreover, for the students, we would like to improve our note-taking skills.” “The participants believe that the educators can improve themselves by having training related to technology use and technology-based learning applications.Although the online class has recorded lectures, respect for the lecturer is important for me. So, I still attend the online (synchronous) class. I feel it is better to attend the class than not coming and just watching the recording." "Although the participants believe that asynchronous learning, such as lecture recording, is beneficial for them, the participants more appreciate synchronous than asynchronous learning. The participants feel synchronous learning is more meaningful and has a 'soul' of teaching and learning than asynchronous, which feels 'disconnected'.…some lecturers have done… Umm… Q&A (quiz) session but not directly to a particular student, but instead s/he used KahootTM(quiz game application), so all students can join. Sometimes some students are shy to answer (direct asking), but with KahootTM, everybody participates, knows right and wrong (answer) simultaneously.” “The participants seemed to appreciate activities while still expecting guided learning to validate the acquired knowledge. The participants identified that a non-marking quiz is beneficial to help them immediately revise, focus on the lecture to prepare for the quiz, and understand what is important in the lectured topic. The participants request all-participate quiz activities such as using game applications; the participants are uncomfortable with individual-calling question-answer activity.…like a way of one lecturer to maintain us energetic until the end of the class. Where s/he always gives us a small task, group work just around 10–20 minutes for a short presentation. So, we feel refreshed and focused." "A simple group activity in the middle of the class is another approach highlighted by the participants. The group activity is perceived as helping break the dull pattern in online learning while making them more active. However, the educator needs to be wise in allocating ample time, not a complex task, conducive and non-threatening environment, and a supportive attitude with immediate constructive feedback.the lecturer cannot like include everything into the slides…" "I like with a technique that is not straight lecture, like if the class is two hours, then that two hours is a lecture. I prefer, some of the lecturers that lecture like one hour, then have gaps to watch the video, do discussions, gave questions, and asking for our opinions about the video." "Excessive information in lectures makes the participants feel overwhelmed and unable to absorb the information thoroughly. The participants hope that the educator may point out which information is critical. A gap between each topic is required to help the students relax and rehearse the information. The participants believe that various teaching approaches implemented during online learning are helpful for them to stay alert. However, the implementation should be nice, not too crowded and, confusing. This includes using uncrowded PowerPoint slides, interactive slide preparation, video, simple reading materials, and demonstration.It is like this; it is like the Labster , make a simulation program. So, like, they make you feel like you are in the lab like you can pick up the test tubes and insert all the kinds of solutions. It is a simulation program, so like you have the interactive lab. It is like, you feel like you're in the lab. So compared to that, I think that's more interactive comparing to like just watching a video, a practical video it's like watching somebody do like all those things, like compared to that I am more like to have an interactive simulations program, for me to try things out instead of just watching videos, yeah.” “Skills learning are the most impaired due to fully online learning. The students hope that the lecturer can replace the skill teaching using other methods. Utilizing sophisticated technology such as virtual simulation can be explored, which provides richer haptic feedback.The lecturer does not give the notes early. So, in consequence, we are rushing to jot down the notes. If the lecturer gives us the notes early, we can refer to it and just note down any important points during the lecture.” “Pressure from the lecturers who like… umm… like to give lots of assignments, sometimes as they wish, change the class at the time they want, and suddenly have a test." “The participants appreciate prepared educators, such as providing the lecture slide early, the assignments early, and informing on any schedule change early. The participants find it difficult if the schedule, either class or test made abruptly or unexpectedly.Some participants had no issue with online learning, especially those in their most senior year. However, several participants feel stressed, and others are demotivated with full online learning. The participants continue with the online learning is not because of the online learning itself but driven by other factors such as their willingness to learn, thinking about the future, wanting to deliver the best for patients, finishing the study, maintaining academic achievement, achieving ambition, family, friends support, financial, and respecting the educator.…what drives me is my family and my future." …I just want to pay my [study] loan after I finish my study. I have studied right.” “…I do not have any motivation for this online learning. However, I have to learn online because I do not want to fail..." “…my motivation is from our… my surroundings and my friends because all my friends also study online and then, ermm... So, I want to follow them, I don't want to isolate myself.” ““…we cannot procrastinate because if we do, then the assignments will be piled up. So, every day we attend the class, we [also] need to study the subject of the day immediately, we cannot just leave like that. Like, if something we do not understand, we cannot delay, then near to the exam will study back. No, I cannot. We need to make notes immediately. Hmm… Because, if we wait until the final exam… Uh, study week to start studying, we cannot, because too many subjects. Furthermore, the time during the study week is not enough.” “I will study early, quite early. Like after the class, I will re-watch the recording or revise my note. Hmm… If I do not understand anything, I will… message the lecturer." “We did group discussions on a certain topic, like who do not understand [can] learn together." “The participants implement several approaches to self-regulate their learning. Some participants do early preparation before attending the online class. Other participants consider group discussion as beneficial for helping in their learning. Some other participants have the initiative to contact the educator for further learning and clarification.…for me, it [online learning] disciplining myself, and teach me to appreciate the time." “…we need to have… umm… a training on time management, for students. And then… one more is about teamwork.” “Most of the participants believe that it is up to one's initiative and individual responsibility to ensure successful participation in learning. Self-determination, such as self-care, preparing the equipment for learning early, ensuring a good internet connection, and preparing an environment conducive to learning, helps to make their learning smoother and hassle-free. In addition, the participants consider time management is an essential skill for them to go through online learning. The participants hope there is also training available for them in time management related to online learning, such as note-taking skills and assignment preparation, and training available on team working in online learning.The findings reported above were synthesized to develop a framework guiding educators to escalate a better education practice. The practice framework integrates learning approaches and educator qualities for a single lecture or class activity. The practice framework is shown in Fig. Online learning is an alternative medium for teaching and learning activities during the COVID-19 pandemic. Online learning transfers teaching and learning approaches from a traditional physical brick-and-mortar environment into a digital platform . The sucAttention should be given to the information provided during online learning. Online learning utilizes multimedia approaches such as PowerPoint presentations, video, pictures, and audio-visual equipment. This has given rich sensory input and a high cognitive processing burden. The extensive use of cognitive processing creates a shorter attention span due to fatigue. This is agreed with previous literature where online learning created work and information overload received from instructors . Mayer’sIn this study, the learners believe that even with the constraints, they will become good and competent practitioners based on their initiative and will. The underlying knowledge they gained from the course, will prepare them to retrieve such information when they encounter the issue in practice. Therefore, what is more important for educators is strengthening the foundation and concept of existing teaching and learning rather than creating and exploring new theories. The current study found that educators have limited knowledge and pedagogical concepts. It was found that some educators rely on didactic lectures, slide reading, and a teacher-centric approach. Unlike school, educators in higher education institutions are not compulsory to have education qualification . HoweverAdapting to a transition in a life event could be a stressful situation. The adaptation requires time for an individual to adjust to the new norm. The transition is an inevitable process that needs to be overcome by learners or educators. The stressful situation is unavoidable, but the adaption can be expedited and tolerated. The current study’s findings are contemplating the criteria for dealing with such a transition . This cuIn this current study, some students felt mentally and physically exhausted. There are impacts of COVID-19 online learning on mental health . HoweverThe current study is parallel with a past study reporting that online learning due to the COVID-19 can be demotivating . HoweverThis current study is parallel with the previous studies, which identify self-regulation as the key for the learners to maintain focus in online learning , 43, 47.One vital limitation of online learning is on developing technical and psychomotor skills. This limitation was consistently highlighted in the literature that explored stakeholders’ perceptions of , 49–52. Meanwhile, augmented reality “allows for digitally generated three-dimensional representations to be integrated with real environmental stimuli”  p.1. Stuthick description; “refers to rich, thorough descriptive information about the research setting, study participants, and observed transactions and processes.” . Although saturation is not conducted, however, the recurrent pattern that emerged in each session indicates the shared perception among the participants.Trustworthiness is the strength of this study. Several steps and measures were taken to ensure the trustworthiness of the findings . For creFurthermore, the number of participants was approximately 20% of the nursing student population in the institution is substantial. Many literatures suggested purposive sampling for qualitative study . HoweverThe study has limitations. The present study was conducted at one institution, and therefore the findings are unable to be generalized to institutions. Meanwhile, the participants were from the bachelor’s program, while majority of nursing students in the country were in the diploma program. The Bachelor’s programme is aimed to train professionals with a high level of critical thinking and responsible for decision making . In contNevertheless, the finding of this study is considered valuable among nursing students. Currently, the practice framework is merely a concept; thus, the efficacy of the practice framework in actual teaching and learning activity is unknown. It is advised that an experimental study be conducted in the future. However, as online learning is expected to become a norm in the future and many international institutions offer full online degree courses , the praIn health, learners are not limited to student or junior health practitioners but also include clients who are patients and their family members. Client education, individually or in the group, as in community health promotion, is beneficial in elevating health quality . The praOnline learning has become a mainstream medium for teaching and learning delivery. Nursing and other health sciences education should prepare to embrace such practice, and the COVID-19 situation has cemented the transition rapidly. Online learning can be made meaningful and interactive by structuring the activities with various didactic and active learning approaches. Students’ participation is emphasized and adapted to the online learning needs. The activities should foster students’ development in other areas beyond just education, such as social life and university experience. The health and wellbeing factors are given attention for online learning by incorporating healthy habits for computer use during teaching and learning. Good educators’ quality and evidence-based teaching and learning approaches underpin the success of online learning.


The COVID-19 pandemic exacerbated existing health disparities and disproportionately affected vulnerable individuals and communities . Despite their higher risk of infection and sub-optimal access to healthcare, Canada’s COVID-19 vaccination strategy focused primarily on age, as well as medical and occupational risk factors.We conducted a mixed-methods constant comparative qualitative analysis of epidemiological data from a national database of COVID-19 cases and vaccine coverage in four Canadian jurisdictions. Jurisdictional policies, policy updates, and associated press releases were collected from government websites, and qualitative data were collected through 34 semi-structured interviews of key informants from nine Canadian jurisdictions. Interviews were coded and analyzed for themes and patterns.COVID-19 vaccines were rolled out in Canada in three phases, each accompanied by specific challenges. Vaccine delivery systems typically featured large-venue mass immunization sites that presented a variety of barriers for those from vulnerable communities. The engagement and targeted outreach that featured in the later phases were driven predominantly by the efforts of community organizations and primary care providers, with limited support from provincial governments.While COVID-19 vaccine rollout in Canada is largely considered a success, such an interpretation is shaped by the metrics chosen. Vaccine delivery systems across Canada need substantial improvements to ensure optimal uptake and equitable access for all. Our findings suggest a more equitable model for vaccine delivery featuring early establishment of local barrier-free clinics, culturally safe and representative environment, as well as multi-lingual assistance, among other vulnerability-sensitive elements. COVID-19 was first detected in late January 2020 in Canada associated with international travel . DespiteIn light of these disparities, the COVID-19 pandemic can be viewed through the closely associated lenses of ‘vulnerability’ and ‘risk’ –16 whichVulnerability is the potential harm incurred by a person, asset, activity or assemblage of items that is at risk… [T]he risk is motivated by natural, technological, social, intentional, or complex hazards and the potential outcome is a disaster. As it is mainly the result of social, economic, political, and cultural factors in decision-making, vulnerability is constructed socially .Vulnerability is shaped by a multiplicity of systems of oppression, including white supremacy, anti-Black and Indigenous racism, capitalism and classism. The US Centers for Disease Control and Prevention (CDC) developed a ‘social vulnerability index’ as an aid to disaster management, organizing census factors by theme: Socioeconomic Status ; Household Composition ; Minority Status ; Housing/Transportation  . Just oncapacities can be operationalized as capabilities  people started paying attention to that. They’re like, “Oh, I’m going to need to have the right brand.” Even people who wanted the vaccine wanted to get Pfizer because Pfizer was something that people [knew]. […] So, a lot of folks were like, “Moderna? […] No one back home knows what Moderna is. They all know what Pfizer is. So, Pfizer is going to be the one that’s going to let me travel.” So, a lot of folks declined Moderna because they wanted to wait for Pfizer.In short, many Canadians, and newcomers who wished to travel internationally, considered brand and company profile, besides well-described concerns about safety and efficacy, when making vaccination decisions . accessible by appointment only. FL6, a primary care physician working in Alberta, described this Phase:After vaccine eligibility opened to priority groups beyond healthcare workers and LTCF residents—defined by each province and typically based on age and medical or occupational risk I think, in the beginning, there wasn’t that awareness that some of the barriers that people were facing, like […] difficulty with transit, difficulty with booking online and literacy. And, you know, if you don’t have an Alberta Health Care number, you can’t use the online booking tool. […] I struggled in my [practice] to get people booked. It was initially rolled out by age, and then, by health comorbidity, and then, by sector. Health services workers were included first. And then, it sort of spread beyond that. So as each wave of people were eligible, it opened up further. […] But the big mass vaccine pushes were done at these big rapid access sites that they established, some of which were downtown. […] We have been telling people who live in our part of the city, “Don’t go downtown, don’t take transit, don’t go anywhere,” for a year. And then all of a sudden, it was like, now, they had to go and do this.Large immunization clinics required conduct counter to advice given, and they had additional barriers that went largely unrecognized at the start of Phase 2. There were technological, language and human resource barriers posed by online and phone booking, as well as requirement of a provincial health card number, which made vaccines inaccessible to many newcomers and the uninsured . AdditioNow, if we move to some of the jurisdictions where we’ve got much more diverse ethnic populations, we know that immigrants and refugees and people who’d lived in Canada for less than five years had much lower uptake rates than people who’d been here for several generations. And part of that was reflected in the kinds of work that many of them were doing, which was […] pay for the hour, minimum wage, many of them were in essential [work]. If we look at Peel Region in Ontario, they were working as essential workers. So, it wasn’t like they could just say, “I’m out of here, okay?” Because they couldn’t. And again, originally, we didn’t go to them to make it easy for them. We didn’t give them paid time off, the ones that were working as PSWs [personal support workers]. We did not have […] the leaders in those [ethnic] communities come after them and support that for being done. […] So again, it wasn’t tailored to fit those groups.The neglect of optimal accessibility conditions for low-paid and precariously employed essential workers who bore the brunt of the pandemic  can be cThis is so important, because, you know, many of our partners are telling us that they […] not just don’t trust the Western system, going to clinics or hospitals. They will go there only as a last resort because of a number of factors. […] Sometimes, it’s a culturally unwelcoming setting, people don’t understand the concerns that they have. So, they’ll just keep saying, “Why are you concerned about microchips? Why are you concerned about this as government experimentation? That’s not true.” […] One has to understand that historically, with residential schools, government has imposed this. And so … if you are from that community, you say, “Hmm, do I trust [that]?” […] We’ve been seeing that when Indigenous clients [and] patients are considering going to vaccination clinics. If there’s cultural environment inside that clinic, including Elders, ceremonies, all of that, that’s very, very helpful. It becomes a celebration…FL2 shared his experience in Nova Scotia:There was a very targeted effort around Indigenous populations. […] Public Health and Department of Health reached out directly to the Bands […] and said, like, “Hey, we’ve got COVID vaccines. […] You’re getting priority on it; how do you want to do it?” […] which was fantastic, right? […] That’s just exactly how you have to do it. Like, “We will support you in any way, here are the resources if you want them, but if you don’t want them, you don’t have to take them.”Several interviewees identified focused outreach, early engagement, and partnerships with Indigenous communities as important aspects of vaccine rollout that occurred unevenly. When it did happen, successes were achieved. King et al. describe the success of a vaccine delivery model led by the Métis Nation of Alberta, which relied on local leadership exercising self-governance and culturally-safe practices . The priOnce COVID-19 vaccines were made available to the general public aged 12+, appointments could be pre-booked at a variety of mass vaccination sites or accessed through pop-up clinics. While this approach was considered a success , FL4, a In Toronto […] you’d have these pop-up clinics […]—I’m sure across the country—and lines that would go around the block. But, you know, whenever I would see them, it really impressed me how many people were [there]. I don’t know if I would stay in a three-hour line. Like, who can stay in a three-hour lineup? And people were doing it, right? They were taking time off work to do it.As vaccine uptake increased, equity concerns were increasingly raised. FL2 elaborates:Okay, how do we get the most people in the quickest amount of time immunized? It’s a noble thing… But I mean, […] that mindset of how we can get the most people, the easiest, is […] the impetus behind systemic discrimination. […] When we’re making a system, the easiest people to get to are people [who] generally have […] a certain level of education, who have a certain amount of income, live in certain areas, usually cities. What happens is our system slowly just gets built up in such a way that people from marginalized populations don’t get access to whatever the resource is because they’re harder to get to. And so, this system, while it sounds great, […] what ended up happening is all the English-speaking middle-income people with […] university education who lived in cities got immunized first. The people with privilege.PH20, a public health official from western Canada, described a reluctance to attend these supersites despite high risk of transmission:It’s hard to know the right balance, but certainly […] supersite, mass clinic approach doesn’t work for everyone. […] Even though the supersites and the booking were open to anyone, phone, online, multiple hours, […] [those] living in that first quintile of income, BIPOC groups that don’t feel as safe coming to sites like this. So, we had multiple pop-up clinics, multiple outreach clinics, in districts that had both high transmission and low vaccine rates, which tended to be those groups. So, a lot of grassroots [efforts]. We found, even though the physical access was there, there were […] still a lot of barriers to accessing that for certain populations and many of them were at high risk of transmission.Multiple interviewees noted that grassroots community organizations and primary care providers did the work to reach vulnerable groups such as low-income racialized individuals, migrant workers, newcomers and refugees, and those who are undocumented and/or uninsured. There was limited support from provincial governments and health authorities. FL6 emphasized the difficulty of getting people to understand the barriers to access faced by these communities:It wasn’t that they didn’t want to be vaccinated at all. It was much more that people couldn’t get to be vaccinated because perhaps they [had] three low-end jobs. […] And so, when we first—as community providers—stood up and kept saying, “Hey, we want to go deliver this, in particular, to the meat plants,” there was some […] pushback in terms of following proper process and not ruffling too many feathers. […] I think whenever these systems evolve, there’s always lots of players. […] Some of that bureaucracy was slowing things down when really it was an emergency, right? […] And now, we’re being held up as an example […] and there’s a van that goes to places and does vaccines. And even just the concept of having a drop-in concept of a clinic […] caused lots of controversy at the time but yet, lo and behold, the Premier showed up. It was all over media, everybody loves it.FL7, a primary care physician, shared his experience providing vaccines to undocumented individuals in Ontario, many of whom had multiple intersecting vulnerabilities:[When we] initially started the vaccines, we had long lineups in the summer, and the spring. And sometimes, the police cars would come by just because they patrol the area we’re in. And people would run from the line. They would run from the vaccine line and hide behind trees and hide behind places that couldn’t be seen. So, that was quite shocking to us […] And these are people who are all without CERB [Canada Emergency Response Benefit]. They have to go to work, […] frontline often. Mostly working in low-paying, entry-level jobs. And often working for less because their status is exploited. Plus, we had over 700 females and a couple of males in the sex trade industry on the streets and in the massage parlors. Virtually 100% of them, Asian women in our area who are being exploited. […] And people that […] both could not use [booking systems] because they wanted to know OHIP [Ontario Health Insurance Plan] number and then, wouldn’t use [it] because they were too afraid to put their names down. […] But you could walk in in some places. But who would walk in? You know, under those circumstances, and fear of exposure.Intersecting socioeconomic, occupational, and housing factors slowed uptake in many communities with high risk of transmission. Although many barriers to access were removed , the time lag had critical consequences, as FL2 explains:So, [due to the barriers] newcomers were not given access to the vaccine for the first 6–7 months. […] Once the numbers were to a certain point where they recognized they were going to have to make things accessible for newcomers, misinformation spread throughout the population. […] Now, the big pressing issue is [that] misinformation has really disseminated within the newcomer population—certain sub-cohorts of the newcomer population—and we’re having a lot of trouble now just convincing people to get the vaccine. Whereas before it was a matter of trying to get them to get access to it. Now, […] we have access to it. They’ve allowed us to have the vaccine at the clinic. But now a lot of folks are just like, “No, I’ve heard too many bad things.”Misinformation and the lack of appropriate mechanisms to address it, especially when published in languages other than English and distributed through social networks, were presented as critical factors affecting uptake. Participants suggested the need for ongoing engagement with communities to instill vaccine confidence, along with providing a welcoming vaccination site. FL5, an infectious disease specialist from Ontario, explained:Several strategies have been used to reduce hesitancy. […] Number one is to ensure that, wherever possible, where mass vaccinations are being done, there’s a good representation of the vaccinators coming from the communities being vaccinated. In the case of Black communities, you want a whole bunch of Black vaccinators. Number two is that you want to vaccinate in a setting where people feel culturally comfortable. […] Community centers that are connected with various diaspora groups, for example, where it’s a family affair kind of thing, it’s a special event that might be similar to other types of events that they have been to, except now a vaccine is being offered. And the atmosphere might be very different than what one would see at conventional vaccine clinic. […] There’s music, and there’s food, and there’s balloons, and there’s ice cream. And […] ensuring that there’s all the infection control measures put in place, but it is different than lining up at a convention center, or sports arena to be vaccinated.Our public health experts identified the importance of representation among vaccinators and healthcare providers providing vaccine counselling along with diversity in decision-making and public health communication for improved trust and adherence to recommendations.The COVD-19 vaccine rollout in the four jurisdictions featured three phases of variable intensity and delivery models that initially relied on mass immunization sites, with targeted outreach approaches established only later in the rollout process, usually in response to community groups or frontline healthcare providers. Concerns about access during Phase 1 and Phase 2 included supply, brand recognition, and site convenience , 68. TheDelivery through large venues like sports facilities and convention centres via online or phone appointment bookings certainly facilitated rapid rollout, as demonstrated in the USA , but masCanadian models ensured delivery to those with easy access to booking technology, transportation, and time, and to those with health cards. For the most, these represent the least vulnerable. The experts interviewed emphasized the negative impact of the initial failure to attend to outreach and services in multiple languages, opportunities for walk-in appointments , location and perceived safety of immunization sites, and cultural safety training for vaccinators as critical shortfalls. While some of these were addressed in Phase 3 of the rollouts, the delay and lack of initial engagement with vulnerable communities contributed to system distrust and hesitancy, further exacerbating existing inequalities and poorer outcomes.Although COVID-19 epidemiology varied significantly across Canada . What geAs evident from the vaccine uptake data, once access was granted to all aged 12+, immunization rates rose quickly before plateauing. Our analysis shows that lack of attention to vulnerability and meaningful engagement with equity-deserving communities contributed to this trend. Nova Scotia, for example, performed well during the pandemic , reachedAlthough Canada’s COVID-19 vaccine delivery effort has been characterized as successful  and may see .Based on barriers to equity identified here , we suggest that vaccine rollout plans during public health and other emergencies must not only be ready to operationalize on short notice, but need to be much more sensitive to conditions of vulnerability within diverse communities. To achieve this improved (more equitable) operation, much more granular data  must be collected on an ongoing basis, and processes for rapidly developing operational/deployment practices that are sensitive to those factors must be designed To achieve equitable vaccine delivery, the barriers to vaccine access need to be identified and acknowledged in close consultation with the communities. Consultations have to be part of ongoing engagement and collaboration with communities, their leaders, and the grassroots organizations that already support them. Increased cultural safety training for healthcare providers and diversification of the vaccinator pool can be integral to improving infrastructure and longitudinal stabilizing of human resources of community clinics.Importantly, a vaccine rollout model that explicitly prioritizes vulnerable communities and seeks to overcome barriers and inequities to health services should not be restricted to an emergency response plan. Routine delivery strategies must also benefit from the insights offered by recognizing the successes and failures of the COVID-19 vaccine rollout. Based on the findings of this study, we identified multiple components that are important in emergency and routine settings, such as multi-lingual outreach and services, immunization appointment assistance , and early establishment of local barrier-free clinics . Immunization clinics can be set up in local health centres , 85 and Notably, the goals of this vaccine delivery model go beyond improving vaccine delivery and uptake but to reduce health disparities and diminish the contribution to vulnerability. We argue that vaccine programs need to be a more integrated part of a better-supported public health system that foregrounds public health as a public good while acknowledging the complexities of intersectional realities. Reformed vaccine  programs must include platforms for ongoing collaboration with the communities they serve, for evidence generation, exchange and shared learning across jurisdictions, as well as ongoing work and advocacy for barrier-free healthcare and health equity for all. Such efforts will go a long way in fostering trust in the public health and immunization systems, and in those operating within the system.In conclusion, Canada’s mass vaccine rollout strategies did not address vulnerability and failed to reach vulnerable communities . While population level data may indicate a successful rollout, more situationally-nuanced, granular and community-specific data would suggest a very different narrative highlighting health inequities and uneven access. Vaccine delivery systems need to be improved in order to ensure more equitable access.Although the data for this study were collected and analyzed using a combination of well-established methods, there were some limitations, most prominently, the lack of complete data within, between and across jurisdictions. Epidemiological and policy data were collected for four Canadian jurisdictions, while the interviewees represented nine provincial/territorial jurisdictions (with some only featuring one participant), as well as federal and global levels. Additionally, we acknowledge that our lack of personal lived experience of racialization, as well as the lack of available race-based data for COVID-19 epidemiology and vaccine status, limits our ability to fully understand to what extent the pandemic has affected racialized communities.S1 TablePriority populations included in vaccine rollouts in Alberta, Ontario, Nova Scotia and Yukon, compared to initial NACI recommendations (published in November 2020).(DOCX)Click here for additional data file.


These themes were: Creativity, Being dynamic, Flexibility, Socio-affective skills, and Higher-order cognitive skills. Core symptoms of ADHD such as impulsivity and hyperactivity were also considered positive aspects of ADHD by a minority of participants. After showing our results to a group of additional individuals with ADHD (focus group) they confirmed the identified positive aspects of ADHD. They also helped us with the interpretation of our findings and mentioned certain positive aspects to be a consequence of living with ADHD (being open minded and being honest). In conclusion, experiencing positive aspects seems to be common in ADHD as almost all participants reported positive aspect of ADHD, these aspects cover many different domains. Awareness about ADHD's strengths might help individuals with ADHD and their environment to better cope with, accept or embrace their diagnosis and for example make educational or occupational choices that fit them well. To incorporate these positive aspects in the understanding of ADHD, future research should focus on quantifying strengths in ADHD, and on investigating the link between these aspects and clinical characteristics and how this new knowledge can be implemented in psychoeducation and find its way to education and occupational settings.Research in Attention-deficit/hyperactivity disorder (ADHD) has had a clear focus on treatment and the dysfunction in specific situation associated with the condition. However, self-report, observational and anecdotal evidence indicates that there are also positive aspects associated with ADHD. Research on the potential positive features in individuals with an ADHD diagnosis is still limited, especially studies with larger representative samples. Here we performed qualitative research to identify positive aspects and strengths associated with ADHD in a large convenience sample from the Dutch organization for people with ADHD, dyslexia and dyscalculia. We sent out open-ended questionnaires to the members of the organization, asking what they consider to be positive aspects of their ADHD. From the responses of individuals with ADHD ( Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental condition, occurring in 5.9% of children . ADHD syThat ADHD may be associated with positive aspects, and/or strengths, is relatively unknown and an often neglected aspect in previous scientific literature. Recently, positive aspects of ADHD have gained attention. This fits well with a conceptual shift that is taking hold in the field of neurodevelopmental conditions, and is being championed by caregivers and individuals with those conditions. Slowly our society is starting to focus more on embracing diversity rather than excluding individuals with a diagnosis. “Neurodiversity” is a term that is often linked to this conceptual shift. One key assumption of neurodiversity is that all forms of neurological diversity might be valuable, depending on the environment, and that this diversity may also have some selective and evolutionary advantages , 15.Although research into positive aspects of ADHD is scarce, three studies aimed to study positive aspects associated with ADHD. Mahdi and colleagues performed a qualitative study to investigate abilities and disabilities in individuals with ADHD in five different countries, by organizing focus groups and interviews with in total 76 individuals with ADHD, and other stakeholders  . In theiIn addition to the qualitative research, there is also quantitative evidence for a link between the positive traits mentioned by individuals with ADHD and the ADHD phenotype. Most of these studies focused on creativity. Creativity is a broad concept and can be divided into different aspects such as convergent and divergent thinking and creative achievements. Divergent thinking, which entails coming up with different solutions for one problem, was found to be associated with ADHD . In addiAlthough the qualitative studies conducted so far offer a great and much needed exploration into the positive aspects of ADHD, they rely heavily on studies in successful adults with ADHD , 18. To via email to anonymously fill out an online questionnaire. The group of members  consists of individuals with an ADHD diagnosis, and/or dyslexia, and/or dyscalculia, and partners and parents of individuals with these classifications. The invitation to participate in the survey was explicitly directed toward individuals with ADHD/dyslexia/dyscalculia and not their relatives. In the survey participants were asked if they have a current ADHD diagnosis (yes/no) and a dyslexia/dyscalculia diagnosis (yes/no). They were also requested to provide basic demographic information about their age, sex, their diagnosis , employment status and about their treatment by a psychiatrist/psychologist or coach (yes currently/no/not anymore/other). Participants were asked to freely report what they considered positive aspects of ADHD and in a subsequent question, what they considered negative aspects of ADHD, with unlimited time. The questionnaire was available between the 15th of November 2019 and the 20th of February 2020. SurveyMonkey was used to collect the data. As our current study had the specific aim to study positive aspects of ADHD, we only used the data from the participants with an ADHD diagnosis.All members of the Dutch organization for people with ADHD, dyslexia or dyscalculia (Impuls & Woortblind) were invited creative, empathic, happy or enthusiastic or quotes such as “always up for something”. The initial analysis consisted of coding those words and quotes, executed by two raters (MH and AOB). The codes are considered the smallest units in the data. In most instances the actual word corresponded with the given code, but in some cases we made a combination of descriptions that were closely linked. For example, when data mentioned “associative”, or “making connections easily”, or “making links quickly” we gave all of these the code: “associative thinking/seeing connections”. Discrepancies between the two coders were resolved by discussing them and deciding on the best code to fit the answer.We extracted the data from SurveyMonkey and imported the output of the open-ended question about the positive aspects of ADHD in ATLAS-ti 9.1.6. The data consisted of answers of one word, such as After the coding process LS, LH, JM, CG, MH discussed the codes and how they could be grouped into subthemes. This was an iterative process and evaluations were done multiple times by discussing the subthemes. Although some codes fit in multiple subthemes, we decided to use the codes only once in the subtheme grouping. In the final step, a similar process was executed to form the themes, please see After we finalized the subthemes and themes, we validated the identified subthemes and themes from our analysis in a focus group session. To recruit participants for this focus group, we placed an advertisement on the website of the Dutch organization for people with ADHD, dyslexia and dyscalculia. These participants had not participated in the original online survey. We presented  to the gt-test, respectively. For sex, we also investigated sex differences per theme by calculating per theme how many men and how many women have reported at least one positive aspect. These are transformed to ratios . The ratios for men and women were compared by performing a Chi-square test, for each theme separately. We used a Bonferroni correction to counteract multiple comparison problems, using a significance threshold of p < 0.01 (0.05/5 themes = 0.01).In addition to the qualitative analysis, we performed exploratory quantitative analysis to further our understanding of the qualitative results. We explored the relationship between the total number of codes that were mentioned by each individual and basic characteristics such as age and sex, by performing Pearson's correlations and To investigate whether employment status was associated with the number of positive aspects mentioned, we performed a group analysis controlling for age and sex and compared individuals who were in employment or were receiving education, with individuals who were unemployed  on the number of positive codes mentioned. Finally, to learn more about the role of treatment on positive aspects in ADHD, we compared the group of people who received treatment (current or past) with those who were not, or had not been in treatment, on the total number of codes mentioned.n = 46) were excluded from qualitative and quantitative analyses because the reasons for leaving these fields blank were unclear. Therefore, the data of 206 participants were included in our final analysis. A full overview of the demographics of the study sample are shown in SD = 12.81). There were more women (n = 129) than men (n = 77) participating in the study and a minority of the study sample had co-existing dyslexia/dyscalculia. A large portion of our sample reported being employed, with unemployment plus disability benefits rates being around 13%. Five participants explicitly reported having no positive aspects related to their ADHD diagnosis (“I don't see any benefits in my case”) and eight participants reported no positive aspects. These subjects were not part of our qualitative analysis, but were part of our quantitative analysis. One participant noted that all aspects of ADHD can be considered as positive without elaborating on these positive aspects. Due to lack of information, we could not incorporate this answer in our qualitative nor in our quantitative analyses.Of the 1,326 members of the Dutch organization for people with ADHD, Impuls & Woortblind, that were sent an email with the invitation to participate, 346 members completed the questionnaire, a response rate of 26%. As we aimed to learn more about the positive aspects of ADHD from individuals with ADHD themselves for this project, we included data from only those with an ADHD diagnosis and not those with dyslexia/dyscalculia without ADHD or those who were relatives of individuals with ADHD. This resulted in excluding 49 individuals who had a diagnosis of dyslexia/dyscalculia without ADHD and 45 individuals who were a family member or a partner of somebody with ADHD but with no current ADHD diagnosis themselves. Participants who did not answer the question about their experiences of positive and negative aspects of ADHD , as these represent positive aspects experienced by only a few participants. A list of low frequency codes can be found in imaginative, creative, resourceful, and associative/seeing connections. Participants in this subtheme mentioned: “Being able to think outside the box” (participant 45), “Creativity in finding solutions” (P14), “Suddenly come up with the craziest ideas that can be brilliant” (P108), “Being able to come up with surprising ideas” (P146), “Always have dreams of what could happen, a rich fantasy” (P129), and “Great problem solving ability” (P26).The first theme that was formed consisted of only the subtheme “creative” and had codes that specified energetic, enthusiastic, up for anything and seeing opportunities. Example quotes from participants for the subtheme “high energy/active” were: “Always having energy for many different things”, (P69), “Being passionate in what you do”, (P30), and “No need for coffee in the morning”, (92). Participants mentioned “Seeing opportunities”, (167)and “Not giving up”, (P36) for the subtheme “positive attitude”. The subtheme “novelty seeking/adventurousness” included quotes like “High degree of curiosity”, (P141), “Dare to take a risk even though it may not go as you hope”, (p81).This theme was composed of the subthemes “high energy/active”, “positive attitude” and “novelty seeking/adventurousness”. Codes that were mentioned in this theme are flexible, broad interests, open minded and quickly getting over fights. Participants in the subtheme “spontaneous/impulsive” mentioned “Being often very spontaneous”, (P154) and “Impulsivity”, (192). Examples of quotes mentioned in the “flexible” subtheme were “Never argue for long because I have forgotten about the cause”, (p124), “Be able to respond to changes”, (P108) and “in my work, I can switch quickly from one task to another”, (P85). The subtheme “open” included quotes like “Broad view of the world”, (P40) and “Many interests”, (P145).The theme flexibility was composed of the subthemes “spontaneous/impulsive”, “flexible” and “open” and consists of codes such as empathic, social, sensitive, and helping/helpful. Example quotes in the subtheme “based on feeling/strong emotions” were “Experience life very intensely with high peaks”, (P141), “I have a huge amount of empathy and emotions”, (P158), “Sharp intuition”, (P133). Quotes mentioned in the subtheme “socially outgoing” were “I can easily make contact with others”, (P75), and “I can get along with different types of people”, (P56). For the subtheme “prosocial/empathic” participants mentioned “Standing up for others”, (P53), “Having a great sense of justice” (P110) and “I have a strong antenna for other people's feelings”, (P46).The Socio-affective theme consisted of subthemes “based on feeling/strong emotions”, “socially outgoing” and “prosocial/empathic”. Examples of codes in this theme were: image thinking, attention for detail, intelligent/smart and analytical. Examples of quotes for the subtheme “executive functions/intelligence” were “Super-fast thinking ability”, (P14), “Good long-term memory”, (P175), “See funny stories and pictures in front of me”, (P90), and “Quick to understand”, (P188). For the subtheme “attention” sentences such as “Can focus for a long time on details”, (P11), “Can focus very well if interest is stimulated”, (P28) and “Having an eye for detail”, (P81) were mentioned.The Higher-order cognitive skills theme consisted of the subthemes “executive functions/intelligence” and “attention”. Codes that were used were playful; “Be able to play well”, (P96), versatile; ”Allrounder/generalist”, (P141), honest; “Being honest”, (P158), stress resistant; “Being able to act in stressful situations”, (P144), not boring; “Being a bit crazy”, (P89), sentience; “Notice more in the environment than other people”, (P106), sincere; “Sincere”, (P168), witty/sharp; “Smart and sharp”, (P97) and non-conformist; “The ability to take a deviant point of view”, (P44).A number of codes did not fit in any of the themes and subthemes described above. Therefore, to categorize these codes we added the codes into a subtheme called “other codes”. We mention those codes here followed by one example: A notable finding of our results is that the core symptom domains of ADHD, impulsivity and hyperactivity, are mentioned as positive aspects of ADHD. These symptoms, which are often a reason for individuals with ADHD to seek help, are also seen as positive aspects of ADHD by people with an ADHD diagnosis. Positive aspects such as “energetic” and “enthusiastic” were mentioned and can be linked to the hyperactivity symptoms in ADHD, and codes such as “spontaneous” and “impulsive” can be linked to the impulsivity symptoms in ADHD. The third core symptom domain of ADHD, inattention, was not mentioned as a positive aspect, but the opposite, attention (skills), such as “hyperfocus”, “attention to detail” and “alert” were perceived as positive aspects of ADHD.SD = 10.54)]. The participants of the focus group reported many positive aspects of ADHD, but after checking our data we noticed that they were all already in our code list. All participants agreed that the themes and subthemes were representative of the positive aspects of ADHD.Eight individuals, five women and three men with ADHD responded to the advertisement and were invited to a focus group session. Two people canceled last minute, and therefore the focus group consisted of six participants . Similarly, employment status had no effect on the number of codes reported .When we compared men to women on the total number of codes, we found a significant difference t= 0.009) . No corrCreativity, Being dynamic, Flexibility, Socio-affective skills, and Higher- order cognitive skills. We validated the results in a focus group, and participants identified themselves with the themes that were found, and the way we organized them. Our quantitative analysis showed that being creative, enthusiastic and energetic were positive aspects that were reported most. Women reported more positive aspects than men, and age, employment status and “ever received treatment by a clinician/coach” were not factors that associated with the number of positive aspects mentioned.In the present study we performed qualitative and quantitative analyses on self-reported positive aspects of ADHD in a sample of 206 adults with ADHD. The qualitative analysis delivered 116 codes of positive aspects of ADHD, which were categorized into thirteen subthemes, and five themes. The five themes are creativity was found across all previous studies and also in our study. This, together with the result of our quantitative analysis of creativity being the most reported positive aspect, means that this is a widely recognized strength in ADHD and is not only reported in high functioning adults with ADHD but also in a more general sample of adults with ADHD. The same is true for our subtheme high energy/active (from our theme being dynamic). It is also reported in Mahdi's theme “energy and drive”, and Sedgwick's theme “energy”. Holthe's study also mentioned “high energy” and “determination”. All studies described that this is both physical energy and a source for perseverance. The subtheme novelty seeking/adventurousness (part of our theme being dynamic) was also found in Holthe's study, mentioning “risk taking” specifically. From our theme higher order cognitive skills, and subtheme attention, hyperfocus is a concept that was also found in Mahdi's and Sedgewick's studies. The theme socio-affective skills with the subtheme prosocial/empathic, comes back in the related themes of “agreeableness” and “willingness to assist others” in Mahdi's results and as “humanity” in Sedgewick's results. (Sub)Themes of positive aspects that, to our knowledge, were found for the first time in our study, are the theme flexibility, and the subthemes positive attitude, strong emotions, and executive functions. This could be due to the relatively large sample that we included which likely captured more positive aspects covering a wider spectrum due to the larger variation of individuals in our sample. In contrast, Sedgwick's study used a sample of 6 high functioning males and Holthe's study included 5 successful women. Themes that were found in Sedgewick's article, but did not come up in our results, are “appreciation of beauty and excellence”, and “sublimation” . This could possibly be due to the differences in participants between the studies. Sedgewick's study included high functioning and highly educated adults who might have more access to art and cultural aspects of life than our community sample. A difference in research methods could also explain this discrepancy as in Sedgwick's study they performed extensive interviews whereas we mainly had one-word quotes and sometimes a short sentence. This might have led to themes with more depth such as the theme of sublimation. Finally, cultural differences could explain differences between samples, as some strengths in one country or culture might not be considered strengths in another country/culture  vs. never having been in treatment by a clinician/coach, did not affect the rate of positive aspects mentioned by individuals with ADHD. We assumed that participants who were not employed or who were receiving disability pensions would possibly be more impaired by their ADHD and therefore might not experience many positive aspects. We also considered that receiving treatment in past or present would lead to increased quality of life and that therefore more positive aspects would arise. Unfortunately, we do not have any additional data on impairment or quality of life in our sample to further unravel these findings. To better understand what it means to report many positive aspects, future research should be dedicated at studying the relationship between the frequency of reported strengths and wellbeing, impairment and quality of life. In addition, we should acknowledge that our treatment variable gave us limited information, for example, we could not specify pharmacological or non-pharmacological treatment. Previous work has provided evidence for pharmacological treatment not affecting the most reported positive aspect, creativity . HoweverIn all, future studies researching positive aspects in ADHD should collect more demographic and clinical information, information about wellbeing and indices of quality of life of the individuals in the study, and possibly also information about the believes and sentiments of ADHD to further our understanding of positive aspects in ADHD.The current study has delivered a list of self-reported positive aspects of ADHD. These were grouped based on the relatedness of the aspects in terms of the meaning of the aspects. There is also the possibility to make a different distinction, based on what the participants of the focus group suggested. For example, there might be positive aspects that are a consequence of living with ADHD such as being open-minded, honest or perseverant. Due to the more advanced age of our sample, we very likely have also captured these positive aspects related to ADHD, that are a result of coping with ADHD. Thus far, little is known about the longitudinal course of positive aspects of ADHD. Future research should aim to explore strengths in individuals with ADHD from an early age, this way, coping mechanisms as a result of having ADHD can be excluded or eliminated.Another group of aspects could be defined as being the counterpart of the deficit aspects of ADHD, originating from the same underlying neurobiological mechanism. This was also proposed in the Dynamic Developmental Model, where adaptive and maladaptive outcomes are evaluated in relation to symptoms of ADHD . Here onThere is also a group of aspects that have, depending on the situation, either a negative consequence or a positive consequence. For example, impulsivity and related characteristics such as spontaneity and novelty seeking, are considered positive aspects of ADHD but are also part of the core ADHD symptoms as defined by international classification systems such as the DSM-5. Dependent on the situation the same characteristic may be beneficial and positive, or detrimental. For instance: acting impulsively in a situation of crisis can be beneficial. Future research using for example digital applications could monitor aspects such as impulsivity throughout the day and identify in which situation impulsivity is beneficial or detrimental. More insights into the situational aspects can lead to better management of these aspects of ADHD and help find a balance between beneficial and detrimental effects.From the above it becomes clear that we do not know much about where the positive aspects originate from. Do they develop together with core ADHD symptoms, or are they causal to having an ADHD diagnosis? There might even be more conceptual groups of positive aspects of ADHD than just the three mentioned above. From the perspective of psychoeducation, it is of high relevance to perform research into the development of the positive aspects of ADHD, as one could imagine that there is a distinction between addressing positive aspects from the “causal” category , from the “positive counterpart” category  or from the “context/situational” category of aspects .Our findings align with current clinical guidelines recommending a multidisciplinary approach for treatment of ADHD, with a range of non-pharmacological treatment options alongside medication if necessary . Our datFinding positive aspects or strengths of individuals with ADHD might also provide other new perspectives for healthcare. First, assessing strengths could become part of the diagnostic process. Ideally, one or more questionnaires could be developed assessing ADHD specific strengths, providing both self and other reports. Second, it paves the way for strength-based interventions and narrative interventions based on positive psychology, complementary to interventions based on symptom reduction. Strength-based interventions have the potential to contribute to beneficial outcomes in various areas of life . Previouvia improving their self-esteem, life satisfaction, wellbeing and health related quality of life. Previous research has shown that strength-use predicts wellbeing and quality of life in the general population  was much higher than the employment rate in a Norwegian sample of individuals with ADHD (24.3%). More than one third of their sample received disability benefits compared to only 8% in our sample . A SwediAnother strength of our study was the participatory evaluation of survey data by members of the focus group. This provided us with meaningful new interpretations of our findings, such as the different categories that might exist within the list op positive aspects that were reported. Participatory research in general has been shown to be advantageous for both researchers and participants, because it leads to more relevant results for both groups .A limitation of our study is the lack of clinical and demographic information of our participants. We did not have information on level of functioning, type and severity of ADHD symptoms, and presence of co-existing conditions . It could be hypothesized that – for example - individuals with ADHD and co-existing depression, may report fewer positive aspects. A study design that incorporates demographic, social and clinical data may explore correlations between clinical characteristics, level of functioning and number and type of positive connotations with ADHD.self-reported- and therefore subjective - positive aspects. Our study does not provide evidence for individuals with ADHD being indeed more driven, empathic, or have more humor (random examples) than individuals without ADHD. Empathy, for example, was reported as a positive aspect of ADHD in our study but also in Mahdi's study, and in quantitative studies investigating self-reported and observant reported empathy was lower in children and adults with ADHD  to identify strengths in ADHD. We need for example quantitative studies with measurements of these strengths and studies using other-report before we can start thinking about incorporating specific strengths into the image of ADHD. The identification of strengths in ADHD can provide implications for the management of ADHD. Awareness about ADHD strengths can help individuals with ADHD and their environment to better cope with, accept or embrace their diagnosis and for example make educational or occupational choices that fit them well. To incorporate these positive aspects in the understanding of ADHD, future research should also focus on investigating the link between these aspects and clinical characteristics and how this new knowledge can be implemented in psychoeducation and find its way to education and occupational settings.martine.hoogman@radboudumc.nl.The datasets presented in this article are not readily available because we do not have consent from our participants to share the data. Data are in Dutch. Please contact the corresponding author for information about using derived data. Requests to access the datasets should be directed to Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study.HV, RP, JM, CG, and MH initiated, designed and set-up the study. LS, LH, and MH performed the analysis. JM, CG, and MH reviewed and debated the qualitative results. LS, LH, and MH organized the focus group session with help from HV and RP. LS, LH, JZ, and MH wrote the manuscript with active contributions from all coauthors. All authors contributed to the article and approved the submitted version.MH is supported by a personal Veni grant from the Netherlands Organization for Scientific Research .The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.