Recently, social networks have become a popular source of information on health topics. Particularly, in Italy, there is a lively discussion on the web regarding vaccines also because there is low vaccination coverage, vaccines hesitancy, and anti-vaccine movements. For these reasons, in 2017, Institutions have introduced a law to force children to make ten compulsory vaccines for school attendance and proposed a vaccination campaign. On social networks, this law has fostered a fierce discussion between pro-vaccinations and anti-vaccinations people. This paper aims to understand if and how the population’s opinion has changed before the law and after the vaccination campaign using the titles of the videos uploaded on Youtube in these periods.Using co-occurrence network (CON) and sentiment analysis, we analysed the topics of YouTube Italian videos on vaccines in 2017 and 2018.The CON confirms that vaccinations were very disapproved before the law. Instead, after the communication campaign, people start to be less critical. The sentiment analysis shows that the intense vaccination campaign also promoted by medical doctors pushed the sentiment to change polarity from a prevailing negative opinion in 2017 (52% negative) to a positive one in 2018 (54% positive).At the population level, the potential misinformation of social networks could be significant and is a real risk for health. Our study highlights that vaccination campaigns on social networks could be an essential instrument of health policies and a sharp weapon to fight ignorance and misrepresentations of non-qualified people influencing individuals’ decision-making. Vaxxed: From Cover-Up to Catastrophe”. The latter is an American pseudoscience documentary film directed by Andrew Jeremy Wakefield, who was a British medical supporting the causal relationship between the trivalent MPR vaccine  and the appearance of autism and intestinal disease. This theory stimulated people to lose their belief in vaccines, and thus it contributed to lead to the so-called “vaccine hesitancy phenomenon” causing a vaccination coverage reduction. The vaccines hesitancy has created health alarmism by pushing countries and international organizations, such as the World Health Organization [The vaccine coverage provides information on the efficiency of the vaccination system and the trust of the vaccination practice. Currently, Europe faces many challenges, including the spreading antivaccination sentiment . In manynization , 6, to lnization . For thinization . Howevernization , 10). Monization , 12. Thenization , 14. Socnization .The aim of the paper is to analyze the online sentiment to understand if the Italian legislative intervention on vaccination is shared by the population and which are the arguments connected with this topic when people share information on YouTube. Indeed, because monitoring social networks could be a good proxy to evaluate vaccine hesitancy, understanding people thinking can guide policy-makers to plan effective information campaigns able to change people mindset regarding vaccinations.Among the European countries, Italy has one of the highest levels of scepticism related to effectiveness and safety of vaccines” [Specifically, we focused on Italy because “accines” –18. MoreWe are Social - Digital in 2018 Report”, the internet users in the world exceed four billion, and in Italy, they are more than 43 million; this means that today, more than half of the world’s population is online. In the world, Facebook has much greater penetration than YouTube [According to the “ YouTube  whereas, YouTube .The main contribution of this research to the existing literature on the problem of vaccination hesitancy is to propose the use of text mining and sentiment analysis. Indeed, to educate people increasingly inclined to use WWW as a source of information and to understand their mindset, policy-maker need appropriate tools capable of dealing with the new digital age. Effectively, these instruments could be adopted by public authorities to understand what people’s concerns are about health, what opinion the population has regarding the health policies implemented by the institutions, and finally to know if the policies and campaigns implemented have had the expected results.This research uses a networked mindset to tackle vaccine hesitancy. Specifically, we aim to understand what the sentiment towards vaccines on YouTube is, and finally to detect if and how the Italians’ opinion has changed from the period before the introduction of the decree-law to the following period, i.e. after the vaccination campaign.vaccin”. The search for the query took place concerning the period from the first of May to the first of October for both the year 2017 and 2018. The iterations used to search the query were chosen equal to ten (fifty items for every iteration) and has been specified to search for each day of the timeframe. The tool provided 3777 videos for 2017  and 3788 for 2018 . The exclusion criteria were a language different from the Italian one; titles not containing the subject under investigation; and finally videos with ambiguous titles were not taken into account.We used Netvizz to collect YouTube videos . NetwizzWe highlight that Netwizz also provided the following variables about videos: number of dislikes and likes, duration, comment count, and view count. We used Google Trends to determine the period in which to focus the search of the query and which was the sought-after query in terms of vaccines.We considered the maximum and minimum of the query’s functions of each year to capture the time-variability of the queries before and after the vaccination campaign. This criterion led to identifying 6 months in 2017 (from May to October) while, for 2018, a two-months range (from June to July). To guarantee the comparability of the two periods and considering that the June–July period lies within the May–October interval, we refer to the May–October periods both in 2017 and 2018.vaccino” (in English “vaccine”), “vaccini” (in English “vaccines”), “vaccinazioni” (in English “vaccinations”), “morbillo” (in English “measles”), and “autismo vaccini” (in English “autism vaccines”). Because both “vaccino” and “vaccini” were much more searched on the web than the others, we used the query “vaccin” that allowed us to search for both the singular and the plural in the Italian language [All relevant material for Italians is available only with the local language; in truth, even on the website of the Ministry of Health in Italy, it is quite difficult to find material in a language other than Italian! Indeed, todate, regarding vaccinations, the English version is still under construction . Therefolanguage .”e”, “o”, “non”, demonstrative adjective, people names, other language words and meaningless words. To analyze the sentiment during the considered periods about the content of the co-occurrence networks, we used the function “get_nrc_sentiment” based on the NRC sentiment dictionary to calculate the presence of eight different emotions and their corresponding valence in a text file from the “syuzhet” R environment package [p < 0.05. For each variable in the study, we have included descriptive statistics.To understand the main topic about vaccines on YouTube, we analyzed the data by using the co-occurrence network (CON) based on Freeman’s betweenness centrality Index by KH Coder 3.0 , 30. Bet package . The worTable compulsory” and “choice” have high degrees of centrality within the network. But also the terms “school” and “decree” have a high centrality within the network although their frequency is low. Particularly interesting is the fact that the term “choice” is connected and many other terms pertaining to the subject such as “vaccination”, “freedom”, “law”, “meeting”, “doctor”, “questions”, “compulsory”, “manifestation”. Moreover, we observe many connected cliques and small clusters stressing strong concern and perplexities. In summary, the graph underlines that there is an interesting connection between vaccinations and freedom of choice.Figures 1 and 2 show the textual analysis through the CON in 2017 and 2018, respectively. Figure medical doctor”, “child”, “deadline”, “vaccination”, “ministry”, “health”, and “parent”. The betweenness centrality index of these words does not coincide with the frequency of appearance in the text, this means that although they do not appear very frequently in the speech, they connect most of the themes acting as bridges to reach the most isolated nodes. The word “ministry” is also the node a high betweenness centrality being the one most connected in the network having a high degree centrality. It can be noticed how taking as a “ministry” centre this constitutes a centre for the formation of a connected cluster that includes topics concerning the Lorenzin decree, conferences, health, regulation at the regional and scholastic level. Interesting is the change in the importance of terms such as “freedom”, “choice”, “risk”, and “compulsory”; hence, it suggests that the previous negative discussions about vaccinations are weakened, bringing the speech back to less polemical tones.Figure Figure p = 0.02).Figure In Italy, the vaccination coverage strongly increased from the 31st of December 2017 to the first 6 months of 2018 –35. In 2The final aim of this paper is to stimulate public authorities to invest in the digital communication for spreading health information, raising awareness among increasingly younger users, and reaching a type of communication that is increasingly popular. Indeed, this kind of information is essential to educate people increasingly inclined to use WWW as a source of information. The competent authorities should invest and apply policies for correct information on the web by financing projects and qualified operators capable of coping with the new digital age.Although a considerable number of videos were selected for analysis, availability and access to API, and time limitations made it unfeasible to examine all videos. For these reasons, we have conducted an analysis completely excluding human judgment. Despite these limitations, to the best of our knowledge, this is the first study to examine YouTube vaccination’s contents in Italy using a text mining and sentiment analysis procedure not affected by a human classification which implies an intense subjectivity in the attribution of sentiment scores such as to cause a strong bias in the study.All European countries have vaccination policies and, in particular, Italy is the first European country to approach comprehensively the growing vaccine hesitancy. Following the disinformation about vaccines, vaccination coverage in Italy has fallen below the critical threshold of 95% for various diseases. This situation can have serious consequences, both for the health of unvaccinated children and for those around them. The issue of compulsory vaccinations introduced by the Lorenzin’s decree has aroused much discussion within the WWW. Social networks express opinions from both experienced and non-experts and reflect the feeling related to the subject of vaccination in Italy. Although in 2017 vaccinations have been highly criticized regarding their safety and ethics, and thus recorded a negative opinion by the Italian YouTube users, in 2018, there is an inversion of polarity in the general sentiment. Indeed, in 2018, users discussed this topic less critically, no longer emphasising the risk and danger of the vaccine but trying to understand and address the consequences of the law-decree regarding the information of the documentation required for access to school.The ongoing debate about the adoption of mandatory vaccination policies, especially in the light of the fragmentation of the vaccination regulatory framework still challenges the scientific community, the political stakeholders and the general population in Italy. Because the pro-vaccine campaigns are designed to raise awareness among parents about the importance of vaccinating their children, policymakers should adopt the appropriate campaigns according to the society they live in. Lawmakers and public health authorities should play a fundamental role in informing the public and should use the media to do this so people can make informed choices. But politics are primarily influenced by what appears in ‘old’ media, such as television, radio and newspapers, and ‘new’ media such as social networks and the Internet are not exploited as necessary. Besides, the link between the media and politics can have a notable influence on vaccination coverage, and thus policymakers should use the ‘old’ and ‘new’ media for enhancing health-related information that can strengthen vaccination coverage.This study shows how the public authority must take into account the WWW and its potential dangers, adopting communication strategies to manage as much as possible the information from social networks by contrasting fake news.


In the last three decades, microfluidics and its applications have been on an exponential rise, including approaches to isolate rare cells and diagnose diseases on the single-cell level. The techniques mentioned herein have already had significant impacts in our lives, from in-the-field diagnosis of disease and parasitic infections, through home fertility tests, to uncovering the interactions between SARS-CoV-2 and their host cells. This review gives an overview of the field in general and the most notable developments of the last five years, in three parts: 1. What can we detect? 2. Which detection technologies are used in which setting? 3. How do these techniques work? Finally, this review discusses potentials, shortfalls, and an outlook on future developments, especially in respect to the funding landscape and the field-application of these chips. Since the advent of microfluidics 30 years ago, many applications have employed the advantages of microfluidic environments: small sample volumes, ready parallelization, high reproducibility, a vast span of experimental timescales, and a high control over local conditions . One very prominent aspect of microfluidic research is diagnostics on the single-cell or even molecular level. The significance of recent research towards microfluidics-based single cell diagnostic chips is apparent in health care, in our homes, and also very prominently in the fight against the COVID 19 pandemic: The diagnostic targets range from circulating tumor cells (CTC) ,3,4,5,6,Due to the small volumes and the readily available lithographic procedures, diagnostic chips often are mass-producible, which makes individual tests cheap. This also opens up a great potential for portable diagnostics for global health issues  even in Plasmodium falciparum  organism)” . Single In general, all single cellular ‘omics’ share a basic setup: a target cell  is lysed, their contents may be treated and are chromatographically separated and analyzed using mass-spectroscopy (or similar techniques). Most often, separation and detection is done using gas chromatography with mass spectroscopy (GC-MS) , high-prFor an overview of the pros and cons of employing polyomics towards single cell level diagnostics, please refer to Point-of-Care (POC) means that these diagnostic devices can be used at the patient level and deliver a diagnosis locally and quickly—without need for taking samples, sending them away for analysis and having to continue care while waiting on the outcome of the diagnostic test. This is often achieved with the LAMP test and its derivatives, LAMPport and NINA-LAMP ,48,55,61Many publications, which demonstrate microfluidic test devices mention at least some of the WHO’s “ASSURED” criteria  for low-cost sensors for the developing world. While the functionality “ASSR” of the low-cost sensors is often easily achieved, their ready user acceptance and field-applicability “UED” often lags behind . Microfluidics devices make it possible to carry out complex analysis outside of highly equipped laboratories, often in a hand-held, portable, and field-applicable fashion , at leasGiven the steady increase in publications and research carried out towards the creation and usage of single cell diagnostic chips, it can really be regarded as a hot topic within the microfluidics community. On the diagnostic side, single cell diagnostics means that infections and diseases can already be diagnosed with a minimal sample volume and from a single pathogenic cell. On the production side, this means that high-resolution techniques have to be used , but also that it is possible to parallelize and mass produce these microfluidic chips. The vast adaptability of microfluidics to other techniques and technologies to handle and characterize cells, from bulk to individual, opens new possibilities and synergies every year. While this plethora of opportunities continues to be explored, it is always a rather long stretch from the “chip in a lab” to the field-applicable “lab on a chip”. Many great diagnostic chips that could help study, diagnose and eventually eradicate diseases—especially neglected tropical diseases (NTDs), do not make it to the final deployment in the field. It is a sad state of affairs and a symptom of some mismatches in the research and funding landscape, that many projects aiming to understand the fundamentals are funded, and even more projects are funded to develop actual applications and physical single cell diagnostic chips, but that only very few devices ever make it across this “valley of death” to their field application. Several funding bodies like the Bill and Melinda Gates Foundation or the UK’s Grand Challenges Research Fund support research to develop such chips for low- and middle-income countries. However, the—now—most important step to get the chips mass produced, certified and deployed, is sadly virtually unfunded; an immense potential to actually make a positive impact on the world is not being seized. In conclusion, there have been many technologies that can be combined to create powerful single cell diagnostic chips, but without a massive change in the system, many of these chips will remain “chips in a lab” rather than unleashing their true potential as “labs on a chip” at the point of care.


Animals, including human beings, modify their behavior when they fall sick. Interestingly, sociology, biology, and psychology have at different times in their history developed constructs of illness or sickness behavior. The aims of the present paper are to consider sickness behavior in animals and humans and to evaluate to what extent the notions of sickness behavior would allow for interdisciplinary research. After distinguishing disease, illness, and sickness, the case will be made that illness behavior and sickness behavior can be considered heuristically as synonyms given the existence of some fluidity between the notion of illness and sickness. Based on this, different faces, phases, and facets of sickness behavior will be presented before addressing the question of how integration of constructs of sickness behaviors would be possible across biology, medicine, psychology, and sociology. It is concluded that interdisciplinary research on sickness behavior between biology, psychology, and sociology is possible and called for with regard to constructs, methods, and explanations, while keeping in mind differences in perspectives, for example between acute and chronic sickness behavior. The sick child painted several times by Edvard Munch between 1885 and 1926 that features his sister suffering from tuberculosis. Since then, there have been many debates, both in society and within academia, about what health, sickness, and disease would, could, or should be. This is important to keep in mind when discussing sickness as it is often positioned or described relative to health and disease. Here we will first consider a few descriptions of sickness in relation to health and disease before discussing differences in more detail.Even though philosophers of medicine may recently have seemed to agree to disagree on the possibility of consensus definitions of health and disease , the AmeThe normal and the pathological published by the French physician and philosopher of medicine Georges Canguilhem during WWII is an interesting starting point because this scholar distinguished “the experience of being sick” from disease, alluded to changes in behavior during sickness, and linked the possibility “to fall sick” to “good health.” According to Canguilhem, medical science should not aim to generate a general disease concept but rather “determine what are the vital phenomena with regard to which men call themselves sick” s sick” .s sick” s sick” Some years after Canguilhem, the American internist and psychiatrist George Engel proposed to link different levels of organization and various responses observed after bacterial infection. At the tissue level, this results in an inflammatory response while at the level of the whole organism it can give rise to a profound alteration of physiology . HoweverIn the mid-1970s, 2 years before Engel's proposal for biopsychosocial medicine, the philosopher of medicine Christopher Boorse put forward a distinction between disease and illness. According to him, disease “applies indifferently to organisms of all species” and “it is to be analyzed in biological … terms” While it is understandable that there has been substantial interest in studying disease, illness, and sickness affecting human beings, it is also important to keep in mind that animals other than human beings can fall ill and are diagnosed with diseases by veterinarians. Animals have been used as work force, life stock, experimental subjects, and pets by man, and it is in these relationships that animals have been considered as victims of disease and sometimes as patients . In the The aims of the present work are therefore to consider sickness behavior both in humans and other animals and to evaluate to what extent the notion of sickness behavior would allow for interdisciplinary research. In the remainder of this introduction, and after having distinguished disease, illness, and sickness, some fluidity between the latter terms will be pointed out to make the case that illness behavior and sickness behavior can be considered heuristically as synonyms. Based on this, the second part of the paper will present different faces, phases, and facets of sickness behavior before addressing the question of how integration of constructs of sickness behaviors would be possible across biology, medicine, psychology, and sociology.Interestingly, and after spelling out differences between these terms, Bjørn Hofmann also admitted that there are conditions that are considered disease and illness, but not sickness, others that are deemed disease and sickness, but not illness, and still other conditions that are viewed as sickness and illness but not disease. Among the latter would be fibromyalgia and chronic fatigue syndrome , in whichttps://www.ncbi.nlm.nih.gov/mesh/?term=%22sickness+behavior%22). Of note, between 1975 and 2008, prior to the current heading of illness behavior, this term was indexed under “sick role” (https://www.ncbi.nlm.nih.gov/mesh/?term=%22sickness+behavior%22). Importantly, interrogating PubMed with “illness behavior” as a keyword set gives twice as many results as “sickness behavior.” Similarly, searching for “illness behavior” on the American Psychological Association (APA) PsychInfo database results in almost 10 times more articles than searching for “sickness behavior.” This difference between the PubMed and PsychInfo databases may be explained, in part, by the fact that illness behavior has been part of the APA Thesaurus of Psychological Index Terms since 1982 and is defined as “behaviors, attitudes, and emotions exhibited by individuals during the course of a physical or mental illness,” whereas “sickness behavior” is not part of this index. Finally, typing “sickness behavior” as a search topic on the Web of Science (WoS) Core Collection yields more hits than “illness behavior.” This suggests that overall in WoS-indexed articles “illness behavior” and “sickness behavior” are used differently than in articles found on PubMed and PsychInfo. Given this varying and somewhat liberal use of both terms, sickness behavior will be considered heuristically here as a synonym of illness behavior.Interestingly, typing “sickness behavior” in the Medical Subject Headings (MeSH) database on PubMed takes one to illness behavior. On PubMed, illness behavior is, since 2009 described as a “[c]oordinate set of non-specific behavioral responses to non-psychiatric illness” that “may include loss of appetite or libido, disinterest in activities of daily living or withdrawal from social interaction” At the end of the 1960s, the South-African physician Issy Pilowsky introduced the notion of abnormal illness behavior to qualify a situation in which the patient does not seem to agree with the physician's diagnosis and proposed solution for the problem that the patient expressed . AnotherIt is therefore not that surprising to see Pilowsky propose the “Illness Behavior Questionnaire” in the 1980s with subscales assessing hypochondria and the “psychologic versus somatic perception of illness” . Around The second line of research has been biological and driven by the idea that sickness behavior is an adaptive regulated response to infection. In his 1988 review that introduced the term “sickness behavior” for animals, Benjamin Hart provided a table of infectious diseases affecting domestic animals and human people that have been reported to be accompanied by fever, reduced food intake and behavioral depression . As indiOne of the ways in which Benjamin Hart described sickness behavior was in terms of motivation . This quPsychology has picked up on the theoretical motivational framework laid down by the sociologists Tascott Parson and David Mechanic and studied the behavior of individuals with chronic medical condition in the context of coping styles. Thus, in adult cancer patients, protective buffering, which includes withholding or denying hiding cancer-related thoughts and concerns , was fouFurthermore, these and follow-up studies assessed emotions and mood, which is notoriously difficult or impossible to do in animals, and reported increased anxiety and depressed mood –49. In aEpidemiology has a respectable historic tract record in pointing out potential causal relationships, for example between smoking and lung cancer, to biomedical disciplines that can mobilize intervention strategies to test the causality of the relationship . While sGiven that concepts of illness/sickness behavior have been developed in biology, psychology, and sociology, one may wonder to what extent these constructs are similar or compatible and what, if any, role illness/sickness behavior plays in the so-called biopsychosocial model of medicine. Indeed, George Engel, who proposed the biopsychosocial model of medicine in the 1970s expressed the hope that the study of all contributing factors would allow to explain “why some individuals experience as ‘illness' conditions which others regard merely as ‘problems of living”' Although the biopsychosocial model of medicine has in large part been practice-oriented, several interdisciplinary fields, such as psychoneuroendocrinology, psychoneuroimmunology, and, more recently, microbiota–gut–brain research, have been presented as research fields relevant to, expression of, or even as validation of the biopsychosocial model –65. HoweIn present-day academia, there are many calls and some incentives to engage in more multi- or interdisciplinary research and it is therefore worthwhile to get a better idea of what may be behind these terms. The social scientist Patricia Rosenfield in an article discussing the possibilities of “transdisciplinary research” to foster and further “the links between the health and social sciences” indicated that multidisciplinary research typically occurs when there is “a common problem or set of problems, [but] each discipline works independently and the results are usually brought together only at the end” , p. 1351, p. 1351While the term multidisciplinary refers to less methodological and knowledge integration than that of interdisciplinary, it has been proposed that both can be grouped under the term cross-disciplinary , p. 1938. This apInterestingly, regarding health and disease, the philosopher and psychologist Derek Bolton together with the philosopher and neurosurgeon Grant Gillett has recently made a plea for more cross-disciplinarity arguing that “[t]here is simply too much going on for one disciplinary approach alone” , pp. 100, p. 101)However, transcending disciplinary traditions may not be that straightforward regarding illness/sickness behavior because, as pointed out by David Mechanic, “social scientists sought to depict the extraordinary variability of behavior, [whereas] physicians sought criteria to define ‘abnormal illness behavior”' , p. 1208. This seThese considerations seem to apply to health, disease, illness, and sickness behavior as well. On the one hand, philosophy has been highly active in trying to develop general theories of health and disease but has paid less attention to illness/sickness behaviors, not to mention on how to measure these. On the other hand, biology, psychology, and sociology have been more involved in trying to measure illness/sickness behavior without being that much concerned about a general theory. Thus, several constructs of illness and sickness behavior may have been put forward in sociology, psychology, and biology. Here it is important to keep in mind that constructs of the same name can be described differently depending on the domain. Indeed and as outlined above, illness behavior is described on the biomedical database PubMed as a “[c]oordinate set of non-specific behavioral responses to non-psychiatric illness” that “may include loss of appetite or libido, disinterest in activities of daily living or withdrawal from social interaction,” whereas on the APA database PsychInfo it refers to “behaviors, attitudes, and emotions exhibited by individuals during the course of a physical or mental illness.”Furthermore, we have recently pointed out that under the same banner of sickness behavior, biology relates behavioral measures in animals while psychology mostly uses questionnaires addressing feelings in humans, even though behavioral observations are possible . Indeed,A historic example of diverse constructs used in different research traditions that have the same name is stress. The Hongro-Canadian physician Hans Selye is often credited for having given contents to the term stress in the life sciences. Indeed, he has proposed to coin his general adaptation syndrome to different adverse situations, stress , and to The philosopher Wim van der Steen considered in 1993 that in the beginning the investigation of stress took place in separate disciplines without much interaction . He credIf interdisciplinary research fields such as psychoneuroendocrinology and psychoneuroimmunology have over the past 25 years widely employed the terms stressor and stress response and have often distinguished physiological from psychological stress, the danger of confusing stimuli, internal states, and responses may be present for more recent interdisciplinary domains less aware of this historic debate. With respect to illness/sickness, one could specify that bacterial LPS fragments constitute a physiological stressor for animals and illness/sickness behavior is part of the stress response. To what the (di)stressed state of an infected organism  corresponds is still a matter of active research, but anxiety may be a good candidate . HoweverInterestingly, the notion of motivation has been mentioned in the context of illness/sickness behavior in sociology, biology, and psychology. Thus, the sociologist Talcott Parsons remarked that illness was motivated, but considered it a kind of “deviant behavior” Benjamin Hart clearly worked from an evolutionary background for sickness behavior when he proposed that an infected animal that is sleepy or inactive “is less motivated to move about using energy that could fuel metabolic increases associated with fever” A classic theme in health psychology is that of coping with chronic disease. In this context, it is considered that social support can promote the adoption of adequate coping strategies by improving understanding and increasing motivation . It is iOn the one hand, many of the interdisciplinary initiatives involving sociology and medicine, like social medicine, the sociology of health and disease, and the biopsychosocial model of medicine, have emphasized the importance of a holistic approach and of considering multiple factors , 98. On JPK conceived of, wrote, and edited this work.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


In response, we designed a digital educational support group, administered through WhatsApp Messenger, for new adolescent mothers. The purpose of this study was to assess if participation in this digital support group could improve health outcomes and health behaviors.(2)Participants completed questionnaires with a health literacy screener, demographic items, knowledge questions, the Index of Autonomous Functioning, and five Patient Reported Outcomes Measurement Information System scales before and after the moderator-led intervention. Differences between pre- and post-intervention scores were calculated and perceptions of the intervention were explored through in-depth interviews analyzed with content analysis. Participants’ well-baby visit attendance and contraceptive use were compared to that of controls and a national sample.(3)N = 58) knowledge scores increased (p < 0.05). Participants were 6.58 times more likely to attend well-baby visits than controls (95% CI: 2.23–19.4) and their contraceptive use was higher than that of the national sample (p < 0.05). Participants indicated the intervention was enjoyable and beneficial.Participants’ ((4)This adolescent-centered digital intervention is a promising method to improve health outcomes and health behaviors of young mothers in limited-resource settings. AdditThe successful management of any mother’s and baby’s health in the postpartum period requires new mothers to acquire much information regarding how to take care of themselves and their newborn ,14. TopiBecause mobile health  technologies are rapidly advancing and are ubiquitous even in limited-resource settings, there is much potential for digital solutions to extend high quality health services to hard-to-reach populations –24. TherA known benefit of digital health platforms is that patients can use them to connect to their providers, as well as to their peers ,31. TherTherefore, the purpose of this study was to assess if participation in our digital educational support group, administered through WhatsApp Messenger through a local health clinic, could improve the following health outcomes among new adolescent mothers: postpartum-related health knowledge, use of modern contraception, attendance at scheduled well-baby appointments, levels of perceived support, and autonomous functioning.2.2.1.To enable a comprehensive evaluation of the FAMA intervention, this multi-method study had three data collection components.Baseline and follow-up surveys. Intervention participants completed surveys that assessed the outcome measures of interest before and after participation in the intervention.Medical record review. Clinical data  were extracted from FAMA participants’ medical records and compared to similar data extracted from the medical records of a control group. Where control group data were insufficient, participants’ medical record data were compared to data from a publicly available national demographic and health survey.In-depth interviews. Participants who completed the FAMA intervention and attended the closing group session were invited to complete an in-depth interview to assess their perspectives of the FAMA intervention and identify areas for future improvement.2.2.This study was approved by two institutional review boards in the DR—the Instituto Dermatológico y Cirugía de Piel “Dr. Huberto Bogaert Díaz” and the Consejo Nacional de Bioética en Salud.2.3.The digital educational support groups were designed and led through the Módulode Adolescentes Materno Infantil (MAMI), a clinic that offers health care services and education to approximately 3000 adolescents in La Romana, DR. At MAMI, family planning counseling and methods are offered, as is sexual and reproductive health education, pre- and post-natal care, pediatric care, and testing for sexually transmitted infections.2.4.MAMI has closely collaborated with Planned Parenthood of the Great Northwest and the Hawaiian Islands (PPGNHI) for nearly a decade. As part of this long-standing partnership, staff from PPGNHI’s Global Programs and Education departments regularly travel to the DR to provide support for MAMI’s health education programs. Our study team, therefore, consisted of bilingual PPGNHI staff, MAMI educators and administrators, as well as the research department and administrators at Clínica de Familia La Romana, the parent organization that supports MAMI.2.5.n = 16) had participated in initial user-centered design sessions and had agreed to participate in this study phase. Therefore, the study team recruited 44 additional adolescent mothers in the waiting room at MAMI. Inclusion criteria were that FAMA participants be 14 to 19 years of age, have at least one child, have given birth in the previous six months, speak Spanish, live in La Romana, and attend pediatric appointments at MAMI. The babies of participants who had participated in the first phase were older (up to 11 months) at the time the intervention began. Exclusion criteria were not having the capacity to understand the study or provide informed consent. As Dominican law 136–03 classifies adolescents who are pregnant and/or have had children as emancipated minors who can consent to participate in research and/or health care services, those who agreed to participate provided written informed consent after study team members thoroughly explained the study and answered any questions.The target sample size agreed upon was 60 adolescents, as determined by funding and logistical considerations. Some participants (2.6.2.6.1.n = 24) completed participatory user-centered design sessions that explored the health information needs of new adolescent mothers in the DR as well as their experiences as new mothers. Participants first identified information and support needs, then worked with each other to prioritize the health information and support topics that were the most meaningful and potentially important to include in the intervention. Growth and development stages of infants, understanding your baby, common infant illnesses, breastfeeding, nutrition during a child’s first year, and family planning were the topics that participants agreed were the most important to address. We then identified pertinent content associated with each identified topic through a brief literature review and established the guide for the FAMA intervention with the corresponding findings.The methods used to establish the content for the FAMA intervention are fully described elsewhere . However2.6.2.n = 16, n = 20, n = 22), to enable meaningful participation for each participant in each group. All groups began with an in-person meeting where participants met the intervention moderators , received a cellular phone, instructions for how to access cellular data packages (replenished weekly), met other participants in the group, discussed intervention procedures, established group norms and guidelines, and completed baseline surveys. If a participant from the first group missed the in-person meeting for their group, they were able to move to the later groups, which accounts for the larger group size in the second and third groups. Two participants did not attend any in-person group sessions and were removed from the study for a final N = 58.We divided FAMA participants into three separate intervention groups  emotional support, (2) informational support, (3) social isolation, (4) instrumental support, and (5) companionship. Benefits of using the PROMIS scores are that they have been extensively validated in diverse populations, including among Spanish speakers, they are freely available, and can be administered in a relatively short amount of time  was practically a family, they guided us and showed us a lot of care and appreciation. You’ve seen how [the moderators] are with us, they are very playful, and I thank you and them because I have learned a lot and I have helped my baby a lot...I had to change environments and look for a job and all that so I don’t participate as much in the group now, but still I felt like I was in a family, I felt the warmth of being in a home with other girls.” Another commented, “ ... some of the girls, we got along well, not a simple friendship ‘Ah we talk on WhatsApp and that’, no we can already say, ‘maybe one day we can go to her house, we are going to hang out, we are going to cook with the children’, you know? And we built trust.” Emotional support was mentioned by 37.0% of the participants. As one participant said, “I felt really good and supported. It even lifted my self-esteem; that was something really nice.” Another participant reported a similar self-esteem boost sharing, “Yes, I even feel that my self-esteem has risen a little because I am a little antisocial and I have opened up a little, speaking in the conversations ... I have met many people.” One participant shared that one of the facilitators provided emotional support during a difficult time, “My experience was very comfortable, I felt very trusting, I could communicate, not only in private but also with the girls, many times...I mean I’ve had a lot of relationship problems with the baby’s father, they [the moderators] have helped me a lot, they advise me, I felt comfortable, we shared a lot, I learned a lot...” Receipt of informational support was expressed by 55.6% of the participants. Many participants shared the sentiment that, “[the moderators] are really good, they helped me significantly, always attentive to whatever question, really good treatment.” Several participants provided examples of the informational support provided to them including about family planning, what to do when their baby is crying or constipated, among other information received.There was evidence of increased social connectedness, companionship, informational support, and emotional support demonstrated in the interviews. Nearly all participants (96.3%) expressed feelings or perceptions of increased social connectedness and/or the availability of someone with whom to share enjoyable social activities as a result of the FAMA intervention. As one participant commented, 3.5.3.“I learned to be more awake, like more agile, and to interact more with other people.” Another said, “before [the intervention] there were things that I didn’t feel that kind of trust [to talk about], not even to talk with my mom. Now I do it, I have opened a little, I’ve left my comfort zone.” Another said, “Oh, with my husband an example, I feel more... I mean, I tell him things he can do with the child and I explain to him that if he can, he can give him his little meal ... before he gave him anise and oregano tea, and I said: ‘No, you can’t give that,’ and he said to me, ‘okay,’ and I explained why.” Similarly, participants indicated decreased levels of susceptibility. As one mother said, “I learned that I can have my own opinion and decide for myself.” Another demonstrated high authorship saying, “I would say in five years I will be working. I would also like to dedicate myself to my family and sometimes hang out with my girlfriends. I would like to be like that in the future.”There was evidence of increased autonomous functioning in the exit interviews as participants expressed heightened interest and ability to take care of themselves and their babies. As one mother said, 3.5.4.“It is a very excellent group, very excellent, it should be extended more in the country because it provides significant help to first time moms.” Another said, “ ... I learned a lot, it was really useful to me the information they gave us, the help with the babies, because I was totally inexperienced.” Every participant expressed they would recommend the FAMA program to others. As one participant summarized, “this group was really, really special, truly it was. I am really very happy, very happy, I am. The only thing that bothers me is that now we aren’t going to be able to participate because this is the end. I was really, really happy in this group, I would pass the day really happy reviewing messages. I wasn’t angry, no, because I would grab the phone and when I grabbed the phone it was for me to smile.” One participant said they would recommend the group because, “ ... sometimes [girls] get pregnant at an early age and they don’t know how to take care of their child, but [in the group] they deal with all topics, there are some girls who know more than others, they can help each other.”Overall, participants expressed general satisfaction with the FAMA intervention. As one participant shared, 3.5.5.“Sometimes they talked a lot, I practically didn’t talk, I only entered [into the chat] to see what interested me, and I didn’t like it, that they talked so much, many voice memos, talked about things that they shouldn’t be talking about and that’s why I didn’t talk much in the group.” Some were frustrated by the lack of participation by some of the participants. One participant said, “in reality, I didn’t like it when other participants didn’t talk much in the group ... that bored me a little. But, I liked it [FAMA] a lot, it was very interesting.”When asked what we could do to improve the intervention, one participant gave content-related feedback, suggesting expanding the baby illnesses topic to include more childhood illnesses. Others voiced other concerns related to the function of the group including the difficulty involved in juggling the group with other responsibilities, determining how to meaningfully contribute to the group, annoyance over long waits for responses to questions, and complaints that some participants did not follow group norms. For example, one participant said, 4.As we move toward an increasingly digital and global world, it is important to effectively design and evaluate technologies that can provide information and improve health among those living in hard-to-reach areas. In this study, we aimed to determine if participation in a digital educational support group administered through WhatsApp Messenger centered on the specific needs of new adolescent mothers was a feasible and efficacious method to improve their health knowledge and behaviors. Overall, participants demonstrated statistically significant improvements in postpartum and neonatal knowledge, better attendance at well-baby visits, and as a group, had a markedly higher modern contraceptive use than other adolescents in the Dominican Republic after participating in the intervention. Additionally, participants indicated feeling increased social connectedness as well as higher levels of informational and emotional support following participation.A particular strength of our study is the evaluation component, as many studies detailing the development of digital technologies for limited-resource settings focus on the feasibility, acceptability, and design of new technologies, while few evaluate the outcomes observed following their interventions . FurtherBeyond our findings, our experience implementing our intervention provided many important lessons that are applicable to future digital interventions. First, it took extensive planning and coordination to determine how to provide cell phones to each participant as well as ensure participants had sufficient internet connectivity or cellular data to be able to participate in the intervention. Despite numerous global statistics indicating there is widespread smartphone use in limited-resource settings ,56, otheEncouragingly, the WhatsApp groups were very active. However, this meant the group moderators had to dedicate more time than anticipated to answer questions, maintain group norms, and correct misinformation. To help manage participants’ expectations , a group norm was developed to clarify that although participants could send messages at any time, the moderators would only respond Monday–Friday during working hours. Beyond monitoring the group chats, responding to individual messages received from participants was a time-consuming task for moderators. The large group size may have exacerbated this problem. For future interventions, it will be important to recognize the time and resources required to manage a support group such as this and establish the norms around, expectations for, and availability of moderators. The size of the digital groups should also be carefully considered, as of course larger groups will maximize impact and a sufficient number of participants is needed to generate meaningful conversation as well as social and peer support. However, groups should not be too big that vocal participants drown out their more timid counterparts and moderators cannot reasonably manage questions received from all group members. Another consideration of the time investment by moderators is the associated cost, which may reduce the cost effectiveness of the intervention. To mitigate this concern, the amount of time moderators are able to spend on the intervention could be more clearly regulated at the outset of the study, participants could be limited on the number of questions they can pose to moderators outside of the group chat, or automated options, such as effectively designed chatbots, could be used to answer frequently asked questions . It is, Two additional considerations important for future studies are informed consent and privacy concerns with the digital groups. As previously mentioned, in the DR, pregnant adolescents are considered emancipated minors who can legally provide informed consent to participate in research studies. As this is not always the case, future intervention designers must consider how to obtain consent for younger adolescents’ participation. Privacy concerns are another large issue that may affect similar interventions in different contexts. Unlike many messaging platforms, WhatsApp Messenger has end-to-end encryption , which mThis study had limitations. First, 16 participants had previously participated in the user-centered design sessions conducted during the intervention design stage. Those participants could, therefore, have been more comfortable with the study team and MAMI clinic, more engaged in their health and/or health care, and more willing to participate in groups. Notably, initial design sessions only explored participants’ experiences as new mothers and their corresponding information needs; participants in those sessions did not receive any type of patient education or health coaching. Therefore, it is unlikely participation in these sessions led to increased knowledge of postnatal concepts or an increase in contraceptive use. A second limitation was that in-depth interview participants were a convenience sample of mothers who attended the final in-person group sessions, which could lead to bias as those in attendance were likely the more engaged participants. Additionally, despite implementing methods such as indirect questioning ,60 to av5.Moderated WhatsApp support groups centered on the needs of new adolescent mothers are feasible for health centers to conduct, acceptable by the target population, and can have a positive impact on health knowledge, perceptions of social support, and health seeking behavior for family planning and well-baby visits. Further study and improved documentation are necessary to determine impacts on childhood vaccination coverage. Our results emphasize that digital technologies are a useful and important technology that can lead to better health outcomes in limited-resource settings globally.


Posterior alien hand syndrome caused by small infarcts seems to be characterized by acute development and transient, yet profound, isolated motor dysfunction with a favorable prognosis unlike other cases due to larger MCA infarcts. Posterior alien hand syndrome caused by small infarcts seems to be characterized by acute development and transient, yet profound, isolated motor dysfunction with a favorable prognosis unlike other cases due to larger MCA infarcts. AHS was first documented in 1908, which was described by Goldstein as “a type of apraxia with a feeling of estrangement between the patient and his hand.” In one case, a 57‐year‐old woman was unable to control her left hand from grabbing her throat. This patient's subsequent autopsy revealed an acute infarct in the right hemisphere and corpus callosum.In this case report, we present a young obese male patient with the chief complaint of “I thought my kids were playing a prank on me.” He was startled by a right hand that “came out of nowhere” rising up to touch his face when he was sitting on the toilet about to have a bowel movement. Symptoms lasted for at most an hour, with similar timing to a TIA‐like presentation.2A 45‐year‐old right‐handed obese man presented to emergency room with a chief complaint of being startled by his own right hand that suddenly, without his awareness, came into his right visual field approaching his face. At that moment, he was sitting on the toilet about to have a bowel movement. The bathroom door was not closed completely, so he thought his young children were playing a prank on him. Upon realizing that this “hand” was actually attached to his own body, he was shocked and found the whole situation incomprehensible. He described this “hand” as doing a wave like motion in the air. He was able to clean himself with his left hand, stood up, and called for his wife. When he arrived at ER via private vehicle, his symptoms had resolved and he had “regained control over” his right upper extremity. At that time, the patient denied any numbness, tingling, weakness, confusion, slurred speech, or any focal neurological deficits. He also denied any chest pain, shortness of breath, abdominal pain, fevers, or chills. At the time of the incident, the patient proceeded to finish his bowel movement and had no incontinencePast Medical History—Patient obese and had chest pain 6 months prior to current admission requiring an overnight admission at another hospital in the area. A review of those medical records revealed normal EKG and troponin levels. During this past admission, the cardiologist did a left heart catheterization and determined there was no stenosis, and the left ventriculogram was normal. Conclusion for that chest pain episode was costochondritis. He denied tobacco, alcohol, or illicit drug use.On examination, the patient had a BMI of 33. Temperature was 98.3F, and he was never febrile throughout the whole stay. His blood pressure was 108/61, heart rate was 51, and atrial fibrillation was never documented during his stay. He was alert and oriented to person, place, time, and situation. Cranial nerve examination was normal with no visual field deficit or neglect. Motor strength was 5/5 in bilateral upper and lower extremities. Tone and bulk were normal with no tremor, myoclonus, asterixis, dystonia, or chorea. Sensory tests revealed response to light touch, ice sensation, and proprioception. Asking him to hold his right upper extremity up in air with eyes closed did not result in any abnormal movement. His gait was normal. Finger to nose testing was intact with no ataxia and no dysdiadochokinesia. CT and CTA of head were both negative. MRI of head, however, showed two small embolic‐like events within the left middle cerebral artery territory within the parietal lobe on the DWI and flair sequences , or nonfinancial interest  in the subject matter or materials discussed.HL: designed the study and wrote the initial draft of the manuscript. AA: contributed to analysis and interpretation of data, and prepared the final manuscript. All authors: have contributed to data collection and interpretation, and critically reviewed the manuscript. All authors: approved the final version of the manuscript and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.


While cannabis has a long history of spiritual use, its normalization in Western societies during the last decades has led to more recreational use. This study aimed to explore the characteristics of spiritual cannabis use as compared to recreational use and to the use of psychedelics such as LSD and psilocybin.N = 29) were recruited at various online fora for individual interviews via private messaging, and were queried in depth about their use of entheogens such as psilocybin, LSD, and DMT in spiritual contexts. The Cannabis and Psychedelics User Survey (CPUS) was constructed on the basis of the reports from these interviews, and recruited 319 participants  from seven different online communities. The online survey consisted of three main sections, with the first asking about demographics, personality, current and past affiliation to spiritual or religious traditions, and non-psychedelic drug use, and the second and third sections containing questions about motivations for, experience with, and consequences of cannabis and psychedelics use. The main statistical analyses used were multivariate linear and logistic regression analysis, which identified the effect from having a spiritual motivation for cannabis use on various aspects of the cannabis experience while controlling for a range of demographic, personality, and drug use variables.The study employed a mixed methods research design that involved both qualitative interviews and a quantitative survey. Participants in interviews (p < .05) of experiences of insight, connectedness, joy, love, and unity with transcendent forces.Respondents differentiated clearly between the use of psychedelics and cannabis. Their use of the psychedelic drug they chose for the survey was restricted to a median of 1–10 use occasions per year, and 69% of participants endorsed having a spiritual motivation for use. Cannabis, on the other hand, was used a median of 51–100 times per year, and 25% of participants endorsed having a spiritual motivation for use. This minority of spiritual cannabis users differed significantly from non-spiritual users in how they approached cannabis use and in the type of experiences their use gave rise to. In multivariate logistic regression models, spiritual motivation was a significant predictor (The study found evidence of a group of spiritual cannabis users who tended to regard cannabis as an entheogen. These spiritual cannabis users had a different mode of engagement with cannabis than recreational users, and reported cannabis experiences that in some aspects resembled experiences with psychedelics. Recent research has not given much attention to spiritual aspects of cannabis use, but the study indicates that spiritually motivated use remains prevalent and deserves further study. Cannabis has a long history of use in spiritual contexts Fuller . Archaeospecialness as the central basis on which people deem certain things as belonging to the domain of religion or spirituality. If spirituality is about ‘things set apart’ and marked as special because of their anomalous nature, anything that is normalized can only have a tenuous connection to the spiritual.As cannabis use became normalized in Western societies during the 1970s and 1980s, however, it seems to have lost much of its spiritual connotations and became, in Fuller’s words, “just one more intoxicant alongside others” Fuller , p. 145.The normalization of cannabis use is reflected in surveys of usage patterns. According to the 2019 World Drug Report (UNODC (United Nations Office on Drugs and Crime) Writers who emphasize the spiritual potential of cannabis often warn against overuse. “With this plant you can free yourself and you can go into other realms of reality, transcendental realms of reality,” the Brazilian ayahuasquero Mariano da Silva , p. 166 Previous research has identified five primary motivations for cannabis use: coping, enhancement, social, conformity, and expansion , meaning soul or mind, and δηλείν (delein), to reveal or manifest. The classical psychedelics include mescaline (the active constituent of the cactus peyote), psilocybin (the active constituent of ‘magic mushrooms’), lysergic acid diethylamide (LSD) and N,N-dimethyltryptamine (DMT). Especially when used in spiritual contexts, psychedelics are also sometimes referred to as ‘entheogens’, which is derived from ἔνθεος (entheos), meaning inspired or filled with God, and γενέσθαι (genesthai), which means to come into being.The article is based on an explorative mixed methods study involving both a quantitative survey and qualitative interviews. The study aimed to explore the characteristics of spiritual cannabis use as compared to both psychedelics use and what may be called recreational or non-spiritual cannabis use. As many cannabis users have both medical and recreational motivations for use, the study did not differentiate between medical and other forms of use; one item in the motivations battery of the survey allowed participants to indicate that they used cannabis for medical conditions. The basic hypothesis of the study was that most respondents would differentiate clearly between entheogens such as the classical psychedelics and recreational drugs such as cannabis and alcohol, but that a minority would regard cannabis as an entheogen. I expected to find significant differences between spiritual and recreational cannabis users in how they approached the drug in terms of motivation and usage pattern.norshroom.org, psychonaut.com, norcan.org, www.dmt-nexus.me, various Reddit groups, and actualized.org, either via general recruitment threads that explained the purpose of the study and invited people to participate, or via private messages to individual users who had previously posted to threads comparing cannabis and psychedelics. Criteria for selection were adulthood (18+) and current or past psychedelic use in self-identified spiritual contexts; these criteria were stated clearly in initial invitations, and no individuals expressing a wish to participate in the study were in fact excluded. Interviews were asynchronous and Internet-mediated, and participants were encouraged to interact with the interviewer via anonymized email or messaging that protected their identity from the researcher. Most interviews lasted from two to four weeks. In communications with interviewees, the term ‘spiritual’ was left undefined to avoid imposing limits on its content. This approach, inspired by Ammerman . Because privacy criteria were fulfilled, NSSDS waived ethical approval for the second part of the interview study, as well as for the survey. The study emphasized the preservation of participant anonymity, and aimed to ensure that no participant would be identifiable either to the researcher or to readers of published material. A few narratives have been translated from Norwegian, and statements have been edited for brevity and relevance. Insignificant details have sometimes been altered to preserve anonymity. Participants gave their informed consent to be included in the study, and were asked to read through and verify the use of their narratives. As interviews took the form of written communication (email or private messages at the forum), transcription was unnecessary. Data were analyzed using thematic analysis , the ability to understand English well, and having experience with a commonly used psychedelic drug. Individuals who did not meet the inclusion criteria were linked to a shorter version of the survey, and their data were not used in the analyses. Respondents reported using between 10 and 30 min to complete the survey.Participants for the survey were obtained from seven communities: N,N-dimethyltryptamine), Ayahuasca , smoked DMT , LSD (Lysergic acid diethylamide), MDMA , Mescaline/Peyote, Psilocybin/Magic mushrooms, and Salvia divinorum. The survey asked participants to choose one psychedelic drug from this list that they had experience with, and they were queried about their motivations for the use of this drug and asked to characterize emotional, cognitive and relational aspects of their most meaningful experience with the drug, of a typical experience, and of their worst experience. This included an assessment of the meaningfulness of the experience taken from Griffiths et al. , but when the gender variable was used as a control in statistical analyses, seven participants who indicated an “other” gender were excluded from the analysis. Education was quantified from 1 = “Have not completed high school” to 6 = “PhD”. Participants were also asked about their religious or spiritual background and their present religious or spiritual affiliations, as well as their current spiritual practice. Further questions examined their usage history and/or present use of cannabis and the psychedelic drugs of the 2C family , 5-MeO-DMT , four were in stable relationships (one with children), six were single, and one in the middle of a break-up. Eleven held steady jobs in retailing, education, music teaching, journalism, industrial services, IT consulting, accounting, and as a hospital worker, one was a business owner, two were students, one was unemployed, and one used to work as a kindergarten assistant but was recently disabled because of an inherited condition.I have had many spiritual experiences with cannabis, and continue to use it for this purpose, although my overuse has dulled the experiences a bit. (ID11)The other trend involved interviewees who were consciously limiting their usage frequency in order to maintain the spiritual value of their cannabis practice. Their usage pattern varied from about once per week to a few times per year:My personal experience with cannabis has been very helpful. When I don’t use it for a week or two I’m getting very good trips. It feels like during my trip a part of my brain gets unlocked. (ID09)Because it is very intense for me, I only do cannabis a few times every year. Also it’s my experience that if I do it too often it gets less intense, and therefore less meaningful for me. I want it to be a special, transformative, revelatory experience, and in order to give it the space it needs I must portion it out. (ID19)In interviews with spiritually motivated cannabis users, there were two main trends for usage pattern. The first involved interviewees who were currently daily or near-daily users. For the most part, these people acknowledged that frequent use diminished their cannabis experiences, but maintained that this usage pattern was still of spiritual importance to them:I experimented with cannabis because I was curious about it. The first five times or so – this was over a period of maybe six or seven years – it didn’t do anything for me. Then suddenly my world exploded with spiritual revelation. (ID19)I have searched for a religious/mystical experience since I was a boy. I came across information about LSD, the Gospel of Thomas, and the Tibetan Book of the Dead on the Internet when the rest of my class in high school was on a trip abroad. (ID30)Participants in interviews were asked about their motivations for starting to use entheogens, and sorted themselves into three different groups. The first group entered into the world of entheogens as part of an explicitly spiritual quest, choosing to engage with these drugs in order to obtain spiritual experiences. The second group expressed a general curiosity about the psychological effects that was not explicitly spiritual, but involved a wish to explore the realm of inner experience, and the third group was just socializing, partying, and having fun. Regardless of their initial motivation, all these interviewees eventually developed a spiritual motivation for continued entheogen use.I found that moderate cannabis use very useful in maintaining a relaxed and meditative state of mind. I found that being in such a state most of the time meant that my conscious mind had a more efficient connection to my sub-conscious mind, which I believe to be the incarnate link between the consciousness of the animal and the Spirit that dwells ‘within’. (ID25)Cannabis changed my life. It brought me into contact with something larger than life – a spiritual dimension to my existence. It made me realize what I now regard as fact: that there is much more to our human existence than we are usually aware of. This earthly life is only a small part of our true life, and to die from this world is only to return home. (ID19)Cannabis is definitely psychedelic for me and expands my consciousness, but most times when I smoke my mind also gets quite foggy. Clear and discerning thinking is not as possible like on other psychedelics, therefore the others are far superior for me. (ID12)Interviewees described entheogenic experiences as being characterized by insight into self, relations, and world, inner visions, feelings of peace, joy, and love, and occasional peak experiences involving ego dissolution and what was interpreted as contact with transcendent forces. The majority did not count cannabis as an entheogen, however, and described the cannabis state as one of peaceful relaxation. Those who did regard cannabis as an entheogen usually – but not always – saw it as less intense than the classical psychedelics. Interviewees who valued the spiritual dimension of cannabis often had a meditative or introspective approach to it.Entheogens have helped me to see the wonder in life, and as a by-product, I have felt renewed energy in my studies at my university and my overall attitude. I feel very grateful for my family and all of those close to me. Life is good! (ID31)Entheogens helped me realize the importance of letting go rather than clinging on to anger or grief. Another thing is that ‘I am my own responsibility’ and therefore have to take ownership of my own emotions, plans for the future, economy, relations, etc. (ID23)Marijuana seems to open up a part of my mind which seems to be able to think higher, better, and more lovingly than without it. Some of my biggest and most successful changes made in my small business have been thought up while under the influence of marijuana. I have also healed a ton of my anxiety, depression, and social anxiety with marijuana. (ID11)Asked about negative consequences, interviewees emphasized the dangers of overuse. Because cannabis and 3,4-Methylenedioxymethamphetamine (MDMA) were seen as giving rise to less intense experiences than other entheogens, they were regarded as easier to overuse. Participants also pointed to a tolerance effect where over-frequent use reduced the intensity of the experience.If you overdo it, you will have less and less interesting experiences. (ID30)I cannot abuse mushrooms in the same way as cannabis. In a way I get filled up by a mushroom trip. Cannabis is not as intense an experience. (ID26)When asked to describe the long-term consequences of their entheogen use, participants in interviews pointed especially to psychological healing and personal growth. They claimed that entheogens had helped them deal with existential issues, personal problems such as social anxiety, and medical conditions such as depression, post-traumatic stress disorder, and addiction to alcohol, nicotine, and gambling. Different interviewees usually emphasized different entheogens as being especially helpful to them, but there were no discernable trends that differentiated cannabis from other entheogens.t = 2.68, df = 317, p = .008), were more likely to be a pensioner , and had higher scores on the personality traits openness  and conscientiousness . See Additional file t = 0.73, df = 263, p = .466), which was the main explanatory variable used in this study. Respondents were free to choose which psychedelic drug they would describe their interaction with in the survey, but usually chose a drug they had much experience with relative to other psychedelic drugs. In paired t-tests, the mean number of use occasions for their chosen drug significantly exceeded that of all other psychedelic drugs at p < .001.A total of 527 forms were submitted, but 202 of these were empty or near-empty and were excluded from analysis. Six responses with substantial discrepancies on repeated drug use assessments were also excluded. Of the 319 included participants, 213 completed the full survey, while 106 opted out from parts of it. There were a number of differences between the two groups: among other things, participants who completed the study had higher education .Participants reported substantial differences in their usage patterns for cannabis and psychedelics Fig. . They reParticipants reported significant differences in their motivations for cannabis and psychedelics use Table . For canFurther statistical analysis focused on the differences between spiritual and non-spiritual cannabis use. Multivariate logistic regression analyses supported most of the differences identified in Table Participants were asked to characterize emotional, cognitive and relational aspects of a typical experience with cannabis and a psychedelic drug. For most characteristics, they reported significant differences between psychedelic and cannabis experiences Table . The disThe spiritual motivation variable retained its impact in multivariate logistic regression models that controlled for a range of demographic, personality, and drug use variables. In these models, having a spiritual motivation for cannabis use significantly predicted most of the characteristics in Table Participants rated the consequences of their drug use as neutral or positive on all indicators, with significantly higher scores for psychedelics than for cannabis Table . SpirituIn order to control the figures for cannabis use for the effects from possibly confounding variables, multiple linear regression analyses were performed using the five-level Likert scales as dependent variables Tables . The anaIn this study, it was clear that cannabis means different things to different people. Many of the participants in the study drew a clear line between cannabis and psychedelics in terms of both their motivations for use and the characteristics of experiences. While often attributing spiritual and self-developmental characteristics to their psychedelics use, which was limited to a median of 1–10 use occasions per year for their chosen psychedelic drug, they regarded cannabis as a drug that could be used quite frequently for the more mundane purposes of recreation and relaxation. In the terms of Simons et al.’s  model foIn interviews, spiritually motivated cannabis users often reported having meditative or introspective cannabis sessions, while recreationally motivated users did not report such an introspective focus. This finding is congruent with the advice from Gray  that canParticipants in interviews often emphasized their intention of maintaining a moderate usage frequency of cannabis in order to preserve its spiritual value, or, in some cases, acknowledged that over-frequent use had somewhat diminished their cannabis experiences. Interviewees generally found that because of a build-up of tolerance, overuse of entheogens would entail a loss of effect, and it seems likely that habitual cannabis users experience cannabis as relatively mild because of such tolerance. This finding is congruent with research that has obtained evidence of tolerance to the subjective intoxication effects of cannabis (Colizzi and Bhattacharyya Both interview and survey respondents reported that cannabis and psychedelics use had an overall positive impact on physical and psychological health, personal happiness, sociability, and spiritual practice. Spiritually motivated users reported significantly better consequences for psychological health and spiritual practice, while users with an escapist motivation reported significantly worse consequences for psychological health, sociability, and personal happiness. These findings generally agree with Bresin and Mekawi’s  meta-anaThe main limitations of this explorative study were that participants were recruited via online psychedelic communities, and had to self-select for participation. It has previously been found that participants recruited on the Internet have more education and higher incomes (Hamilton and Bowers The study suggests several directions for future research. In the survey sample of psychedelics users, 25% endorsed having a spiritual motivation for cannabis use and reported cannabis experiences that, at least in some respects, resembled experiences with psychedelics. It would be interesting to know the extent of spiritual cannabis use among other samples of cannabis users: is this a widespread or a marginal social phenomenon? It is possible that the psychedelics users recruited for this study are more spiritually inclined than nonusers are and that selection bias has affected present findings, but it is also possible that a substantial proportion of the general cannabis-using population would endorse having a spiritual motivation for use, if only someone asked them about this. Furthermore, if some form for entheogenic spirituality based on cannabis use is widespread in Western societies, we should know more about its characteristics. The question of how usage frequency impacts on the intensity and meaningfulness of spiritual cannabis experience via a tolerance effect also deserves further investigation, for instance via a retrospective study that asks participants to rate and compare past and present experiences.The majority of cannabis users in this study regarded cannabis as a recreational drug devoid of entheogenic features. A minority of the sample endorsed having a spiritual motivation for cannabis use and regarded it as an important entheogen, although not necessarily as efficacious in this regard as the classical psychedelics. Such spiritual users differed from recreational users both in their mode of engagement with cannabis and in the type of experiences obtained. Recent research has not given much attention to spiritual aspects of cannabis use, but the study indicates that spiritually motivated use remains prevalent and deserves further study.Additional file 1. Supplemental online material: Survey questionnaire as PDF, SPSS dataset, and online appendix.