Simulation enables learners to practice new skills in a supportive environment. Largely driven by the COVID-19 pandemic, simulation via telepractice, i.e., telesimulation, has emerged. Viable delivery of telesimulation requires consideration of the adaptations needed to conduct simulation via telepractice. The aim of this study was to design and pilot test the feasibility of using telesimulation to provide training in infant feeding management. An iterative process was used across four phases: (1) simulation design, (2) telesimulation adaptations, (3) user testing, feedback, and modifications, and (4) user testing of modified simulation, feedback, and final modifications. During Phases 1 and 2, team members worked together to design and test telepractice adaptations for a simulation experience. During Phases 3 and 4, the telesimulation was pilot tested with a group of speech pathologists, with feedback sought via open-ended survey questions and/or an optional focus group. Manifest content analysis was used to interpret user feedback. In Phase 2, several adaptations were explored to optimize telesimulation delivery and engagement, including Zoom® functions  and supplementary video/auditory files. There were 11 participants across Phases 3 and 4. Specific feedback centered around simulation preparation and structure, session practicalities, supports for realism, Zoom® functions, group dynamics, participants’ experiences, and future enhancements. An overall list of recommendations for telesimulation was generated. Telesimulation for feeding management was considered feasible and participant feedback was favorable. Further research is required to investigate if the learner outcomes of telesimulation are comparable to in-person simulation for infant feeding management. Simulation is widely used in healthcare training and highly regarded for its ability to enable learners to practice new skills in a supportive and safe clinical environment –3. It faTo help improve access to simulation learning experiences, the concept of telesimulation has recently emerged. Telesimulation is defined as “a process by which telecommunication and simulation resources are utilized to provide education, training, and/or assessment to learners at an off-site location” . Telesimulation as a teaching modality has been explored in medical and nursing education –8 and inPediatric feeding disorder (PFD) is estimated to affect one in every 23–37 children under the age of five . The escThis study employed an iterative action learning process to develop, trial, and then engage user feedback to evaluate the feasibility of a telesimulation learning experience for pediatric feeding. This process is presented here as four phases: (1) simulation design, (2) telesimulation adaptations, (3) user testing, feedback, and modifications, and (4) user testing of modified simulation, feedback, and final modifications. This study received ethics approval from [name withheld] (HREC/21/QCHQ/80217) and [name withheld] (2021/HE002620).The simulation involved a 3-week-old infant with laryngomalacia and feeding difficulties. Participants worked through information gathering from a nurse, interviewing the parent, completing a feeding assessment and providing recommendations, and providing feedback to the otolaryngologist. The simulation was developed in line with the eleven criteria proposed in the Healthcare Simulation Standards of Best Practice for Simulation Design  Table 11 and in Learning objectives regarding knowledge development, and practical application of assessment, management, and interprofessional communication were developed, targeted at a novice learner with <6-months experience in infant feeding Table . The goahttps://ilearn.health.qld.gov.au/d2l/login). This online learning framework was developed as a national resource using a working group of clinicians from across our state and involved literature review, consultation, and external peer review. Other preparatory videos illustrating infant oral reflex assessment, positioning, and feeding equipment were also distributed. The pre-brief session commenced with an ‘ice-breaker,’ which served as an opportunity for participants to establish a psychologically safe learning environment and included personal goal setting for the session. There was time dedicated during the pre-brief to explain the concept of simulation and the expectations for the session, as well as exploring the learning objectives  acted as the parent/nurse/otolaryngologist, and Facilitator 2 supported discussion and decision-making for the group. Facilitator 1 (Author 1) had considerable clinical experience in pediatric feeding, affording a high degree of content knowledge, which allowed for flexibility in response to participant actions that may have slightly differed from the planned script. As this was planned as a low-fidelity simulation, Facilitator 2 also provided additional auditory cues to support assessment/management during the simulation . Before the simulations were run, the facilitators met on three occasions to complete training and troubleshoot any issues .Three members of the team  met on two occasions to troubleshoot translating aspects of the in-person simulation scenario into a virtual medium (via Zoom®). Some guidance was taken from previous literature in medical education , 30, 31.It was determined that use of the ‘spotlight’ function to highlight the active participant and the simulated parent/nurse/otolaryngologist would be useful from the participants’ viewpoint see Fig. . The ‘spFor the pre-brief section, use of the virtual whiteboard and polling functions within Zoom® was explored in setting up the ice-breaker tasks. The virtual whiteboard was used to brainstorm participant-specific goals for the session, and these were reviewed during debrief at the end of the session. The part-task activities were carefully designed to enable transfer to a virtual medium and included the use of video interpretations, discussion-based tasks, and an equipment sorting activity in breakout rooms with smaller groups. For example, participants watched videos of infants feeding and practiced identifying indicators of respiratory distress with the support of the facilitators. It was determined that it would be valuable for participants to have a doll or plush toy available with them to support skill development in oral reflex examination and for use during the session .During the simulation itself, from a physical perspective, the team explored the visibility of the infant/mother and their relative distance from the camera. For the infant/mother portion of the simulation, use of a virtual background impacted on how well the infant mannequin could be seen, so a decision was made to use no virtual background and seat the mother against a dark wall wearing dark clothing. The infant/mother were situated 1.5 m from the camera, on a chair that had a swivel capacity, so that the participants could instruct the mother to move to manipulate their view more easily. Simple costumes  were used to help support realism for participants  using convenience sampling through distribution of an expression of interest. Prior to the session, following the informed consent process, participants were asked to report their experience in infant feeding. For the purposes of this study, participants with <6-months infant feeding experience were considered to be ‘novice’ practitioners, and participants with >6-months experience were considered to be ‘experienced.’ Participants were allocated to either Session 1 or Session 2 based on availability and self-identified experience levels.Pilot testing of the developed simulation program for Session 1 occurred with a cohort of five participants, two of whom were novice and three were experienced . Focus groups were conducted virtually via Zoom® and were 20–30 min in duration. As not all participants completed the survey, the same questions were posed during the focus group to allow all participants the opportunity to respond. Additional probes for exploration during the focus group were developed based on responses from the anonymous survey. The survey/focus group guide is provided in Table Results from the feedback survey and the focus groups were interpreted using manifest content analysis  and are Three participants completed the survey and two participated in the optional focus group . As the survey was anonymous, it was not possible to discern whether participants in the focus group also completed the survey. Quotes are presented in the text below with an identifier . Quotes with no identifier were derived from an anonymous survey response.Overall, seven categories were agreed upon regarding Session 1 feedback. These included feedback regarding (a) simulation preparation and structure, (b) session practicalities, (c) supports for realism, (d) Zoom® functions, (e) group dynamics, and (f) participants’ experiences of the simulation. Specific coding associated with each of these categories and the learnings applied for Session 2 are presented in Table simulation preparation and structure, participants reported that the pre-learning activities “set up the course well” and one participant felt that “…if you hadn’t had done that first or even had that theoretical refresher with [Facilitator 1] before getting into the SIM [telesimulation], it would have been really challenging…” (Clinician 1). Participants also appreciated the ‘ice-breakers’ at the beginning of the session and commented that they helped them feel that “others were in the same boat” and that “they’re safe people” (Clinician 2). Participants enjoyed that the activities were layered to build up to simulation participation, i.e., “you sort of built up…you had these little practical tasks along the way prior to getting into the full-blown sim…” (Clinician 1). The overall flow of the simulation was considered to be appropriate by multiple participants.In session practicalities, multiple participants reported that time was an issue during the session. Specific areas for improvement included allowing adequate breaks, increased time for discussion of management options during the simulation, and increased time for the debrief. One participant suggested “it would also be helpful just to have more time to sit to pause and discuss what is the rationale for [that]?” (Clinician 2). This feedback resulted in the extension of Session 2 by one hour. There was also an issue with breakout room initiation, where participants left to join a breakout room prior to having the activity explained to them. This was remedied for Session 2 by not initiating breakout rooms until after the activity description had been completed. Finally, on the day of Session 1, there was a state-wide internet outage, which impacted participants’ ability to join into the Zoom® session at the scheduled start time. This resulted in some participants being late to join in, there was a malfunction of the breakout room function, and some lag with Microsoft PowerPoint® sharing, which caused the session to run slightly late. Participants recognized these issues noting that the “only tech issues were from the…internet.” The team discussed ensuring that contact details are provided to support troubleshooting in the event that participants may be experiencing any technical issues.Regarding supports for realism during the simulation. One participant reported “[Facilitator 1]’s acting was really good and it actually felt very realistic. It made me feel like I was in that clinical situation with how stressed she was…” (Clinician 1). Several participants described that there was not enough auditory information  to participate in the initial assessment with the mother/infant. One participant described their experience:I was sort of holding back and waiting for that [auditory information]. But in waiting for that I was seeing the monitor go up and then getting quite anxious that I wasn’t doing anything. Um, so that was just something that I had to overcome, be like, okay, well, we need to stop, obviously. (Clinician 2)Participants described that the backgrounds, costumes, vital signs monitors, and the “real-looking doll” were all helpful Subsequently, a decision was made to add recordings of infant stridor sounds and more auditory assessment points from Facilitator 2 for Session 2.Zoom® functions, participants reported that use of the ‘spotlight’ function in Zoom® meant that “only the clinician role-playing and the presenter were viewed—this really helped to ‘get in to character’ and act like we usually would in a work scenario.” Although the facilitators had intended to use the ‘hand-raise’ function during the session, this was not used consistently, and several participants reiterated statements regarding preferring to have used the hand-raise function, for example, “to make sure that I’m giving other people opportunity… I would have appreciated maybe more consistent use of the hands up…” (Clinician 1). Subsequently, the facilitators planned to more clearly explain and reiterate use of the hand-raise function for Session 2.Regarding the Group dynamics were an important consideration in setting up the simulation experience to support psychological safety. Participants fed back that the group size of six participants was good, allowing participants to “share ideas/opinions with comfort,” get a “decent go at doing the practical tasks” (Clinician 1), and to “learn and to grow and also make mistakes” (Clinician 2). Having a mixture of experienced clinicians and novice clinicians was viewed as valuable, but it was important to identify different levels of experience early in the session so that the participants are “all on a level playing field” (Clinician 2).Yeah, I was, I was glad that there were some other people that were fairly new to, like Ped [pediatric] feeding clinical work as well. So I think it’s important to have not just one person who’s the newie (Clinician 2).One participant identified that not having any direct supervisors in the group was helpful to her “comfort” and that “if one of my supervisors was there as well, it might then create a bit more anxiety if I were to make a mistake while learning in that space” (Clinician 2).participants’ experience of the simulation put them in a “good headspace.” The case was considered to be “bread and butter” for an experienced clinician but challenging for a novice. One participant reported experiencing some stress during the scenario, although this was more to do with the authenticity of the set up than the simulation experience itself. Participants reported the simulation was “convenient and easy to access” via Zoom®.In general, Following user feedback, modifications were made to the program and a second set of clinicians completed the revised simulation program. This group included six participants, three of whom described themselves as novice practitioners and three of whom were experienced. More participants from Session 2 had participated in simulation experiences previously, although this was predominantly during undergraduate study. The median score for nervousness was 3, ranging from 2 (a little nervous) to 5 (very nervous) (Table Four participants completed the anonymous survey following the telesimulation and four (identified as Clinicians 3–6) participated in the optional focus group (Focus Group 2). Data from both the survey and the focus groups were interpreted using manifest content analysis. Again, six categories emerged, including (a) simulation preparation and structure, (b) session practicalities, (c) supports for realism, (d) Zoom® functions, (e) group dynamics, and (f) participants’ experiences of the simulation with the addition of a new category, “future enhancements”  and setting the expectation that “this was a learning opportunity and not an assessment.” When considering the debrief, participants reported that having the opportunity to “reflect at the end on what I learnt/gained from the experience” was helpful. With regards to session practicalities, participants reported again that they benefited from the pause-discuss format of the simulation, but that there was not enough time for an adequate debrief at the end of the session.Regarding supports for realism, audio clips depicting stridor in the infant were played and increased facilitator cueing was added into the second presentation of the telesimulation learning experience. This, however, resulted in excessive audio-visual activity, which was reported as “distracting” by the participants. The audio quality of the stridor sounds was also described as poor, with one participant commenting, “The sound to me kind of sounded like a cough, but it was actually stridor.” (Clinician 4). As such, the team made the decision to limit auditory information to facilitator cues only for the future and to complete careful scripting and rehearsal of this cueing. Participants again described the overall experience as realistic, commenting particularly on the acting and costumes of Facilitator 1.In response to feedback from Session 1 and to facilitate Zoom® functions, participants fed back that the “hand-raising function worked well to ensure no one spoke over the top of each other” in this session. Additionally, participants enjoyed use of the virtual whiteboard function in Zoom® and felt that the “multiple methods of communication  gave different participants a chance to contribute in a way they preferred,” which was identified as an additional benefit of the telesimulation modality. One participant described feeling that the telesimulation modality allowed them to participate more equally than if they were in-person:Yeah so, one thing that I thought was a great advantage of the telehealth setup was that we were all very much even, it was a very equal experience. Because typically, you know, you walk into a room where potentially a group are quite familiar with each other and they might sit next to, you know, one another, if they’re already well known. And equally, there’s a bit of an ordering in terms of your approximation to the person presenting, etc. And so the fact that we can all visibly see each other, very equally, I thought was a real advantage. (Clinician 3).In This same participant commented on the disconcerting nature of the camera, describing that “when you can actually see yourself the whole time, I think it does add an extra level of intensity and an added level of self-consciousness perhaps” (Clinician 3).group dynamics for Session 2 were different to Session 1. Despite there being more novice participants in Session 2, two novice participants felt uncomfortable to participate, reporting that they “…would have felt more comfortable in a group with other more novice speechies [speech pathologists] in this area” (Clinician 6) and suggesting that novice and experienced clinicians should be split. These clinicians described “feeling inferior to the other clinicians in the group who work with feeding on a daily basis.” Conversely, other participants in the group “loved having a mix, because it created a bit of a safe space” (Clinician 3). These participants described the value of having different perspectives in the group, stating things like “…actually if there are people going back to the basics, asking pretty simple questions, it makes it safer to then be a bit more vulnerable in the learning process, I think” (Clinician 3). Multiple participants also valued the modeling of clinical skills that more experienced clinicians could provide. The research team discussed this issue at length and decided that the benefit of incorporating a group with varied skill mix outweighed the risks in this scenario, but that further preparation opportunities should be provided to novice participants so that they know what to expect during the simulation experience.The participant experiences, where some participants reported feeling uncomfortable and a lack of confidence to volunteer, describing that “they were happy to just sit and observe and learn” (Clinician 5). Other participants in the group, however, reported positive experiences, including that the simulation increased their confidence and consolidated their knowledge, describing it as a “rich learning experience” (Clinician 3) that “met my expectations.” One participant reported that the format of learning for them was more accessible:“I accessed this learning experience without having to leave my worksite and therefore feel that the telehealth format, for me, reduces some barriers to learning .”Skill mix issues did influence the report of future enhancements for the telesimulation experience, including that future cases could include increased social complexity or be conducted over multiple sessions . Further opportunities for peer discussion regarding problem-solving and case management, particularly about “what you wouldn’t do or when things don’t go to plan” (Clinician 3) were reported as suggested future inclusions. Finally, split breakout rooms between novice and experienced clinicians for part-task sessions were suggested to support more targeted discussions at similar skill-mix levels.Finally, this group raised several suggestions for A final list of general recommendations for telesimulation based on these findings is presented in Table This research used an iterative approach across four phases to design, pilot test, and refine an infant feeding management telesimulation. Previous research in telesimulation has predominantly explored training and development for medical and nursing staff , 30, 31.The outcomes of this research suggest that telesimulation may be a solution to providing practical training opportunities for clinicians that may not otherwise be able to access these due to geographical separation. Other studies in this area have also supported the feasibility of telesimulation for remote participants , 35. It There were several technical features adopted during the adaptation process that were considered to be critical to the success of transitioning simulation to the telepractice modality, including changing backgrounds and tile labels, screen sharing, use of the spotlight function, polling, the virtual whiteboard, and hand-raise function. The preparation sessions with the facilitators during telesimulation design were essential in developing familiarity with the different Zoom® functions. Use of the ice-breaker sessions during the first part of the simulation also allowed the participants to familiarize themselves with the view, mute, and hand-raise buttons. This allowed the facilitators and the participants to focus on the activity instead of the Zoom® logistics during the simulation itself. Ensuring participants had a doll or teddy-bear available locally also supported practical activities, such as oral reflex examination and positioning. Future adaptations could include sending preparatory materials for participants regarding the Zoom® platform itself .Multiple participants commented on the authenticity of the simulation, which was contributed to by the use of virtual backgrounds and costumes, the screen sharing of the vital signs monitor, and the “quality of the acting.” Visual supports including the backgrounds, costumes, and monitor were specifically designed to replicate those that might be observed in a clinical environment. Use of a simulation-trained clinician and content expert to act as the parent allowed for spontaneity and flexibility in response to the simulation direction . This increases the realism and authenticity of the experience for participants and is suggested as the reason for perceived high-quality acting. It is known that clinical accuracy of the simulated patient contributes to the fidelity of the simulation and is important for learner outcomes . This prThere were differences in group dynamics between the two sessions. In Session 1, participants indicated that they enjoyed the variation of clinician experience within the group, as it allowed for a feeling of safety for novice participants , and experienced participants were able to act as models for learning and consolidate their knowledge, creating a peer learning opportunity. Certainly, this has been the experience of the research team in previous in-person simulations. In Session 2, however, two participants did not feel comfortable to engage, as they felt they did not have enough baseline knowledge/experience to contribute. It is unclear why these novice participants were different to those in Session 1 in terms of comfort to participate, but it was clear that they did not feel psychologically safe enough to engage. Given simulation is new to many speech pathologists, it was felt that further information regarding structure and content prior to the simulation for these participants may have been helpful to prepare them with regards to expectations and readiness to engage. Distributing a telesimulation agreement prior to the session with details regarding confidentiality and learning expectations is in line with recent telesimulation literature . FinallyIt is acknowledged that this simulation only catered for speech pathologists and was targeted at a specialized area of speech pathology care. Additionally, this pilot work only included a small sample size. Future studies could explore application of telesimulation across multidisciplinary teams and/or across different areas of speech pathology practice.Telesimulation for infant feeding was considered to be feasible, and participants reported generally positive experiences. Adequate preparation, familiarity with the various technological enhancements, small group sizes, and thorough pre-briefing were important success factors for telesimulation. Further exploration as to whether learners can achieve the same outcomes in telesimulation as compared to in-person simulation is now required.


In most traditional African contexts, including Ghana, menstruation is largely treated as a taboo and humiliating topic that is rarely discussed openly. The main aim of this study is to assess perceived factors influencing menstrual hygiene management among adolescent girls in Ghana´s Savannah Region, West Gonja Municipality.we conducted a descriptive exploratory qualitative study among adolescents who had reached menarche. Purposive sampling was used to conduct 24 interviews with 18 teenagers and 6 mothers. Data were analyzed using the thematic content analysis.the majority (55.5%) of respondents were ≥15 years with maximum and minimum ages being 19 and 13 years respectively. The mean age was 15.7, with a standard deviation of 1.8. A higher proportion (38.9%) of respondents were in their final year (JHS 3). Before menarche, all adolescent girls had heard about menstruation, mostly from their mothers, then from instructors and friends. During menstruation, all of the girls in this study used absorbent products. The cost, comfort, heaviness of menstrual flow, and accessibility influenced the choice of absorbent material, with some respondents utilizing multiple absorbent materials. Some girls were forced to dry their reusable absorbent material in their room because of shyness. Girls thought that reusing absorbent materials after drying them in the sun would have killed germs and removed unpleasant odours. During menstruation, girls are barred from participating in social and religious activities.culture and religion have very dire consequences on effective menstrual hygiene management. There is therefore urgent need to dispel the growing myths and misconception on menstrual hygiene as well as providing support for adolescent girls for practicing good menstrual hygiene. Menarterials” . Menstruterials” . Like Ghterials” . As a reterials” .Girls are forced to face fear, humiliation, and guilt during menstruation due to a lack of prior information about menstruation . StillbiFurthermore, studies conducted in Ghana have showed that the prevalence of poor MH ranges from 19.8% to 68.9% among adolescent girls ,14,25,26Study setting: this study was conducted in the West Gonja Municipality of the Savannah Region of Ghana. Damongo is the capital of the municipality as well as the regional capital. The study setting was chosen because no study on this topic was conducted in the area. As a new region, these studies are essential to the policy making in the areas of sanitation, water and girl child education.Study design: descriptive exploratory design using qualitative approach was used.Sample population: the study included adolescent girls who had had their first menses. These girls were enrolled because they had had at least a menstrual cycle and so could provide relevant information based on their respective experiences.Sample size and sampling technique: participants could speak English or Gonja. A purposive sampling technique was used in this study to select participants. The researchers recruited eighteen (18) adolescents for face-to-face individual interviews. Also, six (6) mothers were recruited into the study to provide in-depth information on MH to clarify and support information adolescents provided. The sample size was determined when saturation was reached.Data collection tool and procedure: the interview guide was developed after reviewing similar studies. The interview guide was structured in relation to the study objective. The interview guide was pre-tested in three (3) adolescents and one (1) mother. The interview guide was also shared with senior colleagues with considerable knowledge on the subject to do a face validation. All comments arising from peer validation and pre-testing were addressed before the data collection commenced. The Interview guide for both adolescent girls and mothers included questions on socio demographics characteristics, knowledge on menstruation, practice of MHM and factors influencing MHM. All questions were open ended. This allowed researchers to probe to unravel all issues. Participants who had had their first menses were introduced to the researchers. Participants were given the option of indicating date, time, and location of their interviews. The majority of the interviews took place in the participants´ homes, with a few of them taking place in school. In all, 24 interviews were conducted, comprising 18 adolescents and 6 mothers. The interviews were performed in either English or Gonja, with an interview guide based on the study´s goals. The participants gave their permission for the interviews to be recorded. The interviews in English were transcribed verbatim, whereas the interviews in Gonja were transcribed based on their meaning. A Gonja language specialist was asked to authenticate transcripts that were in Gonja, and the procedure was kept discreet. The interviews ranged from 20 to 35 minutes in length.Data analysis: a manual thematic content analysis was used to analyse the data. Audio recordings were transcribed verbatim. Transcribed data were double-checked for correctness. Researchers coded transcribed material separately before having many discussions to produce themes and subthemes.Ethical Consideration: the ethical approval was obtained from the Committee on Human Research, Publications & Ethics (CHRPE) with a reference number (CHRPE/AP/199/20). Also, permission was granted by the District Education Directorate for the study to be carried out. Parents or guardians of all participants had signed written consent and all participant (less than 18 years) assented to participate in the study. Respondents had the liberty to withdraw from the study at any point in time. Anonymity was maintained by representing participants with numbers.Demographics of adolescent girls and mothers:“…I was told that at a certain point in my life I would see blood from my vagina. I was informed to report to an elderly woman in the house when I see the blood for support …” .Almost all the participants were informed about menstruation prior to their menarche. However, the information given was scanty and so these girls were required to see elderly women in the family when they started to experience their menses. For some participants, fear and calmness was used to communicate about their menstruation. “…She (my mother) told me that now that I have experienced my menses, I am a woman. She cautioned me to abstain from sex. She added that, my friends would have made fun of me and that I might even die in attempting to give birth or abort pregnancy …” .“…Sometimes, it is difficult because they do not open up on menstruation issues unless they trust you. Usually, they consult their trusted friends for assistance; sometimes, information offered by these friends however is not always accurate…” . Most girls resort to their mothers for information on menstruation before menarche. “..Before I saw my menses, my mother had given me information on menstruation and how to go about it when I would have seen it…” . Most girls had information about menses from their teachers. “…We were taught in school about menses and how to manage them by our science teacher...” .The sources of information on menstruation and hygiene-related issues vary. These sources include; mothers, teachers and friends (peers). Some mothers opined that, some of this information acquired from peers were born out of uninformed talks and full of myths and hearsay. The sources of information on menstruation and hygiene-related issues vary. These sources include; mothers, teachers and friends (peers). Some mothers opined that, some of this information acquired from peers were born out of uninformed talks and full of myths and hearsay. This is what some mothers said: “... I use sanitary pad because it makes me feel comfortable and oftentimes nobody knows that I am menstruating…” . Two (2) participants also used more than one absorbent material during menses. Student_11 said: “…Sanitary pads are good but some makes me develop sores (groin areas). That makes me unable to walk well. To reduce the sores, I used both cloths and pad…” . The advantages and disadvantages of these absorbent materials differ from person to person, and this influences the choice of these materials. It is revealed that, three (3) participants preferred sanitary pads in spite of the challenges. “… I prefer to use sanitary pad, but when the flow becomes scanty or little, I resort to the use of tissue paper or cotton. The tissue does not absorb enough blood and starts to tear up and even gets stuck in the vagina …”  “…I prefer using sanitary pad because with the cloth you need to be extra careful if not you can be exposed…” . Two mothers believed that both cloth and sanitary pads, which were commonly used among girls, had some disadvantages which put them in a dilemma. “…Sometimes, some of the sanitary pads are impregnated with medications but I do not know if it has effect on me, it makes you feel very uneasy whilst wearing it. When you wash the cloth, you must be careful that it is clean enough; otherwise, it can harm you. I therefore do not even know which one to use. But most of my children use the sanitary pad and sometimes, the cloth…” .All participants used absorbent material during menses. The material of choice is dependent on personal preference, experience, merits and demerits of the absorbable materials. The absorbent materials being used are; sanitary pad, cloth, tissue paper and cotton. “…When my children begun to menstruate, they informed me. So, I took them through ways to keep themselves clean. The use of cotton and old cloth are difficult for the first-time users. Now, they are able to use any absorbent material with ease…” .Some girls are told how to manage their menstrual flow with the use of sanitary pad, cloth or cotton. Two (2) mothers indicated how their daughters managed menstrual flow, as you can read in the following extract: “…. I sometimes smelled during my menses. I bathed with antiseptic and sweet-scented soap to take away the smell…” . Five (5) participants strongly disagreed with the use of antiseptic and soap to wash the vagina as this was associated with some discomfort and illness. “…. you cannot wash your genitalia with soap and antiseptic. When it enters the vagina, you would feel some unusual pain. I just use water to wash my vagina.” . Another participant said: “… When I use the soap to wash my vagina, I feel very uncomfortable. So, I think it´s better to wash with water only since it takes away the smell as well…” . During menses, sometimes the menstrual blood may stick on the thighs. For four (4) participants that made them uncomfortable and to relieve themselves, they bathed frequently. Participants bathed twice daily. “.. I usually bathe twice. Sometimes, when the menstrual flow is heavy or the absorbent material is not absorbing enough, some of the blood can leak to the thighs. This can be very discomforting unless you bathe…” .All study participants bathed during menses. The foul odor and sticky thighs due to menstrual blood were the main reason for bathing among menstruating girls. Nine (9) participants used water only to wash the vagina, three (3) used water and antiseptic to bathe and wash the vagina to drive away the odor. “…I usually wash my used cloth after bathing. I wash it with soap and water, and dry it of direct sunlight…” . Shyness compels five (5) participants to inappropriately wash the cloth and as well dry them inside the room “.…sometime when you are washing the cloth and people come in. you become shy, and so to avoid the shyness, you would just rinse it and quickly dry it in the room. This makes the cloth to smell. But if air blows on it, the smell is much better…” .Ten (10) participants held the view that; the cloth needs to be wash with soap and water and dried up of direct sunlight after use. “F I wrap it with rubber and throw it into the bush or put it in dust bin so that it is disposed of with other refuse in the bush where nobody would see it...” . “…I just wrap it with rubber, and then dig a hole and cover it with the earth or dispose it in the toilet...” . The reason for the choice of a disposal site has some cultural influence. This is what two (2) mothers said: “…We were told not to dispose of them in the dust bin or refuse dump because this has traditional ramifications. You may never give birth, if it is seen by a wicked man…” . “…Is not good to dispose of it in the gutter or refuse dump because a pig or dog could pick it up and send it back to the community. So, in this era of ritual money, someone could use the blood for rituals to become rich…” . Factors affecting menstrual hygiene managementIt was revealed that socio-cultural factors, socio-economic factors, social support, availability of and ability to reuse the absorbent material were factors that immensely influenced the practice of menstrual hygiene.There are varied ways in which used sanitary pads and other absorbent materials are disposed of. These include; refuse dump/bush, gutter, drains and toilets. The disposal mode is influenced by some cultural beliefs of the participants. “..During menstruation, we are considered impure until the menstrual blood stops and a special bath is performed to make you pure and thereafter you can participate in religious activities…” . There are some restrictions that are influenced by the culture of the person(s) including cooking, fetching water and others. All mothers said: “...In some housing for older people, menstruating women do not fetch fire from that house. It is because the elders may be tabooing that. Growing up, we were told that, you can ‘spoil´ someone´s ‘medicine´ by fetching the fire. We are not allowed to cook for those people whilst in our menses. If you are selling food, you are advised to let someone help you during these times. In some homes too, a menstruating woman is not allowed to sow seeds and even fetch water for domestic use of the family…” .Religious and cultural practices influence greatly the practice of hygiene. The participants opined that during menstruation, there were some restrictions with respect to the inability to participate in social activities such as cooking, fetching water and others. “..For me my mother supports me with a sanitary pad anytime I experience my menstrual flow. My father too is very helpful, he sometimes gives me money to buy my basic needs. I use a part of it to purchase pad for my usage…” . “.. sometimes, my father gives me money to go and buy pads. Also, my mother always buys them for all of us. So anytime we get the money we give it to our mother to buy them or we just buy them and come and leave them in the room for everybody to use…” .Parents, especially mothers, provide the needed support to the girl during menstruation to enable them effectively manage their MH experiences. “…In our village, nobody sells sanitary pads. So, when you start to menstruate, you are left with no option but to explore other materials including cloth, cotton or tissue paper. To buy them we have to travel a long distance …” .The non-availability of absorbent materials and the distance to getting absorbent materials also hinders their use. Three of the participants made this observation; “… I am a widow. We struggle to get our daily bread. I have heard about sanitary pads, but because of the cost, my children use cloth anytime they experience their menstrual flow. The little money I get is used to buy food…” . The ability to reuse this material has a greater influence on the type of material to use. They think that this would save cost. “…Cloth and cotton are cheap. Moreover, cloth can be used for a longer time. Due to the cost of the sanitary pad, I used it for the first few days of my menses. After two to three days, the menstrual flow became scanty. Now, I use cloth with ease….” .Two (2) mothers held the view that the cost and reusability of absorbent material influence the choice of absorbent material used during menses. This is what a mother said: et al. [The study aims at assessing the perceived factors influencing menstrual hygiene management among adolescents in the West Gonja Municipality of Savannah Region of Ghana. Adolescents´ access to menstrual information and the sources of this information before menarche, almost the respondents received menstrual information before their first period. This finding corroborated to the evidence of Sharma and Gupta  in Indiaet al.  found thet al. [et al. [The main sources of this information were parents/guardians, teachers. The majority of girls received information from their parents (mothers). This is in line with the findings of ,30, who  [et al.  showed t [et al. ,33. Thiset al.[This study also revealed that participants used sanitary pads, old(used) cloth, with a few participants using cotton and tissue as absorbent material. Available literature has shown that the majority of girls used sanitary pads. For instance, 93.8% of respondents used sanitary pads in Nepal , and 67.et al. showed tet al. [The participants indicated that the absorbent materials were wrapped in plastic bags before being disposed. According to Emmanuel and Yawson  and Neupet al.  the majoet al.  where moet al.  revealedet al., [Most of those who use reusable absorbent material clean it with water and soap. This is in line with a study conducted in rural Uganda by Hennegan et al.,  where thet al., . This diet al. [In the current study, some participants dried reusable absorbent materials in the sun. The ideal approach is to dry these materials in the sun since sunlight acts as a natural sterilizer, cleansing the material of any germs that might affect the user´s health . Despiteet al.  observedA minority of the respondents used soap and water in washing their genitalia. This was similar to the study undertaken by Belayneh and Mekuriaw  which reParticipants opined that during menstruation, there were restrictions with respect to worship as well as the inability to participate in social activities such as cooking, fetching water, and others. Religion and cultural practice influence greatly the practice of menstrual hygiene. There is a vast literature available to demonstrate that culture and religion have an influence on menstrual hygiene management -46. In NLimitations: as in qualitative studies, findings in this study are not too generalized. Where generalization is intended, it ought to be done with extreme caution. Also, study subjects were selected purposively as such they might be selection bias.Overall, most adolescent girls are making efforts to practice good MHM. However, culture and religion have very dire consequences on effective menstrual hygiene management. There is therefore urgent need to dispel the growing myths and misconceptions on menstrual hygiene as well as provide support for adolescent girls in practising good menstrual hygiene. Formation of adolescent groups by facilitators to provide information on adequate MHM practices is also needed. Quantifying the dangers related to poor menstruation management, school absence and involvement, and risk sexual exposure, as well as developing cost-effective remedies, in-depth quantitative study is required.Menstrual hygiene (MH) is essential for all women, yet it is still a neglected issue in most parts of the world;Misinformation about menstruation influence poor menstrual hygiene practices.The cost, comfort, heaviness of menstrual flow, and accessibility influence the choice of absorbent material;In Northern Ghana, culture and religion were identified as the key determinants to menstrual hygiene management habits;Sensitization of adolescent girls on their sexual and reproductive health (SRH) before menarche could lead to adequate MHM practices.


Driven by different motivations, we have seen a rise in the demand for “natural”, “preservative-free”, and “clean label” foods. Simultaneously, consumers are expecting safer and also more convenient foods with long shelf lives. This is undoubtedly one of the great challenges of the food industry and an opportunity for “Biotechnology Approaches”.Foods, entitled “Biotechnology approaches in Food Preservation and Food Safety”, was devoted to topics focused on biotechnology approaches in the pre- and post-harvesting of produce, food processing and preservation technologies, and methods for monitoring food safety and quality. Subsequent to the peer review process, three original research articles and three reviews were included in this Special Issue of Foods.This Special Issue of Pediococcus acidilactici BD16 . L-alanine is a nonessential amino acid with a wide range of food, pharmaceutical, and veterinary applications. According to the authors, “the novelty of the study is the use of a synthetic system biology-mediated metabolic engineering strategy that abolished the need of complex gene knock-outs for engineering a microbial strain, which may hinder the maximal expression of the desired cloned gene.” The authors suggested that the developed bioprocess using recombinant P. acidilactici BD16  could be the best alternative to the chemical-based commercial synthesis of L-alanine for potential industrial applications.Biotechnological approaches are an alternative to the chemical synthesis of many compounds of interest. In Sharma et al. , researcStudies by Keli et al.  from theGomes et al.  from CBQPinto de Rezende et al. , from thL. monocytogenes in ready-to-eat meats and dairy-ripened products. These researchers stated that “The combination of selected LAB strains with antimicrobial compounds, such as acid/sodium lactate and other strategies, as the active packaging could be the next future innovation for eliminating the risk of L. monocytogenes in meat and dairy-ripened products.”The use of lactic acid bacteria (LAB) as biopreservatives has been gaining interest, since they are “generally recognized as safe” and have antibacterial and antifungal activities due to the colonization and competition for nutrients and space or the production of antimicrobial metabolites such as lactic acid, ethanol, and bacteriocins. Martín et al. , from thDe Oliveira et al. , from FeIn summary, the different papers published in this Special Issue address different “Biotechnology Approaches” in the food sector and highlight the need for more research in this field. We thank the authors for their valuable contributions to this Special Issue, which we hope readers will find interesting and instructive.


Methods: Semi-structured interviews were conducted with patients and HCPs as part of a feasibility study assessing patient-reported outcomes, physical function, and in-hospital mobilization. Interview questions included satisfaction with study recruitment, assessment completion, impact on clinical workflow (HCPs), and perceptions of a future multiphasic exercise prehabilitation program. This study followed an interpretive description methodology. Results: Ten patients and ten HCPs participated in this study. Four themes were identified: (1) acceptability and necessity of assessments, (2) the value of exercise, (3) the components of an ideal exercise program, and (4) factors to support implementation. Conclusion: These findings highlight the value of exercise across the HNC surgical timeline from both the patient and the HCP perspective. Results have informed the implementation of a multiphasic exercise prehabilitation trial in HNC surgical patients.Head and neck cancer (HNC) surgical patients experience a high symptom burden. Multiphasic exercise prehabilitation has the potential to improve patient outcomes, and to implement it into the care pathway, the perspectives of patients and healthcare providers (HCPs) must be considered. The purpose of this study was thus to gather feedback from HNC surgical patients and HCPs on building exercise into the standard HNC surgical care pathway.  Over 550,000 people worldwide are diagnosed with head and neck cancer (HNC) each year ,2. HNC sMultiphasic exercise prehabilitation is an intervention typically delivered over the surgical timeline and into recovery to improve peri and post-operative outcomes ,10,11,12In Calgary, Alberta, current peri-operative HNC care already includes several presurgical consultations, multi-site wound care, speech and swallowing rehabilitation, nutritional care, early mobilization via the Enhanced Recovery After Surgery (ERAS) protocol, and post-discharge follow-up appointments . The useThe purpose of this qualitative study was therefore to understand patient and HCP perspectives on the role of multiphasic exercise prehabilitation considering unique needs across the surgical timeline for HNC patients. Specifically, feedback was obtained on: (1) adding exercise-related assessments across the HNC surgical timeline and (2) the logistics and potential benefits of a multiphasic exercise prehabilitation intervention.Participants included HNC surgical patients and HCPs  who were part of our prospective cohort feasibility study . This feThe lead author conducted semi-structured interviews with patients and HCPs (≤45 min duration) to gather feedback on completing assessments of PROs, physical function, and in-hospital mobilization across the surgical timeline, as well as on the logistics surrounding a future multiphasic exercise prehabilitation intervention, including impact on clinical workflow. These interview guides are available as a Patients were invited to take part in an interview at two timepoints: (1) in-hospital, 7–14 days post-surgery, and (2) 6 ± 2 weeks post-surgery, during a follow-up assessment at the University of Calgary. Interviews were optional and took place only if/when the patient was feeling well enough to take part, according to the judgement of HCPs and in addition to verbal consent from the patient. Some patient interviews took place at the start of the COVID-19 pandemic and as such, were conducted remotely, via phone call, instead of in-hospital or at the follow-up in-person assessment. Questions during the inpatient interview captured patient satisfaction with completing assessments in the study  and took place in the participant’s private hospital room. The second interview gathered important information on the perceived value of implementing a future multiphasic exercise prehabilitation intervention for HNC surgical patients. Specifically, patients were provided with a multiphasic exercise prehabilitation program scenario and were asked questions about program components  principles, as well as other aspects of the intervention, such as preferred location for exercise). To facilitate patients’ understanding of these exercise principles, prompts such as the Rating of Perceived Exertion scale  were useInterviews with HCPs occurred in the last two months of patient recruitment into the feasibility study  once cliThis study was guided by an interpretive description methodology  and consInterviews were transcribed verbatim in Express Scribe  and analn = 20 of patients (n = 10) and HCPs (n = 10) participated in this qualitative portion. The six patients who did not participate in an interview either declined (n = 1), dropped out of the larger feasibility study (n = 1), or were not approached by the study team due to the study ending early due to the impact of COVID-19 (n = 4). HNC surgical patients ranged in age from 44 to 71 years  and were primarily male (n = 9). Due to symptom burden (primarily due to fatigue or difficulties speaking), only one patient completed an interview at both timepoints. Nine completed an interview 6 ± 2 weeks post-surgery, of which three took place remotely. Two caregivers were present, one each at two individual interviews. Ten HCPs participated in interviews, four of whom identified as male and six as female. Six of the ten interviews took place remotely. Participant characteristics are presented in Four unique themes were identified and are presented in n = 7) and some of the individual questionnaire items were not applicable. Having the ability to answer “not applicable” or to skip or streamline questions was identified as important. All patients found the overall recruitment and assessment process to be manageable, appropriate, and relevant to their experiences across the surgical care pathway. Further, patients noted they were happy to participate in a study that could improve care for future patients. While most patients completed questionnaires, the volume was sometimes viewed as excessive or repetitive  as acceptable, many would have preferred more education surrounding its purpose. Hindsight you probably could’ve put a bit more emphasis put on the watch and ‘hey we’re gonna track what you’re doing and really want you to push yourself each day’.P 8.HCPs described challenges and strengths with the steps taken to implement exercise into the care pathway for HNC surgical patients. HCPs described the surgical consent process as an overwhelming time for patients, and although patients are receptive to hearing about an opportunity that may enhance their experience, only a quick conversation is practical. I think we know it’s a very challenging patient population, not because of the people, particularly but because of what they’re being subjected to […] it’s a time-sensitive cancer…when surgery’s involved is complex and so there’s a lot of moving parts.HCP 6—Surgeon.Other challenges were expressed surrounding the use of the activity tracker . However, once workflow was established, the tracker was viewed positively for enhancing patient outcomes and for facilitating the documentation of movement. As you may know, we’re not very good at documenting mobility, and hence, why I think that these uhm, [activity trackers], might be very useful for nurses in helping reduce some of their workload.HCP 1—Clinical Nurse Educator.A main strength described by HCPs was the ongoing and clear communication that led to the development of new workflow practices. One HCP felt proud of the new practices to document multiphasic exercise prehabilitation for patients. I think we’re all really interested and excited and really proud that this is happening for our patients.HCP 8—Surgeon.HCPs also found the PRO and physical function assessments helped patients articulate their experiences. [patient-reported outcomes] get patients to intellectualize what’s going on with their body, and I think that can be a really helpful process, especially when they start realizing what they can do. These questions are pretty, straightforward right, they’re about your body […] there’s no right or wrong, they just have to say how they’re feeling, and I think that kinda introspection’s really important at that stressful time.HCP 7—Surgeon.Finally, HCPs found that providing patients with assessments fosters a sense of hope by giving them something to look forward to completing after their surgery. The fact I’m talking to them about the idea of optimizing their journey through this treatment, it, I guess maybe sends a signal that we’re already thinking about that far, so it’s not all doom and gloom, it’s not like ‘I don’t even know if you’re gonna make it through this surgery.’ If I’m already talking about what comes after, then I think kind of puts a bit of a positive spin on things.HCP 10—Surgeon.Collectively, our sample of patients spoke to the value of exercise as a pillar in their cancer experience. While only four patients reported engaging in regular exercise, all pointed to the need for movement as an integral component of their recovery post-surgery. Specifically, patients described the value of multiphasic exercise prehabilitation at three timepoints, pre-surgery, in-hospital, and post-discharge, into recovery. Some patients spoke to the positive benefits experienced from a multiphasic exercise prehabilitation approach to date  and to the perceived benefits if they had more exercise support during their care . Exercise in general was considered important to help patients feel better both physically  and mentally . Engaging in exercise was viewed as not only important for their recovery and surviving their cancer, but for overall health status.It brings a normality back rather than the sick room and the hospital and sitting in a chair and trying to reach over, it brings movement back to this arm and exercise the muscles on my right shoulder and uhm, doing all those small exercises get the body moving, so I think the whole-body exercise is so important.P 6.I think the only reason why I survived the first time with stage four was because I was fit to be able to do it. How many people survive stage four? Usually that’s a death sentence.P 2.As a result of seeing and hearing the benefits of exercise from their patients, HCPs described a multiphasic exercise prehabilitation approach as critical for recovery, emotional well-being, functional well-being, hospital length of stay, and wound recovery. Some HCPs spoke to the differences observed in patients who engage in exercise across their care trajectory, compared with those who do not. Collectively, HCPs felt that a multiphasic exercise prehabilitation approach should play a role in HNC surgical care, from pre-surgery to in-hospital, through immediate recovery, and into survivorship. Moreover, all HCPs indicated they were already sold on the idea of exercise for their patients. It’s priceless, I mean it can’t be overstated how valuable it is […] having seen so many patients over so many years, the ones that move feel better, recover better and just feel more alive, they just do better, so I think this is very, very important.HCP 6—Surgeon.Exercise is a hugely important part of going through a big surgery and hugely important to the recovery process. I’m kind of already sold on that idea, it plays a huge role and I think it’s huge psychologically and emotionally for that part of things, for people – their resilience, being able to get through the recovery and feeling stronger, and better after the fact.HCP 8—Surgeon. Detailed perceptions of the multiphasic exercise prehabilitation program FITT Principles are described in I’d never thought about going to the gym but I’ve uhm yeah, just walking and in you know, spring summer and fall, working in the garden and other things like that, that sort of physical activity.P 6.All patients agreed that engaging in movement every day is important across surgical care, with higher intensity exercise pre- and post-hospital discharge.I would exercise a bit every day if I could.P 3.Oh, well, pre-surgery, probably pretty intensive.P 3.In-hospital was good, I mean, if you do it for an hour in the hospital, you’re getting quite a bit of exercise in.P 1.Is this in-hospital? I’d suggest it for fifteen minutes to begin with somebody.P 2.Would be good for me in the hospital, there like, five minutes is enough.P 3.Well, I think you should start out slower and increase by the time you get to the six weeks.P 1.Overall, patients spoke to the need of considering individual factors such as exercise preferences, accessibility, and other barriers and facilitators. Individualize it and make them feel more special.P 2.movement” and “physical activity” instead of “exercise.” Further, patients were receptive to the idea of a multiphasic exercise prehabilitation program when presented with the terms “Yeah, I think movement’s a gentle way to say ‘you know, get up and move’ you know what I mean? Get up and walk, your heart doesn’t have to race at 170 beats a minute.P 8.I wouldn’t have bought-into jumping into a high intensity short-term program.P 10.When describing an ideal multiphasic exercise prehabilitation program, HCPs highlighted the need for exercise specialists involved in the care pathway. HCPs also felt that multiphasic exercise prehabilitation should be comprehensive and tailored to each patient, as well as indicated the importance of program timing to promote patient engagement. I wish we could start this tomorrow. I wish we could have an exercise physiologist in our clinic.HCP 2—Oncology Nurse.I definitely think that the patients would be pleased to hear that there’s a program in place that they have access to, and again this whole idea that to some degree, dove tails into survivorship. I definitely see this as a huge bonus, this would really upgrade what we have to offer these patients.HCP 10—Surgeon.The ideal time do present all this to the patient would be on a second visit, that comes after the initial sorta, discussion about the primary treatment […] I think that they need a bit of time to just sort of digest that, even if like, for 24hours, just to kind of get their head around what’s going on […] if there was a way to make this part of the package, to present this information like even a day later or something, the patient would absorb a lot more of this.HCP 10—Surgeon.Overall, it was clear that patients value the role of exercise, with a key focus needed on implementation. Patients spoke mostly to the need for more education and access to resources relevant to their recovery. Patients were interested in education about movement recommendations pre- and post- surgery, data to support the benefits of exercise, nutritional advice, additional support for wound care/rehabilitation during immediate recovery, and more guidance for what to expect along their surgical trajectories. I think a quick consult before they release you from the hospital […] to sit down and say ‘okay, these are resources available and these are the things you can and can’t do,’ cause I have this new flap, am I not supposed to have a beer? What can’t I do with this flap, they never ever told me, right?P 8.Patients also described the importance of having their surgeon advocate for exercise and encourage participation. While patients expressed interest in participating in a multiphasic exercise HNC surgery program, they felt that a fundamental component is receiving support from their surgeon. You really wanna listen to him I would think, he’s the big guy.P 4.If the doctor woulda told me ‘we need you to get your heart movin’ so get workin’ out hard here in the next month’ I would’ve worked out super hard every day before surgery, right? Uhm, but there was really nothing, just ‘go about your life’ right, ‘enjoy your life’.P 8.HCPs were enthusiastic about a future multiphasic exercise prehabilitation program for HNC surgical patients. Key areas for implementation included presenting data for HCPs, including more education for both patients and HCPs, realizing a culture shift in the clinical setting for cancer care , as well as adapting a collaborative team approach along with continuous buy-in from the surgical team. I think what you’re really trying to achieve is a cultural shift, a change in brain functioning for everybody. I think what I would be looking at is what is the brand of exercise in cancer care and how do we change that on a much larger scale than largely advertising what we see in the hospital that is going out to people who already believe it.HCP 7—Surgeon.Similar to patients, HCPs viewed the surgeon’s influence as essential for patient engagement with a multiphasic exercise prehabilitation program. I do think that it’s important that the patient’s surgeon at some point has a direct conversation with the patient to uh indicate how really important it is.HCP 8—Surgeon.Several HCPs also pointed to the need of external funding and sustainability considerations for embedding a multiphasic exercise prehabilitation program outside the context of a study. A majority of HCPs perceived a number of barriers, namely insufficient funding and lack of support from administrative and policy levels.Right now, it’s working because it’s within the context of a study, and even more so when it becomes a [prehabilitation trial]. I would imagine there needs to be some funding to provide support, staff, and so forth to actually take the patients through all this. Like, if it becomes standard of care, who’s actually gonna administer all this stuff?HCP 10—Surgeon.The purpose of this study was to gather information from two key stakeholder groups – patients and HCPs – on adding exercise-based patient assessments across the HNC surgical timeline, and the logistics and potential benefits of a multiphasic exercise prehabilitation intervention. A key finding from this process was both patients and HCPs perceived assessments of PROs, physical function, and mobilization as important and acceptable across the HNC surgical timeline. Moreover, both groups value the idea of a multiphasic exercise prehabilitation program. Both patients and HCPs highlighted that there is limited education and support for patients and that a culture shift is needed, including at the policy level, to support adding exercise to standard cancer care. Finally, both patients and HCPs emphasized the importance of tailoring the future multiphasic exercise prehabilitation program to the unique needs of each individual patient. This study demonstrated the importance of education, attitudes, and access to resources for successful implementation of a multiphasic exercise prehabilitation program. mindset change” regarding the perceptions of exercise as a supportive cancer care resource [Our findings are consistent with earlier work on the perceived benefits of exercise in cancer care in other tumor groups ,31,32. Presource ,33. t”, and limited exercise prescription during times of physical and psychosocial stress . After hospital discharge and into immediate recovery prior to potential start of adjuvant treatment (chemotherapy and/or radiation treatment), exercise prescription can focus on immediate treatment-related side effects and focus on functional limitations. Finally, concurrent to adjuvant treatment as well as after and into survivorship, exercise prescription can begin to address core exercise principles of progression and overload, addressing treatment-related side effects, building fitness and functional benefits in patients, and enhancing overall well-being and quality of life. By “starting low and progressing slow,” exercise interventions will be more likely to facilitate behavior change and build a habit of regular movement and exercise in HNC patients, thus improving recovery. As identified in this study, an important consideration within a multiphasic exercise prehabilitation program is the FITT principle  and the need to tailor to patient needs and preferences at different timepoints across their cancer care trajectory. Based on participant feedback, a multiphasic exercise prehabilitation program may need to focus on “movemenexpert” of their own health [Patient-oriented approaches have emerged with efforts to improve the credibility of research and the delivery of patient care and for recognizing the patient as the “n health . While an health , empowern health . Moreoven health . In an en health ,38. If mI suspect there’s a whole bunch of negative perceptions around encouraging cancer patients to do exercise, so, I’m sure there’s some work that could be done on branding and marketing to make it kind of a standard that both as healthcare professionals, administrators, people financing the whole thing, tax payers, which is the public, see the importance of it”.While this study adds patient and HCP perspectives on the role of exercise across clinical HNC surgical care, other perspectives of key stakeholders will be critical to support exercise implementation. For example, understanding the barriers and facilitators to exercise implementation from administrative and policy levels will support integration into clinical practice. As mentioned by one of the reconstructive surgeons (HCP 7) involved in patient care: “Second, our sample size of 20 allowed us to gather varied perspectives across both patients and HCPs, representing divergent  and consistent  views. Due to the COVID-19 pandemic and HCPs being required on the frontlines of healthcare, we were unable to continue with further interviews. It is possible that a larger sample size may have resulted in supplementary views that would add to our understanding. Third, our sample of patients included mainly self-reported white males (9/10 patients), thus perspectives from other populations  were not included in this study. Further, while all surgical head and neck cancer patients were informed about the study, it is possible that those more motivated and/or keen to be involved in exercise prehabilitation chose to participate. Future work must thus focus on equity, diversity, and inclusion in exercise oncology, from considerations of recruitment into patient-oriented research work and the needs of non-English speaking participants  to assesFinally, within qualitative research, it is important to acknowledge researcher bias. The lead researcher is a white cis-gender female never having been diagnosed with cancer. Thus, to support credible research practices, the lead researcher keeps a reflexivity journal, has more than eight years working directly with patient populations in exercise oncology, and engages in ongoing qualitative training ,41.Despite these limitations, the current qualitative findings, in conjunction with the quantitative findings  support These qualitative findings of patient and healthcare provider perspectives on building multiphasic exercise prehabilitation into the surgical care pathway for HNC identified four themes: (1) acceptability and necessity of assessments, (2) the value of exercise, (3) the components of an ideal exercise program, and (4) factors to support implementation. Together with the quantitative findings , future


Modern technology has made an elegant link between smart materials and interlinked devices thanks to the interplay between materials science, smart sensors and devices, artificial intelligence, and a fierce imagination; this has allowed us to reach every corner of our society. Smart or responsive materials are ones that respond in a controllable manner to an external stimulus by changing one or more of their properties. Some external stimuli include the following: temperature, stress, electric, chemical, and light. an exclusive class of smart materials that are highly valuable due to their magnetically activated smart and/or multifunctional response” [Among these, we have the magnetoresponsive materials and devices, which are materials that respond to an external magnetic field; these are considered as “esponse” . They aresponse” ; they bresponse” ; they inesponse” ,5 and presponse” , among mThe great advantage that characterized the magnetoresponsive materials is contactless activation, their fast switching (in some cases), and their versatile ability with respect to applications in a myriad of devices made by using different fabrication techniques, thanks to its ability to adapt to different needs and applications (such as composites by additive manufacturing , polymerIn this Special Issue, new studies on magnetoresponsive materials and devices will be presented to widen our understanding of this topic, and all of them have different applications, such as magneto-active energy; magneto-active memory-storage; magneto-active sensors; magneto-active actuators; magneto-active material for biomedical applications and devices; and the advanced manufacture of magnetoresponsive materials and devices. This Special Issue welcomes different fabrication techniques for obtaining magnetoresponsive materials and devices, their wide range of applications, their characterization, theoretical works, and all innovative results.


Results indicated that all participants (100 percent) who reported sexual violence were women. Thematic analysis of qualitative results revealed the themes related to familial, non-familial, and the historical oppression of a lack of accountability for perpetrators. Quantitative t-Tests results revealed that experiencing sexual violence was associated with significant differences across ecological dimensions of wellness including (a) structural: higher historical oppression, historical loss, oppression, and discrimination; (b) relational: higher adverse childhood experiences and stressful life events and lower family resilience and social support; (c) spiritual: lower spiritual-well-being and life satisfaction; and (d) psychological/behavioral: higher levels of alcohol use, PTSD, and lower levels of psychological resilience. Thus, sexual violence profoundly affected Indigenous women.Sexual violence against Indigenous women has long been used as a tool of colonial violence and conquest. As a contemporary form of historical oppression that may drive associated health and mental health inequities, Indigenous women in the United States experience sexual violence at greater levels than the general population and at and twice the rate of Indigenous men. We use the Indigenous framework of historical oppression, resilience, and transcendence (FHORT) to understand Indigenous women’s experiences of sexual violence and how it differentiates across ecological outcomes related to health and wellness. This exploratory sequential multimethod study with 563 participants ( Sexual violence against Indigenous women has long been used as a tool of colonial violence and conquest. Given that women were revered, held sacred, and held great authority in many female-centered and matriarchal Indigenous societies, it is not surprising that women were targeted as leaders during colonization , 13, 16.Indigenous people of the U.S.  are disproportionately impacted by sexual violence , 58, 59.Experiences of sexual violence contribute to many of the health inequities experience by Indigenous women, such as poor mental health  decreased sexual urges/pleasure, increased sexual risk behaviors, problem alcohol and drug use, and physical health problems , 61. To The Department of Justice found that rates of sexual violence are approximately 2.5 times higher for Indigenous women than White, African American, or Asian American women  and 17 pDue to a reversal of the prior matriarchal and female centered gender dynamics of many Indigenous communities and the impunity for perpetrators , 13, 16,Further, historic and contemporary federal laws create a multitude of barriers for achieving justice for survivors of sexual assault , 23. TheThe FHORT is a liberatory, culturally responsive, and anti-oppressive, inclusive theoretical framework that helps to contextualize Indigenous women’s experiences of sexual violence in a context of patriarchal and colonial historical oppression . The FHOThe FHORT aligns itself to diversity, equity, and inclusion frameworks while simultaneously employing a trauma-informed lens. In contrast to cultural competency models, which are critiqued for their limited focus on the acceptance of various cultures, the FHORT is better aligned to a cultural humility model . CulturaIndigenous women are distinctive from non-Indigenous groups as experiences of historical oppression encompass patriarchal colonialism  includinhistorical oppression—“the chronic, pervasive, and intergenerational experiences of oppression that, over time, may be normalized, imposed, and internalized into the daily lives of many Indigenous people” (p. 38)  she raised me the way she raised me. Everything was sheltered, if I’m going anywhere, all my brothers, I’m the second but I got a younger brother that’s two years older but everywhere we went, I mean, my world was sheltered.So, so overall [mother] she kept me protected. … I finally figured out, when I was growing up that, the reason why she raised me the way she raised me was… she was raped. … Then the other time before when she was growing up, she was just a young girl. It was an aunt’s husband that tried to get in bed with her, and she kicked him off and got up. But the aunt told her “Don’t tell, don’t tell Grandma, don’t tell Grandma. She’s going to be mad.” I mean you don’t do that…And that’s [how] come , but it’s happened at two different times. … I would go over to my grandpa’s house. My uncle lived with my grandpa. Uh, before my grandpa passed, and, um, he would kind of bring me in his room, and touch me over my clothes, and then it would just make me uncomfortable. … I really didn’t know what he was doing … and so … and then after he got done, he just told me to go sit in the living room … I just didn’t tell anyone. Like, he didn’t threaten me. I was just scared that he was going to get in trouble for what he didThis woman’s mother was determined to protect her from experiencing the same form of abuse she had; however, this participant’s partner ended up perpetrating sexual abuse on other family members. Sexual abuse experiences perpetrated by male family members was described by several speakers, including one woman youth participant from the Inland tribe who was abused by multiple family members:In part because they were family members, this speaker felt she needed to protect the abuser from harm and didn’t tell anyone about the abuse until several years later.Before they [males] were more respectful. [Now], it’s more of, “How many girls can I sleep with?” instead of finding that one girl and then staying with her. It’s “How many people can I sleep with?” And they disrespect the women. Girls, they’re actually girls, and the girls feel like they have to do it because they want the guys to like them. It was kind of bad whenever I was growing up, but it seems like it’s even worse now.Perceiving women in dehumanizing ways – as sexual objects of conquest to exploit – was spoken about by some participants. As evidence of the internalization of patriarchal gender role ideology, a woman Coastal participant expressed this shift from respectful to disrespectful views of women. She stated:sic] talking to them.” When the interview replied, “They serve their purpose type of thing? That’s interesting. How do you think they feel after that?” He repeated, “I don’t care.” Despite this youth wanting to “impress” with his lack of empathy, this male, with a history of drug, school, and family problems, described a pattern of objectifying and using women for sexual pleasure, and then casting them aside, regardless of the consequences or implications.A male youth from the Inland tribe explained how he perceived women as objects of conquest. He stated, “I don’t call them my girlfriend.” When characterizing how males and women in his school go together, he stated, “Yeah, they hook up.” He went on to add, “I’ve had a lot of girlfriends –Hooking up.” When asked, “Do you worry about that like what if they had a kid or something like that?” He replied, “I don’t care. Because if I’m done with a person, I guess I ain’t  neighborhood.” An additional woman youth (aged 20) from the Inland tribe described seeing men taking advantage of young girls and being concerned about the safety of her own daughter “There’s too many guys that just take advantage of little girls a lot. I see that a lot… that’s what scares me sometimes, like because I have a daughter of my own.” Another woman IPV professional recalled being at a party at a young age and almost being assaulted while sleeping:As indicated by this participant, girls could be targeted at as young of an age as nine or ten.When you asked me like, what should I [be] change[d] in in the tribe. It’s law enforcements mainly… You can get away with anything here…You kill a person; you get to walk the streets. You- you see somebody die and you just walk away just thinking there’s nobody gonna help them…No justice at all…Nothing happened…We- we reported it [the sexual assault] and they never got back to us. Our law enforcement is very low and no [justice] … Like, I could honestly just go out here and kill somebody and I would just get released.Many participants spoke about violence and sexual abuse targeting young girls that was exacerbated by the lack of accountability for the perpetrators in the criminal justice and law enforcement systems. A youth woman from the Inland tribe experienced abuse at the hands of family members: “My aunt’s, um, her husband had been taking pictures of my sister when she’s sleeping, and she didn’t notice that … And finally, she came out when she realized what he was doing.” This speaker went on to describe the lack of accountability in the tribe and how she desired that law enforcement do more to address violence in the community:I think they [perpetrators] should, uh, be in jail for what they have done. Well, not jail, maybe prison…As long it’s something not, like, here at the [name of local jail]. It’s like a walk in the park. … Like when my mom came back…they called the police… He [familial perpetrator] came back to the house, and, um, back then they didn’t arrest him … He ended up in jail, but, you know, he didn’t stay in there for very long …What makes me sick is that they didn’t keep [him] in jail that long. I mean … What if he got another girl? I was like, another little girl maybe about that age, and I was like, maybe the [justice organizations] will learn to listen and keep them in there longer … but the thing was my friend was like, his niece, had like kind of beat me up, just because I put her uncle in jail.This woman in high-school described a lack of justice in the court system for her sexual violence:This speaker not only describes her frustration at the short sentence the perpetrator experienced, but also describes being punished and ostracized by community members for coming forward and reporting the assault. In contrast, a woman professional in IPV services reported that her family member was held accountable by other family members for attempted sexual assault:I had almost got raped twice…Luckily, I didn’t because they were drunk. … I was small enough to get away from their hands. And one of them was … Actually, she [family member] was married to one of them…And my uncle had stood up for me and said, um, “Either you divorce him or he’s gonna rot in jail”…So she took, you know, the divorce.Now I just don’t feel safe …It was at my little sister’s softball game…and there was this umpire. And I’ve always talked to him, but I never knew he was like a pervert or anything. And well, um, he put his arm around me, and I just didn’t think it was anything. And that’s when he started… he didn’t go into my shirt, but he was like over my shirt. And he was just touching my left breast, and I didn’t do anything. And then that’s when [I] just told him I was going to my truck. And then, like a couple weeks later, like two [weeks] … I told my mom, and then we just started filing charges, but like it’s been a year already that they haven’t done anything about it. …It makes me mad because … it’s been so long, and they’ve waited on everything…They let him [abuser] be around there still…And work.In this case, the speaker was able to get support from her family and the abuser was kicked out of the family after she reported what happened to her. However, this experience still highlights the vulnerability to sexual abuse young girls experience from male family members. Another youth woman from the Inland tribe described being assaulted at a young age in public:Not only did this speaker not get justice from the courts, but she was also forced to continue to see her assailant at public events, where the perpetrator could access other victims.sic] to talk to them…I look for safety issues … You’re going to come across officers that has [sic] an attitude … talking like I don’t care, I don’t want to listen to it. I’m like, why is he [officer] there?I can’t believe how high the dating, the violence…They’re teenagers…We just have them come in and just have … I know a lot of people don’t agree with that, but I would because if you are sitting there telling your story and your perpetrator is right there … this person still has control over you…You’re looking right at them … I wish they could be able to do that like you said either give a statement or have that person either tape recorded or video.Despite the practitioner noting the increase they saw in teen dating violence, the court justice system seemed to be not set up to handle cases of adolescent IPV. Other barriers in the justice system included victims being expected to testify on the stand, as one practitioner noted:Girls were often described as being at increased risk for sexual violence, both in the community and at the hands of male family members. The justice system was often cited as a barrier for seeking and achieving justice when a physical or sexual assault took place. Thus, results indicated an internalization of patriarchal norms of sexual conquest toward women, exacerbated by impunity for perpetrators.t Tests indicated significant differences on several dimensions of wellness including (a) structural: higher historical oppression, historical loss, oppression, and discrimination; (b) relational: higher ACEs and stressful life events and lower family resilience and social support; (c) spiritual: lower spiritual-well-being and life satisfaction; and (d) psychological/behavioral: higher levels of alcohol use, posttraumatic stress disorder, and lower levels of psychological resilience. t Test results examining these hypotheses.We assessed whether participants who experienced sexual violence perceived historical oppression, loss, and oppression to be prominent, as well as how they experienced support and stressful life events and resilience. We examined how they differed in relationship to key outcomes of health disparities, namely alcohol use and PTSD. To identify differences across ecological aspects of wellness among individuals who experienced sexual violence versus those that had not experienced sexual violence, independent All of these hypothesized relationships were confirmed, namely that survivors of sexual violence perceived higher historical oppression, historical loss, oppression, discrimination, ACEs, stressful life events, alcohol use, and PTSD symptomatology. Moreover, reported survivors of sexual violence reported lower levels of family resilience in their upbringing, life satisfaction, psychological resilience, spiritual well-being, and social support. The effect sizes for all outcomes ranged from medium to high (0.52–1.14). Indeed, historical oppression, historical loss, life satisfaction, psychological resilience, spiritual well-being, and social support all had at least a medium effect size, whereas oppression, discrimination, ACEs, stressful life events, family resilience, alcohol use, and PTSD all had large effect sizes.This research provides perspective on the devastating experiences of sexual violence felt by Indigenous women and girls, lack of accountability for perpetrators, as well as the profound impact across major outcomes of interest of wellness and health disparities. Past research indicated forms of historical oppression and losses leading to the replacement of humanizing, matrilineal roles with dehumanizing, patriarchal gender ideology that placed women at risk of violence. This same research also coupled this historical loss with a lack of accountability for perpetrators, as people tended to keep silent about violence .Qualitative participants extended these sentiments, reporting surviving sexual violence at the hands of both familial and non-familial perpetrators. Internalized patriarchal colonialism was evident with the frequencies with which participants reported family members targeting the women and girls in their families for sexual violence. Unlike other tribes with greater interaction with non-Indigenous communities and because of the context of the focal tribes , 23, 58,Sexual conquest was not only a tool used in colonization, but it was also perpetuated in the present , 16, 34.Not only were experiences of sexual violence deeply consequential in qualitative research, but quantitative results also indicated sexual violence survivors had differential outcomes across structural, relational, and personal levels. Supporting extant research , 46, 61 Second, at the relational level, sexual violence survivors reported higher levels of ACEs and stressful life events and lower family resilience and social support. Historical oppression dramatically undermined Indigenous families. Boarding schools systematically removed Indigenous children from their families and communities –precluding their ability to love and socialize them and rather assimilating and exposing children to environments replete with sexual abuse and exploitation . ConsistFinally, and of utmost concern, sexual violence survivors reported a lower quality of life, resilience, and transcendence across a plethora of measures. Regarding resilience and transcendence, sexual violence survivors reported lower levels of psychological resilience, life satisfaction, and spiritual well-being. Experiencing sexual violence seemed to cut to the core of women’s well-being and potentially constrained their sense of self and wellness. Given that psychological resilience contributes to people experiencing mastery and control in their world, sexual violence may tend to strip women of these protective perceptions, at least for a time. Further, the lack of justice for survivors of sexual violence may act as a further roadblock to resilience, as injustice may contribute to feeling helpless and out of control. Life satisfaction was also lower for violence survivors, along with spiritual well-being, which could connect to violence survivors feeling loneliness and disconnection .Results from convenience samples cannot be extended beyond their context. Variables and surveys were self-report measures rather than direct observations, and the survey measure for sexual violence was within the context of intimate partnerships. To follow IRB protocol, identifiable information was not kept for the survey portion of the study. As such, despite some participants from qualitative component also likely participating in quantitative component, we were not able to track who participated in both portions. Assessments of lifetime sexual violence and assault are likely higher. This research was cross-sectional. Although it displays a snapshot of how people were coping and experiencing life at the time of data collection, it did not capture how Indigenous women were faring over time, where longitudinal analysis would be helpful. With the heterogeneity of Indigenous Nations, results could benefit from replication and examination across additional contexts for a broader understanding. This research was exploratory only. Still, robust medium to large effect sizes indicate that results warrant further investigation to validate, replicate, and extend results. Future research should investigate the preliminary connections identified between historical oppression, loss, and discrimination with sexual violence. This complex relationship could benefit from some close inquiry.Indicating continued forms of historical oppression, this article provides personal experiences of the devastating and helplessness felt by survivors of sexual violence who experienced dramatic consequences, while they often witnessed their perpetrators walk away with impunity. Experiencing sexual violence also meant that survivors experienced higher levels of historical oppression, loss, discrimination, ACEs and stressful life events, with lower family resilience, life satisfaction, resilience, spiritual well-being and social support. They also reported higher levels of alcohol use and PTSD. Thus, sexual violence seems to be a pivotal point around which a host of risk factors accumulate.To our knowledge, this is the first inquiry to examine connections between structural  relational  psychological and behavioral  and spiritual/transcendence factors related  to sexual violence in a rigorous multimethodology with Indigenous women. Connecting these structural, relational, contextual, and psycho-spiritual aspects as they relate to sexual violence and finding such robust findings in this preliminary research is striking.The extent to which sexual violence cut across these dimensions of wellness is in some ways haunting, indicating the strong need to prevent, treat, and address the ecological risk factors in a holistic way. First, historical oppression, loss, and discrimination need to be redressed through decolonizing the patriarchal roles that were imposed and reversed what were protective social norms for many women in Indigenous communities –those that were matrilineal and woman-centered  , 13, 16.There is a clear need for further study on the pathways to recovery or resilience  that inc