The domain of Biomedical and Health Informatics (BMHI) lies in the intersection of multiple disciplines, making it difficult to define and, consequently, characterise the workforce, training needs and requirements in this domain. Nevertheless, to the best of our knowledge, there isn’t any aggregated information about the higher education programmes in BMHI currently being delivered in Portugal, and which knowledge, skills, and competencies these programmes aim to develop.Our aim is to map BMHI teaching in Portugal. More specifically, our objective is to identify and characterise the: a.) programmes delivering relevant BMHI teaching; b.) geographical distribution and chronological evolution of such programmes; and c.) credit distribution and weight.We conducted a descriptive, cross-sectional study to systematically identify all programmes currently delivering any core BMHI modules in Portugal. Our population included all graduate-level programmes being delivered in the 2021/2022 academic year in any Portuguese higher education institution.We identified 23 programmes delivering relevant teaching in BMHI in Portugal. Of these, eight (35%) were classified as dedicated educational programmes in BMHI, mostly delivered in polytechnic institutes at a master’s level  and located preferentially in the northern part of the country (7). Currently, there are four programmes with potential for accreditation but still requiring some workload increase in certain areas in order to be eligible. More specifically, our objective is to identify and characterise the: a.) programmes delivering relevant BMHI teaching; b.) geographical distribution and chronological evolution of such programmes; and c.) credit distribution and weight.22.1We conducted a descriptive cross-sectional study to systematically identify all programmes currently delivering any core BMHI modules in Portugal. Our population included all graduate-level programmes being delivered in the 2021/2022 academic year in any Portuguese higher education institution.2.2The main variables collected were a.) programme general data ; b.) programme specific data ; and c.) teaching details .The variables were extracted from the Portuguese Directorate General of Education and Science Statistics  were collected by manually analysing the official programme’s webpage during April and May 2022.The awarding institution and/or the Portuguese DGES were contacted directly with regards to programmes in which data was missing, to confirm eligibility and/or obtain additional details.2.3Step 1To systematically retrieve information, we used a three-step methodological approach, as follows.Step 2We started by identifying all higher education programmes currently being delivered in Portugal in which the core teaching areas were life sciences or related areas, informatics or related areas, or a combination of both. To achieve this, we searched the DGEEC to find all relevant programmes based on the CNAEF codes and areas of education & training description. All programmes included in the codes/areas listed in Next we identified all programmes that matched relevant BMHI areas by combining and expanding different terms relevant to BMHI, based on the related fields recommended by the International Medical Informatics Association (IMIA) - Table Given the many different terms used in this domain, we have built a broad-spectrum query by using permutations and wildcards, in Portuguese, of the keywords ‘health’, ‘clinical’, ‘medical’, ‘medicine’, ‘nursing’, ‘computational’, ‘bioinformatics', ‘bioengineering’, ‘biomedical’, ‘informatics’, ‘data’ and ‘science’; the query used is detailed in Appendix I.Step 3Programme titles that matched any of the relevant areas previously defined in In this step, the programme’s structure and syllabus was assessed to identify relevant BMHI topics being delivered, and all selected programmes classified into a main area.To achieve this, three unblinded reviewers  with formal BMHI training and experience accessed each programme’s official website, and independently screened all module’s syllabus for alignment with the domains defined by the IMIA , and compiled and organised in a single dataset using RStudio IDE . Statistical analysis, tables, and graphics were performed using R  on RStudio IDE .Categorical variables are presented as absolute and relative frequencies. Quantitative variables are presented as mean and standard-deviation or as median and interquartile range, depending on the distribution.33.1We identified 23 programmes delivering relevant teaching in BMHI in Portugal. A characterisation of all programmes is summarised in Regarding main area of education, nine programmes (39.1%) were classified as having BMHI modules as part of ‘Medical, Nursing, Health Care Management, Dentistry, Pharmacy and Public Health’ (MNHDPP) programmes, whereas eight programmes (34.8%) were classified as dedicated educational programmes in BMHI. The remaining six (26.1%) were classified as having BMHI modules as part of ‘Informatics, Computer Science Programs and Engineering’ (ICSE) programmes - When comparing CNAEF codes with the main areas resulting from the domains credits addition it was possible to identify some heterogeneity between the classifications. For example, programmes classified in CNAEF areas so distinct as ‘Chemical Processes Technology’ and ‘Biology and Biochemistry’ were classified in the ICSE main area. In contrast, other programmes in the ‘Biology and Biochemistry’ CNAEF area were classified in the MNHDPP main area. The updated CNAEF classification , mostly within universities , at a master’s level . When considering programmes by main area, these trends are very similar except for dedicated BHMI programmes being delivered mostly in polytechnic institutes . Portuguese higher education is a binary system, in which universities are mainly focused on providing a solid theoretical background and oriented to promote research and produce knowledge, whereas polytechnic institutes are mainly oriented towards applied research and aim at providing a solid technical/practical approach to problem-solving . NeverthThe median programme’s ECTS was 120, except for MNHDPP programmes in which the median ECTS credits was 240. These results highlight that MNHDPP programmes have a longer duration  and are mostly taught at a BSc level. On the other hand, dedicated BMHI programmes are often of shorter duration, and taught at a master’s level. Although there is no evidence to support these findings, it seems to suggest that BMHI workforce needs are being provided by professionals from diverse backgrounds  who develop some BHMI competencies in their graduate degrees but to work in BHMI they may need further specialization.A summary of these results is presented in 3.2When looking at the distribution by district, it is visible a higher concentration of programmes in the northern part of the country .Fig. 2GeDedicated BMHI programmes are mostly located in the northern part of the country A. MNHDPPThis distribution is in line with the data provided by the DGES , which i3.3There seems to be a prominent emergence of MNHDPP programmes delivering BHMI-related teaching from 2009 to 2014, accompanied, in that same period, by a low emergence of BMHI programmes and a stagnant emergence of ICSE programmes delivering BHMI-related teaching. By 2015, however, that scenario was reversed, with the rapid emergence of several BMHI programmes and ICSE programmes delivering BHMI-related teaching. Since 2019 there seems to be an emergence of new programmes in all areas, reaching an all-time high number of programmes delivering core BMHI teaching in 2021. At this point it is also important to emphasise that in the last 12 years we have seen the emergence of 22 new programmes delivering core BMHI teaching. These findings are consistent with the growth of the Portuguese higher education system potentiated by the Bologna process between 2006 and 2012; similarly, the stringent economic measures imposed between 2013 and 2015 could explain the deceleration of programmes growth . Finally3.4With regards to dedicated BMHI programmes, the programmes delivering the most substantial core BMHI teaching are the ‘Medical Informatics’ programme at Universidade do Porto and the ‘Biomedical Engineering ’ at Universidade do Minho, while providing relevant teaching in informatics but with reduced workload in the medical domain. These two programmes can, potentially, be eligible for accreditation with the IMIA. To fully match the criteria, however, the former needs to increase the workload on the medical domain while the later needs to increase the workload on both the core BMHI and medical domains.The ‘Medical Informatics Engineering’ programme at Instituto Politécnico do Cávado e do Ave delivers relevant and balanced teaching in all relevant domains in the ICSE programmes with BMHI modules category. Nevertheless, to fully match the criteria of IMIA, a workload increase on core BMHI teaching is needed.Similarly, for BMHI modules as part of MNHDPP programmes, the ‘Medicine ’ at Universidade do Minho programme provides robust teaching in all relevant domains, with strong emphasis in the medical domain, and is at present the only programme that meets current criteria for IMIA accreditation in its main area.A summary of mandatory and optional ECTS credits for all programmes delivering relevant BMHI teaching is presented in 44.1Although we believe this work will be paramount in defining the current scenario of BMHI teaching in Portugal, it is not without limitations.Firstly, by using a national database that might not be fully updated we might have missed relevant programmes; however, due to time constraints and the predictable difficulty in obtaining a response from higher education institutions should we had used a questionnaire, we decided that this was the most sensible approach. Moreover, we decided to classify individual modules ourselves instead of asking higher education institutions to do it due to the potential for increased inter-observer variability, and hence the risk of bias; by doing so there is, however, the risk of misrepresenting or misclassifying some modules, which we tried to mitigate by joint discussion and strict adherence to the IMIA recommendations .Secondly, we have considered the ‘best case scenario’ (i.e. the scenario that carried the most BMHI-related credits) for branches within a programme and for optional modules within a programme; this assumption offers no guarantee that any relevant BMHI modules will be chosen but taking a different approach would mean that we could be excluding relevant programmes or branches.Thirdly, and due to the huge number of possibilities, optional modules that allowed students to choose any module from any faculty within the university were not considered.4.2Due to the current pandemic state, derived from the Coronavirus disease, we decided not to evaluate teaching delivery modes (such as face-to-face and remote) as there was a risk of over-representing remote teaching/learning and therefore the introduction of bias. In the future we plan to identify teaching delivery modes and assess their impact on the programme’s performance. In the future we also plan to identify the number of IMIA accredited programmes and explore its impact on the programme’s outcomes.It would also be crucial to understand what presides the decision to start or close some programmes , and the reasons behind the growth of BMHI programmes since 2015, perhaps by directly inquiring course directors. Furthermore, it would be important to understand why some programmes are being taught in different education sub-systems, and how that reflects on the educational approach, student’s competencies, and skills.Since this was a descriptive and exploratory study, it is not clear to us the reason most BMHI programmes were being delivered at master’s level and why they were mainly located in the north region of the country around Porto, and therefore additional research might be warranted.It would be central to identify the real demands of the market in terms of the number of graduates and understand how graduates' competencies map against the needs of future employers. Establishing employment levels, local industry needs, and destination and salary of recent graduates, in conjunction with the competencies mapping and workforce study proposed earlier, would be paramount to adjust the curriculum, training requirements, and workforce planning.Finally, and although some work has been done in that respect  , mapping4.3This is, to the best of our knowledge, the first study to characterise the status of BMHI teaching in Portugal, providing an overview of the number and education level of programmes, the type of education system they are included in, the programme’s geographical distribution and chronological behaviour, and the BMHI-related credit weight. This work allows not only the quantification and characterisation of BMHI programmes in Portugal but, more importantly, might pave the way to a deeper understanding of BMHI scenario in the country.Although we have found some programmes delivering relevant BMHI teaching, the credit weight of specialist BMHI modules is relatively low; nevertheless, we have identified four programmes with the potential to be accredited, which, considering the size of the country, might be significant. The recently updated guidelines from the IMIA  incorporFurthermore, our study has shown that there is only one PhD programme in the country delivering relevant BMHI teaching, possibly meaning that Portugal might be prepared to build capacity in BMHI for the entry and intermediate levels but the future of the area might be compromised if research in not stimulated, namely by the introduction of new PhD programmes and/or a tighter relationship between academia and industry.Finally, by openly sharing our final dataset with the community we believe we can facilitate and propel research in this area, while promoting the advancement of BMHI and, ultimately, contribute to better patient care.10.13039/501100006752Universidade do Porto. The funders did not have any role in the data analysis or the article contents. The content of the project is solely the responsibility of the authors and does not necessarily represent the official views of the funders.PDC was supported by the Fundação para a Ciência e a Tecnologia, I.P, through grant number UI/BD/151574/2021. PA was supported by the Fundação para a Ciência e a Tecnologia, I.P, through grant number SFRH/BD/145719/2019. Publication fees were supported by All authors conceived and designed the experiments, performed the experiments, analyzed and interpreted the data, and wrote the paper.Paulo Dias Costa, João Almeida, Sabrina Magalhães Araújo, Patrícia Alves and Ricardo Cruz Correia are affiliated with the Faculty of Medicine at University of Porto. João Almeida, Sabrina Magalhães Araújo and Ricardo Cruz Correia are actively involved in teaching delivery to the ‘Medical Informatics’ master’s programme at the University of Porto. Ricardo Cruz Correia is the course director of the ‘Medical Informatics’ master’s programme at the University of Porto. John Mantas is the working group chair on education for the ‘European Federation for Medical Informatics’.


There are at least two weaknesses associated with earlier research to assess the size of the effects. As acknowledged in the literature, one relates to attributing causality to empirical findings, due to well-known but inadequately addressed endogeneity biases. The other relates to failure to account for potentially important covariates, sometimes due to data limitations, or because such variables are not frequently used in sociological research. Existing research predominantly finds that the strongest path is from social connectedness to health/mental health, with effect estimates modest in size. I followed a quasi-experimental strategy by modelling adolescent students’ perceptions of social connectedness and mental health perceptions as potentially endogenous variables when estimating bidirectional effects. An instrumental variables (IV) modelling approach was followed, supplemented with a recently developed alternative approach to testing the exclusion restrictions of individual instruments. I exploited the rich information available in the PISA 2018 multi-country dataset, which allows for conditioning for a wide array of information on adolescent students’ personal circumstances, self-reported personality-related attributes, relationships with parents; and school characteristics. I found that (1) accounting for endogeneity biases is important; and (2) as opposed to findings reported in the literature, the dominant effect is from mental health perceptions to social connectedness for both male and female participants. The policy relevance of the findings is that adolescent mental health should be the primary focus of interventions, i.e., identifying and treating mental health symptoms as a primary intervention and as a precursor to improving the social connectedness of adolescents.Research on the bidirectional relationship between social connectedness and health/mental health in adolescents is scarce, with most studies on adults. Some of the existing studies exploited the availability of longitudinal data to provide evidence of the  On the  century . Social  century  proposedInterest in the relationship between various conceptualizations of social connectedness and health, including mental health, grew over the last few decades, especially around the turn of the millennium . From thIn adolescence, a critical period for hormonal changes potentially associated with symptoms of psychological distress, friendships develop involving emotional closeness which fulfils adolescents’ need for intimacy, a sense of belonging, and self-validation. It is the period when adolescents seek more independence from their families as they spend more time and develop intimate relationships with friends , 9. GiveIt has been reported that students’ relationships with their parents, school peers, and teachers are linked to their psychological health and students with lower quantity and quality of peer relationships are at higher risk of developing psychological symptoms , 11. MidSeveral empirical studies have investigated the relationship between social connectedness and health in general, while empirical studies on the relationship between mental health and social connectedness in adolescent students, were designed to estimate effect sizes and were not narrowly focused with respect to the conceptualization of mental health, are few. For example, Diendorfer et al.  reviewedStudies with a broadly similar focus as this study but differing in methodological approach include Ueno , who useWhile the public health literature has clearly established that social connectedness promotes mental and physical health, interest in a reverse causal relationship  is found mostly among clinicians. Studies intending to test bidirectional relationships and demonstrate the direction of causal effects between the two constructs are rare. While some studies on reciprocal relationships exist, evidence on adolescents is scarce.Lester et al.  investig“…is vulnerable to misattributed causality…other factors not directly assessed may contribute to social ties and health behaviours in ways that produce observed links between the two, real or not…” The endogeneity problem is well known, but inadequately addressed in most empirical studies. Although potential biases due to endogeneities are often pointed out as a limitation, researchers have little idea of the magnitude or even direction of the bias [Despite the increased availability of longitudinal data that allow for tests of bidirectionality among constructs, there are at least two weaknesses associated with earlier research on the relationship between social connectedness on health, when the objective is deriving and comparing effect sizes. One relates to attributing causality to empirical findings, due to unobservables/omitted variables and associated biases. As assessed by Umberson and Montez : [past rthe bias . It requthe bias .Of the empirical approaches used which aim to uncover a causal relationship, especially while using observational data, some , do not account for the possibility that one or more important confounders, observed or unobserved, could be another common cause of the outcome and the covariate of interest. There are, however, approaches which allow estimating a quasi-causal effect from data that arise from non-experimental research designs . These igenetic homophily–the genotype of one individual student being predictive of the genotype of his/her friends) and the school environment. The school environment can influence the extent of friendship formations through the mechanism of homophilous relationships [The specific objectives of this study are to model adolescent students’ perceptions of social connectedness and mental health as potentially endogenous covariates , when estimating bidirectional effects, to account for potential biases due to endogeneity. For example, with respect to mental health, relevant unobserved confounders (the effects of person-to-person variation that have not been controlled for) include genetic and environmental factors. As reported in the relevant literature, the heritability estimates for anxiety and depression–among the most common emotional and behavioural problems in childhood and adolescence ‐ are 30–40%. Additional unobserved factors relate to individual-specific environmental influences, which sometimes start in the womb . Similarionships , 26. FinTo address various possible potential sources of endogeneity of covariates of interest, an instrumental variables (IV) modelling approach was followed, supplemented with a recently developed alternative approach to deriving effect estimates in the presence of endogeneity and testing the exclusion restrictions of individual instruments. I also exploit the rich information available in the dataset, which allows for conditioning for a wide array of information on adolescent students’ personal circumstances, including self-assessed health, self-reported personality-related attributes, quality of relationships with parents; and school characteristics. Finally, models are estimated separately by gender, since the role of unobservables and associated biases may differ by gender, resulting in different effects by gender in any direction.In this study, the social connectedness construct (defined in detail in section 2.2.1) encompasses adolescent students’ sense of belonging in school and satisfaction with their friendships in general. School connectedness (or sense of belonging in school) has been defined as ‘the extent to which students feel personally accepted, respected, included and supported by others in their environment’ .The following research questions were investigated:RQ1: Is perceived social connectedness (sense of belonging in school/satisfaction with friends) an endogenous covariate when estimating effects on mental health? Similarly, is perceived mental health an endogenous covariate when estimating effects in the opposite direction?RQ2: Can reciprocal effects be established between social connectedness and mental health of adolescent students, and what is the direction of the dominant effect?RQ3: Are there gender differences in findings associated with research questions 1 and 2?I used the 2018 Program for International Student Assessment (PISA-2018) survey data on 15-year-old students. The 2018 version of PISA, besides the compulsory student and school questionnaires which contains information on students themselves and their family, included questionnaires on different aspects of students’ experiences in school, and students’ attitudes, dispositions, and beliefs. PISA 2018 also included an optional questionnaire on students’ well-being, with nine countries participating . The well-being questionnaire focused on students’ perceptions of their physical and psychological health, subjective well-being indicators, social relationships, and activities outside of school. The well-being questionnaire assessed important factors for the well-being of adolescent students, both objective  and subjective . Among other well-being indicators of students as individuals , satisfaction with one’s body image is included in the well-being questionnaire. It also included an optional ICT familiarity questionnaire with questions on different aspects related to digital media and digital devices, internet access, and related questions.Mental health. Mental health disorders in adolescence are related to anxiety , mood disorders and depression. Such disorders are not rare, for example in the US, one in 10 adolescents has a disorder that causes significant impairment, while one in five has a diagnosable mental health disorder that causes some degree of impairment [pairment . Such dipairment . While i. Symptoms relate to feeling depressed; feeling irritable or bad temper; feeling nervous; experiencing difficulties in getting to sleep; feeling dizzy; feeling anxious; experiencing headaches; and experiencing stomach aches. Based on responses, 16% of 15-year-old students reported that they felt depressed, 17% reported anxiety symptoms, and 21% had difficulties in getting to sleep, more than once a week.In the Wellbeing questionnaire of PISA 2018, students were asked about the frequency of specific symptoms α = 0.88). I used principal component analysis to extract the information from the (reverse coded) item responses, to generate a continuous index taking negative and positive values, standardized at mean = 0 and SD = 1. More positive values indicate fewer mental health symptoms reported, i.e., better mental health.Assessment of internal consistency of the responses to these items in the questionnaire by computing the Cronbach’s alpha statistic  using alSocial connectedness: Sense of belonging and satisfaction with friends. In earlier research, various measures of social connectedness, i.e., the degree to which people are socially connected, have been used. Frequently used measures are egocentric network size and density, representing the number of others  the focal person (ego) is connected to [ected to . HoweverHow satisfied are you with the friends you have? ; (b) Six items related to a sense of connectedness/belonging in school: “I make friends easily at school (reverse coded)”; “Other students seem to like me (reverse coded)”; “I feel like I belong at school (reverse coded)”; “I feel lonely at school”; “I feel awkward and out of place in my school”; and “I feel like an outsider (or left out of things) at school” ; and (c) Number of friends , along with intensity of interaction with friends .PISA-2018 contains the following items: (a) Satisfaction with friendship networks in general: α = 0.806). This is also the case when these six items are combined with the item on satisfaction with friendship networks in general (α = 0.803). However, the items under (c) exhibit very poor internal consistency as a group (α = 0.107), suggesting that the number of friends and related items are standalone items. Furthermore, including these items in the same group of items on sense of belonging in school and satisfaction with friendship networks, reduces the internal consistency of the group considerably. For example, adding “number of friends” in the group containing items under (a) and (b), reduces Cronbach’s alpha statistic from 0.803 to 0.229.The set of six items related to the sense of belonging in school exhibits high reliability for measuring the same construct (Starting with the seven items under (a) and (b) , I used principal component analysis to generate a continuous composite index taking negative and positive values, standardized at mean = 0 and S.D. = 1. More positive values indicate better social connectedness.In specifying the models, I investigated a wide variety of potential predictors of each outcome. When more than one related measure was available, I first investigated which one displays a closer association with the outcome variable. Covariates included in the model specification are:Demographic and family characteristics : Derived from questions on self-reported height in cm and weight in kgs. Using this index, I derived a categorical variable with BMI ranges for being underweight, of normal weight, overweight, and obese.Socioeconomic status (standardised index). Derived from three variables related to parents’ highest level of education, parents’ highest occupational status, and home possessions.Other student characteristicsInterest in ICT (standardised index): Derived from questions such as: “It is very useful to have Social Networks on the Internet”; “I am really excited discovering new digital devices or applications”; “I really feel bad if no Internet connection is possible”; and “I like using digital devices”.Hours of free time in a day: Derived using information on school instruction time and student’s out-of-school study hours.Psychological domain perceptions.Perceived body image (standardized index): The body image continuous index contains negative and positive values and was derived in the survey from questions given on a four-point Linkert scale (from “Strongly disagree” to Strongly agree”): “I like my look just the way it is”; “I consider myself to be attractive”; “I like my body”; and “I like the way my clothes fit me”.Self-efficacy/Resilience (standardised index): Derived in the survey from the following questions, “I usually manage one way or the other”, “I feel proud that I have accomplished things”, “I feel that I can handle many things at a time”, “My belief in myself gets me through hard times”, and “When I am in a difficult situation, I can usually find my way out of it.” Stronger agreement vs. disagreement to each question contributes to more positive vs. more negative values in the index.Fear of failure (standardised index): Derived in the survey from answers to questions the following questions: “When I am failing, I worry about what others think of me”; “When I am failing, I am afraid that I might not have enough talent”; and “When I am failing, this makes me doubt my plans for the future”.Perceptions of relationship with parents.Social connections with parents (standardized index): Derived in the survey from questions capturing the student’s social connection to his or her parents, such as: “My parents help me as much as I need”, “My parents show that they care”; “My parents try to understand my problems and worries”, etc.Emotional support from parents (standardised index): Derived in the survey from questions: “My parents support my educational efforts and achievements”; “My parents support me when I face difficulties at school”; and “My parents encourage me to be confident”.School characteristics.School ownership: Public, vs. Private (independent or government dependent) school.Single-sex vs. coeducational school: Derived from variables on number of male and female students in school.School disciplinary climate (standardised index): Disciplinary climate is measured by the extent to which students miss learning opportunities due to disruptive behaviour in the classroom, such as: “Students don’t listen to what the teacher says”; “There is noise and disorder”; “The teacher has to wait a long time for students to quiet down”; “Students cannot work well”; and “Students don’t start working for a long time after the lesson begins”.When using observational data, to meaningfully estimate models involving an outcome variable (y) and a vector of explanatory variables (x), assumes that: (a) vector x is uncorrelated with the error term in the equation to be estimated; (b) there is no simultaneity/reverse causation; and (c) variables in x are measured without error. When we expect violation of one or more of the above requirements ‐ in isolation or in combination with one or more of the covariates in x ‐ covariate endogeneity is a complication. For example, thinking in terms of the relationship between perceptions of social connectedness and mental health, the correlation between perceptions of social connectedness and the error term could arise because we have omitted one or more important covariates from our model which are correlated with perceptions of social connectedness; alternatively, it could be that perceptions of social connectedness and mental health symptoms are to some extent determined by the same unobserved factors. To address the objectives of the investigation, the methodological approach consists of three steps, as outlined below.Derive a plausible range of degree of endogeneity of the potentially endogenous covariate: Using candidate instrument/s assumed to be relevant and valid , I estimated Extended Regression Models (ERMs) with one covariate assumed to be endogenous. Such models, developed after Heckman’s [eckman’s  originaleckman’s , incorpoThe model to be estimated is as follows:1, other covariates (vector x1), and error term ε1. Having identified candidates for instrument/s (x2), the potentially endogenous covariate, w1, is determined by a vector of variables that are correlated with w1, but not correlated with y, except through their effect on w1 (instrument vector x2), along with variables in vector x1, and error term ε2. Unobservables are represented by the error terms in the four equations.The outcome in each direction of the relationship is determined by the potentially endogenous covariate wThe error covariance matrix is:12) is derived, along with a confidence interval.i.e., from this model, an estimate of the correlation in error terms (unobservables) between the two equations :kinky least-squares (KLS) approach [Excluded instruments need to be correlated with the endogenous regressor, but uncorrelated with the outcome. The exclusion restrictions of candidate instruments  can be tested using the recently developed approach , 33. TheDerive bidirectional effect estimates from IV estimation: Using the proposed instruments, IV estimates of bidirectional effects were derived. When more than one instrument is available, in addition to the KLS-based exclusion restriction tests for individual instruments, conventional overidentification tests of instrument combination are reported .I feel like I belong in school”, with responses ranging from strongly disagree to strongly agree. In the direction from mental health to social connectedness (Model 2), the main instrument set is based on responses to questions on how students felt when last attended math or language classes , with responses ranging from ‘Not at all, to Extremely). In the male regression, a combination of two instruments was used: feeling Nervous/Tense when attending a math class and feeling bored when attending a language class. In the female regression, feeling Nervous/Tense when attending a math class was used as a single instrument.In the direction from social connectedness to mental health (Model 1), the instrument used is the school-level average response (derived using the country-school identifier in the survey) to the question “accomplished something”; “were treated with respect”; “smiled or laughed”; “learn something interesting”; “had enough energy to get things done”; “overall, satisfied with their day”). The instrument is the school average of: “Yesterday, I had enough energy to get things done”. For females, the instrument is based on responses about attitudes towards competition at school , with responses ranging from strongly disagree to strongly agree. The continuous ordered instrument used is the school mean of: “It is important for me to perform better than other people on a task”. Higher values indicate a more competitive school environment.In model 2, an alternative ‐ school-level ‐ instrument was considered (see section 3.4). For males, the instrument is based on Yes/No responses at the school level to questions on how they felt the day before  parameter for every value of the instrument; hence, the linear IV estimator estimates a weighted average of local average treatment effects.Instrument relevance and validity depend on the following main assumptions:Relevance: The instrument and the endogenous covariate are sufficiently associated, either because of a causal association between the two or because the two share a common cause. In observational studies, it is assumed that there is an unmeasured causal instrument which is the common cause of the measured proxy instrument and the endogenous covariate [of an individual member. Finally, belonging in a more competitive school environment is expected to be negatively correlated with the perceived mental health of an individual student.ovariate . In ModeIndependence: The instrument must be uncorrelated with the error term, i.e., the instrument does not share common causes with the outcome. Independence cannot be tested, since the error term is, by definition, unobservable.The exclusion restriction: The instrument is independent of the outcome, after conditioning for additional covariates, i.e., the instrument affects the outcome only through its effect on the endogenous covariate.An additional assumption needed to point-identify a causal effect is that of Monotonicity. This assumption is usually in the context of binary instruments , 36. DetGiven the expectation that the instrument validity assumptions do not hold precisely, in section 3.4 , I implement the procedure suggested by Nevo and Rosen  which reMales assess their health as “excellent” at substantially higher rates than females (48% vs. 33%), while a higher proportion of females assess their health as “fair” (16% vs. 9%). Females reported significantly lower body image satisfaction than males. Females reported a higher fear of failure, while males reported substantially less emotional support from, and worse social connections with parents, compared to females. Finally, based on their experiences in school, males reported a worse disciplinary climate in school (such as noise and disorder in the classroom).kinky least-squares (KLS) approach, which yields statistical inference on the validity of exclusion restrictions regarding candidate external instrument/s  when a plausible range of endogeneity correlations is available, whereas these restrictions were always considered non-testable. In the IV framework, if the model is ‘just identified’  the exclusion restriction cannot be tested; IV estimators assume that the direct effect of the instrument on the outcome is 0. Even in ‘overidentified’ models , tests of overidentifying restrictions rely on the (untested) assumption that at least as many instruments are validly excluded from the model as endogenous regressors [kinkyreg module in Stata) supplements standard IV inference by allowing assessment of the validity of previously untestable “just-identifying” exclusion restrictions [When more than one instrument was available, instrument relevance and exclusion restrictions were assessed using conventional tests from IV estimation. In addition, I used the gressors . The KLSrictions . In otheeregress module in Stata), and the same set of instruments as in the IV regressions. Given a set of instruments, ERMs produce coefficient estimates which closely mimic those from the IV estimation; in addition, they produce estimates and confidence intervals of endogeneity correlations , which served the purpose of a plausible range of endogeneity correlations when testing exclusion restrictions using KLS.Instrument testing using KLS requires prior knowledge of a plausible range of degree of endogeneity (endogeneity correlations) of the endogenous covariate; to derive estimates of plausible endogeneity correlations, I estimated Extended Regression Models (ERMs) with one endogenous covariate (using the Multiple (OLS) regression estimates (column 1) and IV regression estimates (column 2) use the survey weights, along with 80 BRR replication weights for correctly calculating standard errors. Given that the nine countries represented in the data are heterogeneous with respect to geography, culture, etc., to account for such cross-country differences, all regressions control for country fixed-effects. KLS estimates of the effect of social connectedness on mental health (column 3) are unweighted.The estimates of the effect of better social connections on mental health from multiple linear (OLS) regressions are small; one SD increase in the social connectedness composite is associated with about 0.1 SD increase in the mental health composite. The small difference in estimates by gender is not statistically significant. These effect estimates are of similar magnitude to those from other studies which rely on longitudinal data but do not consider endogeneity biases .Columns 2 and 3 in Figs The IV (2SLS) estimates of the effect of social connectedness on mental health are somewhat larger than the OLS estimates, but as is usually the case, less precisely estimated . These estimates are essentially identical to the KLS estimates . While the IV estimates are somewhat larger for females compared to males, the difference is not statistically significant.Endogeneity tests accept the null hypothesis of exogeneity of the social connectedness composite in the male sample. In the female sample, there is evidence of endogeneity, with an associated p-value of 0.09. Finally, tests of instrument relevance indicate that the instrument is not weak. Using the rule of thumb, the first stage F-statistics, at 57 and 81 respectively for males and females, far exceeds 10.However, IV estimates (column 2) are about 5 times larger than the OLS estimates  and the gender difference in effect size is not statistically significant. Effect estimates from KLS present a similar picture . These large effect sizes reflect the strong evidence of endogeneity of mental health perceptions. Point estimates and confidence intervals of error term correlations between the outcome and the equation modelling mental health perceptions are strongly negative . The negative error term correlations indicate that unobservables which tend to improve mental health perceptions occur with unobservables which tend to worsen social connectedness perceptions.In the male sample, the joint null hypothesis that the instrument set is uncorrelated with the error term and that the excluded instruments are correctly excluded from the estimated equation is accepted at high p-values. Further evidence is given from KLS-based estimates and exclusion restrictions tests of each individual instrument Figs –8. UsingOverall, the IV and KLS estimates from the two models tell a consistent story. In the direction from social connectedness to mental health, evidence of endogeneity of social connectedness perceptions is weak, especially in the male sample; hence, after accounting for endogeneity biases the effect of social connectedness on mental health is modest and of similar magnitude for male and female participants. However, in the direction from mental health to social connectedness, accounting for biases associated with the endogeneity of mental health perceptions is important. Comparing effect sizes, the dominant effect is from mental health to social connectedness.Looking at significant associations between covariates and the outcome in the two models, in Model 1 the larger associations are found between better overall health and better mental health. The estimated effect sizes are large, with more than one SD better mental health when the comparison is between assessing health as excellent vs. poor. On the other hand, in the opposite direction, better overall health is only weakly associated with social connectedness perceptions. Looking at other covariates, among student demographic and family characteristics, being of immigrant background is negatively associated with social connectedness . Reporting more interest in ICT is negatively associated with mental health perceptions; however, the opposite is the case for its association with social connectedness. Among psychological constructs, reporting a stronger fear of failure is negatively associated with mental health perceptions. On the other hand, reporting higher resilience associated with better social connectedness, but no association between resilience and mental health was found. Finally, among school-level variables, the association between male students attending a single-sex school and both mental health and social connectedness perceptions is negative, but this is not the case for females for either of the two outcomes.zε = 0, it is assumed that the instrument has (weakly) the same direction of correlation with the omitted error term as the endogenous covariate . If the instrument is less endogenous than the endogenous covariate of interest , then this amounts to essentially considering an “imperfect” instrumental variable.I derived IV bounds on estimates when assumptions underlying instrument validity do not hold precisely, i.e., relaxing the zero-covariance assumption between the instrument and the error term, using the Nevo and Rosen  approachimperfectiv module by Clarke and Matta [Bounds from IV estimation assuming imperfect instruments  to the statement: ‘it is important for me to perform better than other people.’ As expected, the first is positively correlated with individual students’ mental health , while the second , is negatively correlated with individual students’ mental health. Figs The alternative instruments used in IV estimation in Model 2 are school-level instruments. For males, it is the school mean for agreeing with the statement: ‘Some of the covariates in the models other than the covariates of interest, are based on students’ perceptions about themselves, hence potentially endogenous. I re-estimated the models with other potentially endogenous covariates omitted, keeping only demographic, individual student, and school characteristics. From the estimation results  corresponds to about 20 points higher in the distribution of the social connectedness composite. The main finding, therefore, is that the dominant effect is from mental health to social connectedness and effect sizes are large and of similar magnitude by gender. These findings are very different than those reported in the literature, which either assumes only one direction in the relationship (while acknowledging the possibility of presence of effects in the opposite direction) or report a dominant effect from social connectedness to mental health. Finally, addressing RQ3, modest gender differences in effect size were uncovered in Model 1; otherwise, the implications of the findings apply to both male and female participants.The clear implication of the main finding is that the predominance of findings supporting the dominance of the effect in the direction from social connectedness to mental health may be due to failure to account for the influence of unobservables. The intuition for the importance of adolescent mental health in maintaining social relationships is that adolescent students with mental health symptoms can progressively become socially isolated because of negative experiences when interacting with others, as well as negative reactions of others. Mental health can also affect how social situations are perceived which can, in turn, affect one’s behaviour. Given the predominance of earlier findings of a dominant effect in the direction from social connectedness to mental health, policies have been increasingly emphasizing the importance of social relationships for mental health, including adolescent mental health. However, in medical and psychiatric settings, patients’ social functioning is rarely the point of intervention; instead, it is often considered an indicator of impaired mental health , 18.The policy relevance of the findings in this study is that adolescent mental health should be the primary focus of interventions, i.e., identifying and treating mental health symptoms as a primary intervention and as a precursor to improving the social connectedness of adolescents. Schwartz and Litwin  also repI outlined and implemented a quasi-experimental approach to derive effect estimates when the covariate of interest is potentially endogenous. This is often the case with covariates derived from survey participants’ perceptions or when using psychological constructs. As was the case of this study, biases associated with the endogeneity of covariates of interest can be important when looking for answers to research questions.This study has limitations. The data sample used for analysis comprises nine countries, i.e., the countries that participated in the wellbeing module of PISA 2018. Hence, the findings may not be generalizable; had the estimation sample been larger, findings may have been somewhat different. Finally, it would be preferable to implement the quasi-experimental approach used in this study with longitudinal data.


Relapsing polychondritis (RP) is a rare autoimmune disease that can present with various clinical manifestations. Among the affected sites, the ear, nose, and throat cartilages are frequently involved, often leading to subtle and episodic symptoms that can be challenging to diagnose. A high index of suspicion is necessary for the early identification of these subtle signs, which can aid in early diagnosis and prompt management. In this report, we present a rare case of pediatric-onset relapsing polychondritis that was initially misdiagnosed as laryngotracheobronchitis. First described in 1923 by Jaksch-Wartenhorst as “polychondropathia,” relapsing polychondritis (RP) is an extremely rare multisystemic autoimmune disorder characterized by widespread, destructive, inflammatory lesions of cartilage , the, the5], Relapsing polychondritis is an uncommon but progressive autoimmune condition that affects the body’s cartilage and other connective tissues and can result in fatal complications . The disDue to the rarity of RP, many medical professionals are not familiar with its signs or diagnostic standards. Relapsing polychondritis frequently manifests as a variety of heterogeneous, albeit seemingly unrelated, signs and symptoms, which often pose a major diagnostic dilemma ,3. The pRelapsing polychondritis is diagnosed clinically because there are no specific laboratory tests, histological patterns, or imaging tests for it ,8. ClassThe involvement of the laryngotrachea by RP is a significant source of morbidity and mortality and affects approximately 90% of pediatric patients . LaryngeDue to its rarity, no clinical trials have been conducted; as such, there are no evidence-based guidelines for the treatment of RP . The goaRP is a rarely occurring, potentially lethal multisystemic autoimmune condition that typically affects cartilaginous tissues. Due to the wide range of clinical symptoms that patients present with and the low incidence of RP, its diagnosis is frequently made late or not at all in children. Due to the lack of standardized treatment standards, RP therapy is currently empiric and determined by the severity of the organs involved and the activity of the illness. This case demonstrates the importance of being vigilant and exercising critical thinking when treating a patient who has persistent symptoms without a known explanation. Otolaryngologists should have a thorough understanding of this condition in order to help with the diagnosis and treatment of RP-related complications.


This work addresses J.A. Wheeler’s critical idea that all things physical are information-theoretic in origin. In this paper, we introduce a novel mathematical framework based on information geometry, using the Fisher information metric as a particular Riemannian metric, defined in the parameter space of a smooth statistical manifold of normal probability distributions. Following this approach, we study the stationary states with the time-independent Schrödinger’s equation to discover that the information could be represented and distributed over a set of quantum harmonic oscillators, one for each independent source of data, whose coordinate for each oscillator is a parameter of the smooth statistical manifold to estimate. We observe that the estimator’s variance equals the energy levels of the quantum harmonic oscillator, proving that the estimator’s variance is definitively quantized, being the minimum variance at the minimum energy level of the oscillator. Interestingly, we demonstrate that quantum harmonic oscillators reach the Cramér–Rao lower bound on the estimator’s variance at the lowest energy level. In parallel, we find that the global probability density function of the collective mode of a set of quantum harmonic oscillators at the lowest energy level equals the posterior probability distribution calculated using Bayes’ theorem from the sources of information for all data values, taking as a prior the Riemannian volume of the informative metric. Interestingly, the opposite is also true, as the prior is constant. Altogether, these results suggest that we can break the sources of information into little elements: quantum harmonic oscillators, with the square modulus of the collective mode at the lowest energy representing the most likely reality, supporting A. Zeilinger’s recent statement that the world is not broken into physical but informational parts. This work departs from the premise that physical objects are information-theoretic in origin, an idea that has recurrently appeared in human history, especially in physics, particularly in quantum physics research, for over a century. To further put this study in context with other studies and opinions, we would like to first consider the following views of great scientists, which depict a similar point of view.For example, when asked about an underlying quantum world, N. Bohr, physicist and founder of quantum mechanics, answered: “There is no quantum world. There is only an abstract quantum physical description. It is wrong to think that the task of physics is to find out how Nature is. Physics concerns what we can say about Nature.” . N. BohrContemporary to N. Bohr, W. Heisenberg, physicist and founder of quantum mechanics, said: “The laws of nature which we formulate mathematically in quantum theory deal no longer with the particles themselves …,” but “…with our knowledge of the elementary particles.” . For W. A few years later, in a brilliant paper in 1989, theoretical physicist J.A. Wheeler argued that information is the most fundamental thing, giving rise to the physical, a notion he summarized with the expression “it from bit.” Quoting him, “It from bit symbolizes the idea that every item of the physical world has at bottom—at a very deep bottom, in most instances—an immaterial source and explanation; that what we call reality arises in the last analysis from the posing of yes-no questions and the registering of equipment-evoked responses; in short, that all things physical are information-theoretic in origin and this is a participatory universe.” .More recently, A. Zeilinger, quantum physicist and Nobel laureate in physics in 2022, has proposed an informational viewpoint to quantum mechanics in which the world is not broken up into physical but informational parts. According to him, a quantum system represents our knowledge of the world, not the world itself. Quoting him in a recent interview: “We can make measurements but cannot say anything about the essence of reality.” . TherefoOn the other hand, according to neuroscience, we experience reality depending on interactions between ourselves, other beings, and multiple information sources. The nervous system’s different sensory modalities, smell, vision, audition, taste, and touch, generate evoked responses to the many questions we ask of the universe. One could say that sensory responses give rise to the phenomena we experience, with the brain being the natural organ capable of representing the surrounding reality. According to this view, physical observables—the “nature things”—may emerge after this preliminary process. We call this stage “pre-physics”, which refers to the preprocessing of the source data information performed, in principle, by our sensory systems and the brain.With this initial work, we want to support and follow up on these relevant statements by renowned scientists about what we observe to be nothing but information by providing information-theoretic models for representing physical observables. In general, information-theoretic models are defined as theories designed to describe an entire behavior or specific situation with the idea that they will eventually be able to predict that behavior. We want to provide information-theoretic models to explain the “pre-physics” stage from which everything may emerge.Toward this goal, we introduce a novel mathematical framework that can serve as the “informational” foundation for representing physical objects. The proposed approach is based on the field of information geometry, using the Fisher information metric as a particular Riemannian metric defined in the parameter space of a smooth statistical manifold of normal probability distributions. The informative geometry developed by C.R. Rao, extending results from P.C. Mahalanobis and R.A. Fisher, began in 1945 . Since tIn developing the approach, we obtain exciting results about the building blocks of information and how they can be combined to represent the most likely reality. In this way, the laws of physics may come up afterward through a set of linear and nonlinear transformations of the parameters of an informative manifold. The approach is novel because it strives to lay down informational foundations for physics, especially quantum physics. The results are interesting because they connect fields such as information geometry, quantum physics, estimation, and probability theory. We certainly recognize that the project is very ambitious, but we have prospects for continuing work on future publications, making this article the first manuscript.m independent sources is performed in The plan of this section, which, for didactic purposes, we divide into six subsections, is the following. In We start our mathematical description by modeling a single source with a univariate normal probability distribution with σ=1 . This isn samples, n samples asFor a single sample, the normal distribution, the log-normal  distribution, and the derivative (or gradient) of the lognormal distribution with respect to the parameter ormation  as the vWe can now introduce Riemannian manifolds . These an samples derived from the Fisher information (8), is a scalar whose covariant component, contravariant component, and determinant, respectively, areThe Riemannian metric from a single source with C is a constant To calculate the stationary states, we can invoke the time-independent non-relativistic Schrödinger’s equation  or the pcillator .n. The ground state at Some steps now may seem obvious for those used to quantum mechanics. Considering that lsewhere ,14. In tn samples, and n samples, as computed in Equation (8). The quantum Fisher information coincides with the classical Fisher information when in a polar representation of the wave function Assuming that the square modulus of the wave function can be interpreted as the probability density functiond (CRLB) ,15 on th, α(μ)=0 , which im independent sources, each generating n samples, a finite set of m quantum harmonic oscillators may represent reality. Presuming independence of the sources of information, the “global” wave function  can factor as the product of single wave functions. We can write the global wave function asm-system cannot be written as the product of individual wave functions; in this case, we speak of entangled states.With m independent sources. The global wave function writes asEquation (35) constitutes a many-body system, and we may refer to the vector m sources of information for all data values, taking the Riemannian volume of the metric as a prior probability distribution. As proven elsewhere, the Riemannian volume can be considered an objective choice for a prior probability distribution [In parallel, we can compute, using Bayes’ theorem , the posribution . In honom independent sources with a multivariate normal probability distribution n samples that are drawn independently from the multivariate normal probability distribution, the likelihood probability distribution ism quantum harmonic oscillators at the ground state corresponds to the posterior probability density function calculated using Bayes’ theorem from m sources of information for all data values. Interestingly, the opposite is also true, as the prior is constant (42). In other words, we can also say that the likelihood probability distribution from m sources of information for all data values equals the posterior probability density function calculated using Bayes’ theorem from m quantum harmonic oscillators at the ground state. This unexpected and exciting result reveals a plausible relationship between energy and Bayes’ theorem.To start with, we can model Over the past century, renowned scientists have proposed that what we observe is nothing but information. Among many scientists’ opinions, we find that what we actually model is the result of observation, not the world itself (N. Bohr); the laws of nature do not deal with the particles themselves but with our knowledge of elementary particles (W. Heisenberg); all things physical are information-theoretic in origin (J.A. Wheeler); and the world is not broken up into physical but informational parts (A. Zeilinger). From a pure neuroscientific perspective, we can fairly say that we experience reality depending on the central and peripheral nervous system interactions with multiple information sources. In this way, the physical observables—the “nature things”—may emerge after pre-processing the source data information performed by our sensory systems and the brain, a stage we call “pre-physics”, with the laws of physics appearing afterward.n samples can be modeled as a univariate normal probability distribution n, the number of samples. We also modeled m information sources with a multivariate normal probability distribution. It is an approximation for apparent reasons, and we may explore other probability distributions.With this initial work, we wanted to provide information-theoretic models to explain this generative process. We developed a novel mathematical framework for representing physical objects. Our approach is based on information geometry and uses Fisher’s information metric as a Riemannian metric, defined on a smooth statistical manifold of normal probability distributions. We assumed that a single information source generating n is the number of samples. Also, we demonstrated that quantum harmonic oscillators reach the Cramér–Rao lower bound on the estimator’s variance at the lowest energy level, which indicates a relationship between energy and information that deserves to be studied in detail in future work.Investigating the stationary states invoking Schrödinger’s equation or the principle of minimum Fisher’s information, we discovered that information could be represented and distributed over a set of quantum harmonic oscillators, one for each independent source, whose coordinate is the m quantum harmonic oscillators at the lowest energy level, calculated as the square modulus of the global wave function at the ground state, equals the posterior probability distribution calculated using Bayes’ theorem from the m sources of information for all data values, taking as a prior the Riemannian volume of the informative metric. Interestingly, the opposite is also true, as the prior is constant. These results suggest that the m sources of information could be broken into m little elements, in particular, m quantum harmonic oscillators, with the square modulus of the collective mode at the lowest energy representing the most likely reality, which supports A. Zeilinger’s statement that the world is not broken into physical but informational parts. In addition, these findings reveal a very interesting connection between energy and Bayes’ theorem to be explored in the future.We then showed that the global probability density function of the collective mode of a set of Interestingly, apart from the theoretical results we reported to be further explored, such as the relation between energy and information and the connection between energy and Bayes’ theorem, respectively, this mathematical framework offers other multiple alternatives that we are currently exploring. For example, the informational representation on statistical manifolds with Indeed, we can also speculate about the possibility of physical entities being represented this way, for example, in our nervous system. This complex system, consisting of several components, including water molecules, cell types, and conduction systems, could harbor this representation of information. However, we will not discuss these topics in this work. We will leave it now for internal conversations in which we extensively discuss how we may sample and perceive reality, which is possibly the true motivation for initiating and developing this research project.


Spirituality is vital to The Salvation Army’s Bridge model of treatment for alcohol and drug addiction. Spirituality is expressed through Recovery Church, prayer, spirituality lifters, the 12-step programme, and focuses on meaning and purpose. We recruited participants from several regional centers throughout Aotearoa New Zealand and evaluated spirituality using the WHOQol-SRPB and open-ended questions. Most participants held broad understandings of spirituality, only a minority equating it with religion. Participants who completed the Programme had statistically significant increases in spiritual wellbeing at end-of-treatment. These increases were maintained at a 3-month follow-up. Increases in spiritual wellbeing were associated with decreases in severity of alcohol and drug use. There is increasing interest in the role that spirituality may play in the addiction recovery process, with evidence suggesting that a strong sense of spirituality may offer mental and physical health benefits for those in recovery  and its sister programmes , a non-denominational approach based on the incompatibility of substance use and spirituality Miller, . AA is bas we understand Him”   Segal, , which m) Segal, . Researc) Segal, .The Salvation Army, a Christian organization operating across many countries, incorporates the 12-step approach in the provision of residential and community-based alcohol and other drug (AOD) rehabilitation treatment. A review of The Salvation Army’s AOD programmes in the USA reported that participation in the spirituality components of the programme may be associated with treatment completion ; an 8-week multicomponent intensive treatment service for adults with alcohol and other drug addictions. The Salvation Army operates the Bridge Programme in 14 AOD treatment centers nationwide, providing support to approximately 1500 clients each year. The programme comprises four key components: Partnership, the Community Reinforcement Approach, the Twelve Step Facilitation Programme, and The Salvation Army spiritual elements. For a summary of Aotearoa New Zealand’s spiritual and religious context, see Baker et al.  and for Recruitment for the study took place at seven Salvation Army centers nationwide over a 12-month period beginning in January 2014. Participating centers were chosen by the National Manager of The Salvation Army’s Addiction and Supportive Accommodation Services and the National Operations Manager of The Salvation Army’s Bridge Programme. The centers were chosen because they both delivered the Bridge Programme and were representative of the range of clients that utilize the Bridge Programme, including centers located in larger and smaller urban areas, and centers’ with rural clients within their catchment area. During the 12-month period, 675 clients seeking drug and alcohol recovery treatment were invited to participate in the evaluation study. Participants were eligible to participate in the study if they were over the age of 18, entered the programme at one of the participating centers during the recruitment period, had not participated in the Bridge Programme within the previous three months, and gave written informed consent to participate. Ethical approval for the procedures used in the evaluation was received from a New Zealand University’s Human Ethics Committee and from the local Regional Ethics Committee, both of which are approved by the New Zealand Health Research Council and whose guidelines are consistent with those of the American Psychological Association. provided written informed consent to participate. The majority of the participants identified themselves as NZ European (66%) or Māori (31%), 10% identified Pacific Island ancestry , the remainder identified as Indian (1.5%), Chinese (< 1%), or another (7%) ethnicity.A total of 325 participants r Māori 3%, 10% idAs per the standard treatment protocol for the Bridge Programme, all clients underwent a comprehensive assessment at entry to the programme. Those clients who gave written consent to participate in the study also completed a full set of outcome measures at three specific time points: (1) baseline (before treatment), (2) at the end-of-treatment, and (3) at follow-up, 3-months after graduation from the programme or leaving the programme. The measures were completed at a Bridge Programme center. A research assistant supervised each session and if required, provided support with reading and writing.We used a battery of psychometrically-validated measures to evaluate primary and secondary outcomes  completed sufficient treatment to be considered as having received a therapeutic dose. A “therapeutic dose” of treatment was considered to be more than 28 consecutive days of attendance or at least half or more of the treatment programme. Specifically, 182 participants completed treatment and graduated from the programme, and 43 participants did not graduate but completed a substantial portion (more than 28 days) of the 8-week programme. Of those who completed a dose of treatment, 171 (76%) completed the outcome measures at the end-of-treatment, and 108 (48%) completed outcome measures at the 3-month follow-up.Not at all to 5 = An extreme amount/Extremely/Completely/Very satisfied). The items are grouped into eight facets . Responses are summed and mean facet-specific scores and an overall mean WHOQoL-SRPB score are calculated with higher scores indicating higher perceived quality of life within the previous two weeks. Scale reliability analyses on participants’ baseline scores revealed that all 32 items formed a reliable scale ; Cronbach’s αs for the facet-specific scores ranged from 0.77 (wholeness and integration) to 0.96 (faith).We used the WHO Quality of Life-Spirituality, Religiousness and Personal Beliefs . The ASI-MV is based on the interview version of the Addiction Severity Index (ASI), an assessment tool widely used in the evaluation of problem severity in individuals in substance use treatment  Do you have a belief system that is important to you? Has this changed since finishing the Programme? (2) What matters to you most? Has this changed since finishing the Programme? (3) Did the Programme affect your spirituality or religious beliefs? If so, how? (4) Did the Programme alter any sense of meaning or purpose in your life? If so, how? (5) Are there spiritual practices  that have helped you during your time in the Programme? If so, what? (6) How did the discussion about knowledge of a higher power affect your experience in the Programme?n = 225). Measures are reported at three time points .All analyses were conducted on participants who received a ‘dose’ of treatment  scores for seven separate domains but we only used the ‘alcohol use’ and ‘drug use scores.’ We used linear mixed models  to assess the effect of treatment on spiritual wellbeing, and the relation between spiritual wellbeing and our primary outcome measure, severity of use. All models had a random effect on (a) treatment center (city), to allow for clustered observations, and (b) individual, to allow for repeated observations. The models allowed us to determine whether outcome changed from baseline to end-of-treatment or 3-month follow-up. Adjusted means and 95% confidence intervals are presented.The models evaluating severity of alcohol and drug use and its relation to the spirituality overall score were similar in structure to the ones just described. However, the outcome was the alcohol or drug use severity and the overall spirituality score was a predictor. In each case, the model was restricted to those who were referred for alcohol use or drug use, respectively. We adjusted for age, sex time in treatment and phase of treatment and we included a random effect for treatment center and individual.We collated and counted the frequency of ideas contained in participants’ responses to the question, “How would you define spirituality?” We also calculated the number (and percentage) of participants who selected each of the 19 pre-defined conceptualizations of spirituality. As participants were able to select more than one definition, percentages exceed 100%.The first author collated and thematically coded . There was a significant reduction (p = 0.045) in spiritual wellbeing at the 3-month follow-up compared to at end-of-treatment.Table p < 0.01), and from baseline to the 3-month follow-up (p < 0.01). Between end-of-treatment and the three-month follow-up, however, there were significant reductions in scores on four of the facets, spiritual connections, spiritual strength, inner peace, and faith  for a one unit increase in the spirituality scale. Likewise, for participants who were referred for drug use , a decrease in severity of drug use  was associated with an increase in overall mean score on the WHOQoL-SRPB. The adjusted mean decrease in drug severity was 0.005 .Statistical modeling showed that for participants who were referred for alcohol use , a decrease in severity of alcohol use  was associated with an increase in overall mean score on the WHO QoL-SRPB. The adjusted mean Participants were asked to provide their own definition of spirituality, and these answers included energy, justice, wairua  definitions with a median of 6. The most frequently chosen definitions were faith (59%), beliefs (57%), values (56%), meaning (49%), and purpose (49%). Only 5% of participants selected “it [spirituality] is meaningless.”Participants were also asked to define what spirituality meant to them by selecting from a list of pre-defined conceptualizations of spirituality. Figure At the broadest level, the thematic analysis of the open-ended questions 1 to 4 fell into two main types of responses: those that were explicitly religious and those that were more “generically” spiritual . Further analysis revealed the themes of discovery, affirmation, ambivalence and rejection, with a number of sub-themes emerging. These included the importance of sobriety, beliefs and values, awareness, connection, meaning and purpose in life, contribution, compassion, optimism, and acceptance.(1004)My sobriety is the most important thing to me. I have different priorities now. I was all about me when I was drinking. (812)My sobriety. It has started since finishing the programme. This encompasses spirituality, relationships, self-awareness, pride. While attaining and maintaining sobriety is a key outcome of the Bridge Programme, for several participants maintaining their sobriety was the most important thing in their lives:(1007)I was a non-believer. Now I believe in God who I choose to be my higher power and will continue to have faith. (1039)God is very important to me. I only found him here. (554)At first I didn’t want to know but now I have open[ed] my heart to the Lord. A number of participants wrote about discovering new beliefs and value systems after participating in the Bridge Programme, with some participants expressing explicitly religious beliefs and values:“became more clearer”(127) by the end of the programme, while a church-attending participant said that his beliefs had become “more expansive” and that what mattered most in his life now was “being warm and worthwhile to all … finding God’s Spirit in other people”(135).For other participants, the Bridge Programme had led to the discovery of new aspects of their faith. For example, one participant with Islamic beliefs wrote that life (113)It made me aware of spirituality … gave me a sense of belonging and a spiritual awakening. (320)It gave me a better understanding of it . Many participants also wrote about discovering a more general sense of spirituality, or of developing a new understanding of spirituality that was distinct from religion:(129)Yes, it has made my spiritual life stronger by understanding my addiction and myself. (723)Greater awareness of spiritual bankruptcy. I now can say that I have a greater sense of enlightenment. Many participants also commented about greater self-awareness:(537)It introduced me to higher power which I tried to get in touch to during the programme. Higher power supported me and help[ed] me a lot. (522)Couldn’t understand at first but it came slowly that it was something outside myself. This included the discovery and awareness of a personal Higher Power:(1021)It has taught me to look outside myself. (130)Being reminded of the devastation the addiction leaves. Increases in awareness also extended beyond the self, and included the consequences of their addiction:(301)I realized I could rely on my higher power to help me get better. (307)…coming to realize I was powerless over my addiction. For several participants, the awareness of a Higher Power also helped lead them to acceptance of their addiction and recovery process:(555)The purpose and meaning in my life is my children. (750)I didn’t really have a purpose until now and that’s be a great dad. The connection to family/whānau was a prominent theme that ran throughout many participants’ responses, often coupled with finding new meaning and purpose in life:(1027)I have a connectedness with something now where I did not before. (301)… a sense of belonging and hope that things will work out the way they are meant to be. Other participants wrote about a more general feeling of belonging:(129)Yes, that I have meaning for myself and others around me and what my purpose is in life, by learning that drugs, alcohol is stopping me living fiscally, spiritually. (301)I realize there is a meaning and purpose to my life, before my life felt meaning[less]. Participants often wrote about discovering new meaning and purpose in their lives:(313)I feel connected … I want to help other addicts. (524)Yes, helping others, I’ve always wanted to do, I don’t know what area through. But I still want to. For some participants, the opportunity to reflect on themselves and others led to a feeling of wanting to make a contribution to society:(150)Yes, now I believe that I am worthy of a good, happy, full life. I have a sense of direction. (1027)Far more compassion is embodied in my system now, both for myself and others. Many participants wrote about discovering a sense of compassion for themselves and others:(1013)I used to blame God for taking my husband and son from me and I resented him for that. Getting rid of this resentment and accepting God has given me peace. (1038)I reconnected again. My resentment towards him has gone. For two participants, their compassion extended toward forgiveness of God:(119)It made me feel that I could have a meaningful life without alcohol and drugs. (549)…enjoying life. The world is what you make it. When I started I just thought the world was fucked. Finally, optimism was a thread that ran through many participants’ responses:(130)It has resolved my reason for becoming a Christian in the first place. (812)My spirituality has increased hugely. I have always been a spiritual person but I was just tapping on the door. Now the door is open. A number of participants wrote about how participating in the Bridge Programme had reinforced their existing beliefs and values, whether from an explicitly religious perspective, or from a broader spirituality:(554)I still believe I need my cannabis for my pain relief … I won’t smoke when I finish my programme. I stay in pain. A number of participants expressed ambivalence about the Bridge Programme and whether the programme had affected their sense of spirituality. This included ambivalence about the importance of sobriety itself:“willing to accept the ideas but never took [them] on board”(1425), while another wrote “Only in that I pondered it more than I usually would. I have not drawn any conclusions.”(753)The Bridge Programme appears to have increased some participants’ awareness of spirituality without impacting on the person’s beliefs. For example, one person admitted they were (1028)It put me off religion a lot, but gave me an awareness of spiritual awareness. (1050)Discussions about Higher Power in the programme put me off it and closed my mind to it. NA [Narcotics Anonymous] and people in NA opened my mind again. Other participants wrote of how the Bridge Programme had turned them off of religion, but may have opened them to consider the value of spirituality more generally:(1004)Just made me think about it more. Made me aware of what’s out there. Still struggling to believe. Time, I have to be patient. Another participant, while writing about their ambivalence, nevertheless also revealed greater awareness and hinted at optimism for the future:“tedious, relentless”(120), while another wrote about the incompatibility of the programme with their personal beliefs:(1407)I don’t believe in God so it was hard looking at it. Finally, the spiritual and religious components of the Bridge Programme did not resonate with some participants. One person admitted that it was “confusing—didn’t experience it.”(1036)Other participants, many of whom did not complete the Bridge Programme, wrote about feeling confused, with one participant writing Question 5 of the questionnaire asked, “Are there spiritual practices  that have helped you during your time in the Programme? If so, what?” Participants’ responses include religious responses related to prayer and church; then a whole range of responses related to prayer generically, meditation, wairuatanga , and spiritual lifters/classes.Many of the participants noted the help that they received from Recovery Church and bible readings. One participant suggested that Recovery Church added meaning and purpose.“I pray in the morning when I wake up and before I go to bed to thank my higher power for my day.”(1400) Related to this was a sense of surrendering oneself that many felt, “Surrendering my life and will to my higher power.”(1423)Prayer was often noted as being helpful and important, as was meditation. Others noted specifically, the “serenity prayer” was particularly helpful. For example, one participant noted, “spirit lifter”(502) that happens in the mornings for those living in. This was appreciated by some, as was “spirituality class.”(150)The programme offered something called a “haka”  (157) and “karakia” (form of prayer) (509) were noted by a small group of participants, generally this was notably absence from participants’ responses. Those who said there were no spiritual practices per se that were helpful made comments such as, “No, but it was nice to be in a loving atmosphere.”(144)While wairuatanga or Māori spirituality practices, such as The final question (question 6) asked participants “How did the discussion about knowledge of a higher power affect your experience in the Programme?” Like many of the participants’ responses to questions 1 to 5, answers to question 6 also were either explicitly religious or more generic considerations. Within these groups, the responses were generally positive and focused on letting go/surrendering, a better understanding of a higher power, and a springboard to awareness of spirituality generally.(1039)God is very important to me. I only found him here. (108)… it was God that got me here to do this programme. In the explicitly religious group, some made the direct link between a higher power and God, as these quotes suggest,As noted by some of these participants, over the course of the programme, they “found” God or religion, thus it was, in a sense, a conversion experience.(122)... key to enjoy life with my higher power. (132)It made me realize there is something bigger than me. (301)… made me aware of my own spiritual perspective. The more generic spiritual responses to the higher power discussion about how this impacted on their programme experience were largely positive,“informed me that Higher Power didn’t mean ‘god’”(134), suggesting the “god of your understanding” (12 Step definition) approach was useful. Other participants found the higher power discussion of no consequence, saying, “it didn’t”(103) affect their experience; it was “tedious, relentless”(120), it “Didn’t affect me much but I’m ok seeing it as collective consciousness.”(144)Of note was one participant who suggested that the higher power discussions Using validated quantitative psychometrics of spirituality , the present study demonstrated an increase in spiritual beliefs by the end of, and following treatment completion. Although there was a small drop-off in spiritual beliefs at the 3-month follow-up, overall, spiritual beliefs were at a higher level than prior to treatment. These findings indicate that the inclusion of the spiritual component of the Bridge Programme may be effective in producing change in terms of increasing spiritual beliefs. Furthermore, similar to previous research , concur with the literature, affirming the Bridge Programme as an opportunity for spiritual growth that has a positive impact on recovery, at least for the evaluation period examined here.I have found some of my soul” (310), which implies that it was lacking. This is an area that could be further explored in subsequent evaluations by asking questions around whether there is spiritual pain, distress, or a void that is being attempted to be filled with the misuse of AOD.Although the present study demonstrates spiritual growth occurs in an AOD programme and is associated with recovery, the exact mechanism as to the way in which spirituality aids AOD recovery remains unanswered. There is some speculation that addiction is a response to a personal and/or societal spiritual void . Future research that follows up on those who leave a treatment programme before having received “a dose” of treatment would help clarify spirituality-related matters for those leaving treatment programmes early. A further limitation of the evaluation was the lack of inclusion of specifically culturally-related questions, for example, questions asking participants about tikanga Māori aspects of the programme, though as noted, there were very few qualitative results of this nature.Spirituality is a key component of The Salvation Army’s Bridge Programme Model of Treatment. Explicitly this is expressed through Recovery Church, prayer, spirituality lifters/classes, and the higher power component of the 12-Step programme. There are also subtle spiritual aspects of the programme such as focusing on meaning and purpose beyond addiction, a broader “spiritual solution” approach Segal, , p. 2. TMost participants said that spirituality was important and that it had positively changed over the time of the programme. Many participants suggested that their belief system and what mattered most to them was their sobriety and abstinence. Self-awareness, including a general awareness of a generic spirituality, was an important theme in participants’ responses. Another strong theme across all questions was family/whānau, that is, the importance of family in participants’ life, how much they mattered to the participant.The present evaluation demonstrated that the spiritual components of the Bridge Programme were widely valued and deemed helpful. Given its obvious importance, development of the explicit spiritual aspects of recovery need further research and evaluation to build this area of evidence informed addiction processes to help facilitate sobriety, self-awareness and ultimately help those of us challenged by addiction to contribute positively to society.