Headache is one of the most prevalent diseases. The Global Burden of Disease Study ranks it as the seventh most common disease overall and the second largest neurological cause of disability in the world. The “Do Not Do” recommendations are a strategy for increasing the quality of care and reducing the cost of care for headache. This study aimed to identify specific low-value practices in headache care, determine their frequency, and estimate the cost overrun that they represent, in order to establish “Do not Do” recommendations specifically for headache by consensus and according to scientific evidence.This was a mixed methods research study that combined qualitative consensus-building techniques, involving a multidisciplinary panel of experts to define the “Do Not Do” recommendations in headache care, and a retrospective observational study with review of a randomized set of patient records from the past 6 months in four hospitals, to quantify the frequency of these “Do Not Do” practices. We calculated the sum of direct costs of medical consultations, medicines, and unnecessary diagnostic tests.Seven “Do Not Do” recommendations were established for headache. In total, 3507 medical records were randomly reviewed. Low-value practices had a highly variable occurrence, depending on the hospital and type of headache. Overall, 34.1% of low-value practices were related to treatment, 21% were related to overuse of imaging in consultation, and 19% were related to emergency care. The estimated cost of low-value practices in the four hospitals was 203,520.47 euros per 1000 patients.This study identified low-value headache practices that need to be eradicated and provided data on their frequency and cost overruns. Headache is one of the most prevalent diseases and one of the main reasons for consultation in primary care and neurology services . The preThe Global Campaign against Headache, led by Lifting the Burden, together with the WHO, aims to reduce the gap in organizational, diagnostic, and therapeutic approaches to headache worldwide, and particularly in Europe, and seeks to identify the quality dimensions of headache care that should be considered in order to provide integrated quality care , 8. The Overuse is defined as “the provision of medical services for which the potential for harm exceeds the potential for benefit” . UltimatThe “Less is More,” “Right Care,” “Choosing Wisely,” or “Do Not Do Recommendations” campaigns have sought to establish consensus criteria to identify practices that have low value in health care, in an effort to reduce them. Locally, the “Commitment for the Quality of Care of the Scientific Societies in Spain,” of which 49 scientific societies form part, have elaborated a list of recommendations, each one in its specialty or specific field, about what should not be done following the methodology of “Choosing Wisely.” In this case, there is only one recommendation for headache care in Spain (Do not Do neuroimaging studies repeatedly in patients with primary headache (migraine and tension headache) without changes in their profile ). AlthouIn this study, we aimed to identify specific low-value practices in headache care, determine their frequency, and estimate the cost overrun that they represent. “Do not Do” recommendations specifically for headache were established by consensus and according to scientific evidence.This was a mixed methods research study that combined qualitative consensus-seeking techniques, involving a multidisciplinary panel of experts, to define “Do not Do” practices in headache, and a retrospective observational study, with review of a random set of medical records from four hospitals to quantify the frequency of these “Do not Do” practices. This study was conducted between June and December 2019.To prepare for the working session with the panel of experts, a narrative review of the literature was carried out after searching the following databases: PubMed, Scopus, and EMBASE. The following search terms were used: “headache,” “migraine,” “neuroimaging,” “Global Campaign Against Headache,” “quality of care,” “do not do,” “guidelines,” “treatment. Additionally, a manual search was carried out on the websites of the following organizations: Sociedad Española de Neurología, Atlas de Migraña, Choosing Wisely USA, Choosing Wisely Canada, Choosing Wisely Australia, American Headache Society, International Headache Society, National Institute for Health and Care, and Scottish Intercollegiate Guidelines Network (SIGN).The titles and summary of the studies identified were reviewed by two authors to decide whether they were relevant to this study. The full text of the selected articles or documents was revised to extract information on “Do not Do” recommendations in headache. The information was included based on its level of evidence, and feasibility of execution. It was agreed that the SIGN classification should be used as a guide to determine the levels of evidence and degrees of recommendation. Prior to the working session of the group of experts, the information was organized according to the stage of the care process, for example, diagnosis, evolution, treatment, or control, and whether it was an emergency care situation or a neurological consultation.The group of experts consisted of three specialists in neurology, and one specialist each in family medicine, hospital pharmacy, and neurological nursing. The selection of these panelists took into account the involvement of professionals throughout the care process, as well as their experience from the first level of care to monographic consultations for headache, as well as their specialized training. The work of the panel of experts included a group session and multiple telematic meetings until a sufficient degree of consensus was reached. Experts had gathered information during the literature review as well as additional evidence that they could provide. In the face-to-face meeting of the panel of experts, the recommendations identified in the literature review were analyzed one-by-one. In parallel, experts proposed and debated “Do not Do” recommendations associated with the headache care process in their areas of expertise. JM and JJM produced a synthesis of the debate and recorded recommendations through summary sheets that were analyzed individually by successive rounds of telematic meetings, and thereby “Do not Do” recommendations were identified. The consensus on which “Do not Do” recommendations should be proposed considered the quality of the evidence for each recommendation, the feasibility in identifying whether the undesirable practice was implemented in clinical practice, and the foreseeable acceptance of the recommendation by the professional community. Summary cards included the code of the “Do not Do” recommendation, its definition, current problem, number of instances of the undesirable practice occurring within a given number of consultations, sources of information, and evidence.p = q = 50% worst-case scenario, an expected proportion of losses due to incomplete information of 15%, and a confidence level (two-tailed) of 95%. The hospitals had between 367 and 1146 beds. The review of clinical records was carried out by applying algorithms for data extraction from clinical information systems that defined each of the “Do not Do” recommendations determined by consensus in the first part of the study. The International Classification of Diseases (ICD-10) and the Anatomical Therapeutic Chemical Classification System (ATC) were used to select patients who had attended the hospital for headache.We measured the frequency by which these low-value or undesirable practices were implemented in an observational, retrospective, multicenter study. In this study, 3507 clinical records of patients who attended four university hospitals of the Spanish public health system over the past 6 months were randomly reviewed. A minimum required sample size of 3068 patients was calculated for a precision of 3%, Direct costs of ignoring this Do not Do recommendations were estimated by summing the estimated costs of medical consultations, diagnostic tests, and medicines associated with low-value practices. This estimate was made considering the average costs of consultations and diagnostic tests in the health services of Madrid, Castile and Leon, and Murcia (based on data from 2017) and the reference prices for financing medicines by the National Health System in Spain described in Order SCB/1244/2018. The average cost of the first consultations was 82 euros, successive consultations were 71 euros, and emergency care was 175 euros. Brain functional studies with magnetic resonance imaging had an average cost of 400 euros, and electroencephalogram 147 euros.The overall direct cost of these low-value practices at each center in the study period (6 months) was obtained by multiplying the direct cost, in euros, of consultations, tests, and medicines by the volume of patients with low-value practices. Finally, considering a prevalence of 12–13% for migraine, 2–3% for chronic migraine, and 51% for headache , we extrThe literature review identified nine relevant studies and three technical papers. Fourteen “Do not Do” recommendations and two proposals for discussion by the expert group were developed from this information. Overall, the expert panel suggested 17 “Do not Do” recommendations at the group work session  for headaches . FinallyReview of the medical records revealed that consensus “Do-not-Do” practices were implemented clinically in most of the hospitals participating in this study, although with varying frequency Table . PracticRecommendations related to diagnostic tests or procedures accumulated most of the avoidable expenses for the healthcare system, even though there is widely agreement on its low value in specific cases. Costs associated of ignoring this “Do not Do” vary from 88,15€ to 429,00€ each time it happens, depending on the average cost of the procedure or drug. NHC-02 which has been specially tailored and prioritized for Spanish hospitals has an individual direct cost per patient of 142,57 €. If we extrapolated this value to an estimated annual cost per 1000 patients of these seven low-value or undesirable practices, we could reach the amount of 203,520.47 euros  has gradually spread throughout health systems worldwide. The results of this study indicate that there is significant variability between centers in terms of the prescription and use of diagnostic tests that do not provide value or that may even be harmful to patients and emphasize the need for intervention to avoid these low-value practices.The “Do not Do” recommendations for headache care developed by consensus in this study are supported by scientific evidence and experience in daily clinical practice. They address the entire care process, from correct referral from the first level to neurology consultation , to the Our results highlight that implementing these “Do not Do” practices not only jeopardize patient safety, but also endanger the integrity and maintenance of the National Health System. The main avoidable cost was related to non-recommended diagnostic tests, which may also be attributed to the practice of defensive medicine by practitioners, or to pressure from patients . If we eThe reduction of these practices with low diagnostic or therapeutic value or of practices that are harmful to patients has been achieved in some of the centers participating in this study  by incorporating criteria for carrying out examinations or for prescribing medication. It is important to notice the high variability among the participating hospitals. This is due that some services, hospitals, or health areas in Spain can independently generate its own measures to reduce low value care. This can be for one instance the inability of prescribing opioids for headache or the active blocking of CT scans for headaches without alarm signs. This approach in implementation science has been described as PRECEDE, in which there are multiple factors, including knowledge, attitudes and beliefs (as predisposing factors), enabling factors, such as active decision support and work flow innovations in point-of-care tools as the electronic medical record and finally reinforcing factors (motivation to sustain behavior change) .The literature reflects the outcome of interventions based on communication of the benefit of following these recommendations, acting on professional attitudes, knowledge, and behavior, or on changes in patient demands , 26. ForThere are also other possible factors that modify the compliment with “Do not Do” recommendations. Our study doesn’t approached other causes related to sociodemographic and personal characteristics of patient and provider as they have been discussed in other studies .These recommendations pursue the objective of improving quality of healthcare and patient safety, and simultaneously lowering low value care. But “Do not Do” recommendations can’t effectively fulfill this aim by its own. It must be accompanied by other policies related to patient safety and quality of care . These mThis study had some limitations. First, the quality of the information recorded in the clinical records may have led to under-identification of cases of overuse. Although an algorithm was defined with specification of diagnostic and therapeutic codes (numerators and denominators) to record the same data in all centers, possible variability in coding between centers cannot be ruled out. For ethical reasons, professionals could only review the clinical history of patients from their own center, and thus cross-validation of the overuse coding was not possible.In conclusion, the consensus “Do not Do” recommendations developed in this study are relevant to daily clinical practice. We found that the incidence of low-value practices varied depending on the hospital and the type of headache: there was greater variability in drug prescription, and more similar results in the overuse of neuroimaging. This study provided data on low-value practices in headache care, and also illustrated that a reduction of these low-value practices is both possible and desirable.Additional file 1: Supplemental file 1. Do not Do recommendations proposed by the expert panel.


High quality serious illness communication requires good understanding of patients’ values and beliefs for their treatment at end of life. Natural Language Processing (NLP) offers a reliable and scalable method for measuring and analyzing value- and belief-related features of conversations in the natural clinical setting. We use a validated NLP corpus and a series of statistical analyses to capture and explain conversation features that characterize the complex domain of moral values and beliefs. The objective of this study was to examine the frequency, distribution and clustering of morality lexicon expressed by patients during palliative care consultation using the Moral Foundations NLP Dictionary.We used text data from 231 audio-recorded and transcribed inpatient PC consultations and data from baseline and follow-up patient questionnaires at two large academic medical centers in the United States. With these data, we identified different moral expressions in patients using text mining techniques. We used latent class analysis to explore if there were qualitatively different underlying patterns in the PC patient population. We used Poisson regressions to analyze if individual patient characteristics, EOL preferences, religion and spiritual beliefs were associated with use of moral terminology.We found two latent classes: a class in which patients did not use many expressions of morality in their PC consultations and one in which patients did. Age, race (white), education, spiritual needs, and whether a patient was affiliated with Christianity or another religion were all associated with membership of the first class. Gender, financial security and preference for longevity-focused over comfort focused treatment near EOL did not affect class membership.This study is among the first to use text data from a real-world situation to extract information regarding individual foundations of morality. It is the first to test empirically if individual moral expressions are associated with individual characteristics, attitudes and emotions. End-of-life (EOL) care causes many challenges for patients and palliative care (PC) physicians. Decisions that must be made regarding the care of the dying patient must be considered within the context of the psychological, physical, financial and social experiences of the patient’s life . Within In order to get a better understanding of some of these underlying factors, PC communication plays an important role in improving quality. The primary purpose of a PC consultation is to give patients information about their prognosis, as well as discuss goals of care, and address patients’ questions or concerns. Previous research has established that feeling “Heard & Understood” is a promising quality measure for PC communication in the inpatient palliative care setting –3, and tIt is established that patients who have a better understanding of their prognosis are more likely to prefer and have treatments that are aligned with their personal values, goals and beliefs . PalliatIn this context, the choice of language plays an important role in PC consultations. It is well-established in sociolinguistics that the use of particular words in conversation are a reflection of underlying value –24. LittThe objective of this study is to identify specific moral rhetoric used by patients in palliative care consultations and analyze if emotions, self-reported EOL preferences, religion and spiritual needs are associated with differences in moral expressions. We focus on analyzing moral rhetoric in PC consultations and explore the factors related to differences in moral expressions used by patients. The main research question of this study is: “Are preferences, emotions, religious affiliation and spiritual needs associated with vice or virtue and different moral expressions in EOL conversations?” This is a unique contribution to the literature as this study combines attitudinal data and moral expressions and maps how these are being used in a real-life and morally salient context.14 and others have looked at whether these values or beliefs have an effect on PC outcomes, such as coping strategies, emotional outcomes and spiritual quality of life [There has been some research into the role of morality in palliative care. Some scholars have described morality as one of the three sources of transcendence in PC patients of life . This poThe Care/harm foundation: compassion for victim; anger at perpetrator. Relevant virtues include caring and kindness.The Fairness/cheating foundation: anger, gratitude, guilt. Relevant virtues include fairness, justice, trustworthiness.The Loyalty/betrayal foundation: group pride, rage at traitors. Virtues: loyalty, patriotism, self-sacrifice.The Authority/subversion foundation: based on respect and fear. Virtues include obedience and deference.The Sanctity/degradation foundation: based on disgust, virtues include temperance, chastity, piety, cleanliness.There are several schools of thought in moral psychology defining “morality”. The moral foundation theory (MFT), developed by Haidt and Joseph (2004), has been one of the most influential theories within moral psychology in the last decade. The MFT intends to explain the origins of and variation in human moral reasoning based on innate, modular foundations. In one of the key publications, Graham, Haidt and colleagues explain that “monists” describe morality as “one” type: this is usually identified as justice or fairness, referred to as “virtue” . As timeAs can be seen, Graham and Haidt describe the five foundations that can have either a “vice” or a “virtue” realm. For example, loyalty is the “virtue” in the third foundations where betrayal is the “vice”. The authors describe the two different values, positive and negative, as being part of one and the same foundation that can be explained by group pride and rage at traitors.Despite the ongoing work on this MFT in moral psychology, the validity of this scale  across different cultures is not yet fully established. Also, it remains a challenge for the theorists to fully capture the highly variable and subjective nature of individual moral values . For thiTo our knowledge, only one study used the Moral Foundations Dictionary (MFD) to analyze real conversational data. The authors of that study used short-post social media to compare the accuracy of text analysis methods for detecting moral rhetoric and longer form political speeches to explore detecting shifts in that rhetoric over time . They deFor this study, we used data from the Palliative Care Communication Research Initiative (PCCRI), a multi-site cohort study of naturally occurring inpatient palliative care consultations , 31. TheThe study data were collected for 231 hospitalized patients with advanced cancer who consulted with PC in two large academic medical centers in the United States. For our study we used the patient/proxy questionnaire for patients’ demographic information  and self-reported preference for comfort-directed care near EOL, and attitudinal variables such as distressing uncertainty, spiritual distress, emotional distress, religious affiliation (if any), and whether patients felt their spiritual needs were being met by their religious community or the medical system. We used verbatim transcriptions of the palliative care conversations to identify moral words using the MFD data dictionary described in the previous paragraph.The psychologists who developed the MFD did this by classifying words in one of the five moral foundations, by vice or virtue. This results in 10 potential “dimensions” of moral words in the text: each of the 5 foundations with “vice” and “virtue” categories for each foundation.We used 231 audio-recorded and transcribed inpatient PC consultations and data from baseline and follow-up patient questionnaires at two large academic medical centers in the United States. With these data, we identified different moral expressions using text mining techniques and natural language processing. The words that each patient or proxy said were combined into a single corpus of text. We included only text used by patients, not physicians or other members of the conversation. The corpus was then split into a list of individual words, which were set to lowercase and stemmed. Stop words, such as” and”,” the”, and” of”, were removed from each corpus to reduce the noise of the data.First, we added up all the morality words used by the patient in a PC consultation, and counted, after pre-processing, the total number of words used by the patient as a proxy for the length of the conversation. We then disaggregated the words from the data dictionary to create the 10 different categories of moral terminology in the PC consultations. We created a matrix for all categories where a word from the Moral Foundations Theory Dictionary (MFD) occurred in a patient’s text, that patient was assigned a value of” 1″ for that word’s associated MFD category. The text mining process was performed with Python 3.7.3.After merging the data from the text with the data from the PC survey, we analyzed the data in a few steps, adopting an exploratory approach to test relations between underlying factors and moral expressions in the PC consultations.First, we used latent class analysis (LCA) to classify the patterns of MFD expressions into mutually exclusive classes. LCA is based on the idea that a discrete latent variable accounts for observed associations between a set of indicators, such that, conditional on the latent class variable, these associations become insignificant . A statiThe ten indicators in our analysis were created after the text mining phase: each one indicated whether a patient used a vice- or virtue- related word in one of the five dimensions of the MFT. In addition to the indicators  covariates were included in the model to explain class membership: age, gender, race, education, financial security and religion. We also included self-reported variables regarding patient’s spiritual needs, whether they reported emotional, spiritual or uncertainty-related distress, and preferences for comfort-directed treatment at EOL and looked at patterns of several of the attitudinal variables. Our analyses focused on preferences for comfort-directed EOL treatment; emotional, spiritual or uncertainty-related distress; and whether patients felt their spiritual needs were being met by (1) their religious community or (2) the medical system. EOL preference was defined by the answer to a survey question: “During the last few months of my life, I would prefer a plan of treatment that focused on my comfort and quality of life, even if that meant not living quite as long”, which is answered by a 5-point Likert scale.Over the past 2 days, how much have you been bothered by emotional problems such as feeling anxious, depressed, irritable, or downhearted and blue.Over the past 2 days, how much have you been bothered by uncertainty about what to expect from the course of your illness?Over the past 2 days, how much have you felt at peace?The questions related to emotional feelings, also answered by 5-point Likert scales, included:Questions related to spiritual needs included: “How much are your spiritual needs being supported by a religious community (like clergy or members of a congregation)?”, and: “How much are your spiritual needs being supported by the medical system ?” where both were answered by “completely-quite a bit-moderately-slightly-not at all”.Second, to explore which factors were associated with patients’ use of vice- or virtue-related words, and their use of words belonging to the 5 different foundations of morality, we used Poisson regressions. Age was a continuous variable, race was represented by a binary variable for “white”, education was categorical, and “financial security” was represented by a categorical variable: “When you think about the amount of income that you have available in a typical month, how often is it enough for things you really need like food, clothing, medicine, repairs to the home, and transportation?” – answered by “all the time”, “most of the time”, “some of the time”. We included a binary variable for “Christian” religion and one for “other religion” which included Judaism, Islam, Hinduism, Buddhism, and “other” from the survey data. We also controlled for the total amount of words used by the patient in the consultations, as a proxy for the length of the conversation.The summary statistics are reported in Table We continued our descriptive analysis looking at the use of MFD words. We found that about half of the patients did not use any of the MFD words at all. For those who did use MFD words, we looked at the number of words they used per category of the Moral Foundations Theory. Table After identifying how many moral words were being used in the different dimensions of morality and their vice-virtue subcategories, we explored the results of the latent class analysis (LCA). The dependent variable was “moral charge” defined by the number of moral words used in the PC consultation; the indicators were the 10 morality categories. First, we determined the number of latent classes. Table We considered theoretical interpretability and compared the statistical tests of model fit using models for one to five possible latent classes. Table p = 0.62). Overall, the two classes can be interpreted as one in which individuals use many morality words (31.7% of the sample of patients) and one where moral terms occur infrequently (68.3%). Individuals in the first class use some words in the Harm-virtue, Harm-vice and Ingroup-virtue dimensions, but not many in the other dimensions of morality.Table Except for gender, financial security and preferences for comfort-directed treatment near EOL, all exogenous variables  are associated with class membership. Being female, feeling financially secure and preferring comfort-directed treatment near EOL are independent of class membership. There are slightly more males (52% vs 48%) in the class using fewer moral words, and more younger patients and more Whites (80% vs 75%). Overall, among patients in class 1, there were fewer Christians (68% vs 72%) and fewer patients with another religion (6% vs 14%).Following the LCA, we looked at which variables were related to the number of morality words used. First, we explored the variables associated with vice and with virtue, to see if any of the individual characteristics, religious affiliation or attitudes were related to the use by patients of virtue- versus vice-words. The data followed a Poisson distribution: the use of virtue and vice words could be treated as rare events, since many patients did not use MFD words at all. As the Poisson distribution assumes that the mean and variance are the same, we tested the fit of a Poisson model versus Negative Binomial models. The likelihood ratio test is a test of the over dispersion parameter alpha: when alpha is zero, the more flexible negative binomial distribution is equivalent to a Poisson distribution. In our case, alpha was not significantly different from zero, suggesting the Poisson distribution was appropriate, both for virtue and for vice, so we used Poisson regressions to estimate the amount of moral rhetoric in PC consultations. We also used a Vuong test of the zero-inflated model versus the standard Poisson model and found that the excess zeros should not be modeled independently. We used robust standard errors for the Poisson models . In all p = 0.09); − 0.42 (p = 0.05)). Patients who had been increasingly bothered by emotional problems such as feeling anxious, depressed, irritable, or downhearted and blue, felt more uncertain about their prognosis or felt less “at peace”, used more moral terms in the “vice” category of the MFD (p < 0.01).Table After establishing that emotional distress, white race and Christianity were associated with the use of virtue and vice words by patients, we were interested in which variables were related to using words in each of the five distinct morality foundations described by the MFT (merging the vice and virtue sub-categories per dimension).p = 0.07); and being Christian was related to using fewer “Loyalty/Betrayal” words . Feeling more emotional, spiritual or uncertainty-related distress was associated with more words in “Care/Harm” and “Sanctity/Degradation”.Table p = 0.08) and “Authority/Subversion” , and fewer words in “Loyalty/Betrayal” . Interestingly, the more patients felt that their spiritual needs were being supported by their religious community or the medical system, the more words they would use in the “Fairness/Cheating” foundation , but fewer words in “Loyalty/Betrayal” .In addition, we found that patients who were higher educated used, on average, slightly more words in the “Fairness/Cheating” foundation  the moral lexicon as determined by the moral foundation dictionary (MFD) corpus. We found in our LCA that about two thirds of patients use few or no morality words at all while about a third does use a lot of moral rhetoric. Employing the MFD, which distinguishes five moral foundations and vice and virtue subcategories within each dimension, we found that being White and Christian were both associated with the use of fewer words in the “virtue” category and more emotional distress were associated with the use of more “vice” words. These factors were also related to the use of words in Care/Harm, Loyalty/Betrayal, and Sanctity/Degradation dimensions of the MFT. We also found that education level was related to the use of words in Fairness/Cheating, Loyalty/Betrayal and Authority/Subversion. To what extent patients stated that their spiritual needs were being supported by religious community or medical system was also associated with moral rhetoric used in the Fairness and Loyalty foundations.There are a number of limitations in this study. First, our analysis assumes that the MFD is a correct tool to identify morality, and in particular the five different foundations identified in the MFT. However, the data dictionary is relatively novel and has not been tested very often empirically, other than the study mentioned further above. Second, our study results may not be generalizable to other populations of patients. There are further limitations associated with the bag of words-approach that we used in the text mining phase of the study. A disadvantage is that it limits the context of the conversation and loses the order of specific information. Bag-of-words requires supervised machine learning which entails modeling linguistic knowledge through the use of dictionaries containing words that are tagged with their semantic orientation . We usedThe most important piece of our study was to adopt a plurality perspective to morality, and therefore we wanted to distinguish between different types of morality words used by different patients. In order to further explore the differentiation of moral terminology and evaluate which factors are related to specific moral terms, we would need more data as for some groups we did not have enough words in some MFT foundations. Based on our analysis, for example, we found that having any religion mattered but we could not differentiate enough between morality among several religions because of sample size issues.This study is among the first to use text data from a real-world situation to extract information regarding individual foundations of morality. It is the first to test empirically if individual moral expressions are associated with individual characteristics, attitudes and emotions. The results of this study are relevant to those who seek to improve the quality of communication in order to achieve better and more values-concordant treatment at EOL.Some of our findings may be relevant for a broader context. We found that those who feel that their spiritual needs are being met tend to use more moral language than those who do not. This study gives rise to the further development of conversation science which can be used by physicians to align moral and other sensitive aspects of PC consultations . For exa


Questions directing the EmQM research agenda are: Is reality intrinsically random or fundamentally interconnected? Is the universe local or nonlocal? Might a radically new conception of reality include a form of quantum causality or quantum ontology? What is the role of the experimenter agent in ontological quantum mechanics? The Special Issue also includes research examining ontological propositions that are not based on the Bohm-type nonlocality. These include, for example, local, yet time-symmetric, ontologies, such as quantum models based upon retrocausality. This Editorial provides topical overviews of thirty-one contributions which are organized into seven categories to provide orientation.Emergent quantum mechanics (EmQM) explores the possibility of an ontology for quantum mechanics. The resurgence of interest in realist approaches to quantum mechanics challenges the standard textbook view, which represents an operationalist approach. The possibility of an ontological, i.e., realist, quantum mechanics was first introduced with the original de Broglie–Bohm theory, which has also been developed in another context as Bohmian mechanics. This Editorial introduces a Special Issue featuring contributions which were invited as part of the David Bohm Centennial symposium of the EmQM conference series ( The three-day symposium was held at the University of London, right next to Birkbeck College, the final academic home of David Bohm. The symposium offered an open forum for critically evaluating the prospects and significance—for 21st century physics—of ontological quantum mechanics, an approach which David Bohm helped pioneer. The Editorial introduces contributions featuring the original research of the EmQM symposium speakers, as well as additional researchers who are exploring the ontological implications of quantum mechanics. The contributions are thematically organized as follows: (1) Quantum Ontology and Foundational Principles, (2) The Continuing Impact of the Bohmian Theory, (3) Beyond the Bohmian Theory: New Developments, (4) Quantum Ontology and Time: Retrocausality and Irreversibility, (5) Entropy, Thermodynamics, and Emergent Quantum Gravity, (6) Alternative Quantum Models and Tools, and (7) Advanced Quantum Experimentation. “Towards Ontology of Quantum Mechanics and the Conscious Agent” was the heading of the David Bohm Centennial symposium as part of the Emergent Quantum Mechanics (EmQM) conference series  theory and Bohmian mechanics. The opening article by Basil Hiley and Peter Van Reeth engages the historically controversial problem of the reality of Bohmian quantum trajectories . The autRobert Flack and Basil Hiley—again addressing the problem of quantum trajectories—explore “the relationship between Dirac’s ideas, Feynman paths, and the Bohm approach” . After sNicolas Gisin, next, clarifies the long-standing debate between those in the mainstream of physics who argue that the Bohmian approach is “disproved by experiments”, and those who insist that “Bohmian mechanics makes the same predictions as standard quantum mechanics” . After pDustin Lazarovici, Andrea Oldofredi, and Michael Esfeld continue with key arguments in support of the physical consistency of Bohmian mechanics . In partOliver Passon, next, tackles a common misconception regarding the dBB theory , namely Travis Norsen offers an explanation of the Born-rule statistics for the dBB pilot-wave theory . In the Ángel Sanz highlights the impact of Bohmian theory—beyond mere theoretical significance, namely, as a “useful resource for computational and interpretive purposes in a wide variety of practical problems” . SpecifiThe final article in this category is contributed by Roderich Tumulka . He provThis category features research pursuing ideas beyond the Bohmian theory and its typical interpretation. Although the researchers agree that the notion of nonlocality is essential to an ontological quantum mechanics, new developments are explored, based on the assumptions and propositions that are not normally covered by the dBB theory and by Bohmian mechanics.Gerhard Grössing, Siegfried Fussy, Johannes Mesa Pascasio, and Herbert Schwabl present a model of quantum reality that “does not need wave functions”, and one that assumes a “cosmological solution” to the problem of nonlocality . That isMohamed Hatifi, Ralph Willox, Samuel Colin, and Thomas Durt present an analysis of a quantum model inspired by “the properties of bouncing oil droplets”—as observed by the so-called ‘walkers’ in non-equilibrium experiments—and which “have attracted much attention because they are thought to offer a gateway to a better understanding of quantum behavior” . In partMojtaba Ghadimi, Michael Hall, and Howard Wiseman describe research findings related to the Many Interacting Worlds (MIW) proposal, which is “a new approach to quantum mechanics, inspired by Bohmian mechanics” . The MIWTime-related aspects and interpretations of quantum mechanics are the focus of this category. The first three articles present work that considers, in three distinct ways, the possible relationships between the implicit time-symmetry of the quantum formalism and physical ontology. The final article discusses the concept of fundamental irreversibility in nature. Emily Adlam starts by noticing that “the physics community has come to take seriously, the possibility that the universe might contain physical processes which are spatially nonlocal, but there has been no such revolution with regard to the possibility of temporally nonlocal processes” . The autKenneth Wharton introduces a new class of retrocausal models that he hopes will “guide further research into space–time-based accounts of weak values, entanglement, and other quantum phenomena” . This woNathan Argaman reconsiders a central tenet of Bell’s nonlocality theorem—the causal arrow of time. He points out that “the physical assumptions regarding causality are seldom studied in this context, and often even go unmentioned, in stark contrast with the many different possible locality conditions which have been studied and elaborated upon” . ArgamanLajos Diósi compares two fundamental concepts of irreversibility which, as he emphasizes in this work, have “emerged and evolved with few or even no interactions” . First, Theoretical issues are addressed linking entropic and thermodynamical considerations with quantum systems and possible emergent quantum phenomena. The first article by Jen-Tsung Hsiang and Bei-Lok Hu starts out by explaining that–in view of “quantum mechanics as an emergent theory”—thermodynamical theory “is perhaps one of the most powerful theories and best understood examples of emergence in physical sciences, which can be used for understanding the characteristics and mechanisms of emergent processes” . The autOsvaldo Civitarese and Manuel Gadella start with a review of “the concept of entropy in connection with the description of quantum unstable systems”, whereby the goal of this work is to show “that a comprehensive scheme leading to the definition of entropy for resonances can be rigorously designed by adopting path integration techniques” . SpecifiArno Keppens pursues a “complex systems approach, as a kind of toy model, for identifying space–time’s ontological micro-constituents and their interaction, i.e., their sub-quantum dynamics” . TowardsMassimo Tessarotto and Claudio Cremaschini formulate a Bohmian trajectory-based representation for the quantum theory of the gravitational field . SpecifiA wide variety of different approaches, including those proposing the construction of alternative ontologies, are grouped together in this category. The five contributions range from quantum models that seek to explain quantum phenomena by local, yet unconventional, accounts of physical reality to a quantum model based on an observer-independent event ontology.Tim Palmer presents a cosmological model in “which the universe evolves deterministically and causally, and from which space–time and the laws of physics in space–time are emergent” . SignifiThomas Filk continues the challenge for the need of a Bohm-type, nonlocal ontology as an explanation of the EPR-type quantum-entanglement correlations . In partDimiter Prodanov’s contribution describes “the mathematical foundations of the scale relativity theory, its link to stochastic mechanics, and the theory of the Burgers equation” . This woLouis Kauffman reviews “previous results about discrete physics and non-commutative worlds” . As the Rodolfo Gambini and Jorge Pullin provide a short review of the Montevideo interpretation of quantum mechanics . BrieflyThe final category is devoted to experiments, and their interpretation, targeting advanced research questions in quantum foundations, as well as practical applications. The first article is by Lukas Mairhofer, Sandra Eibenberger, Armin Shayeghi, and Markus Arndt, who present quantum-interference experiments with biomolecules, and discuss the sensitivity to weak magnetic fields of the observed fringe patterns . Under sLev Vaidman and Izumi Tsutsui offer a conceptual analysis of “the history of photons in a nested Mach–Zehnder interferometer with an inserted Dove prism” . The ana3S1 state…is within the resolution of conventional microchannel plate detectors indicating that this type of experiment is feasible.”Finally, Robert Flack, Vincenzo Monachello, Basil Hiley, and Peter Barker describe a method for measuring the weak value of spin, for atoms using a variant of the original Stern–Gerlach apparatus . The purThe wide range of perspectives which were contributed to this Special Issue on the occasion of David Bohm’s centennial celebration, provide ample evidence for the continuing possibility of an ontological quantum mechanics. In fact, the case for realist approaches towards explaining quantum phenomena, including in the account of EPR-type quantum correlations, has only strengthened, in recent years. Pivotal to this emerging development—for which stands the project of emergent quantum mechanics or EmQM—has been the following realization: A physical ontology for the quantum level represents a measurement-dependent, contextual, or relational ontology; that is, the advancement of ‘quantum ontology’, as a scientific concept, marks a clear break with classical ontological propositions in the form of direct or naïve realism. Indeed, such an approach to ontology is a vital part of David Bohm’s legacy. He noted that, in classical ontological theories in physics, there has been a tendency to assume that the basic concepts of the theory correspond to independently existing realities, i.e., to realities that are not dependent either on context or deeper levels of being. By contrast, in his ontological interpretation of quantum theory, the basic concepts, such as “particle” or “momentum”, reflect a reality that is inherently dependent either on context, or on deeper levels, or on both. For the future, instead of denying the possibility of a ‘quantum reality’, the mainstream of quantum physics might embrace, and join in, the search for unconventional causal structures and non-classical ontologies, which can be fully consistent with the known record of quantum observations in the laboratory.


Several established school smoking prevention initiatives involve restrictions on places to smoke. The focus on tobacco control in schools is due to the risk of smoking initiation during adolescence and the perception of this life stage as a period of time when health behavior is established. Hence, this period of time is considered to be ideal for health-promoting initiatives. This paper is part of an ethnographic study on adolescents’ perceptions of tobacco use. Focus groups and field observations were used to explore adolescents’ smoking-related practices related to smoking bans at schools. The findings show that smoking, as a place-based practice, is influenced by locally embedded rules and carries social implications resulting in a distinction between smokers and non-smokers. The distinction between smokers and non-smokers contributes to the retention of a stereotypical view of smokers and, moreover, stigmatizes smokers. According to this, restrictions on places to smoke within the school should be considered carefully in order to avoid stigma or ethical issues. Despite an overall decline in smoking prevalence in many western countries during the last decades , smokingDue to the adverse health effects of early smoking initiation, tobacco preventive efforts with youths are considered to be key ,10,11. SFor Danish adolescents, there has been a decline in smoking prevalence since the 1980s, however, this stagnated among school children from 2014 to 2018 . ApproxiIn the World Health Organization (WHO) treaty Framework Convention on Tobacco Control (FCTC), smoke-free policies are recommended as protection from exposure to tobacco . NumerouIt has been suggested that smoking policies at schools have the possibility of decreasing adolescents’ smoking; however, the effects of these policies are inconsistent . For exaDespite the large number of initiatives comprising smoke-free policies in schools, only a few have actually examined in depth how adolescents perceived and approached such school-based initiatives ,26. As iScholars increasingly argue that more comprehensive knowledge about the social responses to tobacco control policies is vital for understanding smoking behavior and eventually reducing the prevalence of smoking ,29. To uWe deploy a notion of identity work, as identity work happens through engagement in behavior and actions. Adolescence is defined and constituted in relation to the surrounding and distinct life periods . Thus, adolescence is characterized by specific behaviors and ways of acting, all of which influence an adolescence’s self-understanding and sense of identity ,30. In  to everyone else, especially minors and people like that, so they think, I’d like to do that too, or something.” Not smoking in the presence of younger children represents a norm concerning smoking and indicates that smoking is an inappropriate behavior for younger children. According to Best , smokingHellum: I’ve always felt that we were a young class. When we were in the third grade, for example, and looked up to the eighth graders, they just seemed so grown up–smoking and driving scooters. Now we’re up here, and I still feel that we’re young.Sofie: Not immature but not mature. We’re not like… We don’t drink and all that.Moderator: Immature?Sofie: No, not that it’s immature. But those that are older, for example, they finished school some years ago, but they were really forward. I mean, not that we’re immature; we’re mature because we’re careful.This illustrates the in-between position of adolescence, which seemingly is reinforced by the adolescents’ understanding of the symbols attached to a specific behavior such as smoking and drinking. Moreover, not practicing these behaviors challenges their self-understanding of being young people . As a reMartin: No, not even the cleaning ladies respect it [the smoking rules].Pelle: No, not at all.Martin: They are standing right outside the multifield and smoke. They leave the school area, but they [go for a] smoke.The above excerpt illustrates the existing norms, because even though the cleaning ladies seemingly complied with the formally stated rules, which was not to smoke at the school premises, they were still considered to not comply with the smoking rules. With this, the informal rules of not smoking in visible places (and in front of younger children) represented the smoking norms at School B. Contrarily, the adolescents at School B accepted that smokers could break the smoking ban . This acceptance was further grounded in an understanding of how pervasive the addiction of smoking can be, “People that are addicted have to smoke because they’re addicted, so I think it’s good that they’ve set up a place where they can go and do it” . The lack of the possibility for smokers to smoke during a school day is considered to have different consequences such as lack of concentration and the possibility of smokers smoking inside the school. This perspective of smoking further expresses sympathy for the smokers and contributes to a perception of smoking (despite a smoking ban) as an acceptable practice when practiced in distinct places. Furthermore, we argue, it reflects local smoking-specific norms, as smoking is a prominent practice that multiple adolescents at School A partake in.As the smoking-specific places are remotely located at the schools, the practice of smoking required movement from the school setting to the thicket, which also means that the smokers physically move away from some students but gather with others. Thus, smoking at distinct places has social implications that have the effect of strengthening and hindering social ties: Simon: We talk to the persons standing over there, and we don’t usually talk to them.Moderator: Yes?Simon: That’s how it is, sort of.Marikka: That’s how you make new friends.The smoking-specific places had a collective dimension which contributed to socialize the smokers, and thus created specific groupings , which had some implications for the interactions among peer groups. This group division is characterized by “those who smoke and those who don’t smoke, so both feel a bit like outsiders” . Smoking, hereby, represented what Best denoted to be a ”symbolic boundary” and contributed to creating a distance between those who participated in smoking and those who did not . This diIt’s kind of a shame that your friends just desert you. But I can also perfectly understand that if they’re addicted to smoking now or something, then they should probably be allowed to do it … but it’s a little annoying that they don’t just do it during breaks but in the middle of class. Sometimes we only have a 10-min break before the next lesson starts and then they just go outside and smoke.This illustrates a friction between the understanding of smoking, on the one hand, as a pervasive addictive behavior (which needs to be practiced) and, on the other hand, as a practice that disrupts the social intercourse between smokers and non-smokers. This disruption, we argue, is a consequence of the distinct places smoking is practiced, and hence smoking adolescents’ movements to these places. The distinct locations of the smoking-specific places and their exclusivity for smokers act as and reinforce symbolic boundaries between peer groups. The boundaries further create a conflict between smokers and non-smokers as the non-smokers feel excluded from the socialization taking part among those who smoke. However, commenting on smoking behavior contributes by exposing and alienating the smokers.Simon: Yeah, but Mads says it every time, you know. Even if he … I’ve only been gone for two minutes, and he’ll ask, ‘have you just been out smoking?’ That’s a bit strange. Like, a bit…Marikka: Yeah, he’s like super annoying, so he always has to make some shitty comment.Moderator: You think it’s annoying that he comments on it?Carlos: Yes.Simon: Yes, also just because he talks, even when there are other classes, he talks loudly about it. And it’s not because you don’t want them to know, but that you actually couldn’t care less. But then–why even…?The fact that the adolescents who smoke express a feeling of discomfort, when their smoking is exposed, indicates that smoking, regardless of being a normal and relatively accepted behavior, has some negative connotations which may challenge the smoker’s self-representation. The replacement of smoking, for instance, the move to the thicket, may function to hide their smoking practice but ends up exposing it. The negative connotation of smokers was illustrated by Ruben who was a non-smoke.Ruben: It [smoking] might make a worse first impression. No, I don’t know.Moderator: Yes?Ruben: it was just to say something. [Laughs]Fie: Oh Rub [nickname of Ruben]!Moderator: A bad first impression?Ruben: Yeah, a little. It probably depends on whether they’re nice when talking to them, then it goes away again quick … It’s just that if there are a lot of people over here smoking, then you might not want to go over to them. Because, yeah, I don’t know.Despite the general acceptability of smoking at School A, some adolescents still express a perception of smokers as special types of people. This expresses norms and, moreover, results in stigmatizing smokers. The perceived social bond between smokers and the stereotypical view of smokers influence the interactions between non-smokers and smokers. Hereby, practicing smoking becomes a pervasive identity statement. Similarly, the adolescents at School B expressed a tendency to keep a distance from smokers because of their smoking status.“I feel a bit like… Now I’m just using the ninth grade as an example. If you know that some of the ninth graders smoke, you get a kind of overall idea–a prejudice about what they’re like and, ‘that’s probably not someone you want to talk to because they smoke’.”Smoking represents, as earlier described, a symbolic boundary. However, in the case of School B, the boundary is influenced by the pervasive anti-smoking norms and a certain perception of the kind of people smokers are.In this paper, we aimed to explore adolescents’ smoking-related practices in light of smoking bans at schools; particularly, we focused on place(s) to smoke. Our results highlight how an analytical focus on place contributes to an understanding of how the social meaning of smoking, as a place-based practice, is (re)created and further carries social implications. These findings are considered to be valuable, especially considering the focus on smoking prevention among adolescents and the increase in smoking regulation policies in adolescents’ everyday settings.Our results show that smoking adolescents feel discomfort when their smoking behavior is exposed, indicating that smoking is not well regarded. Thus, when smokers practice smoking at distinct places, it indicates that smoking has a negative connotation. Moreover, many smokers experienc stigmatization ,45, amonWhile some research addresses how smoking is experienced by different and combined social identities such as gender and race, (non)smoking as social identity is not addressed ,50. In lAs mentioned, our findings further underscore how the practice of smoking at distinct places can create pro-smoking communities, and, conversely, also disrupt the socialization, as the distinct places are exclusively for smokers. This is, among others, supported by Pokhrel et al., who found that young adults initiated using e-cigarettes to join the smokers at the smoking-specific places, but without smoking conventional cigarettes . AlthougThis study has a few limitations. In general, a low percentage of adolescents smoke. This was also reflected in our sample. The number of adolescents at the two schools who practiced smoking was limited. Thus, the smoker perspective presented in the analysis draws from statements from only a few adolescents. Furthermore, the ethnographic study was undertaken at two secondary schools. The inclusion of more schools could have contributed to more contextual nuances and possibly more adolescents who smoke. Neither of the two schools enrolled in the X:IT intervention had a complete smoking ban during school time. Thus, conducting an analysis of how adolescents interact with a complete smoking ban during school time was not possible, even though this strategy has received political support, among others, in Denmark. Moreover, it is known that different factors such as ethnicity, gender, and socioeconomic status influence socialization . HoweverOverall, the results of the present paper imply that although some studies have shown that banning smoking from the school ground was effective in decreasing smoking, there could be some unintended side effects of such initiatives. These side effects are of an ethical character and, moreover, possibly countervail the effect of a smoking ban. This should be considered when establishing future smoking initiatives. On the basis of the results of the present paper and exciting research, we do not recommend establishing smoking-specific smoking places in school settings. Given the political attention and support to implement smoke-free school time, among others, recently in Denmark, we suggest that future research investigate the possible implications of such an initiative.


Establishing a valid communication is not only a basic clinical need to be met but also a relevant ethical commitment.On the basis of the relevant literature, ethical issues arising from specific, important situations in clinical practice were identified.The main ethical problems regarding communication about the disorder, both in general and in relation to prodromal stages, were described and discussed together with those regarding communication about voluntary and involuntary treatments, “dual roles” enacted in clinical practice, genetic counseling, and end-of-life conditions; on the basis of what emerged, ethically driven indications and suggestions were provided.Several situations put the psychiatrist in front of relevant dilemmas and doubts which are no easy to face with; an ethically driven approach based upon the principle of the best interest of patients may support clinicians in their decisions. The quality of psychiatrist-patient relationships plays a central role in engaging subjects in treatment and obtaining positive outcomes ,2. In thEstablishing valid communication is not only a basic clinical need to be met but also a relevant ethical commitment. Application of the basic ethical principles of psychiatric practice is implemented largely by means of communication processes. Psychiatry shares with other medical specialties a set of common ethical principles. However, psychiatric ethics has been considered having a special status, due to the specific impact that mental suffering may produce on individual autonomy , the uniinformal caregivers,” frequently being charged by a heavy emotional and practical burden [gravely disabled, incapacitated and/or incompetent to exercise proper judgment because of a mental disorder” [The main reason for including families in a paper regarding ethical principles to be applied in communication is due to the awareness that, at least in Western countries, between 50 and 80% of patients affected by severe mental disorders are in close contact with their relatives . This iml burden ,20. Accoisorder” . Therefoisorder” .In communication with individuals affected by mental disorders and with their families/caregivers a set of basic ethical principles should be accomplished , namely:How to effectively and supportively communicate diagnosis is crucial for all medical specialties . Doubts It is the duty of psychiatrists to provide the patient with all relevant information….” Moreover, on discussing the issue of disclosing diagnosis in the context of Alzheimer’s Disease, the Declaration states that “AD patient’s right to know is a well-established priority…,” although it is acknowledged that “at the same time, patients have the right also not to know if this is their wish. All must be given the opportunity to learn as much or as little as they want to know.” Indeed, the “right not to know” has been applied from an ethical point of view to those disorders associated with stigma, irreversibility and lack of effective treatments [“the physician should give accurate and reliable information, using simple language” [The right of patients to receive face-to-face information about diagnosis is widely acknowledged . With reeatments . Culturaeatments . In the eatments . Timing eatments . Thus, aeatments . Similareatments . In the anguage” . Transpaanguage” .The psychiatrist should provide information and discussion, respond empathically to patients’ emotions in relation to the news they receive, and respond to individual needs allowing further occasions to discuss the diagnosis and related issues ,39. CommConfidentiality and privacy relating to diagnosis are not only an ethical obligation, but also an aspect of fundamental importance in the building up of a trusting relationship. Thus, communication with caregivers with regard to patients’ diagnosis and the breadth of information to be given should only be considered after discussing these issues with patients. Moreover, caregivers should only be informed once explicit consent has been obtained from patients. See The “prodromal stage” is the time frame generally characterized by mild, nonspecific, or vague symptoms or signs which precedes the full-blown syndrome in a series of mental disorders. In recent decades, the introduction of specific semi-structured interviews, screening instruments, and diagnostic biomarkers have facilitated the early identification of people at risk of developing psychotic disorders such as schizophrenia, or neurocognitive disorders such as Alzheimer’s disease (AD). This possibility has given rise to a series of multifaceted ethical problems related to diagnostic communication, which are amplified by the paucity of information and studies reflecting patients’ and families’ perspectives with respect to prodromal stage. With regard to psychosis, the fact that only one third of those deemed to be “at risk” will develop psychosis over the ensuing 1–3 years  has raisIn view of the complexity of this matter, from an ethical point of view, discussion, and negotiation relating to some aspects may be considered mandatory. In particular, the possibility of whether to receive or not the findings of medical examination should always be discussed with patients prior to evaluation, and the possibility of choosing whether to be informed or not left up to the patient, who may, of course, change his/her mind at any time. Moreover, patients’ understanding of the difference between common clinical practice and research should be carefully assessed . Indeed,Informed consent is “the ongoing process that involves disclosing information important to the patient and/or the decision maker, ensuring the patient/decision-maker has the capacity to make treatment decisions and avoiding coercive influences” . The priInvoluntary treatments include interventions legally established according to national laws and regulations, including psychiatric hospitalization, outpatient treatments, admission to residential facilities for therapeutic and rehabilitative purposes, and so on. Although involuntary treatments do not seem to be associated with a significant risk of negative outcomes, they may have a relevant impact on quality of life and treatment satisfaction .Inherent ethical tensions between values relating to individual autonomy, provision of adequate patient care and community protection are intrinsically linked to enforced treatments, psychiatrists are therefore called upon to exercise these forms of involuntary intervention using the greatest possible sensitivity, finding a balance between these competing values, while respecting the informed consent process and patients’ decision-making capacity as much as possible . Ethics “may have competing obligations that affect interactions with patients” [, “it is the duty of a psychiatrist… to disclose to the person being assessed the nature of the triangular relationship and the absence of a doctor-patient relationship, besides the obligation to report a third party even if the findings are negative and potentially damaging the interests of the person under assessment” [“reconcile these interests against other competing commitments and obligations” [“tell the truth” [In relation to their activities and different professional roles, psychiatrists atients” . These sessment” . Althouggations” . Even whgations” . Should e truth” , and of e truth” . This cae truth” . See TabFollowing recent reports demonstrating how the risk of mental disorders such as schizophrenia, bipolar disorders, and autism spectrum disorders may be significantly increased in individuals who test positive for specific genetic markers, psychiatric counseling has shifted from the simple estimation of family history-based risk to estimates deriving from specific and, at times, sophisticated tests . As a coPsychiatrists should take particular care in communicating with patients and families over genetic risk issues, providing updated information of the current state of the art in the field, and making it clear that current genetic knowledge is still incomplete, as being a developing issue, the future findings may alter the current notions . When gePalliative psychiatry” provides support to patients, including those affected by severe mental disorders, in coping with and accepting distress, helping them to live as actively as possible until death, enhancing quality of life, and supporting families in coping with end-of-life patients [to be truthful with patients about their diagnoses and prognosis” and “must have the requisite compassion and skill to thoughtfully and sensitively foster dialogue with patients who are seriously ill and suffering from a terminal illness” [Psychiatrists collaborating with palliative care teams have increased significantly in recent decades, frequently practicing under the label of palliative care psychiatry . Psychiapatients . Successpatients . Talkingpatients . Psychiaillness” . See Tab


Morale can be viewed as a future-oriented optimism or pessimism regarding challenges associated with aging and is closely related to subjective well-being. Promoting morale in old age could be considered to have important implications for aging well, and increased knowledge about morale in different stages of old age is needed. Hence, the aim of this study was to investigate factors associated with morale in different age groups among old people. Data were derived from a survey conducted in 2016, as a part of the Gerontological Regional Database (GERDA). The sample consisted of 9,047 individuals aged between 65 and 86 years from Ostrobothnia and Southern Ostrobothnia in Finland, and Västerbotten in Sweden. Morale was measured with the Philadelphia Geriatric Center Morale Scale (PGCMS) and regressed upon a number of sociodemographic, social, and health-related factors using linear regression analyses. The results showed that older age was an independent factor explaining lower level of morale. Additionally, the sociodemographic, social, and health-related variables could explain a large proportion of the variance in morale. Perceived loneliness, having gone through a crisis in life, poor self-rated health, and depression were associated with lower morale, and sleeping well with higher morale, in all age groups. Furthermore, the oldest age groups seem to be more exposed to several risk factors of lower morale identified in this study. Multidimensional interventions targeting especially social and mental health and the oldest-old could therefore be recommended. In this study, we explore morale in old age, described as a multidimensional concept containing future-oriented optimism or pessimism regarding challenges associated with aging, satisfaction with oneself, a feeling that there is a place in the environment for oneself, and acceptance of things one cannot change , 2. FurtBy large, SWB has progressively received increased attention from researchers as well as policy makers and can serve as an important marker of societal progress . SWB canVarious social and health-related factors such as social support, chronic conditions, and self-rated health have previously been associated with level of morale in old age . MorThe amount of studies exploring age differences in morale is limited, and no study has to our knowledge had age as a main focus of inquiry. On the one hand, previous studies have indicated that the majority of very old adults have moderate or high morale , 17. On Research on other measures of SWB, such as life satisfaction, has also come to somewhat conflicting results regarding age differences. There are studies claiming that well-being is u-shaped over the life span, i.e., higher in younger age and older age . There Furthermore, it is also uncertain whether the associations between morale and different sociodemographic, social, and health-related variables varies in different stages of old age, and only one study on morale has so far touched upon this matter. In the study of Näsman et al. , no inteTo explore morale in different age groups, various social and health-related changes occurring in old age need to be taken into account. A certain change in the individual's social life is likely, which in turn can affect the well-being of the individual. Socioemotional selectivity theory (SST) is a lifespan theory of motivation and time perspective that offers explanations to these changes . It argVery old age is often characterized as a period of frailty and high disease-burden and is related to the transition from the third age to the fourth age , which iThe selective optimization with compensation (SOC) theory, offers an explanation as to why very old adults are able to retain a high level of well-being despite adversities . In shorIn sum, few studies have investigated age differences in morale in old age, thus motivating further examination. There is also a need for increased knowledge about whether the association between various sociodemographic, social, and health-related variables, and morale varies in different age groups, which could in turn have implications for policy as well as social and health-care development. Hence, the aim of this study was to examine factors associated with morale in different age groups among old people. In particular, we explored whether (1) the level of morale differed between the age groups, (2) whether possible differences could be explained by sociodemographic, social, and health-related factors, and (3) whether the same factors could explain level of morale in the different age groups.The study is based on data from the GERDA  survey collected in 2016 in Västerbotten, Sweden, and in Ostrobothnia and Southern Ostrobothnia, Finland. The aim of the multidisciplinary GERDA project is to investigate health and living conditions of older adults living in these regions, and it has been conducted in a collaboration between researchers from Umeå University in Sweden and Åbo Akademi University, Novia University of Applied Sciences, and Seinäjoki University of Applied Sciences in Finland. The participants were selected from the National Tax Board in Sweden and the Population Register Center in Finland. The questionnaire was sent out by post to every 66-, 71-, 76-, 81-, and 86-year-old  living in the rural areas and in the city of Seinäjoki (Finland), whilst to every second living in the city of Vaasa (Finland), and every third in the city of Umeå and in the city of Skellefteå (Sweden). The questionnaire was sent out to 14,805 persons of whom 9,386 answered the questionnaire. In Finland, which is a bilingual country, the questionnaires were sent out in either Swedish or Finnish depending on the registered language of the respondent. The response rates and number of individuals in the different language groups/regions and age groups are presented in Morale was assessed using the Philadelphia Geriatric Center Morale Scale (PGCMS) . The insThe sociodemographic variables included information regarding education, marital status, and other living conditions. Ten years or more of education indicated higher educational level. Being in a relationship meant being married, cohabiting or living apart with a partner in opposite to being divorced, unmarried, or widowed. A respondent was considered to make ends meet without difficulties if he or she answered “without difficulties” as opposed to “with some difficulties,” “rather difficult,” and “very difficult” to the question “Do you make ends meet.”Some previous research has shown that there are differences regarding health-related aspects such as self-rated health and psychological health between the language groups in Finland , as welFrequency of social contacts was based on the question “How often do you have contact with the following persons?”. Friends and neighbors were merged into one variable, and children and grandchildren into another. A person was considered to have frequent contacts if he or she chose the alternative “several times a week” as opposed to “several times a month,” “sometime a year,” “never,” or “the person does not exist.” Membership in associations was dichotomized in the way that being an active member in at least one association was given the value one and not being a member, or being a passive member, was given the value zero.The number of confidants was based on the question “Do you have a confidant with whom you can speak about anything that is sharing both concerns and joys?”. The answer alternatives included “spouse,” “children,” “grandchildren,” “siblings,” “parents,” “other relatives,” “friends,” “neighbors,” “home-care staff,” “nurses,” and “someone else.” The variable was dichotomized using median split .A person was considered to have high trust in friends and neighbors if the person chose the answer alternative “high trust” as opposed to “neither high or low trust,” “low trust,” or “cannot take a stand” to the question “How high trust do you have for the following persons and groups?”. In order to be considered to have high trust, the respondent needed to have high trust for at least one of the categories. Perceived loneliness was based on the question “Do you suffer from loneliness?” .The variable “Gone through a crisis in life during the preceding year” was based on the question “Have you during the preceding year (12 months) experienced anything that you would consider a crisis in life?”. The alternatives were “yes”: “own disease,” “disease of a significant other,” “death of a family member,” “death of a friend,” “divorce,” “other problems in the family,” “moving to another location,” “worsening economy,” and “others” or “no: there have not occurred those kinds of changes” . Since the majority of the events included in the variable could be considered interpersonal events, the variable was placed among the social variables.Impaired vision was considered present if the respondent reported that he or she was unable to read the text in the newspaper with or without visual aids. Impaired hearing was considered present if the respondent stated that he or she was unable to hear normal conversation from a one-meter distance with or without hearing aids. The occurrence of stroke was based on the question “Have you had a stroke?”  and pain on the question “Have you had ache/pain during last week?” . Sleep was measured with the question “Do you have good night sleep”?  and having mainly own teeth with the question “Do you mainly have your own teeth?” .The variable regarding instrumental activities of daily living (IADL) was based on four questions: “Do you clean your dwelling (vacuum and wipe the floor) without the help from others?”; “Do you do grocery shopping without the help from others?”; “Do you use public transportation such as busses, planes, or trains without the help from others?”; “Do you cook without the help from others?”. A person was considered independent in IADL if he or she answered yes to all four questions. The autonomy for personal activities of daily living (PADL) was measured with the question “Do you shower without the help from another person?”. If the respondent answered yes, he or she was considered independent in PADL. The question originates from the Katz ADL index , where bSelf-rated health was based on the SF-36 item “In general, would you say your health is:” with the answer alternatives “excellent,” “very good,” “good,” “fair,” and “poor” . AnsweriLinear regression was used for the multivariable analyses of morale. In the first model, the age groups were included as explanatory factors. In the second model, sociodemographic variables were added. The third model additionally included the social variables and the fourth model the health-related variables. Based on the VIF-value in the collinearity diagnostics, we found that multicollinearity was not a problem.To test whether possible associations between the sociodemographic, social, and health-related variables and morale varied in the different age groups, joint effects with age were calculated, which correspond to models that include both the main effect and the interaction effect. For example, in the analyses for the joint effects of age and gender on morale 66-year-old men were the reference category for 66-year-old women, 71-year-old men reference category for 71-year-old women, etcetera. The effects were estimated in separate models for each joint effect, adjusting for the main effects of all the other variables.p value of <0.05 was considered statistically significant in the interpretation of the results. The IBM SPSS Statistics version 24  was used for all calculations.The analyses were performed using unweighted data. Analyses using weighted data were also tested to ensure that the selection process, i.e., selection of every second person in the city of Vaasa and every third in the city of Umeå and Skellefteå, as opposed to every person in other areas, would not have affected the results. A The distribution of PGCMS scores in the different age groups are presented in R square changed, the social variables and the health-related variables explained a proportionately equal share of the variance in PGCMS.The regression analyses are presented in p < 0.05): older age, being a woman, perceived loneliness, having gone through a crisis during the preceding year, stroke, pain, poor self-rated health, and depression. Variables associated with higher morale (p < 0.05) were making ends meet without difficulties, frequent contacts with children and grandchildren, frequent contacts with friends and neighbors, high trust in friends and neighbors, having two confidants or more, being active in an association, sleeping well, and independence in IADL. Accordingly, all of the social variables remained statistically significant when controlling for the health-related variables. Of the social variables, perceived loneliness and having gone through a crisis during the preceding year had the largest negative association with morale (standardized β −0.144 and −0.134). Of the health-related variables, depression had the largest negative association with morale (standardized β −0.295) but also poor self-rated health had a larger negative association (standardized β −0.180), and sleeping well a larger positive association (standardized β 0.154) compared to the other health-related variables that were statistically significant.In the final regression model in Estimates for the joint effects of age and each sociodemographic, social, and health-related variable are presented in The aim of this study was to investigate factors associated with morale in different age groups among old people. The results showed that older age was independently associated with lower morale, but also that the sociodemographic, social, and health-related variables could explain a large proportion of the variance in morale. The analyses including joint effects provided additionally more nuanced information on factors affecting morale in the different age groups. When comparing the regression models, the health-related variables seemed to attenuate the effect of age on morale the most. Nevertheless, considering that all social variables remained statistically significant when controlling for the health-related variables, it is clear that health-related as well as social factors need to be taken into account when promoting morale. Additionally, sociodemographic factors such as gender and perceived economic situation should also be taken into consideration.In contrast with some previous studies of morale and age , 18, theOf the sociodemographic variables included in the study, being a woman was significantly associated with lower morale and making ends meet without difficulties with higher morale, when controlling for social and health-related variables. Being a woman has also in previous studies been associated with lower morale , 18, butIn line with previous studies , 12, socEven though the prevalence of frequent social contacts was similar in all age groups, the prevalence of perceived loneliness increased across the age groups. The highest prevalence of loneliness was noted in the oldest age group, which is in line with, for example, the study of Yang and Victor . CorroboAs described in the introduction, the association between health and morale, as well as health and SWB, is complex. In the present study, stroke, pain, sleeping well, independence in IADL, poor self-rated health, and depression were independently associated with morale, which corroborates previous findings , 53, 54.Depression was found to have the largest negative association with morale, which supports previous findings , and wasFurthermore, sleeping well was associated with higher morale in all age groups, which is in line with the results of Yokoyama et al. . In theiIn sum, factors in all three domains  were found to be associated with morale. Regarding age group differences, morale was lower in the older age groups even though fewer variables were significantly associated with morale, especially in the oldest age group compared to the younger. One possible explanation to this could be that the proportion of women in the 86-year-olds was higher, and being a woman was in the regression analyses associated with lower morale, but the analyses including joint effects did not corroborate this interpretation. Another plausible explanation could be found in the sample characteristics . When loThis study is based on a representative sample of older people including individuals from age 65 to 86 and contributes to an increased understanding of morale in different stages of old age. However, there are a few points that need to be taken into account when interpreting our results. Considering the cross-sectional design and the inclusion of individuals born from 1930 to 1950, it is impossible to distinguish age and cohort effects. Furthermore, there is a risk of nonresponse bias in all age groups, especially in the 86-year-olds who had the lowest response rate. It could, for example, be expected that the included sample is to some extent healthier than the overall oldest-old population, considering that factors such as higher levels of multimorbidity and frailty compared to younger age groups are likely to affect the probability of participating in a survey. Nevertheless, for the same reasons, it could be expected that the actual occurrence of, for example, poor self-rated and depression would be even higher among the oldest-old, implying that the conclusions drawn regarding these risk factors would still be valid. The sample sizes in the older age groups were also smaller, due to fewer oldest-old adults within the population. Hence, it cannot be ruled out that the results regarding that some variables were statistically significant only in the younger age groups were affected by differences in the sample sizes. Due to missing values in variables included in the regression analyses, a part of the sample was also excluded from the final regression model. There is also a possibility that factors previously associated with morale, which were not available in our data, such as personality , would hBased on the results, a comprehensive view of the living conditions of the individual is needed in order to successfully promote morale in old age. It is evident that sociodemographic, social, and health-related variables are important to take into account when assessing risk factors and promoting factors for morale. Perceived loneliness, having gone through a crisis in life, poor self-rated health, and depression were associated with lower morale, whilst sleeping well was associated with higher morale, in all age groups. Furthermore, independence in IADL was associated with lower morale only in the three younger age groups, suggesting that physical function played a more important role in younger old than in the oldest age groups. Nevertheless, it is worth noting that especially the oldest age groups seem to be exposed to several risk factors of lower morale identified in this study. Multidimensional social and health interventions targeting especially mental health and social inclusion among the oldest-old could therefore be recommended. Future research could examine whether the use of SOC-strategies could be beneficial when strengthening morale.