The benefits of breastfeeding for both mother and baby are well recognized. However, the separation of the mother-newborn dyad leads to a lower breastfeeding rate. These parturients who are separated from their hospitalized infants are sometimes unaware of the importance of breastfeeding, while nurses do know how important health education on breastfeeding is and how it can be improved. This descriptive qualitative study aimed to explore the experiences of nurses regarding health education on breastfeeding and summarize the potential ways to improve it.A descriptive phenomenological qualitative approach was utilized in this study, and in-depth, semi-structured interviews were conducted with nurses at a tertiary A-grade obstetrics-and gynecology-specialized hospital in Shanghai, China. The purposive and snowball sampling method was used and Colaizzi’s seven-step phenomenological analysis was employed. The Consolidated criteria for Reporting Qualitative research (COREQ) was followed to report findings.Fifteen nurses participated in the study and shared their suggestions based on their experiences. Four overarching themes emerged from the data: (1) extending the education duration, (2) enriching the educational content, (3) expanding the education subjects, and (4) perfecting the educational process. Each theme included several subthemes.Health education on breastfeeding should focus on the time, content, subjects, and process as a whole. The nurses’ statements provided a reference for nursing or hospital supervisors to take measures to improve education and increase the breastfeeding rate of hospitalized neonates. Further research from the perspectives of parturients and their family members is needed, to find out what the key points are that all of them attach importance to.The online version contains supplementary material available at 10.1186/s12884-022-05227-4. The benefits of breastfeeding (BF) for both mother and baby are well-documented in the literature. Maternal health benefits include a decreased risk of postpartum hemorrhage  and prolWith medical technology advancing rapidly, a larger number of premature or at-risk neonates have survived. However, these infants are usually admitted to the hospital for further treatment or observation, which leads to them being separated from their mothers physically and psychologically. Besides the newborn’s congenital immaturity or illness, if the mother is not in a clinical condition that allows her to stay with the baby in the same room, they have to be separated from each other. The separation of the mother-newborn dyad occurs with an incidence of 10.0-21.3% , 12. As For hospitalized infants, the benefits of human milk are even more pronounced. The risk of infection, short- and long-term health morbidities, and mortality is higher in those who fail to receive human milk with immunological properties . The BF While there has been attention to mothers’ experiences BF a hospitalized preterm infant , little A descriptive phenomenological qualitative approach was utilized in this study. Descriptive phenomenology originated from Husserl’s 1960) work and is commonly used in nursing and midwifery research 60 work a. In HussThis study was conducted at Shanghai First Maternity and Infant Hospital, a tertiary A-grade obstetrics-and gynecology-specialized hospital in China, which is affiliated with Tongji University and joined the Baby-Friendly Hospital Initiative in 1992. Every year, about 30,000 babies are born in the hospital. The hospital holds pregnancy schools; once registered, expectant mothers can take a course free of charge. If her fetus is diagnosed with some defect or complicated condition in prenatal examinations, the woman will be offered a “one-stop” diagnosis-therapy service by the Fetal Medicine Department, which follows the philosophy of seeing the “fetus as a patient.” After delivery, if the infant is considered to be at-risk, they will be admitted to the NICU inside the Neonatology Clinic. There are also several out-patient clinics for discharged mothers and infants, like Jaundice Clinic and High-risk Neonatal Follow-up Clinic. If the parturients face difficulties breastfeeding, the International Board-Certified Lactation Consultants (IBCLCs) at the Breastfeeding Department can help them; if their breast duct is plugged, they can turn to the Milk Duct Clearing Department; and if they have little idea how to take care of their babies, or whether the babies’ responses are normal or not, the Home Care Department is a good choice. In China, there is a tradition “zuòyuèzi”, or “sitting/doing the month.” Parturients have to stay home and rest for a “confinement period” of about 1 month (or 42 days) after giving birth, which is thought to facilitate recovery. During this period, a maternity matron (yuesao) may be hired to take care of the new mother, and help with household and childcare tasks .All of the team members were female registered nurses with experience in descriptive qualitative research and a background in breastfeeding research. All interviews were conducted by the first author HF, studying for a master’s degree. She had no child of her own or experience with breastfeeding, which wouldn’t lead to a bias. JL was studying for a master’s degree as well, without a child. YL, a doctoral student, had one two-year daughter and successful experience in breastfeeding. HJ, an experienced qualitative researcher, who had an adult child, provided specialist methodological support frequently.Ethical approval was obtained by the Ethics Committee of Shanghai First Maternity and Infant Hospital before conducting the research (No. KS20238). The study was performed in accordance with the Declaration of Helsinki and followed the institutional guidelines. All participants were informed of the purpose and confidentiality of the study. Every participant explicitly consented to the study and to be recorded while being interviewed. Confidentiality was ensured by not disclosing any participant names or personal information. All of the audio recordings and transcripts were coded and saved on a password-protected computer. Nurses who agreed to participate were allowed to withdraw at any time without any consequences.The purposive and snowball sampling method was applied . To be sEach in-depth, semi-structured interview was held face-to-face in the head nurse’s office or retiring room without anyone else present; some nurses at the Neonatology Clinic were interviewed in the breastfeeding room, which was quiet and unused at the time in consideration of COVID-19. The participant’s sociodemographic data were collected before the interviews were conducted. After that, they were asked several questions, like “What challenges do you encounter when doing health education on breastfeeding to these special mothers?” “Do you feel that these mothers benefit from your health education?” and “What kind of training on health education should be increased or enhanced?”. These questions were revised with two nursing experts and pilot tested with three nurses. The duration of the interviews ranged from 30 to 60 min based on the participant’s willingness to share. Two participants were interviewed twice for clarification and addition to their data because of their undefined responses. The whole course of each interview was recorded by cellphone. Field notes were written during and immediately after each interview.All of the interviews were conducted in Mandarin Chinese, and the recordings were transcribed verbatim within 24 − 48 h after each interview for coding purposes. Transcripts were returned to six participants because the others were so busy that they refused to read them carefully. Those who read through the transcripts didn’t report any mistake or make changes. The transcripts were managed and analyzed with NVivo 12 software, a Computer-Assisted Qualitative Data Analysis Software (CAQDAS) . Two autn = 9). Most of the nurses worked in the Obstetric Department or the Neonatology Clinic doing a job concerning breastfeeding for 6–10 years (66.7%). General characteristics of the participants are presented in Table In total, fifteen nurses participated in this study. All of the nurses were female and ranged in age from 29- to 50-years-old. Twelve nurses reported having a bachelor’s degree, while the other three had acquired a master’s degree. More than half of the participants had worked as a nurse for 11 years or longer  prenatal preparation and 2) postpartum follow-up. The ones for “enriching the educational content” were (1) lactation mechanism, (2) hand-expression skills, and (3) myths and rumors. The ones for “expanding the education subjects” were (1) husband who is the key, (2) other family members who are important as well, and (3) a yuesao who seems professional. The ones for “perfecting the educational process” were (1) content standardization, (2) constant repetition, and (3) educational training or practice for nurses Nurses agreed that there was a lot of information online, and with the service of pregnancy school, it might be more effective to give prenatal care more publicity.“How to mention it? If you talk about the separation after birth, won’t she be shocked about it? You can’t swear at them, can you? Most mothers are separated from their babies all of a sudden. Only if their fetus was determined to be abnormal, or at risk of preterm birth, with the possibility of being hospitalized or referred, our Fetal Medicine Dept. would hold a consultation. For these pregnant women, they are prepared to learn and listen to your suggestions, in which way their compliance and anxiety will get better afterward. I think these special mothers-to-be are our new target, and we intend to move forward on the work as well. (P12)Although prenatal education is useful and helpful, most of the time, it is challenging.Parturients are usually discharged before their babies. When they stay at home or somewhere near the hospital, most mothers choose to send their breast milk to the Neonatal Department.“If the amount of breast milk is small, we will make a phone call to ask for further details. But, you know, sometimes the feedback is not that timely, because we are so busy that we can only arrange for some nurse to make the calls once a week, unless the baby is too severe [of a case] to accept any formula except human milk. Then we will teach them how to express milk, and what the frequency is, again.” (P10)“For those who don’t send breast milk, we will ask them why, like ‘is it because you didn’t express the milk, or just because you didn’t send them here.’ Even if their milk isn’t consumable due to drug use, or it is not convenient for them to send milk, we will tell them to keep expressing their milk, whether discarding it or storing it in refrigerators.” (P4)After the infants are discharged, they return back to their mothers. Bottle-feeding at the hospital makes it relatively hard to latch onto the breast, for which reason, follow-up guidance is of great significance. However, it is currently random and doesn’t cover all subjects.“Actually, like babies treated for jaundice, we don’t follow up with them after discharge. Neither do we ask them how the breastfeeding is going. It is compulsory to follow up only with high-risk babies. For others, the obligatory target is 30% every month. So, the mothers are randomly chosen and educated.” (P8)“Not even one baby should be omitted. Otherwise, whether it can get breastfed is basically up to luck.” (P12)Nurses are supposed to offer an all-round education content on breastfeeding, involving the “lactation mechanism,” “hand-expression skills,” and “myths and rumors.”The extraction of breast milk timely and regularly after delivery is a determining factor in the success of breastfeeding. Nurses are always talking the parturients into expressing milk, while they seldom tell them the reason, which induces incomprehension.“Our education content focuses on how to collect, store and send their milk, rather than on why to express the milk.” (P3)“For her, it’s hard to understand, like ‘Why should I send my milk to you? The doctor said my baby had to fast; so why?’ or ‘You told me my baby just ate 1 ml per meal, 8 ml a day in total, so who will you give it to if I expressed so much milk?’ They don’t know the lactation mechanism, and why she should do this in the first two days.” (P1)Their incomprehension may also lead to a vicious cycle.“Only if the mother kept milking, the brain could make a reflex response to the stimulus. But they think their breasts haven’t produced milk yet, so they just give up trying. Why bother, right?” (P8)“They don’t know what to do when their breasts feel ‘full.’ That’s why they do nothing at all. They fail to express milk at a regular time, or to massage their breasts. Sometimes, they think there is no need to express milk at night because they have already done it regularly in the daytime.” (P7)“They don’t know what the consequence is, but they won’t produce enough milk when they really need it.” (P1)Without infants’ sucking, expressing milk is a necessary replacement. There are two ways for the parturients to express their milk, namely hand-expression or machine-pumping. Considering that the former is indispensable, especially in the first postpartum days, nurses will introduce the related skills to all of them, though the learning effect is far from satisfactory.“Actually, I think sometimes, what we need to teach is no longer the importance of expressing the milk, but how to succeed in doing it.” (P12)“I feel that many of them don’t know how to express their milk by hand. They just lack the skill, you know. And, at last, the milk will be blocked in there.” (P5)“When in need, she may find she is incapable of hand-expression, and nobody is gonna help her, and then she will get really anxious.” (P1)“Some mothers feel that hand-expression is painful, but they couldn’t figure out whether they were doing it right or not.” (P3)In today’s information age, the parturients are always overloaded with various kinds of ideas, from the Internet or friends and neighbors. Some traditional Chinese cultures like zuòyuèzi also subtly influence them. This ancient tradition, like a natural order, means that mothers should be confined at home, and do or not do a series of things during the first postpartum month (or 42 days). Nurses ought to do pertinent education while keeping this in mind.“The seniors living together find it essential to supplement nutrients after delivery, so they incline toward a greasy diet, which makes the milk thick and hence easy to get blocked.” (P5)“Once we know [that] the mother’s breast duct is plugged, we will suggest her to visit our Milk Duct Clearing Dept. But many mothers don’t think they will go out during the special period. So, how can we help them?” (P1)“There is the tradition of ‘zuòyuèzi,’ so mothers refuse to leave the home. After the baby returns back to their mom, they will try feeding at the breast. If the mother fails to breastfeed, like in a month, and doesn’t turn to our Breastfeeding Dept. for guidance, her breast milk is doomed to dry up.” (P9)“Some mothers-in-law are always intervening. For example, they would tell the mother that breast milk is bad. Especially when the mother’s periods return, the elderly will probably ask her to stop breastfeeding, since they think the breast milk is no longer healthy. Horrible rumors!” (P1)Pregnancy and delivery are not about mothers only but is also about everyone around them. Therefore, the number of education subjects should be expanded, and more attention should be paid to the “husband, who is the key,” “other family members, who are important as well,” and a “yuesao, who seems professional.”Husbands are the main caregiver during the perinatal period. They are the key to mothers sticking to breastfeeding because their support is the most meaningful and their ideas and behavior matter. Health education has already been offered to them, but is still not enough.“When admitted to the hospital, health education is primarily offered to fathers because mothers are so tired in bed after the delivery or in pain due to a cesarean section. If the husband didn’t attach importance to breastfeeding, the mother probably won’t think it important after being conveyed information to. And if the husband isn’t that reliable, the information the mother received might be more problematic.” (P10)“In the process of conveying information, since it’s impossible for the husband to remember 100% what we say, there is always something mistaken or omitted. What they care about most is their baby’s condition, rather than how to express or send human milk, so many mothers don’t even know about it.” (P4)“The mother has to get up in the middle of the night, pump the milk, wash, and disinfect everything. Without husband’s help, they are less likely to persist.” (P5)To express the milk to be sent is real, hard work. The husband should be aware of it and be encouraged to lend a hand.“The elderly in the family may question the quality and nutrition of the breast milk given its light color, praising the formula given in the hospital, and persuading the mother not to bother sending her own milk… Sometimes, it’s the mother’s own mother who is heartbroken seeing her daughter keep expressing milk around the clock. Pumping deprives the mother of enough rest, and makes her haggard and her nipples swell. As her mom, she will worry so much that she may advise [her that] a little milk is enough to stop. (P1)As paternity leave in China is relatively short, many parturients are looked after by other family members, who will have various aspects of support, breastfeeding included.“In the first days, the baby just comes back, they will probably refuse the mother’s nipple. Some mothers-in-law would consider the mother short of breast milk, wouldn’t wait for the mother to try, or would sneakily bottle-feed the baby with formula. Some may suggest that formula is not bad since her son grew up healthily with formula as well. (P5)Some parturients’ mothers-in-law may put themselves in a stronger position, imposing their values upon their daughters-in-law. Unfortunately, some values they believe to be true and experienced are actually in need of correction.“The yuesao they find are not necessarily professional; you know, not necessarily qualified. Well, I feel that those yuèzi centers in the market are somewhat complicated.” (P9)The convention of “zuòyuèzi” prevails. Accordingly, a special population called “yuesao” has emerged, known as maternity matrons trained to take care of parturients and their infants, from breastfeeding to daily life. With regards breastfeeding, there is no professional qualification certificate for non-medical personnel confirmed by the country yet. Therefore, whether the information yuesao provide is reliable or correct is still in question.“We should educate our own yuesao to make sure their breastfeeding knowledge is up-to-date, and their hand-expression skills are right. They have a lot of contact, so I hope they can pass on the right information to the mothers.” (P12)While the mothers are still in the hospital, they can be served by the yuesao cooperating with the hospital, who are trained for the position. Relatively reliable, they should be on the list of education subjects as well.The success of health education is not only about its rich content but also about how the education is implemented. Therefore, the educational process needs perfecting through “content standardization,” “constant repetition,” and “educational training or practice for nurses.”Although personalized education is highly praised in modern nursing, the educational content on average problems is yet to be standardized. For example, if parturients receive different answers from different nurses to the same question, they will be very confused.“All [of] our nurses will educate the mothers, so [in] the education method or content, I think, there must exist bias. We have a PowerPoint on health education, but does everyone conform to it? We also have a booklet on breastfeeding, but can everyone explain it beautifully? I doubt it.” (P6)“Maybe we can arrange for one nurse to give the education, well, to keep the consistency. If 60 nurses go do it, there will probably emerge 40 versions of educational content. When the mother or family members ask us about something out of the education booklet, we may answer based on our own experience or knowledge. We have made a PowerPoint on health education, but there is not one about breastfeeding in special.” (P4)Slim chances are that the parturients and their significant others can remember everything the nurses have said to them only once. Education is just like an examination; it requires constant review to obtain a satisfactory result.“Well, our health education is complete only on admission. After that, we will make a phone call once a week while the baby is still in hospital. But, in fact, many babies are discharged within one week, so their parents haven’t enough access to professional information. They may not pay attention to breastfeeding, and no wonder they can’t persevere…. For these mothers separated from their babies, if someone keeps droning on about breastfeeding every day when they stay in the Obstetrics Dept., like a novice chanting, I believe they will realize its importance.” (P10)“Maybe it’s useless, but, you know, better doing [it now] than never!” (P8)Repetition can be realized verbally, and we can also increase the methods of health education.“I think we can play some videos about breastfeeding on the TVs in our ward. In one way, it will be easier for them to understand what we tell them after watching the videos. In another way, it can deepen their good impression of breastfeeding.” (P8)“We should do more about the education. One or two ways are far from enough. Like the booklets we deliver, you know, they don’t remember to read them. Sometimes, they are just seen as reference work. They browse them just when they need them. It is a must to stress the importance of breastfeeding in different aspects.” (P3)Nurses are professionals in breastfeeding and equipped with sufficient knowledge. However, how to impart everything to the parturients in an effective way is a big issue.“The training in education techniques can be enhanced. We do have a lot of professional knowledge, but how can we make them realize the significance of breastfeeding in such a short time? I think our skills in teaching or talking require improving. It’s really important…. How to transform the professional information into something easy to understand, and meanwhile, vivid enough that parents are willing to pay attention to it? If we can’t, it’s in vain, as it means we fail to apply the theory to practice.” (P10)“Sometimes, because we are busy, we have to finish the education quickly. When we speak too fast, they may not be able to fully understand. It’s worth our reflection indeed.” (P2)This qualitative study focused on four aspects critical to improving health education on BF from 15 nurses’ perspectives, focusing on the time, content, subjects, and process. More often than not, several of the four themes were related and interwoven together, as has also been reported in previous studies.The period from conception to the child reaching the age of age two is a key phase, which not only affects the physical and cerebral development during the first years of life but also has an impact on the health in adulthood . Thus, iOther than personal choices, many mothers don’t practice BF due to a lack of knowledge or incapability to do so . InabiliWhether when, what, or to whom the health education on BF will take place, the way or method of doing it should be emphasized. Standardization is the premise of education. The NICU Family Support (NFS) Core Curriculum, a standardized education program, was implemented for parents of infants in NICUs; the project found that, among 3,648 attendees at 41 sites across the country, 77% of them reported learning “a lot” and 85% reported boosted confidence, with higher satisfaction and a positive knowledge change . SimilarSince receiving human milk is crucial for hospitalized infants, relevant measures should be adopted to increase the BF rate as soon as possible, with reference to the findings of this qualitative study. In regions where BF-oriented education isn’t paid enough attention to or needs improving, like China, nursing or hospital supervisors are suggested to assume the leading role. For example, they can encourage more healthcare providers to get trained and qualify as IBCLCs, who demonstrate specialized knowledge and clinical expertise in BF . With moThe main limitation of this study was the sampling method. There were a couple of IBCLCs at this specialized hospital, but only two of them were recruited. Although the data was saturated, some surprising and meaningful statements or themes might emerge if more IBCLCs were interviewed; after all, they were more professional and experienced in breastfeeding among this special population. The perspective of a “nurse” was a feature of the study, but it was also a limitation. What the nurses thought important in health education on breastfeeding was not necessarily important or essential for the parturients and their family members. Future studies should focus on the thoughts of parturients, as they are the ones who actually breastfeed. Their family members may also be interviewed to help identify better interventions for this group. A mixed-methods design in qualitative research, which can help to achieve impartiality, is expected in the future. The use of both quantitative techniques and qualitative techniques can bring balance and hence impartiality to the qualitative research.This qualitative study has identified four major themes regarding health education on breastfeeding, which also highlighted four aspects of how the effects of breastfeeding-oriented education for parturients separated from their hospitalized infants can be improved. The education should start from pregnancy and continue even after discharge, during which period nurses should provide the woman and her husband, family members, and the yuesao, with information, including on the lactation mechanism, hand-expression skills, and correct any myths and rumors. To perfect the entire education process, nurses should make sure of content standardization and repetition, and keep training and practicing. Further research from the perspectives of parturients and their family members is needed, to find out what the key points are that all of them attach importance to.Additional file 1. COREQ  Checklist.


Previous developmental research shows that young children display a preference for ingroup members when it comes to who they accept information from – even when that information is false. However, it is not clear how this ingroup bias develops into adolescence, and how it affects responses about peers who misinform in intergroup contexts, which is important to explore with growing numbers of young people on online platforms. Given that the developmental span from childhood to adolescence is when social groups and group norms are particularly important, the present study took a Social Reasoning Developmental Approach. This study explored whether children and adolescents respond differently to a misinformer spreading false claims about a peer breaking COVID-19 rules, depending on (a) the group membership of the misinformer and their target and (b) whether the ingroup had a “critical” norm that values questioning information before believing it. 354 United Kingdom-based children (8–11 years old) and adolescents (12–16 years old) read about an intergroup scenario in which a peer spreads misinformation on WhatsApp about a competitor. Participants first made moral evaluations, which asked them to judge and decide whether or not to include the misinformer, with follow-up “Why?” questions to capture their reasoning. This was followed by asking them to attribute intentions to the misinformer. Results showed that ingroup preferences emerged both when participants morally evaluated the misinformer, and when they justified those responses. Participants were more likely to evaluate an ingroup compared to an outgroup misinformer positively, and more likely to accuse an outgroup misinformer of dishonesty. Adolescents attributed more positive intentions to the misinformer compared with children, with children more likely to believe an outgroup misinformer was deliberately misinforming. The critical norm condition resulted in children making more positive intentionality attributions toward an ingroup misinformer, but not an outgroup misinformer. This study’s findings highlight the importance of shared group identity with a misinformer when morally evaluating and reasoning about their actions, and the key role age plays in intentionality attributions surrounding a misinformer when their intentions are ambiguous. Misinformation is false information which circulates as the truth and has been regarded as one of modern society’s biggest threats , and yetSpreading misinformation can be perceived as a moral transgression, yet we know it often emerges to serve the concerns of social groups . This suggests both the development of morality and intergroup processes are key to understanding if and when children and adolescents accept misinformers. The present study, therefore, took a Social Reasoning Developmental SRD;  approachPrevious research using the SRD approach has documented that when it comes to evaluating peers who commit acts with moral and social implications, such as group-based exclusion, children tend to focus on concerns about morality, e.g., whether it is right or wrong to do so . HoweverA big part of living in our current digital society involves being presented with information from various sources and with varying levels of accuracy. It is, therefore, vital to understand how young, developing minds determine who to accept information from, and when the information source, or who the information is about, matters more than its accuracy. Past research shows that young children up to the age of 7 years old prefer new information that comes from ingroup peers rather than outgroup peers  and theiTraditionally, children’s moral evaluations have been measured through their assignment of punishment and decisions about whether to include or exclude someone  and typiResearch also suggests that the intentions of the person committing the morally dubious act are important when children make social and moral judgments . This isIn addition to these developmental differences, group peership and consequently ingroup biases can also influence intentionality evaluations. For instance, from as young as 5 years of age, children refer to an ingroup peer’s mental state more than an outgroup peer’s  and oldeWhat remains unclear is whether these ingroup biases come into effect in the context of morally evaluating someone who is spreading false information with intentions that are ambiguous. If they do so, it is also unknown how these evaluations develop over the course of late childhood and adolescence, when attribution of intention can become more positive , but is With age, children start paying increased attention to their group’s norm, and even make moral judgments, such as whether or not to exclude someone, based upon the norms of their ingroup . SimilarOne way to tackle the spread of misinformation amongst children is by introducing them to the idea of critical thinking. This would promote a way of thinking that encourages being questioning and evaluative about information and its source. While research shows that adolescents and young adults are relatively poor at discerning false information from credible news, there is promising evidence to suggest that improved critical thinking skills can lead to better ability to identify misinformation . This suThe aim of the present study was to explore the factors that influence children’s (8–11-year-old) and adolescents’ (12–16-year-old) moral evaluations and intentionality attributions with regards to a peer spreading misinformation about another peer within an intergroup context. These age groups were chosen for a number of reasons. Firstly, around 8 years old is when children become capable of nuanced reasoning that considers factors pertaining to others’ beliefs and mental states, as well as social and moral concerns, simultaneously . As a reMoral evaluations were measured in the form of making a judgment about the misinformer, as well as the decision to include the misinformer. Intentionality attribution was measured by asking participants to rate the extent to which they thought the misinformer was deliberately spreading misinformation, and so the intentions of the misinformer were unknown to the participants, to capture differences in attributions based on the manipulated factors.The first factor which was manipulated was the type of ingroup norm participants were prescribed upon being introduced to their school group, which served as the intergroup context for the present study. Half of the participants were assigned to a control condition where the only expectation was to be competitive, and where a default of showing loyalty to fellow ingroup peers was expected given the sample was all above 7 years of age, when children are known to evaluate peers based on their loyalty to the group . Indeed,The second factor which was manipulated was the group membership of the misinformer and the target of their misinformation. Half of the participants were exposed to an ingroup misinformer who spread misinformation about an outgroup peer, and the other half read about an outgroup misinformer who spread misinformation about a peer of the participant’s own group. This was done to examine whether ingroup biases are present when children and adolescents make moral judgments and attribute the intentionality of someone who is sharing information that is potentially false.It was therefore expected that both moral evaluations and intentionality attributions would differ depending on both manipulated factors. Due to the past research which has shown children’s intentionality attribution toward a moral transgressor becomes more positive with age  while adH1: Children and adolescents’ moral evaluations and intentionality attributions of the misinformer were expected to be more positive when they were assigned an ingroup misinformer/outgroup target than an outgroup misinformer/ingroup target.H2: Children and adolescents’ moral evaluations of the misinformer were expected to be less positive if they were assigned the critical norm condition, compared to if they were assigned to the control condition.H3: Adolescents were expected to attribute more positive intentions to the misinformer compared with children.H4: When justifying their moral evaluations of the misinformer, children were expected to be more concerned with moral factors in their reasoning, whereas adolescents were expected to also be concerned with social-conventional or psychological factors in their reasoning.N = 354) were recruited from schools in the South-West of England. The participants consisted of 206  children 8–11 years old  and 148  adolescents 12–16 years old . This sample size was determined by conducting an a priori power analysis for an ANOVA with eight groups under the assumption that there would be main effects and interaction effects in G*Power using an alpha of 0.05, a power of 0.95 and a medium effect size (2η = 0.25) (Participants ( = 0.25) . This caThis study used a 2 (age group: children vs. adolescents) × 2  × 2 (group membership: ingroup misinformer/outgroup target vs. outgroup misinformer/ingroup target) between-participants design.Ethical approval for this study, its procedure and its measures was obtained from the first author’s University. This study only consisted of participants whose parent or guardian had given consent for their child to take part. Participants who were happy to begin the questionnaire were informed about a nationwide inter-school “Spelling Bee” competition, in which their school was taking part, and had made it to the final where they would be competing with a  rival school from their local area for a much coveted trophy, a picture of which they were shown. Information about the competition detailed how the winner would be decided based on a points system, and that COVID-19 guidelines  were required be followed at all times, such as hand-washing, avoiding touching the face, and social distancing by standing at least 2 m apart at all times. In order to establish group peership with their school, participants chose a logo and a mascot for their school team. This is a commonly used way of heightening group identification by making group identity salient in children, as demonstrated by previous developmental research .Welcome to the team. Our goal is to win this competition!” Participants in the critical norm condition were shown the following message: “Welcome to the team. Our goal is to win this competition! Now that you are a peer of this team, you should know what is important to us. We think that we should make sure something is true before we believe it, no matter who it comes from.”Participants then received a message from their school team, which was randomized by the survey software Qualtrics, and so they received one of the following messages: Participants in the control condition were shown the following message: “Next, participants were introduced to ingroup and outgroup peers who were also competing in the Spelling Bee competition. These group peers were always gender-matched to the participants.Participants in the ingroup misinformer/outgroup target condition were first introduced to Sam, who was representing the same school as the participant, and was therefore in the participant’s ingroup. The participant was then shown other ingroup peers who were also representing the participant’s school in the competition, Charlie, Jamie, Joe (or Jo), and Jordan. Then, an outgroup peer, Alex, was introduced, who was representing the opposition school team in the competition.Participants in the outgroup misinformer/ingroup target condition were first introduced to Alex, who was representing the same school as the participant, and was therefore in the participant’s ingroup. The participant was then shown other ingroup peers who were also representing the participant’s school in the competition, Charlie, Jamie, Joe (or Jo), and Jordan. Then, an outgroup peer, Sam, was introduced, who was representing the opposition school team in the competition.Just saw Alex breaking social distancing rules! [shocked emoji].”After being shown their ingroup and outgroup peers, participants were then informed that on the final day of the National Interschool Spelling Bee Competition, Sam posted a video to WhatsApp. Alongside the video, Sam had written: “I trust Sam, he/she is right. Alex was breaking the rules!”). If participants were in the outgroup misinformer/ingroup target condition, their ingroup peers were disagreeing with outgroup peer Sam to support fellow ingroup peer Alex . The ingroup peers within the WhatsApp group always defended the ingroup peer whether they were the misinformer or target to provide ecological validity to the context. This is because from an early age, ingroup peers typically expect loyalty from members of their peer group . They saw this response from fellow ingroup peers regardless of whether their misinformer was an ingroup or outgroup peer.Participants in the critical norm condition saw responses by most of their fellow ingroup peers underneath Sam’s comment, which were always in support of seeing more information, and so congruent with the explicit norm those participants had seen in the beginning  to 5 (very happy face).Participants were asked to give their judgment of Sam, the misinformer, “Do you want Sam to still be in/join your team?” They selected their answer from a 5-point Likert scale which went from 1 (“Definitely not”) to 5 (“Definitely yes”).Participants were then asked to decide whether they wanted Sam to be a part of their team, “Do you think Sam thought he/she was doing something OK when he/she posted the video and comment on WhatsApp?” They gave their responses on a 5-point Likert scale which went from 1 (“Definitely not”) to 5 (“Definitely yes”).Participants were finally asked about the misinformer’s intentions, “n = 89). A high level of interrater agreement was achieved for both measures . Participants who referenced moral concerns in relation to fairness and equality or personal concerns in terms of autonomy were dropped from the final analyses due to the frequency of their use being less than 10%, along with participants who referenced other matters . Often, participants referenced more than one subcategory in the same response  and so multiple coding was adopted. Each subcategory was given a code, where 1 = full use of the subcategory, 5 = even use with another subcategory, 0 = no use of the subcategory. Both negative and positive responses were included in each subcategory.After participants indicated their judgment and inclusion decisions about the Misinformer, they were asked each time to elaborate on their response by answering open-ended ‘Why?’ questions. These responses were coded in accordance with Social Domain Theory  and the t-tests for interaction effects were conducted with Bonferroni corrections for multiple comparisons applied. Participants’ interest in spelling and their identification with their school group was controlled for in each analysis.The first analysis set out to examine H1, H2, and H3, which concerned the misinformer evaluations . These hypotheses were analyzed with a 2 (age group: children vs. adolescents) × 2  × 2 (group membership: ingroup misinformer/outgroup target vs. outgroup misinformer/ingroup target) univariate ANOVA. Follow up independent-sample t-tests were used to break down interactions. Participants’ interest in spelling and their identification with their school group was controlled for in each analysis.To investigate H4, another analysis was conducted on participants’ open-ended reasoning responses for Judgments and Inclusion of Misinformer. This was achieved with a 2 (age group: children vs. adolescents) × 2  × 2 (group membership: ingroup misinformer/outgroup target vs. outgroup misinformer/ingroup target) × 5  ANOVA with repeated measures on the final variable . Where sphericity was violated, the Huynh–Feldt adjustment was reported. Pairwise comparisons were observed for main effects, and independent-samples F = 16.02, p < 0.001. Participants with an ingroup misinformer/outgroup target judged Sam, the misinformer, more positively  than those with an outgroup misinformer/ingroup target . There were no significant main effects of ingroup norm (p = 0.58) on this measure, and no interactions.As expected, there was a significant main effect of group membership on Judgment of Misinformer, F = 79.73, p < 0.001. Participants with an ingroup misinformer/outgroup target included Sam, the misinformer, more  than those with an outgroup misinformer/ingroup target . There were no significant main effects of ingroup norm (p = 0.36) on this measure, and no interactions.Again, as anticipated, there was a significant main effect of group membership on Inclusion of Misinformer, p = 0.08), ingroup norm (p = 0.12) or group membership (p = 0.28) on Intentionality of Misinformer. However, there was a significant three-way interaction effect between age group, ingroup norm and group membership, F = 4.70, p = 0.031 (see There were no significant main effects of either age group (.031 see . Age-relt(76) = 2.45, p = 0.017, but not between children and adolescents with an outgroup misinformer/ingroup target (p = 0.32). Adolescents in the control condition attributed more positive intentions to an ingroup misinformer with an outgroup target  than children in the control condition did . In the control condition, children’s intentionality attributions did not significantly differ by group membership, (p = 0.61) nor did adolescents’ (p = 0.21).Amongst participants in the control condition, there was a significant difference between children and adolescents with an ingroup misinformer/outgroup target t(71) = 2.16, p = 0.034, but not between children and adolescents with an ingroup misinformer and an outgroup target (p = 0.78). Adolescents in the critical norm condition attributed more positive intentions to an outgroup misinformer with an ingroup target  than children in the critical norm condition did . In the critical norm condition, children’s intentionality attributions did not significantly differ by group membership, (p = 0.055) nor did adolescents’ (p = 0.53).Amongst participants in the critical norm condition, there was a significant difference between children and adolescents with an outgroup misinformer and an ingroup target t(101) = 2.33, p = 0.022, but not with an outgroup misinformer and ingroup target (p = 0.95). Children in the critical norm condition attributed more positive intentions to an ingroup misinformer with an outgroup target , than children in the control condition did .Amongst the children in the sample, there was a significant difference in intentionality attributions by ingroup norm for those with an ingroup misinformer and outgroup target, p = 0.60), nor those adolescents who had an outgroup misinformer and an ingroup target (p = 0.19).Amongst the adolescents in the sample, there were no significant differences in intentionality attributions by ingroup norm for neither those who had an ingroup misinformer and an outgroup target  = 6.31, p = 0.012, η2 = 0.02 in participants’ open-ended responses about their Judgments of the Misinformer. Welfare reasoning  was used more by children  than adolescents, , t(335) = 3.85, p < 0.001. Lying and deceit reasoning  was also used more by children  than adolescents , t(342) = 4.37, p < 0.001. However, reasoning referencing conventional norms and expectations  was prioritized by adolescents  more than children , t(231) = 3.83, p < 0.001. This interaction shows that children’s reasoning about their judgments of the misinformer included more moral concerns , whereas adolescents included more social-conventional matters .There was a significant reasoning by age group interaction, F = 2.76, p = 0.046, η2 = 0.008 in participants’ open-ended responses about their Inclusion of Misinformer evaluation. Children used more lying and deceit reasoning  to justify their inclusion decisions , than adolescents did , t(346) = 4.46, p < 0.001. Adolescents used more group functioning reasoning  in their inclusion justifications , than children did , t(293) = 2.17, p = 0.016. These interaction shows that children’s reasoning about their inclusion evaluations of the misinformer, referred to more moral concerns (lying and deceit) whereas adolescents’ reasoning referred to social-conventional matters more (group functioning).There was also a significant reasoning by age group interaction, F = 4.24, p = 0.007, η2 = 0.012. Participants cited lying and deceit concerns  more when they had an outgroup misinformer and an ingroup target , than when they had an ingroup misinformer and an outgroup target , t(346) = 4.46, p < 0.001. Alternatively, participants used more personal reasoning,  when they had an ingroup misinformer and an outgroup target , than when they had an outgroup misinformer and an ingroup target , t(335) = 3.45, p < 0.001. This shows that inclusion evaluations were justified using moral concerns such as lying and deceit more for an outgroup misinformer with an ingroup target, whereas inclusion evaluations about an ingroup misinformer with an outgroup target were justified more using personal reasoning.There was also a significant reasoning by group membership interaction, The present study used a Social Reasoning Developmental SRD;  approachWith regards to the ingroup norm, contrary to predictions (H2), there was no main effect of the critical norm condition on participants’ moral evaluations of the misinformer. In terms of intentionality attributions, while there were no main effects of either age group or misinformer identity on participants’ attribution of intentions, there was a three-way interaction between age group, ingroup norm and group membership. The three-way interaction indicated developmental effects in line with predictions (H3), insofar as adolescents attributed more positive intentions to the misinformer compared with children in both norm manipulation conditions, but this was dependent on the identity of the misinformer/target. The interaction also highlighted the role of the critical norm condition in increasing children’s intentionality attributions compared to the control condition, but only when the misinformer was an ingroup peer who had spread misinformation about an outgroup peer. Finally, H4 was also supported as children used more moral reasoning  to justify their evaluations of the misinformer than adolescents did, whereas adolescents comparatively used more social-conventional  reasoning than children did.moral evaluations of the misinformer, it would need to be prioritized over the strong ingroup preference that children display. The question is then what may encourage children and adolescence to prioritize being critical over supporting their ingroup.In line with Social Identity Theory SIT; , childreFrom the trends observed in participants’ reasoning, it is clear that the group identity of the misinformer and their target led to different justifications being used by the participants. When participants had an outgroup misinformer and an ingroup target, they cited lying and deceit concerns to justify their inclusion evaluations, which involved more accusations of dishonesty. In comparison, participants with an ingroup misinformer and an outgroup target used more personal reasoning to justify their inclusion evaluations, which tended to include more perspective taking on the misinformer’s part. This highlights that despite the misinformer’s claim being the same for participants in both misinformer identity conditions, having an ingroup peer as a misinformer can result in more likelihood to engage in mental state understanding, whereas having an outgroup peer as a misinformer results in less belief in their claim. This is in line with past research showing that children and adolescents are more likely to consider the mental states of ingroup peers than outgroup peers . It is aThere were important age-related differences that emerged in the present study. Firstly, children made more references to moral concerns, such as welfare and lying and deceit, than adolescents did when judging the misinformer. On the other hand, adolescents’ reasoning about their judgments consisted of more references to social-conventional matters, such as group functioning and conventional norms and expectations. This developmental shift is congruent with previous research, which claims that children are relatively more concerned with moral factors in their reasoning, whereas adolescents become comparatively more concerned with social-conventional or psychological matters  as explaFurthermore, as predicted, and in line with previous research , particiFirst, in the control condition where loyalty to the group was expected, adolescents attributed significantly more positive intentions to an ingroup misinformer compared with children. This could have been due to adolescents’ superior perspective taking abilities, which may have resulted in them being more likely to regard the misinformer’s actions as accidental, an effect exacerbated by the ingroup status of the misinformer, the outgroup status of the target and the expectations of loyalty in the group.Second, the other condition that showed an age difference was when there was an ingroup norm that encourages thinking critically. In this condition, children’s intentionality attributions for an outgroup misinformer were significantly more negative than adolescents’, suggesting the critical norm facilitated a dislike for the outgroup amongst the children only. This could have been linked to the evidence that shows younger children are worse at acknowledging and interpreting the mental states of outgroup peers, and consider the mental states of ingroup peers more, than older children and adolescents do .Further, when children were assigned to the critical ingroup norm condition, they made more positive intentionality attributions about an ingroup misinformer than when they were in the control condition. This finding opens up the possibility that a group norm of being critical may encourage children to be more positive in their perspective taking regarding an ingroup misinformer’s intentions. Hence, a norm of thinking critically may have made children question their assumption of a misinformer’s intentions, but in a negative direction for outgroup peers and in a positive direction for ingroup peers, given children are better at interpreting their ingroup’s mental states. The present study did not take an isolated measure of participants’ social-cognitive perspective taking ability, such as their Theory of Mind ability, so it is not possible to underpin the mechanism responsible for this effect. Future research should, therefore, explore Theory of Mind ability in relation to age-related effects of a critical ingroup norm on intentionality attribution.These developmental differences may also have been linked to children’s open-ended justifications of both moral evaluations, which were significantly more concerned with lying and deceit than adolescents. Hence, it is possible that given the misinformer’s intentions were ambiguous in the study, children were more likely to presume the misinformer had deliberately spread misinformation, and so committed an intentional act of deception. This is supported by prior research, which has shown that even when a false claim is made unintentionally, children justify negative evaluations of the claim with references to lying . DevelopThe manipulation of the ingroup norm, which failed to have a predicted effect, is a limitation of the study. This may have been because, with regards to the critical norm condition, a norm message from their school team telling them what they value may not have been enough to influence their judgments and decisions. Rather, seeing their fellow peer group members being critical, or being presented with a context that explicitly highlights moral concerns over group concerns might have been needed. Without seeing what being critical means in practice, it is possible that it is not strong enough to influence the participants as much as the manipulation of the misinformer’s identity did. Given this was the first time a norm of this kind was used in a study manipulation, it is possible that with more development and further studies, it can become more effective. The control condition may also have been a possible weakness for not having an explicit norm, and for assuming loyalty to be the norm without making it a more salient expectation. Together, this may have been why the effect of the norm was not as predicted, and may need to be strengthened in future studies. From this study alone, the findings suggest that critical thinking is something that requires more than just a single norm message to encourage in children and adolescents, and perhaps first it needs to combat the strong effect of ingroup biases.The present study’s design manipulated the group membership of both the misinformer and the target of the misinformation, so the misinformer was always in the opposing team of their target. This was done to create an intergroup context with ecological validity, as in real-life contexts, it is unlikely for a group member to share a false accusation about their fellow group member in a competitive intergroup context, resulting in a disadvantage for their own group. We still acknowledge that not having comparative groups where an ingroup misinformer targets a fellow ingroup peer, and an outgroup misinformer targets a fellow outgroup peer, is a limitation of the present study. Adding such manipulation conditions would have made the conclusions much clearer in terms of whether it is the group membership of the misinformer or the target that drives the evaluations made by our sample, which we are aware is currently unclear from our present study. Future research should include such comparisons for more comprehensive conclusions and include evaluation questions about both the misinformer and their target.Ingroup and outgroup membership in this study was related to school teams in a spelling competition. We recognize that the inclusion evaluation may have been affected by the presumption that an individual cannot easily leave their school team to join another. Nonetheless we would have anticipated similar results in an alternative intergroup context other than a school, such as a sports team, where moving between groups is also potentially difficult and risky. In future research, this question could be reframed around the inclusion of the misinformer in a future event and a different intergroup context, for instance, rather than the same inter-school context.It should also be noted that this research was conducted during the COVID-19 pandemic, in-between national lockdown cycles and during strong, government-led norms about social distancing and following rules for the sake of saving lives. It is unclear from this study how the COVID-19 social distancing guidelines, which feature in the intergroup context, were perceived by the participants. This was not a factor we had controlled for, as to our knowledge, there have not been any studies conducted around children and adolescents’ reasoning about COVID-19 rules. It is therefore uncertain whether they perceived social distancing as a matter of moral concern, social-convention or personal choice. This lack of certainty is a limitation of the present study, but a definite exploration for future research to undertake.health risk was only commented on twice , suggesting COVID-19 and its guidelines were not seen as much of a moral matter, but was frequently commented on in the context of just following the social distancing rules , which on its own was regarded as a social-conventional matter. While these indications alone are insufficient to draw conclusions from, there is a likelihood that the participants of the study viewed the social distancing guidelines as a social-conventional matter rather than a moral welfare concern.Nonetheless, in some cases participants’ reasoning about their evaluations indicated that the welfare concerns of not social distancing  were not a priority. From the whole sample, welfare concerns in the context of Overall, the findings in this study make a strong case for focusing on group identity effects, as highlighted by both evaluation responses and open-ended reasoning, when trying to address ingroup biases toward misinformers. In the adult literature, it has been demonstrated that misinformation belief and spread can be attributed to individuals’ desire to gain the acceptance of an identity group, often at the expense of maintaining the accuracy of the information itself . The preThe present study provided a novel contribution to existing research by demonstrating that group membership and age-related differences influence moral and intentionality evaluations and reasoning about a misinformer. Ingroup preferences emerged both when participants morally evaluated the misinformer, and when they justified those responses. Participants were more likely to engage in perspective taking when the misinformer was an ingroup peer targeting an outgroup peer, and more likely to level an accusation of dishonesty toward an outgroup misinformer targeting an ingroup peer. The age-related differences highlighted in the present study also extend previous research, reinforcing the relative importance of moral concerns for children and social-conventional matters for adolescents, and providing insights from children’s reasoning for their more negative intentionality attributions compared with adolescents. Altogether, this study argues for an approach to tackling the spread of misinformation that takes into account factors such as shared group identity with, and developmental differences in attribution of intentionality to the spreaders of misinformation itself.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Dr. Nick Moberly, University of Exeter Ethics Committee. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.AF, AR, and AA conceived of the study and contributed to manuscript revision, read, and approved the submitted version. AF carried out the data collection, performed the data analysis, with assistance from EK on reliability coding, and wrote the first draft of the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The term central nervous system (CNS) autoimmunity refers to an immune reaction directed against the body´s own antigens within CNS structures from an immunological point of view. The immune reaction is so diverse and complex that it cannot be simplified as two main mechanisms. Autoantibody-associated psychiatric disease can, however, be categorized as two main immune mechanisms, although other important immune mechanisms also exist. One potential immune mechanism in autoimmune-mediated secondary psychiatric disorders that are associated with autoantibodies to intracellular antigens, is likely to be characterized predominantly by a T cell-dependent mechanism. This suggestion is based on the observation that in encephalitides associated with antibodies and intracellular antigens, CD8+ T cells were frequently found in encephalitic brain tissue . The othThis review addresses, on the one hand, whether autoimmunity can be reduced to the distinction between an attack on the self as an autoimmune response and an attack on the non-self as an action that is not part of an autoimmune response. On the other hand, it may also be that autoimmunity, in particular, which has been found in psychiatric disorders probably mediated by autoantibodies, is more complex than the theory of the distinction between self and non-self. We favor the latter, and will make some arguments in our review. In our view, in addition to autoimmunity in psychiatric disorders , many other factors that may contribute to autoimmunity are important, such as T cells, regulatory T cells (Tregs), and B cells.We searched PubMed for articles on theories of autoimmunity and autoantibodies related to psychiatric disorders. Our narrative review is based on the selection of these articles.We first introduce relevant theories of autoimmunity and then describe autoantibodies in psychiatric disorders as a possible manifestation of autoimmunity. Later, three different types of autoimmunity are presented, representing possible autoimmunity in autoantibody-associated psychiatric disorders. A philosophical consideration of CNS autoimmunity comprises two main models entailing explanations, namely the “self-model or non-self-model” as suggested by Burnet , and theTo understand the role of autoimmunity in psychiatric disease, we will elucidate the role neural autoantibodies play in psychiatric disease. Neural autoantibodies are increasingly detected in association with different psychiatric disorders, ranging from dementia to psychotic disorders ,20,21,22We found a protective autoimmunity with autoantibodies if the immune reaction takes place and eliminates “foreign” or “continuous” antigen epitope elements, such as a paraneoplastic action that causes the elimination of a tumor. Note that neural autoantibodies can be paraneoplastic in nature, such as intracellular antibodies, which means that neural autoantibodies can be the precursor or even consequence of cancer. Neural autoantibodies are often indicative of an unspecified immune response against tumor antigens sharing features with the targeted neural antigens. Thus, neural autoantibodies may be protective, as they are indications of a tumor immunity process taking place. Moreover, these autoantibodies may indicate a potentially harmful future, in that the appearance of these autoantibodies could act as the body’s alarm system before a potential cancer develops, and can thus be interpreted as protective.No symptoms are felt from the patient and the action leads to optimization of survival. The immune reactions are believed to be part of an active process that is regarded as a complex “normal” physiology . It is kPsychiatric symptoms coinciding with autoimmune-based psychiatric disease are potential correlates of CNS autoinflammation. Although such patients suffer from transient and reversible psychiatric symptoms, no relevant brain damage or brain inflammation is detected when conducting diagnostics such as EEG, CSF analysis, and MRI. The immunity process serves to regulate immunity against the self along with ongoing negotiation of the interaction between the self and “non-self”, as described by Tauber , or via Autoimmune processes in the CNS can cause severe damage and neuronal loss. Persistent psychiatric symptoms associated with neural autoantibodies might be a severe and harmful consequence of CNS autoimmunity A. HarmfuOur opinion article shows that autoimmunity based on autoantibodies may play different roles, ranging from physiologic homeostasis to regulatory processes in brain functioning and mental health, as well as building antibody-antigen complexes that might precede severe inflammation and brain damage. These varied expressions of autoimmunity serve to maintain brain homeostasis and are thus part of the “multi-systemic dynamic continuum model” B in mult


Museums have widely embraced virtual exhibits. However, relatively little attention is paid to how sound may create a more engaging experience for audiences. To begin addressing this lacuna, we conducted an online experiment to explore how sound influences the interest level, emotional response, and engagement of individuals who view objects within a virtual exhibit. As part of this experiment, we designed a set of different soundscapes, which we presented to participants who viewed museum objects virtually. We then asked participants to report their felt affect and level of engagement with the exhibits. Our results show that soundscapes customized to exhibited objects significantly enhance audience engagement. We also found that more engaged audience members were more likely to want to learn additional information about the object(s) they viewed and to continue viewing these objects for longer periods of time. Taken together, our findings suggest that virtual museum exhibits can improve visitor engagement through forms of customized soundscape design. For the past several years, virtual exhibits [VEs] have proliferated. Broadly defined, these consist of virtual exhibition spaces that complement, augment, or otherwise enhance museum experiences through personalization, interactivity, and related augmented content , 2. In sVEs have proliferated for various reasons: for example, the widespread efforts by museums to use web-based technologies for attracting larger, more diverse publics, and global initiatives such as Google Arts, which functions as an aggregator of museum and heritage sites’ virtual tours . More reAt present, most VEs tend to display objects without any accompanying sounds—a tendency we discovered after conducting a preliminary survey of several hundred such exhibits in China, Japan, the United States, and the United Kingdom. Nevertheless, one emerging feature of VEs is their incorporation of sound: for instance, in the form of background music, object descriptions, narrated tours, or ambient noises.On its own, the small but growing array of efforts to incorporate sound into VEs is not entirely surprising. After all, audio guides have a long tradition within the physical spaces of museums, so it stands to reason that VEs would adopt a similar approach for conveying pedagogical information, particularly as such exhibits become more sophisticated. Additionally, numerous curators and other museum professionals are by now keenly aware that sound may enrich a spectator’s experience of artworks and other forms of cultural heritage. This is suggested by the many audio augmented-reality systems that have found their way into museums, sculpture parks, and sites of cultural heritage, largely through pre-recorded narratives and soundscapes that dynamically respond to a visitor’s location and/or the objects being viewed. In such contexts, sound has the potential to create a more individualized experience for spectators by adapting to their “goals, preferences, knowledge, and interests,” as Andreas Zimmermann and Andreas Lorenz have persuasively shown . It alsoTo begin addressing such questions, we conducted a series of online experiments with 97 adult participants to explore how soundscapes may shape an audience’s experiences in VEs. To briefly clarify our use of the term “soundscapes,” we refer to “acoustic environment[s]…perceived or experienced and/or understood by a person or people, in context” as defined in , where I is a natural number that can take the value 0 (no information requested), 1 (first information recording requested), 2 (first and second information recordings requested), or 3 .Second, we measured the Pearson correlation coefficient between the value of I and the responses given by participants to each of the other affect and engagement questions listed in Finally, we analyzed the open-ended questions to understand how sound types affect engagement with the objects. We used inductive reasoning to identify themes and patterns emerging from the analysis and how these resonate with the results of the quantitative analysis. The process, which is probably the most common qualitative analysis in social and behavioral sciences research , consistA total of 97 individuals with normal or corrected-to-normal hearing and vision were recruited to participate in our experiments via a combination of an online experiment platform for conducting behavioral research studies (labinthewild) and email-based advertisements.A total of 3 participants (approx. 3% of the dataset) were found to be giving the same responses to all questions asked of them. Subsequently, they were removed from the dataset prior to further analysis.We first investigated the affect of types of soundscape and objects on affect and engagement levels. We used linear regression to model the relationships between objects, soundscape types, and participant responses. We then used the resulting estimated model parameters to estimate the affect of object types and soundscapes on participant responses.p > 0.05).We did not find any significant effects of either soundscape type or object on affect (questions 1 and 2 in t(561) = 3.268, p = 0.001, object: t(561) = 2.487, p = 0.033) and “Engagement Q5” (soundscape: t(561) = 3.645, p < 0.001). Note, we used the weighted z-method to correct for multiple comparisons  and music shared the sacred aura. This enriched my experience”; 2: “The sound really helps to contextualize this object in a church.”Finally, the qualitative analysis suggests that while sound triggered the study participants to think about connections with the object’s meanings, narratives, and original contexts, in the absence of sound spectators might focus more on visual and material details of the objects under analysis. Eight participants among the 45 participants providing qualitative feedback noticed such connections. But two remarks that instantiate this tendency read as follows: 1. “I could have spent even more time to focus on the fine details of the object in silence. Silence enables [one] to focus on details” (about the Mayan Lintel); 2. “I had more time to look at the object and think about answers that were mainly related to the qualities of the objects rather than the object in association with music” (about the Statue of Livia).Our findings support the hypothesis that the pairing of soundscapes with objects displayed in a VE can effect audience engagement. The analysis of our results also suggests that three types of soundscape in particular increased participant engagement with the VE objects. Namely, object-inspired soundscapes, IADS, and synthetized soundscapes increased engagement and participant’s reported valence more than either silence or the real museum soundscapes. These findings are broadly consistent with our initial hypothesis that targeted soundscapes would facilitate greater engagement with the objects on display.Previous work has demonstrated that presenting pleasant soundscapes in a real museum context has a positive effect on audience engagement and knowledge gain . HoweverThat said, our findings also refined our hypothesis by revealing that a participant’s level of interest in the displayed object(s) correlates with their engagement level, and that a participant’s reported valence and arousal also correlate positively with engagement. Taken together, these two findings suggest that VEs may be able to increase engagement levels by pairing objects with soundscapes, particularly in cases when the objects are likely to be perceived as “less interesting”. Furthermore, we found that “happier” participants, as defined by their reported valence, are more likely to request further pedagogical information about the objects on display. In other words, the pairing of objects with soundscapes increases engagement, which, in turn, heightens the possibility that the individual will want to learn more about the objects.Responses to soundscapes depend on a participant’s perception of the displayed object’s context, which, in this experiment, could be either the virtual exhibition space or the history of the object itself. Nevertheless, it is striking that synthesized soundscapes were associated with higher engagement levels than the real museum soundscapes, IADS soundscapes, and silence. This suggests that the use of creative “sound design” processes may be more useful in generating higher engagement levels than attempting to recreate an accurate museum sound-world—a finding that recalls the so-called Foley effect of using non-realistic sounds in films and video games. Indeed, bespoke sound design may be a time-consuming and ultimately costly process. Yet it is also possible that, in the future, the automated design of soundscapes might offer a useful solution, especially when creating soundscapes in the object-inspired category.Any attempt to use sound to increase engagement levels, however, also demands that we develop a far more granular understanding of how soundscapes function in VEs. After all, our qualitative data reveals that sound does not simply trigger higher engagement rates or changes in valence and/or arousal, as if a participant were a passive vessel. Instead, a participant often attempts to decode the relationship between an object and its soundscape (including soundscapes that are not from the object-inspired category). Additionally, although some participants reported higher engagement levels when they perceived objects accompanied by certain soundscapes, others reported being annoyed by the soundscape, even to the point of casting doubt about the authenticity of the objects on display. Given such findings, some degree of customization may be preferable for individual spectators, depending on their preferences. Alternatively, a responsive sound system that dynamically responds to individual participants reactions may be beneficial: for example, by harnessing the power of behavioral or physiological measures of audience engagement as a control signal.It may prove to be the case that different groups of spectators respond to soundscapes differently. For example, individuals of different ages and from different cultural backgrounds are known to produce different affective responses to music , 29 and Our findings also raise more complex questions for exploration in future studies. For instance, assuming silence encourages greater focus on an object’s specific visual features and physical details, might some alternation between sounds and silence help to further optimize engagement while reducing a participant’s negative reactions to the sounds and, by extension, to the objects themselves? Additionally, assuming sound provides one means to shape a spectator’s valence, then how might user-defined soundscapes productively disrupt the implicit control of a spectator’s thoughts and experiences? Ultimately, our results demonstrate the potential for soundscapes to enhance engagement within a VE and have potential applications in a wide range of contexts, for example both in real and virtual exhibits.S1 Table(PDF)Click here for additional data file.