Due to decades of nonstandardized approaches to the naming of chemotherapy regimens, representation in electronic health records and secondary systems is highly variable. This hampers efforts to understand patterns of chemotherapy usage at the population level. In this article, we describe a proposal for rules to standardize the nomenclature of chemotherapy regimens and illustrate applications of these rules.Through our experience with building HemOnc.org, which has been under construction since 2011, we formulated a set of guidelines and recommendations for the standard representation of chemotherapy regimen names. We then performed a mapping between the HemOnc and National Cancer Institute Thesaurus vocabulary’s regimens and evaluated conformance with the naming conventions. Finally, we assembled a database of acronyms and names for multiple myeloma regimens to illustrate the scope of the problem.For the first use case, 242 of 527 (45.1%) of the regimen names differed. The schema was able to allocate a preferred source for 217 (89.4%) of these regimens. For the second use case, we expanded 130 multiple myeloma regimens to 1,138 unique regimen names and demonstrate ways in which the schema can collapse these into disambiguated, but abbreviated, regimen names.To our knowledge, this is the first proposal to normalize chemotherapy regimen nomenclature. If our recommendations are adopted, we expect that the uniformity of treatment exposure representation in hematology/oncology will increase, which will enable large-scale efforts such as ASCO’s CancerLinQ to achieve better standardization. This creates confusion with an older regimen that was a standard of care for many years, VAD,5 where V stands for vincristine (as opposed to Velcade [bortezomib]).The introduction of combination chemotherapy in the 1960s and 1970s has led to ever-increasing complexity of cancer treatment regimens. On the basis of the success of certain combinations in curing certain cancers, multidrug combination regimens, often with complex sequencing and dosing parameters, have become common. As a result, an informal jargon based primarily on acronyms arose to facilitate communication between oncologists and with patients. This jargon is idiosyncratic and can include a mix of generic, chemical, and brand names of antineoplastics. For example, the lymphoma regimen CHOP, originally named the uninformative “Combination 2,” contains two generic abbreviations (C for cyclophosphamide and P for prednisone/prednisolone), one brand-name abbreviation (O for Oncovin [vincristine]), and one chemical name abbreviation (H for hydroxydaunorubicin/hydroxyldaunomycin).6 and dose-adjusted R-EPOCH7 contain the same drugs but are distinct in terms of doses, indications, administration times, and other details. The predictable result is chaos when approaching the problem of aggregating real-world data at a population scale, as is envisioned by the US Food and Drug Administration (FDA)8 as well as efforts such as ASCO’s CancerLinQ,9 Flatiron, and American Association for Cancer Research Genomics Evidence Neoplasia Information Exchange (GENIE).10As drug development accelerates, and an increasing armamentarium of antineoplastics is incorporated into treatment regimens, examples such as this will become increasingly common. The oncology community needs a lingua franca for documenting the consideration, planning, administration, and history of chemotherapy regimens. There are many potential downsides to the current state of nonstandardized representation. Most importantly, clinical care can be affected. For example, a tertiary referral center might misinterpret the “VAD” in a patient’s treatment history as having contained bortezomib and might consider the patient exposed and resistant when they are actually bortezomib naïve. In addition to facilitating better communication between clinicians, a standardized regimen-naming convention would facilitate secondary use of treatment exposure data by external registrars and learning health systems such as CancerLinQ and for studies using electronic health record (EHR) data. At least in part because of difficulties with regimen naming, the cancer registry community has historically only recorded individual drug exposures, when they are recorded at all. This can lead to ambiguity and insufficient detail to understand patterns of treatment exposure. For example, R-EPOCHKey ObjectiveThe aim of this work was to develop the first standardized nomenclature, to our knowledge, for representation of chemotherapy regimens, which have been long recognized to have ambiguous and nonstandardized naming conventions.Knowledge GeneratedRules for the representation of chemotherapy regimens as standardized concepts were developed. These rules were applied to map regimens represented by HemOnc.org and the National Cancer Institute Thesaurus and to adjudicate preferred regimen representations, as well as to demonstrate the degree of ambiguity in regimen representation for multiple myeloma regimens.RelevanceIf adopted, this nomenclature has the potential to improve uniformity in representation of treatment concepts, facilitating large-scale data analysis for learning health systems and electronic health record–based investigation.11 the largest freely available resource of chemotherapy drug and regimen information, we have introduced the first standardized vocabulary for chemotherapy regimens in the Observational Medical Outcomes Partnership common data model, allowing for transformation of data derived from distinct observational sources into a uniform format.12 Here, we take this further, proposing a standard nomenclature for chemotherapy regimens. What follows is inspired by the model of the desiderata proposal of Cimino,13 which establishes criteria for standardizing medical vocabularies including unique identification of concepts, concept permanence, and orientation. It is meant to spark a discussion within the communities of clinicians , guideline creators, and clinical data consumers (secondary users of EHR data). We propose 13 rules for naming chemotherapy regimens on the basis of our experience curating HemOnc.org and our day-to-day experience as clinicians. Subsequently, we evaluate the scope of the current challenge in the area of multiple myeloma and perform a mapping and comparison of the HemOnc12 and National Cancer Institute Thesaurus (NCIT)14 content.Informed primarily by our experience building HemOnc.org,15 Relevant examples are given in We propose a schema for standardized nomenclature of categories of chemotherapy regimens, organized in increasing order of regimen complexity. Our recommendations use the conformance verbs SHALL, SHOULD, and MAY as defined in Network Working Group Request for Comment 2119.These shall be expressed by the generic drug name followed by the suffix “monotherapy.” Alternatively, they can be expressed by the prefix “single-agent” followed by the component name. The suffix “monotherapy” is preferred, unless referring to a category . Using acronyms to represent a single component should be avoided, as single letters will be frequently confused with other EHR artifacts.When the two components are of the same drug category, these shall be expressed in alphabetical order of the generic name, separated by “and” or “&.” When one of the components is a cytotoxic and the other is a monoclonal antibody, a steroid, or radiation, the cytotoxic shall be expressed first. For each component, only the first word is capitalized.This is generally discouraged except for one case: the abbreviated component is radiation therapy (RT). In this case, the rule is the same as above: “Cisplatin & RT” is correct; “RT & Cisplatin” is not.Avoid acronyms that are easily confused with other medical acronyms .Avoid acronyms that use a brand name .Avoid acronyms that are much more commonly used for other regimens .Use the acronym that is most often used in the published literature.These guidelines can be in direct conflict. For example, a Google Scholar search for “EC SCLC chemotherapy,” “EP SCLC chemotherapy,” and “PE SCLC chemotherapy” yields 8,580, 12,200, and 11,100 results, respectively. Comparatively, a Google Scholar search for “EC breast cancer chemotherapy” yields 357,000 results; as such, acronym EC should be reserved for the breast cancer regimen, and, given the violation of rules 1, 2, and the relative inconclusiveness of rule 4, the drug names cisplatin and etoposide should be used instead of the acronyms PE or EP.These are particularly prone to ambiguity. For example, the small-cell lung cancer (SCLC) regimen comprising cisplatin and etoposide has been variably called EC (etoposide & cisplatin), EP (etoposide & Platinol [cisplatin]), and PE (Platinol [cisplatin] & etoposide). In these cases, it is probably best to expand the acronym and follow the rules outlined in 2.1. Otherwise, there are four guidelines to consider:Components shall be separated by a comma, without the use of “and” . Components shall be listed alphabetically within subcategory, as follows: cytotoxics first, then monoclonal antibodies, then steroids.As before, the component of radiation therapy can and should be abbreviated as RT.If two or more components compose a well-known “backbone” that is conventionally referred to by acronym.For regimens containing radiation therapy, the acronym should be listed last . For regimens containing “backbones” represented by acronyms , the acronym should be listed first; the additional component should be listed last. As in section 3.1, components or acronyms shall be separated by a comma, without the use of “and” if there are three or more components, and by “and” or “&” if there are two components or acronyms.There are two cases where this is acceptable:In many cases, a philosophical disagreement exists over whether abbreviating a regimen is necessary or advisable for a particular regimen. Exchanging more-precise for less-precise terminology always introduces potential ambiguity. There is no a priori way to adjudicate this issue, as the specifics of individual regimens are important. However, shortening the names of regimens potentially reduces documentation burden for clinicians and registrars, especially when regimens contain more than three drugs or involve alternating combinations of chemotherapy. Regimens should therefore be abbreviated in some form when it is possible to do so in a way that clearly conveys the treatment protocol being used for a particular patient.In contrast to the situation described in rule 2.3, ambiguity is less common in this setting, but it still exists. R-CHOP is a concrete example; 3,952 patients at Vanderbilt University Medical Center have the acronyms “R-CHOP,” “RCHOP,” “CHOP-R,” or “CHOPR”—representing the chemotherapy regimen of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone—present in their EHR. In this case a Google Scholar search is informative; there are 24,100 results for “R-CHOP chemotherapy,” 6,060 for “CHOP-R chemotherapy,” 2,230 for “RCHOP chemotherapy,” and 64 for “CHOPR chemotherapy.” R-CHOP is preferred.R-GemOx); when this is done, it is typically separated from the chemotherapy backbone by hyphenation. In other cases, the approved biologic agent is affixed on the back end , in which case it is often added to the chemotherapy backbone with no separation. Empirically, we find that this convention generally holds, and we propose that it be followed for novel analogous combinations.Additional ambiguity arises when a biologic agent is added to a chemotherapy backbone and is itself abbreviated. In many cases, the abbreviated biologic agent is affixed on the front end .These regimens consist of subsets of regimens that cannot be inextricably unlinked because of the alternation schedule . In these cases, when the subsets are acronyms, individual subsets should be separated by a “/”. The “/” indicator shall be reserved for this purpose only; using it elsewhere creates ambiguity as to whether the drugs separated by “/” are given sequentially or together. If the subsets are full names, the separator should be “alternating with.”Many widely used regimens are variants of other regimens, involving the same drugs on an alternate dose level or schedule that does not easily fit into the modification paradigm as explained above. Sometimes these variants exist to avoid toxicity in the context of antecedent organ dysfunction or to treat patients who were too frail to be studied in initial trials. If such variants are indicated by widely accepted modifiers, these should be used, as they can avoid significant complexity in regimen naming while conveying the same meaning. If not, the modification to the existing regimen should be indicated as succinctly as possible, with the modified drug indicated in the same fashion as in the initial regimen.These are often complex treatments that consist of two or more sequential procedures or regimens assembled into a total protocol. Each temporally distinct regimen or procedure should be separated by “, then.” There are some exceptions to this; for example, some widely used sequential breast cancer regimens involve a sequence of an anthracycline/cyclophosphamide doublet and a taxane, and the temporal separation between regimens is represented by a dash . Unless such representations are nearly ubiquitous, they should be avoided.We manually mapped the preferred distinct regimen names in the HemOnc vocabulary to the corresponding preferred concepts in the NCIT. The purpose of this was two-fold: 1) providing additional external mappings in HemOnc , and 2) determining the degree to which the preferred names in the vocabularies align with these proposed rules.There were 527 successfully mapped regimens; of these 285 (54.1%) are described identically on NCIT, when accounting for semantic differences in punctuation and labeling concepts as “regimens” (Data Supplement). This leaves 242 (45.9%) in which the same concept is represented divergently by the two databases. Of these, the schema above was able to identify a clearly preferable regimen for 217 (90.0%); the HemOnc nomenclature was preferred in 194 cases (89.4%), and the NCIT nomenclature was preferred in 23 cases (10.6%). Rationales for allocating a preferable regimen are summarized in For 25 discrepancies, the proposed rules could not allocate a preferred name. The two sources generally chose ways to abbreviate regimens that were equally unambiguous and potentially useful, are distinct, and have similar representation in the literature. It is challenging to adjudicate these cases until one particular nomenclature is adopted more widely. Beyond the nomenclature evaluation, this mapping offers utility to the community. For example, native NCIT users can layer HemOnc relationships into their applications .18 Four-drug combinations are currently under active investigation.19 Because of these developments, increasingly complex regimens combining chemotherapeutic agents and monoclonal antibodies are becoming the standard of care. An additional complication arises because lenalidomide plus high-dose dexamethasone has been compared with lenalidomide plus low-dose dexamethasone.20 These are different regimens and are often represented distinctly . One can imagine that representation of these regimens is not homogeneous, both in the literature and in clinical documentation. Some examples of variants of commonly used regimens are listed in The magnitude of this problem truly comes into focus when examining the landscape of multiple myeloma regimens. There are 17 FDA-approved drugs for the treatment of this malignancy, 7 of which were approved in 2012 or later; more than 100 regimens have been evaluated in multiple myeloma in phase II or III studies. Several recent randomized controlled trials have demonstrated superior progression-free survival for three-drug combinations compared with two drug combinations in a variety of treatment settings.We reviewed the 130 multiple myeloma regimens contained within HemOnc. On the basis of the representation of these regimens in the literature and our empirical experience in clinical practice, we have recorded 1,138 acronyms representing these regimens (Data Supplement). This is not intended to be comprehensive but nevertheless illustrates the scope of the problem. Individual regimens have a median of six distinct representations, with a maximum of 31 for one four-drug combination . This heterogeneity in representation creates challenges in determining prior treatment exposure, and therefore eligibility for subsequent therapy at relapse, which is inevitable for this incurable malignancy.21 Although alternate representations for these concepts exist, this approach does so in a way that allows significant abbreviation and minimal ambiguity as to the regimen being used. To our knowledge, this is the first proposal for a schema to normalize chemotherapy regimen nomenclature. We have demonstrated with two use cases that this schema is useful to disambiguate regimen representation. Our schema can be used to adjudicate differences in regimen representation and can collapse an increasingly complex landscape of regimen representation into a short, digestible list of concepts.Using the rules-based approach for uniform nomenclature, we collapsed these myeloma regimens into representations fitting our schema .21 AlthoWe acknowledge that different potential methodologies exist to standardize chemotherapy regimen representation. We do not claim or aim to demonstrate that our proposal is definitively superior to possible alternatives. Because no standardization schema yet exists, were the standard presented in this paper adopted, the uniformity of treatment representation in the literature and in clinical documentation could increase. As regimens grow more complex and involved over time, it is becoming increasingly important to develop a priori best practices for naming new regimens. Adopting a standard nomenclature, whether the one proposed here or an alternative, would facilitate this. We hope that this effort stimulates discussion surrounding standardization of chemotherapy nomenclature. This would facilitate a variety of efforts, including knowledge aggregation, real-world data analysis, and developing an oncology learning health system.


Strategies to support the psychosocial well-being of older adults living in aged-care are needed; and evidence points toward music listening as an effective, non-pharmacological tool with many benefits to quality of life and well-being. Yet, the everyday listening practices  of older adults living in residential aged-care remain under-researched. The current study explored older adults’ experiences of music listening in their daily lives while living in residential aged-care and considered how music listening might support their well-being. Specifically, what might go into autonomous listening activities? 32 Australian residents (aged 73–98) living in two Australian care facilities participated in semi-structured interviews. The results of a qualitative thematic analysis revealed three themes pertaining to “previous music experiences and interest,” “current music listening,” and “barriers to listening.” While an interest in and access to music did not necessarily result in everyday listening practices, of those participants who did listen to music, perceived benefits included outcomes such as entertainment, enjoyment, relaxation, and mood regulation. Drawing on Ruud’s notion of music as a “cultural immunogen” supporting well-being and Self-Determination Theory, theoretical implications of the findings are addressed, relating to how to create and support music activities in aged-care facilities so that they are engaging, meaningful, and promote emotional regulation, community, and well-being. Globally, average life expectancy is increasing . As the Well-being encapsulates key components such as one’s satisfaction in life and the presence of positive emotions . When coHumans have been making music for millennia . This acOlder adults listen to music in order to reminisce, experience enjoyment, regulate moods, feel socially connected, and to express identity , and resStudies investigating music listening and well-being have commonly used participants’ preferred music to generate personalized playlists and create listening programs . While CWith listening, it is important to acknowledge the role of technology . Mobile The review of literature highlighted a significant gap in understanding the music listening experience for people living without dementia in residential aged care. It is important to understand this phenomena because older adults often listen to music , and thiRQ1: How does music listening fit into the daily lives of older adults living in residential aged-care?RQ2: How do older adults access music? What is the role of technology ?RQ3: How does music listening influence older adults’ perceived psychosocial well-being?M = 86.86, Mdn = 87.00, SD = 5.75), and most of the sample was Australian , with the remaining individuals reporting their nationality as Canadian, English, Polish, and Dutch (one participant did not report).Thirty-two individuals living in two residential, aged-care facilities in the regional Melbourne area  participated in one-to-one interviews. This gender representation reflected the overall population of the facilities. Of those who provided their age (90.63% of the sample), participants were between 73 and 98 years of age  to support the lifestyle programming.The human ethics committee at The University of Melbourne granted approval for this study (Ethics ID: 1851094.2). A qualitative approach was used to examine the role of music listening in everyday life and how music listening might influence perceived quality of life. Semi-structured interviews were chosen as a data collection method because they are a practical/useful qualitative approach when researching older adults  and becaThe focal questions included in the interview schedule explored (1) people’s current music listening routines  and (2) their previous experiences with music-making and music listening throughout their life. Additionally, questions centered on people’s (3) weekly routines and how music might fit in, as well as (4) their lived experiences of the residential aged-care facility. As such, the data obtained was based on participants’ reflections of their personal experiences.Participants were provided with information about the study, and were informed that they could discuss their participation with family, friends, and staff if they wished before consenting to take part. Individuals provided written consent prior to the interviews taking place. Individuals stated their age, gender, and country of residence on the consent form in order to report on the demographic details of the sample . All interviews took place in the aged-care facility at a time agreed upon by the individual participants.With the consent of the participants, all interviews were audio recorded. Each recording was transcribed verbatim. Following Three overarching themes arose from the thematic analysis. These themes were labeled “previous music experiences and interest,” “current music listening,” and “barriers to listening.” These overarching themes and their sub-themes are summarized in The first theme concerned the participants’ experiences and interest in music prior to living in residential aged-care. During the interviews, residents spoke about their childhood, adolescence, and adulthood . This theme is divided into four sub-themes: music-making, music listening, social dancing, and the fact that people’s past experiences do not necessarily relate to their present music experiences or interest.n = 12) or learning to play the piano (n = 5). Most of this previous experience was limited . Only three participants spoke about a longer-lasting involvement with music-making. One woman learned piano and violin, earning a music degree and assisting/accompanying music groups as an adult (P05), one woman’s husband was a piano tuner who was also in bands and so she recounted how “there’s been music in my life all the time really” (P09), and one man had been in choirs from childhood through later life . A few more participants expressed that they had a desire to learn an instrument when younger, but that their family circumstances did not facilitate doing so . Some mentioned family members who were musically inclined – often mentioning a mother or grandmother who played the piano , though a few other instruments were mentioned .To begin the interview and introduce the topic of music experiences and interest in their lives, participants were asked about previous musical experience using a purposely broad question to embrace everything they might consider from formal music learning to informal or occasional social engagement involving music  and as adults , and of having music collections. Collections involved records, cassette tapes, and CDs . A small number of individuals also mentioned going to concerts, musicals, and theater performances . Attending dances was another way participants mentioned experiencing music, with one participant saying that she could not get records because she was living with other people, but was able to hear music by going to dances.In contrast to the limited music-making experiences, engaging in music listening activities was far more common in the participants’ lives. Twenty of 32 participants stated that music listening activities featured in their life (at some stage) prior to residing in the aged-care facility. Participants mentioned listening to the radio, as children . Even for those who stated that they were not very much interested in music, dancing was an important social activity. Participant 04 stated,The presence, and role, of social dancing is an interesting sub-theme. Of the 18 discussions about social dancing, only four people stated that they did not go to dances (the subject was not raised in the other 14 interviews). ‘In other words, social dancing featured in many of the residents’ lived experiences  – both Participant 09 and 17 met their husbands at a social dance.For some of participants, dancing and dating went hand in hand , on the other hand, “hasn’t kept playing” but stated that she does attend the facility concerts – plus, while she had a collection of cassettes and CDs in her room, she said she watched the television more than listening to music. Other participants who previously sang or played the piano as a child finding enjoyment in it stated they did not listen much at the present time  or did not “get around to it” often. The reverse pattern was also present, Participant 21 did not learn an instrument or seek out much music when younger, but made use of a radio in his room, leaving “it on all day.”Interestingly, participants’ past music experiences did not seem to relate to their current music experience or interest in music. People distinguished their past music experiences from their present “relationship” with music; and the evidence shows a variety of patterns for changes in these relationships throughout life. For instance, the two participants with arguably the most musical experience throughout their life presented contrasting levels of engagement and interest at the time of the interview. The life-long singer (P03) continued to seek out musical activities, and, while he recognized he was “Three sub-themes arose with regard to the participant’s current music listening experiences: people’s practices, preferences, and the perceived outcomes.a bit of light, soft music, yeah. I just leave it on all day”). Participant 32 listened “most days,” drawing on her cassette tape collection, while participant 01 estimated he listened to the radio 2–3 h per week. In contrast, Participant 17 listened “now and again.” Participants drew on a range of formats and devices to listen to music – the radio, stereo, cassettes, CDs, DVDs, the TV, and tablets were all used (and often on display in people’s rooms). Fifty-six percent of the sample had some sort of listening technology in their room. Additionally, some participants (38%) mentioned facility lifestyle activities  as ways they listened to music while living in residential aged-care.A number of participants did listen to music in their everyday lives (44% of the sample), though these individuals spent different amounts of time listening. For instance, Participant 21 used a stereo (radio) in the room daily, listening to a radio station that plays light classical music  by others in the facility.Other participants acknowledged they did hear some music in their daily lives, although it was not necessarily sought after. For instance, Participant 30 stated “never been a great radio listener”). For others, it was not something they disliked, rather something that it simply was not prioritized .Of course, although music listening is a common leisure pursuit, not everyone is interested. This lack of interest was present in some of the participants in the present sample, as a few participants stated that they did not have an interest in listening to music in their daily life. For some this was in line with a longer-standing relationship with music . For many, this included musicals  and operettas  and “all the popstars” (P25), such as Frank Sinatra, Doris Day, Elvis and others from the movies and “the great musical comedies like Annie Get Your Gun and My Fair Lady” (P02).Participants’ mainly conveyed their listening preferences via broad genres and particular artists. While there was individual variation in the type and range of music enjoyed, most participants favored classical and popular music. Classical composers referenced included Mozart, Beethoven, Vivaldi, Bach; mentioned performers included the Three Tenors and André Rieu ; and some clarified their classical music interest in terms of instruments  or radio station . Most participants enjoyed popular music from earlier in their lives . Some also expressed enjoying dance band and jazz music , which often was associated with previous social dance experiences. Lastly, music is – it’s like a medicine.” However, not every participant spoke with such clarity. For instance, after Participant 06 stated that she loves music, she was asked what it is she likes about it and replied “I enjoy it” without further explanation. Similarly, to the same sort of follow-up question, Participant 12 replied “I can’t tell you. I just like it.”In some  interviews, natural discussion arose relating to the perceived outcomes or benefits of listening to music in everyday life. Participants referenced outcomes including entertainment, enjoyment, and relaxation, as well as benefits including mood regulation and aiding worship. The highly engaged life-long singer (P03) was aware of the well-being benefits of engaging with music: he declared that “lay back time” on most days, stating that the music relaxes her. Thus, in addition to enjoying the music listening or fighting boredom, this participant actively used music for relaxation. Music was also to assist some in falling asleep (P10).The participant who made use of her cassette tape collection to listen to music in her room (P32) explained that she has “cheer [her]self up with something” and Participant 25 referenced times when she would turn to music to let go of frustrations. Additionally, with a radio in her room set to a local Greek station, Participant 22 was able to listen to music and virtually attend church services in her native language.As in previous research, participants also used music listening to regulate mood. Participant 23 stated she would “A number of barriers to regularly listening to music in residential aged-care were identified in the interview conversations. The barriers mentioned pertained to access and opportunities (further divided into five sub-themes), facility noise, and facility activities (further divided into two sub-themes).The primary barrier to listening to music in aged-care concerned access and opportunities. This is evident from the data with regard to the fact that not everyone had technologies that would facilitate music listening and that, for those who did, access to technologies and recorded music collections did not align to their usage. Related issues concerned self-efficacy with listening technologies, physical limitations, and competition for engagement by the TV.room doesn’t have the ability to play music.” While debatable, such a seemingly simple declaration has nuance, when interpreted relative to other facility residents’ experiences. It illuminates differences in opportunities that can arise depending on residents outfit their individual spaces. While it is, of course, possible to play music in residents’ rooms, that action depends on having the technology. For some residents, securing such technology is not easy. For instance, participant 04 stated, “I’ve often thought I should buy myself a radio because of music, but I haven’t got around to doing it because I can’t get out. So …someone’s got to buy it for me.” While family could assist in the acquisition of listening technology (P03: “I’m trying to organize my son to get me a record player”), family members can also take it away: Participant 24 did not listen to the radio because her daughter took it in an effort to decrease “clutter” .For some residents, one barrier was the absence of (compatible) listening technologies. When asked, Participant 20 stated that her “Further, any technology must also be facility-compatible. Participant 25 recounted that, “when I came in, John went out and bought me a digital radio and it wouldn’t work and he got the maintenance man to come and have a look. He said, “is that digital?” Jack said “yes,” he said, “it won’t work here.” Jack said, “why ever not”? He said because of all the electronics. He said “there’s no room for digital.” He said “you’ll have to do something with it and … go and get another one because this one won’t work.””we’ve got all those CDs and there’s records down below. There’s tapes over here which we used to listen to much more before we came here.” She goes on to acknowledge she and her husband sometimes thought about engaging with their listening collection , but that their lifestyle had changed, shifting leisure pursuits.However, the data does not suggest that the presence of opportunity is enough. Just as previous experience or interest in music did not necessarily result in present listening, the presence of listening technologies and recorded music collections did not necessarily result in the usage of said technology or collections. Many of the participants had listening devices  and collections  in their rooms. Yet, even the collections visibly on display were not indicative of regularly daily listening. Participant 02 remarked, “I’m not very good at these sort of things.” Participant 23 also had a tablet, and similarly stated she had “to keep getting somebody in to help.” References to a lack of confidence more often concerned the use of digital devices, though self-efficacy concerns were raised with other media as well. For instance, Participant 03 listened to the news on his radio, but did not use the radio for music because he did not know how .For some participants, use of their listening devices depended on their level self-efficacy . In particular, using tablets (often provided by family members) presented challenges. For instance, Participant 30’s daughter set up a tablet with Spotify for her, but she stated that she did not use it, saying “I never – I haven’t watched any of this since I’ve been in here, because I can’t get to the machine. That’s the trouble. Same with the tapes I’ve got. …I really love music. It’s just a pity that I can’t get to them.”Other participants faced physical limitations with regard to engaging in music. A lack of physical mobility and dexterity prevented individuals from listening, even when the desire was present. For instance, Participant 09 had a collection of tapes, CDs, and DVDs in her room but did not use them: “It is also worth noting that such physical limitations also present barriers to participating in musical activities supported by the care facility.When there’s a choir coming here, I attend, and if I know the songs, I try to sing with them. But because my eyes are no good, I can’t read the words, it makes it difficult”P03: “I’m lucky I can talk. But I can’t sing anymore. But I take …a tambourine and I do percussion now [at the sing-along sessions].”P05 had an accident, altering her ability to engage with music: “I moved to Melbourne and came into this place, and of course they’ve had times when they needed a pianist but they haven’t had one. But it’s terribly hard to hear a need and then not be able to.”P08 desired to play the piano in the facility lounge, and found it hard because of her memory problems: “Such examples reveal how, for some people, physical limitations will overshadow an interest in music. In other words, declining mental and physical health pose real challenges for older adults living in residential aged-care to engage in music activities.I’ve got a radio there, my son fixed it up. I do, but I tend to watch the television more”). Most of the participants expressed a greater use of the TV in daily life . Interestingly, only one participant (P16) mentioned that they could access music on the TV – for the others, this did not seem to cross their mind. For instance, Participant 04 had Foxtel (a cable provider), but when asked about using the cable TV to listen to music via the dedicated channels, he had not considered it . The TV may offer untapped opportunities for music listening as the use of it as a tool is highly familiar to all participants, even though its technological potential is not fully understood or explored.A final barrier concerns the consideration of listening to music relative to watching TV. Even for many of the participants who had listening technologies in their rooms, the TV appeared to be more engaging .Yet, two barriers concerning the facility offerings were identified: resident awareness and preference. Notably, the participants’ level of awareness of music-related activities greatly varied. When asked if she attended concerts, Participant 17 said, “The present study explored older adults’ experiences of music listening in their daily lives while living in residential aged-care. Results of a thematic analysis of the semi-structured interview data highlight a difference between people’s previous musical experiences and interest with present music listening practices and a number of barriers to everyday listening. While the majority of participants may not have actively created daily music listening opportunities for themselves, they largely enjoyed the listening experiences they did encounter. Although previous work on listening technologies has indicated that listener choice and control is associated with positive outcomes e.g., , 2015, icurrent engagement with music. The perceived outcomes, or benefits, of listening to music that the participants mentioned indicate that, for some older adults, engaging with music is linked to these senses of vitality, belonging, and meaning. For instance, the highly engaged life-long singer’s (P03) identity was tied to his musical engagement, having participated in choirs throughout his life. While he stated he was “not as active as [he] used to be in music” at the time of the interview, he attended all of the facility’s sing-alongs and performances, suggesting he continues to support his identity and derive coherence and meaning via his continued musical engagement. Additionally, one interpretation of using music listening to promote relaxation, mood regulation, and sleep is that this particular use of music promotes vitality through promoting physical and emotional well-being. Further, there was evidence that listening to music was associated with the sense of belonging; for instance, one participant made use of a local community language radio station in order to continue participating in her Greek community.Thus, the resulting themes and sub-themes concerning older adults’ everyday listening practices can be considered relative to access does not equal agency. As demonstrated, some individuals may need support – for instance to overcome physical limitations, bolster self-esteem, or a reminder of what is possible. As most of the sample enjoyed music listening and experienced known well-being benefits, the consideration of how to support listening for older adults living in aged-care is a worthwhile endeavor.With regard to agency, however, as the results indicate, previous musical experiences and engagement (both making and listening) do not necessarily translate into current, active listening practices. It appears that access is not enough to spur usage; rather, listening to music can be perceived as an effortful activity. Indeed, the identified barriers overshadow many older adults’ interest in and desire to include more music listening in their daily lives. In the context of Importantly, well-being and quality of life are not fixed. As 1, meeting the three innate needs of competence, relatedness, and autonomy leads to personal growth, vitality, and well-being  listening technologies to the needs for autonomy and competence. Indeed, the noted barriers in the present study suggest that some older adults may need personalized support to bolster their everyday engagement with music. Technological support to available listening technologies could assist older adults’ with self-efficacy, and, thus, also expand their competence. Such support could be an assistant who works with the residents in learning to use listening technologies and/or modifications to the technologies employed. Handheld digital devices  can offer personalized selections and overcome the physical challenges associated with using physical media; however, the participants’ comments regarding self-efficacy suggest a switch to newer technology may not suit everyone. Facility-compliant radios were popular and easy to use. Additionally, the TV  should be considered as an alternative listening device that could increase daily listening. By offering the potential for both aural and visual stimulation, the use of TV raises interesting questions: it is prudent for future work to consider the potential importance of the visual component when designing engaging music listening opportunities in residential aged-care. TVs and other devices with touch screens  may offer older adults opportunities for engaging in audiovisual activities, while at the same time promoting technology skills.Aged-care staff may also consider the variety of (recorded and live) music on offer . Providing residents with agency in choosing the music through consultation will promote autonomy. Such consultation could mean that residents’ who lack in competence could still feel a sense of agency and autonomy. Staff could make use of people’s varied past experiences and interests as a catalyst for planning purposes . Moreover, drawing on residents’ personal histories and interests as well as including them in decisions will promote feelings of relatedness. It is important to note, however, that listening to self-selected music still has the potential for adverse reactions: for instance, given music can promote reminiscence, it can trigger distressing memories . Thus, iOne strength of music listening is that it is a versatile activity: it can be private or shared and can happen at most times in most places. Indeed, even if someone is listening alone, music can promote feelings of belonging and community e.g., . HoweverThe present research is not without its limitations. Firstly, it draws on qualitative data from the focal questions from interviews with 32 individuals. Although the theme concerning the barriers to listening arose without direct prompt, the other themes speak to key questions such that other experiences may not have been explored in depth . Moreover, the participants resided in just two aged-care facilities. Aged-care facilities differ in terms of their chosen care model and lifestyle activities on offer. Individuals’ music experiences and interests will vary, as will their physical and mental health care needs and existing social support structures. Drawing on the present findings, future research might overtly examine such related variables, drawing on quantitative measures as well as methodologies that utilize real-time data collection  to further our understanding of everyday listening experiences in residential aged care. Future research aimed at developing strategies to promote and facilitate music listening should take into account physical and mental health as well as the existing social support structures. Additionally, participants had resided in the facilities for varying lengths of time, and it is possible that this influences people’s daily practices, care experiences, and motivations. For instance, research suggests that transitions are often difficult for residents e.g., , so futuWhile the findings demonstrate that a range of technology is currently used to listen to music, more and more people entering residential aged-care in the future will have higher fluency and self-efficacy with using digital technology. This will likely shift the use, and role, of personal technology devices, including those used to listen to music. Given the rise in people using digital devices and listening to personalized playlists , more anIn summary, the present study examined the nature of everyday listening practices of older Australians living in residential aged-care facilities. Although the findings identified some barriers aged-care residents face to listening to music, residents largely enjoy listening to music and listening experiences offered opportunities for entertainment, relaxation, and interaction with others. When considering that music listening can support well-being, the findings have broad implications regarding how aged-care facilities might encourage and support residents to meaningfully engage with music in order to promote well-being.amanda.krause1@jcu.edu.au.The datasets presented in this article are not readily available because of the ethics conditions. Requests to access the datasets should be directed to AK, The study involving human participants was reviewed and approved by The University of Melbourne – Human Ethics Committee (Ethics ID: 1851094.2). The participants provided their written informed consent to participate in this study.AK obtained funding and ethics approval for the research, conducted the data analysis, which was then reviewed with JD, and wrote the initial version of the manuscript with JD offering later input. Both authors carried out the facility visits and interviews. Both 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.


Each approach has advantages and disadvantages.Mental health literacy (MHL) is key for mental health development, particularly in low-and-middle-income countries (LMIC) where mental health resources are limited. MHL development can be thought of as occurring at two levels: the The present mixed methods study assessed the status of and best approaches for development of mental health literacy in the Southeast Asian LMIC Vietnam. Because there has been relatively little discussion of MHL development at the public health level, this assessment focused on the public health level, although not exclusively. Because mental health professionals generally have the most in-depth understanding of their mental health system, study participants were 82 Vietnamese mental health professionals who completed a quantitative survey, with 48 participating in focus groups.Most of the professionals viewed MHL in Vietnam as low or very low, and that it was difficult or very difficult for the general public to find effective mental health services. Main barriers underlying these problems and more generally for developing MHL in Vietnam identified in the focus groups were: (a) misinformation in the media regarding mental health and mental illness; (b) lack of licensure for non-medical mental health professionals ; (c) lack of interest in mental health from upper-level leadership.To the best of our knowledge, this is the first study assessing professionals’ perceptions regarding mental health literacy at both the public health and individual-person levels. Although sampling was restricted to Vietnamese professionals, results may provide initial preliminary guidance for other LMIC considering mental health literacy development at multiple levels. The term “mental health literacy” was defined by Jorm  as knowlindividual person level, which involves development of mental health literacy through (a1) direct contact with (a2) specifically targeted persons. This includes, for instance, mental health literacy programs provided in specific schools for specific identified staff and/or students. For example, Kutcher, Wei [African Guide. Conversely, the second level at which mental health literacy development can occur is the public health level, which is broader and involves (b1) non-direct contact  targeting (b2) the general public rather than specific individuals, via public health campaigns. The Australian “beyondblue” national depression program, for instance, involved a variety of community awareness campaigns  intended to increase the general public’s mental health literacy regarding depression.Mental health literacy development can be thought of as operating at two levels. The first level is the her, Wei  providedeffective, as not all mental health-related programs are effective. In high-income countries (HIC) such as the United States, the United Kingdom, etc., there typically are a number of factors supporting access to effective (vs. non-effective) treatments and providers [Help-seeking behavior as part of mental health literacy extends beyond help-seeking per se. Rather, it involves the ability to find mental health services and providers that are likely to be roviders , 6. For roviders , 6.In many low- and middle-income countries, in contrast, these structures are not yet in-place or are not consistently enforced , 8. In Vindividual person level. Relative to the public health level, mental health literacy training such as this at the individual person level has a number of advantages. First and foremost, there is extended direct contact between the individual and the trainer, where detailed information can be provided with questions and uncertainties answered, in the context of a trusting professional relationship. Such an approach thus can overcome many of the challenges inherent in finding appropriate mental health services in countries like Vietnam.Mental health literacy training can increase individuals’ effective mental health help-seeking, including in LMIC such as Vietnam. For instance, a recent study  conductepublic health level is necessary. One potential challenge to developing mental health literacy at the public health level is the lack of accuracy of much of the publicly available mental health information. This issue of course is not restricted to LMIC but also occurs in HIC with, for instance, the anti-science movement in North America and Europe [www.Cochrane.org), but how to convince the general public regarding the value of such information is unclear: Anyone can assert a scientific basis for their claims regardless of the actual scientific evidence as with, for instance, the anti-vaccine movement in the West [One limitation for programs such as this is, however, that the proportion of the population that they reach is small  and generally constrained to relatively easy to access groups . To achieve improved population-level mental health literacy and appropriate help-seeking, mental health literacy development at the d Europe , and thed Europe  claimed the West . In HIC the West .Thus, because professionals will be a center of change and provide solutions to develop mental health literacy at the public health level, understanding professionals’ perspective on these issues is a critical component to mental health literacy development. Given that a central goal of the study was to provide guidance on how mental health literacy can best be developed at the public health level, the study focused on the perceptions of mental health professionals who, as noted above, are most connected to the health care system and understand its potential to promote mental health literacy. Therefore, the specific aims this study were (a) to quantitively examine Vietnamese professionals’ perceptions of (a1) the current status of mental health literacy and mental health services in Vietnam and (a2) their evaluations of perceived barriers and possible solutions for public information seeking of effective mental health support; and (b) to qualitatively explore in more depth their perceptions of these issues. Given the value but particular challenges of mental health literacy development at the public health level, these discussions focused on the public health level.A mixed methods design was used that included a questionnaire survey as well as four focus groups conducted in Hanoi, Vietnam. The mixed methods approach allowed for extension of the quantitative results by the qualitative data . The quath International Conference on Child Mental Health in Hanoi, Vietnam, in October 2019. During one section of the meeting, participants were invited to participate in a session on mental health literacy or a session on developmental disabilities, allowing participants to self-select for interest and background in mental health literacy. Participants selecting the former session were introduced to the study and those interested reviewed and signed the consent form. Participants could decide to take part in either or both sections  of the study. Of the 85 Vietnamese professionals participating in this portion of the conference, 82  completed the quantitative survey; 39% were practicing psychologists, 23% mental health researchers, 17% school counselors, and 11% medical staff (MD or nurses), with a median of nine years working in their field. Forty-eight of these individuals choose to participate in the focus groups, which lasted slightly more than one hour.The goal of the sampling frame was to identify mental health and education professionals with interest and understanding of mental health literacy and the challenges of mental health literacy development at public health level. That is, the goal of the sampling frame was not to obtain a random sample of the general population nor a random sample of mental health professionals, but rather to obtain a sample of mental health professionals actively involved in the professional community and interested in mental health literacy, thus most likely to have an understanding of mental health literacy in Vietnam. Consequently, the study design was structured to recruit participants at the 5The survey assessed basic demographic information, with the primary questions covering four areas, assessing participants’ perceptions regarding the current status in Vietnam of the: (a) availability of effective mental health services; (b) public’s level of mental health literacy, and the difficulty of increasing mental health literacy at the public health vs. individual levels; (c) barriers for the general public finding accurate information about mental health; and the (d) feasibility and effectiveness of different solutions at the individual and public health levels to improve the accuracy and utility of public mental health information   introduction to the concept of mental health literacy at the public health level. The focus group moderator’s guide contained four questions, all focused on Vietnam. The focus group questions focused on the public health level, given the value but particular challenges of mental health literacy development at that level: (a) how serious of a challenge development of mental health literacy is at the public health level; (b) what kinds of challenges focus group participants had encountered in their professional work related to providing mental health-related services; (c) what kinds of challenges focus group participants had experienced trying to support development of mental health literacy at the public health level; and (d) how Vietnam can best address these challenges, to increase access to evidence-based mental health treatments , it was difficult or very difficult for lay people to find effective mental health programs in Vietnam. The qualitative data provided a more in-depth picture, with QDA Miner identifying one theme in this area, a scarcity of such effective services in Vietnam in conjunction with difficulty in finding the few available quality services. One focus group participant commented, for instance “The national television channel VTV (Vietnam Television) has provided inaccurate information about autism, that makes the public think that every mental health problem is autism”; “On the television, journalists have said depression and stress cause schizophrenia”. The second subtheme was related to the stigma-inducing effects of this misleading information. One participant commented “A newspaper article reported that a man was attacked and killed ‘by a person with mental illness’, without saying what the ‘mental illness’ was. This kind of report creates misunderstandings about mental health problems, that mental illness in general is connected to violence and danger”. Another participant commented that ““VTV interviewed people about mental health. These people were celebrities, not experts in mental health. The information they communicated was incorrect and highly stigmatizing. For example, a famous singer said on TV that children will develop ‘mental’ problems such as depression or autism if the children watch too much TV”. A third subtheme about misleading information in mass media was in regards to conflicting information provided by different media sources, making it difficult for the public to know the actual state of affairs. For instance, one participant said that “Two newspapers reported on the same child mental health conference. One newspaper stated that 20% of Vietnamese children in general had experienced mental illness (which was an accurate summary of the findings), whereas a different newspaper indicated that 20% of Vietnamese students in schools had mental illness, implying that academic pressure, etc. was at least in part responsible for this relatively high rate of mental health problems. So it can hard for people to develop an accurate understanding” The final sub-theme involved misleading mental health postings with a hidden commercial purpose . One participant commented, for instance “Businesses make money from mental illness by posting misleading information on their websites, related to their products or services”.Focus groups participants were asked about the mental health literacy-related challenges that they encounter in their mental health-related work. Four domains of challenges were raised by the participants see . A high “People have no trust in scientific psychotherapy or psychologists. If they have problems, they will look for help from traditional healers, fortune tellers, or untrained religious providers, or anyone who is known to their family or friends as a “good advisor”. Other comments in this area focused on the public’s preference for specific non-evidence based treatments, with a participant stating “Many parents of children with autism trust hyperbaric oxygen treatment, or things such as ‘field trip therapy’ provided by special education teachers. Given their preference for such treatments with wildly exaggerated effectiveness claims, it is very difficult to help parents develop understanding and trust in evidence-based treatment such as ABA with more reasonable claims”.The two other major challenges participants raised were (a) the public’s lack of trust and hence valuing of evidence-based mental health treatments, and (b) Vietnamese culture’s valuing not talking about personal problems involving emotions or relationships. The former challenge was reflected in comments such as Vietnamese culture says you do not talk about your personal problems, your inner-self, with anyone, which makes coping with and treating these problems quite difficult”. Another participant stated “There are Vietnamese proverbs, such as ‘if there is a problem, the family should close the door and teach each other’, or ‘Do not wash your dirty linen in public’. Beliefs such as this make people not want to seek professional help for their problems even when it is necessary”.In regards to the latter challenge, one participant commented that ““Many Vietnamese people do not even know what mental health is, how important it is, how it affects our lives, even staff and educators at schools don’t know”; “I work in the hospital and most of the medical doctors do not have good understanding or knowledge of mental health”; “Vietnamese people are unconcerned about mental health. They only care about academic achievement or being well behaved in public”. These issues were seen as particularly relevant in rural areas, exemplified with comments such as “Vietnamese people in general have limited or no understanding about mental health, but this is particularly true in rural areas”. Three sub-themes related to mental health stigma were identified in the qualitative analyses. The first involved the fact that the formal Vietnamese word for “mental health” (sức khỏe tâm thần) itself is a stigmatized term, somewhat akin to “crazy” or “insane” in English. Participants’ comments in this area included “The Vietnamese term for ‘mental health’ is primarily associated only with the most severe psychiatric disorders such as schizophrenia, and carries with it a negative connotation close to ‘madness’ or ‘crazy’ in English”; or “The public has a negative stereotyped attitude towards anything related to the word ‘mental health’, even intervention programs, or TV or talk shows having the word ‘mental health’ in their title” The second sub-theme involved public stigma towards individuals with mental health problems. Comments included “Mental illness is generally seen as an individual’s own fault, due to personal weakness, or life style choices. So individuals with mental health problems experience significant discrimination”; “The Vietnamese public are over-anxious about and over-reactive towards people with mental health problems; for instance, if a student says she is depressed, her school will isolate her and require a forensic psychiatric evaluation” (to determine whether it is safe for other students to be around her). The third area identified was self-stigma, with comments such as “If someone experiences mental health problems, they feel guilty and ashamed about their illness, and do not want to talk about their experience with their family, relatives, or anyone”.More than three-quarters (77%) of the professionals in the survey reported that the level of mental health literacy among Vietnamese was low or very low, with a mean rating of 2.2 (SD = 0.48) on a 1 (very low) to 5 (very high) Likert scale. Themes raised within the focus groups on this topic centered around the Vietnamese public’s lack of knowledge, understanding and concern, and high stigma towards mental health problems . Specifi“Mental health literacy at the public level is difficult, because people and even agencies simply do not care about mental health, and are not interested in investing in public mental health campaigns”; “Public mental health campaigns are difficult because the Vietnamese government does not have supporting policy, so we cannot do campaigns due to a lack of money and human resources. In foreign countries such as Australia, there have been effective mental health literacy campaigns funded by the government and implemented by governmental agencies”. The focus groups did, however, identify and emphasize the necessity and advantages of the public health level and challenges associated with the individual level, commenting “Conducting mental health literacy campaigns at the public health level is difficult but necessary, because they can reach large numbers of people” and “If we do want to improve the general level of mental health literacy for Vietnamese people, working with each individual takes so much time and will not influence many people”.In the next survey question, participants were asked about the relative difficulty of improving mental health literacy at the individual vs. public health levels in Vietnam, rated on a scale of 1  to 5 . Participants were equally split across the scale, with a mean of 3.02 (SD = 1.08), and a skewness of 0.01 indicating a highly symmetric distribution around the midpoint of 3. That is, equal numbers of participants saw the public health level and the individual level as more difficult, with one quarter (26%) indicating that they were equally difficult. However, in the focus groups where the issues were discussed (rather than simply rated as in the survey), participants focused more on difficulties at the public health level, such as effects of a lack of interest, policy, and funding on mental health literacy development: The quantitative survey assessed professionals’ evaluation of nine different possible barriers see  to mentaVietnam Television  produces mental health reports or shows without collaboration with any mental health professionals, making it difficult to raise people’s awareness on this issue. Moreover, whether the mass media even publishes reports about mental health depends on the personal interest of the organization leaders.” Another participant commented on the lack of mental health policy and financial resources at the national Ministry of Health, stating “There is no money for public health campaigns on mental health. Mental health simply is not a priority for the Vietnamese government and Ministry of Health. The Ministry of Health does not understand the importance of mental health, and cares only about physical health”. In regards to the lack of control over mental health-related information sources, one participant stated “If you Google mental health in Vietnamese, you will find many websites posting articles on mental health, most of which are without any scientific validity. The quality and sources of the information is totally uncontrolled”. Another comment within this theme was “Information about mental health treatment is not controlled or checked regarding its quality or sources. Anyone can post information about mental health, even highly inaccurate or misleading information. Anyone without training or a degree in psychology can claim online or anywhere that they are psychotherapist, counselor, or psychologist, and even provide treatment for clients”. Finally, regarding the lack of human resources as a barrier to public mental health literacy development, one participant commented, “Human resources in mental health are very limited. Few mental health professionals are competent, and most of the qualified professionals only focus on their clinical work, they’re not interested in public health work”.In the focus groups, the primary barriers to increasing mental health literacy at the public health level that were identified were: (a) a lack of interest and mental health literacy among upper-level health and education administration and leadership, (b) a lack of mental health policy at local, provincial, and national levels, (c) a lack of governmental control over public sources of mental health-related information, (d) a lack of human resources in mental health, (e) scarcity of financial resources for mental health and (f) limited collaboration with media. One participant stated “We must advocate for mental health policies, so that the profession of psychologists is recognized legally, and service quality controlled and assured. Then people will seek mental health information and support from licensed psychologists and authorized agencies”. In regards to the latter sub-theme of explicit and intentional promotion of mental health, one participant stated “Explicit mental health policies are very important. Only when there is clear, intentional policy from the government will the Ministry of Health and other ministries work together to promote mental health literacy through the mass media or other methods”.In the focus groups, participants were invited to suggest public health solutions for increasing mental health literacy . The majwhen we develop mental health campaigns, we should collaborate with journalists and other media experts, and key opinion leaders. The methods of communication should be interesting and varied, with interesting photos and videos. We could for example invite celebrities to share their own experiences with mental health and mental health challenges. We could collaborate and guide them so they would know what was important in regards mental health, what they should focus on”. Another participant suggested “we could collaborate with radio, and do soap operas of stories about kids going through puberty and adolescence to show how normative challenges relate to mental health. People could also send in questions or suggestions for the next soap opera episode. And we could use a podcast approach as well. This could impact on public mental health literacy”.Comments within the second theme (b) “collaboration with media” focused on different approaches for effective collaboration. One participant suggested “a program to train traditional healers in basic mental health literacy, assessment and intervention could be very useful”; and “district health stations could do community education programs for the neighborhood on different mental health topics, for example, one on depression, one on stress”. The second sub-theme focused on programs that were related to mental health but were not necessarily formal mental health programs, such as “life skill programs for children”, “emotional regulation programs”, “how to balance your personal life and job”, and “anger management programs for children and young adults”. In regards to the third sub-theme, school-based programs, one participant suggested “We should start with mental health psycho-education programs for everyone in the schools: administrators, staff, teachers, students, parents, everyone”.Regarding the third theme (c) “development of effective mental health programs”, three sub-themes were identified: (c1) the importance of task-shifting and community mental health programs; (c2) the value mental health-related programs, and (c3) school-based mental health programs. In regards to the first sub-theme, participants suggested ““Governmental agencies such as the National Institute of Mental Health and psychiatric hospitals and NGO in Vietnam such as WHO or UNICEF should have brochures and websites providing accurate information on mental health that could be trusted”; and “People trust governmental organizations and universities more than random websites”. Regarding the fifth theme (e) “Networking across professionals from different sectors, including beyond health and education ”, one participant suggested “In order to effectively promote public mental health literacy, we must network across mental health professionals, educators, journalists and media experts, even social enterprise agencies that make a profit but share some back to society”. Comments regarding the sixth theme (f) “Development of Vietnam database(s) on effective mental health services and service coordination” included “There should be a general public dataset with scientifically-based information regarding mental health problems and treatment, and listing of psychologists, psychiatrists and other providers. This database should be easily accessible and organized by geographical area, mental health problem type, etc.”; “We need to develop information systems for mental health professionals and institutions, covering providers, hospitals, social organizations, and other relevant areas, to increase cross-discipline collaboration”. Finally, in regards to the seventh (g) theme, “Increasing the mental health literacy of political, medical, educational, and media leaders”, participants stated: “The solution for public mental health literacy development is to first increase the mental health literacy of the leaders. For example, school principals, directors of provincial Departments of Education, or media agencies should be helped to become more aware of the importance of mental health. They then will be likely to support implementation of mental health programs in their organizations”; “Even in general hospitals , leaders need a good understanding of mental health, so that they can facilitate mental health-related services. At psychiatric hospitals, we need to work with hospital directors to increase their understanding of the importance of public mental health literacy, and collaboration on community programs and campaigns. At present, most psychiatric hospitals focus only on direct within-site services”.Regarding the fourth theme (d) “Information on mental health should be organized by governmental or authorized agencies”, participants suggested The first question upon this study focused was Vietnamese mental health and education professionals’ perceptions regarding the current status of mental health services and mental health literacy in Vietnam. There have been a number of similar studies investigating these topics focused on LMIC, including Vietnam –19. The A number of our findings are consistent with previous reports regarding mental health infrastructure in Vietnam. Niemi, Thanh , for insOther of our findings, however, are new. Perhaps most importantly, concerns about a lack of accuracy and quality of publicly-available mental health information in Vietnam were a central concern raised by the professionals in our study. They reported, for instance, that a significant portion of the information in the popular media regarding mental health is misleading, including (a) what mental health problems and their symptoms are ; (b) conflicting mental health information across different sources; (c) deceptive information, with a lack of acknowledgment of conflict-of-interest issues ; and (d) several other issues, as discussed in the Results section. The professionals saw these problems as key factors underlying low public mental health literacy and high public mental health stigma, with the low mental health literacy of political leaders linked to a lack of necessary governmental support for mental health. These perceptions and their implications highlight why assessment of professionals’ perceptions is critical for mental health literacy development at the public health level: Given their knowledge, understanding, and expertise, they can identify fundamental causes  underlying low mental health literacy among the general public, and suggest solutions (as below) for these challenges.In previous decades, research in HIC has found that the media  is one of the, if not the, most important sources of information for the public regarding mental health and mental illness , 25. PriMental Health Policy and Service Guidance Package [Mental Health Global Action Plan for 2013–2020 [Related to the issue of misinformation in the media, the professionals recommended public as well as professional information systems be developed and enhanced. These suggestions included: (a) a lay public-oriented online database, similar to the Cochrane database, with scientifically-based mental health information but also with a listing of providers evaluated regarding the extent to which they follow a scientific approach; and (b) a parallel database for mental health professionals and institutions regarding current EBT status for mental health assessment and treatment approaches, to enable informed decision-making within the mental health system. This latter recommendation parallels that of the WHO in its  Package  and Ment013–2020  recommen013–2020 .Another critical barrier identified by the professionals to public access to EBT treatments was a lack of governmental licensure of non-medical mental health professionals, including psychologists. Vietnam is one of the few countries in Asia that does not license or regulate the practice of psychologists and similar mental health professionals , 32, 33.Finally, contrary to expectations, participants believed that improving mental health literacy at the individual and at the public health levels in Vietnam both would be challenging, of approximate equal difficulty. Ultimately, mental health literacy development at either level has the same goal: increasing people’s mental health literacy. The two approaches differ in their mechanisms but not in this goal. Together this suggests that a detailed analysis of mechanisms  will be important. Such analysis should help to increase the effectiveness and efficiency of mental health literacy development efforts.The present study has several limitations that should be considered in interpreting our findings. First, a sample of mental health and education professionals attending one child mental health conference in Vietnam was used, potentially limiting generalizability. However, this sampling has the strength that the participating professionals were specifically interested in mental health literacy in Vietnam, and thus were likely knowledgeable with potential influence in this area. Although generalizability to other LMIC in the region is unclear, the results may at least provide a starting point for consideration of these issues in similar countries. Second, a related issue is that the professionals were attending a conference on child mental health, and thus may have been most knowledgeable about child mental health. It is worth noting in this regard, however, that none of the points raised or focus group comments had any direct connection to child (vs. adult) mental health literacy development. Finally, a third limitation was that the challenges to public mental health literacy development identified  were the participants’ perceptions, and not confirmed with objective assessments. However, although the assessment did not directly assess the objective reality of the situation, it did assess the perceptions of key stakeholders, who will be central in moving the field forward. Despite these two limitations, this study highlights the importance of professionals’ perceptions and key barriers to the development of public mental health literacy. Given the centrality of such professionals’ involvement in public mental health literacy, understanding the barriers they see is critical.S1 Appendix(DOCX)Click here for additional data file.S2 Appendix(DOCX)Click here for additional data file.


In a assay published in Nature, Valentin Amrhein (University of Basel) and its colleagues Sander Greenland  & Blake McShane (Northwestern University), present a series of arguments against the stablished “P value-based statistical significance dichotomania”.Importantly, the essay clearly states that the authors are not advocating a ban on P values or statistical measures, but that P values should not be treated categorically or to support dichotomization as statistically significant or not. Similarly, a 2016′ statement of the American Statistical AssociationWhile such discussion is at least provoking and mind challenging, this Editorial goal is to take advantage of the “statistical dogma” questioning to draw some attention to steps that precede the statistical analysis and the generation of a given P value. Indeed, a proper study design can even improve the statistical findings power in a measurable way, but also several aspects of study design and the subsequent data analysis may have a significant , but not statistically quantifiable, impact in the data “significance”. The big mistake would be the overvaluation of statistical analysis methods with the undervaluation of experimental design. In the sequence, some practical examples (derived from our research group data) will be used to illustrate how study design can increase the both “statistical significance” and “biological significance”.Genetic studies are usually based in a classic control approach, were controls and subjects presenting a given condition are compared in regards of the occurrence and frequency of genetic variants. In this context, the P value derived from the unaffected and affected individuals' comparison is essential to draw any conclusion. In such studies, the number of individual in such groups, but also the frequency of the target genetic variation, the frequency of the studied condition, impact the study power and the determination of the P value, and evidently, the conclusions derived from such data. However, experimental design features, apparently incomputable in the study power determination, can also present a significant impact in the analysis outcome. Thus, in this situation, stratified sampling considering these possible confounding factors could balance the study groups and minimize the effect of external variables on the final data analysis.In the periodontal genetic studies, generally affected individuals (presenting some form of periodontitis) are compared with periodontally healthy subjects.In other words, the absence of an archetypical control with a defined resistance phenotype may limit the odds of the identification of genotypic differences when compared with a susceptible group. In order to adapt the study design to the exposure concept, in periodontitis genetic studies the control group should comprise a microbially exposed group with a distinct phenotypic outcome than chronic periodontitis.Phenotypic variation can also be a supporting factor for data analysis and interpretation in order to determine the possible involvement of a given factor in a pathological process. Still in periodontitis context, molecules that control osteoclastogenesis process have been regarded as potential determinants of disease onset, progression and severity. In this framework, the osteoclastogenic factor RANKL and its endogenous inhibitor OPG, have been in the focus of numerous studies in the field over the last years.A healthy tissue represents homeostasis and a diseased tissue represents pathology. However, both allegedly destructive (RANKL) and protective (OPG) factors are upregulated in diseased tissues, similarly to numerous inflammatory and also anti-inflammatory mediators.vs chronic comparison. Importantly, the comparison on distinct disease forms points to a differential balance in the levels of pro- vs anti-osteoclastogenic and pro- vs anti-inflammatory mediators as determinants of disease outcome. However, the determination of the “tipping point” that separates homeostasis from pathology may require additional approaches, which will be explored further below.In this scenario, the use of additional distinct and phenotypes can allow additional data analysis and provide some insightful information about how host inflammatory immune response mediators can impact periodontitis outcome. One possible approach is to compare periodontitis variants, such as aggressive and chronic, each one characterized by its unique features, such as early vs late onset and different progression rates.One may argue that phenotypic variation may not be necessary, since it would be possible to perform some severity disease stratification within an individual disease form, based in clinical readouts such as bleeding on probing, probing depth and attachment loss. However, it is mandatory to consider the intrinsic limitations imposed by periodontitis features, which include the cumulative nature of disease severity, and the uncertainness about disease progression patterns, impose critical limitations to data interpretation.Therefore, the comparison of periodontitis-derived data with other conditions can also support better interpretation of RANKL/OPG ratio association with active or inactive bone resorption. While the definition of active bone resorption is complex in periodontitis, in orthodontic tooth movement such patterns are more straightforwardly distinguishable.vs diseased tissues comparison), are presented in inflamed and diseased periodontal sites? However, such study also demonstrates that SOCS levels are higher in chronic gingivitis than in chronic periodontitis, which provides some interesting additional biological clue, but such association present a “less significative” P value (P<0.05) than the healthy vs diseased approach.vs diseased” analysis (P<0.001) is higher than in the “phenotypic variation” comparison (P<0.05), the second comparison may be biologically “more significant” or more relevant for data interpretation.In an additional example on how the use of distinct phenotypes can provide “biological significance” that can overcome “statistical significance” in providing data interpretation support, let's consider that a family of molecules, collectively called SOCS. SOCS are intracellular proteins that acts as suppressors of inflammatory cytokine signaling, and therefore, are putatively involved in the control of inflammatory response in periodontitis, which ultimately interfere in the RANKL/OPG ratio modulation and in the disease outcome.vs diseased” analysis. Please remember that diseased periodontal tissues are characterized by high levels of theoretically destructive elements, such as osteoclastogenic factors (including RANKL) and pro-inflammatory molecules, but also for high levels of supposedly protective elements, such as OPG and anti-inflammatory molecules (such as IL-10), when compared to healthy tissues. Since a high variation in the levels of such molecules is present between health and disease conditions, correlation analysis including samples from both groups presents a high trend to biased “false correlations”.vs diseased” correlation analysis can result in positive correlations between IL-10 and OPG, but also between IL-10 and RANKL, with “very significative R and P values” (unpublished data). When such correlation is performed observing the “phenotypic variation”, or performed only with a single disease from samples, the positive correlation between IL-10 and OPG is sustained, but with “less significative R and P values”. Additionally, such analysis also reveals that IL-10 and RANKL are non-correlated, being RANKL levels actually correlated with pro-inflammatory mediators (unpublished data); being this data in accordance with IL-10 properties previously mentioned.Indeed, the analysis of data generated from “phenotypic variation” other than the simple “healthy vs diseased” dichotomy allows a series of correlation analysis that would result in false positive results in the “healthy Moreover, when biological events are evaluated such as those mentioned above, it may be naive to trust that a single independent variable would be responsible for the outcome response evaluated. Correlation analyzes may present significant p values between OPG/RANKL with IL-10, but most likely are not the only factors influencing the such ratio values. Therefore, any consideration about the subject that is not based on a broader spectrum of possible influencing factors (independent variables) is naturally weakened, even if based on significant p values. Thus, for biological analyzes involving complex mechanisms, multiple regression models  could be extremely useful in assessing the impact of a number of independent variables, such as age, gender, ethnicity, oral hygiene, specific clinical variables, presence or absence (and quantity) of a series of inflammatory mediators and pathogenic microorganisms, genetic variants, among others in the analysis of a simple outcome such as having or not having the disease. However, due to the biological complexity involved in this example, the list of independent variables could be infinite if it had no methodological impact either. For regression models to be robust in data analysis, for each independent variable included in the research, in a very simplistic way, 10 to 15 sample units  should ideally be included in the study. However, in some cases this theory may be beautiful on paper but impossible in practice as it could make a methodologically unviable study due to the large minimum sample size required.Also, it is mandatory to consider that dichotomization or comparisons based in phenotypic data completely differ from dichotomization or stratification based in random scores frequently attribute to the analysis process. Indeed, it is common to receive in JAOS the submission of papers comprising the use of percentage scores, derived from the quantification of cells positively stained for a given target, such as RANKL. In this virtual scenario (roughly based in submitted papers), score zero refers to 0 to 5% of stained cells, score one refers to 5 to 25%, score two to 26 to 50%, and so on. Therefore, a 25% sample and a 26% sample would receive different scores, while 26% and 50% samples would receive the very same score. It seems that it is not necessary to apply complex statistical tools to realize that some qualitative ‘downgrade’ may not be the best option for the subsequent data analysis, especially when the quantitative data is available. This strategy leads to a weakening of the dependent variable and consequently a less robust and accurate data analysis. When the stratification is necessary, and phenotypic data is not available to guide the stratification, the use of tertiles, quartiles, deciles or cluster analysis can be more adequate than the random assignment of samples into scores or subgroups. Indeed, a cluster analysis demonstrated that the clustering of osteolytic periapical lesions was primarily based in RANKL/OPG,Another non-mathematical tool that can be supporting factor for increasing data strength refers to the combination of different approaches in the study design, such as combining clinical and experimental data. Return to the unclear nature of bone activity or inactivity in periodontitis, and the possibility of determine a theoretical threshold value that distinguish presence of absence of active bone resorption based in tension/pressure sides of orthodontic movement. Despite comprising and valid and interesting approach, one may argue that orthodontic tooth movement features may be not applied to periodontal disease. It is possible to argue that such assumptions are purely associative, and are not definitive demonstration of lesions activity/inactivity status. In this context, experimental models appear as a very important experimental tool do provide non-mathematical/non-statistical “biological significance” support to the clinical data. The possibility of performing longitudinal and controlled analysis, and to implement cause-and-effect experiments, with the induction or inhibition of a given factor , can provide definitive demonstration of such factor role in a determined condition.Still in the periodontitis activity/inactivity setting, experimental periodontitis in mice is characterized by sequential stages, where the initial response involves a major influx of inflammatory cells, and rapid and evident bone resorption and a high RANKL/OPG ratio.While experimental data does not provide any kind of additional “statistical significance” to the associative data derived from human studies, including those previously mentioned along this essay, the “biological significance”, despite being numerically unmeasurable, is remarkable. Despite the unprivileged position in the scientific evidence pyramid, the “pre-clinical” research is essential in unraveling mechanistic evidences for biological and pathological processes, and to provide the basis for subsequent clinical interventions.Finally, we reiterate that this piece (similarly to the Amrhein's Nature assay) are not advocating a ban on P values or statistical measures, which remains essential. However, it is crucial to consider that statisticians are not mystical magical creatures and therefore there are no statistical miracles to marvelously overcome poor experimental design.Thus, despite any major change in the way of P values or statistical tests are applied and interpreted, we must consider that the attention to the proper study design may have an immediate and positive influence in the numerically unmeasurable data “biological significance”.