Generalized Anxiety Disorder (GAD) is a prevalent emotional disorder associated with increased dysfunctionality, which has a lasting impact on the individual’s quality of life. Besides medication, Cognitive-Behavioral Therapy (CBT) represents the golden standard psychotherapeutic approach for GAD, integrating multilevel techniques and various delivery formats that enable the development of tailored treatment protocols. The objective of this study was to compare the efficiency of a standard CBT protocol targeting worries, dysfunctional beliefs, and intolerance of uncertainty with an integrative and multimodal CBT intervention augmented with Virtual Reality (VR).Mage = 22.53 years; SD = 2.21) with moderate GAD symptoms that were randomized to the standard CBT group  and the Integrative and Multimodal CBT augmented with VR  group. The interventions comprised 10 weekly sessions conducted by trained CBT therapists, including cognitive restructuring, problem-solving, behavioral exposure, and relaxation techniques. Baseline and post-assessments were conducted with both groups. Primary outcome measures included the Hamilton Anxiety Rating Scale (HARS) and Penn-State Worry Questionnaire (PSWQ) to evaluate the severity of GAD symptoms and worries, respectively. Secondary outcomes involved the administration of Automatic Thoughts Questionnaire (ATQ), Dysfunctional Attitudes Scale (DAS) and Unconditional Self-Acceptance Questionnaire (USAQ).This study included 66 participants (d = 2.76) and worries (Cohen’s d = 1.85), in contrast to IM-VRCBT. Also, secondary analyses revealed positive correlations between changes in anxiety and worries level and the reduction of dysfunctional cognitive processes.Both interventions determined statistically significant effects on both primary and secondary outcomes (ps < 0.001) in the expected direction. However, CBTs was associated with higher effect sizes for anxiety (Cohen’s This research emphasized the effectiveness of CBT interventions for treating adults with moderate GAD symptomatology. Specifically, both interventions were efficient for reducing anxiety symptomatology present at individuals with GAD. However, regarding cognitive dysfunctions like worries, the standard CBT protocol performed better, as compared to the IM-VRCBT. In addition, we conclude that VR could be integrated within CBT interventions in a single protocol for GAD treatment. From the entire group of anxiety disorders included in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), the Generalized Anxiety Disorder (GAD) represents one of the most common affective disorders . The lifFrom the perspective of treatment, many studies showed that, besides medication, Cognitive-Behavioral Therapy (CBT) constitutes one of the most efficient psychological interventions for GAD . In thisThere are many CBT protocols in the treatment of GAD, including diverse strategies with the aim of decreasing the level of anxiety symptoms and associated comorbidities, as well as dysfunctional behaviors . Among tSpecifically, possible advantages of augmenting psychological interventions with Virtual Reality (VR) technology may include the reduction of both financial and temporal costs for individuals suffering from mental health disorders, as well as the opportunity to generate scenarios that are not possible in real world . Also, wThus, the general objective of our study is to compare the effectiveness of two CBT protocols for alleviating GAD symptoms. First, standard CBT based on the Beck protocol , 2021, fThis clinical trial was approved by the Ethics Committee of George Emil Palade University of Medicine, Pharmacy, Sciences and Technology of Targu Mures, under the approval number 1138 from 22th Sep 2020, as part of a research grant won within a research funding competition.SD = 2.21), most participants being females (78.8%). There were no age or gender significant differences between the two treatment groups.Participants were recruited from the George Emil Palade University of Medicine, Pharmacy, Sciences and Technology of Targu Mures, Faculty of Medicine. In the first phase of the study, a screening regarding the presence/absence of clinical anxiety was conducted. From the total number of 1920 individuals who went through the screening, 93 individuals were selected, presenting a score over 25 points at the Leahy Anxiety Checklist, which was considered a cut-off point for moderate anxiety . In addiThe Hamilton Rating Scale for Anxiety HRSA;  is an inThe Penn State Worry Questionnaire PSWQ;  is a 16-The Automatic Thoughts Questionnaire ATQ;  is a selThe Dysfunctional Attitudes Scale DAS;  is a 40-The Unconditional Self-Acceptance Questionnaire USAQ;  is a 20-Initially, participants were recruited through an online form that provided information regarding the purposes and methods of this research. After the application of inclusion and exclusion criteria, eligible participants met a research team member to discuss general characteristics about the intervention process and signed the written consent, ensuring confidentiality and protection of data. During the same initial meeting, the initial assessment was carried out by two research team members. After the intervention, the final assessment was conducted by each therapist involved in the study.Mage = 22.75; SD = 2) that received a traditional CBT intervention, and the IM-VRCBT group (IM-VRCBT) including 34 participants  that received an IM-CBT intervention augmented with VR , including 32 participants . Autogenic training , whereas psychotherapists working with the IM-VRCBT group had an average clinical experience of 4.14 years (SD = 4.76). Before applying the interventions, all involved therapists were trained in the specific protocols implemented in this research.A total of 20 CBT psychotherapists were implicated in this study, from this number 7 being trained as clinical psychologists and 13 as psychiatrists. Out of the total number, 6 psychotherapists were assigned to work with the CBTs group, while 9 worked with the IM-VRCBT group exclusively. The remaining 5 psychotherapists provided interventions within both groups, that were the most experienced from the entire group of therapists, as required for synchronizing treatment progress among both groups. Regarding the professional background, all involved psychotherapists had at least 1 year of CBT experience either within the public health system , or private practice. Psychotherapists working with the CBTs group had an average clinical experience of 6.12 years  = 0.06, p = 0.803, η2 = 0.001, but it revealed a significant treatment by time interaction on PSWQ–F = 5.13, p = 0.027, η2 = 0.074. Likewise, there were significant main effects for Time (ps < 0.001). There were no statistically significant differences between the interventions from pre- to posttest. Hence, whereas both interventions were effective in reducing the anxiety and worry levels (ps < 0.001), the CBTs was slightly more effective than IM-VRCBT in reducing the accompanying worries, and both were equally effective in reducing the anxiety level. Higher pretest – posttest effect sizes were found for anxiety (Cohen’s d of 2.76 for the CBTs group and of 2.34 for the IM-VRCBT group) than for worry (Cohen’s d of 1.85 for the CBTs group and of 0.97 for the IM-VRCBT), but all values indicate strong intervention effects (see The 2 (Treatment Condition) × 2 (Time) mixed-model ANOVA revealed no significant treatment by time interaction on HRSA–ects see .ps > 0.05) for any of the secondary outcomes. In all cases we did find significant differences for the within-group comparisons  in the expected direction  × 2 (Time) mixed-model ANOVA revealed no significant treatment by time interaction  = 0.55, p < 0.001, and the magnitude of decrease in negative automatic thoughts, respectively–r (64) = 0.65, p < 0.001. Likewise, there was a positive association between the magnitude of decrease in anxiety and the magnitude of decrease in negative automatic thoughts–r (64) = 0.30, p = 0.014, and a non-significant association between magnitude of change in anxiety and magnitude of change in dysfunctional thoughts–r (64) = 0.02, p = 0.88. A similar pattern of results was found when investigating unconditional self-acceptance changes. No association between the change scores in USAQ and anxiety was found–r (64) = 0.02, p = 0.83, and a strong negative association between the change score in USAQ and change score in PSWQ was found–r (64) = −0.64, p < 0.001. These results rely on correlation analyses, therefore causality inferences are not supported.Theory suggests that CBT efficacy in reducing anxiety and worry is associated with debating and restructuring the NATs ,b. We inThe aim of the present study was to compare the effectiveness of a standard CBT and an IM-VRCBT protocol for adults with moderate GAD, showing that both interventions are equivalently successful in reducing the intensity of anxious manifestations and dysfunctional cognitive processes involved in this disorder. Several investigations found that CBT is the golden standard psychological treatment in GAD . Other aFrom the perspective of primary outcomes, we demonstrated a significant reduction of anxiety symptoms and worries after both treatment protocols. As reflected in our results, high remission rates of anxiety symptoms in GAD were outlined following CBT interventions . HoweverFurthermore, our results emphasized that psychological interventions built on a CBT conceptualization are successful in terms of reducing both symptom and cognitive dysfunctional process outcomes. This idea was previously supported by Concerning secondary outcomes, we indicated that NATs and dysfunctional attitudes decreased, whereas unconditional self-acceptance increased, after the CBT intervention, with comparable improvements in both groups. Previous research found that NATs are correlated with depression and anxiety, representing common characteristics among these disorders . In concAnother important particularity of our study is represented by the fact that, to our knowledge, this is the first study that explored the feasibility of an extensive IM-VRCBT protocol for GAD. To date, the VRCBT , leadingNevertheless, this study has some limitations. First, our sample consisted of a small number of participants selected from a young adult outpatient population. This does not allow the generalization of our outcomes to the entire population, neither the clear identification of change mechanisms in GAD. This aspect is also likely to affect the chance of finding a significant treatment x time interaction due to lower statistical power to detect such smaller improvements. Second, it was established that medical students develop more emotional disorders symptoms compared with the general population, especially during the preclinical years of medical school, due to the complexity of academic tasks and exams. It is possible that the anxiety levels observed in our samples could be more or less influenced by the context described above. Third, the investigation of two combined interventions that were compared simultaneously raises a major constraint due to the incapacity to indicate what specific processes counted for our results. This is particularly true regarding the efficiency of the VR-augmented intervention, since it is uncertain if the benefits of the treatment were correlated to the difference between psychological approaches, despite minor variations between the protocols, or the VR supplement. Therefore, an important direction for future studies would be to explore the advantages of VR-augmented CBT treatments for GAD, by comparing a stand-alone protocol with proved efficiency with the VR-enhanced version of the same intervention. Fourth, another drawback of our study is implied by the correlational analyses that do not permit the identification of potential causal effects. Fifth, this research did not include repeated measures for the assessment of symptom and process variables during the interventions. For this reason, the specific time when changes occurred and the interaction between primary and secondary measures could not be captured over the course of the CBT treatments. Sixth, our investigation did not include follow-up evaluations. Therefore, we are not able to draw firm conclusions about the differentiation between acute and chronic aspects of GAD. Also, the maintenance of the results on the long term could not be demonstrated.CBTs and IM-VRCBT are effective psychological interventions in the treatment of GAD. Even though both interventions are equally beneficial for the reduction of anxiety symptoms, the standard CBT was more effective for alleviating worries. Also, significant decreases in GAD-specific negative automatic thoughts and dysfunctional attitudes were associated with an increase in unconditional self-acceptance following both interventions. Furthermore, IM-CBT can be successfully augmented with VR in a single protocol for GAD treatment. Future studies could investigate the processes of change by incorporating multiple assessments of potential mediators throughout psychological treatments tailored for GAD.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Ethics Committee of George Emil Palade University of Medicine, Pharmacy, Sciences and Technology of Targu Mures. The patients/participants provided their written informed consent to participate in this study.COP contributed to the development of intervention protocols, as well as the framework and procedure of the study. He also coordinated the training of the research team members and the process of data curation, wrote the first draft, and reviewed the manuscript. FAS led the statistical analysis, wrote the results section, and reviewed the manuscript. SM supervised the screening, was involved in the process of data curation, and wrote and reviewed the manuscript. AS was involved in the screening of participants, data curation, supervised the intervention process within the standard CBT group, wrote the first draft, and reviewed the manuscript. CMC was involved in the screening of participants, data curation, supervised the intervention process within the IM-VRCBT group, provided support for the first draft, and reviewed the manuscript. LMM was enrolled in the screening process, data curation, contributed to the first draft, and reviewed the manuscript. PO contributed to the design and framework of the study, coordination of the research project and feasibility, and ensured the allocation of funding and the availability of the equipment. All authors contributed to the article and approved the submitted version.This work was supported by the George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu-Mures, Research Grant number 239/7/14.01.2020.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The imaging features of GGNs were analyzed by qualified physicians, including lesion size , location, CT values , lesion morphology (round and irregular), marginal structure (pagination and burr), internal structure , and adjacent structure . CT imaging analysis was performed for the subtype of infiltrating adenocarcinoma (IAC). In CT findings, GGNs were greatly different from adenomatous hyperplasia (AAH), pure GGN adenocarcinoma in situ (AIS), and microinvasive adenocarcinoma (MIA) in terms of marginal structure, lesion morphology, internal structure, adjacent structure, and size (P < 0.05). The mean and relative CT values of mural adenocarcinoma, acinar adenocarcinoma, and papillary adenocarcinoma of IAC subtypes were greatly different from those of AAH/AIS/MIA (P < 0.05). In summary, the CT images of GGNs can be used as the basis for the differentiation of AAH, AIS, and MIA early noninvasive types and IAC invasive types, and the CT value of the IAC subtype can be used as the basis for the classification and differentiation of IAC pathological subtypes.To investigate the correlation between computed tomography (CT) image characteristics of multiple lung ground-glass nodules (GGNs) and pathological classification, the CT image data of multiple lung GGN patients confirmed by pathology ( Lung cancer is a relatively common malignant tumor with the highest morbidity and mortality throughout the year . AlthougGGN refers to the fuzzy nodules in the lung. The density of nodules is slightly higher than that of the surrounding lung parenchyma, but the outline of blood vessels and bronchus within the nodules can be seen . Causes After the widespread use of low-dose computed tomography (CT) in lung cancer examination, the number of GGNs detected has increased. Preoperative detection and positioning of GGNs by CT to identify the subtypes of early lung adenocarcinoma is crucial for accurate preoperative pathological diagnosis of patients by clinical staff . HoweverIn this study, 132 patients with chest CT examination and pathologically confirmed GGNs in hospital from May 2020 to May 2021 were enrolled. Inclusion criteria are as follows: complete and clear preoperative CT images of patients can be harvested through picture archiving and communication system (PACS); there were at least two GGNS with maximum diameters of no less than 25 mm in both lungs; postoperative pathology required thoracoscopic or thoracoscopic resection and staining, which was reviewed by at least one senior pathologist with 10 years of experience in diagnosis of tumor pathology, and pathological subtypes were classified according to the new classification in 2015. Exclusion criteria are as follows: patients unable to undergo surgical treatment and patients with incomplete imaging data. At the beginning of this study, patients or their families signed informed consent. This study was approved by the ethics committee of the hospital.64-slice spiral CT machine was employed. Breath-holding training was performed before scanning, and the breath-holding state under breathing was calm during scanning. The supine position was the dominant position, and some patients were in the prone position. First, the whole lung was scanned with a thickness of 5-10 mm, including the axilla and chest wall on both sides. After GGN was found, a CT scan was performed again. The layer thickness was 1.25 mm target scan, and the standard algorithm and bone algorithm were reconstructed. The target scanning parameters were as follows. The collimator was 1.25 mm, the pitch was 1.375, the tube voltage was 120 kV, the tube current was 250-350 mAs, the field of vision was 16-24 cm, and the matrix was 512 × 512. MPR was performed on all patient raw data at a 1.25 mm layer thickness on an ADW 4.5 or 4.7 workstation. The accompanying signs of GGN were displayed, with emphasis on the walking, morphology, and lumen of the relevant bronchi, and the relationship between them and lesions was recorded.The images were analyzed separately by two highly qualified physicians in the Department of Radiology, and the results were statistically analyzed. If there was any deviation in the analysis, the consensus of the two physicians was taken as the result.L, short diameter W, and thickness T (number of nodular layers × layer thickness) of GGNs were calculated, and the volume was calculated according to Equation , lesion morphology (round and irregular), marginal lobulation and burr, internal structure , bronchial truncation, adjacent structure , lesion size (diameter and volume and mass), mean CT value, and relative CT value. Diameter was the average diameter of GGN, that is, the average of long diameter + short diameter on the largest layer of GGN in CT images. The maximum layer length Equation . The masEquation  18].  in 2015 .H test was used when the samples did not conform to a normal distribution. The χ2 test was used for technical data. P < 0.05 indicated that the difference was statistically significant.SPSS 22.0 was used for data processing. ANOVA was used for measurement data. The Kruskal–Wallis P < 0.05). The data of various pathological subtypes of IAC are shown in P > 0.05).The patients were divided into two groups according to the degree of invasion. Sixty-seven patients had preinvasive lesions of lung adenocarcinoma (AAH/AIS/MIA group). There were 65 patients with infiltrating adenocarcinoma (IAC group). In the IAC group, there were three subtypes, including 38 cases of adherent growth type IAC, 18 cases of acinar IAC, and 9 cases of papillary IAC. The clinical data of all GGN cases are shown in P > 0.05). There was no significant difference in the location of each pathological subtype of IAC (P > 0.05).In P < 0.05), and there was no significant difference among IAC subgroups. Comparison of noninvasive and invasive GGN lesions showed no significant difference between IAC and AAH/AIS/MIA or between IAC subgroups.In P < 0.05). There were no significant differences among the IAC subgroups.Since the bronchial inflation sign and air bubble sign are not easy to judge, both were counted as bronchial inflation signs in this experiment. In P < 0.05). There was no significant difference between IAC subtypes .In P < 0.05).In Atypical adenoma hyperplasia  is a benLung cancer is more insidious than other cancers, and once symptoms appear, it is basically at an advanced stage, so physical examination is an effective means to find early lung cancer. CT is the most commonly used method for the diagnosis of lung cancer at present, which also leads to the delayed early diagnosis of lung cancer, so early CT detection is crucial . GGN, asPathological studies of lung cancer have found that the increase in density and size of lesions is often a symbol of malignant lesions, so the size, volume, and mass of lesions are correlated with the degree of malignancy of lesions . Three-dIn this study, CT features and pathological features of multiple GGN were used to explore the correlation between the two. It was found that the imaging features of GGN could be used as a reliable basis for the identification of AAH, AIS, MIA, and IAC, which were especially effective in the features of GGN's edge structure, lesion morphology, internal structure, adjacent structure, and size. The pathological subtypes of IAC can be distinguished by the mean CT value and relative CT value in early noninvasive lung adenocarcinoma of AAH, AIS, and NIA. However, the deficiency of this study is that the number of patient samples is small, which cannot reflect the actual situation more objectively. More experimental cases should be included in subsequent studies. In addition, follow-up was not considered in this retrospective study, and multiple GGNS proved to be atypical adenomatous hyperplasia, AIS, microinvasive adenocarcinoma, and invasive adenocarcinoma after thoracoscopic or thoracotomy resection was included. The included samples were somewhat deviated, and isolated GGNS were not considered. In conclusion, this study is helpful for surgeons and radiologists to distinguish between patients with invasive and noninvasive lesions before surgery and to adopt different treatment regimens to improve patient outcomes.


The intervention group participated in a blended learning program for 12 weeks. A self-administered questionnaire was completed by both groups at pre-intervention, post-intervention, and follow-up. Chi-square test, Fisher’s exact test, and repeated measures analysis of variance (ANOVA) were used for data analysis. The mean score of the intervention group in knowledge, attitude, intention to cope with cyber sexual harassment, behavioral coping strategies, and cyber sexual harassment after completing the program and follow-up were significantly different from baseline and the control group (p < 0.05). A positive effect of the blended learning program was observed among female students. Therefore, this program can be useful for victims, supporting their self-confidence with decreased frequency of cyber sexual harassment experiences.Cyber sexual harassment has been increasing and has become a major public health problem among youths. Therefore, this study primarily aimed to evaluate the effects of a blended learning program on knowledge, attitudes, intention to cope with cyber sexual harassment, behavioral coping strategies, and cyber sexual harassment among female high-school students in Bangkok, Thailand. A quasi-experimental study with a two-group design was conducted from May 2021 to October 2021. A total of 112 students were recruited into either an intervention ( Online or cyber harassment has increased in recent years to become a major public health issue among adolescents . DigitalThe prevalence of cyber harassment and other forms of gender-related violence online has become increasingly harmful . In EgypIn Thailand, the use of smartphones, the Internet, and social media is increasing . Nearly Several prevention methods for cyber sexual harassment have been implemented, including providing education, improving awareness, changing norms, empowering students, and seeking social support ,19,20. OStudents’ attitudes were associated with their intention to perform such behaviors, which may not be changed due to inadequate knowledge and poor attitude. A significant factor in the theory of planned behavior is the intention to perform (or not to perform) a certain behavior. Although a variety of factors influence intentions, most research does not utilize a behavioral theory . This stFurthermore, some of what is already known regarding online sexual harassment derives from in-person sexual harassment research and other related online behaviors ,28. BlenQuasi-experimental research with a two-group design was conducted. The intervention group received a blended learning program, whereas the control group did not receive any program. The intervention program was conducted from May 2021 to October 2021. To determine the sample size, power analysis with a power of 0.80  was performed . The calTo recruit students, a multi-stage sampling technique was applied. Two high schools in Bangkok under the supervision of the Office of the Basic Education Commission were selected by simple random sampling based on their similar characteristics, such as their curriculum, size of school, and reporting of cyberbullying as high-level online harassment. Female students in grade 10 were selected using purposive sampling for both the intervention and control schools. Finally, simple random sampling was used to select the female students. The inclusion criteria were students who experienced cyber sexual harassment in the last 6 months, had a smartphone and Facebook account, and could use Facebook’s features by themselves. Students with mental and physical health problems and those who missed classes in more than two sessions during the program were excluded. Permission from students and their parents was obtained using a consent form.The blended learning program consisted of 12 activities and was carried out for 12 weeks. Each session included classroom and online learning. Classroom activities took 90 min every week with Facebook assignments and games. Before starting the activity, students were divided into six subgroups. The reason for group gathering or group process was that students could have positive interactions with each other and support their peers. Four research assistants were trained and helped to run the program in-class and online. A private Facebook group (closed group) was created as a part of the online learning. Using this platform, students could learn content related to each in-class activity whenever and wherever they wanted to. Group discussions, lectures, games, and the sharing of personal experiences all took place throughout the class sessions. Assignments, questions and answers, online tests, videos, and opinion exchanges on tasks at any time were all used in online activities. The information was only accessible to the participants and the researcher team. Students’ privacy and information were carefully protected. The program contents are shown in The measurement tools were a self-administered questionnaire consisting of seven parts, including (1) sociodemographic characteristics, (2) Internet usage, (3) knowledge regarding cyber sexual harassment, (4) attitude toward cyber sexual harassment, (5) intention to cope with cyber sexual harassment, (6) behavioral coping strategies, and (7) number of cyber sexual harassment occurrences. The content of the questionnaire was validated by five experts. The item objective congruence index of all items was within the range of 0.74 to 0.91. The reliability of the questionnaire was assessed for knowledge regarding cyber sexual harassment , attitude toward cyber sexual harassment , intention to cope with cyber sexual harassment , behavioral coping strategies , and cyber sexual harassment . The questionnaire was provided to both control and intervention groups at baseline, week 12, and week 20 of the study.p < 0.05. Chi-square and Fisher’s exact test were used to analyze the difference between intervention and control groups on sociodemographic characteristics and Internet usage in categorical data. A repeated measures ANOVA was used to evaluate the effects of the program with the difference in mean scores of knowledge regarding cyber sexual harassment, attitude toward cyber sexual harassment, intention to cope with cyber sexual harassment, behavioral coping strategies, and number of cyber sexual harassment occurrences among the three time periods.Data analysis was carried out using Statistical Packages for the Social Sciences version 22.0. The significant level was set at a Ethical approval was obtained from the Ethics Review Committee for Research Involving Human Research Subjects, Health Science Group, Chulalongkorn University (COA No. 065/2564). Before starting the intervention, parents willingly consented to their children as study participants by signing an informed consent form.p > 0.05) as shown in A total of 56 students in the intervention group and 56 students in the control group were included. The results are presented in three parts: (1) sociodemographic characteristics, (2) Internet usage, and (3) effects of blended learning program. At baseline, the majority of students in the intervention (51.8%) and control groups (48.2%) had a grade point average between 2.01 and 3.00. Most of the students were heterosexual: 85.7% and 91.1% in the intervention and control groups, respectively. The majority of the students were single and stayed with their parents. Their parents’ marital status was married or living together. No statistically significant difference was observed on the sociodemographic data between two groups at baseline (p > 0.05), as shown in More than half of the students in the intervention (53.6%) and control groups (66.1%) spent more than 7 h a day surfing the Internet. Approximately 72% and 63% of the students in intervention and control groups, respectively, used Facebook. They usually used the Internet between 18:01 and 21:00 h without their parents’ supervision. At baseline, the Internet usage characteristics of both groups were similar. There was no statistically significant difference observed between the two groups (p = 0.028), attitude (p = 0.014), intention to cope with cyber sexual harassment (p = 0.016), behavioral coping strategies (p = 0.031), and occurrence of cyber sexual harassment (p = 0.025), after completing the 12-week program and 2 months after the program ended. The mean knowledge score showed a small but statistically significant (p = 0.014) increase in the intervention group from baseline to post-test and at follow-up . Comparing the mean knowledge scores between the control and intervention groups at each assessment time, the intervention group showed a higher mean score at both time points (p = 0.022). Regarding students’ attitude toward cyber sexual harassment prevention, the intervention group’s score slightly increased after the intervention and this increase persisted at the follow-up assessment . The increase in the score for the intervention group was higher than that for the control group at the same assessment time (p = 0.003).Students’ knowledge, attitude, and intention to cope with cyber sexual harassment, behavioral coping strategies, and experiences of cyber sexual harassment were assessed at the end of the program (week 12) and 2 months after the program ended (week 20). The comparison of the mean scores using repeated measures ANOVA revealed an interaction effect between group and time. There were statistically significant differences between the intervention and control groups for all five outcomes i.e., knowledge (p = 0.003) for the intention outcome and 23.30 ± 2.18, 24.25 ± 2.02, and 24.14 ± 2.08, respectively (p = 0.004) for behavioral coping strategies. In addition, the mean scores for intention and behavioral coping strategies of students in the intervention group were higher than those of students in the control group at the end of the program and at follow-up . The blended program also influenced the occurrence of cyber sexual harassment, with the mean score of the intervention group decreasing after completion of the program and persisting at follow-up (p < 0.001), as shown in In terms of intention and behavioral coping strategies to prevent cyber sexual harassment, the mean score of the intervention group was slightly increased from baseline to post-test and follow-up with values of 39.43 ± 5.26, 41.34 ± 4.62, and 41.84 ± 4.93, respectively (This study used a quasi-experimental research design to evaluate the effects of a blended learning program for cyber sexual harassment prevention among female high-school students. The program is based on two theories that support the contents of the program. First, the empowerment theory helps adolescents exert more strength than their harassers, which is related to strategies and resources that encourage females to escape from negative situations in their lives and to assist students in improving their lives, avoiding inappropriate use of new technology, and increasing understanding and techniques to protect themselves on the Internet. Some studies have implemented their programs based on the concepts of the empowerment theory  and the There was a significant difference between the intervention and control groups, as well as between the times of measurements on knowledge, attitudes, intention, behavioral coping strategies, and cyber sexual harassment. This could be due to using different methods of educational program, such as lectures, videos, presentations, games, quizzes, and group discussion-based programs. The knowledge scores of the intervention groups appeared to improve from the baseline to the follow-up assessment. The follow-up test revealed that this knowledge was more consistently retained through week 20. Thus, it is likely that the lesson on definition, risk factors, and prevention strategies helped students to more consistently retain knowledge and improved awareness of the significance of understanding cyber sexual harassment. This finding was consistent with previous studies, students in the intervention group showed significant improvement in sexual knowledge as compared with the control group after they underwent a sexual abuse and harassment prevention program ,32. MoreAt the baseline survey, students in the intervention group tended to have a more negative attitude. The students’ attitudes improved after the educational session. The use of simulated news articles and Facebook messages was successful in addressing and raising participant attitudes about cyber sexual harassment because they were so similar to the participants’ usual online experiences. By emphasizing potential negative effects for the victims, group discussion, empathy training, skill training about online protection strategies, and holding awareness-raising sessions, the program may have a positive influence on attitudes. This was consistent with a previous study on the Media Heroes program for cyberbullying prevention. The program is theoretically based on the theory of reasoned action and the theory of planned behavior. Education implemented by conveying negative consequences for and improving empathy with the victims influences their attitudes in a positive way . MoreoveThe average score of intention to cope with cyber sexual harassment after the intervention and follow-up increased from baseline with a significant difference. The intention to cope with cyber sexual harassment may be increased by implementing a program based on the theory of planned behavior that includes an introductory lecture, peer-led discussions, brainstorming sessions, group activities, and sharing experiences sessions. This was consistent with Lijster et al.’s findings wherein students in the intervention group reported improving behavioral intention to prevent sexual harassment at post-test. . A previThrough program activities, including emotional management, empowering techniques, sharing experiences, slogan creation, and help-seeking processes, students have multiple opportunities to practice their coping skills, which helps to increase their confidence and competence. Several coping strategies were actively used by the students in the intervention group. Students can develop their coping mechanisms by expressing empathy and care for themselves, expressing compassion to peers who have gone through similar things, and fostering help-seeking activities. Students also learned how to recognize symptoms of harmful thinking, such as self-blame, helplessness, and isolation, applying cognitive behavioral therapy. This program may help cyber sexual harassment victims in eliminating self-blame and boosting their confidence to deal with the problem. This was consistent with Kerry et al.’s study wherein their program engaged adolescent victims’ coping skills. Their results showed that students had significant increases in coping skills after completing the psychoeducational program . FurtherIn the present study, the average score of cyber sexual harassment after the intervention and at follow-up decreased from baseline, with a statistically significant difference between the intervention and control groups and measurement times. These findings support the effects of a blended learning program in reducing cyber sexual harassment experiences among female students. The results of this study can be explained in various ways. It is reasonable to assume that specific program components, such as cooperative activity, victim emotional support, peer support, and coping strategies addressing cybervictimization, increased its effects. In this setting, students listen to each other, identify possible harassment circumstances, and support each other during difficult situations. The findings of this study are congruent with that of previous studies on programs to prevent cyberbullying. The use of intervention strategies, such as educating students safe online behavior or how to avoid cyberbullying, have significantly decreased student cybervictimization ,42,43.No dropout or loss of student participation in the program occurred in this study. However, not all activities stimulate participation and performance. Students were found to have diverse perspectives when it came to online activities. The effects of program participation may vary according to the content of the interaction, Internet connection, willingness to participate in the discussion, and environmental factors. Blended learning can be made more effective by students’ interactions with their peers and the research team. In blended learning, infographics, videos, graphs, and other types of learning materials are employed. This makes it easier for students to concentrate and integrate information. It enables students to access interactive contents no matter where they are or what they are learning about . TherefoThe results of the present study showed that after female high-school students received a blended learning program, they have improved knowledge, attitude, intention to cope with cyber sexual harassment, and behavioral coping strategies. Furthermore, the blended learning program also decreased cyber sexual harassment experiences among students. To learn more about cyber sexual harassment and victims’ feelings, a mixed methods study and in-depth interviews should be conducted. In addition, applying for this program in other areas or groups, while including a 6- or 12-month follow-up phase to develop a better understanding of intervention effects, sustainability, or long-term maintenance of the program’s beneficial results, is recommended.


Functional dyspepsia (FD) is one of the most common functional gastrointestinal disorders, with a high prevalence and significant influence on the quality of life (QoL). Either acupuncture or moxibustion is effective for dyspepsia, which is confirmed by both ancient documents and modern research. However, the therapeutic advantage and underlying mechanism between acupuncture and moxibustion for FD remain unclear.This randomized controlled fMRI trial aims to (i) evaluate the therapeutic advantages of acupuncture and moxibustion treatment for FD, (ii) investigate the similarities and differences in cerebral activity elicited by acupuncture and moxibustion, and (iii) analyze the possible correlations between brain responses and clinical variables thus to explore the potential central mechanism of acupuncture and moxibustion for treating FD. Ninety-two FD patients will be randomly assigned to either the acupuncture group or the moxibustion group in a 1:1 ratio. Twenty sessions of acupuncture or moxibustion treatment over 4 weeks will be performed on each patient. The short form Leeds Dyspepsia Questionnaire, the Nepean Dyspepsia Index, etc., are used to evaluate the therapeutic effects. The heart rate variability will be analyzed to investigate the autonomic nerve function. Thirty-six FD patients in each group will be randomly selected for the fMRI scan to detect cerebral activity changes.We expect the results will deepen our knowledge on the clinical value and underlying mechanism of acupuncture and moxibustion and provide a reference for a better selection of interventions for treating FD.www.chictr.org.cn) ChiCTR2100049496. Registered on 2 August 2021Chinese Clinical Trial Registry (The online version contains supplementary material available at 10.1186/s13063-022-06411-9. Functional dyspepsia (FD), as one of the common functional gastrointestinal disorders (FGIDs), refers to a group of upper gastrointestinal syndromes, including epigastric pain, epigastric burning, meal-related fullness, and early satiation . AccordiAcupuncture and moxibustion have been used for gastrointestinal symptoms for more than 2500 years in China and are increasingly accepted as the nonpharmacologic alternative therapies for FGIDs around the world –9. RecenIn Roma IV criteria, FD is defined as a disorder of brain-gut interaction . TherefoThe present study is a single-center, parallel-controlled, equivalence, randomized clinical trial, and a total of ninety-two patients with FD will be recruited. These patients will be randomly allocated into either the acupuncture group or the moxibustion group with a 1:1 ratio. The study period includes a 1-week baseline, 4 weeks of treatment, and another 4 weeks of follow-up. Clinical measurements will be performed at the baseline, at the end of the treatment, and at the end of follow-up, respectively. Neuroimaging scans will be performed at the baseline and the end of the treatment. More details of the study design are shown in Fig. https://www.chictr.org.cn/) (ID: ChiCTR2100049496). The study will follow the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidance for protocol reporting  . All parThe FD patients will be recruited from the outpatient department of the Hospital of Chengdu University of Traditional Chinese Medicine (TCM) and the campus of the Chengdu University of TCM from September 2021 to December 2022. WeChat, posters, leaflets, free medical consultations, etc., will be used to inform and recruit potential FD patients. All potential FD patients will undergo a physical examination and laboratory tests, including normal gastroduodenoscopy, upper abdominal ultrasound, routine blood, urine and stool test, and blood biochemical test . A qualified digestion physician will make the final diagnosis for each potential FD patient.Patients will be enrolled if they meet all the following criteria: (1) right-handed and aged 18 to 40 years, (2) matching the Rome IV diagnosis criteria for FD (Supplementary file The patient will be excluded if they meet any of the following criteria: (1) being unconscious or being unable to cooperate in assessment; (2) suffering from cardiovascular, neurological, renal, liver, or blood diseases; (3) women being pregnant or lactating; (4) suffering from mental disorders such as anxiety or depressive disorder, bipolar disorder, schizophrenia, and claustrophobic syndrome; (5) having a history of head trauma, migraine, or dysmenorrhea; and (6) having received acupuncture or moxibustion treatment in the past month.Eligible patients will be randomly allocated in a 1:1 ratio to the acupuncture or moxibustion group. An independent researcher will generate the random sequence by PASS 15.0 . Every random sequence number will be sealed in an opaque envelope by another research coordinator. The acupuncturists will finally open the sealed envelope to learn the group allocation of a participant prior to the delivery of the initial intervention session.It is difficult to blind acupuncturists and patients in this trial for different types of intervention. Acupuncturists will not participate in any outcome assessment process. All the outcome assessors and statisticians will be masked in randomization assignments and intervention during the whole study.Participants will be withdrawn from the trial if (1) participants develop the serious disease, (2) seriously adverse events happen, and (3) participants request to withdraw from the trial, voluntarily. The reasons and exit time will be recorded in standard case report forms (CRFs). Patients who withdraw from the trial for any reason will be considered a drop-out. All the information from participants who have dropped out will be used for intention-to-treat (ITT) analysis.d = 0.758) to estimate the sample size of this study. To achieve 90% statistical power (α = 0.05), at least 76 participants are needed. Besides, assuming a 20% attrition rate, ninety-two participants (46 participants per group) will be recruited to detect a two-sided significant difference. The sample size calculation steps are shown in Supplementary file The sample size was estimated based on the results of a study on the changes in the short form Leeds Dyspepsia Questionnaire (SF-LDQ) in response to a 4-week acupuncture intervention versus moxibustion intervention, which showed a mean improvement of the SF-LDQ was − 5.62 ± 2.81 (mean ± SD) in the acupuncture group and − 3.56 ± 2.62 in the moxibustion group respectively . It provAccording to previous fMRI-based studies , 27, thiZhongwan (CV-12) and Zusanli (ST-36) will be selected as the treatment acupoints, which are the most commonly used acupoints for FD [Participants in both groups will receive 20 sessions of acupuncture or moxibustion treatment in 4 weeks. Five times per week on s for FD . The locngwan CV-2 and Zusdeqi sensation . The needles will be retained in the acupoints for 30 min, and the aforementioned manipulation will be applied every 10 min.After skin sterilization, the sterile needles   Fig. C will bedeqi phenomenon is a special sensation of acupuncture and moxibustion, and it is closely related to clinical efficacy [deqi sensation will be evaluated by the Chinese version of modified Massachusetts General Hospital Acupuncture Sensation Scale (C-MASS) [deqi sensation of moxibustion also will be evaluated by the C-MASS-based 10-point visual analog scale (VAS) form. Patients will self-assess the sensations by this scale. The sensation of acupuncture and moxibustion will be measured after the 1st and 20th interventions, respectively.The efficacy , 30. The(C-MASS) , and theGastrointestinal motility regulating drugs, proton pump inhibitors, Chinese medicine, etc.), participants need to tell us the time to take, dosage, and the specific information about the drugs, or any other therapy. Finally, we will record the details of the treatment in the case report form.If the symptoms are unbearable and FD patients have to take drugs  . Graded The secondary outcomes contain the NDI, the SID score, the SAS, and the SDS. Among them, NDI is a commonly used questionnaire to assess upper gastrointestinal symptoms and QoL of patients . It inclThe autonomic nervous system (ANS) plays a role in the physical function and pathological change of the digestive tract . Dysfunc2, and slice thickness = 1 mm. The parameters of blood oxygenation level-dependent resting-state functional image will be set as follows: repetition time/echo time = 2000 ms/30 ms, flip angle = 90°, slices = 30; data matrix = 64 × 64, field of view = 240 × 240 mm2, slice thickness = 5 mm, total volume = 240, and total scan time = 480 s. Twenty-four hours before scanning, every patient will be asked to keep their regular lifestyle, avoid staying up late, smoking, and drinking coffee or tea. Before scanning, every patient will stay at a restroom for 30 min and keep calm without thinking. During scanning, patients will be required to keep their eyes closed and ears plugged.The fMRI data will be acquired with the Siemens 3.0T MRI  at the Imaging Center of the fifth Chengdu Hospital, Sichuan, China. A 3-dimensional MRI sequence will be used to gain the high-resolution structural image. The parameters as following: repetition time/echo time = 1900 ms/2.26 ms, slices = 176, data matrix = 256 × 256, field of view = 256 × 256 mmSafety monitoring will be executed strictly throughout the study with reporting for adverse events (AEs) and serious adverse events (SAEs) such as subcutaneous hemorrhage, vertigo, infection, and burn and scaled injures. AEs/SAEs will be handled properly, recorded carefully, and report the SAEs and treatment to the principal investigator and the Ethics Committee immediately. We will pay all medical fees. Additionally, free medical and psychological consultation will be provided until they recover from AEs/SAEs.Clinical data will be managed with printed case report forms and electronic data capture (EDC). An independent data administrator will keep the data. Only principal investigators have the access to the full dataset and will perform double-data entry. The evidence-based medicine center of the CDUTCM is responsible for monitoring the study and data every 3 months and will make the final decision to terminate the trial. We will publish our results in peer-reviewed journals.t-test or the Mann-Whitney U test for continuous variables and the chi-square test, Fisher exact test, or Kruskal–Wallis test for categorical variables will be used, when suitable. We will describe 24-h HRV using time-domain measurements. Time-domain indices of HRV quantify the amount of variability in measurements of the interbeat interval (IBI), which is the time period between successive heartbeats. These values may be expressed in original units or as the natural logarithm (Ln) of original units to achieve a more normal distribution [p<0.05 with a two-tailed test.All analyses will be done on the ITT population. An independent statistician will conduct clinical data analysis with SPSS 24.0 software . Kolmogorov–Smirnov test will be used to analyze data distribution, and Levene’s test will be used to analyze homogeneity of variance. The quantitative variables will be presented as mean and SD or median and interquartile, whereas qualitative measures will be reported as percentages with 95% CI. Analysis of variance (ANOVA) test will be used with Bonferroni post hoc comparisons for continuous variables. The independent-samples ribution . Pearsonp<0.01 in voxel-level and p<0.05 with false discovery rate in cluster-level. While in connectome-based analysis, the threshold will be set to p<0.05 with false discovery rate corrected. Furthermore, the Pearson correlation analysis between the clinical results and fMRI results will be conducted to investigate the potential correlation between symptom improvements and brain activity changes elicited by different interventions.The fMRI data will be analyzed with MATLAB 2 017b . After data preprocessing, amplitude of low-frequency fluctuation (ALFF), functional connectivity (FC), and large-scale functional brain network analysis, etc. will be conducted to investigate the difference of central responses between acupuncture and moxibustion. In voxel-based analysis, the threshold will be set to This randomized control fMRI trial will compare the differences in clinical effects and the central responses between acupuncture and moxibustion. The results might deepen our understanding of the advantages and central mechanisms of acupuncture and moxibustion for FD and besides provide a reference for a better selection of interventions for treating FD.Acupuncture and moxibustion are two important external therapeutic methods in traditional Chinese medicine (TCM). Both of them are guided by meridian and acupoint theory, but their manipulation is different. Acupuncture is a kind of mechanical stimulation with inserting specific needles into the acupoints for lifting, thrusting, and twisting, while moxibustion is to place moxa or moxa stick directly or indirectly on an acupoint to produce a warm stimulation; Therefore, they are different and related in clinical practice. For example, a multicenter RCT showed that 4 weeks of acupuncture can significantly increase patient-reported adequate relief and improve FD symptoms and QoL, and the effects of acupuncture persisted through the 12-week follow-up without symptom relapse or rebound . BesidesTo explore the similarities and differences in potential mechanism, the MRI  scans will be performed on the selsected patients in each group, and the HRV tests will be performed on all the patients, at the baseline and the end of the treatment. Using 24-h dynamic ECG, the HRV changes of FD patients in each group will be calculated to investigate the influence of acupuncture and moxibustion on the function of the autonomic nerve. By MRI scan, the cerebral activity changes will be analyzed to explore the brain responses to acupuncture and moxibustion, respectively. In addition, by correlation analysis, the correlations among HRV changes, cerebral activity alteration, and clinical variables improvement in each group will be used to further explore the characteristics in the pattern of central responses to acupuncture or moxibustion.deqi sensation of acupuncture and moxibustion will be recorded. Furthermore, to quantify and control the dosage of moxibustion, a novel portable moxibustion stick  will be used in this study, which can be easily fixed on an acupoint to burn for 30 min with a relatively stable temperature. (iii) MRI scan. All MRI scans will be performed in the morning by the same operator, and female patients will be performed during the same menstrual cycle. Twenty-four hours before scanning, participants will be asked to maintain their routine lifestyle, avoid staying up late, smoking, and drinking coffee or tea. Before being scanned, every patient will stay at a restroom for 30 min and keep calm without thinking. During scanning, patients will be required to keep their eyes closed and their ears plugged. To eliminate head motion, the participant’s head will be placed in the head mask, and a sponge will be used to strengthen the fixation of the head.To improve the reliability of the results, strict quality control will be conducted in the following aspects: (i) the selection of FD patients. To avoid the influence of age, and handedness on cerebral function and structure, right-handed and aged 18 to 40 years patients will be recruited. (ii) Acupuncture and moxibustion manipulation. Two experienced registered Chinese Medicine acupuncturists will perform the manipulation with a standard operating procedure and the In summary, acupuncture and moxibustion are safe and effective for FD. However, the characteristics of these two therapies for treating FD remain uncertain. With the development of neuroimaging technology and analytical methods, it is possible to further investigate the advantages and the underlying mechanism. The results will provide a new perspective to understand the different clinical values of acupuncture and moxibustion for FD, and their central mechanism.Currently, the trial is not yet in the process of patient recruitment. We plan to start patient recruitment in August 2021 and end in October 2022.Additional file 1. Ethics approval.Additional file 2. SPIRIT checklist.Additional file 3. Rome IV diagnosis criteria.Additional file 4. Sample size calculation steps.Additional file 5: Table S1. Detailed location of acupoints.Additional file 6. Consent form.


Since the mid-20th century, the study of Self-Regulated Learning (SRL) has aimed to identify the distinctive characteristics that enable individuals to acquire new knowledge and skills under their control. The theory of Internal Self-Regulation vs. External-Regulation in Learning  has postulated that a large number of self-regulatory variables are mediated by regulated/non-regulated or dysregulated features of the context. After signing their informed consent, a total of 616 university students completed validated instruments of SRL vs. ERL, behavioral regulation (SRB), regulatory teaching (RT), and metacognitive study control strategies (SRS). Using an ex-post facto design and correlation, regression, structural equation model and mediation analyses, the present research aimed to establish multicausal predictive relationships among the analyzed variables. Results indicated positive predictive effects between the external regulation variables on the self-regulation variables in learning [regulation (SRL)/non-regulation (NRL)/dysregulation (DRL)]; as well as positive predictive effects between SRL on SRB, RT and metacognitive SRS. Additionally, external regulation (ERL) not only predicted but mediated numerous relations among the variables studied. Other findings and important considerations for future research in the field of self-regulation are discussed. In European countries such as for example Spain, Switzerland, France, Italy and Germany, the average adult will have been immersed in the formal education system for more than 15 years of their lives . Over theffective teaching is teaching that builds a teaching-learning environment which encourages learners to be committed to their own learning. More recently, in the framework of SRL vs. ERL Theory  are associated with different levels of behavioral self-regulation in learning, general behavioral self-regulation, the perception of RT and the use of metacognitive strategies before, during and after study behavior. This research seeks to provide significant empirical evidence in the field of self-regulation and external regulation in the processes of teaching and learning.There has been much research in Educational Psychology into SRL. However, that research has tended to focus on the subject and although some account is taken of the role of context, context has been seen as more peripheral and incidental. In fact, rather than seeing context as a ‘theater’ in which SRL is performed, we need to scrutinize the relationships between the subject and their context in relationship to learning ‘with a magnifying glass’ in a more systematic fashion. It is necessary, in addition, to carry out that scrutiny on the basis of a specific theoretical model, such as the model proposed by The pattern of behaviors that characterize student’s predisposition to organize their learning can be broken down as follows:(1)Self-Regulated Learning and Academic Achievement: Theory, Research, and Practice a significant volume of important research has been conducted up until today Metacognitively and cognitively: They plan, monitor and direct their mental processes in order to achieve their aims (metacognition); they are aware of and use different cognitive strategies to acquire, develop and recover information.(b)In terms of motivation, they are capable of generating, monitoring and modifying their motivational beliefs  and their emotions to adapt them to the demands of a given task and a given learning situation.(c)In terms of behavior, they are capable of creating and structuring environments that are conducive to learning .(d)In terms of context, whenever possible they join with the teacher in the selection and control of matters concerning tasks, the organization of classes, etc.(e)In terms of volition, they are capable of creating and following habits that enable them to maintain their concentration, application and task persistence despite internal and external distractions.One of the best known and accepted models, from a sociocognitive perspective, is the one proposed by (A)preparation or planning, takes place before the attempted learning starts. Its important elements are: goal setting, analysis of the tasks to be performed and the selection of the resources and strategies that will be used to achieve the goals set. In this phase, it is key to activate interest and beliefs in self-efficacy. To that end, specific, proximate and challenging goals are more effective than diffuse, delayed or easy goals to task motivation and good performance performance/control, concerns performance, continuous monitoring and adjustment exercised by the subject during the task , self-instruction for the development of information, monitoring time and degree of application, mood, etc.).Phase Two, (C)final self-assessment, comes after the performance phase and involves self-assessment of what has been achieved. Here, the subject reflects on what they have learned, on the level of performance reached in relation to the goals set, on the reasons for any successes or failures , evaluates their emotional reactions and degree of satisfaction, thinks about where and how to transfer what they have learned to other situations, and tries to identify errors so as to do better in future self-regulation cycles to address other tasks Non-regulated learning (NRL): NRL can be conceptually defined as a lack of proactivity or the absence of self-regulatory behaviors (SRB) in the process of learning. Conceptually, it is equivalent to what has been mentioned by (3)Dys-regulated learning (DRL): DRL is a negative level of proactivity, i.e., an approach that is active but inadequate to regulate the individual’s own learning behavior. As can be seen, this dysregulation can have ‘negative consequences’ in terms of maintaining self-esteem, because individuals avoid the effort involved in proactive self-regulation and use self-handicapping, procrastination strategies, increased cheating in the exam hall, psychological reactance or other disruptive behaviors that ultimately do not promote learning or good psychological and moral adjustment , there are also contexts that make self-regulation more likely to occur, do not promote self-regulation or tend to lead to dysregulation of the subject. SRL vs ERL Theory therefore, categorizes external regulation in three levels  that may(1)Externally regulated learning: In relation to the environment, (2)Externally NRL (ENL): this level is characterized by the absence of stimuli that promote SRB in students: there are no external signs or stimuli that make self-regulated or unregulated behavior more probable at the beginning, during or at the end of the subject’s behavior in a learning situation. In a non-regulatory context, which is neutral toward regulation, an individual may engage in at least a moderate level of SRB, because there are no features of the context to steer them either toward greater self-regulation or toward dysregulation of their behavior. An example of external deregulation in the classroom might be the absence of clear guidance from the teacher as to the use of mobile devices in class when it is known that indiscriminate use of such devices by students is associated with increased cyberbullying, cheating and poorer mental health Externally DRL (EDL): in this level, a student’s context actively promotes dysregulation of learning. That is, “non-positive, inadequate, or negative proactivity” is externally promoted. There are many external signs or stimuli that make dysregulation of behavior more likely, favoring active dysregulation at the beginning, during and at the end of the behavioral episode. In this type of context, the individual has to make a great effort to attempt to self-regulate their behavior  behaviors and actual behaviors. That requires the person to be capable of constant feeding back to themselves concerning the narrowing or widening of any gap and adjusting their efforts and strategies to achieve the target behavior.Self-regulated behavior and a lack of SRB have been extensively linked to sports performance, driving behavior in traffic psychology and to the general notion of people’s lifestyle . Many deadaptive expert  and not just conceptually (knowing) .As has been said, students can regulate three important dimensions of learning: cognition, motivation/emotion and apparent behavior, as well as context factors. To do so, they use different kinds of strategies: cognitive, metacognitive and support .support strategies We expected to find a positive correlation between learning regulation variables of the subject and their context (SRL/ERL), and variables of general SRB, RT, and self-regulated study behavior (SRS). We also expected to find a negative correlation between the variables of non-regulation and dysregulation of the individual and their context (NRL/ENL and DRL/EDL) with those same variables (SRL/ERL/SRB/RT/SRS).(2)We expected to find a positive correlation between corresponding internal and external levels of regulation of learning: (regulated) SRL with ERL; (non-regulated) NRL with ENL, and (dysregulated) DRL with EDL.(3)It was expected that large part of the variation in the variables of SRB, RT, and SRS would be explained by variables of both subject and context (SRL/NRL/DRL-ERL/ENL/EDL). And that SRL would positively predict RT and general SRB. Together, SRL and RT would positively predict SRS. We also expected that SRB would be negatively predicted by both NRL/ENL and DRL/EDL.(4)Each level of external regulation of learning will predict the same level of self-regulation: ERL will predict SRL; ENL will predict NRL; EDL will predict DRL. In complementary fashion, both internal and external non-regulation will positively predict internal and external dysregulation of learning, that is: ENL predicts EDL and NRL predicts DRL.(5)We expected to find significant models of mediation in which especially SRL mediates the relationship between contextual variables and other personal variables such as NRL and DRL.A total of 616 students from different universities voluntarily participated in this research. The sample was composed of students particularly in the fields of psychology, education and other social sciences. Of the total, 68.9% were women and 31.1% were men. The age range was 17–34 and the mean age was 22.19 years (SD = 3.19). The sample was incidental rather than probabilistic because the sample could not be randomized. The students voluntarily completed self-reports in a learning context . Participation was anonymous and voluntary. The questionnaires were completed online.p < 0.001; Ch/df = 2.851; RMSR = 0.05; IFI = 0.91; TLI = 0.90; CFI = 0.91; RMSEA = 0.05). The internal reliability figure for the instrument was good .That questionnaire , is strup < 0.001; Ch/df = 5.26; SRMR = 0.07; CFI = 0.97, RFI = 0.96, IFI = 0.97, TLI = 0.96, GFI = 0.97, RMSEA = 0.08). Internal consistency was acceptable for the total of items in the questionnaire in this sample .This variable was measured using the abbreviated version of the Self-Regulation Questionnaire SRQ; . That in2 = 2260,907, df = 492, p < 0.001; Ch/df = 4.59; SRMR = 0.05; CFI = 0.84, NFI = 0.85, RFI = 0.802, TLI = 0.83, NNFI = 0.80, RMSEA = 0.07) and the internal reliability value of the instrument is excellent .The abbreviated Interactive Evaluation of the Teaching-Learning Process Scales  , were us2 = 462,242, df = 116, p < 0.001; Ch/df = 3.98; SRMR = 0.05; CFI = 0.90, GFI = 0.91, AGFI = 0.90, RMSEA = 0.07) and the internal validity value is good .This questionnaire , has a shttp://www.inetas.net. That tool provides assessment and intervention in a self-help system for the university students and their teachers. The R&D project was approved by the Ethics Committee of the University of Navarre (ref. 2018.170). Compliance with the ethical principles of psychology was ensured , bivariate Pearson correlations were performed. For the prediction hypotheses , linear regression analyses were used, and it was confirmed through remainder analysis that the data were adequately compliant with the assumptions of the linear regression model. Subsequently, predictive structural equation modeling (SEM) was performed . For thaThe computer programs used to conduct this analysis were SPSS 26.0  for relip < 0.001) and the Shapiro–Wilk test (p < 0.001) were significant, such that analyses appropriate for non-parametric samples were performed. In general terms, regulatory variables  had means and medians higher than those for non-regulation or dysregulation, both internal and external. In addition, those variables showed negative asymmetry in which the values observed tended to be concentrated in the superior/higher segment of the relevant scales  were significantly positively correlated with each other. In addition, the different levels of both internal and contextual non-regulation and dysregulation were significantly positively correlated . Levels of SRL and ERL were significantly negatively correlated with levels of internal and external non-regulation and dysregulation .Following the same trend, and relative to the variables of SRB and RT, the results showed significant positive correlations between those two variables and SRL and ERL. SRB and RT were significantly negatively correlated with NRL/ENL and DRL/EDL.Finally, SRS tended to be significantly positively correlated with RT, SRB and with SRL and ERL. Conversely, SRS was significantly negatively correlated with DRL/EDL and NRL/ENL see .F]. SRL and ENL were the most significant subject variables.p < 0.05), the variability of SRS was partially negatively explained by EDL ; similarly, SRB explained more than half of the variation of EDL .In relation to RT and SRS, it was observed that for both variables, approximately half of the variability  was explained by the variables of SRL and ENL. With a lesser degree of significance  = 354.817, p < 0.001)]. In turn, around 28% of NRL was explained by ENL . The same pattern was found with dysregulation variables: EDL together with NRL explained more than 50% of the variability of DRL .Within SRL and ERL, it was found that ERL and RT explained approximately 53% of the variability of SRL [Model 1 tested the prediction for the relationship between the external factors of ERL, ENL and EDL with the internal factors of SRL, NRL, and DRL; and for the relationship between RT and SRB, SRL and ERL and the predictive effect of SRL, RT, and EDL in relation to SRS. Model 2 generated the closest ratios and prediction of internal variables by external variables was maintained. We tested SRL as a predictor of RT, SRS and SRB. We also assessed the predictive effects of NRL for SRB; of SRB and RT for SRS; of RT for SRS; and, ENL for SRL  ERL and SRS; (2) ENL and SRS; (3) ENL and SRB; (4) ERL and SRB; (5) ERL and RT; and (6) ENL and RT. ENL mediated the relationship between: (7) ERL and EDL; and (8) ERL and NRL.The following were characterized by multiple mediation: the relationship between ERL and DRL, which was mediated by the indirect effects of ERL and of EDL as well as NRL. The relationship between ENL and DRL was mediated by the direct effects of the relationships between ENL and NRL and EDL.RT partially mediated the relationship between SRL and SRB and (2) and between SRL and SRS. Finally, we found evidence that the predictive relationship of ERL relative to SRL was partially mediated by ENL.Three partial mediations were found: (1) All students can learn to regulate their learning, because the capacity for self-regulation is not a personality type or trait that a person cannot control, but rather something modifiable and capable of change that can be improved with, among other things, the help of an appropriate teaching environment . The finThus, in relation to hypotheses 1 and 2, the results showed that SRL and ERL were positively correlated with RT, SRB and with SRS. Those variables , were significantly negatively correlated with NRL and ENL. That is consistent with the findings of earlier research and is evidence of the external validity of the theoretical construct previously put forward by The results described in this study prove the interdependence identified by (a)External-regulation learning was significantly positively predictive of SRL; ENL predicted NRL, and EDL predicted DRL. As an additional finding, in this study we identified that perceptions of RT positively predicted SRB.(b)Non-regulated learning and ENL predict DRL and EDL with significant predictive weights . The data indicate that personal dysregulatory behaviors, such as procrastination, psychological reactance, etc. and contextual factors such as inadequate family guidance, risky group behaviors, etc., can be predicted by the absence of norms or other clear aspects of context that could steer the behavior of students before, during and after performance. The same results have also been found in the field of health, where the absence of orientating stimuli positively predicted internal and external dysregulation in relation to health adjustment behaviors in university students. In addition and in relation to executive functioning, it has been found that non-regulatory and dysregulatory contexts are positively associated with executive dysfunction and problems with emotional regulation .(c)In a direct and interactive way, EDL had a significant positive effect on DRL (0.72), which was mediated by both NRL and EDL.(d)SRL mediated the relationship between contextual variables such as ERL and ENL relative to SRS and SRB. It can be said that a regulatory context favors SRL , which might assist in classifying behavioral problems, should itself be confirmed. Second, cross-cultural studies should be performed to gather evidence of the intercultural validity of that categorization and the instruments developed to assess those constructs. In addition, there would be value in future research to determine the weight of each context – distinguishing family, school, and peers – in these predictive analyses so as to determine any discrepancies or similarities between the perceptions that students have. On the path toward those goals, these preliminary results provide empirical support for the proposed General SR vs. ER Theory ,b.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.http://www.estres.investigacion-psicopedagogica.org/lib/pdf/CERTIFICADO_COMITE_DE_ETICA_UNAV.pdf. The patients/participants provided their written informed consent to participate in this study.The studies involving human participants were reviewed and approved by MP-B: study design, data analysis, and drafting of the initial report. JF: director of the thesis and R&D project. MG-T: supervision and revision of the writing of the article. JM-V: director of the R&D project. FP-S and MV-M: data collection. All authors contributed to the article and approved the submitted version.


For the optimal growth and development of high-quality professional nursing care for hospitalized children, a partnership between pediatric nurses and parents within the context of the family is essential. The aim of the present study was to evaluate the factorial validity of the Pediatric Nurse Parent Partnership Scale for hospital pediatric nurses (PNPPS-PN) and to investigate the associations of its components with the Nursing Professional Value Scale and Compassion Competence Scale. This study used survey data from 236 pediatric nurses collected between March and June 2019. The seven-factor structure showed an acceptable to good fit in the confirmatory factor analysis, and the scale correlated as expected with measures of compassion competence and nursing professional values. The Cronbach’s α for the scale was 0.89, indicating good internal consistency reliability. The PNPPS-PN is a psychometrically sound instrument for assessing pediatric nurse-reported partnerships between pediatric nurses and parents in hospital settings. In a hospital, pediatric nurses and parents are both crucial to providing care to a child. In pediatric nursing, it is the collaborative relationship between pediatric nurses and parents that result in optimal care for the child . During Pediatric nurses know the importance of family-centered care (FCC); however, they experience difficulty implementing this approach due to a lack of clarity. Research has been conducted on the NICU context  and the Gallant et al.  indicateIt is important for pediatric nurses to form partnerships with parents for providing optimal nursing care to hospitalized children. There is insufficient evidence to examine whether pediatric nurses’ perceived parental partnerships are associated with pediatric nursing performance and outcomes in children. Therefore, studies are needed to confirm the construct factors of partnership between pediatric nurses and parents.Research on the aspects of the pediatric nurse–parent partnership that are essential to nursing hospitalized children and the development of relevant instruments is still limited and ambiguous . TherefoThis validation study had a cross-sectional and descriptive design. To evaluate the factorial validity of the PNPPS-PN for pediatric nurses, the scale was administered to pediatric nurses at four hospitals in South Korea. Four tertiary hospitals with pediatric nurses caring for a variety of hospitalized children were selected in Seoul, Busan, or Chungbuk Province. Pediatric nurses included nurses working in the general pediatric ward, pediatric cancer ward, neonatal intensive care ward, or pediatric intensive care ward that required constant interaction with the parent of the child. Only nurses with more than 12 months of hospital experience were included. The reason for limiting the subjects to nurses who have worked for more than 12 months was based on the findings that there was a difference in partnerships between nurses working less than 12 months and those working more than 12 months in pediatric wards . Data weThe general characteristics questionnaire asked for information on participants’ age, marital status, education, religion, current work unit, total years of career experience, and number of years working in pediatric units.The PNPPS-PN was adopted by Choi and Bang . This scNursing professional values were measured using the Korean version of the Nursing Professional Values Scale (NPVS) devised by Yeun et al. . The scaCompassion competence was measured using the Korean version of the Compassion Competence Scale (CCS) devised by Lee and Seomun . The scaThe data were analyzed using SPSS  for windows version 27.0 and AMOS  version 27.0 . Participant characteristics were analyzed using frequency, percentage, mean, and standard deviation. The construct validity of the scale was evaluated using CFA. Factor analysis for scale validation is based on prior theories, and it is desirable to perform CFA with the objective of determining the structure of the factors . CFA of Based on the values of several model fit indices, the Goodness-of-fit indices for the data were assessed and compared: Chi-square (χ2) value, Chi-square minimum/degree of freedom (CMIN/DF), Comparative Fit Index (CFI), root mean square error of approximation (RMSEA), Goodness-of-Fit Index (GFI), Normed fit Index (NFI), Tucker–Lewis index (TLI), and Akaike’s information criterion (AIC). A CMIN/DF of 2 or less is good. The CFI, GFI, NFI, and TLI are generally considered good if they are 0.9 or higher. In general, the RMSEA of 0.08 to 0.05 is good. The AIC is used to compare two or more models, and the lower the AIC, the better the fit. Correlations between factors were analyzed using Pearson’s correlation. Convergent and discriminant validity were assessed using the average variance extracted value (AVE) and construct reliability (CR) . FurtherEthical approval was obtained from the Institutional Review Board of the researcher’s university (CBNU-201812-SB-751-01). Informed consent was obtained from all the participants. Participants were informed of the purpose of this study before consenting to participate. The survey took about 10 min to complete. After the survey was completed, each respondent received approximately $5 as a token of appreciation.All participants were women, and the mean age was 29.29 ± 5.49 years (range 23–49). The average length of total career was 6.53 ± 5.47 years (range 1–26) and the average length of career in the pediatric unit was 5.90 ± 4.62 years (range 1–25). One hundred participants (42.2%) worked in newborn and neonatal intensive care units or pediatric intensive care units, and 76 participants (32.1%) worked in pediatric wards .p < 0.001), the AIC was lower in Model 3 (427.52) compared with Model 1 (1358.55) and Model 2 (1034.42). The conceptual framework of the original PNPPS-PN and the items were reviewed to categorize each factor as follows: Reciprocity, Professional knowledge and skill, Sensitivity, Collaboration, Communication, Shared information, and Cautiousness. The model fit of the final PNPPS-PN was tested with CFA. The fit of the model was found to be acceptable: χ2 = 309.52, CMIN/DF = 2.36, CFI = 0.91, RMSEA = 0.078, GFI = 0.88, NFI = 0.85, TLI = 0.88, and AIC = 427.52. In general, it showed good model fit. Since the CMIN/DF value was less than 3, the overall fit could be satisfied [The results of 7-factor models are summarized in odel 2 10.42. The Convergent and discriminant validity were assessed using the AVE value and CR. The AVE value of professional knowledge and skill and shared information did not reach the recommended standard of 0.5; however, in the case of the other five factors, it was more than 0.5. Each factor had convergent validity, with a CR range of 0.70–0.96. Discriminant validity is an indicator of whether there is a low correlation among factors for measuring different concepts and is secured by the AVE of a latent variable larger than the square of the correlation coefficient with other factors. Each of the seven factors in this study was found to have discriminant validity .Items with at least 0.30 for a correlation with the total score were included, and no items were excluded. The internal consistency reliability coefficient (Cronbach’s α) for the scale was 0.89. Cronbach’s alpha for the subscales were as follows: 0.88, 0.54, 0.69, 0.67, 0.54, 0.56, and 0.90 for Reciprocity, Professional knowledge and skill, Sensitivity, Collaboration, Communication, Shared Information, and Cautiousness, respectively .p < 0.001; Concurrent validity was evaluated by examining the relationships between the PNPPS-PN and measures of compassion competence (the CCS) and nursing professional values (the NPVS). The PNPPS-PN scale in its entirety and all seven subscales were significantly positively correlated with the CCS and NPVS . PearsonAs more focus is placed on the partnership between medical staff and families in the field of pediatric nursing practice, pediatric nurse–parent partnerships are increasingly accepted as an important concept. The PNPPS-PN is used to measure the perceived partnership between pediatric nurses and parents by pediatric nurses and parents, respectively. Many studies in Korea have used the PNPPS-PN to measure the concept of partnership among pediatric nurses. In contrast, there are no studies that tested the reliability and validity of the PNPPS-PN with only pediatric nurses. This study was conducted to evaluate the appropriateness of the pediatric nurse–parent partnership measurement tool as perceived by pediatric nurses—an important concept in nursing research and practice. After the factor structure of a scale has been identified, it is appropriate to perform CFA . In thisThe original scale consisted of seven factors and 34 items; however, in this study, five items with an SMC of 0.5 or less were deleted. A total of five items were deleted in consideration of the factor structure of the original scale. The first deleted question was ‘I immediately help parents who ask for help during the care of their children’. The four items deleted in step 2 included one item relating to the Sensitivity aspect (I encourage those parents who face difficult circumstances.) and three items relating to the Professional knowledge and skill aspect . It is judged that the items were deleted because they were similar to the items in the ‘Collaboration’ aspect. Based on the literature review and the theoretical background of the original scale, it is presumed that these results were obtained because the subjects of this study viewed the partnership as a more equal relationship . InteresThe AVE values checked to verify the convergent validity of the PNPPS-PN in this study reached the recommended standard of 0.5 . TherefoThe CCS and the NPVS were used to test the PNPPS-PN for criterion validity; significant positive correlations were found with the scales, supporting concurrent validity. Nurses’ compassion competence refers to the personal skills and abilities necessary to relieve the difficulties of the patient based on their understanding of the patient . NursingThis study has several limitations. First, the PNPPS-PN was validated based on a sample of pediatric nurses at four hospitals in South Korea. Therefore, the results of the analyses may not be generalizable to other pediatric nurse populations. Since this study evaluated the validity of the tool only for child nurses in South Korea, differences with the results for pediatric nurses in other countries cannot be excluded. In other words, differences in the nursing environment such as the scope of work of pediatric nurses in South Korea, a country where scales were developed, and the nursing delivery system, may affect the results. Future research needs to examine the cross-cultural validity of the PNPPS-PN with different populations internationally. Second, the PNPPS-PN was tested in the context of a child’s hospitalization and has limitations in its application to diverse areas of pediatric nursing practice. Therefore, it is necessary to evaluate the validity of the scale in more diverse settings of pediatric nursing practice. Third, the PNPPS-PN was only validated for use with pediatric nurses. Further research should be conducted to validate an instrument for measuring parent–pediatric nurse partnerships for use with parents and compare the degree of partnership perception between pediatric nurses and parents. Finally, some indices of model fit met the criteria less. In the future, it is suggested to develop a theoretical framework that reflects recent trends, and to conduct research that confirms the factor structure and continuously validates it.The PNPPS-PN is a psychometrically sound instrument for assessing pediatric nurse-reported partnerships between pediatric nurses and parents in hospital settings. The PNPPS-PN has utility for measuring the strength of pediatric nurse–parent partnerships and can provide data that can be used in educating nurses, research on nursing care, intervention programs, and policies to improve the pediatric nurse and parent partnership. The PNPPS-PN contains seven subscales and 19 items: Reciprocity has five items, Professional knowledge and skill has two items, Sensitivity has four items, Collaboration has two items, Communication has two items, Shared Information has two items, and Cautiousness has two items. Responses to the questionnaire are measured on a 5-point Likert scale, and total scores range from 19–95. The higher the score, the greater the degree of nurse–parent partnership perceived by the pediatric nurse. The instrument has been shown to be valid and reliable and is expected to be useful in understanding partnerships with the parents, as perceived by pediatric nurses, and in accumulating nursing knowledge and developing interventions. Based on these results, the following suggestions can be made for future research. First, the instrument can be used in repetitive research to assess and validate its stability. Second, the instrument can be used to identify the variables affecting pediatric nurse–parent partnerships. Third, the instrument can be used to develop an intervention program to improve pediatric nurse–parent partnerships and determine its effectiveness. Fourth, it is necessary to develop an instrument that can measure partnerships with pediatric nurses from the perspective of the parents.