The popularity of video gaming has generated significant interest in research methods to examine motivations for gaming. Current measures of gaming motives are limited by lack of scope and/or their applicability to specific game genres only. We aimed to create a comprehensive motivation inventory applicable to any gaming genre and to evaluate its psychometric properties in a large sample of highly engaged video gamers.Stage 1 of this project involved a systematic review that generated the items for the Gaming Motivation Inventory (GMI). Stages 2–4 involved an evaluation of the psychometric properties of the GMI. A sample of 14,740 video gamers  were recruited via an online survey promoted by a popular gaming magazine.In Stage 2, twenty-six gaming motives were identified, which clustered into six higher-order dimensions . In Stage 3, construct validity of the six higher-order motives was assessed by associations with gaming-related, personality, and psychological variables. In Stage 4, the relationships between motives and depression symptoms and gaming disorder symptoms were explored. Although gaming motives had weak associations with gaming genres, they were moderately related to variables such as competitiveness, sociability, and positive and negative affect. Gaming disorder symptoms were directly predicted by depression symptoms and indirectly via Immersion/Escapism, Habit/Boredom, and Competition motives.These findings support the notion that motives are one of the primary causes of gaming behavior and play an important role in predicting its problematic nature. The GMI is a psychometrically valid tool that will be useful for gaining insights into factors underlying gaming behaviors. The popularity of video gaming is continuously growing in all regions of the world  and its Motivation is the psychological force that activates and maintains goal-directed thought and behavior ; the stuStudying gaming motives is crucial in exploring the line between healthy and problematic engagement. For example, research on alcohol use and alcohol use disorder has consistently found that drinking motivation is of high importance in determining decisions about whether to drink or not , and motInternational Classification of Diseases and Related Health Problems, 11th ed., in 2019 under the name gaming disorder  are associated with GD  and alsohttps://quanticfoundry.com/), proposed a model comprising 12 distinct motives belonging to six higher-order motivation clusters  players in the early 2000s. Another established motivational scale developed from a large sample of online game players of several different genres is the Motives for Online Gaming Questionnaire MOGQ; , comprisAlthough these instruments were developed by generating large item pools and using a factor analytical approach to arrive at a final model, other instruments were developed mainly from a theoretical perspective. For instance, the Player Experience of Need Satisfaction scale  and the Existing motivational scales have several limitations. First, although they cover a number of different motives  and genre neutral; that is, it can be applied to any video game genres. To achieve these objectives, we conducted a systematic literature review to identify all of the gaming motivation scales developed up to late 2019. We then selected the most popular scales, along with the motivational factors from less used scales that seemed relevant to consider, and developed a comprehensive item pool that covered all motives in the scales. We aimed to cover each gaming motive with three to five items and test the psychometric properties of the factors created. Furthermore, we assumed that numerous different motives would emerge from the systematic literature search and measurement instruments identified; therefore, we aimed to test the higher-order structure of these motives and the construct validity of the structure obtained.The study comprised four separate analytical stages. In Stage 1, we conducted a systematic literature review of studies in which psychometric instruments were applied to assess video gaming motives empirically. From these instruments, a comprehensive and genre-neutral item pool was generated, in which items were clustered in motivational factors derived from the previous literature on gaming motives. Data were collected from a large-scale sample of highle engaged video game players to examine (a) the psychometric properties and higher-order structure of the motivational factors (Stage 2); (b) associations of the higher-order motivational dimensions with demographic, gaming-related, personality, and psychological variables (Stage 3); and (c) associations of the motives with depression symptoms, GD symptoms, and gaming time (Stage 4). The aim in Stages 2 and 3 was to test the construct validity of the identified motives.The study was approved by the Institutional Review Board of ELTE Eötvös Loránd University and was performed in line with the Helsinki Declaration.supplemental materials for a flowchart of the search procedure including exclusion criteria; the table comprising the selected papers can be requested from the corresponding author).To develop a comprehensive and genre-neutral pool of items assessing gaming motives, we first ran a systematic literature review to identify studies in which gaming motives were measured empirically. We conducted a computer database search of PubMed, ScienceDirect, Web of Science, and Scopus on November 21, 2019, using the following search terms and logic:  AND . All searches were limited to full-text papers  published in English. These database search parameters yielded a total of 3,965 hits: PubMed (396 results), ScienceDirect (300 results), Scopus , Web of Science . After duplicates were deleted, 2,463 hits remained. Abstracts and full texts, where necessary, were examined and studies were selected on the basis of using a psychometric instrument to assess video gaming motives empirically. The reference lists of the papers included were also examined. In total, 163 papers were retained . A list of 100 items covering 27 motives was generated from these instruments and factors. Considering that these items were meant to serve as the initial item pool for the development of the Gaming Motivation Inventory (GMI), we aimed to be as comprehensive and inclusive as possible, covering motives used consistently in previous studies, as well as those proposed to address recent developments in gaming . Furthermore, we aimed to generate items that were genre-neutral, which involved modifying some items to remove specific references to certain games or features. The items followed two different formats: (a) “Why do you play video games? I play video games…” and (b) “What kind of gameplay do you prefer? I like video games that…”. Both item formats were answered on a 7-point Likert scale from 1  to 7 (it corresponds exactly). The 100 items and the generation process are presented in detail in Supplemental Table S2 in the online supplemental materials.Next, the most frequently used motivational instruments were identified, along with motivational factors from less used scales that were assessed by the present authors as not identical, yet relevant to consider  to collect data from highly engaged video gamers . The most popular Hungarian gaming magazine, GameStar, targeting the Hungarian-speaking gamer community , promoted our survey among online readers and Facebook followers. Three advertisements containing the link to the questionnaire were posted on the magazine's website and Facebook page in March and April 2020 (a period when stay-at-home restrictions due to the COVID-19 pandemic were in force in the target countries). Paid Facebook ads were also used to reach the target audience during this period. Incentives were offered in the form of shopping vouchers . All articles contained the link to the questionnaire, as well as a description of the aims of the survey, the cooperation between our research group and the gaming magazine, and the opportunity to win some of the prizes. We also emphasized that the results of the survey would be reported on the website of the magazine, which was done in the first half of 2021.An online survey was designed and administered in Qualtrics . Email addresses were obtained from those willing to participate in the draw and used only to contact the winners.n = 105 in total). Because of the length of the questionnaire, we noticed a gradual attrition, in which 49.8% of the sample  fully completed the survey and 59.7%  had a maximum of two missing values. We decided to remove cases of participants who withdrew before answering the motivational item list. Therefore, a sample of 14,740 cases was used for the analyses. The listwise deletion method in SPSS version 25  for an average weekday and weekend day. Values could be given between 0 and 12; if respondents played more than 12 h a day, they were instructed to record 12. The two variables were combined during the analysis ([hours on an average weekday × 5] + [hours on an average weekend day × 2]). Gaming platform use in the previous year was assessed by asking respondents to divide 100% use among four response options: (a) PC/laptop, (b) gaming console, (c) smartphone, and (d) mobile devices other than smartphones . Game genres were measured in a similar way for the previous year by dividing 100% use among the following response options: (a) shooters, first-person shooter, third-person shooter , (b) battle royale , (c) multiplayer online battle arena , (d) auto chess/auto battler games , (e) open-world action-adventure , (f) role-playing games , (g) online role playing games (RPGs), MMORPGs , (h) strategy games, real-time strategy, turn-based strategy , (i) card games , (j) sport games , (k) simulations , other .Sociodemographic information  and questions regarding gaming habits were collected. The following gaming-related variables were assessed: weekly gaming time, gaming platform, and game genres. Gaming motives were assessed by administering the motivational item pool comprising 100 items  to the sample. To avoid systematic missing values on the later part of the item pool because of fatigue that may have appeared due to the lengths of the inventory, we randomized the items of the two blocks for each participant individually.Sociability was assessed with five items proposed by strongly disagree) to 5 (strongly agree), with one reversed item. Summarized scores ranged from 5 to 25, higher scores indicating stronger sociability. Cronbach's alpha was 0.82 in the present sample.Competitiveness was assessed with three items from the nine-item Enjoyment of Competition subscale of the Revised Competitiveness Index (strongly disagree) to 5 (strongly agree). Summarized scores ranged from 3 to 15, higher scores indicating a more competitive nature. Cronbach's alpha in the present sample was 0.84.ss Index . The iteSensation seeking is the tendency to enjoy and pursue activities that are stimulating or exciting and the willingness to try new and unconventional experiences. It was assessed with the four-item subscale of the short version of the UPPS-P Impulsive Behavior Scale  to 4 (strongly agree). Summarized scores ranged from 5 to 20, higher scores indicating higher self-esteem. Internal consistency on the present sample was 0.87.em Scale . These iSelf-esteem when playing video games was assessed with a modified version of the five positive items of the Rosenberg Self-Esteem Scale  was operationalized with two items to avoid having double-barreled questions. These two items were merged during the analysis in such a way that an “often” response given to any of the two items meant a “yes” for the merged criterion. Furthermore, in this study, we decided to exclude Item 8 of the IGDT-10 that assesses “escapism or mood relief” to avoid overlap with the Immersion/Escapism higher-order motive when assessing the association of the two variables . Scores ranged from 4 to 24, with higher scores indicating higher depressive mood level or more depression symptoms. Cronbach's alpha was 0.81 in the present sample.e CES-D; , used ine CES-D; . When anD Report . Items whttps://osf.io/tfhjx/. All research materials are described in detail in the manuscript. Analyses were performed with SPSS version 25  and a range between 14 and 75 years. Approximately half were single (48.3%), the other half being in a relationship and living either separately (22.8%) or together (28.3%). Some of the respondents were studying at the time of data collection (47.0%), and 50.6% had a full-time job. Overall, the sample comprised highly engaged video gamers, who played 27.6 h per week on average (SD = 14.9). Respondents divided 100% of their time between four gaming platforms that they had used in the previous year: PCs/laptops were the most used at 47.7% on average, consoles followed at 36.2%, and then smartphones at 14.7%. Gaming genres were assessed similarly. The most popular genre in the present sample was shooters (25.1%), followed by open-world action-adventure games (17.0%), RPGs (12.0%), battle royale games (10.1%), and sport games (9.4%) , with a mean age of 24.1 years (s (9.4%) .supplemental materials). According to the results, 66.4% of the sample played more in this period than before the pandemic , whereas gaming habits  were unchanged for 42.0% of the sample and changed only a little for 28.0%.Data collection took place in March and April 2020 when restrictions were applied in Hungary because of the first wave of the COVID-19 pandemic. To examine the effects of the lockdown situation, we administered additional questions  was used to perform an initial EFA of the theoretically proposed motivational factors (items were averaged). Sample 2  was used to conduct a separate EFA to cross-validate the factor structure found in the first analysis. Samples 1 and 2 were used to define the factor structure tested separately, with an exploratory structural equation modeling (ESEM) analysis on Sample 3 . The two EFAs were conducted with a principal axis factoring estimation method and oblique rotation, Promax (Kappa = 4), because factors were expected to be correlated. The number of factors was determined from the eigenvalues (larger than 1.0) and theoretical interpretability of the factors.First, psychometric properties of the 27 theoretically proposed motivational factors were examined by using CFA and checking Cronbach's alphas as internal consistency measures separately for each factor in the total sample. A Pearson-correlation was run to test the strength of the associations between the theoretically proposed factors. On the basis of these analyses, items with low factor loadings or overlapping content were removed and all items belonging to one motivational factor were parceled into one composite score for each motive. Second, the total sample was divided into three non-overlapping random subsamples. Sample 1  test of exact fit; however, this fit index tends to be oversensitive to sample size and minor model misspecifications , we relied on a combination of several different goodness-of-fit indices : the comications . Missingsupplemental materials. Each of the 27 factors comprised three to five items. When only three items covered a factor, the degree of freedom was 0 and model fit was not informative. However, factor loadings were > 0.6 for all items in all these cases . For factors with four or five items, fit indices did not meet the proposed thresholds in a few cases. In these cases, items with relatively low factor loadings were removed. Where modification indices indicated high error covariance between items, one or two items per factor were removed. The process for each factor is detailed in Supplemental Table S4. After “cleaning” the factors, we conducted a correlation analysis to determine the associations between the 27 motives. All correlations were < 0.7 except for Exploration and Mechanics motives (r = 0.744). These factors were merged, and four items were retained in the final merged factor, fitting the data well. Psychometric details related to the newly merged factor can also be seen in Supplemental Table S4. Finally, 88 items remained, parceled in 26 motives  and r = 0.695 (P < 0.001) and can be seen in Supplemental Table S6 in the online supplemental materials.First, CFAs were performed separately on each of the 27 theoretically proposed motivational factors to examine their psychometric properties. Fit indices, modification indices, factor loadings, and internal consistency measures were examined and are shown in Supplemental Table S4 in the online Second, we conducted two EFAs on two non-overlapping random subsamples  to investigate how the 26 motivational factors cluster into higher-order motivational dimensions. Six factors had eigenvalues above 1, and structures with five, six, and seven factors were examined. The factor structure with six factors was retained because of theoretical considerations. Mastery. The second factor was labeled Immersion/Escapism because escape, fantasy, coping, identity, and introjected regulation loaded strongly on it. In addition, autonomy, recreation, competence, and story had weak loadings. The third factor had status, competition, competence, and game skills loading on it strongly and several other motives loading weakly, including financial, introjected regulation, skill development, social, action-arousal, and identity, of which only financial did not have cross-loadings on other factors. The third higher-order factor was labeled Competition. The fourth higher-order motivational dimension was called Stimulation because it had arousal-action, destruction, and graphics loading on it, whereas competition, customization, and recreation had weak loadings and cross-loadings with other higher-order factors. The fifth higher-order factor had cooperation and social loading strongly on it and strategy loading weakly. Therefore, it was labelled Social. The last higher-order factor was called Habit/Boredom because it had only two motives loading on it: amotivation and boredom.In line with the eigenvalue information, the first three factors were more robust with more motives loading strongly on them, whereas the last three factors had only two to three motives loading on them. The merged motivation of exploration and mechanics, completion, advancement, and game skills loaded strongly on the first higher-order factor, whereas autonomy, strategy, story, customization, and skill development loaded weakly, and some  had cross-loadings with other higher-order factors. On this basis, the first factor was named 2 (184) = 3,264.4, P < 0.001; CFI = 0.944; TLI = 0.901; RMSEA = 0.059, 90% confidence interval 0.057–0.060; SRMR = 0.021. Autonomy, game skills, introjected regulation, skill development, and strategy motives had considerable cross-loadings. Furthermore, recreation, skill development, customization, story, and strategy had low factor loadings. Correlations between the six higher-order factors ranged from −0.013 to 0.480 . The model had an adequate fit to the data, χto 0.480 , the strIn Stage 3, we aimed to investigate the associations of the higher-order motivational dimensions with gaming genre, demographic, gaming-related, personality, and psychological variables to test the construct validity of the model.Gaming motives were introduced in the analysis as latent variables . A correlation analysis between the six higher-order motives and the game genres was conducted, complemented with a graphical illustration of the associations between these variables. Factor scores of the six higher-order motives obtained from the ESEM analysis (having a mean of 0 and standard deviation of 1) were rescaled with minimum-maximum normalization ranging from 0 to 100.We performed a multiple indicators multiple causes (MIMIC) analysis with the MLR estimation method in Mplus 8 to validate the six-factor motivational structure and test the association with personality traits  and psychological variables  on the total sample. Gender and age were introduced in the model as control variables. The MIMIC technique, a specification of SEM, was chosen because it can estimate the effect of indicators on latent variables  at the same time when direct effects of grouping variables or other continuous variables on the latent variables are also included, and it increases the precision of estimations because of the elimination of measurement errors. In addition, the zero-order correlation matrix of the variables included in the MIMIC model was established.supplemental materials). Correlations were very weak in general, ranging from −0.251 to 0.201, the former being between the Competition higher-order motive and the RPG genre. The highest positive correlation coefficient found was 0.201 between the Social higher-order motive and the MOBA genre. Second, we created a graphical illustration of the motives and the seven most popular genres in our sample . Furthermore, players with a preference for the MOBA genre had the highest scores in the Social, Competition, and Habit/Boredom higher-order motives; players with a preference for the RPG genre had the highest scores in the Mastery and Immersion/Escapism higher-order motives; and players with a preference for action-adventure, first-person shooter, and battle royale genres had the highest scores in the Stimulation higher-order motive.supplemental materials for the correlation coefficients of the variables included in the model). For instance, the Mastery higher-order motive was moderately associated with positive affect and weakly with sensation seeking. The Immersion/Escapism higher-order motive was positively and moderately associated with negative affect and weakly with perceived stress, and it was negatively associated with competitiveness with weak effect size. The Competition higher-order motive was most strongly associated with competitiveness, and it was also weakly associated with negative affect and negatively associated with age with weak effect size. The Stimulation higher-order motive was also weakly associated with competitiveness, sensation seeking, and negative affect. The Social higher-order motive was moderately associated with sociability and negatively associated with age with medium effect size, and the Habit/Boredom higher-order motive was moderately associated with negative affect and negatively associated with positive affect and age, having medium effect sizes in both cases.A MIMIC analysis was done to test the associations between the six higher-order motivational factors and numerous predictors. According to the results, associations between relevant personality and psychological variables and the six higher-order motives were as expected . Results showed that the relatively small group whose mood has improved due to the pandemic situation reported significantly higher scores across all motives than those whose mood has not changed or worsened. Besides, the group whose mood worsened scored higher on Immersion/Escapism and Habit/Boredom motives and lower on Social motive than the group whose mood has not changed.In addition, the relation of COVID-19 distress with the six higher-order motivational factors was analyzed  of depression symptoms on GD symptoms and gaming time, we performed structural regression analyses within structural equation modelling (SEM) with the MLR estimation method. We assumed that depression symptoms have both a direct and indirect effect (via the mediating effect of the six higher-order gaming motives) on GD symptoms and gaming time. Depression symptoms were measured with the short version of the CES-D and introduced in the model as a continuous observed variable. GD symptoms were assessed by the summarized score of the dichotomized IGDT-10 items, except for Item 8 , and implemented in the model as a continuous observed variable. Gaming time was calculated from time spent on games during weekdays and weekend days and was also entered in the model as a continuous observed variable. Higher-order gaming motives were introduced in the model as continuous latent variables as defined in the ESEM analysis. In addition, Pearson's correlation coefficients of the variables included in the mediation model were calculated.supplemental materials for the predictive effects in the model, and Supplemental Table S10 in the online supplemental materials for the correlation coefficients between the variables included in the model), depression symptoms had a significant direct effect on GD symptoms , as well as on four of six higher-order gaming motives, the strongest effects being on Habit/Boredom  and Immersion/Escapism . Regarding the associations between motives and GD symptoms, Immersion/Escapism, Habit/Boredom, and Competition motives had considerable effect sizes .According to the results of the mediation model (see P < 0.001 level: (a) depression symptoms → Immersion/Escapism → GD symptoms ; (b) depression symptoms → Habit/Boredom → GD symptoms ; and (c) depression symptoms → Competition → GD symptoms . However, the latter pathway had a negligible effect size. The mediation pathways added up to a total standardized indirect effect size of 0.195 (P < 0.001). The proportion of the mediated effect in the total effect was 52%. Therefore, higher levels of depression symptoms were associated with higher Immersion/Escapism, Habit/Boredom, and Competition motives that were associated with higher GD symptoms. The full model explained 28.5% of the total variance of GD symptoms.In relation to the indirect effect between depression symptoms and GD symptoms, three paths were statistically significant at the β = −0.063, P < 0.001). Regarding the association between motives and gaming time, Immersion/Escapism, Social, and Competition had considerable effect sizes . Comparing the correlation and path coefficient between Stimulation and gaming time , we suspect a negative suppressor effect . The path through Habit/Boredom had an effect size of β = 0.030, P = 0.021, whereas the one through Competition was β = 0.010, P < 0.001 and the one through Social motive was β = −0.009, P < 0.001. The mediation pathways added up to a total standardized indirect effect size of 0.121 (P < 0.001). Consequently, higher levels of depression symptoms were associated with a stronger Immersion/Escapism motive that was associated with higher GD symptoms. The full model explained 18.0% of the total variance of gaming time. Finally, the association between gaming time and GD symptoms was 0.172 (P < 0.001) in the model.In relation to the indirect effect between depression symptoms and gaming time, only the pathway through Immersion/Escapism was close to 0.1  gaming motivation inventory (the GMI) and test its psychometric properties and associations with personality and psychological constructs. After developing a large item pool identified by a systematic literature review, we retained 26 motives that clustered into six higher-order motivational dimensions. The findings support the validity and good psychometric properties of the basic factors, as well as the higher-order structure.The six higher-order motives retained in the GMI appear to be sufficiently comprehensive to cover those in most previous video gaming motivational models. For example, the higher-order motives in our model cover the three overarching motivational components  from Yee's research (2006) to a high degree. The Achievement component is covered by two of the six higher-order motives retained in the GMI: Mastery and Competition. In our model, these motives were clearly separated; the first refers to advancing in games, exploring, mastering game mechanics, and completing tasks and challenges, whereas the second refers to competition and winning, as well as social comparison and recognition within the gaming community. Yee's higher-order Social component is covered by the higher-order motive of the same name in the GMI. Finally, Yee's Immersion higher-order component is mostly covered by the Immersion/Escapism higher-order factor in the GMI, and some of the subcomponents of Immersion (discovery and customization) can be found in the GMI's Mastery higher-order motive. Although the motives escape, fantasy, and coping appear as distinct motives in the MOGQ , they ber = 0.48) in the GMI.Another interesting point when comparing these motivational models is that competition and community cluster together in Quantic Foundry's model in the overarching dimension called Social, and Yee argues that gamers who enjoy social interaction tend to enjoy other types of social interaction too, including competing with fellow players . In lineTo test the construct validity of the six higher-order motivational dimensions in our model, we first checked their associations with gaming genres, relevant personality and psychological variables, age, and gender. The associations between the six higher-order motives and game genres were generally weak. The reason for this may be that video games today are designed in a way to motivate gamers in several different and complementary ways; consequently, there are few differential links between distinct game genres and specific motives. MMORPGs, for instance, are known for the large variety of different gameplay choices that they offer. They can be highly competitive through the so-called player versus player challenges and highly cooperative through the so-called player versus environment challenges, but they also offer quests for players who like to play alone and focus more on exploration, customization, or role playing an imaginary character . FurtherThe associations between the higher-order gaming motives and relevant personality and psychological variables  were in line with expectations and previous findings supporting the validity of the motivational structure. The Competition higher-order motive was strongly associated with competitiveness and the higher-order motive Social was moderately associated with sociability. Stimulation was weakly associated with competitiveness, sensation seeking, and negative affect. Stimulation is about playing for the excitement and enjoying action and destruction, and it is associated with game genres that are highly competitive and full of fast-paced action such as first-person shooters. The Mastery higher-order motive had the highest association with positive affect. This indicates that playing to complete challenges, master skills, and explore different options is associated with a positive affective state, which is in line with findings from previous studies that have applied the self-determination theory to video games and report that perceived in-game competence and autonomy are associated with game enjoyment and increased well-being .Immersion/Escapism was moderately associated with negative affect and weakly with perceived stress and positive affect. This aligns well with previous studies that consistently report a moderate association between psychiatric symptoms and escapism, fantasy, and coping motives  negative association with Habit/Boredom, Social, and Competition higher-order motives. The latter two are in line with the results of other studies that reported that younger players are more competitive and more social than older players  and thatAccording to the literature, certain gaming motives  mediate between psychiatric distress and problematic gaming . To furtRegarding the first outcome variable, depression symptoms had a significant direct effect on GD symptoms and an even stronger indirect effect via Immersion/Escapism, Habit/Boredom, and Competition higher-order motives, the latter having a much weaker effect size than the others. These results are in line with previous findings and suggest that depression symptoms lead to an apathetic, escapist type of play by reducing positive affect and goal-seeking behavior . The indThe Immersion/Escapism motivation can be considered a form of distraction, an emotion regulation strategy when the person diverts his or her attention away from an emotionally difficult situation . When anThe Habit/Boredom higher-order motive includes amotivation and boredom, which were both found to be associated with problematic gaming . It is pThe weakest mediator was the Competition higher-order motive. In this case, a possible explanation is that players who experience depression symptoms also lack sources of success in their lives and may be more prone to play to achieve success in video games and a respected status within the gaming community. Although there is no problem with playing games to attain success, if this becomes the main or only source of success for the individual, he or she may start playing in a compulsive manner, which increases the risk of GD.Regarding the second outcome variable, depression symptoms had a very small negative direct effect on gaming time, but had a considerable indirect effect via the Immersion/Escapism, Habit/Boredom, and Competition higher-order motives, the latter two having much weaker effect sizes than the first. Interestingly, the direct effects between Immersion/Escapism and GD and between Immersion/Escapism and gaming time were of similar size in this study, whereas the former was much stronger in a previous study . It appeStrengths of the study comprise the systematic literature review which was used to create the initial item pool and which contributed to the development of a truly comprehensive measure. A series of statistical analyses and numerous variables were used to validate the instrument, which shows good psychometric properties. The motivation inventory can both be used in research and in the clinical practice (see the implications in the next section).Nevertheless, the study also has several limitations. The sample was a self-selected convenience sample; therefore, it is not representative of the entire gamer population. However, research demonstrates  that onlsupplemental materials). It remains the task of future research to develop a shorter scale covering the six higher-order motives.The GMI can be used in two ways. First, it can serve as a profiling tool, useful in both research and clinical settings. Scores on the 26 motives provide a motivational profile of the individual, comprising information regarding the latent psychological needs motivating him or her in gaming, and may also provide information regarding everyday motives and behaviors. Second, given the length of the inventory (88 items), parts of it can be used alone. If, in research or clinical settings, there is a specific interest in certain motives and underlying psychological needs, subscales or specific motivation factors can be used alone to explore them. The use of GMI subscales is supported by adequate internal reliability and high factor loadings of the items . OK was supported by the János Bolyai Research Scholarship of the Hungarian Academy of Sciences and by the ÚNKP-21-5 New National Excellence Program of the Ministry for Innovation and Technology from the source of the National Research, Development and Innovation Fund.OK, UR, JB, DLK, and ZD took part in conceptualization. OK and UR conducted the formal analysis. OK, UR and ZD designed the methodology. ZD and OK were responsible for funding acquisition. OK, EP and PK took part in the investigation. OK and PK was responsible for project administration. OK, JB, DLK wrote the original draft. All authors took part in the review and editing process.ELTE Eötvös Loránd University receives funding from the Szerencsejáték Ltd. to maintain a telephone helpline service for problematic gambling. ZD has also been involved in research on responsible gambling funded by Szerencsejáték Ltd. and the Gambling Supervision Board and provided educational materials for the Szerencsejáték Ltd's responsible gambling program. The University of Gibraltar receives funding from the Gibraltar Gambling Care Foundation. However, these funding aren't related to this study and the funding institution had no role or any influence on this publication. ZD has been member of a WHO advisory group on the public health consequences of addictive behaviors. In this capacity he has been eligible for travel support from WHO or the host center to attend advisory group meetings but have not been remunerated for their work. ZD is the Editor-in-Chief of the Journal of Behavioral Addictions. JB, DLK and UR are Associate Editors of the Journal of Behavioral Addictions.The other authors do not have conflicts of interest.https://osf.io/tfhjx/.All data and analysis code are available at the open science framework (OSF):


Many mental illnesses begin during adolescence. Parents of adolescents need to have sufficient mental health literacy (MHL) to recognize mental health problems in their children and to assist them with help-seeking. Although several educational programs have been developed to enhance parental MHL, their effectiveness has not been established. This study provides a systematic review for the effectiveness of MHL programs in parents of adolescents.PubMed, PsycINFO, CINAHL, ERIC and Web of Science were searched from the earliest date possible until February 2022; references of studies which met eligibility criteria were also screened. Studies that assessed quantitative change in at least one of the following components of parental MHL were included: knowledge of mental health/illnesses; stigma toward people with mental health problems; confidence in helping children with mental health problems, and intention, knowledge or behavior of helping children with mental health problems. Risk of bias (ROB) for each outcome within the included studies was rated using the revised Cochrane risk-of-bias tool for randomized trials for randomized controlled trials (RCTs), and the Risk of Bias Assessment Tool for Nonrandomized Studies for nonrandomized studies.Nine studies , reported in 10 articles, were included. Mental health knowledge and/or confidence was significantly improved in several studies, while no studies observed significant improvement in stigma and/or intention/behavior of helping children. ROB was high in five out of nine studies (10 out of 18 outcomes) and unclear in the others.A limited number of studies have evaluated effects of MHL program in parents and inconsistent quality contributes to difficulty in establishing their overall effectiveness. More studies with appropriate methods of recruitment, measurement and analysis, and transparent reporting are needed.https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020193072, Identifier: CRD42020193072. The first onset of mental illness usually occurs during adolescence . HoweverTo assist their children with mental health problems, parents need good mental health literacy (MHL), which is knowledge and beliefs about mental disorders that aid in their recognition or prevention . MHL hasA number of studies have assessed MHL in parents, finding that parental MHL is generally limited . ParentsParents may also need to have better knowledge of the MHL needs of their children. Recent work highlights these needs, which includes components such as knowledge of mental health professionals and of how to seek mental health information , 19. AlsThus far, several educational programs have been developed to improve MHL in parents of adolescents –23. AlthThe present systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines , 25. TheOur review included studies which examined the effectiveness of MHL educational programs in parents of adolescents (preteens and teenagers) in the general population, regardless of study design. Studies were included when they met both of the following two criteria.They implemented programs aimed at improving literacy about mental health problems which start to increase in prevalence during adolescence. Specifically, we included programs addressing mood and anxiety disorders or related problems, which are the two most prevalent types of mental illness , and schQuantitative change was assessed in at least one of the following four components of MHL in parents: (a) knowledge of mental health/illnesses and their treatments, (b) stigmatizing attitudes toward people with mental health problems, (c) confidence in helping children with mental health problems, and (d) intention, knowledge or behavior of helping children with mental health problems.Studies with any comparison condition  and studies using any measurement methods were included. Doctoral dissertations as well as studies from peer-reviewed journals were included, if they were written in English.Studies were excluded when they met any of the following: (1) Baseline measurements were not conducted; (2) Studies that tested programs which exclusively targeted parents of adolescents suffering from physical illnesses or mental illnesses. Also, studies which tested programs exclusively for suicide prevention were excluded, because they have already been systematically reviewed .PubMed, PsycINFO, CINAHL, ERIC and Web of Science were searched from the earliest date possible until February 2022. With the exception of PubMed and Web of Science, these databases were searched via EBSCO. Search terms included were: “parent”, “mental health”, “literacy”, “young people”, “program evaluation” and other related terms as below. In addition, the reference lists of included studies were scrutinized to identify any relevant publications according to eligibility criteria.* OR family) AND  AND (literacy OR belief* OR attitude* OR perception* OR stigma OR competen* OR abilit* OR capabilit* OR confiden* OR know* OR identif* OR aware* OR recogni*) AND  AND (adolescen* OR child* OR “young adult” OR “young people” OR teen* OR “young person”) AND .Search terms: (parentTwo reviewers (S.K. and S.Y.) independently screened the titles and abstracts, and excluded studies not relevant to the topic of interest. They independently reviewed the full-texts of the articles for final selection of included studies. A third reviewer (T.S.) was invited to resolve disagreements between the two reviewers.The first author (S.K.) extracted the following data from included studies: study design, country, comparison condition, sample size, timing of data acquisition, targeted age of children, participant baseline characteristics, details of intervention , outcome measures, outcome data and participation rates. We attempted to contact authors of included studies when they did not report all of this information. The second author (S.Y.) confirmed the extracted data. A third reviewer (T.S.) was invited to resolve any disagreements between S.K. and S.Y.Risk of bias (ROB) was rated for each outcome in each included study. The revised Cochrane risk-of-bias tool for randomized trials (RoB2)  was usedThe Risk of Bias Assessment Tool for Nonrandomized Studies  was usedTwo reviewers (S.K. and S.Y.) independently rated these domains. When the judgment was different between the two reviewers, they discussed with the third reviewer (T.S.) to reach a consensus.Within-group effect sizes  were calculated for each of the intervention groups and control groups as follows :In this calculation, the denominator is the standard deviation at pre-test, and numerator is the mean score at post-test minus the mean score at pre-test. When follow-up tests were conducted in the included studies, SMD was calculated by replacing mean score at post-test by mean score at follow-up test. Effect sizes are considered to be small, medium, and large, when SMD is between 0.2 and 0.5, between 0.5 and 0.8, and over 0.8, respectively .We did not conduct a meta-analysis of results, because methodological and clinical heterogeneity was high across the included studies and no studies had low ROB (see results section). Publication bias was also not assessed. We instead present a narrative synthesis for each of the following four outcomes: (a) knowledge of mental health/illnesses and their treatments; (b) stigmatizing attitudes toward people with mental health problems; (c) confidence in helping children with mental health problems; and (d) intention, knowledge and behavior of helping children with mental health problems.Studies where parents of adolescents participated in interventions were included. They covered information about, or skills to recognize the signs/symptoms of mental health problems/mental illness , 32–38. Timing of data acquisition was also varied; one out of the nine studies measured outcomes before (pre-test) and immediately after (post-test) the intervention . Pre- anROBs in the four included RCTs are summarized in Regarding the mode of delivery, knowledge was improved in three . This iWe searched studies which examined the effectiveness of MHL educational programs in parents of adolescents and identified a limited number of programs (eight programs in ten articles). Six programs addressed depressive disorders and/or related problems , 36, 37,ROB was “high” in the majority of included studies and “unclear” or “some concerns” in some others, for the following reasons. First, some of the descriptions of methods and results appeared to be unclear or lacking –36, 38, n < 100 in several studies , health care systems, as well as society at the whole, these are issues must be given urgent attention.First, studies from sources other than scientific databases such as non-profit organizations and governments may have been overlooked. Second, relevant studies not written in English were also not examined. Third, although we tried to obtain information that was missing or unclear in the included studies, not all authors were available. Finally, publication bias was not assessed, given inadequate amounts of comparable data due to the variety of measurement tools used in the included studies.The quality of the literature assessing effectiveness of previously developed MHL programs in parents of adolescents was inconsistent. Therefore, it remains unclear whether the programs overall were truly effective in improving parental MHL. However, significant positive effects were shown in several studies. It appears useful and worthwhile to develop educational programs to support parental MHL, although higher quality studies with clearer and more transparent reporting are needed. For example, in-depth description of details such as participation rates, methods, statistical analyses and outcomes are necessary. The effects on actual helping behavior in parents need to be measured in more studies.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.SK and TS designed the study, and wrote the review protocol with SY, JF, and FT. SK and SY carried out the study selection and the assessment of risk of bias. SK also conducted the data extraction, and SY confirmed the extracted data. TS was the third reviewer to help the study selection, the assessment of risk of bias and the data extraction. SK drafted the study, and TS, FT, JF, and SY revised the draft. All authors approved the final manuscript.This study was supported by grants from the Japan Society for the Promotion of Science .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.


To assess the efficacy of home-based cardiac rehabilitation and traditional outpatient rehabilitation in stage II after percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI).  From September 2019 to March 2020, 80 AMI patients in Cangzhou Central Hospital were randomly assigned to one of the two groups: the control group or the observation group, 40 cases in each group. The control group received old-fashioned outpatient rehabilitation treatment, and the study group received long-distance family rehabilitation nursing intervention. The blood pressure, examination results, compliance, satisfaction evaluation, incidence of cardiac events, heart rate, quality of life score, and 6-minute walking test were compared between the two groups. P < 0.05). There were substantial variances in left ventricular discharge portion, low-density lipoprotein, medication compliance, satisfaction, and quality of life (P < 0.05); there was substantial inconsistency in the 6-minute walking test concerning the two groups afterwards discharge for 3 months (P < 0.05).  There were no deaths in both groups. There were significant differences in heart failure, unstable angina pectoris, unplanned readmission rate, walking compliance, and 6-minute walking test at 6 months after discharge ( Home rehabilitation is a new home cardiac rehabilitation model with high efficiency, convenience, and whole process monitoring and barrier-free follow-up management. It can effectively improve the cardiac function, workout patience and worth of life expectancy of victims with AMI, improve their self-management awareness and rehabilitation compliance, reduce the risk of cardiac events, and have a positive impact on the prognosis and rehabilitation of patients with AMI. Acute myocardial infarction (AMI) is caused as a result of severe and lasting ischemia or necrosis of the corresponding myocardium because of the sharp drooping or interruption of blood supply on the basis of coronary artery dysfunction . AMI is Cardiac rehabilitation and prevention can fundamentally reverse the simple biomedical model. Cardiac rehabilitation reduces the sudden death rate, recurrence rate, and readmission rate of cardiovascular disease through the combination of five core prescriptions . Cardiac rehabilitation can be divided into three stages: stage I, hospitalization rehabilitation, 4–7 days after onset; II stage, outpatient rehabilitation, 7 days to 3–6 months after onset; and the third stage, family rehabilitation, from 6 months after onset to the whole life process . The traTherefore, the proposed study on victims with acute myocardial infarction PCI postoperative stage II remote home rehabilitation, compared with old style casualty rehabilitation efficacy , hope byP > 0.05). Participants in randomized controlled trials are randomly allocated to either the treatment or control arms. The practice of arbitrarily allocating sample members to treatment or control arms is referred to as randomization. To randomly select, a variety of tools can be utilized . The two factors of randomization are the creation of a random pattern and the implementation of such a random pattern, ideally in a way that leaves participants unaware of the sequence . The danger of systematic error or prejudice is eliminated by randomization. The most important benefit of an RCT is that it accounts for both predictable and unpredictable confounding variables, which can result in errors.Eighty patients having acute myocardial infarction who received emergency PCI in Cangzhou Central Hospital in the period of September 2019 to March 2020 were nominated for the examination as objects. The parallel randomized control method was used in the proposed study, and selected patients were arbitrarily allotted to one of two groups: observation or control, considering 40 cases for each group. In the observation group, there were 27 males and 13 females, (55.4 ± 8.9) years old, while in the control group, 25 males and 15 females, (55.6 ± 8.3) years old. There was no significant difference in general data between the two groups  ; emergenExclusion criteria were as follows: the history of myocardial infarction; there are serious complications, such as cardiogenic shock, severe arrhythmia, severe congestive heart failure, hypotension, obvious persistent or episodic chest pain, and mechanical complications; a history of mental disorders; serious other diseases, such as serious cerebrovascular disease sequelae, mobility inconvenience and physical disability and other factors affecting sports, severe anemia, and serious chronic lung diseases.Exercise prescriptions were formulated as stated by the strategies of the American College of Sports Medicine , and theChest tightness, chest pain, and shortness of breath appear after exercise. The heart rate after activity was lower than 50 beats/min or more than 130 beats/min. Postactivity Brog rating was >15.Walking frequency ≥50 times is considered as compliance standard . Those wThe nurses collected and sorted out the patients' heart rate, blood pressure, laboratory results, compliance, satisfaction assessment, incidence of cardiac events, quality of life score, and 6-minute walking test.χ2 test was used. P < 0.05 was considered as statistically major difference.The statistical software SPSS 17.0 was used to analyze the data. The statistical data were expressed as percentage (%), and the χ2. The χ2 test could be used to evaluate if two variables are highly correlated or not.The chi-square 2 statistic measures the difference between the observed and predicted probabilities of the consequences of a series of actions or variables. The chi-square test is a useful tool for determining category differences, especially those that are only nominal. The sample size, the degree of freedom, and the amount of the disparity in actual and recorded values all have an impact on the value of P < 0.05) ; there were significant differences in LDL, satisfaction, and left ventricular ejection fraction (P < 0.05).The difference of unplanned readmission rate was statistically significant (Most of your body's cholesterol is made up of LDL (low-density lipoprotein), also known as “bad” cholesterol. LDL cholesterol levels that are too high put you at risk of heart disease and stroke.To compute LDL, the following given formulation is used:P < 0.01). There was no substantial change in the occurrence and mortality of reinfection (P > 0.05).There was major change in the occurrence of unstable angina pectoris and congestive heart failure (P > 0.05). 3 months after discharge, the difference was statistically significant (P 0.05). The variance was statistically substantial 6 months after discharge (P < 0.01).There was no statistically substantial transformation between the 6-minute walking test at releasing and one month later (P < 0.05).There was significant difference in the scores of life quality between the two groups at 6 months after discharge (P 0.05) than the control groups, whereas the 6-minute walking test and quality of life were significantly greater (P 0.05). The rates of reinfection and mortality in the two groups were not significantly different. Home rehabilitation may help AMI patients improve their heart function, activity tolerance, and quality of life, but not increase the incidence of cardiac events and mortality, so it is safe and feasible for patients.The remote home rehabilitation mode of “Internet+ integrated medical care rehabilitation team” was applied to form a comprehensive, quantitative, individual, and sustainable new mode of home exercise rehabilitation, which improved the participation and safety of cardiac rehabilitation for AMI patients . The proAMI guidelines of the European Cardiology Society in 2012 pointed out that walking is the best way for stage II rehabilitation of AMI patients . Since eAccording to some researchers, cardiac rehabilitation must be done through exercise under medical observation . In the Six months after discharge, the walking compliance of patients in the control group was only 50% (20/40) and that of patients in the study group was about 95% (38/40), which was similar to foreign studies . Two groIn this respect, we suggest a procedure for implementing a statistical approach to questionnaire validation that incorporates exploratory factor analysis and reliability analysis. The research focuses on the psychometric examination of data from a survey.The home cardiac rehabilitation mode effectively ensures the safety and scientific nature of stage II home rehabilitation for AMI patients, improves patient compliance and quality of life, and is worthy of promotion through the standardized walking program, real-time monitoring of heart rate by APP or exercise bracelet, and barrier-free follow-up management on WeChat platform of medical rehabilitation team. The limitation of the projected study is that only exercise and medication intervention were carried out. With the development of information technology and cloud technology, more rehabilitation procedures and simple and effective monitoring equipment should be developed in the future, and behavioral intervention should be included in the stage II cardiac rehabilitation of AMI patients, so as to make cardiac rehabilitation more humanized, individual, convenient, and systematic.


Gender is one of the important social determinants of health known to be highly associated with health status. Despite the importance of gender awareness, it has not been addressed and researched in the Arab region, including Palestine. This study aimed to contextualize an Arabic version of the Nijmegen Gender Awareness in Medicine Scale (N-GAMS) and to assess the level of gender awareness and its associated factors among primary health care providers. The N-GAMS tool was translated and adapted through a gender expert consultation and a focus group discussion. Then, it was administered online to a sample of primary health care general physicians and nurses of all health care providing actors in Ramallah and al-Bireh Governorate. The reliability of the N-GAMS subscales using Cronbach’s alpha (α) was 0.681 for the gender sensitivity (GS) scale (9 items), 0.658 for the gender role ideology towards co-workers (GRIC) scale (6 items), and α = 0.848 for the gender role ideology towards patients (GRIP) scale (11 items). The results showed that participants had scored near the midpoint of the gender sensitivity subscale . They also expressed moderate gender stereotypes towards patients , where females held lower stereotypical thinking. Participants also expressed low to moderate stereotypes towards co-workers  and females expressed less stereotypical thinking compared to males. Furthermore, the participant’s age had some effect on the outcome, specifically on the GRIP subscale, while gender was associated with both GRIP and GRID subscales. The rest of the social and other variables showed no association with the gender awareness subscales. This study adds to our understanding of gender awareness. Further tests are required to confirm the psychometric qualities of the instrument. While males and females differ biologically (sex), they also differ in the assigned social responsibilities and roles (gender) ,2. Sex iStatistical data and research have documented significant gendered differences in health between women and men ,11,12,13Further, as suggested by Heise and colleagues, there are multiple gendered pathways to health. These pathways are gendered differences in exposure, gendered health behaviors, gendered impacts on accessing care, gender-biased health systems, gender-based health research, and institutions and data collection .During the previous two decades, gender awareness has been recognized as a critical factor in the interaction between health care professionals and patients, thus affecting health outcomes for both women and men . The WorThus, gender awareness conveys that the health care worker holds gender-sensitive attitudes, the knowledge and understanding of the whole meaning and sense of gender in illness and health, and the skills required to apply their visions to the medical practice ,23. GendPrevious research has operationalized the concept of gender awareness in healthcare into three main sub-components: gender sensitivity, gender-role ideology, and knowledge ,33,34. TThe N-GAMS was used in the literature to assess and compare Dutch and Swedish medical students’ gender awareness ; evaluatDespite the importance of gender awareness, it has not been addressed and researched in the Arab region generally and in Palestine specifically. Additionally, no previous studies have measured gender awareness among health care professionals, and there is no validated tool in Arabic. Therefore, this study aims to contextualize the internationally validated quantitative tool (N-GAMS) that measures gender awareness in health care, through translating and adapting an Arabic version of the N-GAMS among primary health care (PHC) general physicians and nurses in Ramallah and Al-Bireh Governorate, Palestine.The N-GAMS questionnaire assesses the gender awareness levels among health care workers. This scale is divided into three subscales: (1) gender sensitivity (GS): the degree to which health care professionals/medical students are sensitive and sympathetic to the impact of gender in medical practice (14 items); (2) gender-role ideology towards patients (GRIP): health care providers’ stereotypical views towards male and female patients (11 items); and (3) gender-role ideology towards co-workers (GRIC): health care providers’ stereotypical views towards male and female co-workers (7 items) . AnswersThe forward and backward technique was used to produce (adapt) a linguistic equivalent Arabic version of the scale. First, two bilingual independent translators did the forward translation (from English to Arabic). One translator was aware of the concepts the questionnaire intended to measure, and the other was a naïve translator (unaware of the measured concept of the questionnaire). Then, the translation discrepancies were discussed and resolved between the two translators. The next stage (backward translation) was done by two independent translators (mother tongue is English) who were unaware of the questionnaire concept. Then, both backward translation versions were compared for discrepancies between each other and the original English version. Afterwards, both (Arabic and English) versions were sent to a gender expert to confirm that the translated version was equivalent to the original version. Finally, recommendations from the gender expert and any discrepancies were discussed and applied by the research team.One focus group discussion was held, which included a total of 6 participants. Their occupations varied, including nurses, physicians, and pharmacists. The focus group was done to confirm that the Arabic version of the questionnaire is understandable and reflects the same ideas as the original version.The questionnaire was piloted at two stages to increase its face validity. The first pilot stage was done on health center staff consisting of one male physician, two female nurses, and one male nurse. Each participant was interviewed face-to-face. Participants evaluated the clarity of the instructions and items of the questionnaire (clear or unclear). When the item or the instruction was evaluated as unclear, the participant was asked to suggest how to improve the clarity. The results from this stage were used to modify the pre-final version of the questionnaire. The pre-final version was used for the final stage (second pilot), which included piloting the questionnaire on one female nurse and one male physician.We utilized a descriptive  study design to test the psychometric properties  of the Arabic version of the N-GAMS, which was translated in the first step of the research. The study was conducted in the period from June to August 2020.The study took place in Ramallah and Al-Bireh Governorate, in the center of the West Bank, Palestine. The target population (eligible participants) included the PHC professionals  in Ramallah and al-Bireh Governorate. The selection of the sample from the target population was based on three primary strata: (1) type of provider , Non-Government Organizations (NGOs), and the United Nations Relief and Works Agency (UNRWA)), (2) type of health care worker , and (3) gender , proportionally taking into consideration the total target population. The estimated sample size was 150 health care providers.Before starting the data collection, we obtained permission from the Ramallah and Al-Bireh Health Directorate to invite the PHC general physicians and nurses to participate in the study. Initially, the study was planned to be conducted through field visits to the PHC centers and face-to-face interviews with the general physicians and nurses to collect the data. However, due to the COVID-19 pandemic, this could not be achieved. Thus, we switched to an online alternative to collect the data. First, the survey was created on Google forms. Then, it was piloted on four participants to test the online version of the survey.The participants were recruited by sending the online survey link to their WhatsApp groups through coordination with administrators of the groups. Two groups were managed by Ramallah and Al-Bireh Health Directorate (one for each profession), and the third group was for UNRWA’s physicians and nurses. We reached out to these groups by contacting members, who sent the link to the rest of the group. Invited participants were sent two to three reminders over three months.Before starting the analysis, the response set for each individual was examined. We looked for participants who had the same response for all statements on the three subscales and excluded them from the analysis, because it may signal a lack of interest or understanding of the questions.Descriptive statistics were used to present the participants’ characteristics. The continuous variable (age) is presented as Mean (M) ± Standard Deviation (SD). The categorical variables  are presented as percentages (%). The number of units (n) values is stated for all the variables.The descriptive statistics of the N-GAMS items included mean ± standard deviation (M ± SD) for each item in the scale and the scored minimum and maximum values. Further, the direction of the negatively worded gender sensitivity items was reversed . Thus, higher scores reflect higher sensitivity levels. Then the mean scores of each subscale  were determined by computing the average values of each subscale’s individual items. Normality testing of the  computed variables, and the continuous variable (age) showed normal distribution; this was proven by utilizing the Shapiro–Wilk normality test and Q–Q graphs, in addition to the close value of the mean and the terminated mean supporting the normality of the variables.The internal consistency reliability of the subscales was assessed by measurement of Cronbach’s alpha coefficient (α). For the validity assessment, Bartlett’s test of sphericity and the Kaiser–Meyer–Olkin (KMO)—a measure of sampling adequacy—were used to assess the ability to perform Confirmatory factor analysis (CFA). To support the validity, we tested the following hypotheses: there is a positive correlation between the gender role ideology towards co-workers (doctors/nurses) and the gender role ideology towards patients (hypothesis 1), and an inverse association with gender sensitivity (hypothesis 2).t-test was used to test the association between gender awareness measured by N-GAMS subscales  (dependent variables) and each independent categorical variable (two-category: sex). Moreover, one-way variance analysis (ANOVA) was used to assess the relationship between the dependent variables and the independent categorical variables (three or more categories), including marital status, place of residence, locality, highest education level, and study country. Further, Pearson correlations assessed the statistical significance between the dependent and continuous independent variables (age) and evaluated the relationship between the N-GAMS subscales . Multiple regression was conducted to assess further the relationship between the dependent and the independent variables based on the Bivariate analysis.An Independent sample p < 0.05 and a 95% confidence interval (CI) were adopted.All statistical analyses were conducted using the Statistical Package for Social Sciences (SPSS) version 20.0. A significance level of Ethics approval was obtained from the Institute of Community and Public Health’s Research Ethics Committee at Birzeit University, Reference number: 2020 (2-1). All participants provided written informed consent. All methods were performed in accordance with the relevant guidelines and regulations.The total study sample consisted of 120 PHC nurses and physicians , males n = 15 (12.5%)), . Nurses made up 90% of the total sample (n = 108); the majority were females (97.2%), . Physicians formed only 10% of the total sample, and they were all men, . Participants, on average, showed low to moderate levels of gender sensitivity . On the other hand, for the gender role ideology toward patients, participants, on average, revealed moderate gender stereotypes towards patients . Lastly, participants, on average, had low to moderate adherence to gender stereotypes (gender role ideologies towards co-workers (nurses/doctors)) .The literature established a strong positive relationship between factor analysis (FA)—a statistical data reduction method—and construct validity . Scholarp < 0.05) for the FA to be considered suitable. The KMO index varies from 0 to 1 [p = 0.000), the KMO value was 0.673, which is a mediocre value; thus, factor analysis was not possible in this case [However, to run an FA test on a data set, two main issues must be considered, the strength of correlations between the items and the sample size. In our study, the sample size, according to , should m 0 to 1 . In our his case .Although the construct validity of the instrument (N-GAMS), could not be confirmed through FA, the following hypotheses were assumed and studied to support the construct validity. In compliance with the previous studies , we expep < 0.001), which backs up the presence of a common ground for gender found between GS with GRIP  and GS with GRIC . Thus, findings partially support the hypothesis that the components contribute uniquely to the construct of gender awareness.As shown in Cronbach’s alpha (α) was 0.681 for the GS subscale (9 items), 0.658 for the GRIC subscale (6 items), and (0.848) for the GRIP subscale (11 items). Items with an item total correlation lower than 0.2 were removed as shown in Excluding the “weak” items improved Cronbach’s alpha (α) from 0.611 to 0.681 for the GS scale, and 0.642 to 0.651 GRIP scale. The mean inter-item correlation for the GS scale improved to 0.21 from 0.1 and 0.25 from 0.2 for the GRIP scale. Since it is the first time using the Arabic version of the N-GAMS, CFA should still be carried out to test the tool’s structure after deleting the items.p = 0.004, two-tailed) with a mean difference of 0.495 . GRIC scores in the female group (M = 2.81 ± SD = 0.49) were significantly lower than the male group (M=3.01 ± SD = 0.4340) (t (117) = 5.96, p = 0.000, two-tailed) with a mean difference of 0.95620 . Yet, there were no statistically significant differences between mean GS scores between males and females. When compared according to participants’ age, using the Pearson correlation, a negative significant association between the GRIP subscale and age  was found. However, GS and GRIC showed no significant association with age where r = −170, p >0.05 and r = −0.011, p > 0.05, respectively. There were no statistically significant differences in the mean score of the gender awareness subscales with the other variables .The independent sample t-test showed significant differences in the mean GRIP and GRIC scores for males and females. GRIP scores in the female group (M = 3.06 ± SD = 0.599) were significantly lower than the male group (M = 3.55 ± SD = 0.645) (t (117) = 2.967, This study aimed to contextualize and adapt an Arabic version of the Nijmegen Gender Awareness in Medicine Scale (N-GAMS) , among pThe three-domain construct of the N-GAMS is partially supported by confirming hypothesis 1 (there is a positive correlation between the gender role ideology toward co-workers (doctors/nurses) and gender role ideology toward patients), the primary and more common test used to assess and investigate the structural construct validity is confirmatory factor analysis (CFA). Research highly suggests using CFA as an appropriate technique to validate instruments/scales by confirming the instrument’s construct .In this respect, factor analysis has specific requirements to be met to have more reliable outcomes. First, it is stressed that an adequate sample should be present. Generally larger sample sizes are better, results based on small samples are not reliable . The reqReliability and internal consistency reflect the degree of correlation between the scale items (if the items measure the same construct). Cronbach’s alpha coefficient is one of the most common indictors of internal consistency . InternaItems with an item total correlation lower than 0.2 were removed. Thus, the mean inter-item correlation for the GS scale was 0.21, while it was 0.33 for the GRID scale, and 0.25 for the GRIP scale, reflecting an acceptable inter-item correlation. Since it is the first time using the Arabic version of the N-GAMS, CFA should be still be carried out to test the structure of the tool after the deletion of the items.Regarding the excluded items, the gender sensitivity subscale required the most modifications, a total of five items were excluded due to low item total correlation  and based on SPSS recommendation for the Cronbach’s alpha value. The GRIC subscale had only one item exclusion, while the GRIP subscale included all the original items. The exclusion of a high number of items from the subscale was observed in the previous research ,35. ThisMeasuring gender awareness and the associated stereotypes and attitudes by using a quantitative scale have advantages and disadvantages. Regarding the advantages, employing such a tool will provide the capacity to conduct research and evaluations on the gender awareness topic, while including more individuals from the target population simultaneously, and is cost and time-efficient .On the other hand, since N-GAMS only measures the attitudinal component of gender awareness, a comprehensive understanding of the health professionals’ gender awareness is required. Future studies should assess health care workers’ knowledge on how sex and gender may influence an individual’s health and health care, along with the skills required to incorporate such knowledge in clinical practice . Hence, Participants held neutral opinions on the GS subscale statements. In this respect, even though health care workers observe daily disparities between males and females in everyday actions and tasks, their views, expectations, assumptions, and values are also influenced by societal conditions and their behavior . This coGS subscale statements reflect the significance of gender disparities in biology and communication related to clinical practice. However, the GRIP and GRIC subscales statements are explicit and evaluative regarding male and female physicians and doctors; for instance, statements expressed that one gender for patients or physicians is characterized as “too much”, “less”, or “better” than the opposing gender. Therefore, when the health care workers agree with statements, it reflects believing and accepting in gender differences and the hierarchy of these differences. One gender’s characteristics are considered better and more favorable than those of the opposite gender . The staConsistent with previous studies ,32, therAge and gender were the only variables that were significantly associated with some subscales of the N-GAMS. The other background variables could not statistically help to understand the gender awareness levels.Gender sensitivity was not significantly different between male and female participants, which was found in other studies ,37. On tOther studies that used the N-GAMS also reported females having/scoring lower with regard to stereotypes than males toward patients and co-workers including Swiss medical students , Sweden We should note here that we are aware of comparing our results with studies that used the N-GAMS tool but with different target populations, but we had to due to the limited studies done on similar groups to ours. Males and females differ in terms of the outspokenness of gender role ideologies . In our Older health care workers had a better gender awareness, specifically on the gender role ideologies stereotypes domain, which was also reported in previous studies . Older gThe nurse’s male: female ratio in our sample  was consistent with the ratio of the target population , based on unpublished data provided by the MoH. By contrast, the physician’s male: female ratio did not reflect the target population ratio; no female PHC physicians have participated in our study, compared to 41% female and 59% male physicians found in the target population.On the other hand, participants reflected the distribution of physicians and nurses in PHC centers in Ramallah and al-Bireh in terms of the type of the center. A total of 79.2% of the total participants were from MoH centers, 13.3% were from UNRWA, 6.7% were from NGOs and the MoH, and finally, 0.8% were from NGOs. Thus, we could not reach our physician’s target sample size, reflecting the low response rate (12%) from the physicians, especially the females. Research has shown that it might be challenging to conduct surveys of health care professionals. Low response rates are prevalent among health care practitioners in general and physicians in particular . This paSome possible factors could explain why physicians had a low response rate. Possibly, participants did not find interest in our research topic or found it irrelevant and insignificant. Additionally, it is likely that physicians had a busier schedule and thus had less free time to fill out the survey. Therefore, we addressed this issue by keeping the link accessible for a long period with easy access . Ultimately, we could not eliminate the nonresponse bias, this study lacked the participation of physicians, especially females, which impacted the generalizability of the result and its applicability.This study attempted to contextualize an Arabic version of an international tool (N-GAMS) measuring the gender awareness concept, which to the best of our knowledge, will be the first Arabic version of the tool. We would like to acknowledge some limitations for this study. First, the results and its applicability were impacted by the small sample size and nonresponse bias. Physicians had a very low response rate of 12% and there was no response from female physicians. Further, psychometric qualities of the Arabic N-GAMS need further testing on larger sample size, as we could not meet the requirements for the CFA. In addition, the results of this study might be affected by the social desirability bias, as the topic is sensitive and the responses were based on self-assessment. Finally, even though this instrument focused on the attitudinal components of gender awareness, qualitative research is needed to understand the other aspects of gender awareness.Gender awareness among primary health care physicians and nurses has not been studied extensively globally and in Palestine. This study attempted to contextualize an international tool (N-GAMS) measuring the gender awareness concept in the Palestinian context. However, a larger sample size  is required to confirm the psychometric qualities of the instrument along with qualitative research to understand the other aspects of gender awareness.


The nursing goal of patients with cancer is to provide them with holistic care, including physical, psychological, and social adaptation, and spirituality. This research aimed to explore the influence of the social workers' empathy ability on suicidal ideation of patients with cancer and its path.There was a sum of 358 patients with cancer and the 45 social workers serving them participated in the survey. Data of their self-efficacy, depression symptom, stigma, and suicidal ideation were measured before the social work provided (T1) and 3 months after the social work finished (T2) were collected and compared. Pearson correlation analysis was used to assess the relationships between social workers' empathy ability and patient indicators at T2. The influence path of social workers' empathy ability on cancer patients' suicidal ideation was explored by path analysis at T2.At T2, patients reported higher self-efficacy and lower depression symptoms, stigma, and suicidal ideation than at T1. At T2, social workers' empathy ability was positively related to patients' self-efficacy and was negatively related to depression symptoms, stigma, and suicidal ideation. Social workers' empathy ability affected patients' suicidal ideation directly. In addition, patients' self-efficacy, depression symptoms, and stigma played mediating roles in the influence of social workers' empathy abilities on their suicidal ideation.Social workers' empathy ability not only directly affected cancer patients' suicide ideation but also affected suicide ideation through the mediating roles of self-efficacy, depression symptoms, and stigma. Therefore, the improvement of the empathy ability of medical social workers needs to be paid attention to. Health management of patients with cancer has always been a multidisciplinary issue. It requires not only the participation of doctors and nurses but also psychotherapists and social workers to help patients improve their mental health and social adaptation. In some developed countries in Europe and the United States, medical social workers have become a mature and specialized profession to intervene in the medical process of patients in the whole process, and their education and training system is sound . PatientEmpathy refers to the ability to experience the situation of others, to feel and understand the feelings of others . PreviouHowever, in medical practice, especially from the perspective of psychosocial oncology, the impact of social workers' empathy on patients' psychosocial health has not been reported. According to previous research and clinical practice, patients with cancer are prone to psychosocial problems, such as suicidal ideation, stigma, depression symptom, anxiety symptom, insufficient self-efficacy, and sleep disorder , 16. TheAccording to the literature, self-efficacy is a protective factor against suicidal ideation, and increasing self-efficacy can be strategically beneficial for larger suicide prevention . To someFor patients with cancer, many people have depressive symptoms and stigma because of the severity of the disease, the negative impact on the patient's physical function and social function, and the stigmatization of the disease , 21. TheBased on this background, this study explores the impact of empathy of social workers on suicidal ideation of patients with cancer and tries to analyze the action path. Through this study, we hope to verify the impact of the empathy ability of social workers on patients' psychosocial health and call on medical social workers to pay attention to the improvement of their empathy ability. We established two hypotheses about the impact of social workers' empathy on suicidal ideation in patients with cancer. Hypothesis 1: Social workers' empathy ability affected cancer patients' suicidal ideation directly. Hypothesis 2: Social workers' empathy ability affected cancer patients' suicidal ideation through the mediating roles of self-efficacy, depression symptoms, and stigma.From 2019 to 2021, 358 patients with cancer were selected as the research objects by using the convenient sampling method and were asked to complete the questionnaires. Because the total number of medical social workers in mainland China is very small, these social workers and patients come from Beijing, Guangdong, and other provinces. The inclusion criteria of patients: (1) They were diagnosed with cancer and knew their diagnosis. (2) They had no mental illness and did not use psychotropic drugs. (3) They would receive social work case service. Social workers serving them were also asked to fill out questionnaires. Each social worker can serve multiple patients, but each patient can only receive the services of a single social worker.The inclusion criteria of the medical social worker: (1) Since there is no medical social worker certificate issued by a special authority in mainland China, participants are required to hold a social worker certificate. (2) They should actually engage in medical social work for more than 6 months after obtaining the social work qualification. (3) They should be social workers from hospitals, social work agencies, or NGOs.This research aimed to confirm whether there was a relationship between social workers' empathy ability and patients' suicide ideation. We performed a mediation analysis to test how social workers' empathy ability affected patients' suicide ideation. The main steps of the research were as follows: (1) Before the social work provided (T1), patients were asked to complete an anonymous questionnaire, including questions on demographic sociological information and disease situation. And their self-efficacy, depression symptoms, stigma, and suicide ideation were measured. Their social workers' empathy abilities were measured. Because empathy is a relatively stable ability, we only measured it once. (2) According to unified standards, social workers provided case services for patients, including helping patients and families fully understand their own resources and potential, psychosocial health counseling, improving their self-management and coping abilities, and improving their abilities to adapt to the treatment stage and solve difficulties. The social work was provided at least 6 times for each patient, and each time lasted for 30–60 min. These six services were completed within 2 months. The services were provided in hospitals or in patients' homes according to the actual situation. (3) Three months after the social work finished (T2), patients' psychological indicators were measured and were compared with T1. The relationships between social workers' empathy ability and patient indicators at T2 were measured. The influence of social workers' empathy ability on cancer patients' suicidal ideation and its path was explored.The data of demographic information of patients comprised sex, age, family residence (countryside/county town/urban area), and disease situation was collected.The IRI questionnaire was applied to evaluate social workers' empathy ability. The IRI consists of a 5-point Likert Scale with 22 items. These items are divided into four dimensions: Perspective taking, empathic concern, fantasy, and personal distress. The score for each item ranges from 0 to 4, and the total score ranges from 0 to 88. A higher score indicates a stronger empathy ability . The score for each item ranges from 1 to 4, and the total score ranges from 20 to 80. The standard score is the total score multiplied by 1.25. A higher score indicates more severe depression symptoms . The CroThe SIS questionnaire was applied to measure patients' stigma. The SIS consists of a 4-point Likert Scale with 24 items. These items are divided into four dimensions: social rejection, financial insecurity, internalized shame, and social isolation. The score for each item ranges from 1 to 4, and the total score ranges from 24 to 96. A higher score indicates more stigma . The CroThe BSI questionnaire was applied to test patients' suicide ideation. The BSI consists of 19 items. The score for each item ranges from 0 to 2, and the total score ranges from 0 to 38. A higher score indicates more suicide ideation . The scat-test was applied to compare the indicators on T1 and T2. After the data were proved to be consistent with the homogeneity of variance, variance analysis was applied to compare the indicators of the groups. Pearson correlation analysis was used to test the correlations between social workers' empathy ability and patients' indicators. Structural equation modeling (SEM) was applied to analyze the relationships between variables. SPSS Amos version 25.0 was applied to assess variables' mediation effects. Setting the bootstrap number as 5,000, the bias-corrected non-parametric percentile bootstrap method was used to estimate the significance of specific mediating effects and simple slope analysis. A P value < 0.05 was considered statistically significant.EpiData Entry version 3.1 and SPSS version 25.0 was applied to enter and analyze the data. The data were tested for normality with a P-P diagram. In this research, all data was presented by mean ± SD because it conformed to the normal distribution. The paired There were a total of 380 patients were asked to participate in the research, and 358 of them provided valid questionnaires, with a participation rate of 94.21%. Their average age was (55.2 ± 3.8) years. Gender distribution: 170 were male, accounting for 47.49%; 188 were female, accounting for 52.51%. Family residence distribution: 127 came from rural areas, accounting for 35.47%; 31 came from county towns, accounting for 8.66%; and 200 came from urban areas, accounting for 55.87%. Their average course of disease was (4.2 ± 0.8) years. There were 78 patients had respiratory cancer , 85 patients had gastrointestinal cancer , 62 patients had reproductive system cancer , 23 patients had urinary system cancer , 68 patients had breast cancer, and 42 patients had head and neck neoplasms. The 358 patients with cancer were served by 45 social workers, with an average service time of 278 min in total for each patient.The psychological indexes of the patients at T1 and T2 were compared. At these two time points, the psychological indicators of patients showed significant differences. The results are shown in To clarify the situation of patients with different types of cancer, we compared the psychological indexes in 6 types of patients with cancer at T2. There was a significant difference in the comparison of stigma (SIS) among the groups. Patients with breast cancer had the highest stigma. The results are shown in At T2, social workers' empathy ability was positively correlated with patients' self-efficacy, and negatively correlated with patients' self-efficacy, depression symptoms, stigma, and suicidal ideation. P < 0.001), which meant that social workers' empathy ability affected patients' suicide ideation directly. Therefore, hypothesis 1 was confirmed. Moreover, social workers' empathy ability had a significant positive impact on patients' self-efficacy and a significant negative impact on patients' depression symptoms and stigma. Patients' self-efficacy had a significant negative impact on their suicide ideation. And patients' depression symptoms and stigma had a significant positive impact on their suicide ideation. 2/df = 2.615, RMSEA = 0.067, GFI = 0.997, TLI = 0.974, CFI = 0.997, IFI = 0.997, AGFI = 0.956, and NFI = 0.996. The mediating effect model is shown in The results of path analysis showed that social workers' empathy ability had a significant negative impact on patients' suicide ideation (P < 0.01). In the path of IRI → CBI → BSI, CBI played a significant mediating effect between IRI and BSI . In the path of IRI → SIS → BSI, SIS played a significant mediating effect between IRI and BSI . In the path of IRI → SDS → CBI → BSI, SDS, and CBI had a significant chain-mediating effect between IRI and BSI . In the path of IRI → SIS → SDS → BSI, SIS, and SDS had a significant chain mediating effect between IRI and BSI . In the path of IRI → SIS → SDS → CBI → BSI, SIS, SDS, and CBI had a significant chain-mediating effect between IRI and BSI . Therefore, hypothesis 2 was confirmed.Overall, it was confirmed that patients' self-efficacy increased, and depression, stigma, and suicidal ideation decreased 3 months after the social work service in this study. This showed that social work services were helpful to the mental health of patients with cancer. Among these patients with cancer, breast patients with cancer had the highest stigma. This shows that in the future psychosocial intervention, we should pay more attention to helping them reduce the stigma.In the path analysis of social workers' empathy ability on patients' suicidal ideation, the two hypotheses in the study have been confirmed: Social workers' empathy ability not only directly affected cancer patients' suicidal ideation but also affected the suicidal ideation of patients by acting on self-efficacy, depression symptoms, and stigma.Our results showed social workers' empathy ability affected cancer patients' suicidal ideation directly. This just echoes the “offering empathy without endorsing suicidal ideation” advocated in other studies . We got In addition, social workers' empathy ability affected cancer patients' suicidal ideation indirectly, and self-efficacy, depression symptoms, and stigma were mediating roles. In the first path, social workers' empathy ability affected patients' suicidal ideation through the mediating role of self-efficacy. Although there haven't been reported the effect of social workers' empathy ability on patients' psychological indicators, the results were similar to the studies on medical staff and patients. It has been proved doctors' empathy ability was associated with patients' self-efficacy . In sociIn the second path, social workers' empathy ability affected patients' suicidal ideation through the mediating role of depression symptoms. Social workers with high empathy ability may help reduce patients' depression symptoms. A former study reported that showing perceived physician empathy was related to patients' psychological distress, which was similar to our research . When taIn the third path, social workers' empathy ability affected patients' suicidal ideation through the mediating role of stigma. A former study confirmed doctors who had strong empathy ability and skills can reduce cancer patients' stigma . This isIn addition, this study found that the depressive symptoms of patients affected their self-efficacy and stigma. Therefore, there were three chain mediating effects in the influence of social workers' empathy on patients' suicidal ideation.Although this study had some limitations, such as it was not a big data statistical analysis, and the influencing factors of patients' suicidal ideation were multiple, we could not remove all confounding factors. Because the total number of medical social workers in mainland China is small, it was difficult for us to select social workers in the same region, and it was also difficult to strictly limit the course and type of disease of patients. In our study, the average course of the disease was as long as 4.2 years. In the future, we can carry out some studies on social work services for patients at the initial stage of diagnosis or at the stage of hospice palliative care. We think that social work services may have a better effect on patients at the initial stage of diagnosis, because patients at this stage have just been diagnosed with cancer, which is a major traumatic event for them. Therefore, their psychosocial health needs more attention. In addition, targeted social work services for patients at different disease stages are needed in the future.The original intention of this study was to call for the involvement of social workers in the health management of cancer patients. And we advocate strengthening empathy training for medical social workers, such as narrative medical education. It is necessary to strengthen the communication between medical staff and social workers and establish a holistic healthcare team to comprehensively improve the physical-mental-social health of patients with cancer.In cancer patients, social workers' empathy ability not only affected their suicidal ideation directly but also affected their suicidal ideation through the mediating roles of self-efficacy, depression symptoms, and stigma. Therefore, in terms of industry access to medical social workers, higher requirements for empathy ability should be required. For medical social workers, professionals should provide them with systematic training on humanistic competence, such as empathy.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 College of Humanities and Social Sciences, Harbin Engineering University. The patients/participants provided their written informed consent to participate in this study.NY and GY: conceptualization. NY: methodology, investigation, resources, and data curation. ZL: software. ZL and FW: validation. YZ: formal analysis. NY and YZ: writing—original draft preparation and writing—review and editing. FW: visualization. GY: supervision. GY and XH: project administration and funding acquisition. All authors have read and agreed to the published version of the manuscript.This study was supported by the Foundation of Nursing Key Laboratory of Sichuan Province (Grant No. HLKF2022-6), Fundamental Research Funds for the Central Universities of Harbin Engineering University (3072022WK1306), SZU Top Ranking Project (86000000210) and 2021 Heilongjiang Higher Education Teaching Reform Research Project (SJGY20210232).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.