This was also reflected in their group performance, where horses performed above chance level in the choice task and the visible displacement task only. In the invisible displacement task, the group performed significantly worse than expected by chance indicating that horses persistently chose the side where they had last seen the target. None of the individual characteristics included in the study had an effect on performance. Unsuccessful horses had higher heart rate levels, and expressed more behavior indicative of frustration, likely because of their inability to solve the task. The increased frustration/arousal could lead to a negative feedback loop, which might hamper performance in subsequent trials. Care should thus be taken in future experimental designs to closely monitor the arousal level of the tested individuals in order to safeguard comparability.Many frameworks have assessed the ultimate and ontogenetic underpinnings in the development of object permanence, but less is known about whether individual characteristics, such as sex or training level, as well as proximate factors, such as arousal or emotional state, affect performance in these tasks. The current study investigated horses’ performance in visible and invisible displacement tasks and assessed whether specific ontogenetic, behavioral, and physiological factors were associated with performance. The study included 39 Icelandic horses aged 2–25 years, of varying training levels. The horses were exposed to three tasks: (a) a choice test ( In their daily management routines, horses face novel and sudden stimuli or objects (re-)appearing in their environment, which may elicit stress responses. Knowledge of horses’ ability to track hidden objects can thus shed light onto how horses predict the movement of visible and invisible items in different handling situations. A better understanding of how horses perceive and interpret changes in their environment could also be used to improve equine welfare and training.Object permanence refers to the cognitive ability of mentally representing the existence and movement of hidden objects . Such abPan troglodytes), gorillas (Gorilla gorilla) (Pongo pygmaeus) (Saguinus oedipus)  , orangutygmaeus) , cotton oedipus) ] and in oedipus) , corvidsoedipus) , psittacoedipus) , and theoedipus) ].Canis familiaris) (Sus scrofa domestica) , and goats (Capra aegagrus hircus)  , pigs (Smestica) , sheep ( hircus) . As thes hircus) , and pos hircus) . Domesti hircus) . One of  hircus) , suggestEquus caballus), studies on object permanence are limited, although knowledge of horses’ abilities to follow hidden objects is important information for humans interacting with horses. Horses may e.g., react fearful toward re-appearing objects, conspecifics or humans, if they do not have the ability to mentally follow the objects. Such fear reactions could be unexpected by humans, which could lead to potentially dangerous situations. n = 16) and as only one sex was included . Further investigation of object performance abilities of horses is therefore needed, and is highly relevant to the keeping and management of horses.In horses  of the results. The motivation to e.g. engage in a learning task is a crucial factor for learning as it will affect the horse’s willingness to participate, and its attention span. In a recent study by In addition to the above mentioned individual characteristics, an individual’s current affective state may also affect learning performance . This isThe current study aimed to investigate horses’ performance in visible and invisible displacement tasks and investigated whether specific ontogenetic, behavioral and physiological factors were associated with performance. The hypothesis was that horses would be able to solve visible but not invisible displacement tasks following the results from per se, we would expect unsuccessful horses to experience a certain level of frustration resulting in higher heart rates and more behavior linked to frustration than successful horses during the tests.Lastly, the study aimed to examine if there was any association between physiological parameters  of the horses and performance in the tests, and between behavior indicative of frustration and performance. While we did not expect any difference in horses’ heart rate between the different tests Prior to the experiment start, the owner of the stud was informed and agreed to all experimental procedures, data collection and publication . All procedures were conducted in accordance with national legislation on animal experimentation by the Danish Ministry of Justice, Act. no. nr. 253 (8 March 2013) and § 12 in Act. no. 1459 (17 December 2013), as well as met the ARRIVE guidelines  and the As the experiment was conducted during the COVID-19 pandemic, measures were taken to comply with the current precautions. The experiment were conducted in Denmark, and hence complied with the Danish COVID-19 regulations effective in the experimental period 1st of March–15th of April 2021. Only one experimenter was part of the experiment to avoid contamination risks between persons. The experimenter was PCR tested for COVID-19 bi-weekly and only traveled to the stud if test results were negative  before the experiment started and were never in near proximity (less than 2 m) to any other persons at the horse stud. Clothes were washed between each visit to the stud, and hands were disinfected with alcohol upon arrival and frequently during an experimental day. The experiment was conducted in a separate section of the stud, where no other daily activities connected to the stud (training and preparation for training) were performed.Thirty-nine privately owned Icelandic horses participated in the study. Thirty-two females and 7 males with a mean age of 12 years (range: 3–25 years). All horses were from the same owner and were either born at the stud where the experiment was performed, or had been trained at the stud for minimum 6 months. The stud owner was also the horses’ regular trainer. The experiment was performed in a stable section of the stud, separate from the normal daily activities going on at the stud. This stable had six individual pens with grating openings in the front of each pen toward to stable aisle. All horses were group housed when outdoors, and individually housed when indoors, in individual pens. All horses were thus acquainted with the individual pen(s) used for the experiment beforehand. All horses were also used to being alone in a pen with visual access to at least two familiar peers. Upon arrival to the stud, the owner of the horses provided data on each horse: ID, age, sex, and training level (T0–T5) . The scaad libitum water at all times.No changes were made to the horses normal feeding (roughage and concentrates were provided 6–7 am and at 5.30 pm) or training routines  or lunging in the indoor riding arena). All horses had access to The experimenter stayed on the stable aisle in front of the particular pen . From inn = 2, who were selected by the stud owner), or horses who had already been tested to exclude any bias due to socially acquiring information about the task. Each group was habituated over a 1–2 days period, depending on progress. All horses were habituated, trained and lastly tested from their respective pen (3.1 × 3.5 m). The individual pens were bedded with wood chip bedding and had an automatic water cup adjacent to the box opening. The horse would initially be habituated to wearing a wireless heart rate monitor  on an elastic girth, and heart rate was monitored during habituation, target training, and testing.Horses were habituated, trained and tested in groups of 3–5 horses at a time, with at least one older and calm companion present in a nearby pen to ensure a calm atmosphere. The calm companions were always familiar horses which were physically distanced but within visual contact from the particular individual being trained or tested. The companions were either not part of the experiment  placed on the aisle floor in front of a bar opening in the grating. The horse was then backed behind the grating, and given another treat on the aisle floor. This was repeated at least three, but maximum 12 times until the horse ate the treat from the aisle floor three times in a row without showing neophobic behavior  (success criterion for step 1),–step 2; the sliding board was placed in front of the grating of the pen , and theHereafter, a target training was initiated to teach the horse to follow a target: The horse was presented with a small black box  placed in the middle of the sliding board. The target was placed on the board in full view of the horse, and the board was then pushed toward the pen grating. As soon as the horse touched the target it was rewarded with a treat (the treat was delivered by the experimenter on the board by the experimenter’s hand). The sliding board was moved away . In these trials, the experimenter placed the target  in full view of the horse and pushed the board toward the horse, allowing it to make a choice. Each side was baited once in these trials without covering it, and the horse was rewarded with each correct choice. In the experimental session, the experimenter placed the target on one side of the board in full view of the horse, and covered both sides (thereby shielding the target) with white cups , and pushed the board toward the horse . Each siTesting if the horse follows the target when it changes position: The procedure followed that of the choice test (above), but in this case, the target and the experimenter’s one hand was simultaneously placed on both sides of the board , therebyA video illustrating a successful completion of a trial in the visible displacement task can be found in Testing if the horse follows a hidden target when it changes position. In this last experiment, the horses were presented with an invisible displacement, where two identical cups crossed paths on the sliding board. The target was placed in either the left or the right side of the board while the other side was also touched by the experimenter’s hand as in the visible displacement task . Both siA video illustrating a successful completion of a trial in the invisible displacement task can be found in Video recording of all habituation, training and tests was conducted from the stable aisle, using a Sony HDR-cx240E handycam on a tripod (150 cm high). After each experimental day, video files were downloaded and raw data was extracted into Excel (version 2016) by an experienced observer. Trials needed to reach the step 1 habituation criterion were counted, and the duration of time needed for the horse to accomplish the step 2 habituation criterion was measured. During target training, horses had different ways of approaching the task. Some were more active and had more trials per minute than others had; hence, trials per minute were noted for each horse to form a variable indicative of the individual’s motivation to the task . Success rate in target training was also noted as successful trials out of 10 trials total . For all tests; choice test, and visible and invisible displacement task, success rate  was noted, and behavior potentially indicative of frustration , consisting of a belt/elastic girth with two electrodes, a wireless heart rate sensor and a wristwatch receiver. The belt with electrodes was fitted around the horse’s belly behind the shoulder. Water and ultrasound gel  were applied for optimal connection between electrode and skin. Data were downloaded using the online software Polar Flow. Average and maximum heart rate from habituation, target training, choice test, visible displacement task, and invisible displacement task, respectively, were noted. Heart rate variability was not considered as the duration of each trial or registration period  was shorter than 10 min each .All trials were video recorded and coded live while testing. All choices of the horses (left or right side and corresponding correct or incorrect) were clear and unambiguous; hence, we did not calculate inter-observer reliability.n = 39, and target training n = 38). From the choice test, all but one horse  complied with the success criterion (One horse showed strong neophobic reactions during the habituation period and was thus excluded from the study for welfare reasons. All remaining horses complied with the habituation criterion (both step 1 and step 2) and all but one horse complied with the target training success criterion and thus proceeded to the choice test , binomial tests were used. To test the group performance in the tests, one-sample Wilcoxon tests with chance level set at 50% were used. To analyze which individual characteristics affected performance of the horses, a Generalized Linear Mixed-effects model was fitted to the data from each test . Each full model included: training level , age , sex , color , motivation to the task , baited side , and for the visible and invisible displacement tasks the displacement direction in each trial  on performance in the tests. As the primary response variable was binary , data was analyzed using a logistic regression with package lme4  in the RSpearman correlation analyses were lastly carried out to test if successful horses in the visible displacement task also were more successful in the invisible displacement task .In the analyses of heart rate data, Linear Mixed-effects models were fitted for mean heart rates and maximum heart rates, respectively, using packages lme4  and nlmeLinear Mixed-effects models were used to elucidate if behavior indicative of frustration was linked to successful or unsuccessful trials, and to assess if an association between success rate and incidence of the behavior occurred, using the same model as mentioned above for heart rate analysis, with the number of frustration behaviors being fitted in the model.p < 0.05). In the first 10 trials of the choice test, 27 horses performed better than expected by chance, and eight horses performed better than expected by chance in the visible displacement task. In the invisible displacement task, none of the horses performed significantly better than expected by chance .The fitting of the three models showed that none of the fixed effects  had a noteworthy effect on horse performance in any of the three tests  and maximum (Fdf = 79.55858 and p < 0.001) heart rate during the tests. The model output moreover showed that low average and low maximum heart rate were significantly associated with high performance in the invisible displacement task  but not in the visible displacement task  and the choice test   heart rates in one test also had high (or low) heart rates in the next test  of the trials, and in the invisible displacement task, the percentage further increased to 43% , but the behavior was still mainly linked to unsuccessful trials .The occurrence of behavior indicative of frustration was generally low, but increased from Choice test to the visible displacement task and again from the visible displacement task to the invisible displacement task. In the choice test, behavior indicative of frustration was noted in 6% of the trials , and of these, the majority of trials were unsuccessful  affected performance of the horses. Horses performing well in the displacement tasks had lower mean and maximum heart rates, and showed lower levels of frustration behavior. In practical terms, we can expect horses to follow and remember the previous placement of visible objects in their environment, but we cannot expect horses to follow these objects if moved while occluded from the horses. The results also show that horses express both behavioral and physiological signs of frustration when being unable to solve a task. This highlights the need for adaptation of the tasks we ask of horses to ensure they are able to solve them in order to safeguard their welfare.mariav.rorvang@slu.se.The two datasets from this study can be found in The Board for Animals in Research and Teaching at SLU, Sweden reviewed and approved the animal study and all procedures were conducted in accordance with national legislation on animal experimentation by the Danish Ministry of Justice, Act. no. nr. 253 (8 March 2013) and §12 in Act. no. 1459 (17 December 2013), as well as met the ARRIVE guidelines and the ethical guidelines proposed by the Ethical Committee of the ISAE . Written informed consent was obtained from the owners for the participation of their animals in this study.MR initiated the idea for this study, applied for (and was later awarded) funding for the project, was in charge of data management and prepared data for analyses, and conducted the study in virtual collaboration with all authors (due to COVID-19 restrictions). MR and CN designed the experimental protocol adapted to horses. Data and corresponding analyses were discussed by all authors, and MR subsequently performed the statistical analyses in collaboration with CN. KN and MR wrote the first draft of the manuscript. All authors contributed in the discussions of the protocol in the beginning of the experiment and contributed in writing, proofreading, and fine-tuning the manuscript for publication.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.


Migraine and depression are highly prevalent and partly overlapping disorders that cause strong limitations in daily life. Patients tend to respond poorly to the therapies available for these diseases. OnabotulinumtoxinA has been proven to be an effective treatment for both migraine and depression. While many studies have addressed the effect of onabotulinumtoxinA in migraine or depression separately, a growing body of evidence suggests beneficial effects also for patients comorbid with migraine and depression. The current meta-analysis systematically investigates to what extent onabotulinumtoxinA is efficient in migraineurs with depression.A systematic literature search was performed based on PubMed, Scopus and Web of Science from the earliest date till October Our search retrieved 259 studies, eight of which met the inclusion criteria. OnabotulinumtoxinA injections administered to patients with both chronic migraine and major depressive disorder led to mean reduction of Treatment with onabotulinumtoxinA leads to a significant reduction of disease severity of both chronic migraine and major depressive disorder in patients comorbid with both diseases. Comparative analyses suggest an equivalent strong effect in monomorbid and comorbid patients, with beneficial effects specifically seen for certain migraine features. Migraine and major depressive disorder (MDD) are two highly prevalent disorders worldwide, being a leading cause of significant limitations in life quality and disability. Despite several pharmacological and psychotherapeutic treatments available, patients tend to respond poorly, which can in turn worsen their health condition. Part of the burden is caused by the coexistence of these two disorders. Migraine has a large comorbidity spectrum which comprises many prevalent psychiatric disorders including depression, anxiety, different types of phobias and panic disorders , 2. It iClostridium botulinum and it prevents the release of acetylcholine from nerve endings, thus leading to muscle paralysis until the nerve develops new endings to communicate with the muscles. OnabotulinumtoxinA is typically used to treat muscle contraction or spasms, hyperhidrosis from armpits, urinary incontinence in adults with multiple sclerosis and spinal cord injury. However, many studies showed that injections of this toxin can improve chronic migraine and that it can have a  beneficial effect on MDD [One of the new and innovative therapeutic strategies for both migraine and depression is the treatment with onabotulinumtoxinA . This tot on MDD , 6.The underlying mechanism by which onabotulinumtoxinA leads to the observed beneficial effects in depression or migraine is not well understood. In the case of depression, one hypothesis is that the application of this drug inhibits the feedback of facial expressions to the brain, which can affect emotions positively or negatively . NegativAs for depression the mechanisms underlying the beneficial effect of onabotulinumtoxinA in migraine are not fully elucidated either . It has Many studies have been performed addressing the effectiveness of onabotulinumtoxinA on depression and migraine separately , 6, 11. A systematic search of the literature in accordance with the PRISMA guidelines was carried out using the databases PubMed, Web of Science and Scopus as search engines. The literature search has been performed independently by Oreste Affatato and Victoria Babasieva. Any disagreements were settled through discussion and under the supervision of Dr. Jessica Mwinyi.All articles published in English before October In the first screening of the articles, we considered only titles and abstracts. In this phase we excluded (i) articles not written in English, (ii) articles not reporting original data, such reviews, and (iii) articles not describing clinical experiments in which the aim was to assess the efficacy of onabotulinumtoxinA treatment in patients with both chronic migraine and major depressive disorder. At this stage, mentclass2pt{minimArticles were selected on the basis of the following criteria: prospective or retrospective studies assessing the efficacy of the treatment with onabotulinumtoxinA in patients over the age of 18 years suffering from chronic migraine, as defined by any edition of the International Headache Society criteria , and froThe studies selected follow the same protocol (PREEMPT) for the administration of the onabotulinumtoxinA , but theFrom each study, the sample size as well as the mean decrease in migraine and depression scores from baseline including the standard deviation (SD) were extracted. In the few cases where mean reduction and SD were not reported, at least the means and the SD at the baseline and all the following visits during the treatment period were available. In these cases, data were used as follows. Let be ished in  to give The mean reduction and corresponding 95% confidence interval (CI) were derived using a random-effects model, which accounts for the intrinsic variation in the studies considered. The Empirical Bayesian method has been used to apply this model, known to be more accurate in the random-effects model when just few studies are under analysis . It has To investigate the heterogeneity between studies Q and It was not possible to assess the publication bias via Begg’s funnel plot, or correcting through Egger’s regression asymmetry test, due to the small number of studies available. We contacted all the authors of the studies included in the meta-analysis in order to ask for collaboration and sharing of possibly not published data. Doctor Elif Ilgaz Aydinlar  and doctAll p-values below 0.05 were considered as statistically significant.The statistical analysis was carried out using the software Stata, version 16 .Based on the described inclusion criteria and the selection process presented in Fig. Maasumi et al.  performeBoudreau et al.  performeKollewe et al.  performeRusso et al.  performeDemiryurek et al.  performeGuerzoni et al.  performeAydinlar et al.  performeBlumenfeld et al.  performeIn the case of MDD, a subgroup analysis according to three different disease severity scales was performed, i.e. BDI, BDI-II and PHQ-9. Within each subgroup, the studies also presented different durations of treatment. For this reason, for each subgroup we selected the outcome data for the statistical analysis according to the shortest study. In some studies, the results at each visit along the treatment were not available. In these cases, we chose the data for the calculations according to the visit with more outcome variables available. This procedure was adopted to maximize the number of studies in each subgroup analysis. In the case of studies using the BDI scale, we considered the outcome results of the treatment with onabotulinumtoxinA after 3 months. In the case of studies operating with the scales BDI-II and PHQ-9 our calculations were performed based on treatment outcome data obtained 6 months after the treatment start. Meta-analysis results are presented in Fig. The BDI scale has been used to assess the depression level in a total of 87 patients. We found a significant . Notably, partly high discontinuation rates were reported in some studies. As stated in the studies, the major reasons why the patients tend to giving up with the treatment are lack of efficacy, lost to follow up, withdrawal of the consent and adverse events. In general, subjects affected by chronic disorders tend to be discontinuous in following treatments which makes the statistical analyses of the experiments less powerful , 25.A limitation of our study derives from the variety of the scales used to assess the impact and severity of migraine and depression, which led to the necessity to perform the statistical analyses on several smaller subgroups although the overall number of subjects is, with more than a thousand individuals, quite large. The division in subgroups weakened the statistical power of our study. This heterogeneity in the scales highlights the aspect that the use of common scales assessing migraine or depression severity would provide a more robust basis for broader and more reliable comparisons. The studies also exhibit a significant variety in their run time, spanning from 3 months to almost 2 years. The duration of treatment is known to have a relevant impact on the treatment success with onabotulinumtoxinA, but we were not able to further assess the impact of this variable because of the limited number of studies in each subgroup. Statistical analyses are also characterized by a very high heterogeneity, but since a very limited amount of studies were included in each analysis, this heterogeneity could not be interpreted as meaningful.Overall, the onabotulinumtoxinA treatment showed promising results and, in this sense, more studies are needed to eventually confirm the positive effects that have been found in this meta-analysis. It may be possible that some issues related to this specific therapy contribute to the high number of patients giving up on continuing the treatment. This makes more difficult to perform further studies, thus slowing down the progress of the research in this particular area. Nonetheless, we believe that these preliminary results are robust and that further success in the implementation of this therapy will lead to a broader use and to a better health care for chronic migraineurs with depressive symptoms.The use of onabotulinumtoxinA in patients with comorbid migraine and major depressive disorder leads to a significant reduction of symptoms of both diseases. OnabotulinumtoxinA may be slightly more effective in patients with both migraine and depression regarding certain disease features , compared with patients with just one of these two disorders. More studies are needed to assess and compare long time efficacy in chronic migraineurs with depressive symptoms and monomorbid patients.


As vulnerable road users, elderly pedestrians are more likely to be injured in road crashes due to declining physical and perceptual capabilities. Most previous studies on the influence of the built environment on elderly pedestrian safety focused on intersections or areal units. Using a district of Shanghai as the study area, this research investigated the effects of the built environment at the road segment level with elderly pedestrian collision, taxi tracking point, point of interest, street view image, open street map, land use, housing price, and elderly population datasets. In particular, this research employed both Poisson and geographically weighted Poisson regression (GWPR) models to account for spatial nonstationarity. The Poisson model indicates that green space, sidewalks, and junctions on the roads significantly affected elderly pedestrian safety, and roads around nursing homes, schools, bus stops, metro stations, traditional markets, and supermarkets were hazardous for elderly pedestrians. The results of the GWPR model suggest that the influence of factors varied across the study area. Green space could decrease the risk of elderly pedestrian collisions only in areas without congested environments. Separations need to be installed between roadways and sidewalks to improve elderly road safety. The United Nations reported that, for the first time in history, the number of people aged 65 years or over exceeded the number of people under five in the world in 2018 [If older people can remain mobile and care for themselves longer, the costs for long-term care will be lower . WalkingEnvironmental characteristics can influence the safety of elderly pedestrians despite physical limitations ,11. In tThis study investigates the effects of the built environment on elderly pedestrian collisions at the road segment level in an urban area. In particular, this research introduces some facilities relevant to the activities of the elderly and some roadway features derived from street view images that may reflect perceptions of the elderly when they are walking along the streets. Additionally, this research employed both Poisson and geographically weighted Poisson regression (GWPR) to account for spatial nonstationarity.Located in the eastern part of China, Shanghai is one of the largest metropolitan cities in the world and has been experiencing a surge in the number and proportion of the elderly. According to China’s Population Census 2020, 23.4% of the residents were aged 60 or above in Shanghai [In this research, factors that may influence the occurrence of elderly pedestrian collisions can be classified into two categories. One type is known as exposure variables in road safety research . PreviouThe elderly pedestrian collision data were collected from the Shanghai 110 Calling Center. A total of 3653 traffic collisions occurred in Changning District from 2013 to 2015, of which 410 involved elderly pedestrians. The database records the geographic coordinates and the address of each crash. As collisions are rare events, we aggregated the data from three years to ensure the representativeness of the sample. The road network dataset was derived from Open Street Map (OSM) . By extrExposure variables play a crucial role in crash prediction models . In modeStreet view images were used to portray characteristics of the road environment. They cannot only describe the road conditions but also, to some extent, reflect the visual perception of streetscapes ,30. We uPoint of interest (POI) and land use data can, to some extent, reflect people’s activities, which may influence traffic conditions and the behavior of road users. The former were collected from the 2014 Baidu map API  and wereHousing price can be used to describe the socioeconomic characteristics of a community. We collected the housing price information in 2016 from FangTianXia , a real Each road was divided into several segments with an equal interval. As elderly pedestrian collisions are rare events, a road segment has to be long enough to allow the significant variation of collision counts but short enough to reflect changes in the road environment . FollowiIn this study, 18 independent variables related to exposure and built environment were identified for analysis. Many studies have suggested that generalized linear models, such as Poisson and negative binomial regression (NBR) model, perform higher accuracy in random and discrete data fitting ,41,42. UAs global collision prediction models such as Poisson regression are limited in capturing spatial heterogeneity in the collision data, this research also employed an advanced modeling technique, GWPR, to deal with spatial nonstationarity for frequency data ,44,45,46i have a greater influence than those far away. It can indicate the degree of influence of different spatial locations on the estimation of regression point parameters. There are two commonly-used weight functions, Gaussian and Bi-square:Fotheringham et al.  used weiGaussian:Bi-square:Compared to the choice of weighted function, GWPR is more sensitive to the bandwidth. Due to the unbalanced distribution of elderly pedestrian collisions in Changning District, this research utilized Adaptive Bi-square, Golden section search, and the corrected Akaike information criterion to acquire the optimal bandwidth value. GWR4 software was employed to establish the GWPR model .N is the number of total road segments, Mean absolute deviation (MAD), mean squared prediction error (MSPE), and normalized root mean square error (NRMSE) were employed to measure the goodness of fit of the two models. Among these indicators, MAD represents the average misprediction of the model, MSPE indicates the model’s error associated with a prediction, and NRMSE summarizes the residual variance. For all of the three indicators, a lower value means better model performance. The algorithms are as follows:I statistic to test the spatial autocorrelation of residuals. The measure is given by [i from its mean, i and segment j, n is equal to the number of road segments, and The degree of spatial autocorrelation of regression model residuals can help detect possible problems in spatial data modeling ,48. Thisgiven by ,50:(8)I=I is that the residuals are randomly distributed in the study area. The value falls between −1 and 1. A statistically significant p-value indicates that the residuals of the model are not randomly distributed.The null hypothesis of Moran’s Under the assumption that the study area was homogeneous and there was no spatial relationship between road segments in the region, a global model was used to explore the relationship between dependent and independent variables. For roadway variables, the number of junctions (num_junction) had significant impacts on pedestrian road crashes. The result provides additional evidence that road junctions are dangerous places for the elderly because of the complex traffic environment and the physical limitations of older people ,15. RegaCommunities with more schools may have higher risks for elderly pedestrians (see variable of num_school). In China, especially in metropolitan cities such as Shanghai, seniors and the elderly are usually responsible for taking care of their grandchildren in the daytime. They always take their grandchildren to and back from school on foot. The travel environment is highly complex around schools in the morning when children go to school and in the afternoon when classes are over, owing to the traffic mix, including cars, bicycles, and electric motorcycles with highly concentrated road users. This may pose a significant threat for the elderly. Consistent with previous studies such as Lee et al.  and Kim I statistics of the residuals of predictions using the Poisson and GWPR models. For the former, there was a positive spatial autocorrelation in the residuals at a 95% level of significance, reflecting that the regression coefficients of the global model could not adequately represent detailed local variations in the data and the residuals were spatially correlated with clustering tendency. For the latter, the spatial autocorrelation of the residuals was not statistically significant at the 95% level. Given the same variables, the local model was better than the global model in accounting for the spatial nonstationarity of the elderly pedestrian collision data at the road segment level in the study area. The GWPR model was established to account for spatial nonstationarity. We calculated the Moran’s p-values less than 0.01 in the global model, they were detected as not significant on some of the local road segments in the GWPR model. The problem was severe for the variable of num_elder. The reason could be that we used the number of elderly residents at a community level rather than the elderly pedestrian flow at a road segment level to represent the elderly pedestrian exposure because of data unavailability. The former could not capture specific types of older persons’ activities such as purchasing food in traditional markets, visiting friends at nursing homes, or taking grandchildren to school. Therefore, the variable could not fully reflect the activities of the elderly at a segment level [nt level . NonetheThe coefficient values and significant levels of roadway variables are portrayed in The World Health Organization defines healthy aging as “the process of developing and maintaining the functional ability that enables wellbeing in older age” . WalkingOne limitation of this research was the exposure variable. As the detailed elderly pedestrian flow was unavailable, this research used the number of elderly residents living around the road segments as a proxy. As the exposure variable can help better understand the influence of risk factors, more research efforts can be dedicated to measuring the elderly pedestrian flow at the micro-level. One more limitation was that we aggregated crashes within 24 h without considering temporal variation because of the sample size. However, a more indepth analysis of elderly pedestrian collisions by the time of day will shed great light on the influence of the glare and brightness due to the afternoon or morning orientation of the sun. For instance, when the sun is lower in the sky, it may be difficult for both the driver and the pedestrian to see each other, resulting in a greater risk of colliding. Additionally, we found that green space could improve the safety of elderly pedestrians. However, the way in which greenness influences the traveling behavior of the elderly remains unclear. As a further step, more experiments should be conducted to illustrate the mechanism.


The results demonstrated a faster response time in neurotypical children compared to ASD and ADHD children, with ADHD participants performing better than ASD participants on the same task. The overall accuracy parameter between the ADHD and ASD groups did not significantly differ.Recognizing a person’s identity is a fundamental social ability; facial expressions, in particular, are extremely important in social cognition. Individuals affected by autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) display impairment in the recognition of emotions and, consequently, in recognizing expressions related to emotions, and even their identity. The aim of our study was to compare the performance of participants with ADHD, ASD, and typical development (TD) with regard to both accuracy and speed in the morphing task and to determine whether the use of pictures of digitized cartoon faces could significantly facilitate the process of emotion recognition in ASD patients (particularly for disgust). This study investigated the emotion recognition process through the use of dynamic pictures (human faces vs. cartoon faces) created with the morphing technique in three pediatric populations (7–12 years old): ADHD patients, ASD patients, and an age-matched control sample (TD). The Chi-square test was used to compare response latency and accuracy between the three groups in order to determine if there were statistically significant differences ( Faces are complex stimuli that convey social and affective information; recognizing a person’s identity is a fundamental social ability . In factThis is one of the reasons that the practical and clinical applications of automatic emotion recognition have been extensively tested and validated in some neurodevelopmental disorders ,5,6, parFacial expression recognition involves dynamic and multimodal phenomena. Facial transformation from a neutral expression sends complex signals, which are converted into emotions . The praASD is known to be associated with difficulties in using facial expressions to convey emotions and deficits in emotional reciprocity ,15,16,17ADHD is a neurodevelopmental disorder characterized by attention deficit, hyperactivity, and impulsivity ) . A numbeChildren with ADHD are less accepted and often rejected by their peers ,36,37. TThe recognition of facial expression involves dynamic and multimodal phenomena. The transformation of the face from a neutral expression sends complex signals, which are converted into emotions ,41,42,43The morphing task has been used since 2001 to evaluate children with ADHD and ASD , and it We aimed to investigate the performance of ADHD, ASD, and TD participants with regard to both accuracy and speed in the morphing task and to determine whether the use of dynamic pictures representing cartoon faces could significantly facilitate the process of recognizing emotions in ASD participants.We hypothesized that children with ADHD would respond faster than ASD participants due to their executive and attention deficits , which iOur study aimed to provide a watershed in the understanding of the emotion recognition process. While many studies have investigated this process in ADHD and ASD populations, comparative studies between the two clinical populations are scarce and results have been conflicting, especially when conducted using tasks with dynamic images (representing cartoon faces). Therefore, we used dynamic images of cartoon faces in emotion recognition, with the perspective of using the morphing task as a tool to enhance the expression recognition process at the rehabilitation level.Sixty-two children in the age range 7–12 years were recruited and assigned to one of three groups: (1) an ADHD combined type (ADHD-C) group; (2) an ASD group; and (3) an age-matched control group.All children and parents recruited for the first two groups were referred to the Department of Human Neurosciences at Policlinico Umberto I clinic in Rome for a follow-up evaluation, which included recruitment to our study between May and September 2019. The 21 children in the ADHD group and the 20 children in the ASD group were included after meeting the DSM-5 diagnostic criteria for ADHD-C or ASD, respectively , and aftAll participants were evaluated using a morphing task. The morphing technique is an image processing technique commonly used to metamorphosize from one image to another .In our study, 24 videoclips with neutral faces gradually developed basic emotions . Videoclips were built using FantaMorph , a software used to create morphing images and sophisticated animation effects, including the transformation of the images used.It should be emphasized that the group of complex emotions  was excluded since these emotions imply the attribution of a cognitive state as well as an emotion and are more dependent on context and culture . They caThese videoclips were split into two conditions to compare emotion recognition in human and cartoon faces. These two conditions were chosen on the basis of studies carried out by Jusyte in 2017  and BrosDuring the training session, participants watched two videoclips in which a neutral expression turned into a sad or happy expression in order to introduce children to the task. All children passed the initial trial and were then admitted to the experiment.In the first condition, we presented greyscale images representing 12 young adults, six females and six males, selected from the Cohn-Kanade database ,57. We rIn the second condition, we used colored pictures showing cartoon faces of six females and six males. These images were included in the Facial Expression Research Group Database (FERG-DB) . They weParticipants and their parents were informed about the study procedures and all parents provided written informed consent to participate. The administration room, which was the same for the two clinical groups, was located within the school for the control group. The room had a table with a notebook and two chairs (one for the participant and one for the doctor) and no distracting elements such as posters, billboards, or games.In the training session, participants were instructed by the child neuropsychiatrist to press a button on the keyboard as soon as a face corresponding to the lexical label appeared on the screen.Each videoclip lasted 7 s and included 60 frames. We recorded answers and response latency on the appropriate answer sheet. In both conditions, videoclips were presented in the same random order obtained by pseudo-randomization for each child. The experiment was conducted using a Microsoft Office PowerPoint presentation , shown on a computer with a 10-inch screen and at a distance of 50 cm.2) was performed to investigate potential relationships between the number of errors  and the six emotions in the two conditions (human and cartoon faces);The Chi-square test  was used to investigate group differences with regard to response latency (speed in seconds).For statistical analysis, SPSS 19 software  was used. In order to compare the performance obtained by ADHD, ASD, and TD participants with regard to both accuracy and speed on the morphing task, we performed the following analyses:The clinical participants were 20 children with ADHD combined type (ADHD-C) in the age range 7–12 years old , 21 children with ASD in the age range 7–12 years old , and 21 children in the control group (TD) in the age range 7–12 years old . Demographic characteristics are reported in p < 0.05; p < 0.01) in the recognition of basic emotions. In condition 1 (human faces), ASD children exhibited a significantly higher error frequency as compared to TD participants when they were asked to recognize disgusted faces . With regard to surprise, the ADHD group exhibited the highest error frequency compared to the other two groups .The Chi-square test was used to compare response accuracy between the three groups in order to determine if there were statistically significant differences . With regard to disgust, the ADHD group had the highest percentage of errors .In condition 2 (cartoon faces), we found a significant difference in error frequency distribution relative to the emotion of sadness between the ADHD group and the other two groups . In condition 2 (cartoon faces), the percentage of error in identifying the emotion of disgust was higher in the ADHD group relative to the ASD group , and the error frequency for sadness was higher in the ADHD group .We compared the response accuracy for the aforementioned emotions between the two clinical groups (ADHD and ASD). The results were similar to those obtained in the previous phases of this study. In particular, in condition 1 (human faces) we found no significant differences between the ADHD and ASD groups in identifying the emotion of disgust, while the error frequency distribution for surprise was significantly higher in the ADHD group . The ADHD and TD groups tended to confuse fear and the facial expression of sadness more frequently than the ASD group, while the ASD group more often confused fear and surprise compared to the other two groups . In condition 2, the ADHD group more frequently confused disgust and anger as compared with the TD group, which confused these emotions less frequently .In condition 1, the emotion disgust was more frequently confused with anger in both clinical groups compared to the control group . To report these results, we report the name of the emotion followed by M  or F  to indicate the gender of the stimulus presented. In the post hoc comparison in condition 1 (In order to explore the presence of significant differences between the three groups regarding response latency (parameter speed in seconds), we conducted a multivariate analysis of variance (MANOVA). Wilks’ multivariate Lambda test suggested the existence of statistically relevant differences in response latency between the three groups  of ADHD and ASD individuals in response to dynamic emotional images in a morphing task. When compared to the ASD and ADHD groups, children with TD performed better in terms of speed, while the ADHD group performed better than the ASD group. In terms of accuracy, there was no significant difference between the ADHD and ASD groups.The findings in our analysis confirm previous studies that found a deficit in the emotion recognition process in subjects with ASD and ADHD. Our study shows that the poor performance of the ASD group, particularly for the emotion disgust, is consistent with literature data, especially in regard to Lozier’s meta-analysis . Meta-anSpecifically, in condition 1 (human faces), the emotion disgust was least recognized by the ASD group, while the emotion surprise was least recognized by the ADHD group. In condition 2 (cartoon faces), the highest error frequency was shown for the emotions sadness and disgust, in both cases by the ADHD group vs. the TD and ASD groups.These results suggest that digital faces/cartoons may facilitate recognition for participants in these groups. The ASD group made fewer mistakes recognizing disgust, one of the hardest emotions to perceive, in condition 2. This facilitation suggests that the ASD group may be able to use atypical strategies to recognize emotions. This hypothesis originated from previous studies ,57,58,59A qualitative observation showed that in our sample there was a lower error rate in cartoon emotion recognition than in human faces. Happiness is the easiest emotion to recognize. Disgust and fear, especially in condition 1, were the most difficult to recognize. This is consistent with literature stating that fear is easier to perceive than recognize. Of the six basic emotions, fear may be defined as the one that conveys the strongest multisensorial signals. These signals, such as environmental threats, may play an important role in decoding emotions .Disgust, after fear, was the most difficult emotion to identify, and was recognized better in the oldest neurotypical participants (similar to fear). Conversely, in ASD, the recognition deficit increased with age, especially for disgust, fear, and sadness . The varMajor latency in emotion recognition for both clinical groups;Greater emotion recognition error rate compared to the control group;Tendency to confuse some emotions .In brief, the difficulty in complex emotion recognition in these participants was evident by:We hypothesized that there would be an emotion recognition deficit in children with ASD and ADHD compared to the control TD group when using a dynamic stimulus, such as the morphing test. Overall, a faster response time was detected in the group of children with TD compared to the ASD and ADHD groups. The ADHD group, in turn, had a faster response time than the ASD group. Regarding the accuracy of the overall performance, the ADHD and ASD groups did not show a significant difference, and mostly seemed to be superimposable, while the performance of the TD group was qualitatively better. Our data confirm previous studies in the literature. The advantages of the morphing technique have been proven by evidence. Dynamic stimuli may somehow facilitate the emotion recognition process in both groups because a “dynamic picture” impersonalizes human interactions in a more realistic way. In everyday life, facial expressions are rarely transmitted and decoded as static snapshots of internal states . DynamicConsidering the remarkable facilitation and improved response to dynamic pictures, we hypothesize that the morphing technique could be a valuable aid to reinforce the bases of mind theory and may support the improvement of social reciprocity in ADHD  and ASD Several studies have been performed in order to better understand the utility of computer-based interventions (CBIs) in teaching social and emotional skills to subjects with ASD ,68.Ramdoss et al. , in a syConsistent with these studies, the findings of the present study evidenced the possibility that the morphing task might be a way to simplify emotion recognition in these populations, allowing them to understand the internal states of others, enhance their empathy, and, hypothetically, reduce their gaps in social relationships. In our study, this improvement occurred above all for disgust. However, it can be hypothesized that an improvement for other emotions could be achieved by perfecting the videos through the contextualization of cartoon faces.This study has some limitations. First, the clinical sample included children of a specific age (7–12 years old). Extending the sample from preschool to adulthood would allow the emotion recognition process to be evaluated throughout life and would allow the accuracy and response latency to be associated with age in these populations, as Richoz showed for the normotypical population [Second, the visual attention parameter (using eye tracking or configurable face processing skills) was not assessed, and consequently the differences in face perception could represent a bias of the study.Third, all participants included in the study had a pure diagnosis of ASD or ADHD; none had an overlap of the two diagnoses. In addition, all participants had an FISQ of 85 or more. While there is no evidence that these factors influenced the results obtained, we cannot rule out this possibility.Fourth, the images used in condition 1 were grayscale images of young adults. This could represent a bias with respect to the use of color cartoon images in condition 2. In fact, it has been suggested in the literature, despite the scarcity of studies, that the use of color images of child and adolescent faces may represent a more realistic confirmation of the ability to recognize emotions in the pediatric population.Additional aspects of interest may be represented by functional Magnetic Resonance Imaging (MRI) studies and the activation of specific brain structures during the emotion recognition process through dynamic tasks  and eye-This study demonstrates that emotion recognition was facilitated through the use of cartoon faces in ASD and ADHD populations, and that the quality of emotion recognition was comparable between ASD and ADHD participants. This is the first study to compare facial recognition in participants with ADHD, ASD, and TD using a morphing task.The findings of this study may have clinical implications in the planning of alternative strategies for rehabilitation settings for children with neurodevelopmental disabilities. The theoretical implications include a better understanding of the maturational changes underlying social skill deficits. We believe that the morphing task has proven to be useful in behavioral investigations and that its use in a more natural or ecological assessment setting is promising. Finally, these results are important for future research evaluating the emotion recognition process as a therapy goal and the morphing task as a rehabilitation tool in order to improve the social and empathy skills of children with ASD and ADHD.


As the world continues to grapple with the COVID-19 pandemic, emerging evidence suggests that individuals from ethnic minority backgrounds may be disproportionately affected. The United Kingdom Research study into Ethnicity And COVID-19 outcomes in Healthcare workers (UK-REACH) project has been initiated to generate rapid evidence on whether and why ethnicity affects COVID-19 diagnosis and clinical outcomes in healthcare workers (HCWs) in the UK, through five interlinked work packages/work streams, three of which form the basis of this protocol. The ethico-legal work (Work Package 3) aims to understand and address legal, ethical and acceptability issues around big data research; the HCWs' experiences study (Work Package 4) explores their work and personal experiences, perceptions of risk, support and coping mechanisms; the stakeholder engagement work (Work Package 5) aims to provide feedback and support with the formulation and dissemination of the project recommendations.Work Package 3 has two different research strands: (A) desk-based doctrinal research; and (B) empirical qualitative research with key opinion leaders. For the empirical research, in-depth interviews will be conducted digitally and recorded with participants’ permission. Recordings will be transcribed, coded and analysed using thematic analysis. In Work Package 4, online in-depth interviews and focus groups will be conducted with approximately 150 HCWs, from across the UK, and these will be recorded with participants’ consent. The recordings will be transcribed and coded and data will be analysed using thematic analysis. Work Package 5 will achieve its objectives through regular group meetings and in-group discussions.Ethical approval has been received from the London-Brighton & Sussex Research Ethics Committee of the Health Research Authority (Ref No 20/HRA/4718). Results of the study will be published in open-access journals, and disseminated through conference presentations, project website, stakeholder organisations, media and scientific advisory groups.ISRCTN11811602. Doctrinal and empirical research (Work Package 3) to understand ethical and legal implications in big data health research is novel to the UK Research Study into Ethnicity and COVID-19 Outcomes in Healthcare Workers (UK-REACH) study and has potential to inform policy and practice in the area.UK-REACH is the first comprehensive qualitative research (Work Package 4) with healthcare workers, particularly from ethnic minority backgrounds, in the UK exploring their experiences during the COVID-19 pandemic and perceptions of risk and coping mechanisms.The engagement of stakeholders (Work Package 5) in every stage of UK-REACH is exemplary and provides real-world relevance to the research and the findings.As the ethico-legal empirical research will recruit key opinion leaders (and not members of the wider population), the demographic diversity of the sample and the opinions gathered in interview may be limited by the characteristics of those in leadership positions in the field.Due to the pandemic restrictions, interviews and focus group discussions will be conducted via online methods as a substitute for face-to-face meetings, posing practical and technological challenges for dynamic interaction with participants.Since the start of the COVID-19 pandemic in December 2019 in China, the SARS-CoV-2 has spread rapidly to almost all parts of the world, infecting officially, and to date, more than 170 million people and claiming around 3.5 million lives.et al point out that while ethnic minority workers constitute about 21% of the NHS workforce, they have accounted for nearly 63% of the total deaths.Occupational risk has been identified as a contributing factor in COVID-19 morbidity and mortality, with healthcare workers (HCWs) accounting for a large proportion of the total case load.www.uk-reach.org for more details). Work Package 1 is an analysis of a linked data set with anonymised health data on COVID-19 outcomes, among clinical and ancillary HCWs The United Kingdom Research study into Ethnicity And COVID-19 outcomes in Healthcare Workers (UK-REACH), led by the University of Leicester, has been initiated to fill this gap. This study has been badged as an Urgent Public Health study by the National Institute for Health Research, and will run until August 2021 to rapidly examine differences in COVID-19 diagnosis, clinical outcomes, professional practices and physical and mental well-being among HCWs from different ethnicities through five interlinked work packages .Undertake qualitative interviews and focus groups with HCWs to examine experiences, risk perceptions, coping and support and physical and mental well-being pertaining to COVID-19 (WP4).Develop a multiprofessional, national stakeholder group to inform the conduct of the research, and facilitate rapid dissemination and translation of the research findings into policy (WP5).Research involving large data sets containing personal and health information raises legal, ethical and social issues surrounding the processing of such sensitive data, even when then the data are putatively anonymised. Understanding HCW concerns regarding trust, engagement, risk perception, barriers to participation and confidentiality is paramount for a project like UK-REACH to succeed and be conducted in a way that both respect participants’ rights and interests, and also hold ethics and law at the forefront of each research activity. To do so, we will undertake two different strands of research. First, we will undertake desk-based doctrinal research to identify the relevant legal and ethical issues and provide a policy report with ongoing recommendations for implementation within the project. Second, we will conduct empirical qualitative research with key opinion leaders to explore their views on the ethical and legal implications of large data set analyses/cohort studies, such as risks of reidentification and identifying core principles of information governance in the context of sensitive data and HCW data sets. We explore each of these research strands in more detail below.The ethico-legal work will commence with a comprehensive literature and doctrinal review based on consultation of relevant legal, regulatory and policy-based documents  to identify the legal framework and ethical issues pertinent to UK-REACH. This will focus on concerns surrounding privacy, data protection and human rights, and how to ensure an ethical approach for UK-REACH, particularly in the context of linking data concerning healthcare professionals’ employment, registration and health. Key issues we will consider include the limits of anonymisation, the risks of reidentification, particular ethical concerns arising from the use of sensitive data concerning ethnicity and what appropriate safeguards can be considered.From this, a comprehensive policy report will be formulated to outline the key legal and ethical issues and provide recommendations for UK-REACH, to be delivered in month 3 of the project.The proposed empirical qualitative research will have key opinion leaders (≥16 years of age) working in a healthcare and biomedical research, or in health-related organisations . Approximately 15–20 participants will be purposively selected and recruited through gatekeepers, members of the UK-REACH research team, stakeholder group and snowballing.Data will be collected using a semistructured topic guide, which has been developed by ED in consultation with other investigators and the Professional Expert Panel (PEP), which is the public involvement group in UK-REACH. The topic guide will include key areas of inquiry, such as participants’ past experiences of research or knowledge of research processes, real or perceived barriers to research participation, views on current safeguards in law, policy and regulation around participants’ rights and interests, exploring how ethnicity and race may influence risks and stigmatisation in research, or perceptions of the same and, finally, to gather views on protection measures that can or should be put in place by law or policy to adequately protect research participants. Additionally, for purposes of describing the cohort, basic demographic information such as age, gender, job role and geographic location will be collected using a short demographic data template.Interviews will be conducted by a member of the research team via Microsoft Teams, or via telephone, depending on the availability, preference, COVID-19 limitations and/or work requirements of the participant. The interviews are likely to last between 45 and 60 min. Interviews will be recorded through the relevant platform software  or on encrypted digital dictaphones, always with participants’ express written permission. As interviews are conducted orally, data will be transcribed and then anonymised prior to data analysis.Digital files of the recorded interviews will be immediately uploaded securely and transcribed in intelligent verbatim by a transcription specialist company. The transcripts will be anonymised by removing all identifying information that enables indirect or inferential identification. Once transcribed, we will compare the transcription with the recording to ensure accuracy.The data from the interviews will be coded using qualitative thematic analysis. The process will consist of generating initial codes by comparing each of the transcripts. Coding is expected to be done manually and in multiple stages. We will adopt an inductive, data-driven approach and will begin with ‘open coding’, that is, reading each transcript (word by word and line by line). During the coding process, we will take notes in a memo-style format by writing down words and thoughts considered to be of use during the data analysis and serve as a reference for potential coding ideas. After completion of the open coding, initial codes will be constructed based on what emerged from the text, and we will proceed to code the remaining transcripts with those codes. When we encounter data that do not fit into an existing code, we will add new codes. We will then group the similar codes and place them into categories. These categories will be reorganised into broader, higher order categories, then grouped, revised and refined, and finally checked to determine whether the categories are mutually exclusive. At this point, we will form final categories, identifying subthemes both within and across the categories, which will then be organised into main themes.We will undertake qualitative research with HCWs to understand their experiences during the COVID-19 pandemic. We will engage with clinical and ancillary staff from ethnic minority and White backgrounds working in healthcare settings  to gain insight into their perceptions around risk factors, support, coping mechanisms and their mental and physical health during the pandemic in order to inform response strategies to reduce COVID-19 morbidity and mortality in these individuals. We will conduct semistructured interviews and focus groups, which will enable in-depth explorations of individual participants’ experiences and perspectives,Participants will consist of adult individuals (≥16 years of age) with capacity to consent, from ethnic minority and White backgrounds with experience of working in healthcare settings during COVID-19, including both clinical and ancillary staff. We will recruit a purposive sample and will aim for theoretical saturation, including approximately 50 in-depth semistructured interviews and focus groups with a total of approximately 100 participants. Saturation describes the point at which no new data or insights are being gained from interviews or focus groups,We will recruit participants through collaborators/partners/stakeholders, community organisations and NHS organisations throughout the country. We will promote our research through posters, which will be advertised on-site and digitally . Interested individuals will be able to contact the research team directly via the information provided on the poster. We will also work with gatekeepers in our partner and NHS organisations, who will send out communications regarding UK-REACH’s qualitative research on HCW experiences to their networks or staff to facilitate recruitment. Additionally, a subset of cohort participants from the longitudinal cohort study (Work Package 2) who have given their consent to be contacted for further research will be invited to participate in the interviews/focus groups.Semistructured interviews and focus groups will be conducted by the research team informed by a topic guide. The topic guide has been developed in consultation with the PEP members and piloted before commencement of actual data collection to trial out the questions as well as the online processes. Key topics included in this guide are: exploring participants’ experiences of working during COVID-19; their fears and concerns at work and outside of work; perceived risk factors; challenges faced in accessing information to keep themselves safe; concerns around stigma, discrimination and racism; and identifying facilitators and coping mechanisms. To accommodate multiple participants, approximately 1.5 hours will be allocated to the focus groups compared with the 45–60 min for the one-to-one interviews. Following their participation, a token payment will be given to HCWs in recognition of their contribution to the research.The topic guide will be the same when engaging healthcare staff through focus groups or one-to-one interviews. As in WP3, we will also collect basic demographic information about the participants using a short demographic data template. Interviews and focus groups will take place in a secure, virtual environment  or via telephone at a time that is convenient to the participants. Where prior consent is given, interviews and focus groups will be recorded through the relevant software platform . Interview and focus group recordings will be transcribed by professional transcribers and pseudonymised before the start of analysis. The transcriptions will be supplemented with notes taken by the researchers during the interviews and focus groups.Interview transcripts will be analysed using thematic analysis. Thematic analysis involves identifying themes or patterns in the data, lending coherence and order to it.The rich diversity of the UK-REACH research will be complemented by a robust stakeholder involvement and engagement strategy, which has been in-built into the project (WP5) and conforms to the principles of (1) being receptive of public views and opinions, (2) collaborating and cocreating with the public, and (3) involving the public in wider dissemination of results. Within this work package, a stakeholder group (UK-REACH STAG) has been created to provide feedback and insights, and support in the formulation and propagation of the project recommendations. The group has membership from a range of partner stakeholder organisations  and associations of ethnic minority professionals such as Filipino Nurses Association-UK and Association of Pakistani Physicians in Northern Europe. The group will meet virtually, once a month, until the end of the project, and will be governed by a set of terms of reference. Group meetings will be chaired by a nominated HCW chairperson/deputy chairperson, and a member of the research team will help with the coordination. Common email forums may also be created for the group members to share their views, opinions and feedback among each other outside of the periodic meetings. Progress with the delivery of other work packages, and where needed input from a stakeholder perspective is sought through these meetings. The stakeholder group’s primary approach is through informal consensus building during the monthly meetings. Formal consensus approaches such as Delphi may be used if a more challenging decision need arises during the implementation of the project or for the purpose of optimising dissemination.Views and opinions expressed by the group members will be aggregated, and individual names will not appear in any of the published documents. Meeting minutes will only be shared with the respective group members and on a need-to-know basis with members of the research team. The UK-REACH STAG will also provide support in the dissemination of the project recommendations.Public involvement has been a central tenet in the UK-REACH project since its early stages. The project was developed in consultation and collaboration with national stakeholders including the General Medical Council, Nursing and Midwifery Council, royal colleges and ethnic minority HCW associations like British Association of Physicians of Indian Origin. The public involvement and engagement component has been further streamlined into the project with the creation of the PEP comprising healthcare professionals in various roles and from different ethnic backgrounds. The group members provide unique insight—relating to their professions and ethnic groups by virtue of their lived experiences—to certain aspects of the project. The PEP meets virtually and has provided inputs on the participant recruitment strategies for the different work packages, as well as questionnaire for the cohort study, topic guides for WP3 and WP4 and other study-related documents . We will continue to consult the PEP on other matters, such as data collection, analysis, reporting and even dissemination, as the project progresses.Prior to focus groups and interviews, potential participants will be given participant information sheets (PIS), which will detail the nature of the research, objectives and any risks involved with participation. In light of COVID-19 constraints regarding face-to-face interaction, consent will be sought digitally  from the participants and a downloadable version of the completed form will be available to participants for their record. The right to decline to participate, and to withdraw consent at any stage of the research, will be explicitly stated on both the PIS and in discussion with potential participants. It will be explicitly stated that their signing of the consent form at no point supersedes their right to withdraw from the study. The PIS also states that if a participant withdraws from the study after collection of data, the collected data will be stored and analysed by the research team, unless the participant specifically requests for removal of the data at the time of withdrawal. The opportunity will also be given before every interview and focus group for participants to ask any questions about the scope of the research, or their rights as participants throughout the consent process.While this study is low risk, particularly with respect to WP3–WP5, we recognise that exploring and discussing experiences around COVID-19 and ethnicity  could be distressing to participants. We aim to manage this risk through the consent process, clearly explaining to individuals what the study entails, and giving ample opportunities to question the process and decline to take part if individuals wish. We also aim to make the interview process as comfortable as possible, and ensure participants know they may stop, take a break or decide to withdraw from the interview and/or study at any point. The interview will always proceed at the comfort and discretion of the participant.We will inform participants that participation will be confidential, and any personal information collected will be anonymised. Interview transcripts relating to individuals will also be pseudonymised using a unique numerical and date reference as the means to identify individual data sets. Such a system will ensure the anonymity of the participants and allow identification of individual data sets should a participant wish to exercise their individual rights . Individual data and transcripts will be held in secure digital drives, and original recordings will be deleted after transcription. Access to the full data set will only be provided to the members of the research team. The only circumstance in which individual-level data will be released is in the form of deidentified, anonymised excerpts within the final publication, which is a standard procedure in qualitative research of this type.www.uk-reach.org). We have also enlisted the support of our stakeholders in disseminating the findings and recommendations through their organisational websites, newsletters, internal communications, blogs or social media channels like Twitter. Following suggestions from our STAG members, we will also endeavour to make recommendations available in other languages such as Welsh, for greater uptake. In addition, we will make our findings available to the Scientific Advisory Group for Emergencies and other policymakers in a timely manner so that policy decisions can be made in near real time. As a topic of immense public health significance, we will also endeavour to make our results available through print and electronic media. We will also publish the outputs of this research in peer-reviewed journals in line with the University of Leicester’s Open Access publication policy to enable us to share the results widely with the academic community. We will also make presentations at relevant academic conferences as well as non-academic events organised by our collaborators.We will ensure that the findings from the work packages are reported rapidly and published on our public-facing website (UK-REACH, led by the University of Leicester, is one of the first studies in the world that sets out to understand why HCWs from minority ethnic backgrounds are disproportionately affected by COVID-19 as compared with their White counterparts. While emerging evidence from epidemiological studies is pointing to varied COVID-19 outcomes among different ethnic groups, not much is known about the reasons behind this variation. The qualitative work packages of the project, that is, WP3 and WP4, are expected to generate evidence which will be crucial in understanding some of the ethnicity-linked risk factors in COVID-19. The aim of the stakeholder engagement work package is to disseminate this evidence widely and in a timely manner. Additionally, our ethico-legal work package will generate important guidance on ways to minimise risks associated with research participation, and best practices in protecting the rights and interests of participants. Through our qualitative study on HCW experiences we aim to increase knowledge about risk perceptions, support and coping mechanisms relevant to COVID-19, which in turn will enable healthcare organisations to protect the mental and physical health of ethnic minority staff. We appreciate the insights that stakeholders can bring into our project and have enlisted their support from early on to maximise our reach and impact. It is the ultimate hope that through this project we will gain clear insight into the differences in COVID-19 clinical outcomes, professional practices and well-being among ethnic minority and White HCWs, in turn leading to a robust evidence basis for policymaking to minimise the impacts of COVID-19 on HCWs across the UK.


The use of wearable biosensor devices for monitoring and coaching in forensic psychiatric settings yields high expectations for improved self-regulation of emotions and behavior in clients and staff members. More so, if clients have mild intellectual disabilities (IQ 50-85), they might benefit from these biosensors as they are easy to use in everyday life, which ensures that clients can practice with the devices in multiple stress and arousal-inducing situations. However, research on (continuous) use and acceptance of biosensors in forensic psychiatry for clients with mild intellectual disabilities and their caretakers is scarce. Although wearable biosensors show promise for health care, recent research showed that the acceptance and continuous use of wearable devices in consumers is not as was anticipated, probably due to low expectations.The main goal of this study was to investigate the associations between and determinants of the expectation of usability, the actual experienced usability, and the intention for continuous use of biosensors.A total of 77 participants  participated in a 1-week trial. Preceding the study, we selected 4 devices thought to benefit the participants in domains of self-regulation, physical health, or sleep. Qualitative and quantitative questionnaires were used that explored the determinants of usability, acceptance, and continuous use of biosensors. Questionnaires consisted of the System Usability Scale, the Technology Acceptance Model questionnaire, and the extended expectation confirmation model questionnaire.r=.80, P<.001) and usability and continuous use  than clients, who showed more moderate correlations between usability and acceptance  and usability and continuous use . The qualitative questionnaires in general indicated that the devices were easy to use and gave clear information.Only the experienced usability of the devices was associated with intended continuous use. Forensic clients scored higher on acceptance and intention for continuous use than staff members. Moderate associations were found between usability with acceptance and continuous use. Staff members showed stronger associations between usability and acceptance (Contrary to expectations, it was the actual perceived usability of wearing a biosensor that was associated with continuous use and to a much lesser extent the expectancy of usability. Clients scored higher on acceptance and intention for continuous use, but associations between usability and both acceptance and continuous use were markedly stronger in staff members. This study provides clear directions on how to further investigate these associations. For example, whether this is a true effect or due to a social desirability bias in the client group must be investigated. Clients with mild intellectual disabilities might benefit from the ease of use of these devices and their continuing monitoring and coaching apps. For these clients, it is especially important to develop easy-to-use biosensors with a minimum requirement on cognitive capacity to increase usability, acceptance, and continuous use. The use of wearable biosensor devices for monitoring and coaching in forensic psychiatric settings for people with intellectual disabilities and their caretakers yields high expectations for improved self-regulation of emotions and behavior. This is based on the expectation that wearable biosensor devices can be used to detect changing levels of emotional states  and behaA potentially complicating factor in the use of these biosensors are the mild intellectual disabilities and borderline intellectual functioning  of the user. Clients with MID-BIF might not benefit from cognitive behavioral therapies  like people with average intelligence  due to tAlthough wearable biosensors show promise for health care, research into the use and acceptance of wearable biosensors is almost absent in forensic psychiatry, let alone in clients with MID-BIF. Recent consumer research, however, showed that the acceptance of wearable devices in consumers is not as was anticipated , and, moTo increase the usability, acceptance, and continuous use of biosensors, user preferences, needs, and wishes, especially for people with MID-BIF, must be known. In addition, it is necessary to determine the goals of the user and the tasks for which the biosensors will be used. Finally, the functions of user interfaces and biosensor devices should be evaluated to make them more attractive, desirable, and efficient for the users by integrating the outcomes of the evaluation ,18. Kim Research on the use of biosensors for clients with MID-BIF is scarce while the potential benefits might be significant. Therefore, we investigated the use of everyday wearable biosensors to establish what would lead to their (continuous) use and acceptance. Biosensor information could potentially benefit not only clients but staff members as well. To this end, qualitative and quantitative questionnaires were used to explore the psychological  and functional (tasks and functions) determinants of usability, acceptance, and continuous use of biosensors in both staff members and clients. The main goal of this study was to investigate the expectation–experience–continuous use connection to see whether there is a gap between expectations of usability and the actual experience that will preferably lead to continuous use and whether there are differences between clients and staff members. In addition, we investigated the key determinants involved in the usability, acceptance, and continuous use of biosensors using validated questionnaires. The following research questions were formulated:Are there differences between clients and staff members in expectations of usability and the actual experienced usability that will lead to continuous use of biosensors (expectation–experience–continuous use)?Which key determinants contribute to the usability, acceptance, and continuous use of biosensors in forensic psychiatry for clients with MID-BIF and staff members?The participants for this small-scale study consisted of two groups of users: clients with MID-BIF who are residents of forensic psychiatric living units and staff members who work as nurses or sociotherapists on these forensic psychiatric living units. Clients are often referred to the units as a result of aggressive and violent behavior and are at an increased risk for severe behavior problems, offending behavior, and recidivism . During After multiple sessions with a user group consisting of staff members and clients, we selected 4 devices that were thought to benefit the participants in domains of self-regulation, physical health, or sleep. All 4 devices used in this study are US Food and Drug Administration and CE approved and can be bought in regular stores .The Spire Stone  is a wearable device in the form of a stone that can be attached to a belt (men) or bra (woman). It measures the contraction of the torso to indicate the rate of breathing. The device comes with an app and classifies the respiration rate as calm, focused, or tense  is a physical activity tracker with a heart rate monitor that provides users with real-time feedback on heart rate and physical activity. In addition, it can provide users with information on sleep and exercise. The app provides users with detailed information on stress, sleep, and activity  is a physical activity tracker with a heart rate monitor that provides users with real-time feedback on energy expenditure, stress indications based on heart rate, and sleep quality assessment. The app provides users with detailed information on sleep, stress, and energy expenditure .The TicWatch E (Mobvoi Inc) is a smartwatch running WearOS with a heart rate sensor. It can be used as a biofeedback device when running the Sense-It app , an ambuTo assess determinants of usability, we evaluated user satisfaction with the wearable biosensors  with theAs the questionnaires were not available in Dutch, they were translated by 3 researchers and 8 staff members who work in forensic psychiatric settings with MID-BIF clients. The questionnaires were then back-translated by native English speakers. As the formulation of the questions was deemed too complex for the MID-BIF clients, an easier version of all 3 questionnaires was constructed for MID-BIF clients consisting of fewer, more easily formulated questions. The choice of which questions to select for the short version for clients was made by the researchers and staff members based on two key principles: the question should easily be understood by the MID-BIF client and represent the implied construct to be measured.The SUS is a 10-item questionnaire with good reliability (.85) ,24 that To answer the first research question on the expectation–experience–continuous use connection, the questionnaire was administered twice. The SUS questionnaire was administered preceding the study to measure the expectation of the participants. Following 1 week, the SUS was administered to measure the actual experience with the biosensors.The TAM questionnaire  is one oPal et al  proposedThe full TAM and EECM questionnaires would be too much of a burden for the clients with MID-BIF. Therefore, we selected one question from each factor on the TAM and EECM for the clients to answer. The staff members completed the full version of the questionnaire. For ease of reporting and interpretation for both clients and staff members, the results reported in this paper consist of the SUS, the short version of the TAM, and the short version of the EECM . All shoThe qualitative questionnaires consisted of an individually administered semistructured interview based on the quantitative questionnaires. Participants were asked to elaborate on thoughts they had on the aspects of usability, acceptance, and continuous use. Additional determinants of usability, acceptance, and continuous use were derived from the semistructured interview in order to further explore the second research question.The research was conducted from May to August 2019. Recruitment of the participants was done at the sites of the living units. Participants were invited to participate and informed about the aim of the study through posters, flyers, and email. After a participant agreed to participate in the study, wearable biosensors were given to the participants with instructions on how to use them. If a user did not own a phone to connect to the app, a P smart (Huawei Device Co Ltd) was provided to the participant . One of four commercially available devices was randomly assigned to the participant. Before wearing the device, they completed the SUS questionnaire to assess their expectations of usability. The research coordinator completed the SUS questionnaire with the participant if necessary. Sheehan and Hassiotis  identifyThe participants were given time to get familiar with the biosensors. The research coordinator functioned as a contact person in case the participant had any technical problems . After tDescriptive statistics were used to describe the devices that were worn and the age, education, and gender of participants. A 2-way mixed analysis of variance (within: pre-post and between: client-staff) was used to test the main outcome on the expectation of usability with the actual experience. The SUS scores were calculated both preassessment and postassessment for each participant to determine their correlation with continuous use to answer the first research question. To test whether there was an association between the expected and experienced usability with (the intended) continuous use of the EECM questionnaire, we used Spearman correlations to answer the second research question, as the scores on the SUS were not normally distributed. To determine the key determinants that contribute to the usability, acceptance, and continuous use of biosensors, the proportion and number of responses for all questionnaires was computed for clients and staff members.Further exploratory statistical analyses consisted of a 2-way analysis of covariance (ANCOVA) to test which demographic factors were associated with the judgments of the participants concerning the usability, acceptance, and continuous use of biosensors. Last, an analysis was performed on the qualitative questions of usability, acceptance, and continuous use regarding word frequency. All analyses were done in R  software .To investigate whether there were differences between clients and staff members in expectations of usability and the actual experienced usability that will lead to continuous use, 77 participants were included (31 clients and 46 staff members), with an age range varying from 18 to 63 (mean 34.9 [SD 10.8]) years. Participants were included from 4 mental health institutions in the Netherlands that provide forensic care for clients with MID-BIF.Participants wore a Charge 3 (31/77), vívosmart 4 (21/77), Spire Stone (14/77), or TicWatch E 11/77; . The difA small proportion of clients with MID-BIF were not allowed to use a mobile phone (6/77). They were therefore unable to answer questions regarding the use of the biosensor in combination with the app. The missing values were therefore imputed with the “don’t know or neutral” categories of the questionnaires. t tests showed that these differences were nonsignificant for both clients  and staff members . The discrepancy between the experienced (posttest) and expected (pretest) usability seems to have been caused by the Spire Stone and TicWatch E .The mean for the clients increased over time while the mean for the staff decreased . Paired ch E see . There wP=.12). The correlation between the experienced usability and the EECM was .54 (P<.001), which indicates a higher relevance for continuous use after participants wore the device.The correlation between the expected usability and the EECM was .18  and continuous use  for group; in both cases the clients scored higher on acceptance and intention for continuous use. There was no significant interaction between gender and education on the usability score , acceptance score , or continuous use score . This indicates that the effect of gender on usability, acceptance, and continuous use does not depend on the level of education or vice versa. As can be seen in r=.80, P<.001), usability and continuous use , and acceptance with continuous use . Clients obtained moderate correlations between usability and acceptance , usability and continuous use , and strong correlations between acceptance and continuous use .We explored which demographic variables contributed to the usability (SUS), acceptance (TAM), and continuous use (EECM) of biosensors. We included age, level of education, and gender in separate 2-way ANCOVAs as the dependent variables were correlated, which prohibited a multifactorial multivariate analysis of covariance. In addition, we performed a Box-Cox transformation on the SUS and TAM as these were not normally distributed; the ANCOVAs were adjusted for age. There was a significant difference for both acceptance  of wearable devices and the intention of continuous use (EECM) was found. This seems to indicate that these two questionnaires measure overlapping constructs, and the question arises whether both need to be administered. Especially when the load on participants should be kept to a minimum as in our sample with forensic MID-BIF clients. These results must be interpreted with care as the design of our study, without proper counterbalancing, and the use of short questionnaires limit the conclusions that can be drawn from the study.As far as the determinants for usability, acceptance, and continuous use are concerned, answers from the usability scale indicated that most of the clients and staff members felt confident using the biosensors and after they wore the devices and thought that most people would learn to use the product very quickly and want to use it frequently. The acceptance scale indicated that the majority have positive attitudes toward technology, their affective quality, relative advantage, mobility, availability, and perceived ease of use. The continuous use scale showed that the majority of staff members and clients gave positive answers on satisfaction, self-socio motivation, perceived comfort, and hedonic motivation. However, the majority had doubts on the perceived accuracy and functional limitations. It is also interesting to note that a minority of staff members and clients were not positive about the usability, acceptance, and continuous use of the devices. These people might not want to use the devices or think that they need help in using the devices. For instance, a minority of people think that they would need help from a technical person to use the device. It might well be that providing them with proper support might increase their intention to use the device. Also, some find that wearing the device is uncomfortable and the accuracy of the fitness data could be improved. These devices might thus benefit from developments in accuracy and form factor ,3,15,31.Two particular strengths of this study are the use of simply worded questionnaires adapted for clients with MID-BIF as this was not available in the literature. In addition, we used qualitative questionnaires and a diverse and heterogeneous sample as Kalantari  pointed Future research should focus on longitudinal research investigating usability, acceptance, and continuous use, should include a counterbalanced design in which all devices are worn at least once, and should investigate measurement invariance for the short questionnaires ,33. BiosAnother important topic for future research is the reliability and validity of the sensors, especially in comparison with gold standard equipment used in laboratories. Peake et al  reportedLast, for people with MID-BIF, it is especially important to develop easy-to-use biosensors with a minimum requirement on cognitive capacity to increase usability, acceptance, and continuous use in the future. It must be noted, however, that clients scored similar to staff members on ease of use of available devices and higher on acceptance and (intended) continuous use. Whether clients indeed grasped the information provided by the sensors must be investigated further.Actual perceived usability of wearing a biosensor and to a much lesser extent the expectancy of usability were associated with continuous use. Clients with mild intellectual disabilities might benefit from the ease of use of wearables devices and their continuing monitoring and coaching apps. Clients scored higher on acceptance and intention for continuous use, but associations between usability and both acceptance and continuous use were markedly stronger in staff members. For clients, it is especially important to develop easy-to-use biosensors with a minimum requirement on cognitive capacity to increase usability, acceptance, and continuous use.