Community health participation is an essential tool in health research and management where community members, researchers and other relevant stakeholders contribute to the decision-making processes. Though community participation processes can be complex and challenging, evidence from previous studies have reported significant value of engaging with community in community health projects.To identify the nature and extent of community involvement in community health participatory research (CHPR) projects in Ghana and draw lessons for participatory design of a new project on diabetes intervention in Accra called the Contextual Awareness Response and Evaluation (CARE) diabetes project.A scoping review of relevant publications on CHPR projects in Ghana which had a participatory component was undertaken. PubMed, PsycINFO, African Journal Online, Health Source: Nursing/Academic Edition, Humanities International Complete and Google Scholar were searched for articles published between January 1950 and October 2021. Levac et al.’s (2010) methodological framework for scoping reviews was used to select, collate and characterise the data.Fifteen studies were included in this review of CHPR projects from multiple disciplines. Participants included community health workers, patients, caregivers, policymakers, community groups, service users and providers. Based on Pretty’s participation typology, several themes were identified in relation to the involvement of participants in the identified studies. The highest levels of participation were found in two studies in the diagnosis, four in the development, five in the implementation and three in the evaluation phases of projects. Community participation across all studies was assessed as low overall.This review showed that community participation is essential in the acceptability and feasibility of research projects in Ghana and highlighted community participation’s role in the diagnosis, development, implementation and evaluation stages of projects. Lessons from this review will be considered in the development, implementation, and future evaluation of the CARE diabetes project. Community participation has been reported as a tool for improving health through a social process where communities are empowered to identify and develop practical solutions to their health concerns . We defiThe benefits of participatory and empowering approaches for community health have been extensively reported in literature to include improved healthcare initiatives , improveThe principle behind community participation as a tool in chronic disease research and management is that lay individuals, families, and the wider community are also producers of health, and not solely professionals in the health sector . The WHOThe Community Health Participatory Research (CHPR) approach aims to equitably involve community members, researchers and other relevant stakeholders in the research process, where all partners contribute knowledge and resources and play a part in the decision-making process  CHPR hasDespite these initiatives and wide acceptance of community involvement, some challenges to successful implementation have been reported. These include the complexity and meaning of the community participatory process to community members . AlthougThis scoping review aims to identify the nature and extent of community involvement in CHPR projects in Ghana to inform the participatory design for, the Contextual Awareness Response and Evaluation (CARE) diabetes project, with study sites in Accra. The CARE diabetes project will focus on exploring methods for examining the social context of T2DM risk, experiences and response. The CARE diabetes project will also explore how best practices in community health participation can inform our approach to data collection, analysis, dissemination, and uptake to help ensure interventions are relevant to local needs and informed by local knowledge and priorities. The CARE project focuses on T2DM, but lessons can be learned from the way other chronic NCDs are managed. Therefore, for this review, we will focus on CHPR that addresses non-communicable diseases in Ghana.This scoping review adopted Levac et al.’s  methodolFive peer-reviewed databases , Health Source: Nursing/Academic Edition, and Humanities International Complete) and one search engine (Google Scholar) were searched. In addition, three local journals  were searched. The search terms used are provided in We identified 38,658 publications and 10 additional publications from the local journals and discussion with an expert in CHPR (AdGA). A total of 27 duplicates were removed and the remaining 38,641 publications were retained for subsequent screening for eligibility. After title and abstract screening, a total of 38,602 were excluded because they did not focus on NCDs and did not use a CHPR approach. Studies that were published in the English language, focused on NCDs, were conducted in Ghana and used a CHPR approach were included in the review. A total of 39 publications met the inclusion criteria. The full text of the 39 publications were then retrieved for detailed review. After the full text review, only 15 studies were found to have used the CHPR approach, and are therefore included in the synthesis.The extent of community participation was assessed using Pretty’s  participFor the 15 eligible studies, the level of community participation was assigned a score between 1 and 7 for each of the phases of project development. These are summarised as follows: no participation (score 1); passive participation (score 2 – meaning the community was only informed about the project); participation by information (score 3 – meaning information was collected from the community without their participation and without providing feedback); participation by consultation ; functional participation ; interactive participation ; and self-mobilisation (score 7 – meaning outsider’s work in community was based on community’s terms) . The scoFifteen studies were included in this review; all the included studies were published between 2006 and 2021. Community Health Participatory Research (CHPR) in Ghana has been conducted by researchers from multiple disciplines including public health, global health, epidemiology, population science, economics, psychology, and anthropology, based on the affiliations of the authors. Study sample sizes ranged from twenty-seven 27)  to two t  to two 1As of 2020, there are 16 regions in Ghana. Prior to this and at the time the majority of the studies were conducted, there were 10 regions in Ghana. This may explain why studies were not retrieved for some of the new regions. Three studies were conducted in rural areas, six in urban areas, four in both urban and rural, and two in peri-urban sites. A map highlighting the regions can be found in Appendix 1. Twelve studies focused on NCDs, and three on general healthcare/quality of care. Studies adopted several methods, including mixed methods. Ten studies used quantitative methods within the broader project while ten adopted qualitative approaches.Studies have been divided into two key themes – ‘Health promotion and prevention’ and ‘disease management and control’. ‘Disease management and control’ includes studies that focus on primary healthcare, treatment and interventions that are primarily focused on managing existing conditions. ‘Health promotion and prevention’ focuses on health promotion activity including education, screening, and interventions to prevent disease or promote healthy behaviours.The participation of the community was described with insufficient detail to be assessed (unknown category) for one study in the Development phase (5.8%)  and one A summary of the studies’ aims, and outcomes is provided in The purpose of this scoping review was to identify existing knowledge on and the extent of community involvement in participatory health research projects in Ghana. This was done to understand how best practices in community health participation can inform approaches to project design and implementation. A total of 15 studies were identified and reviewed. Most of the included studies had some level of community participation, although the extent of this participation varied. The review also showed that levels of community participation were dependent on the type of project, the health condition being explored, and the study design. Regardless, the findings of this review suggest that CHPR projects in Ghana were largely successful, whereby studies reported that community participation is a promising approach to improve the well-being and health of a community.Community participation has been identified as a key element of building relationships and strengthening people centred primary healthcare . Communi2Although not a traditional health determinant, this study explores the community response to local health services which can have an impact on health.Several trends were identified in relation to the involvement of participants in the identified studies. As mentioned, most of the identified studies involved low levels of participant engagement. Overall, the greatest level of involvement in the phases of project development, as determined by our scoring , was theThe two studies ,32 that The lack of studies with the highest level of participation (level 7) may be a result of existing structures around research formulation and development. Many research projects are developed in response to funding opportunities, and objectives are decided by researchers and relevant stakeholders, such as funders, ahead of time, therefore making it less feasible for the community to be involved in the ‘diagnosis stage’ or for studies to reach the most active levels of participation. It could also be said that many projects would not occur without the input of those with the time, skill, and commitment to the research, who are likely to be outsiders to the community . AlthougAs indicated earlier, the level and type of participation varied between studies. In several studies, community participation was achieved through individual interviews (semi-structured or in-depth) and focus discussion groups with the community, often before the intervention was developed or implemented . Also, kAn important finding was that in some of these studies, particularly the studies conducted in rural areas, community leaders such as chiefs and elders and lay community members were approached prior to the commencement of the studies ,42. ThisIn the same study , where aSeveral limitations have been identified. This review aimed to identify the breadth of information available on CHPR in Ghana as opposed to the depth so further analysis was not conducted. It was also a rapid review so relevant studies may not have been included. Studies were mainly identified through database searching so studies not published or available online would not have been included and paper did not undergo critical appraisal as this was beyond the scope of this study. It is also important to note that although no studies were identified as having the most active participation (level 7), research that is entirely community led may not be feasible in the context of these projects and scoring for this review, although standardised, was subjective to the reviewers. Regardless, the lack of studies with active participation (levels 5–7) makes it clear that research encouraging more active participation (levels 5–7) from the community is necessary. There is also opportunity to engage with donors regarding the value of early and sustained community participation to project effectiveness and sustainability given that funders’ requirements can act to prevent such participation.Despite the variability in the studies, there are many positive examples of community participation in Ghana that highlight the benefits of involving the community in the various stages of project development. All studies largely demonstrated that community participation plays an important role in the acceptability and feasibility of a study. However, it is important to note that studies are specific to their context, whether that be rural, urban, or targeting a specific health condition or behaviour. Therefore, applying these findings in an external context may be limited, yet important lessons can be learned from this approach.Following on from this review, we believe there is a greater need for research focusing on more active participation from communities in Ghana including those affected by NCDs. This research should be largely led and determined by the community. This should be at all stages, from diagnosing the issue to designing, implementing and evaluating the study. There is also a need for more early engagement in projects as most participation was found to be in the later phases of projects, and it is clear researchers would benefit from working with community leaders and elders as it has proven to be effective. For this to be done, more funder commitment to implement research that prioritises community participation, particularly in the early stages of research, is necessary. In thinking through and planning for the CARE project, the team has actively incorporated the above lessons in the development, implementation, and future evaluation of the project.Click here for additional data file.


During the mass curfews, travel bans, school shutdowns, face-to-face education was discontinued, and many universities had to urgently switch to online education. Academics, most of whom are not familiar with digital pedagogy, had to adapt their lectures to online learning. The aim of this study is to analyze how Open Educational Resources (OERs) are used in practice during emergency remote teaching (ERT) and whether this influences the regular practice of academics on a global level and in Turkey in the longer term. Methodologically, we adopt a mixed-methods approach in two stages: (i) an empirical study conducted in Turkey to find out what prior knowledge and experience academics have with OERs and how they use OERs during ERT; (ii) a complimentary desk study on the global situation of OER use. Our results show that academics who did not know about OERs before the pandemic are still hesitant to use them, even though they have prior experience with online teaching. In addition, academics with higher rank and academics in architecture, philology, and arts have the most negative opinion about campus education being fully accessible online. The novel Coronavirus disease, Covid-19, first appeared in Wuhan, China, in late December 2019 . The CovWith the tightening of curfews around the world, the situation of educational disruption has arisen. It has led to the widespread closure of schools, colleges, universities, and other educational establishments in many countries in order to stem the spread of Covid-19. As a result, the face-to-face (F2F) campus education offered by higher education institutions was stopped to adapt to the new situation and required an emergency transition to online education.The institutional basis of distance learning goes back to the time long before the invention of the Internet and the World Wide Web (WWW) . The evoOERs are defined by UNESCO as educational materials that are publicly available or licensed by an open license allowing free access, use, adaptation, and redistribution by others with no or minimum restrictions . The motGiven the low-cost  online access to OERs, they could be a great resource for use in emergency online education, where everything from lecture notes to classrooms is web-based . Howeveronline emergency remote teaching and certainly has shortcomings  as an open and distance education application were to bring down on-campus education when the first MOOCs started broadcasting . The MOOAccording to UNESCO, more than 190 countries have closed schools and educational institutions, affecting almost 90% of the world’s student population as of 13 May 2020 . The verA 2017 report by EDUCAUSE reported that 91% of academics would not prefer online learning Zooming into the perception of academics from Turkey, the literature provides some critical situations. A number of studies reported how academics in Turkey perceived distance learning, open educational resources, and MOOCs. The studies conclude some common findings as follows:The majority of academics are not willing to give lectures online because they believe face-to-face education is one of the key factors for success .Academics usually believe that online education alone is not enough; it should be blended or used only for lifelong learning, not for a degree .If academics find it easy to use the technology, they are more willing to change their traditional tool and blend them with technology, which has a positive correlation with the success of using online education .This being said, we should mention the theory that explains the stages of adoption of an innovation. Diffusion of innovation refers to the process that occurs when people adopt an innovation such as a new idea, a new product, a new practice, and a new philosophy . The theThere is, of course, research on OERs available in the literature, such as Taking into account all potential difficulties and emergency solutions, the main objective of this study is to examine how willing university lecturers are to teach online, how they are aware of OERs and open licenses, whether they have already used OERs, and how they have used OERs during the recent emergency transition to online learning due to Covid-19. In this study, we seek to investigate answers to these research questions:RQ1: What is the example of providing opportunities for a smooth transition to online education in higher education due to the pandemic worldwide, that is, closure of campuses, online lectures, available resources for online education, measures taken for quality online education?RQ2: What is the readiness of academics in Turkey in terms of pedagogical and technological information and tools at the knowledge and practice level, that is, knowing, accepting, or using the information and/or tools on digital pedagogy and technology?RQ3: Are academics in Turkey aware of OERs and Creative Common (CC) licenses? If so, to what extent have they used OERs in their lecture preparation and made their own resources publicly available?RQ4: Is there a change in the habit/awareness of academics in Turkey regarding the use of OERs before and during the pandemic?RQ5: If there is a change in the educational practices of academics in Turkey regarding the use of OER before and during the pandemic, is there a difference among academics according to age, gender, the field of study and academic rank?This study follows a mixed  methodological approach by conducting an empirical research study with complimentary desk research for a systematic mapping. We conducted an online survey with over 130 academics from Turkey to understand how they used open educational resources in preparing their lectures and the challenges and benefits of an emergency transition to online education for them comparing their readiness before the pandemic. Regarding the collected samples, it provides a limited representation of the academics in Turkey. In order to generalize the findings across the country, bigger research needs to be conducted with a larger proportion of academics. The results analyzed in the related section represent the behavior in the sample case.The survey was produced in Turkish and distributed via an online tool, Google Forms. The survey consisted of eight parts: general information, transition during the pandemics, readiness for online education, use of OERs, assessment and evaluation, infrastructure and tools, sharing of educational materials open, and post pandemics. Most of the questions are multiple-choice questions. Some open-ended questions to identify their challenges, rationale, and thoughts are added to the end of the parts.Emergency Remote Teaching: A Case Study on Higher Education in Turkey. To provide complementary results for the empirical study on Turkey, desktop research on the worldwide use of OERs during emergency remote education is also conducted by using (i) academic articles on academic prospectus databases, that is, Web of Science and Google Scholar and (ii) online news and reports via the Google Search browser.The survey is distributed over online academic network platforms such as LinkedIn and online academic groups. Although we conducted the survey during such a disastrous time when there were overwhelmingly many requests for participation in scientific questionnaires regarding the pandemics in the mailboxes, we reached 133 academics who voluntarily participated in our questionnaire. Our dataset is almost evenly distributed in terms of gender and role of the participants in order to provide meaningful insight into the situation in Turkey. The results are presented in Section The Turkey specific analysis is a piece of proof that academics’ awareness and readiness of OERs are satisfactory to thoroughly exploit all the free open resources along with those paid options that are made free during the pandemic. However, Turkey is not a rare example of this matter. Our motivation to prepare this section is twofold: to show (i) how OERs are used as one of the first solutions to ease the process of online education during the global pandemic and (ii) the gap between countries’ use of OERs during emergency online education considering the countries’ infrastructural readiness and wealth. We aim to put a picture of how institutions from different countries around the world have become accustomed to emergency remote teaching using OERs to support the educational process.Some universities have already established infrastructure for distance education and have already practiced blended teaching on campus long before the pandemic. For example, Harvard University has continued to use the existing distance learning tools that were already in use before the pandemic. The university also developed a platform to collect resources on best online practices, tools, and support for online learning. For synchronous online lectures, Harvard University preferred the Canvas platform as a learning management system that integrated a web conferencing system, Zoom.As an example, apart from the Ivy League universities, the University Utara Malaysiahas already introduced blended learning in recent years, where students learn online as well as F2F. Therefore, the transition to online learning was very smooth during the Covid-19 pandemic.Singapore, like Malaysia, is one of the countries with the least difficulty in the process, thanks to its technological infrastructure. Singapore-based technology company Larkannounced that due to Covid-19, it has been making its digital collaboration tools available free of charge in the Southeast Asian region, including Singapore, Malaysia, Indonesia, the Philippines, Thailand, and Vietnam, since March 2020. UNESCO has also recognized all of this along with others from the world as a platform that can make learning easier for students, parents, and teachers and enable social interaction during Covid-19.Higher education institutes exploit all the freely and openly tools available to ease the transition. OER platforms, including MOOCs, therefore, are one of the immediately available resources. For instance, the Italian MOOC platform Federica.eu, which supports over a hundred University Naples Federico II (UNINA) professors, uses Federica MOOCs and uses Microsoft teams to deliver online lessons . UNINA tSlovenia’s VideoLectures.Netthe UNESCO award-winning freely accessible repository for educational video lectures represents a nice example of how OERs are transformed during the pandemic. VideoLectures.Net offered conference organizers the service of holding the conferences online and publishing the content free of charge, as many conferences have to be held online due to the pandemic travel restrictions.The private companies also contributed to the support for distance education. For example, Telecom Egypt provides free access to the Egyptian Knowledge Bank, which was identified as a fairly reliable source that was used during the transition . More exTo show the collaborative effort at the global level for supporting education during the pandemic, we created a timeline in These examples can be considered as a representative that digital technologies in the form of open content, open licenses, open formats, and open software have the potential to break down some of the barriers in education . HoweverThe transition to emergency remote teaching in some regions shows that the transition has not always been smooth and competent. Universities with inadequate technological infrastructure are most affected by this process. For example, Universidad Mayor de San Andrés (Bolivia) has suggested that educators use generic applications such as email, video calls, and WhatsApp in the absence of a virtual campus.There are attempts to overcome the regional handicaps with the aid of OERS. For example, Sub-Saharan Africa is already disadvantaged with its infrastructure, that is, low internet density, low electricity and mobile phone access, which are essential for online learning . OER AfrIn addition, the countries already struggling with wars and poverty have difficulties in taking measures against the pandemic. For example, according to UNESCO, Palestine suffers from obstacles to e-learning, mainly infrastructure, weak internet networks, power cuts , and a lack of awareness among students and their families of the importance of e-learning. Keeping in mind these obstacles, Palestinian universities also applied online distance learning through video conferencing tools and free social media platforms such as YouTube.Universities in Turkey rapidly switched to online education in March 2020 and continued online in the Spring 2021 semester. This section provides analyses of the survey conducted with academics from Turkey on how OERs are used during emergency remote teaching. According to the Higher Education Council of Turkey (YOK), 123 out of over 200 universities that have Distance Education Application and Research Center (UZEM), over 90% have made an urgent switch to online education in March 2020. However, not all of them have an adequate infrastructure to offer their students decent distance learning. During the pandemic, new centers for distance education opened. However, there is a lack of evidence to say they are fully operational. In addition, the YOK Open Courseware project promotes the uploading of lecture notes to the platform - initially, four universities are contributing to the collection. Currently, lecture notes from 27 bachelor and 47 pre-bachelor courses, 2,408 books for 35 departments of eight faculties and 2,320 books for 46 pre-bachelor courses are freely available. However, almost all openly accessible materials are written notes and books, which shows that higher education institutions in Turkey do not have properly prepared lecture notes for interactive online education .Apart from the state resources and the international companies, many universities have already published MOOCs in Turkish such as Akadema, Atademix, and Turkcell Academy. In addition to these platforms, Khan Academysupports the Turkish language, and Koc University is a partner of Coursera. However, the amount of content is still very limited; in turn, the participation level remains low . The accThe pandemic process has also shown that both students  and educThe remainder of the section analyses the survey responses of 134 academics from Turkey on how they use the OERs, global and local ones, in emergency remote teaching.More than 130 academics who are officially employed at a private or state university in Turkey participated in the survey. Of all participants, 86% work for a state university. The participants who work for a state university are evenly distributed: half of them work for a newly founded university, while the other half are older than 13 years. It should be noted that with the project “one university in every city” launched by the Turkish government, many small universities have been established since 2008 . We thinParticipants were also asked whether they thought their lectures were suitable for remote education: 44% of them replied as partial, 37% of them said yes, only 19% of them said it was not a suitable instrument for the content of their lecture . This result could be interpreted as an encouraging result that the lecturers could be motivated to keep their lectures online with constructive help.Our results show that the majority of participants (78%) are neither experts in distance learning nor have they been trained in the design of a distance learning course. Moreover, 70% of them have never had any experience in delivering a lecture online.Based on these findings, it is becoming increasingly important to provide lecturers with the necessary training on designing, delivering, and evaluating an online course. In addition, 62% of respondents said they had some difficulties in digitizing their lecture notes for remote education. The main challenges are identified as follows:Limited time for the digitization of all lecture notes (44%)Effective use of the time allocated to the online lecture and appropriate preparation of the materials (23%)Prepare interactive slides (12%)Search for the right material/tool for the presentation of mathematical equations, laboratory equipment etc. (12%)The survey seeks to understand whether academics are aware of the OERs and include them in their course preparation in addition to intellectual property licenses.The Sankey diagram in This result is consistent with another finding from the survey, which found that over 40% of them never used openly and freely shared educational resources in their course preparation. The most frequently used OER resources are: (i) social media such as YouTube and personal blogs (32.3%), (ii) open coursewares of national universities (31.6%), and finally, (iii) a national platform for university courses from the Higher Education Council of Turkey(18.8%). One of the most common concerns expressed in the open questions of the survey is that it is difficult to find OERs authored in Turkish. This result could explain why the three commonly-used repositories are from national/Turkish sources.A noteworthy result is that some of the respondents who said they had never heard of OERs also indicated that they benefit from resources such as open national courseware. This result shows that some academics use OERs without knowing the theoretical concept of OERs. Considering the theory for adoption of an innovation, some academics are not even at the first stage, Knowledge or Awareness.When it comes to MOOCs as a specific OER, most academics in Turkey have never heard of them even before the pandemic (43%). Only 22.6% of respondents said that they know MOOCs well. Not surprisingly, only 9.8% of academics use a MOOC in their class, either fully or partially. The studies show that experts in distance learning consider MOOCs to be a promising development that we should incorporate into the Turkish education system . HoweverThe respondents were also asked whether they had ever heard of the CC License. Although there are other open licenses, CC is one of the most widely known, which is why it is explicitly mentioned in the survey. CC License is a standardized way of granting copyright permission for creative works that creates a balance within the traditional “all rights reserved” setting created by copyright law.Almost 70% of respondents said that they did not know what CC is. In addition, 29% of respondents are not aware of the need to share copyright licenses when making their own materials available in a non-public area. There are also many misconceptions and hesitations that academics have when it comes to sharing materials for teaching, which is summarized in What academics think about continuing online education even after the pandemic is over is analyzed in the section. In this section, we present a number of charts to present the opinion of academics by gender, the field of study, and academic role (rank) on whether or not to maintain the change in educational practices forced by Covid-19.The bar graph in The heat map in Overall, the majority of participants, regardless of their expertise, indicated that they would most likely not continue to teach online. In one of the most common answers from academics, it can be observed that they consider open and distance learning to be less valuable. When they are asked about their motivation for their answers, it can be observed that many of them are in favor of blended learning. Among the others, academics in architecture, philology and art have the most negative opinion about campus education being fully accessible online. However, there are also academics from other disciplines who are thinking positively about online education in the wake of a pandemic, such as law, engineering, health and education. It should be noted here that the subsets of groups, that is, academics grouped by the area, are rather small, sometimes less than people. Even though this result implies the overall tendency of the sample case, one should be cautious about generalizing the results to the country or global level.The heat map in An interesting result is that the lecturers responsible for the theoretical lessons and tutorials  are the second group of academics who usually say that they ’most likely will not do’.According to the answers to the open questions, most academics stated that blended learning could be an effective way to improve on-campus education.In order to have a deeper insight into why the academics are mostly hesitant to conduct online teaching, education, students, and distance are common in both, those academics who do not tend to continue online education after Covid-19 put the emphasis on education, interactivity, and efficiency. The academics who tend to continue online education after Covid-19 speak of reach (massive number of learners), location, and capacity. The terminology associated with traditional face-to-face education in the classroom has been replaced in In addition, to reflect the general perspective of the academics based on their tendency to continue online learning after COVID-19, word clouds are created. These are generated using all the answers given to the open questions in the questionnaire. Some of the words in the word cloud have become notions that have a permanent presence in our life as a result of the pandemic. The phrases originally reserved for people interested in online education have evolved into a notion that is now understood by the majority. Emergency Remote Teaching: A Case Study on Higher Education in Turkey, we primarily examined academics as individuals, how they have embraced this change, and whether they are willing to continue, and in Section Investigation on Exploitation of OERs during Emergency Transition to Online Education we additionally examine the efforts of the countries and universities in the sample.The global pandemic Covid-19 forced universities to offer online education, known as emergency remote teaching. However, the change on this scale was not a smooth transition, as many universities lacked the experience or the necessary infrastructure. The readiness to provide distance education and use Open Educational Resources (OERs) is threefold: at country, university, and individual levels. In Section Some higher education institutions had already established distance/hybrid education systems and were already producing/exploiting OERs. Some countries set up national YouTube channels and provide already available communication tools for general purposes to be used for distance education, such as e-mail. Some countries started working together to provide richer content to teachers and students in their region due to the pandemic. However, the sad fact is that there are countries whose education systems have already been disrupted by war and poverty that also maintain emergency distance education. To facilitate the process of emergency distance education while fighting Covid-19, some companies and institutions offer free access to OERs, some of which are shown in the timeline created see .Emergency Remote Teaching: A Case Study on Higher Education in Turkey The findings show that while the majority of academics are suspicious of the effectiveness of online education as a substitute for face-to-face teaching, it is also found that many of them are not trained in preparing and delivering online lectures. One of the interesting results of our study is to show differences of opinion on OERs and distance learning between academics from different faculties and different roles. For example, academics from the arts, philology, and architecture are the most opposed to distance education, while academics from law, engineering, and health are the most positive  licenses . In addiRegardless of their age, gender, academic role, and field of study, the majority of academics who participated in our study found the most difficult things during emergency remote teaching: online assessments, less engagement during lectures, less interaction, which is especially crucial in language learning, running tutorial courses, adapting lecture notes to the digital environment. Moreover, academics are confused about open licenses, how to create and share OERs and how to mix their lectures with OERs.Academics’ Future Plan on OERs and Online Learning provide the arguments that academics in Turkey are mostly at the first stage of the theory of diffusion of innovations, namely Knowledge or Awareness Stage.Our study found that many academics are not aware of the OERs that are freely available to them to design their digital learning content. Very few of them were familiar with OERs and open licenses and were able to use them effectively during emergency remote teaching. The misconceptions and reluctance of academics to use OER in their lectures and distance education in general (see sub-Section Our paper is proof that university lecturers do not know very well how to give sufficient online lectures and how to use OERs and licenses to keep up with changes in educational practice. Governments and open universities should lead national higher education policy on distance and blended learning teacher training. As We believe that our study paves the way for new studies. For example, there is a need to investigate the correlation and comparison of academics’ attitudes toward distance learning and OERs and the infrastructure provided by their institutions. Furthermore, one of the striking findings is that an academic, who suffers from bullying, finds distance learning and online teaching entirely satisfactory and mentally facilitating. Therefore, we have no evidence of what other participants experienced, but we certainly recommended that our fellow researchers conduct a study on bullying and home working during the pandemic.As a good example of action, we can mention the European Commission’s Erasmus+ extraordinary 2020 call titled “Coronavirus response: Extraordinary Erasmus+ calls to support digital education readiness and creative skills” which encourages the applicants to use existing tools to enhance online, distance, and blended learning - including supporting teachers and trainers, as well as safeguarding the inclusive nature of digital learning opportunities . The preCopyright 2016© SAGE Publications Ltd, 1 Oliver’s Yard, 55 City Road, London, EC1Y 1SP, UK. All rights reserved.


Usually, the administration of drugs by feeding tube in dysphagic patients involves handling of marketing licenses outside their term, due to the lack of suitable formulations. This circumstance has put health professionals in the dilemma of choosing the formulation whose manipulation possibly does not alter the effectiveness of the drug. In this regard, a practical guide providing indications on the prescription, handling, and administration of drugs through enteral feeding tube could be of paramount utility. For this purpose, we have considered the 1047 solid oral pharmaceutical forms included in the formulary of San Paolo Hospital . From our analysis, it emerges that 95% of medicinal products are worryingly used off-label and 40% have to be managed by the hospital pharmacists without having suitable indications by either the manufacturers or by literature studies. To fill this gap, we have compiled a detailed table containing missing indications derived from pharmacist expertise and evidence-based practices, with the aim that the sharing of our procedures will contribute to make uniform pharmacological therapies from one hospital to another. This study will allow doctors to have easy access to information on drugs that can be prescribed and nurses to become familiar only with the pharmaceutical forms that can be administered. In the past, interest in enteral nutrition (EN) was rather low, due to the introduction of new and safer parenteral administration techniques. However, in the last two decades, EN through percutaneous endoscopic gastrostomy (PEG) has been reevaluated as a valid metabolic rebalancing therapy, both by virtue of an improvement in the quality of the tubes and nutritional mixtures used. Additionally, thanks to the recent dietary and physiological acquisitions of the digestive system, a more correct overview of the limitations of total parenteral nutrition (TPN) has been achieved ,2,3. AccIn clinical practice, the feeding tube is also necessarily used as a route of administration for pharmacological therapies, because this route is less risky for systemic infections (septicemia) and more economical with respect to parenteral drug administrations . Even coConsequently, this study arose from the necessity to accomplish a proper therapy for dysphagic adult and pediatric patients, whose needs are usually unmet by the pharmaceutical companies. In this context, the role of the hospital pharmacist is essential in selecting and compounding the medicinal product able to ensure the best outcomes of the pharmacological therapy. In the case of patients subjected to EN, it becomes impossible to keep the medicinal product intact, since it is often necessarily crushed or diluted. Meanwhile, it would be mandatory to guarantee that such manipulations do not affect the pharmacokinetics of the drug, and that no interaction between the drug and the nutritional mixture could occur. The essential need to ensure a therapy for dysphagic patients too often pushes health-care professionals to seek impromptu solutions, in which it may happen that not all the necessary pharmaceutical items have been evaluated. In fact, the guidelines still refer to general behavior and general principles, without directing towards specific protocols. In this scenario, off-label drug administrations—sometimes adequate, others often incorrect—have been justified.From these considerations, it is clear there is a need for shared procedures deriving from the fusion between clinical practice and what exists in the field of academic research. The aim of our study was to provide a practical guide on the correct use of solid oral formulations for patients subjected to EN through PEG. With this purpose, practical suggestions for the prescription, methods of handling, and administration of drugs through enteral feeding tube not only in hospitals but also at home have been provided in form of a reader-friendly and easily consultable table. We report advice received from manufacturers, collected from the literature, or deriving from the experience born within the pharmacy of the hospital. Particularly, we firstly asked pharmaceutical companies to share information regarding active pharmaceutical ingredient (API) stability following manipulation of the formulation and change of route of administration. Secondly, we analyzed the medicines managed by the local health authority ASL 2 Savonese, providing information about their suitability for administration by tube. In addition, extemporaneous liquid formulations of some drugs to be administered through the enteral tube are proposed, which can be of valuable help in order to make therapies uniform and to improve the quality of medical practice. Finally, we have also outlined the procedure for hospital staff to administer pharmacotherapy by tube.The medicinal products considered were those available in the district area of Liguria , according to the local formulary PTRO , and according to the minor formulary ASL 2 Savonese. The list of medicines analyzed comprises 1047 solid oral pharmaceutical forms, equal formulations but with a different dosage from the same company, have been grouped together in the same line, thus obtaining a list of 701 formulations. The information regarding the splittability/crushability of the considered medicinal products was obtained by evaluating the summary of product characteristics (SmPC) of the drug  [Meantime, 124 pharmaceutical companies were contacted with a specific letter, requesting detailed information on the API’s stability upon crushing of the tablets or opening of the capsules (1), on suitability of mortar for crushing (2), and on possible recommendations for API administration via tube or alternative routes (3) .Other eminent sources considered were the practical guidelines from the Società Italiana di Nutrizione Artificiale e Metabolismo (SINPE) and European Society for Clinical Nutrition and Metabolism (ESPEN). In particular, the SINPE guideline on Nutrizione Artificiale Ospedaliera  and the For each solid oral drug formulation listed in the hospital formulary, the Anatomical Therapeutic Chemical (ATC) Classification System, the name of the API, the trade name, the manufacturer, the pharmaceutical form, if the product can be administered via tube or not, instructions for handling, and finally the sources of the information are highlighted in different colors according to their level of reliability. An attempt was made to provide as much information as possible: the events that the administration by tube can be carried out, when to administer the drug, compatibility between the drug and EN, and the presence of some particular excipients .V) to be added has been calculated with the following formula:desiredmOsm is 300–500 mOsm/kg, initialmOsm is the osmolality of the pharmaceutical product, iV is the volume of the liquid pharmaceutical product before handling, and fV is the volume of the final product with the desired osmolality.Since the use of oral liquid pharmaceutical forms creates a minimal risk of tube obstruction and ensures adequate absorption of the drug, a switch from a solid oral formulation to a corresponding one in liquid form was considered advisable whenever possible. However, the liquid formulations may be hyperosmolar and require appropriate dilution. The volume of water  . Such deNowadays, the need to carry out a correct manipulation of oral drugs to be administered to patients subjected to EN is an increasingly emerging problem. Before deciding whether to modify the original pharmaceutical form in any way, the compounding pharmacist refers to SmPC, but, unfortunately, the clinical studies on the bioavailability of oral pharmaceutical forms performed by the companies rarely consider administration via artificial tubes. In most cases, manufacturers lack data to support the chemical stability of tablets when crushed and dispersed in water prior to use, and there are no studies comparing the efficacy or bioavailability of split and crushed solid pharmaceutical forms, which means that no company feels able to provide recommendations on the use of drugs by means of a tube. In this study, we contacted 124 pharmaceutical companies to obtain more detailed information on drug stability after crushing or switching routes of administration. Unfortunately, only one company (0.8%) gave us further information. In most cases, companies only suggested referring to the SmPC. Indeed, drug stability assessment performed by pharmaceutical companies generally involves the testing of the drug substance or drug product using a stability-indicating method in order to establish the retest period (for premarket stability) and shelf life . Since the companies had not carried out any evaluation of the stability of the drug after handling and/or change of administration route, they avoided taking any kind of responsibility in giving us advice. However, before resorting to off-label use, the general indications stress first of all evaluation of the existence of formulations suitable for alternative routes to oral administration. When such alternatives are not suitable, as indicated in the column of limitations, or only oral formulations are available, the PEG also becomes a unique access route for drug administration. In these cases, the SINPE guideline for Hospital Artificial Nutrition states that the administration of drugs by enteral tube preferably requires the use of liquid pharmaceutical forms, when available, or as a last resort the trituration of the solid forms and their dispersion in a suitable solvent . It mustMany members of health-care teams, especially pharmacists, are in a position to raise the awareness of potential drug–nutrient interactions and incompatibilities that may derive from the off-label use of a drug. Pharmaceutical incompatibility arises in dosage forms where the release of API is controlled by enteric or delayed coatings. In these cases, the manipulation  of the medicinal product leads to an immediate release and absorption of the API with overdose at the start of treatment and subtherapeutic dosages thereafter. As shown in Pharmacological incompatibility manifests itself with an alteration in pH, motility, or gastrointestinal secretions resulting from a pharmacological effect of the drug and generally alters the tolerance or absorption of enteral nutrition and/or the absorption of other drugs administered in polypharmacy. It is the case of drugs with anticholinergic effect that relax smooth muscle and inhibit gastric motility, such as antihistamines , tricyclic antidepressants , phenothiazines , and antiparkinsonians .Pharmacokinetic interactions can occur following the simultaneous administration of drugs and EN blends since the nutritional mixtures can alter the processes of release, absorption, distribution, metabolism, and excretion of drugs, which, in turn, can alter the kinetics of nutrients. Clinically, the most significant drug–enteral feeding interactions concern phenytoin and carbamazepine. The greatest number of compatibility studies with EN preparations have been performed for phenytoin . The plaPharmacodynamic interactions occur when alterations in the action of the drug are related to pharmacological antagonism at the receptor site. The vitamin K content of nutritional preparations can determine an antagonism towards the therapeutic action of oral anticoagulants, such as warfarin. Initially, it was thought that this antagonism was only to be attributed to the quantity of vitamin K contained in the nutritional mixtures and therefore preparations with low doses of the same  were recommended. Recently, this antagonism has also been observed for preparations with minimal contents of vitamin K and therefore the decrease in the therapeutic effect of the drug has been related to an alteration of its absorption probably attributable to its union with soy proteins and caseinates. This makes monitoring the prothrombin time necessary to guarantee the anticoagulant effect, as well as the indication to prefer heparin in critical clinical conditions .The best choice of a formulation to be administered via tube could be represented by a liquid one. Indeed, the liquid formulations can be easily administered with sufficient tranquility by means of a tube and generally they are immediately diluted in gastric juices and promptly absorbed. However, the assumption that liquid formulations are the first choice may be questionable. Cosolvents, such as ethanol, glycerol, and propylene glycol, may be present in all drug formulations being used and the acceptable daily intake (ADI) may be easily exceeded. Therefore, before shifting from a solid dosage form to a liquid, it is recommended to consider this worrying issue, i.e., ranitidine syrup (Ranidil 150 mg/10 mL) .2O) [2O) if administered without dilution could cause intolerance phenomena, especially if introduced at high speed or with tubes located in the duodenum or jejunum. This type of interaction is sometimes misinterpreted as the symptoms tend to be attributed to an intolerance to nutritional support or to gastrointestinal infections resulting in an incongruous interruption of the enteral feeding. Sorbitol is a case in point. Sorbitol is a common excipient of liquid formulations, often used as a stabilizer and sweetener. High amounts (>10 g/day) can cause intraluminal production of gas and abdominal tension, and, at higher doses (>15 g/day), important secondary effects, such as abdominal spasms and diarrhea. Pharmaceutical forms with a high sorbitol content include iron protein succinylate oral solution (Rekord Ferro 40 mg/15 mL) [Another noteworthy aspect relates to the osmolality of liquid formulations, which is one of the physical characteristics that most affect individual tolerance to a preparation. Osmolality values close to those of intestinal secretions are better tolerated (100–400 mOsm/kg H2O) . Formulag/15 mL)  and acycg/15 mL) . In caseAlso, formulations in drops are frequently hyperosmolar , and the amount of water used for drug dilution must then be obviously counted in the water–electrolyte balance. In some cases, their administration is not recommended for the adhesion of the drug to the plastic walls of the tube, resulting in therapeutic ineffectiveness  more frequently predisposes to clogging of the tubes because it does not allow washing between meals, as well as not leaving free margins for drug absorption in the fasting state. Therefore, bolus and intermittent techniques are preferable. For flushing the tube, no solution has been shown to be superior to water in preventing occlusion. Obstruction may arise also from inadequately crushed tablets, precipitate formation caused by interaction between feed and drug formulation, or between drugs, and consequently it is always suggested to give each API separately, avoiding the fixed formulations ,24. In aFrom the analysis of the solid oral formulations of the 701 drugs included in the hospital formulary, 339 (48%) cannot be crushed or administered via tube; however, for 211 of these (30%) alternative dosage forms or other routes of administration are possible . For theMedication management is not so obvious. It often represents an area in which there can be many differences from one hospital to another due to the lack of standardized protocols. At San Paolo Hospital in Savona, the key role played by the hospital pharmacist is particularly evident from The practical suggestions embedded in The analysis of the prescriptions within the hospital shows that liquid pharmaceutical forms are administered only to a small extent, despite being the most suitable for this route of administration. This low percentage of liquid forms can be partly explained by the lack of a wide availability of liquid medicinal products in the hospital formulary. As for the pharmaceutical form in most cases, tablets were prescribed, followed by liquid formulations , powders for oral solutions, and capsules. To increase the administrations of liquid forms and meanwhile reduce the use of off-label prescriptions, the pharmacists are used to compounding some magistral preparations .if the patient is undergoing EN, temporarily stop the infusion;before administration, wash the probe with 30 mL of water;take, where necessary, a tablet crusher, wash it with water and dry it, then grind the tablet to a fine powder;put the powder or other pharmaceutical forms directly in a plastic cup, add 30 mL of water at room temperature, shake and dissolve (possibly with the help of a disposable plastic spoon);once a solution or a suspension is obtained, draw it with a 60 mL catheter cone syringe (dedicated syringe for EN). Make sure there are no drug residues left in the glass;check the correct positioning of the tube; insert the syringe cone into the tube connector and flush the medication dose down the feeding tube. If the medical prescription provides for the administration of several drugs at the same time, do not simultaneously grind several drugs and do not mix them in the same syringe, but it is necessary to rinse the tube between one drug and another with at least 5–10 mL of water to ensure that the tube is clean during the transition to the next drug;rinse the tube with at least 40 mL of water after the administration;restart the feed, unless a break is required.The administration of drug therapy should be a unitary act, performed by the same person. It is necessary to avoid, as far as possible, interruptions during the preparation and administration of drugs. The main steps of the procedure can be listed as follows:A thorough description of the recommendations for each pharmaceutical form is summarized in The present paper has highlighted the need to oversee and investigate the problem of administering drugs by feeding tube in dysphagic patients. The management of therapeutic pathways, due to the complexity and high clinical risk that it entails, requires advanced, updated, and integrated skills. The alteration of oral pharmaceutical forms, if not properly managed, can lead to errors in therapy, side effects, occupational exposure by inhalation or contact with the drug, and cost increase. The advice of the clinical pharmacist, especially for the verification of alternative pharmaceutical forms, can prove effective in reducing therapeutic errors. This study provides health-care teams a practical guide for the correct administration of oral drugs in patients undergoing EN through PEG. The hope that has accompanied the drafting of this document is that it can be a tool that allows the prescriber to receive the correct information on the drug and consequently to adapt the pharmacological prescription for the new type of administration. Secondly, we want to provide nurses with practical suggestions regarding the correct methods of handling and adequate administration of drugs via tube, in order to ensure continuity of care and adherence to the therapeutic program.


The increasing number of people with anxiety disorders presents challenges when gathering health information. Users in anxiety disorder online communities (ADOCs) share and obtain a variety of health information, such as treatment experience, drug efficacy, and emotional support. This interaction alleviates the difficulties involved in obtaining health information. Users engage in community interaction via posts, comments, and replies, which promotes the development of an online community as well as the wellbeing of community users, and research concerning the formation mechanism of the user interaction network in ADOCs could be beneficial to users. Taking the Anxiety Disorder Post Bar as the research object, this study constructed an ADOC user interaction network based on users’ posts, comments, and personal information data. With the help of exponential random graph models (ERGMs), we studied the effects of the network structure, user attributes, topics, and emotional intensity on user interaction networks. We found that there was significant reciprocity in the user interaction network in ADOCs. In terms of user attributes, gender homogeneity had no impact on the formation of the user interaction network. Experienced users in the community had obvious advantages, and experienced users could obtain replies more easily from other members. In terms of topics, pathology popularization showed obvious homogeneity, and symptoms of generalized anxiety disorder showed obvious heterogeneity. In terms of emotional intensity, users with polarized emotions were more likely to receive replies from users with positive emotions. The probability of interaction between two users with negative emotions was small, and users with opposite emotional polarity tended to interact, especially when the interaction was initiated by users with positive emotions. With the rapid development of the economy and the improvement of living standards, people have been growing more concerned about not only their physical health but also their mental health. Correspondingly, the need for health information such as treatment experiences, drug efficacy, and emotional support has also been increasing. Traditional face-to-face communication has not been able to meet the growing mental health demands. The emergence of online health communities has provided an effective means for the rational allocation of medical resources . MedicalAnxiety disorder is a psychological disorder requiring long-term treatment. Due to social prejudice and discrimination , people Users in an ADOC discuss different topics through a series of content creation behaviors such as posting, commenting, and forwarding. The interactive network between users in a community is also formed in the user communication process. An ADOC is different from a traditional entertainment online community. Users in an ADOC often have clear health information needs  and highOnline communities are platforms for communication and interaction using the Internet. They are widely used in the education and entertainment industries, and they have developed significantly in the field of medical and health care, such as WebMD, MedHelp, Yahoo Health, 39.net, haodf.com, and chunyuyisheng.com. These online health communities (OHCs), organized and managed by relevant professionals in the industry, have not only enabled medical professionals to provide remote online consulting services, but they have also allowed laypeople to exchange treatment experiences and provide emotional support. The vigorous development of online health communities has provided a new service model for the medical industry. With an increasing number of users in online health community, research into these communities has become a focus. Thus far, the research into online health communities has included aspects such as the community itself, users, and information exchange. The community dimension has considered the operating modes of patient interaction, doctor–patient interaction, and doctor interaction in a community. The user dimension has focused on the overall structure of the user relationship network and the motivation and influencing factors of user behaviors. The information dimension has explored the topics of user-generated content and information privacy. In terms of the community dimension, Guo et al. studied the social and economic advantages doctors received by participating in an online health community from the two dimensions of doctors’ status and professional knowledge, and then they discussed their impacts on different groups of doctors. The study found that in addition to a doctor’s status and reputation, the professional level of doctors was an important part of determining their returns in OHCs . In termIn an online community, users form a relationship network by engaging and showing concern via posting and responding to others. At present, many researchers have studied online communities from the perspective of networks, and the research method has been focused on social network analysis. The types of online communities studied in the existing literature have included social, academic, and question-and-answer (Q&A) online communities. Shiau et al. found the network structure of the clustering among papers through a social network analysis of papers published on academic websites . Sun stuThrough the literature review, we found that the existing research into online health communities mostly focused on users, and research on user relationship networks was relatively scarce. Studying online communities from the perspective of networks has been a current focus. However, most of the existing studies have focused on social online communities, and few scholars have studied online health communities, especially those focused on mental disorders, from the network perspective. The ADOC itself is an online health community for psychological disorders. Users participate in different topics according to their interests and needs. Furthermore, users’ posts and comments in the community contain a large number of emotional expressions. Therefore, based on the user data of the Anxiety Disorder Post Bar and with the help of an exponential random graph model, this study explored the formation mechanism of the user interaction network and the effects of the network structure, user attributes, topics, and emotional intensity. This study supports communication between users in ADOCs and may improve the activity of experienced users and the longevity of new/inexperienced users, which could improve the success of these communities.An ADOC is an online mental health community that provides communication platforms and information on anxiety disorders. The various content creation behaviors of users in ADOCs, such as posting, comments, and replies, and the interaction between these users form a user interaction network. To explore how the network structure and user attributes affected the formation of relationships within the network, this study proposed a series of hypotheses and empirical research based on community characteristics and previous theories.Reciprocity refers to the characteristic that two nodes tend to connect with each other in a directed network . ReciproH1: Users tend to have reciprocal interactions in ADOCs.A social network is formed by the interconnection of many nodes in a network. Therefore, the formation of network relationships is related not only to network self-organization but also to the attributes of the nodes in the network, which play an important role in the formation of network relationships . AccordiH2: Users of the same gender are more likely to interact in ADOCs.H3: Users who prefer the same topic are more likely to interact in ADOCs.According to the priority connection principle in social networks, the newly added nodes in the network would tend to establish connections with the nodes with higher network centrality among the existing nodes . The lenH4: Experienced users are more likely to receive replies from other users in ADOCs.As one of the important factors affecting social media , emotionH5: Users with polarized emotions are more likely to receive replies from users with positive emotions in ADOCs.The data were sourced from the Anxiety Disorder Post Bar. The Anxiety Disorder Post Bar is one of the communities with the most users among the online communities. The users in the community were predominantly receiving treatment for their disorder. They could communicate, seek help, share disorder knowledge, and engage in other actions in the community. By 2021, the number of posts had reached 3.586 million. This study obtained the posting and comment data of users and the attribute data of the relevant users in the Anxiety Disorder Post Bar. To ensure the integrity of user attributes, we screened the data and finally obtained the complete attribute information of 6158 users. The user communication network formed by these users contained 16,521 edges.Users participated in discussions on different topics in the community and expressed different emotional intensities according to the text data. To explore whether these different topic preferences and emotional intensities affected the interaction between users and how they affected the communication and interaction between users, in this study, the user post and comment data obtained by text mining were further processed. Seven different topics, including social support (SS), pathology popularization (PP), drug efficacy (DE), emotional catharsis (EC), panic attack records (PAR), symptoms of generalized anxiety disorder (SGAD), and diagnosis and examination of hypochondriasis (DEH), were obtained. Social support referred to sharing treatment experiences and providing emotional support. Drug efficacy referred to the effects and side effects of taking anti-anxiety medications. Symptoms of generalized anxiety disorder referred to the symptoms related to generalized anxiety disorder. Emotional catharsis referred to users expressing negative emotions. Panic attack records referred to the experience and symptoms of a panic attack. Diagnosis and examination of hypochondriasis referred to suspected anxiety and going to the hospital for examination. Pathology popularization referred to popular science and explanations related to anxiety. In addition, we calculated the emotional score of each user’s text data through emotional analysis and obtained the average of each user’s emotional score.The measurement methods of user node attributes are provided in This study used an exponential random graph model (ERGM) to test the proposed hypotheses. The ERGM is a statistical model based on relational patterns that can handle complex dependencies in a network . The expij. If yij = 1, it indicates that there is a connection between node i and node j; otherwise, there is no connection between node i and node j. The general expression of the ERGM isIn the network diagram, n represents the number of nodes, and the relationship between nodes is represented by a random variable yThis article synthesized the characteristics of users and their posts and comments in the ADOC and other previous studies on similar networks and related theories and selected user gender, user registration time, the emotional polarity of the content posted by users, and preferred topic types as node attribute variables. The variables and measurement indicators are shown in p values. According to existing research, the network structure corresponding to the positive parameter estimate is easier to form than the random network structure. That is, if the parameter estimate of the model is positive and significant, then the probability of occurrence in the network structure corresponding to the parameter estimation is higher than that of its occurrence in the random network structure [The test results of the exponential random graph model are shown in tructure .p value was significant, indicating that the probability of reciprocity appearing in the ADOC was greater. Therefore, H1 was verified. Users in the ADOC tended to exchange information with each other. In the Anxiety Disorder Post Bar, we observed that some users received help from other users in the community after posting for help. Users who received help would also express their gratitude through posted replies. In addition, users in the community exchanged information regarding anxiety with each other in the form of posting replies. These processes also embodied the principle of reciprocity. Some studies have also found that reciprocal motivation played a significant role in users’ willingness to share knowledge in online health communities [In terms of network structure effects, munities , which eIn terms of user attribute effects, p value was significant, indicating that the experienced users who had been registered for a long time had a higher probability of receiving replies from others in ADOCs. In short, H4 was verified. Experienced users were usually accompanied by a higher user level. Users could increase their personal level by signing in, posting, and replying to posts. High-level experienced users posted a large number of posts in the community or frequently replied to other users. These experienced users’ posts received more attention from other members of the community. At the same time, some studies also showed that trust had an important impact on the interaction between users [The parameter estimation value of the user registration time was 0.103, and the en users . ExperieExperienced users played a decisive role in the development of the ADOC. We observed that some inexperienced users in the Anxiety Disorder Post Bar usually posted for help, and most of the responses they received were from experienced users. Improving the activeness of experienced users in the community could not only promote the interaction between inexperienced users and experienced users but also enhanced their sense of belonging among inexperienced users in the community, thereby promoting the sustainable development of the community and the wellbeing of community users.The topics of user texts, according to p value was significant, indicating that the probability of interaction between two users with the same positive emotion was greater. The estimated value of the parameter of the same negative emotion was negative, and the p value was significant, indicating that the probability of interaction between two users with the same negative emotion was small. In the Anxiety Disorder Post Bar, users who posted negative messages hoped to receive support in the form of shared emotions or information, and supportive responses were typically not negative texts, which could also explain why there was little interaction between users with negative emotions. In addition, the results in p value was significant; furthermore, the parameter estimates of the “negative_positive” attribute were negative, and the p value was significant. These two results indicated that the negative emotions of users were more likely to obtain replies from users with positive emotions, and users with positive emotions were more likely to obtain replies from users without negative emotions. In previous studies, some researchers have considered the emotional effects of user messages [Regarding the emotional impact of user text data, the second column in messages , but theThis research used five models to test the robustness of the basic model (M0). Among these models, Model M1 was the model test result obtained after removing the gender attribute, and Model M2–Model M5 were the model test results obtained by experienced users with different value ranges. In the basic model M0, this study selected 25% of the newly registered users as inexperienced users and the remaining 75% as experienced users. To test the robustness of the model, we selected the top 70%, 73%, 77%, and 80% of the users with registration times from high to low as the experienced users. By examining the number of different attributes and different values of the same attribute, the influence of changes in these variables on the user interaction network was tested.Based on the users’ data of the Anxiety Disorder Post Bar, with the help of the exponential random graph model, we examined the formation mechanism of the user interaction networks in ADOCs. We analyzed the effects of the network structure, user attributes, topics, and emotional intensity on the formation of the user interaction network. This research found that there was significant reciprocity in user interaction networks in ADOCs. In terms of user attributes, gender homogeneity had no obvious influence on the formation of user interaction networks in ADOCs. Experienced users in the community had obvious advantages, and experienced users were more likely to obtain replies from other members. In terms of topics, some topics showed obvious homogeneity. For example, users who preferred pathology popularization were more inclined to interact, while other topics showed obvious heterogeneity. For example, users who preferred the topic of symptoms of generalized anxiety disorder were more inclined to participate in discussions on different topics. In terms of emotional effects, users with polarized emotions were more likely to receive replies from users with positive emotions in ADOCs. The probability of interaction between two users with negative emotions was small. Users with opposite emotional polarity tended to interact, especially when the interaction was initiated by users with positive emotions to users with negative emotions.This research had theoretical and practical significance. Based on the ERGM, combined with priority connection theory, emotion communication theory, social capital theory, as well as other theories, this paper constructed a model of an ADOC’s user interaction network. The study enriched the related research of the exponential random graph model and expanded its application scope and scenarios. In addition, the research in this study provides much needed data and perspective on interactive networks in ADOCs and revealed the formation mechanism of user interactive networks. Existing studies on social networks in online communities have mostly focused on the overall structure of the network. There have been few studies on the formation mechanism of the network structure. In addition, in previous studies, few researchers have considered the topic and emotional impacts on user interaction networks. This research enriched the understanding of the network effects of social networks.In terms of practical significance, this research revealed how the formation of user interaction networks could be impacted by the network structure, user attributes, topics, and emotional intensity. The internal connections between users’ posts, comments, and replies and users’ personal attributes, topic preference, and emotional tendency were clarified. For example, concerning the user attribute of user registration time, experienced users who had registered for a longer time were more likely to receive replies from other users, resulting in the formation of an interactive network structure in which other users point to experienced users. Regarding the specific practical significance, the research could help community workers consider corresponding measures to promote communication between community users and increase user activity by, for example, establishing different topic sections and different topic labels. It could help users accurately locate their interests and needs and promote exchanges and interactions between users on various topics. Second, the resource advantages of experienced users in the community could be used to encourage experienced users to actively participate in topic discussions in the community. The community could also encourage experienced users to provide social support to inexperienced users through comments, replies, and so on. This could not only improve the participation of inexperienced users but also promote the development of the community and the wellbeing of community users.Although this research contributes to the field, it also has certain limitations. This article only studied the user interaction network of the ADOC and did not consider the influence of the friend network on the user interaction network. In follow-up research, friend networks should be included to study the influence of the interaction between different networks on the network structure. In addition, the research in this article only selected static data for a period of time. In future research, we should consider the dynamic changes of these effects on the mechanism of user interaction networks.


Previous studies have examined how smartphones influence the life satisfaction of the elderly, but the existence of conflicting conclusions suggests the existence of a “black box”. In this study, using a survey from 941 elders, we examine whether smartphone use can improve life satisfaction of the elders by inducing emotional affordance offered by social networking Apps and functional affordance offered by healthcare system Apps. It is found that both emotional affordance and functional affordance acted as intermediating variables between the use of smartphone and elders' life satisfaction. In addition, it is founded that living arrangement with adult children moderates the positive impact of smartphone use on functional affordance, but there was no such moderating effect on emotional affordance. This study offers insights about how digital healthcare innovation will be applied to increase well-being of elders by applying framework of selective optimization with compensation. During the past decade, information and communication technologies (ICTs) such as smartphones, tablets, and laptops have rapidly penetrated into people's daily life –6. ICTs Life satisfaction is regarded as the essential form of perceived well-being, and previous studies have focused on the relationship between smartphone use and the life satisfaction of the elderly. Some scholars see a positive effect, and believe that older adults can use smartphones to promote life satisfaction in a variety of positive ways, including expanding their social network , 9, obtaAlthough it can be difficult to understand why a specific ICT may provide different utility for different individuals, the actors' role is one of the vital explanations , 21. ThaThe study reported here uses the framework of selective optimization with compensation theory (SOC) to examine the mediating effect of technology affordance between smartphone use and life satisfaction of the elderly. We also explore the moderating effect of living arrangements between smartphone use and technology affordance for healthcare. This study theoretically and empirically advances our current understanding of gerontechnology usage for aging well from a perspective of subjective activity of the elderly. This study makes three unique contributions to extant literature. First, based on SOC, we identify two pathways by which smartphones affect the life satisfaction of the elderly. In the aging process, the life goals of the elderly are bound to vary compared with those of younger people because of changes in living conditions  and because of a decline of physical and psychological functions . In old Second, we investigate the mediating effect of technology affordance for healthcare between smartphone use and elderly life satisfaction. Existing studies separately discuss the application of specific mobile phones in promoting well-being in later life , 40. In Third, we explore the moderating effect of living arrangements in the context of China. In contrast to the emphasis on individualism in western countries, strong family ties are important in the Chinese filial piety culture . We therOver the past few decades, a significant volume of research has focused on the question of how to age well , 42–44. With the rapid development of science and technology, some researchers are paying attention to how ICTs—which are an important part of an individual's resources—promote aging well during the process of selective optimization with compensation , 44, 48.Seniors may crave social support and emotional pleasure first . CompareAffordance theory  originalIn China, many older migrants, who moved to other communities due to the withdrawal or merger of their original rural villages, and trailing parents, who migrated with adult children in their later years, are more likely to use smartphones to promote social integration and life satisfaction , 9, 66. Hypothesis 1: Emotional affordance can mediate the impact of smartphone use on elders' life satisfaction.In recent years, the smartphone has become the most popular ICT in the world, and this has attracted attention from researchers who want to know if it improves people's lives , 67, 68.The relationship between smartphone use and life satisfaction may vary with age , 4. SomeAccording to SOC theory, although people decline or lose physical and mental functions with age, they still have the possibility of recovery and development , 47, 78.The functional affordance for healthcare of smartphones for the elderly refers to products or systems integrated by information and communication technologies that improve older people's security , daily living and health management. These include human activity monitors, health management systems, smart rehabilitation devices, smart mobility aids, and so on , 80, 81.The functional affordance of smartphones has had a strong impact on people's cognitive competence, which raises awareness of ICTs usage and is judged to be the most adequate in reaching the elderly population regarding all issues relating to the incorporation of new technologies in their daily lives . den HaaWe therefore propose the following hypothesis:Hypothesis 2: Functional affordance can mediate the impact of smartphone use on elders' satisfaction.The details of affordance actualization are contingent on the technology context, which may result in a variety of mechanisms acting as conditions that enable or constrain the actualization of affordance and produce indeterminate outcomes . In esseResearch on the relationship between living arrangements and cognition or sensibility of the elderly is mixed. Some authors believe that living with adult children is conducive and beneficial to the cognitive function of the elderly , 92. OthSome studies have found that elderly people living alone may not get enough support from their children, and that may worsen their psychological and cognitive health. Other studies show that older people living alone may have a lower risk of cognitive impairment than with their families, because they must focus on taking care of themselves and completing housework . The convia the technical supported that is provided by their adult children   .Changes in economic development and urbanized living arrangements have implications for China's elderly, but there are conflicting patterns. On the one hand, there is an increasing trend of older adults living with their spouse only or living alone rather than living with their children . On the Hypothesis 3a: Living with adult children will positively moderate the relationship between smartphone use and emotional affordance.Hypothesis 3b: Living with adult children will positively moderate the relationship between smartphone use and functional affordance.Based on all of the above hypotheses, we propose the model in We collected data from Zhejiang Province, since it is one of the earliest provinces to enter the “aging society,” and since the degree of aging in that province ranks among the top level in China . ZhejianThe data are from a survey questionnaire developed by Zhejiang University of technology and Zhijiang laboratory, a research institute established jointly by Zhejiang Provincial Government, Zhejiang University and Alibaba Group. In China, smart elder-care devices are promoted to communities and families due to government pressure. Pilot communities of smart care from 11 cities in Zhejiang Province were randomly selected for this survey. All investigators had received professional training and were required to carry out one-to-one online questionnaire item explanations for the interviewed elderly respondents to prevent misunderstanding.Referring to previous studies , 105, liRespondents were asked, “Do you use one smartphone at least?” with a response of yes or no. We created a dichotomous variable indicating older adults' smartphone use.The value of affordance arises from the perceived content and the process of the interaction of human and products , 106. InThe reflective multi-item constructs, including emotional affordance and functional affordance, were assessed by analyzing factor loadings, Cronbach's alpha (α), composite reliability (CR), and average variance extracted (AVE). The test results are listed in Since the direct blood relationship is regarded as the most important social relationship in China, and since the adult children play a vital role in elderly technology learning , 89, 107Participant characteristics might influence their learning capacity and motivation to use a smartphone, and this might relate to life satisfaction. Consistent with the previous literature , 66, 100According to Baron and Kenny's suggestion, we tested the mediation and moderation effects in the study by using separate hierarchical multiple regression analyses through STATA 17.0. In all equations, the control variables were filed in before the other independent variables to eliminate their effects from the relationships of principal interest. We finally constructed 11 models.The descriptive statistics and correlation matrix are shown in p < 0.01) is significant and positive. Models 2, 7, and 8 examine the mediation effect of use of emotional affordance between smartphone use and life satisfaction of the elderly. Model 2 predicts smartphone use has a positive impact on emotional affordance . Model 7 shows that emotional affordance is significantly and positively related to life satisfaction of the elderly . Model 8 indicates that smartphone use is not significant, while emotional affordance is significantly and positively associated with life satisfaction of the elderly . These results support H1, which means that emotional affordance mediates a positive relationship between smartphone use and life satisfaction of the elderly.In p < 0.01) is significant and positive. Models 2, 7, and 8 in p < 0.01). Model 7 shows that functional affordance is significantly and positively related to the elderly life satisfaction . Model 8 indicates that smartphone use is positive related to the elderly life satisfaction , while functional affordance is significantly and positively associated with the elderly life satisfaction . In all, these results support H2, which means functional affordance mediates the positive relationship between smartphone use and the elderly life satisfaction.In Refer back to p < 0.05). Thus, H3b is supported.We believe this study makes three contributions to the literature. First, the study distinguishes two different mechanisms to explain how smartphones can promote life satisfaction of the elderly based on elective selection and loss-based selection to improve the subjective well-being of older adults. In terms of social development goals, the emotional affordance of smartphones, which means the possibilities to accept more compatible and prolonged applications or service concerning spiritual pleasure or comfort to improve life satisfaction, old people have more opportunities and choices to accept new technologies by smartphones to enhance social connection and enrich the spirit world. In order to maintain physical and/or mental functions, older people with high functional affordance are willing to learn and accept different types of intelligent care devices to enhance their independence and autonomy; this provides another way to improve their life satisfaction. Previous studies have focused on the qualitative analysis of active aging through technology learning and adoption in the SOC framework, especially discussing specific activities in three processes of SOC  separately , 83, 108Second, we contribute to the literature by examining the effects of the two different aspects of technology affordance  in the aging context. Technology affordance exists independently on users and works only if the user perceives and actualizes it . So the Third, we examine the moderating effects of living arrangements on the different types of technology affordance when the elderly use smartphones. These results suggest that smartphone use may broaden functional affordance by strengthening learning capabilities and experiences when the elderly live with adult children. This is consistent with previous studies showing that the internet usage of older adults expanded as a result of encouragement from their children , 110. HoThere are several practical implications of our study. Firstly, the elderly can benefit by accepting the concept of active aging and giving full play to their subjective initiative to use smartphones and related gerontechnologies because more and more mobile applications are linked to intelligent care devices. They would have more chances to obtain the healthcare resource though technology affordance. Meanwhile, this will require that elderly people improve their knowledge about smartphones and their applications. It's never too late to start learning something new, even in the late period of life , 114. ThWe recognize that there are several limitations in this study. First, the geographical limitation of data collection may affect the generality of research conclusions. Although Zhejiang Province plays an essential role in digital aging in China, we should not ignore the variations in this issue between regions with different degrees of economic backwardness and aging. Future research is necessary with samples from various regions to increase the generalizability of the results. Due to cultural heterogeneity, future research is also needed to examine the cross-national generalizability of our results. Second, this study focusses only on living arrangements in the context of cross-technology affordance. Future research should analyze digital aging from an integrated perspective, such as taking living arrangements with age together . In addiThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval were not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study.BW contributed to conception, design of the study, and participated the refining of the manuscript. GL wrote the first draft of the manuscript and was responsible for following revision. BZ organized the database and wrote the section of theoretical part. CJ performed the statistical analysis. All authors contributed to manuscript revision, read, and approved the submitted version.This research was funded by Major Project of Zhejiang Provincial Philosophy and Social Sciences Research Planning Project, grant No. 20YSXK02ZD; the Planning Program for Science and Technology of Zhejiang Province of China, grant No. 2021C35024; and Major Fund of National Philosophy and Social Science of China, grant No.17ZDA088.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. 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