The COVID-19 pandemic and containment measures have severely affected families around the world. It is frequently assumed that digital technologies can supplement and perhaps even replace services for families. This is challenging in conditions of high device and data costs as well as poor internet provision and access, raising concerns about widening inequalities in availability of support and consequent effects on child and family outcomes. Very few studies have examined these issues, including in low- and middle-income countries.The study objectives were two-fold. The first objective was to gather data on the impact of the COVID-19 pandemic on families of young children using an online survey. The second objective was to assess the feasibility of using a data-free online platform to conduct regular surveys and, potentially, to provide support for parents and families of young children in South Africa.We used a data-free mobile messenger platform to conduct a short digital survey of the impact of the COVID-19 pandemic on caring for young children in South Africa. We report on the methodological processes and preliminary findings of the online survey.More than 44,000 individuals accessed the survey link and 16,217 consented to the short survey within 96 hours of its launch. Respondents were predominantly from lower classes and lower-middle classes, representing the majority of the population, with urban residential locations roughly proportionate to national patterns and some underrepresentation of rural households. Mothers comprised 70.2%  of respondents and fathers comprised 29.8% , representing 18,672 children 5 years of age and younger. Response rates per survey item ranged from 74.8%  at the start of the survey to 50.3%  at completion. A total of 82.0%  of parents experienced at least one challenge during the pandemic, and 32.4% (2737/8441) did not receive help when needed from listed sources. Aggregate and individual findings in the form of bar graphs were made available to participants to view and download once they had completed the survey. Participants were also able to download contact details for support and referral services at no data cost.Data-free survey methodology breaks new ground and demonstrates potential not previously considered. Reach is greater than achieved through phone surveys and some social media platforms, men are not usually included in parent surveys, costs are lower than phone surveys, and the technology allows for immediate feedback to respondents. These factors suggest that zero-rated, or no-cost, services could provide a feasible, sustainable, and equitable basis for ongoing interactions with families of young children. The COVID-19 pandemic has affected families everywhere, both directly through illness and death, and indirectly through the effects of containment measures on economic activities and routines of daily life. Lockdowns, with varying degrees of restriction, have been imposed in many countries, and by the end of March 2020, more than 20% of the world’s population was estimated to be under lockdown [In South Africa, as in many other countries, early childhood development centers, public nurseries, kindergartens, and preschools have been closed since late March 2020 under one of the strictest lockdowns in the world. Private facilities began to reopen in late July 2020, but by August 2020, only 13% of children under the age of 6 years were attending their usual facility .Among exacerbating concerns about childcare, some 3 million South Africans are estimated to have lost their jobs as a result of the effects of the COVID-19 pandemic on the economy, with women most affected . InestimBoth short- and long-term adverse physical, psychological, and social effects of the pandemic conditions on children are predicted, with supporting evidence emerging. These include interrupted, delayed, and missed preventive health care visits for pregnant women and children, separation of parents and neonates at birth, closure of day care facilities, household poverty and food shortages, parental and child mental health stresses, and increased risk of parental substance abuse and interpersonal violence, including child abuse . OngoingThere is considerable optimism about the potential application and expansion of digital technologies to fill gaps in knowledge and supplement health and social care during the pandemic . These iWhile important efforts are being made to understand the effects of the COVID-19 pandemic on parents and young children using digital technologies, a number of challenges have to be addressed. Among these are that few studies have specifically looked at effects on preschool children; survey samples tend to be small, undefined, and/or selective, and questionnaires tend to be long, taking 40 minutes to an hour to complete . FurtherIn low- and middle-income countries, the most immediate challenge is to establish communication channels to reach the greatest number of affected families in order to convey accurate information on how families can protect themselves and their children, solicit the changing needs of families, and respond effectively to their needs. In this respect, it has been recognized that even in high-income countries, few of the most marginalized groups are reached by digital technologies, and that it is essential to develop tools to address gaps in internet access to avoid a COVID-19–related increase in inequality due to the “digital divide” ,22. AccoIt is estimated that internet usage worldwide varies from approximately 87% in Europe to approximately 34% in Africa, with the lowest access (23%) among African women . The mosSome online surveys have been conducted to ascertain understanding, practices, and impacts of the COVID-19 pandemic among South Africans, although none specifically have focused on parents of young children or on young children themselves -29. In oother were included, but participants could move backward to edit prior responses. The questionnaire was translated into the most common languages used in South Africa: Afrikaans, English, Sesotho, isiZulu, and Sepedi. The questionnaire and translated versions were programmed into REDCap (Research Electronic Data Capture), a secure web platform designed to support survey distribution and data capture for research [We designed a short questionnaire consisting of between 18 and 30 questions, depending on response options, with one item displayed on-screen at a time and a progress indicator. Skip patterns and branching logic were used to streamline questions and improve participant experience by reducing the number of irrelevant questions requiring a response. The small number of questions also eliminated the need for their randomization. Participants were required to provide a response for each question to move forward in the survey and nonresponse options in the form of research . A list A set of screening questions excluded participants younger than 18 years of age, those not caring for a child under 5 years of age, and those not living in South Africa. All participants were required to consent to the survey, as mandated by the Human Research Ethics Committee of the University of the Witwatersrand (H20/06/38). The informed consent process included disclosures of the nature and purpose of the survey, risks and benefits of participation, uses to which the data would be put, guarantees of anonymity, and investigator contact details as well as those of the responsible ethics committee. Demographic details were kept to a minimum to make the survey as short as possible and encourage participation. Questions covered challenges of caring for young children, sources and types of help received, as well as unmet needs. The questionnaire was piloted among staff and colleagues speaking each of the languages. The English version of the questionnaire is attached as We used the Moya Messenger platform, hosted by biNu , as our population source for convenience sampling . biNu’s The data-free services are used in two ways. The first is to have all survey content reverse-billed. This generates a data-free link that can be shared through any medium so that participants can access and complete the survey without paying for data. The second is to share survey links with the sample of Moya subscribers who have access to the interface where the survey is pinned and are able to complete the survey without incurring any data costs. A grant awarded to the University of the Witwatersrand was billed for data used by participants at the rate of 20 South African cents (US $0.015) per megabyte, averaging R6 (US $0.44) per survey response. By February 2020, the Moya platform had in excess of 2.3 million active daily users  of all gREDCap generated a URL link to the survey that could be distributed from the web platform or from other sources. biNu reconfigured the URL and all its content to be reverse-billed to a secure account held by the research team. All responses linked to the URL were transmitted directly to the REDCap server and collated in a secure database. For distribution on the Moya Messaging platform, biNu placed a pinned notice of the survey on the platform’s interface where users are able to view news, updates, and survey alerts. Since the survey link was available to any user of the platform, it was considered an open survey. The link was the initial contact with potential participants who were able to see the pinned notice on their user interface and could open it to complete it . Once thResponses to the survey were collected and stored in REDCap in real time, allowing continuous online analysis of data. Once the responses reached time and budget allocations for the study, the survey was terminated on both the REDCap and Moya platforms. Data cleaning and quality control were undertaken on the REDCap platform using built-in data validation features. The data were exported into SPSS, version 26.0 (IBM Corp), for further data cleaning and analysis. Cases with missing data were not excluded from the analysis and no statistical corrections were performed to adjust for any nonrepresentativeness.The progression of participation in the survey was tracked by calculating attrition at each stage of the screening questions. The survey link was opened by 44,292 users within 96 hours of it appearing on the data-free platform; 21,993 participants were of eligible age, 17,325 participants were caring for a child under the age of 5 years, and 16,217 participants consented to participate in the survey, at a recruitment rate of 36.6%. A total of 1.9% of respondents  were caregivers of groups of children in day care centers. These responses were excluded from the analysis, and 15,912 eligible consenting participants comprised the analytical sample.Response rates and missing values are shown in By residence, respondents were roughly representative of the South African urban population residing in cities, suburbs, and townships, with lower representation from rural respondents who have less access to mobile phones and the internet  completed the survey in English, the main language of instruction in South African schools, following the teaching of mother tongues in Grades 1 to 3. A substantial proportion of participants were fathers .Responses to the survey questions  showed tTwo-thirds of parents said they needed help, the majority of whom were in urgent need of money, vouchers, or food parcels. Clothes; blankets; personal protective equipment (PPE), such as masks and soap; and medicine were also high on their list of needs. When asked what help they had received from different sources, more parents reported getting assistance from governmental organizations  than from neighbors and community groups  or from NGOs . Among those who did receive help, the most common form was reported to be money or vouchers from governmental organizations . Help received from NGOs was most frequently reported to be food parcels . Neighbors and community groups were reported to give a wide range of help, most commonly food, financial loans, PPE, information, relief childcare, and emotional support for mental distress.We assessed the feasibility of an online survey delivered through a data-free platform to investigate the variability of challenges facing families of young children. We restricted the survey to individuals living in South Africa and to adults caring for children 5 years of age and younger at home. In this paper, we report on the strengths and weaknesses of the use of an online survey in general, and of a data-free platform in particular, to monitor COVID-19 effects on families over time. This is an important question, given the likely long-term aftereffects of the pandemic on daily life  and the We were not able to locate any published COVID-19 surveys that focused on young children and that were delivered on a data-free online platform, a gap that this paper attempts to fill. Many surveys used phone or email interviews  or sociaIn contrast, online data-free surveys cast a wide net and arguably reach those most affected by the pandemic, as demonstrated through the findings of our study. This reach is dependent on the availability of telecommunication entities with the capacity to partner with multiple major networks in a given country to offer reverse-billing services. The additional user pool that the Moya Messenger platform presented—users who were familiar with the survey alert system—contributed to the high response rate. Efforts to share the survey links on Twitter and other social media sites garnered drastically fewer responses without a strong and sustained communication strategy and networks with access to large groups. Eligibility criteria led to a large drop-off of respondents, suggesting that users of zero-rated  services “cruise” around looking for topics of interest to them and, most likely, those that offer incentives. The effects of incentives on response rates and data quality have long been debated, particularly in the context of online surveys where control of multiple responses is much more complicated. The offset costs of online surveys, compared to traditional data collection methods, may encourage the use of incentives for respondents, particularly with some evidence that incentives increase response rates without reducing data quality .In contrast to telephone interviews, data-free online surveys are very cheap. We received 15,912 surveys at a cost of R110,000 (US $7333), including setup costs, or R6.9 (US $0.46) per survey. By our calculation, using current rates for interviewers, training, and telephone supervision costs, as well as second or third attempts, approximately 20% of the time, to get an answer from calling telephone numbers , a singlThe use of online surveys offers a larger degree of anonymity compared to other data collection methods and may be more effective at eliminating social desirability bias for sensitive issues and at encouraging participation from those who would otherwise be reluctant. The wide reach of data-free online platforms is illustrated by the comparatively large number of fathers  who completed a survey about young children. It is notoriously challenging to engage male caregivers in parenting issues , and menWe were able to provide immediate feedback on response trends on the data-free platform for those respondents who were interested to look at them. This was made possible because the questionnaire was designed in REDCap  and survDigital and other technologies are advancing quickly to fill gaps created in information collection and service provision occasioned by the COVID-19 pandemic . Howevernet neutral and that service providers can exercise control over content [As anticipated, families from rural areas were underrepresented compared to national population distributions. Rural households in South Africa and other countries have less access to smartphones, and even when these devices are present, access to the internet due to high data costs and available signal is lower than in urban areas. Data-free technology goes a long way to reaching rural families, but additional measures, such as WhatsApp and push message services, may be needed to close the gap further. Zero-rated services are not new. Concerns that they are not  content  need to We refrained from asking for detailed personal information  for fear of deterring respondents from completing the survey in the face of a long run-in of questions perceived to be less salient to the topic to which respondents were attracted ; that isMany of the features of the online data-free survey described here are specific to the technology used by the researchers. Capabilities for programming multilingual surveys and revealing individual and aggregate findings instantaneously, among others, are not standard across the growing number of online survey platforms. In addition, the use of any individual feature is rarely without disadvantages on the flip side. For example, the option to prevent a single device from submitting multiple responses may prevent an individual from submitting multiple survey responses, but does not allow more than one eligible household member to complete the survey when relevant. Forced response options, which conventionally were thought to improve completeness of data, result in an individual dropping out of the survey altogether rather than missing individual items along the survey path. Researchers need to carefully consider the packages, platforms, and survey options against their research aims and objectives to ensure that the benefits of online surveys are fully realized and that disadvantages are minimized.Although digital technologies show tremendous promise to bridge gaps created by the suspension of face-to-face surveys and services, we have yet to come to grips with the very stark inequalities of internet access, both between and within countries. In this study, we demonstrate the feasibility and value of using a zero-rated service provider to conduct a survey of COVID-19 pandemic impacts on families of young children in a lower-middle-income country. The response rate was higher than comparable surveys, the survey was affordable, and it drew in a wide audience, demonstrated by the large number of fathers who participated. Further developments in digital services to respond to COVID-19 pandemic impacts, whether through surveys or online services such as counseling and education, need to consider using data-free platforms to ensure that the most vulnerable families are reached and can participate, and new sources of funding need to be opened up to do so.


Nowadays, fused deposition modeling additive technology is becoming more and more popular in parts manufacturing due to its ability to reproduce complex geometries with many different thermoplastic materials, such as the TPU. On the other hand, objects obtained through this technology are mainly used for prototyping activities. For this reason, analyzing the functional behavior of FDM parts is still a topic of great interest. Many studies are conducted to broaden the spectrum of materials used to ensure an ever-increasing use of FDM in various production scenarios. In this study, the effects of several phenomena that influence the mechanical properties of printed lattice structures additively obtained by FDM are evaluated. Three different configurations of lattice structures with designs developed from unit cells were analyzed both experimentally and numerically. As the main result of the study, several parameters of the FDM process and their correlation were identified as possible detrimental factors of the mechanical properties by about 50% of the same parts used as isotropic cell solids. The best parameter configurations in terms of mechanical response were then highlighted by numerical analysis. As opposed to traditional production, which is mainly subtractive in nature, additive manufacturing represents the idea of future production, thanks to its considerable savings in materials and the extended possibilities in producing complex geometries. The major advantage of the fused deposition modeling (FDM) additive process lies in the customized production of printed objects. At the same time, various limitations prevent their dominance in the production of fully functional mechanical components, for example, the limited size of produced parts, but the cost should not be underestimated as well . FurtherFDM additive process is based on the extrusion of material and on the principle of stacking layer by layer, in order to create parts that can have sophisticated 3D geometries. Due to this principle of deposition of the material, this technology presents some pitfalls. In fact, by building FDM parts from bottom to top, the material in the current layer solidifies before the next one is placed on it , causingIn this study, the printed parts under examination were lattice structures made of the repetition of three different unit cells with the same relative density—namely, open cell, closed thin-walled cell, and closed thick-walled cell. The unit cells repeated with the principle of tessellation along the three principal directions constitute the resulting lattice structures  Figure . FabricaHence, this paper aimed at evaluating the stiffness of produced lattice structures under compression, both numerically and experimentally, to make a comparison between the consistency assumed by finite element software and layering effects of experimental samples.Lattice structures were made by means of tessellation of a unit cell repeating it along the three main directions, essentially creating a honeycomb structure; see Three configurations of lattice structures were designed and analyzed, starting from three different unit cells with the same relative density, respectively, open cell, closed thin-walled cell, and closed thick-walled cell. These configurations of cells were designed based on the design for additive manufacturing. In detail, in accordance with the printing parameters used in the laboratory shown in It is immediately evident that the number of adjacent contours,  objects ,16.The building orientation for all the configurations of lattice structures was the horizontal building direction, shown in The greatest advantage of these designed lattice structures, in addition to lightness, is that no support structures are required during the printing phase. This is due to the maximum overhang angle of 50 degrees of the used MEX 3D printer machine  .To simulate the behavior of lattice structures in TPU, an advanced model of hyperelastic material with hysteretic capability was defined in the Abaqus/CAE software . Uniaxial tensile test data from a TPU 90A dog bone sample were included in the Abaqus material model to identify the best match between experimental behavior and the different strain energy potential models available in the software, in the strain range of interest. It was found that in the strain energy potential model, described by means of Equation (3), the best approximate value of the experimental nominal stress-strain trend is the second-order Ogden model .(3)UdefBσ is the effective stress. S is the stress scaling factor, The strain energy potential Voids left in the structure by additive technique and layering effects also need to be considered and analyzed in depth in FE analysis. FDM, as previously mentioned, generates an anisotropic, layered structure. This was considered by defining a local orientation of the lattice structure. Material structure orientation was used in conjunction with a new material model, i.e., an anisotropic elastic material model with an “engineering constants” option, to compare the isotropic and anisotropic behaviors.By means of the second-order Ogden model, the isotropic behavior was analyzed since the FE software considers structures as isotropic solid. Simulations were also performed for a linear elastic material, both for anisotropic and isotropic materials, to show the possible effects of anisotropy on the mechanical response of the samples.A linear elastic anisotropic material model was then adopted, in order to tune and reproduce the experimental results. The engineering constants that define this model—namely, elastic modulus, Poisson ratio, and shear modulus, in three principal directions  were arbTo simulate these tests in the Abaqus/CAE environment, the lattice structures were placed between two rigid analytical plates. The load was applied to the reference point of the upper plate by means of an imposed displacement . Three dAfter a variability analysis that did not show major effects in a range from 0.025 to 0.3, a friction coefficient equal to ructures . Table 5Load-displacement curves were obtained, as the reference point is affected by the sum of every single nodal response in the contact surface. From these curves, stiffness was calculated as the slope of the line that best fits the loading curve .All the obtained results, both experimental and numerical, are reported in In accordance with the results shown in By plotting the stiffness results obtained for the hyperelastic model and experimental tests in a distinctive graph , it was The two graphs in Geometrically, the graph in Discrepancies in geometrical configurations response are certainly due to the effects of the FDM process . In factTo understand the causes of discrepancies between experimental and numerical tests, all phenomena occurring in the printing process that influence the mechanical property of the FDM printed lattice structures were studied in depth. Several previous papers have found how FDM additive manufacturing technology widely affects the mechanical properties of printed parts ,36. FDM Firstly, the porosity was studied both with SEM analysis and weight analysis. In their work, Abbot et al found that the simulated printed parts were at least 50% more solid than experimental printed samples . This stanisotropic layering factor was identified, N) and imposed deformation N in a cell’s wall, equal to Finally, in the printing phase, there is another effect that is generated in the printed parts—the layering effect. It is extremely complex to simulate this phenomenon through a numerical model. For this reason, an Firstly, the real trend of experimental curves was reproduced by means of a regression model with the R-squared coefficient of 0.98. Consequently, the parameters of Equation (6), α and β, were identified through an iterative process on varying the critical parameters that adversely affect stiffness, N on the deformation level (The plot of Equation (6) reveals an increasing effect of the number of layers on level . This isNow, after recalibration of the simulated curves obtained by the Ogden hyperelastic model by dividing the stiffness values by the By the traditional FE analysis, an anisotropic behavior of such structures was proven;Anisotropy was ascribed to the layering process of filament, not always quantifiable a priori;lφ was defined that tries to correlate the number of FDM contours, the deformation level, with the anisotropy degree;A phenomenological layering factor On the basis of the layering factor, thin-walled cell structures were confirmed to be the less affected, whereas larger walled structures were negatively affected;The mechanical and functional behaviors of this kind of structure were confirmed to be influenced by many parameters, related to material and process, as well asa specific geometry.This study was conducted in order to analyze and understand the mechanical behavior of specimens of cellular structures obtained by additive deposition process fused in thermoplastic polyurethane. Particular attention was paid to the layer-by-layer deposition effect on the resulting stiffness, showing that the mechanical behavior of printed samples with this technology is not easily predictable. Major findings can be summarized as follows:


This study is aimed to identify the relative (direct) effect of online review ratings and perceived crowding on purchase intentions of a consumer. Our study also investigated the contingent effect of gender and perceived crowding between the relationship of exogenous and endogenous variables. This study was conducted in the Malaysian restaurant industry. We applied the purposive sampling technique to identify respondents, the mall intercept survey method was used for data collection. Smart PLS software was applied for data analysis (200 respondents). This study demonstrates through its results that online review ratings and perceived crowding have a positive effect on purchase intentions of a consumer. Moreover, if a consumer perceives crowding at a restaurant, this has a positive contingent effect on the relationship between review ratings and purchase intentions. This demonstrates that the consumer is more inclined to choose a restaurant with a high online review rating and has high perceived crowding at some unfamiliar place. Lastly, no evidence is found for the gender difference between review rating and purchase intentions; however, gender shows contingent effect and results confirmed that males preferred more crowded restaurants as compared to females. There are theoretical and practical implications for managers in the findings of this study. Consumers are able to express their opinions and feelings about their experience of a product or service on online platforms, thanks to the significant growth of the internet and online networking sites. These online platforms  play their role as a source of information for consumers in their decision-making about which product to use. The business scenario has been completely changed by this consumer reliance on the user-friendly mobile technology of internet for information search. Almost all restaurant businesses in Malaysia have adopted the internet as one of their primary communication methods to persuade the consumer through websites. To increase restaurant sales and win new patrons, companies have invested a significant portion of their budget in managing activities on online platforms.Restaurants are most commonly selected by first-time customers who have done their research by visiting online platforms. They use the review ratings of different restaurants to make a risk-free choice that fits their taste and preferences . In MalaThe sales of the product or service are enhanced or given an extra boost by positive online reviews with high star ratings because high online reviews influence perception of key facts of a shopper about product quality, value, and price . AnotherMost of the studies highlighted the importance of online reviews by describing their role in the formation of consumer intentions to purchase , but basHence, this study has three research objectives. The first objective is to identify the direct effect of online review ratings and perceived crowding on consumer purchase intentions. The second objective is to investigate the moderating effect of perceived crowding between the relationship of review ratings and purchase intentions. The third objective is to investigate the moderating role of gender between the relationship of review rating and purchase intentions, and crowding and purchase intentions, respectively.This study makes four different contributions to the existing body of research. First, we investigated the effect of online review ratings and perceived crowding stimuli on purchase intentions, to analyse the influence of these online and offline information sources to better understand the consumer decision-making process. Secondly, previous studies have focussed on the direct effect of online reviews on purchase intentions, but this study also investigates the moderating role of perceived crowdedness in the relationship between review ratings and purchase intentions, which helps us to understand the consumer decision-making process from a different perspective. This study also investigates the contingent effect of gender, which helps us to understand how gender differences modify the effect of online reviews and perceived crowding on consumer decision-making (purchase intention). Fourthly, this study used a real-time survey, and data were collected from respondents (first-time visitors) while looking for a restaurant to dine in, in contrast to most of the past studies which used experimental methodology to investigate the direct effect of online reviews and perceived crowding on consumer purchases. We decided on this approach because experiments do not capture the real essence of a phenomenon due to their controlled environment and manipulation. Lastly, this study is specific to the Malaysian context. Malaysia is a collectivist society where values and consumer behaviour are different from Western society , so understanding consumer behaviour in a collectivist society was the focus of this particular study.The latter part of this study consists of a literature review and hypothesis development. After the literature review section, the methodology section is presented along with the data collection procedure, and finally, the last part of this paper is dedicated to data analysis and contributions of the study.A consumer’s perception of crowding is considered vital in the retail service context for patronage decision and behavioural response. Most extant studies in the past identified the dark side of perceived crowdedness and confirmed its negative effects on consumption evaluation, intention to stay, and propensity to spend , but conThanks to advancements in technology, the consumer can obtain any type of information from online sources, such as sharing their experiences with other customers on the social networking site, such as Facebook, and third-party independent reviewer sites . The uncIn general, when consumers have inadequate information, they follow decisions or views of other consumers to make inferences about the product or service quality of a restaurant so they can make a risk-free choice. Therefore, travellers search for online reviews on their mobile devices and choose the restaurant which best fits their needs, based on its review rating. When travellers are in an unfamiliar place and need to select a restaurant, they search for information about the restaurants in that area through mobile devices and decide based on review ratings. The higher the online review ratings, the more consumers are likely to choose that product or service . HoweverBased on these assumptions, the following hypotheses are suggested:H1: There will be a relationship between perceived crowding and consumer purchase intentions.H2: There will be a relationship between review rating and consumer purchase intentions.H3: Perceived crowding moderates the relationship between review rating and purchase intentions.Past studies have shown that males selectively process information to form judgements. Males follow heuristic information cues, which are openly available in the context. In contrast, females are more evaluative and make purposeful evaluations of the situation before making any judgement . Based oMoreover, the literature review confirms that positive online reviews positively influence purchase intentions . In partHowever, there is a scarcity of studies dedicated to investigating the moderating role of gender for first-time visitors, in the context of a full-service restaurant. Past studies have shown mixed results regarding the contingent effect of gender on the association of online reviews and purchase intention. For instance, H4: Gender moderates the relationship between perceived crowding and purchase intentions, and that this influence is stronger over males than females.H5: Gender moderates the relationship between online review ratings and purchase intentions, and that this influence is stronger for males than females.We developed a conceptual framework . To make the results as general as possible, we distributed 250 questionnaires, but later, 50 questionnaires were discarded due to incomplete information. Therefore, the data of 200 respondents were used for further analysis using the Smart Partial Least Square Structural Equation Modeling (PLS-SEM) Technique.We used the purposive sampling technique for the identification and selection of respondents for this study. For data collection, the mall intercept technique was used, which is a survey method where respondents were intercepted in a social setting. This procedure includes interacting with the customer and asking screening questions before proceeding with the survey. For this study, the researcher first contacted the management of the restaurants, explained to them the purpose of this study, and asked for their permission for data collection. After getting their formal approval, the researcher contacted the customers who had just entered the respective restaurant, were sitting in its waiting area, and had not placed their order yet. The respondents were briefed about the purpose of the study and inclusion criteria before they were asked to fill in the questionnaire, starting with the preliminary questions. Qualified respondents who fulfilled the inclusion criteria were then requested to fill in the survey form regarding online review rating, perceived crowding, and purchase intention variables. The G power technique was applied to calculate the total sample size. For this study, the total sample size required was 129 at medium effect size  of the reflective measures, the researcher conducted confirmatory factor analysis . In the 2 values, while decreasing the error term. These attributes and benefits make PLS-SEM a favoured method for data analysis when the aim of the researchers is to identify variance between endogenous and exogenous variables. Hence, we employed Smart PLS-SEM for this study . Firstly, Smart PLS-SEM is preferred when a theory is at the initial level of development, and the aim is to predict the influence of independent variables on dependent variables. PLS-SEM is a second-generation multivariate analysis technique that is also useful for small sample sizes, and there is no specific condition regarding the normal distribution of data. In contrast to CB-SEM, PLS-SEM is ideally suitable for complex (reflective and formative) models, due to strong statistical power, and the ordinary least squares (OLS) method provides better results with elevated efficiency and higher Ris study , 2019.Preliminary analysis was done before conducting a formal Smart PLS analysis and results depict there was no sign of any outlier, and data were normal within range of ±3 SD. Results of Harman’s one-factor test depict single factors account for 41.40% of variation and combining all components which are less than 50% . This coThis study also used a reflective measurement model. At the initial level, the reliability and validity of the measurement instrument were confirmed. For this purpose, the researcher takes into account important parameters, such as outer loading of the measurement items, CR, and average variance extracted. Past literature confirmed that the value of acceptable factor loading and composite reliability should be more than 0.7 for both, while values of Cronbach’s alpha and average variance extracted (AVE) should be more than 0.7 and 0.5 independently. We tested discriminant validity using the Heterotrait-Monotrait (HTMT) approach and the Fornell-Larcker criterion. 2 values for further analysis. The results of the path analysis confirmed the proposed hypotheses H1 and H2 (main effect hypothesis). Review rating  has a statistically significant positive main effect on purchase intentions. On the other hand, perceived crowding  also explains the statistically significant variance in the dependent variable. Together, the variables of review rating and perceived crowding explain the 29.2% variance R2: 0.29.2 in the dependent variable. Effect size is another important indicator, depicting the magnitude of the effect of each independent variable on the dependent variable. The effect size of the review rating (f2: 0.198) is medium level and comparatively higher than perceived crowding (f2: 0.104). The last section reveals the moderating effect of perceived crowding and gender. The results in p: 0.000] with effect size (f2: 0.058) and supported H3. Moreover, gender also moderates the relationship between perceived crowding and purchase intentions such an effect is high for males than females, these findings are statistically significant , and supported H4. While, on the other hand, gender does not moderate the effect of review rating on purchase intentions, and results are statistically insignificant leads to the rejection of H5 .Smart PLS was used for model estimation and moderation analysis, a method suggested by Moreover, The results of this study show that online review ratings, perceived crowding, and gender are important factors in consumer restaurant choice (purchase intentions) in an unfamiliar place. Moreover, perceived crowding also has a moderating effect and positively increases the influence of online review ratings on the purchase intentions of a consumer. Gender also moderates between the relationship of perceived crowding and purchase intentions such that the relation is stronger for males than females.Information integration theory and dual processing theory both explain the phenomenon of consumer restaurant choice in an unfamiliar place. While selecting a restaurant to dine in, consumers choose different methods to find information about a product or service, such as online reviews (star ratings) and the behaviour of other consumers (crowding), which prove to be vital sources of information for risk-free decision-making . AlthougA online review rating of consumer has a significant influence on consumer choice, as confirmed by the results. A high online rating is considered a sign of decent service and food quality, resulting in a positive attitude and motivating people to prefer the high-rated restaurant. These findings are in line with a previous study on consumer decision-making by The interaction effect of perceived crowding and online review rating significantly predicts consumer purchase intentions. Different levels of crowding, for example, low or medium crowding, have shown interesting effects on consumer choices, since consumers were particularly more inclined to select a restaurant with high crowding as compared to a low-crowded restaurant. Moreover, intention of a consumer to choose a particular restaurant is high for a highly rated and high-crowded restaurant as compared to a highly rated but low-crowded restaurant. On the other hand, for low-rated restaurants, purchase intentions of consumer were significantly higher for a high-crowded restaurant instead of a low-crowded restaurant. These findings are consistent with This study is based on information processing theory and herd theory and has demonstrated important theoretical contributions. The first findings demonstrate that high online review ratings develop high purchase intentions, and these findings are in line with previous studies on consumer decision-making . HoweverSecondly, this study provides the unique implication that the interaction effect between restaurant ratings and crowdedness is at a high level. The intentions of consumers to patronise the restaurant would be highest for a restaurant that is both high on review rating and has a high level of crowdedness. Hence, the transition of a restaurant from a low level of crowding to a high level of crowding positively influences consumer purchase intentions. Therefore, this is an important theoretical contribution to the existing body of knowledge on consumer decision-making.Finally, gender as a moderator has been investigated in many studies in different contexts . HoweverThis study has important practical implications for the managers of restaurants. Firstly, the study demonstrates that online reviews/ratings are a vital source of information, and the results of the study depict their significant direct effect on consumer purchase intentions. A higher online rating is a desirable goal of every company or restaurant, but negative reviews adversely affect or influence reputation of a company and may make it fail to attract new customers. Review/online ratings of a consumer are based on their experience with the company, but negative reviews are easy to make due to unaccountability and anonymity.To establish a high star rating, zero-defect service should be the policy of the company, and in case of a failure of service, problems should be resolved with proper compensation on the spot. This policy shift will decrease the probability of customers posting negative review ratings. Moreover, delighted customers should be encouraged to give their opinion or rating online, which will increase the online rating of the restaurant and help to win the trust of new customers.Moreover, restaurant managers should hire experts to manage the online information flow of review ratings, to help the company identify and eliminate fake reviews posted by unknown people or by competitors. Moreover, experts can also calm annoyed customers by giving positive replies and showing concern for the issues posted in negative online reviews and ratings. Reply with a proper apology will reduce the negative emotions of the consumers and will generate re-patronage intentions with the result that consumers will delete or change negative remarks to positive comments, which will be useful for attracting new customers.Secondly, the managers of the restaurants should manage both online review ratings and the level of crowdedness at the same time, since the results of the study demonstrate that due to the easy access of the internet, the majority of consumers in unfamiliar places look for online reviews/ratings, and their intention to dine in a restaurant also depends on the crowdedness of the restaurant. Consumers prefer highly crowded restaurants in both high and low rating situations. Although star rating is an important indicator of consumer purchase intentions, since consumers always have multiple options available online, in an unfamiliar place the consumer himself might be looking for a crowded restaurant to dine in. Hence, despite the high online rating, offline conformity of information in the form of crowdedness is necessary to make a risk-free decision. Moreover, to manage restaurant crowdedness, employees should be provided a suitable working environment with proper training, as a toxic work environment negatively influences work engagement of employees . In addiIt is also important for restaurant managers to make sure that a certain number of consumers are present at the restaurant during peak hours. People follow the behaviour of the crowd, although the presence of other consumers is considered as a sign of popularity and good food quality, it has different implications for males and females. The presence of other customers will attract the attention of prospective male customers looking for a restaurant to dine in, and there is a high probability that in such a situation the consumer will choose a more crowded restaurant compared with a less crowded one. The situation is different for female customers, as females have shown a tendency to not choose a crowded restaurant. Females are an important segment of the Malaysian population distribution where the female percentage (51%) is higher than males (49%) .Restaurant managers should take into account this important demographic element and develop restaurant strategies accordingly. For instance, restaurant managers can make design and seating arrangements, and allocate appropriate space in such a way that it suits the requirements of male and female customers concurrently. For instance, patrons  could be seated along with the windows or in other visible parts of the restaurant to attract new customers, and there should be adequate space between the tables with proper walkaways so that female customers might not feel a breach of personal space and feel comfortable and confident during their visit. Moreover, special meal discounts, offers or, loyalty cards should be announced and offered to existing customers. This strategy will be beneficial in maintaining existing customers in the restaurant and will be useful in attracting new customers.This study does have some limitations. Firstly, although this is a real-time study, the data are collected at a single point in time , and the same framework can be used in a longitudinal study to identify fluctuations in consumer behaviour for the restaurant choice process. Secondly, we used the purposive sampling technique to identify respondents, so future studies can use a probability sampling technique to make the results more generalised. Thirdly, the literature suggests that online reviews do not only consist of review ratings but also have multiple characteristics, such as review volume, review relevance, and review credibility. Future studies can be used to check the comparative effect of other online review characteristics on consumer purchase behaviour. Moreover, the role of crowding can also be explored in other areas, such as gambling, tourism, and sports.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.MAA: conception or design of the work and drafting the article. MAA and DT: data collection. MA-U-R: data analysis and interpretation. SA: facilitate in critical revision of the article. FS and MM: helped in proofreading to improve the quality of the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Encouraged by the Framework Convention on Tobacco Control, Korea has implemented a nationwide School-based Smoking Prevention Program (SSPP) to reduce the prevalence of youth smoking. This qualitative study explored the school contexts of launching the SSPP in Seoul, Korea. Five focus groups were studied with 29 lead teachers in charge of the SSPP. Thematic analysis reveals three key findings. First, while infrastructure was insufficiently prepared due to the abrupt implementation, lead teachers agreed on the purpose of the SSPP. However, they perceived the program as myopic in only targeting smoking students and spending the mandatory budgets as a burdensome task. Second, the SSPP increased experience-based activities, influenced smoking family members, and created a smoke-free school environment. Third, to ensure more effective implementation, school principals should support inducing staff engagement. The teachers also maintained that the SSPP must be institutionalized as part of regular curricula with standardized books. For a more meaningful impact, the SSPP needs instructors and counselors to support smoking cessation programs that reflect school contexts. The teachers urged tobacco prevention measures at community, policy, and society levels. This study provides insights into a nationwide approach to initiating school-based smoking prevention program to achieve a tobacco-free generation. Smoking results in about seven million deaths worldwide each year . BetweenThe Korean government has taken steps to reduce adolescent smoking. The most significant was the implementation of SSPP in all elementary, middle, and high schools in the country since 2015. Prior to the SSPP, mandatory school health education in Korea was focused on the prevention of substance abuse overall including tobacco, alcohol, and drugs, which required smoking prevention education at least twice a year in elementary school and at least once a year in middle and high school . In an aIn terms of both policy and budget, the raising of the average tobacco price, which was 80.0% (about USD 2) on January 1st, 2015 , since tCountries such as Australia, Singapore, and the United Kingdom implement tobacco prevention school education at a national level, emphasizing multi-pronged approaches, interactive delivery methods, and tobacco-free policies ,13,14. AThis study aimed to qualitatively explore the school contexts of SSPP after the first year of the nationwide program implementation in Korea in 2015. Since the actual content and implementation of the program are decided by the schools themselves, its research questions are: (1) How is SSPP being implemented at schools? and (2) What are the school contexts and how does this relate to the successful implementation of improvements in SSPP?School education in Korea starts at the age of six. It consists of nine years of compulsory education at the time of the study (six years of elementary school and three years in middle school) , and thrTo examine the implementation of SSPP, this study focused on Seoul, the largest jurisdictional area of the Office of Education in Korea. In 2015, there were 599 elementary schools, 384 middle schools, 318 high schools, and 38 schools of other types  in Seoul for approximately 1.03 million students and 72,000 teachers .Focus groups, a method of sharing and comparing thoughts and opinions among participants, was conducted for comprehensive understanding of experiences, perceptions, and beliefs . We recrPrior to the focus group discussions, the research team explained the purpose of the study and the focus groups process to the participants, including that they would be recorded. Written informed consent was obtained and participants were provided with a copy of the consent form. A short survey was administered to collect the basic sociodemographic information of the participants. Conducted between September and October 2016, the semi-structured focus groups lasted for 120–150 minutes per group. One researcher and more than one research assistant attended each focus group session: the researcher facilitated the focus group while the research assistants took notes. The major focus group questions included the planning process and contents of the SSPP that were implemented, use of the END textbook in the SSPP, implementation issues, evaluation methods, and the perceived effects of the SSPP. The focus groups concluded by reviewing the topics with the participants and asking whether they wished to clarify or expand on anything discussed during the focus group. All verbal data were audio-recorded, transcribed verbatim, and enhanced by field notes taken during data collection. The study protocol was approved by the Institutional Review Board of the corresponding author’s institution (IRB No. 1609/001-007 & E1610/003-015).Thematic analysis  was perfThe demographic characteristics of participants are shown in Most lead teachers—that is, those in charge of the SSPP at their respective schools—expected the non-smoking students of SSPP to have a lower likelihood of smoking. While lead teachers believed that SSPP implementation needs improvement, the majority agreed on its expected effect. They strongly agreed with the program’s focus on smoking prevention rather than cessation. Lead teachers anticipated that the smoking rate of Korea will decrease because of current education. Lead teachers at elementary schools were particularly positive toward the SSPP’s purpose, believing that smoking prevention education at elementary schools will effectively prevent the children from smoking by using diverse educational activities. This optimism is reflected in the following participant’s statement:I did not expect much for the program. … Now I think the program has preventive effects on non-smoking students at least by informing them about the consequences of smoking with audio-visual materials. I came to think the program has some effects after hearing girls saying, “I won’t smoke.” I think the program has a possibility for smoking prevention.(D-5)Schools were informed in a top-down manner about the Korean government’s decision to implement the SSPP in all schools nationwide using funds from increased tobacco taxes. The SSPP requires substantial efforts for the school to operate and manage, and lead teachers felt frustrated in the way such a school health program was announced and initiated unilaterally. There was also antipathy toward the program regarded by some as a justification for a tax increase. Moreover, health was an optional subject at middle and high schools, so it was not included in the curricula in many schools. Therefore, it was challenging for some schools to spare class time and space for smoking prevention education that is not part of a regular curriculum. Abrupt mandatory implementation made the SSPP difficult for lead teachers to administer.Lead teachers also noted that some of the SSPP contents were similar to those of already available public programs offered by the District Office of Education, Seoul School Health Promotion Center, and Community Health Center. Some schools were informed about such public resources available for low or no cost only after employing puppet shows and musicals in their SSPP by hiring services [to spend the] school budget.It’s too much for schools to do everything. It would be efficient to divide and clarify roles. For smoking prevention, schools focus on its fundamental role of education, Community Health Centers host events, and the Office of Education leads campaigns.(A-2)A shared opinion was that implementation support for the SSPP lacked contextual understanding of school-based programs. While schools set annual plans at the beginning of the calendar year before an academic year begins in March in Korea, a list of public resources for the SSPP became available in the middle of the year. Some event materials sent to schools from a public agency without prior consultation were unused and discarded.Most lead teachers tended to consider that the SSPP education for parents was designed for those with smoking children and adolescents. A few lead teachers believed that parents of smoking students should be involved in the SSPP activities in school. However, parental involvement was one of the most difficult tasks for the teachers particularly in the daytime on weekdays, and most schools chose to distribute printed materials instead. Already existing school events such as festivals and athletic competitions were considered as a great opportunity to link to the SSPP to connect with parents.The hardest thing is parent education. In the area where my school is located, most parents are working. When I host an education session for parents at school, less than ten parents participate. And those participants are mostly the parents of well behaving students.(D-5)Lead teachers also thought that the SSPP for teachers was only for teachers who smoke. Smoking teachers tended to feel opposed to the SSPP created and financed by the tobacco tax increase, which made it difficult for the lead teachers to intervene. Another point was that many elementary teachers are women in Korea where the prevalence of female smoking is low. For those lead teachers in elementary schools, it was difficult to apply the SSPP to their teacher colleagues who thought the SSPP was intended to identify smokers and coerce them to quit smoking.In contrast with its predecessors, the SSPP consists of multiple elements to implement and a mandatory annual budget to spend. For some of the educational activities on smoking prevention could be provided without a budget as they had been prior to the SSPP, spending the mandatory SSPP budget took priority over developing and implementing a quality program. Lead teachers felt pressured to spend the budget, otherwise they had to write a case report on the budget that was unused and returned. An unused program budget could also mean that a teacher did not do the work.The government demonstrates that tobacco price was raised for the health of the people and part of the raised tax is given to schools for smoking prevention. But teachers only agonize over how they can use all of the given budget.(D-2)Although some challenges were experienced as described in the first theme, the teachers noticed the unique characteristics and impacts of the SSPP.A noticeable distinction between the SSPP and its predecessors was the its orientation toward experience-based learning in smoking prevention. The teachers evaluated that experiential learning in the SSPP was considered highly satisfactory by both students and teachers. Students were interested in and enjoyed the exhibits and experience provided at SSPP booths set up in schools and hands-on activities to make campaign products. The SSPP booths offered activities for students to engage in lung capacity measurement, visual displays of health consequences of smoking, and fingerprinting of a promise not to smoke in the future. Lead teachers appreciated that students were able to talk about smoking with one another while viewing the exhibition pieces. For a smoking prevention campaign, which is essential to the intensive type SSPP, students designed picket signs or campaign t-shirts. Due to the difficulty in securing class hours, students’ writing and posters on smoking prevention were displayed in schools.Of 17 health education sessions I had per class per semester, I let students make campaign items for one class. Then the students and I went to the subway station next to the school to do a 30-minute smoking prevention campaign.(B-5)Schools that adopted the intensive SSPP type held a smoking prevention family camp involving both students and their parents. In middle and high schools, a safety map of the school area was created using a mobile phone application. Some schools participated in events hosted by the District Office of Education and Community Health Center that can be related to the SSPP.Our school did a painting on the wall at the request of the District Office of Education. The drawing was related to smoking prevention and done in an underground parking lot that had been messy. A lot of children were excited to have “a wonderful mural in our school.”(A-3)Most of the lead teachers—regardless of school and program type—acknowledged that the SSPP has a strong influence over family members who smoke, particularly in encouraging fathers to stop smoking. The concern of students regarding the health of their family and fathers during the smoking prevention class appears to have had a significant positive influence on the whole family. Indeed, a health teacher responsible for an intensive program at an elementary school reported that students had told her that “my dad said he is going to quit smoking” or “my father promised that he would smoke outside of the house from now on.” This effect on the family appears to be more significant in elementary schools than in middle and high schools.The SSPP influenced enactment or amendment of smoking-related policies in schools specific to their situation. Schools employed penal policies for the students who smoke in school and created a norm for smoking prevention and a smoke-free environment.We could not go the toilets in our school due to cigarette smoke, just about three years ago. Now we are known as a school with no cigarette smell and smoke. In the change process several students had to be expelled for their smoking. Being next to smoking students is regarded as being smokers now. Since students often smoke because of their smoking friends, we focus on the importance of refusing, emphasizing that “If you cannot refuse, you are a smoker.” The students followed the atmosphere of the school.(D-5)Although most participants were skeptical about implementing a smoking prevention program outside the school and influencing their community with the SSPP, there was an example that showed a potential for influencing the community illustrated in the quote below.My [middle] school is located together with a high school and a university. Our students go to school passing a smoking area in front of the university. Members of a school club ran a campaign once each semester last year to emphasize the need for a non-smoking area. After a while, schools brought up the problem officially and decided to close [the smoking area].(E-4)Most significant for SSPP’s success was the positive attitude of principals to create the ideal school climate for smoking prevention. Principals’ support laid the foundation for SSPP implementation overall, creating a legitimate atmosphere for implementing the SSPP, fostering broader engagement of school staff, and influencing an active, effective operation of the SSPP committee. Training of principals is considered as a strategy for encouraging principals’ support to provide a comfortable climate for the SSPP in school.The principal of my school last year was a strong supporter of smoking prevention. A smoking cessation campaign was launched with the declarant of smoking prevention in school. The atmosphere has been a little different since a new principal came this year. He told me “don’t do anything related to smoking...”(A-3)The principal of my school, a smoker for 20 years, suggested [to] smoking teachers, “Let’s quit together.” A couple of staff members stopped smoking and the principal actively supported the smoking prevention program, so the other teachers cooperated as well.(E-3)Lead teachers reported that the standard textbook for the SSPP, END, was not used widely in both basic and intensive programs because it contains excessive writing activities and assignments while lacking contents relevant to student-specific characteristics such as gender, school year, school type, and the health impacts of electronic cigarettes (e-cigarettes). The teachers requested SSPP textbooks and curricula specific to school level and even school years particularly for elementary school covering six years of student development. It was also emphasized that health classes for smoking prevention should be institutionalized as part of regular curricula.[The standard textbook] should be developed according to the target students. The current textbook is not usable for teens in general. Wouldn’t it be more helpful if there are textbooks for girls, boys, seniors in middle schools, and freshmen in high schools, for example?(C-6)Implementing a smoking cessation program for students was a demanding task for lead teachers. Smoking students tended to have underlying problems of low self-esteem and family issues, and the lead teachers needed professional advice and assistance from specialists to help these students. Meanwhile, the teachers evaluated that a school-based smoking cessation program for students can be effective with the following characteristics: a close rapport between teachers and smoking students; experience-based programs offered on a regular basis; and contents on self-esteem.It is important for a smoking cessation program to help students want to come to the program voluntarily. If there is no rapport [with the teacher], the students may pretend to have quit smoking in front of teachers but might not have actually quit.(D-1)[The] smoking cessation program is the most difficult to do. It is not easy to arrange time for it in school [to begin with]. I ran a program for five smoking students last year, which felt like teaching a hundred students. I burned out when the program was over.(E-4)Recognizing the influence of community and society on smoking in terms of tobacco sales, tolerance to tobacco, and media portrayal of tobacco products and smoking to name a few, the teachers noted that the prevention of youth smoking should include tobacco control efforts at community, policy, and social environment levels. However, they defined the SSPP as an education program for students within schools. Despite the recognized need for multilevel efforts to prevent youth smoking, the teachers, particularly those of basic SSPP, were not enthusiastic about extending the SSPP beyond schools. Although a teacher of intensive SSPP reported a positive experience of stopping tobacco sales to students at nearby stores by campaigning to ban tobacco sales to minors and reporting a case to the police, most teachers rather expected more preventive measures to be implemented at policy and society levels besides the SSPP.This study provides evidence for the school contexts of initiating a national smoking prevention project at the school level. In particular, the lead teachers recognized SSPP as important educationally, but they felt technically insufficient by the abrupt initiation of top-down approaches. Despite the lack of preparation for implementation, perceived impacts of SSPP resulted in increased experience-based activities, positive effects on family members, and creating smoke-free school environments. It was emphasized that the SSPP should be more structured in terms of principals’ support, enhancing the standard textbook in the institutionalized curriculum, and enhancing the program components for smoking students, and tobacco preventive measures at community, policy, and society levels. Based on these results, the SSPP is meaningful because it can be adapted when initiating large-scale school-based smoking prevention projects in other countries.The principal’s leadership is essential so that the school staffs create a comfortable climate for the SSPP, which can allow many school staffs to engage in the operation of the SSPP ,18. A prOur results showed that participants fully agreed that an SSPP program is effective in slowing the onset of smoking for non-smoking students and reduces the amount of tobacco usage among smoking students ,27. NeveCooperation and coordination between institutions is considered at the stage of planning the SSPP. In this study, many institutional supports overlapped with SSPP and were inefficient for both the implementation and attainment of the particular SSPP goals of the individual schools. According to the WHO’s Global Standard for Health Promoting Schools, the role of each institution should be clearly identified in order to use resources and implement SSPP effectively . Thus, dThese results were consistent with the results of a previous study that experience-based activities are effective in improving the knowledge and attitudes toward smoking . To maxiAlthough this study deals with the cases of smoking prevention programs in Seoul among Korea, SSPP is conducted in all schools nationwide. The prior study about the US national diabetes prevention program stated that the overall weight loss effects were achieved by increasing the duration and intensity of the session based on the national project . The SSPAlthough 76% of the participants were female, about 69% of teachers are female, as are 99% of the health teachers—the latter of whom tend to be responsible for SSPP in Korea . ParticiThis study contributes to the improvement of SSPP by generating strategies based on the exploration of SSPP implementation using the experiences of teachers involved. The theme of “educationally important but technically insufficient” results from insufficient preparation due to the abrupt initiation of the program, including a narrow perspective of the SSPP education for parents and teachers. Nonetheless, the results of this study indicate that the SSPP has a positive impact on reducing smoking rates. To improve the SSPP, this study suggests the creation of supportive environments through the positive attitudes of school principals, enhancing the standard textbook in institutionalized curricula, providing further support to teachers, and demarcating the roles of public institutions to prevent overlap. In addition, this study suggests the development of methods for educating parents and smoking teachers, as well as a smoking cessation program aimed at smoking family members. More research needs to be conducted among non-smoking students, smoking students who participate in SSPP, as well as the staffs of public institutions from a multilevel perspective.


Background. Following the adoption of the UN Convention on the Rights of Persons with Disabilities, there has been increased interest in supported decision making (SDM) as a strategy to realize the right to legal capacity of persons with intellectual and psychosocial disabilities. Support for decision making has been delivered formally through SDM services as well as informally through interpersonal networks. Various SDM programs have made efforts to systematize informal support, showcasing a variety of SDM delivery models that could benefit SDM implementation in low- and middle-income countries. Methods. This article examines and discusses three SDM projects in South America  that have been directly implemented by civil society organizations, including organizations of persons with disabilities and their families. Analyzed program components include person-centered planning, the nature of support relationships, the presence of supporter training, community involvement, and the utilization of quality assurance measures such as monitoring and program evaluation. Conclusions. The results and learning from these initiatives constitute a valuable source of information for legislators and policymakers for the future development of supported decision-making programs, which are an essential form of support and a mechanism for fulfilling the right to legal capacity in low resource settings. Interest in supported decision making has increased significantly following the adoption of the United Nations Convention on the Rights of Persons with Disabilities (CRPD). Article 12 of the CRPD acknowledges the universal right of persons with disabilities to enjoy legal capacity on an equal basis with others in all aspects of life [Throughout history, persons with disabilities have been denied or have had restrictions placed on their right to legal capacity in different areas. These limitations have been commonly justified on the basis of the diagnosis of an impairment (status approach), previously made decisions and their outcomes (outcomes approach), or deficient decision-making skills  . The ComFrom a rights-based perspective, guardianship and other forms of substitute decision making represent a violation of the right to equal recognition before the law and, more specifically, the right to legal capacity, which is necessary for the enjoyment of all other rights . Even suThe adoption of the CRPD in 2006 represented a paradigm shift away from substitute decision making, largely due to the inclusion of Article 12.2, which affirms that “persons with disabilities enjoy legal capacity on an equal basis with others in all aspects of life” . DespiteWhile there is no universal conceptualization of SDM , the terDespite this early attempt to distinguish SDM as a purposeful, principle-based practice, SDM remains an elusive concept, having been adopted and appropriated in various ways ,10,11,14SDM can be delivered through a variety of formats, both as formal service provision through agencies and organizations or on an informal basis through interpersonal networks. On a project to project level, the differences in SDM delivery between varying projects can be attributed to differences in the needs of the participating persons with disabilities . SimilarSDM tools and resources that support families and service providers to implement SDM also vary based on local standards for accessible information  and the availability of assistive technologies individuals may use as communication supports , both ofWhile there is no agreement on a singular conceptualization of SDM that is applicable across all global contexts, there is empirical consensus that additional research on the implementation and impact of SDM is needed ,19. BigbThis article analyzes three supported decision-making projects in South America—Colombia, Peru, and Argentina—which have been directly implemented by civil society organizations, including organizations of persons with disabilities and their families (OPDs). The Colombia-based SDM project was first identified in a wider exploration of SDM pilots and initiatives around the world that were reviewed by the authors in preparation for the UN Special Rapporteur on the rights of persons with disabilities’ thematic report on legal capacity . This inThese three programs were selected for review and consideration in the present paper because of the limited empirical attention paid to SDM in South American countries, despite their advances in legal capacity reform. In addition, these SDM projects provided an opportunity to analyze SDM in low- and middle-income countries in light of the overrepresentation of SDM models from high-income countries in the literature. However, this paper does not aim to present a comprehensive overview of all existing SDM pilots or SDM programs in the region. It is likely that many organizations or associations offering SDM programs or services do not have published information about such programs if they do not have websites, are not required to publish reports per funding agreements, or are in early stages with limited data.While some jurisdictions within the region have implemented legislation to govern SDM, including Argentina, Brazil, Colombia and Peru, the exploration of legislative strategies falls outside the scope of this paper.In Colombia, the pilot project “Supported Decision Making and Community Life in Colombia, under Article 12 and 19 of the Convention on the Rights of Persons with Disabilities” was implemented between February 2015 and December 2016, as part of a collaboration between Asdown Colombia, Nodo Comunitario de Salud Mental and PAIIS , and with funding from the Open Society Foundations. This project was conducted with a participatory action research framework and was grounded in person-centered planning. It included 23 adult participants, 12 with intellectual disabilities and 11 with psychosocial disabilities, from six localities within the city of Bogota. The selection of the participants was based on home-based interviews and quick participatory assessments.The pilot aimed at building a personalized support system designed to contribute to capacity building for decision making and the encouragement of independent living. This support system also sought to improve relationships with close relatives, the extended family and the community. For that purpose, the research team established relationships with participants and their family members and identified communication and support needs. Then, the participant and their family developed a map of networks that the person could use for support. Participants also engaged in a “Projection of a Life Plan” project that contributed to the creation of their personalized booklet. This allowed them to describe their goals, dreams, and basic preferences. Information on support for community life, autonomy, and daily living were also included in the booklet. Family members also participated in training to learn about providing support. Participants and their families were able to evaluate goals based on the life plan created .This project evaluation reported that most participants lacked the autonomy for decision making prior to this project . The parIt is important to note that this pilot was developed prior to the legal reform reached by Colombia in 2019, which eliminated guardianship from the Colombian legal system and replaced it with regimes for supported decision making .From 2016 to 2018, Sociedad y Discapacidad (SODIS) and the Peruvian Down Syndrome Society (SPSD), implemented the pilot project “Support Networks for Decision Making and Community Life” as part of a set of strategic actions aimed at achieving legal capacity reform, which was finally achieved in September 2018 when the Peruvian government passed the Legislative Decree No. 1384. The project was funded by the Inter-American Foundation, with additional support from the Open Society Foundations. Its main goal was to promote decision-making support networks for people with intellectual and psychosocial disabilities in order ensure they could exercise of their rights to legal capacity and to live independently in the community. The pilot included 20 adult participants from Lima, 10 with intellectual disabilities and 10 with psychosocial disabilities, as well as their respective family members and other community actors identified as potential supporters.The project involved interventions at three levels. At an individual level, the facilitating team implemented person-centered planning activities and individual counselling. At an interpersonal level, they developed group workshops, peer support meetings, and family meetings. At a community level, stakeholder mapping and outreach activities with community-based organizations were conducted. All interventions were developed separately for people with intellectual and psychosocial disabilities. They were carried out in partnership with public entities, the Social Security Health System  and the community mental health center of Alto San Gabriel.This project benefitted from an external evaluation. This evaluation included semi-structured interviews with participants and families and networks, as well as the facilitating team ,24. WhilThe evaluation highlights the importance of exploring different flexible strategies based on identified support needs, barriers and networks, as well as incorporating people with disabilities themselves as co-facilitators ,24.In Argentina, the National University of Mar del Plata carried out the pilot project “Persons with Disabilities, the exercise of their legal capacity and decision making: implementation of supports in different contexts” from February 2017 to April 2019. This project aimed to identify and critically analyze support systems for decision making based on the daily experience of participants and was conducted with a participatory action research framework. The project was implemented in partnership with local institutions, such as the segregated school “C.I Alito” for persons with intellectual disabilities, the Down Syndrome Association of Mar del Plata, the Municipal Mental Health Centre, and the Mental Health Centre “Proyecto Be”. They also had financial support from the Open Society Foundations. The project involved 16 adult participants, 8 with intellectual disabilities and 8 with psychosocial disabilities. Some participants had “therapeutic companions,” which are paid health workers who support vulnerable individuals for improvement in their recovery and quality of life, often judicially appointed .Similar to the previous projects discussed, this project used a person-centered planning methodology, which included tools such as genograms, ecomaps, and network maps . From thThe evaluation identified the need to support a flexible and dynamic “toolbox”, co-built with people with disabilities themselves. Likewise, the role of organizational structures in the design of supported decision making was stressed .This section discusses program components that were identified as recurring among the examined SDM pilot projects. Program design elements, strategies used, and limitations across projects are discussed. Due to program evaluations being small-scale, the available information proves insufficient to draw conclusions about the effectiveness of individual elements of the programs. As a result, the following discussion does not present a single ideal program structure, but rather offers insight into a range of structural elements and approaches and potential strengths and limitations.Notably, the three experiences described were grounded in the CRPD. The CRPD, and in particular the CRPD Committee’s interpretation of article 12 , served Person-centered planning (PCP) was a recurring structural element in all three projects. PCP is a life planning strategy centered on the will and preferences of an individual with intellectual disabilities, and allows service providers to support decisions and actions that will help the individual to achieve their goals . PCP hasAll three analyzed projects used elements of PCP as a strategy. In Colombia, the project used a wide variety of PCP tools that were adjusted to the needs of the participants and their families. Each participant was given five (5) sessions with a duration of approximately 2.5 h to engage with the life planning tools. In Peru, participants were expected to develop and implement a person-centered plan with specific objectives and activities. However, this aim was later abandoned with the group of people with psychosocial disabilities in favor of less structured approaches for identifying goals and supporters. Of the 10 participants with intellectual disabilities, eight designed a person-centered plan during the project. While there is little information about how PCP was applied in the Argentinean experience, the project reported using PCP tools including genograms, ecomaps, and network maps.While PCP is commonly utilized in SDM work, the conflation of SDM and PCP can be potentially problematic. While PCP can be a useful tool for supporters to engage with during the implementation of SDM, PCP as a philosophy must be clearly distinguished from more concrete strategies for SDM. There is a risk of turning support into a tick-box exercise; that is, reducing support—a complex process—into procedures and rules which are task-focused. Moreover, to be successful, PCP requires skillful facilitation, the availability of support and services, intensive training, and a shift in perceptions , which mThe three programs focused on both people with intellectual and psychosocial disabilities as their primary beneficiaries. Within such groups, the participant sample included men and women, people with and without guardianship, people with different education levels, and people with and without family support. However, none of the three programs included participants who had higher support needs. This limitation is not unique to South America—although supported decision-making strategies for people with profound intellectual and multiple disabilities (PMID) have been found to be successful ,41 and tWhile the pilot projects in Argentina and Colombia included persons with intellectual and psychosocial disabilities in the same activities, the Peruvian program worked separately with both groups, prioritizing group and peer support strategies for persons with psychosocial disabilities. This is again consistent with international SDM practice, where pilot projects vary in their inclusion of participants with different types of impairments ,44.Including participants with different types of disabilities and varying levels of support needs in pilot projects may better prepare organizations to provide support services to the diverse disability community and encourage greater individualization in the execution of SDM programming. However, because long-term results have not been reported from the discussed programs, it is difficult to ascertain how the results for individual participants are affected when the SDM programs focus on a specific constituent group versus the cross-disability community. The diversity of the disability community demands heterogenous support, and it is arguable that programs which focus on the needs of a specific group could be more effective than a singular model or “one size fits all” approach ; howeverThe relationship between an SDM user and supporter can be analyzed using two variables: the number of supporters, and the relationship between the decision maker and supporter. SDM programs often use either primarily single supporters or multiple supporters ,46, althExisting, trusted relationships have shown to be constructive because familiarity contributes a degree of comfort to the support relationship, and supporters already had a working knowledge of the SDM user and a level of trust that benefitted the decision-making process ,52. The The three programs explored in this paper used supporters from existing, trusted relationships within broader support networks identified from members of the community. In Peru, each participant with an intellectual disability selected a “support network.” They were almost always people known and close to the participants, such as family, friends, and neighbors. In some cases, because of the lack of commitment of the supporters, the responsibility for the most support activities was taken up by the main caregiver or other members of the participant’s family, some of whom felt burdened by complying with the PCP’s activities . In the It should be noted that, due to the exploratory nature of the three experiences, the focus was placed on exploring support needs and identifying potential supporters, which did not allow sustained SDM work. However, it was noted that preconceived notions and paternalism may affect SDM relationships based on existing relationships. These limitations are not uncommon and may jeopardize the person-centered nature of SDM .Training for supporters can contextualize the role of the supporter and provide a rationale for the support they are providing. The training that supporters receive can influence a support relationship, and training that occurs in an ongoing, systematic fashion has been documented as a key factor in quality SDM practices .Pilot programs in Colombia and Peru provided training to supporters and family members throughout the project. Family understanding and support can benefit SDM processes between a person with a disability and their family member supporter. The evaluation of the Peruvian project indicates, for example, that these training exercises were positively valued by family members as spaces for learning and reflection . Some SDThe Colombian pilot project also showed that training and access to resources on SDM does not need to be limited to the individual playing the support role, and opportunities can be provided for training individuals with disabilities in SDM strategies as well. This program developed training resources for participants, with the “Projection of a Life Plan” tool, which provided information on community life, autonomy, and daily living in a personalized booklet that participants could then use to detail their goals and preferences . EnsurinWhen considering community attitudes towards SDM, it is important to note that historical discrimination against people with intellectual and psychosocial disabilities has contributed to a culture of exclusion and low expectations . Hence, Among all three projects analyzed, a specific objective of involving the community in the implementation of the project was a feature. In Peru, community organizations were identified and participated in reflection on the importance of SDM and on their own needs, resources, and possibilities for action . The ColThe monitoring of SDM practice was not a strong feature of these three pilot programs, largely because involvement of the organization in the interactions between decision makers and supporters was limited. The Colombian project emphasized regular follow up, but the report did not offer clear, systematized methods . For exaThese programs could benefit from monthly meetings with the decision maker to ensure the process is working. Monitoring not only collects data to inform the overall SDM movement but can help SDM programs identify challenges in their implementation and address them as they arise . It is lThe three SDM programs in Peru, Colombia, and Argentina all made an effort to include evaluation as a component of the projects. The inclusion of an evaluation phase is significant because evaluation is uncommon among SDM programs, and the evaluation is often poor when it is included in SDM programs . The proThe three programs analyzed used interviews and observation to collect data on project results. SDM, as a personalized and flexible tool, is well suited for qualitative studies. Qualitative data collection methods are beneficial because they allow evaluators to learn more about broader attitudes of participants in the program and their communities. They could also benefit the understanding of interactions between SDM programs and legal structures.Evaluations did not include data on the cost of implementing SDM. Publishing details of a program’s operating budget appears to be a rarity among SDM projects, but this information is a necessary advocacy tool in encouraging governments and organizations to adopt their own pilot programs to begin the process of introducing these mechanisms in their jurisdictions . DetaileThis article discussed three SDM experiences in South America across reoccurring variables and dimensions of SDM: strategies, participant diversity, the nature of support relationships, supporter training, the monitoring of SDM process, program evaluation, and the role of community advocacy. Building upon Bigby et al.’s work, this article highlights a greater need for data collection and evaluation, inclusivity in participant recruitment, effective safeguards, and additional pilot projects . The fleWhen considering the application of SDM in the South American region, it is important to acknowledge that contextual factors likely played a role in SDM implementation. Building on the learning from other regions that pursue SDM, this exploration of delivery models in South America can help to refine conceptualizations of best practice in program design and its applicability across different contexts. Among the literature which primarily emphasizes learning from SDM projects in high-income countries, the South American experience indicates that SDM projects can be implemented successfully in low- and middle-income countries. Notably, the projects in Colombia, Peru, and Argentina made use of strategic partnerships between OPDs, other civil society organizations, and universities. This delivery-through-partnership model can be effective for cost-sharing and maximizing resources, which is particularly applicable to the implementation of SDM projects in low-income settings. Particularly in contexts where formal service delivery organizations do not exist, these strategic partnerships in low- and middle-income countries can fill gaps and ensure the availability of SDM resources where they otherwise may not exist. Moreover, the projects benefited from international cooperation, which highlights the critical role of international agencies and private donors in supporting innovative research and practices for the advancement of the rights of persons with disabilities, in line with Article 32 of the CRPD.One significant limitation is the small scale of the practices analyzed, which is a major barrier to broader policy reform. Future SDM efforts should focus on the establishment of large-scale programs, long-term projects, the consideration of program costs, and the evaluation of what formal SDM services and programs do or should look like. Sequential projects could also be beneficial, as follow-up projects could correct shortcomings in initial projects.Finally, it is not insignificant that these SDM projects have been carried out in countries that have achieved legal reforms in the legal capacity of people with disabilities. This may indicate that SDM efforts may contribute towards a transition away from substitute decision making and guardianship. While some proponents of SDM have argued that the practice can exist in tandem with substitute decision-making regimes , the con