Child maltreatment, due to its high prevalence and often long-lasting  consequences, is one of the main reasons for global health inequalities. The medical field offers many opportunities to support affected children. This gives physicians and other health professionals the opportunity to provide protective measures and therapies to affected children at an early stage. However, the level of training concerning child protection is often too low among health professionals. This can affect the quality of care as well as providing the appropriate treatment and thus, the long-term  burden. The present work aims to survey the state of knowledge and capacities of health professionals regarding child protection in medicine and elicit health professionals' perspectives who absolved a child protection online course on a potential need for action in Germany.From June 2016 until February 2021, 3,360 health professionals were interviewed. Using quantitative and qualitative items, the questionnaire assessed demographic and professional background information as well as assessments regarding the awareness of child protection, abilities in child protection among health professionals and training offers in medicine.n = 3.159) of the health professionals stated that they need more knowledge and capacities regarding child protection in medicine. More than half of the health professionals assessed the importance of the issue of child protection as low among health professionals. The reasons cited included child protection as an uncomfortable topic, an unwillingness among managers, and a lack of training on the topic.The analysis indicates that the topic of child protection in medicine is not as present as the high prevalence of child maltreatment would imply. The majority (94.0%; There is too little awareness and importance regarding child protection in the medical field in Germany. Hence, it is difficult to ensure adequate care for those affected. Child protection topics should be mandatory in the training curricula of all health professionals, and quality standards for prevention and intervention should be implemented in medical institutions. Furthermore, networking in child protection has to be improved, and medical campaigns should address the topic to sensitize health professionals and society to the issue and to destigmatize the topic. The World Health Organization (WHO) estimates that child maltreatment is one of the main causes of social and health inequalities worldwide . AlthougThe literature shows that physicians are among the privileged first contact persons for those affected by child maltreatment , 14. FurFor health professionals in Germany, the Federal Child Protection Act currently regulates the procedure to follow in the event of suspected child maltreatment. Thus, if health professionals become aware of significant indications of child maltreatment in the course of their professional activities, they may first discuss the situation with the child and the legal guardians and, if necessary, urge the legal guardians to seek help. In addition, health professionals have a right to anonymous consultation with a child protection specialist. If the risk to the child cannot be averted together with the legal guardians, the Youth Welfare Office must be called to avert further danger for the child , 18.However, it became clear that the level of training in the field of child protection in medicine is often too low among health professionals, and the WHO estimates that 90% of child maltreatment cases remain undetected by institutions , 19, 20.Unfortunately, it has become apparent that there is very little evidence on the perspectives and experiences of health professionals regarding the state of training and quality standards in child protection and the needs and requirements of health professionals. This study collected quantitative and qualitative data on this topic to address the current gap in the literature by examining the views and experiences of health professionals who have completed continuing education on child protection.This research aimed to analyze and reflect on the perspectives and experiences of health professionals who absolved a child protection online course to identify needs, barriers and opportunities in medical child protection among health professionals and to improve the treatment and management of children and adolescents affected by child maltreatment in the future.From June 2016 until February 2021, the Department of Child and Adolescent Psychiatry/Psychotherapy at the University Hospital of Ulm in Germany offered a free-of-charge online course on child protection in medicine funded by the German Ministry of Health, which imparted knowledge and skills on epidemiology, risk factors, anamnesis, procedures and legal basis in cases of (suspected) child abuse . The parAltogether, 3,998 participants absolved the online course successfully and took part in the evaluation. Of those, 3,360 participants were included in the analysis, based on their profession as physicians, health care professionals, psychotherapists (in training), other therapists  (in training) or medical students. All data evaluated in this paper were collected in the evaluation of the online course. The evaluation was conducted in German.Data include demographic and professional background information, the level of motivation for further training in child protection as well as assessments regarding the meaning of child protection, level of knowledge, capacities and self-efficacy in child protection among other health professionals and themselves.The hypotheses behind this study stated that health professionals need more support and capacities in child protection and that targeted interventions can support them to do so. To prove these hypotheses, quantitative and qualitative research were performed. This design analyzed the capacities and needs of health professionals on the one hand and assessed their specific and individual needs on the other hand. The study is approved by the Ethics Committee of the medical faculty at the University of Ulm on June 16, 2016.Demographic data, except age and professional experience, and assessments of the availability and status of training on child protection in medicine were collected using nominal and ordinal items, respectively. Quantitative data on personal experience, requirements of the participants concerning child protection, the self-assessment of knowledge, acting and emotional capacity as well as self-efficacy were measured by the agreement to statements using endpoint-named scales. So these data can be considered as interval scaled Fig.   . The fig“What do you think are the reasons for insufficient awareness of the topic of child protection in medicine?”“What do you think would be necessary for more attention to be given to the issue of child protection in medicine?”The qualitative data were assessed by two open questions concerning the participants’ awareness of the topic of child protection in medicine. Both questions were only asked if attention to the topic of child protection in medicine was considered insufficient by the participant.The answers were studied in detail, and a qualitative content analysis according to Mayring was performed. This analysis combined quantitative analysis steps, such as categorizing the material and counting these categories, and qualitative ones, such as analyzing the statements. In the course of this analysis, inductive categories, which derive directly from the material without pursuing already existing presuppositions, were formulated step by step. Mayring hereby differentiates between four steps that are based on each other. In the first step, the research team discussed and defined the research questions and hypotheses (see section on Research design). Subsequently, an overview of the collected qualitative data was created by analyzing the qualitative data and dissecting it according to a previously defined procedure in order to ensure intersubjective comprehensibility. In the course of this, all individual statements were extracted from the participants' statements and documented individually. Based on this, codes were created from the data by extracting the content of each individual statement made by the participants. The coding and categorization were discussed and defined within the research team. To ensure the objectivity of the analysis, independent raters also analyzed the qualitative data and created categories. These categories were then compared with the categories already formed and adjustments were made where necessary .n = 2,718) of the health professionals were employed, 16.5% (n = 553) were self-employed and 6.3% (n = 211) were unemployed or on parental leave. Figure The 3,360 health professionals who were analyzed in the study were 39.5 years old on average (standard deviation (Stdv) = 10.5). A total of 80.9% n = ,718 of tTable The health professionals gained professional experience for an average of 10.9 years (Stdv: 9.7); nevertheless, they estimated their personal experiences in child protection in the lower area Fig. .Fig. 3Pan = 3,159) of the health professionals included in this study already recognized this problem and stated that they need more knowledge and capacities in child protection in medicine. Table The level of the participants’ self-assessed professional experiences in Fig. p < 0.001; n = 3,360). Moreover, a Kruskal–Wallis and subsequent post-hoc tests revealed only weak differences between the professional groups according to Cohen's d.It seems that even before training in child protection, the participants estimated their own level of knowledge and capacities in child protection to be higher than the average knowledge and capacities in their professional group. This was also confirmed by a significant Pearson correlation between professional experience in years and the self-assessment of experience in child protection  did not estimate the training offers and services in child protection as sufficient; however, almost all of them  indicated a high need for a larger dissemination of knowledge and abilities in child protection among health professionals. Moreover, broader and more flexible access to training offers and services is required.It became clear that most of the health professionals  mentioned that they needed more knowledge and capacities in child protection in their daily professional routines, and for almost half of them , the offered online course was the only training offer available.The majority of the health professionals .The participants pointed out that, in their opinion, the topic of child protection should receive more importance in society and politics and that measures of a structural or financial nature, for example, should be implemented on this basis. Currently, the importance is still low because child abuse is an The interviewees also emphasized the role of the media, stating that child maltreatment, its origins and consequences should be more strongly addressed in the media, rather than simply scandalizing cases of maltreatment, and should be included in campaigns to sensitize society as a whole to the issue and to destigmatize the topic.Numerous respondents commented that more knowledge and competencies, and thus more training, of health professionals on the topic of child protection is necessary. "More awareness-raising activities among all staff groups and specific training opportunities."In addition, nonmedical or nonspecialist staff, in particular, would need training on the topic of child protection, as they may also come into contact with cases of child maltreatment. There was also a call for better support in child protection cases. "Low-threshold offers for physicians in case of questions, advice in the event of suspicious cases, also availability after hours or in the evening, support regarding local contact addresses."  Another point of criticism concerned the education and training of health professionals, which often does not address the topic of child protection. This gap also needs to be closed."Courage to be vigilant for child maltreatment by those in authority."Some of the respondents would like to have more support from managers in their institutions in the context of child protection cases. There are reports of managers who explicitly do not want to address the topic of child protection in their facility.On the one hand, support in dealing with suspected cases would be important to the respondents, but on the other hand, support in further training on the topic would also be essential. Furthermore, there is a requirement for a child protection specialist for each medical facility."Establish networking with external resources for practices and clinics as a mandatory structural requirement."Dealing with child protection cases usually requires different professional groups in different institutions. In addition, it was noted that better networking between all professionals involved in child protection, within but especially beyond the medical field, is necessary and should therefore be established and financially supported in all medical institutions. This also includes the knowledge of the other professionals involved in cases of child maltreatment, their fields of activity and possibilities.Some respondents already reported successful networking and its success in dealing with cases of child maltreatment.The results of this work show that the participants in this study, who took part in an online course on child protection in medicine, rated the knowledge of child protection among health professionals as too low. The results allow for the conclusion that the level of knowledge among the surveyed professionals is, on average, higher than the level among all health professionals. Therefore, we assumed that the participants are particularly committed and sensitized to the topic of child maltreatment. Similar trends can be observed internationally, although the current state of research on this issue is not yet broad enough –28.In the field of education and training, different areas become clear in which increased efforts on child protection should be realized: first, in the area of health professionals’ education. The study showed that health professionals who are currently in training consider their competencies in child protection to be rather low. Although there were no clear differences in the assessment of knowledge and competencies between the professional groups considered in the analysis, it became clear that the higher the level of professional experience, the higher the assessment of one's own competencies in child protection. Thus far, medical training does not address the topic sufficiently. This confirms the demand of the "German Society for Child Protection in Medicine", which calls for child protection to be part of the training of every physician working in child and adolescent medicine .As child protection cases can appear in all areas of the health system, (non-) physician health professionals that do not work with children and adolescents on a daily basis, such as nurses or employees of a general practitioner's office, should also be trained on the topic. This also confirms the demand of Berthold and colleagues to implement the topic obligatory in the education and training of all health professionals. In addition, these recommendations suggest that medical facilities maintain a multiprofessional child protection group. This interdisciplinary approach could also be used to better train all physicians, not just those in traditional "pediatric specialties" such as dentists, who play for example a significant role in the field of dental neglect. . These tFinally, the interviewees in this study repeatedly emphasized that they did not feel sufficiently supported or where even hindered by their executives in child protection cases. However, executives play a decisive role in the establishment of child protection measures because the importance that a manager attaches to this topic will also determine how employees handle it. Child protection in institutions is a relevant topic for management staff since the issue of child maltreatment affects a wide range of institutions. At the same time, an emotional topic requires a high degree of sensitivity on the part of executives . TraininThe statements of the interviewed health professionals clearly show that there still seem to be many gaps in dealing with child protection cases, especially in the area of exchange and networking. Studies on networking in the field of child protection indicate that there is a coexistence rather than cooperation in child protection. In pedagogical and medical institutions, there is a clear divide with the youth welfare office due to the fear of losing the trust of affected children, which has a negative effect on the health professionals’ willingness to cooperate. The fact that youth welfare offices can provide hardly any feedback on the further course of cases after a report for reasons of data protection makes cooperation more difficult, especially in crises. Mutually divergent expectations of the roles and tasks of the cooperating institutions and unclear responsibilities are also problematic –35.Effective and sustainable child protection, however, requires a functioning network between all professions and institutions involved. Easy communication and long-term cooperation often enable low-threshold solutions to problems. In principle, the exchange of information and networking in child protection should not only take place in a case-related manner during a crisis but should be established beforehand. In this context, it is important to understand the theoretical foundations and models of thought, as well as the possibilities for action and limits of all professionals involved in child protection, and to develop joint case definitions, risk assessments and standards and guidelines for action , 37.In addition, quantitative and qualitative interviews with health professionals have shown that the media should give more attention to the topic of child protection. However, the aim is not to scandalize the topic and spread anxiety but to reduce the fear of contact with cases of maltreatment and to sensitize society to the topic. In addition, the stigmatization of the topic should be reduced. In Germany, there are a number of campaigns, such as "Those who break the silence break the power of the perpetrators", a campaign that used video spots on all major German TV stations in 2010 to encourage sexually abused persons to break their silence , 39. AnoThe present study is limited in terms of its transferability of findings to the full health sector, as it analyzed a nonrepresentative sample of health professionals who have a special interest in the field of child protection. Furthermore, it is important to note that questions may be answered differently in the context of a training evaluation than in a stand-alone survey on training in medical child protection. However, because the goal of the work was to identify individual perspectives and opportunities for improvement in child protection the validity of the data is given. As the sensitized target group was particularly important to the research design by having experience with and insights into the handling of child protection cases in medicine of which they were able to report. Indeed, the participants in this study can be considered experts in the field of child protection in medicine, as they are familiar with both the everyday medical practice and the topic of child protection. To establish comparability of the results with other countries, it would be necessary to use the same questions that were used in this study. It can be assumed that, at least in part, structural and cultural factors in Germany contributed to the results. The quotes from the interviewees presented to illustrate the research results were gathered in German, translation bias in the content of the statements was addressed through professional language editing. Regardless of these limitations, this participatory research leads to a better understanding of the needs of health professionals in the field of child protection.The results of this work indicate that increased training, networking and awareness are needed among society and professionals about child maltreatment and its health consequences.A major problem here is a lack of time resources among professionals, as well as fear of contact with and stigma surrounding child maltreatment. A shortage of health professionals and funding attributes to the lack of time resources. Fear of contact with cases of maltreatment and stigmatization of those affected by it can lead to further  health impairments among them , 47. RüsThe results of this work on improving training, networking, and awareness in the media on the topic of child maltreatment reflect these strategies. This demonstrates, once again, the importance of these strategies and the need for action in administration, policy and society.Dr. Anna Maier is a research associate in the working group "Knowledge Transfer, Dissemination, E-Learning" and supervises several projects in the field of e-learning and child protection. She conducts research on the transfer and dissemination of knowledge between science and practice as well as prevention in the field of child protection.Prof. Jörg M. Fegert is the Medical Director of the Clinic for Child and Adolescent Psychiatry/Psychotherapy at Ulm University Hospital and Head of the Competence Centre Child Protection in Medicine Baden-Württemberg. In addition, he is a member of numerous scientific and political advisory committees and heads a wide range of research areas in the transition from research to practice in child protection. He has been researching the prevention of Child Sexual Abuse and clinical issues for 30 years.Dr. Ulrike Hoffmann heads the working group "Knowledge Transfer, Dissemination, E-Learning" in the Department of Child and Adolescent Psychiatry/Psychotherapy at Ulm University Hospital. She was involved as a research assistant in several projects on the topic of child protection at the University Hospital Ulm. Her research focus is on protection concepts in medical institutions.


Understanding how street spatial patterns are related to street vitality is conducive to enhancing effective urban and street design. Such analysis is facilitated by big data technology as it enables more accurate methods. This study cites data from street view imagery (SVI) and points of interest (POI) to assess street vitality strength after the classification of street spatial and vitality types to explore the relationship between street spatial patterns and street vitality with a further discussion on the layout features of street vitality and its strength in various street spatial patterns. First, street spatial patterns are quantified based on SVI, which are further classified using principal component analysis and cluster analysis; POI data are then introduced to identify street vitality patterns and layout, and the strength of street vitality is evaluated using spatial overlay analysis. Finally, relevance analysis is explored to cast light on the relationship between street vitality layout and street spatial patterns by overlaying street spatial pattern, street vitality types, and street vitality strength in the grid cells. This paper takes the urban area of Guiyang, China, as an example and the analysis shows that a pattern is discovered in Guiyang regarding the layout of street vitality types and vitality strengths across different street spatial patterns; compact street spaces should be prioritized in designing street space renovation; and cultural leisure vitality is most adaptive to street spatial patterns. Based on big data and using grids to understand the intrinsic relationship between street spatial patterns and the type and strength of street vitality, this paper brings more options to urban street studies in terms of perspective and methodology. Streets are the main spaces of public life in cities, carrying diversity and vitality . At the In this context, a large number of studies on the vitality and spatial patterns of urban streets have emerged, but the assessment of street vitality and the classification of street spatial patterns are largely based on manual survey methods, such as questionnaires, field statistics, and measurements ,13,14. IExisting studies of street vitality are currently dominated by vitality evaluation. Liu et al., used POI data as the basis for urban vitality identification, which was combined with the features of land use in surrounding areas to calculate the space–time layout of vitality and analyze the influencing factors of layout evolution . Zeng etStreet space morphology studies, on the one hand, evaluate the quality of street space by analyzing peoples’ perceptions of street space from the public viewpoint ,26. Wu eThere also exist many studies which act as support to the analysis of street vitality and spatial patterns, while we can find equally abundant evidence for the relationship between the two. Studies on how the environmental features of buildings improve street vitality can be dated back to the 1960s . Xu et aThis study emphasizes the interactive relationship between the spatial patterns of streets, vitality types, and vitality strength . It explores the differences in street spatial patterns, which are believed to be a perspective to the spatial layout features of street vitality types and strength, so as to contribute to enriching the methodology and angles towards urban street space renovation design and the shaping of street spatial vitality.Exploring the classification of urban street spatial patterns;Exploring methods for determining street vitality types and vitality strength;Analyzing the inter-relationship between the spatial pattern, vitality type, and vitality strength of streets.Street spatial patterns embody the feature of the area by integrating the function of the buildings and the morphological elements. As such, streets and buildings, the functions the buildings have, and the vitality of such functions are closely interconnected . StreetsThis paper proposes a classification method of street spaces and an evaluation method of street vitality based on multi-sourced data based on ArcGIS. Such methodology and quests into a perspective on urban street analysis that integrates street spatial pattern and vitality serve as compliments to the existing system of urban street analysis and are more suitable for the urban design of intensive city centers.The scope of this paper is the city center of Guiyang, Guizhou, China. To be more specific, it is north of Beijing Road, south of the southern section of the central ring road; west of Huaxi Avenue, and east of Guiyang Ring Highway. The urban streets in the abovementioned scope are considered research subjects, which are cut by intersections. The total number of streets concerned in this study is 1153.Guiyang is located in the mountain area of southwest China, and cities of its kind typically lack flat lands . As a reA total of 1153 central points, latitude, and longitude coordinates of all streets in the research scope were collected. The starting point, ending point, and central points of street sections were used as anchors to crawl SVI data in Tencent Map, which resulted in three street photos for each section. A total of 3459 Tencent Streetview pictures of central Guiyang were collected, as shown in From the perspective of humans’ perceptions of the enclosing state of street space, this paper draws on the street skeleton variable system proposed by Harvey Chester Wollaeger in 2014  to incluAs shown in the indicator table, this study requires six data sets, namely, street length, street width, higher building height, lower building height, building width, and the number of buildings. Street length is calculated using the Calculate Geometry tool in ArcGIS and street width is calculated based on high-resolution satellite images.As for building heights, widths, and numbers, four undergraduates with urban and rural planning and design backgrounds were recruited to make estimations based on the street view pictures and input into the software. They started with the collective measurement using a shared method to collect street building data from street view pictures and then worked individually to import data into ArcGIS street network attributes table. The imported data were converted into indicator data using the aggregated statistics tool in ArcGIS. In total, this took six days. Specifically, every undergraduate was required to complete 48–49 streets each day, and the import time of each street was controlled within 10 min; hence, each student was supposed to work less than 8 h a day.The calculation of the mean and standard deviation for each indicator data set was completed as shown in A total of 7398 buildings were counted in the research scope. Most of the streets were two lanes in both directions in terms of average width. The mean heights of buildings fell in the range of 10.32–19.7, and most of the buildings had one floor or a couple of floors. Street wall continuity, which in general was high at 59% in dense places and 42% in sparse places, reflects the proportion of the length of the street versus building width.This was based on the deviation calculation formula:In the formula, CV is the deviation value, SD is the standard deviation, and Mean is the mean. The CV values for each indicator were calculated (within a reasonable range of 5–35%) and it was found that the CV values for the street space indicators within the data collection area were all higher than the maximum skewness value of 35%, indicating that the street spaces in downtown Guiyang are significantly different with a wide range of street types.Principal Component Analysis (PCA)PCA is conducted in SPSS on street space data, yielding a matrix as shown in In the component matrix, we selected data with component indicators greater than 0.6. In the first principal component, the indicators that met the criteria were building height (lower and higher) and street wall continuity (1.2); in the second principal component, it was the number of buildings; in the third and fourth principal components, there were no values that met the selection criteria. Hence, the three categories of building height, street wall continuity, and the number of buildings were used as the basis for classifying the street space for analysis in the next step.2.Cluster AnalysisBuilding height, street wall continuity, and the number of buildings were used as the basis for cluster analysis of street spaces, which was conducted using Ward’s method (sum of squares of deviations). The indicators were grouped into four categories according to the results. As breakdown data show in Closed streets are characterized by high continuity of street walls and multi-floor or high buildings. The street space looks narrow from the human eye’s perspective;Compact streets are similar to closed streets in street wall continuity and building numbers, but most buildings in this type of street are ground-floor buildings or podiums of high-rise buildings. The buildings are lower than those in closed streets;Semi-open streets are occupied by fewer buildings and characterized by large gaps in the continuity of the street walls on both sides of the street, with large building spacing and independent distribution;Open streets are spacious, with squares, public buildings, or vacant lots appearing on both sides of the street. The wall continuity is low, and the obstruction of views is fewer.Urban street vitality is represented by the categories and frequency density of POI data. Based on the street type classification method of Better Street Plan in San Francisco  and the This paper draws upon the San Francisco street type classification method and quantitative identification method of urban functional area ; the resFirstly, the frequency density of every POI category was calculated according to the following formula:In the formula, Then, the frequency density of each POI category within each grid was compared to the total frequency density to determine the dominant POI category and thus the type of street vitality within that grid. The formula to calculate total frequency density of POI is as follows:In the formula, By overlaying the four vitality types, more vitality types appear in a grid, the higher the vitality strength of the grid that is considered, and the grid vitality strength is graded according to this method. Hence, streets can be classified into four levels: grids with four vitality types are high vitality grids, which correspond to high vitality streets; grids with three vitality types are relatively high vitality grids, which correspond to relatively high vitality streets; grids with two or one vitality type(s) are relatively low and low vitality grids, which correspond to relatively low and low vitality streets.This paper overlays the maps of vitality grids with street spatial pattern layouts to calculate the proportion of different patterns in each grid. The pattern with the highest proportion becomes the pattern of the grid. As a result, the layout of street vitality types is generated by counting the number of grids with a certain type of street vitality under a certain spatial pattern. Then, the vitality strength level grids are overlaid with the grids of street spatial patterns to show the numbers of grids with a certain type of vitality under a certain spatial pattern, so as to generate the vitality strength layout of various spatial patterns.The four street types are connected in the ArcGIS street network map according to the classification of indicator data to form a visual analysis model to obtain a spatial distribution of street types in downtown Guiyang see .The street spatial patterns in downtown Guiyang are concluded as follows: compact (540) > closed (483) > open (95) > semi-open (29); in terms of distribution, the closed street spaces are located in the city center, while the closed streets are surrounded by compact streets. The two types of streets are in typical commercial, office, and living areas and most of them have two narrow lanes for two-way traffic. The semi-open and open street spaces are located close to hills, squares, large public buildings, and express roads. Such a distribution structure is closely related to the type of urban street vitality and the degree of street vitality.As shown in The street vitalities can also be classified according to their levels. The percentage of the grids considered to have high vitality levels is 25.29%; it is 44.83% with relatively high vitality, 28.74% with relatively low vitality, and 1.15% with low vitality levels. An investigation of space distribution of vitality levels shows that most of the study area is covered by grids with high and relatively high vitality levels that stretch out in patches.As shown in In general, compact street spaces enjoy the highest level of vitality. Among compact streets, 33.33% are high vitality streets and 43.33% are relatively high vitality streets. Closed street patterns are the second highest, with high vitality accounting for 25.00% and relatively high vitality accounting for 45.45%; in open street spatial patterns, the vitality level is the lowest, with 75.00% of the streets considered to be relatively low vitality streets see .This paper proves that the space data in SVI are feasible for the quantified classification of urban street spaces, avoiding uncertainty in spatial pattern classification. Meanwhile, the POI data help to accurately identify street vitality types and layout features. The two quantitative methods for street analysis provide a sound foundation for the quest into the relationship between urban street space and vitality. Moreover, a new method and perspective are introduced for urban street research when grids are used to breakdown the spatial layout of street spaces and vitality types.Driven by quick urbanization, the street vitality types in the central area streets of Guiyang continue to overlap and the street space form is undergoing rapid transformation. Hence, Guiyang is in urgent need of clarifying the relationship between street space form, street vitality type, and street vitality strength, so as to provide guidance for shaping street space scientifically and efficiently.In terms of vitality types, an obvious difference is found in Guiyang regarding the layout of different vitality types in different spatial patterns. The commercial vitality has the widest layout in closed street spaces; residence, cultural leisure, and management and medicine are mostly found in compact spaces; and in semi-open street spaces, all vitality types show the lowest distribution.In terms of vitality strength, closed and compact street spaces are stronger than semi-open and open. Compact street spaces registered as the highest strength level, whereas the semi-open spaces registered as the lowest.Among the four street spatial patterns in central Guiyang, compact street spaces show the highest level of vitality and most diverse vitality types, also making them the best street patterns for dense and rich vitality. As a result, it is recommended that more emphasis should be given to compact street spaces in urban and street design in Guiyang. To be specific, on one hand, this would strengthen the refined design of existing compact street spaces to give full play to the street vitality carried in such street spaces and, on the other, it would intentionally cultivate new compact street spaces in the city to promote urban vitality.In central Guiyang, it can be found that cultural leisure vitality is the most widely distributed vitality type in its street spaces, especially in compact and closed patterns where cultural leisure outnumbers others extensively. This shows that cultural leisure vitality in central Guiyang streets can adapt to different spatial patterns and co-exist with them, which is highly conducive to both the mental and physical health of the Guiyang people .


Background: Drug-related problems (DRPs) are a global issue that impacts the efficacy and safety of the therapy, and pediatric patients are considered to be more vulnerable to DRPs, thus requiring more attention. Community pharmacists (CPs) are in a position that allow them to identify and alleviate these DRPs. Objectives: This study evaluated the ability of CPs in identifying and resolving DRPs in a pediatric prescription. Methods: A cross-sectional study was carried out in 235 community pharmacies to evaluate the ability of CPs working in the Khartoum locality to identify DRPs in a pediatric prescription and how they intervene to resolve these problems. Fifth-final year B. Pharm. Students were selected and trained to act as simulated patients (SPs) for this study. The visits were performed by using a simulated prescription that contains three different types of DRPs. The information obtained from the visits was documented immediately by the SPs after leaving the pharmacy in a data collection form. Results: All planned SPs visits were completed. Of the 235 community pharmacies, only 50 (21.3%) CPs were able to identify at least one of the DRPs. The most common type of DRP identified was the wrong duration of the treatment 19%, followed by the wrong dose 4%. The interventions made by CPs to mitigate the identified DRPs included recalculation and correction of the dose according to weight, which was made by 10 CPs, and correction of the duration, which was done by 45 CPs. None of the CPs who identified the presented DRPs communicated with the physician or referred the SP to the prescriber. The average dispensing time of the CPs was 68.18 ± 36.1 s. Conclusions: The majority of the CPs in the Khartoum locality were unable to identify DRPs in a pediatric prescription. Correction of the dose and duration of treatment were from the attempts of CPs to resolve DRPs. However, no collaboration was observed between CPs and physicians. In general, the practice of CPs in Khartoum locality in this area requires substantial improvement. Community pharmacists (CPs) are an indispensable asset to healthcare. Their patient care role in the healthcare delivery system cannot be denied . They arAround the world, their role has been extended to encompass chronic disease management, weight management, immunization services, and providing advice to other healthcare members . DespiteDrug-related problems (DRPs) are, according to The Pharmaceutical Care Network Europe (PCNE), “an event or circumstance involving medication treatment that actually or potentially interferes with the patients’ desired health outcomes”. Several domains have been described by PCNE to cause DRP; some of these are drug selection, dosage form, dose selection, treatment duration, and others . DRPs caIt is known that childhood is a period of rapid growth associated with various changes in the development of the internal organs and in the activity of the hormones and enzymes that handle drugs . As the Children are considered vulnerable to DRPs, and any error that might be tolerated in adults can result in considerable consequences on the child’s health . One stuIn Sudan, there is only one study that addressed DRPs. The study was in the adult patient population at a tertiary hospital, and it revealed that the most common DRPs detected were incomplete drug therapy, inappropriate drug use, and high drug dose . TherefoA cross-sectional design was used in this study agreeing with the STROBE statement that must be included in reports of cross-sectional studies  to evaluOne scenario was developed by the researchers in consultation with two members of the university of Khartoum: a pharmacy practice educationalist and a pediatric specialist. The paper prescriptions used in this simulation were obtained from a well-known hospital in the Khartoum locality. The condition and the medications in the scenario were selected depending on the most common conditions and medications that the CPs encounter in their daily practice. The most common conditions and medications were identified from data collected previously through questionnaires for another study.There is no global standard for a prescription format and they vary from country to another, but there are legal requirements for a valid prescription, and there is a global agreement that the age, gender, weight, and diagnosis of the patient should be stated in the prescription, especially for children . Thus, an = N/1 + N(e)2, where (e) an error margin of 0.05, the formula is based on a degree of variability of p = 0.5, and a 95% confidence interval. The number of registered community pharmacies in the Khartoum locality represents the study population (N), which is equal to 568. Using the equation, the necessary sample size required for this study (n) was 235. By applying a simple random sampling technique, 235 community pharmacies were selected.The Sudanese General Directorate of Pharmacy list, which includes all registered community pharmacies in the Khartoum locality, was used to select the community pharmacies enrolled in this study. The sample size was calculated, according to the equation: A data collection form was developed by the researchers to document the required information for the study. It was validated by three academic members from the University of Khartoum who had excellent experience in pharmacy practice. Then, the collection form was piloted in twenty-five community pharmacies. The form consists of three sections; the first one assesses the identification of DRPs which includes closed-end questions (yes/no). In this study, the simulated patients (SPs) were final-year students from the Faculty of Pharmacy University of Khartoum. Two males and three females were available for participation in this study as SPs. Before the data collection, the principles of the methodology were well explained to the SPs. They were also trained to act as patients and introduced to a real-life scenario. After the simulated patients were familiarized with the scenario and the contents of the assessment form, several rehearsals were conducted to ensure that they could identify the pharmacist practice in the particular situations. After that, a pilot study was carried out to ensure the readiness of the SPs in performing the method, and to confirm the functionality of the data collection form. A total of 25 community pharmacies were visited (five visits for each SP), and all the visited pharmacies were not part of the study sample. Prior to the visits, the community pharmacies were randomly distributed across the five SPs. The test visits were conducted between September 2021 and December 2021. At the time of the study, the disease control measures that used to control COVID-19 pandemic were difficult to implement in Sudan due to economic, social, and political challenges, and people in the Khartoum locality were living their normal daily lives. The pharmacies were approached only after ensuring that they were empty. Each pharmacy was visited by a SP and an observer (one of the researchers), whose main role was to measure the time spent by CP engaging with the SP using a stopwatch. Each SP made 47 visits to complete 235 pharmacy visits. In each visit, to ensure that the prescription was assessed by a pharmacist, the SP requested the pharmacist first before providing the prescription. The data collection form was completed immediately after leaving the pharmacy by the SP to minimize the recall bias and the time of dispensing recorded by the observer.p-value of less than 0.05 being considered statistically significant.For the analysis of data, Statistical Package for Social Sciences software, version 23.0  was used. Initially, all information was collected via a data master sheet and then coded into variables. Descriptive statistics involving frequency tables were used to present the results. The relationship between variables was tested using an appropriate statistical method (the Chi-square test) with a A total of 235 pharmacy visits were accomplished by the SPs with a prescription containing three different types of DRPs, resulting in a completion rate of 100%. By using the prescription, the SPs tested the competence of the community pharmacists in identifying the DRPs and observed their resolution accordingly. Of the 235 community pharmacists, 72 (30.6%) were males and 163 (69.4%) were females. These CPs held a Bachelor degree as a minimum qualification to practice their job. Socio-demographic characteristics of the CP in Of the 235 community pharmacists, 50 (21.3%) were able to identify at least one of the DRPs presented in the prescription, while 185 (78.7%) failed to identify any of them. The most common type of DRP identified was the wrong duration of the treatment, followed by the wrong dose. There is no significant association between DRPs identification by CPs and their gender, years of experience, and daily working hours in the pharmacy. The identification of DRPs is listed in In resolving the DRPs presented to the community pharmacists, referring the patient to the prescriber was not done by any community pharmacist. However, appropriate actions were also sometimes taken; six (100%) refused to dispense the unnecessary medication with the wrong indication, and ten (100%) recalculated the dose according to weight and corrected the wrong dose. Results are shown in Preventing harm from medicines is one of the components that is required to achieve the mission of pharmacy practice in improving the health of patients, this harm may arise from DRPs causing ineffective therapy and may lead to drug-related morbidity and mortality ,21. CommMany studies focused on assessing hospital and clinical pharmacists’ ability in detecting and correcting DRPs in pediatric wards ,25,26,27In the current study, the findings revealed that 78.7% of the community pharmacists under study were unable to identify any DRPs presented in the simulated prescriptions and they did dispense inappropriate medications. In our study, 96% of the CPs failed to identify the wrong dose, and 97% and 81% of them did not identify wrong indication and wrong duration, respectively.The failure rate of identification is high comparing it with the simulated patient study from the United Arab Emirates conducted in 2020 that assessed the ability of community pharmacists to identify DRPs in prescriptions, where 56% of CPs also failed to identify DRPs. This study used prescriptions containing different five DRPs; among them were wrong drug dose, wrong duration of treatment, and wrong indication. A wrong dose was not identified by 50% of the CPs similarly for wrong duration of treatment, while 20% of the CPs failed to identify the wrong indication . In anotWrong medication dose as a high dose may lead to harmful effects, and if the dose is inadequate, the therapeutic target will not be achieved. Regarding pediatric dose, it is known that the majority of drug dosage depend on the child’s weight. A study conducted in France in 2018 found that several DRPs in the pediatric population were due to the absence of the weight of the child on the prescription . MoreoveIn this study, the weight of the child was written in the prescription, despite that only 10 (4%) CPs identified the wrong dose and recalculated the dose based on the weight and age of the child. This result was low compared to the study conducted in Jordan which assessed the knowledge of community pharmacists about appropriate dosing of antibiotics among pediatrics, where about 29% of CPs determined the correct dose of Co-amoxiclav in otitis media . FurtherThe wrong or inadequate duration of antibiotics is considered inappropriate antibiotic use. Inappropriate antibiotic use is the direct cause of antibiotic resistance, a nationwide issue that enhances the strength of infectious diseases resulting in increasing the hospitalization period, treatment costs, and mortality rate . In thisAntibiotic resistance is the utmost danger that threatens public health, especially children. According to World Health Organization (WHO) data, there are 700,000 deaths across all ages due to infections caused by multidrug-resistant bacteria. One of the causes of antibiotic resistance is the use of antibiotics for wrong diagnoses and indications . In thisOnly 3% of the CPs identified the inappropriate indication of metronidazole and all refused to dispense the medication. However, 97% of the CPs did dispense the drug, putting the pediatric patient at risk of developing the side effects of the drug which include gastrointestinal disturbances, oral mucositis, anorexia, thrombocytopenia, rash, and jaundice .Upon discovery of an inappropriate prescription that may contain an improper dose, unnecessary treatment, or interaction, the pharmacist should contact the prescriber to resolve the drug-related problem . AccordiEffective counseling required time. According to the WHO, pharmacists need to spend at least three minutes with every patient to provide the necessary orientation . In thisThis study has some limitations. The study is a cross-sectional study, and only community pharmacies in the Khartoum locality were visited. Thus, the findings might not be able to be generalized to the entire country’s practice. In addition, as audio recording which helps in minimizing the recall bias was not used in this study, there is a possibility that some information might not be documented while completing the checklist. In addition to that, the current study did not assess the practice of community pharmacists regarding other types of DRPs like drug interactions and adverse drug reactions. Certain factors that might affect the pharmacist’s performance, such as their participation in post-graduations and training courses and previous experience in hospital and clinical settings, were not covered in this study. Further, the findings have reflected a specific scenario because only one simulated prescription with specific medications were used. Hence, it may be difficult to extrapolate the results of this study to the entire pharmacy practice of community pharmacists in Sudan.The findings of this study recommend the need for improving community pharmacy practice standards. Continuing education is necessary for community pharmacists to enrich their knowledge and improve their skills. Thus mandatory educational programs should be endorsed by stakeholders. Such training should include a look at the most common pediatric prescriptions, focusing on confirming the accuracy of weight-based dosing, as well as ways for detecting and preventing DRPs in pediatric prescriptions. The findings also suggest further in-depth research should attempt to quantify the ability of community pharmacists in identifying and managing DRPs in pediatric prescriptions and other areas of their practice.Although the pharmacist is the last safety guard of the health care system, this study has shown that the majority of the community pharmacists in Khartoum locality were unable to identify DRPs in a pediatric prescription. Correction of the dose and duration of treatment were from the attempts of CPs to resolve DRPs. However, no collaboration was observed between CPs and physicians to resolve the identified DRPs, as none of the pharmacists tried to contact the prescriber or referred the patient. The findings also revealed that CPs spent minimal time when counseling the patients. In general, the ability of community pharmacists to identify DRPs in a pediatric prescription in Khartoum locality was below expectation.


The approach to the education and professional advancement of physiotherapists is particularly relevant today. To date, no studies have compared the perceptions of physiotherapists regarding professional issues in geographically close European countries such as Poland and Germany. Therefore, this study’s purpose was to compare Polish and German physiotherapists’ perceptions related to their profession, entry-level education, and career opportunities.We recruited 565 physiotherapists from Poland and 560 physiotherapists from Germany. An opinion polling method based on a questionnaire was applied in the study. The survey was conducted in 48 facilities located throughout the territories of the two countries. The assessment focused on the following three issues: 1) professional education ; 2) professional development and career opportunities; and 3) the relationship between years of service and perceptions of professional education, career satisfaction and advancement opportunities.p = 0.001). A highly significant negative correlation was identified in both groups between all the assessed aspects of professional education and years of service .German respondents rated specific aspects of their education, development opportunities and professional careers more highly than their Polish counterparts (Opinions on their professions expressed by physiotherapists from closely neighboring countries, namely, Poland and Germany, were surprisingly disparate. Compared to their Polish colleagues, German physiotherapists viewed their experiences more favorably vis-a-vis entry-level education, career opportunities, and professional status. Further study is needed to establish whether these findings reflect actual differences, sampling bias, or other factors. Physiotherapy is recognized as a health care profession in all European Union (EU) countries . ConsequStudies evaluating physiotherapy courses and teaching curricula aim to identify the most effective educational methods and existing deficiencies . For exaPoland and Germany, two neighboring countries located in central Europe, in the course of history have not always had a good relationship, but over the years, the countries have become closer to each other in many respects. This is reflected by the partnership within the EU and by a variety of joint projects carried out in scientific, social, economic and other domains . The phyHowever, knowledge of the differences and similarities between the education systems and professional development of physiotherapists in Poland and Germany is insufficient. No studies have yet been conducted in this area. The related research findings may provide important information and enable professional organizations to standardize the educational systems and organization of physiotherapy practice in neighboring EU countries.Q1) Based on the opinions of Polish and German physiotherapists, how do the systems of entry-level physiotherapy education in the two countries compare?Q2) According to participants’ perceptions, are there differences between the two countries in the professional status of physiotherapy as well as related career opportunities and working conditions?Q3) Do years of service impact Polish and German physiotherapists’ perceptions of their formal education, job satisfaction and career opportunities?This study aimed to assess similarities and differences in the systems of education and professional development of physiotherapists in Poland and Germany based on their perceptions. The following three research questions were formulated:The group enrolled for the principal part of the study included 565 physiotherapists from Poland and 560 physiotherapists from Germany. The Polish group comprised 192 (33.98%) women and 373 (66.02%) men, and the German group consisted of 79 (14.11%) women and 481 (85.89%) men. Polish and German participants of the study on average were aged 36.48 (SD 11.22) years and 42.83 (SD 17.98), respectively. The participants’ characteristics are presented in Table The study was designed to enable conclusions related to the entire statistical population based on the information collected from a representative sample. A minimum size of a sample representative for the community of physiotherapists was calculated for this purpose. The sample size was defined at a confidence level of a = 0.95, with a fraction size of 0.7 and a maximum error of 0.04. The minimum sample size for Polish physiotherapists was defined as 500 participants and for German physiotherapists as 502 participants. The study involved 565 participants from Poland and 560 individuals from Germany.The cross-sectional nonrandomized cohort study was carried out in two stages in 2017–2018. A pilot study was conducted at the first stage and was followed by the principal part of the study. The project received approval from the University of Rzeszów’s Bioethical Commission. Experimental conditions conformed to the policies and mandates of the Declaration of Helsinki.In view of the fact that the study was designed to apply a questionnaire developed by the authors, the accuracy of the tool was verified in a pilot study. The set of questions was prepared in the German language in cooperation with German physiotherapy specialists and an orthopedic surgeon. Consultations with these experts made it possible to refine the content of the questionnaire. The translation and cultural adaptation process consisted of a few stages . The firSociodemographic profile comprising 11 questions .Evaluation of physiotherapy education comprising 23 questions .Evaluation of professional development and career opportunities comprising 16 questions .The study applied an opinion polling method and was based on a survey that was carried out using a specifically designed questionnaire. The research tool consisted of 50 questions divided into the following three thematic groups:At the time the study was initiated and carried out, random selection of the Polish participants was impossible because the databases of the Polish Chamber of Physiotherapists were still under construction. Additionally, in Germany, there is no organization associating physiotherapists in the country; hence, it was also impossible to randomly select a group of participants. Therefore, to recruit participants for the study, online databases were reviewed to identify entities employing physiotherapists, and 52 facilities were selected each in Poland and Germany. Subsequently, letters were sent to these entities via Poczta Polska and Deutsche Post asking whether they agreed to participate in an anonymous survey. No responses were sent back by 42 entities, and 14 facilities refused to participate in the survey, whereas 48 entities agreed to take part. A request for consent to participate in the study was sent to the facilities that agreed. This recruitment procedure covered the whole territory of the two countries. The survey forms were sent via Poczta Polska and Deutsche Post.Because of the insufficient number of participants recruited, a request was sent via e-mail to the Polish and German administrators of social networking sites for professional groups including physiotherapists. The purpose was to recruit an appropriate number of participants, in line with the calculated statistically adequate sample size. Health care entities  providing physiotherapy-related services were selected in both countries. In addition to physiotherapists working for public entities, the study participants included self-employed private practitioners. In addition to these traditional methods of recruitment, the survey was also conducted among physiotherapists active on online social networking sites. For this purpose, approval was obtained from google.pl and google.de administrators.p < 0.05.Data analysis was performed using the program SPSS Statistics. Distributions of the investigated variables were examined for normality using the Shapiro–Wilk W-test. Regarding the physiotherapists’ perceptions of their formal education, professional development and career opportunities, comparative analysis took into account median values of the ratings in the specific questions by the two groups of respondents; the significance of the differences in the ratings between Polish and German respondents was assessed using the Mann–Whitney U test. The relationship between the respondents’ years of service and their perceptions of their formal education, career opportunities, and job satisfaction was assessed using Spearman’s rank correlation coefficient. At the last stage, regression analysis was carried out taking into account the variables describing the participants’ perceptions of the educational process and professional career in relation to years of service and, additionally, age of the respondents. For the needs of this analysis, it was assumed that the rating scale used in the research tool was a linear scale. Statistical significance was assumed for values of p = 0.001). Notably, the responses provided by German participants did not include low ratings , whereas some aspects of the Polish education system received the lowest possible rating from many participants. This tendency is most visible in the perceptions related to student facilities, which German respondents rated as “good” (13.9%) or “very good” (86.1%); these highest ratings were used by only 20.4% of the Polish respondents, and 6% of Poles reported that student facilities were “poor” or “very poor”. This distribution of responses may result from cultural differences between the two nations  the teaching/learning component, i.e., the form and content of curricula, 2) organizational issues, and 3) effectiveness of education. German respondents commonly expressed more favorable perceptions of specific aspects of their education than their Polish counterparts. Only three aspects of physiotherapy education received higher ratings from Polish respondents: opportunities to study abroad, practical education for the profession and the system of internships. In these items, the analysis showed higher median values of the ratings awarded by Polish participants than those of German respondents. On the other items, the German education system received higher ratings. Ultimately, according to participants’ perceptions, the two entry-level physiotherapy education systems differed in all the evaluated characteristics, with most aspects of the Polish system receiving lower ratings. The significance of the differences between the ratings awarded by Polish and German respondents was confirmed by the result of the Mann–Whitney test (p = 0.001). The largest difference can be observed in responses to the question about career advancement; the median value of the ratings by Polish respondents was 6, less than the median of 9 in the case of German respondents . For their evaluation of their formal education, German respondents used high ratings (7–9) far more often than Polish respondents, and they did not use ratings below 5 at all. Conversely, many Polish respondents selected very low or low ratings, e.g., in question 48, ratings between 1 and 4 accounted for 33.8% of the responses in the Polish group, while no German respondent selected a rating lower than 5 , which they rated on a 10-point scale. German respondents provided a higher rating in each of the five aspects, reflecting more favorable perceptions of their job than Polish respondents. As in the case of the first research question, median values of the ratings in the specific items were compared, and significance of the differences between the perceptions of Polish and German respondents was examined using the Mann–Whitney U test (at a significance level of p = 0.001). This shows that therapists with more work experience tend to present less favorable perceptions of their formal education than their more inexperienced counterparts. This is true for both Polish and German respondents . Negative coefficients of correlation between years of service and perceptions of all the aspects of work show that therapists with more work experience tend to be more critical about their job , work experience in the range of 16–20 years increased the rating on average by 0.36 points.The effect of the selected factors on self-reported job satisfaction was assessed using linear regression analysis, which showed that the independent predictors of satisfaction with the occupation of physiotherapist included the following:Age: each subsequent year of life decreases this rating on average by 0.001 points,Years of service: compared to physiotherapists starting their professional career, those with work experience in the range of 16–20 years increased the rating on average by 1.10 points.With regard to the assessment of the effect of the selected factors on self-reported career advancement, the linear regression analysis showed that the independent predictors of subjective perceptions of one’s professional career included the following:A review of the related literature suggests that no studies thus far have investigated differences in the formal education and professional development of physiotherapists in Poland and Germany. Such research would make it possible to identify positive aspects of the education system in one country and introduce them into the education system in the other country; as a result, it would also be possible to continue to align practice in both countries to the evolving scope of physiotherapy practice and epidemiological needs in an ever-evolving dynamic manner.The first research problem was related to the assessment of the coherence of the findings about Polish and German physiotherapy education systems based on participants’ perceptions. The acquired findings suggest that the physiotherapy education systems differ in terms of all the evaluated characteristics, and the Polish system received poorer ratings in most aspects. It should be pointed out, however, that the education systems were assessed using a subjective method by individuals living in different socioeconomic environments. Even though these are neighboring countries, Germany and Poland represent different historical and cultural backgrounds, since traditionally they are linked to Western and Eastern Europe, respectively. Generally, the standard of living is much higher in Germany than in Poland, which reflects the different economic statuses of these two countries, with the gross domestic product per capita in 2020 being approximately three times higher in Germany than that in Poland . TherefoThe current study also aimed to compare the professional status of physiotherapists in Poland and Germany. Our findings support that German physiotherapists perceive their professional situation as superior to that of their Polish colleagues. Additionally, in this case, no reports were found to be used as a reference in the discussion of the results and in support of the hypothesis. It seems, however, that the findings of a study assessing occupational satisfaction of physiotherapists in West Pomerania, Poland, are interesting in this context. The term was defined as “satisfaction resulting from performance of specific tasks”. The findings showed that the financial factor of occupational satisfaction is directly proportional to the remuneration received at the time when job satisfaction is inhibited . This maThe third detailed research problem was related to the professional development of physiotherapists in Poland and Germany and their career opportunities. The survey showed that perceptions of physiotherapy education, as well as perceptions related to working conditions and job satisfaction, are closely linked to the respondents’ years of service. The negative correlation coefficients between years of service and perceptions of all aspects of the occupation provide evidence that therapists with more work experience are more critical about their profession. This may be because as they gain experience, their expectations toward the employer and toward themselves increase. This phenomenon may be associated with a tendency to reflect on one’s life, occurring irrespective of the country of residence. This may also be linked to older physiotherapists’ awareness of the progressive changes taking place in various areas related to their profession, e.g., the inevitable differences in entry-level education between the past and today. This in fact is absolutely understandable and is to be expected. The evolution of curricula, teaching methodology, and the use of evidence-based theories for curricular content corresponds to changes in the scope of physiotherapy practice. These changes are needed and desirable, given that physiotherapy is the leading ‘nonpharmacological and nonsurgical’ health profession with a capacity to provide effective noninvasive treatments to prevent, manage or even reverse the effects of lifestyle-related noncommunicable diseases (NCDs), which in today’s world are the most urgent health problem.We must also point out that the youngest participants were only 1 year out from graduation, whereas the oldest participants graduated 20 years before the study. This fact definitely explains some differences in perceptions related to entry-level education. The opinions presented by older graduates may be affected by the passing of time and their ability to accurately recall the specific aspects of their professional education. Furthermore, more work experience leads to greater awareness of the actual needs related to one’s profession, which might bring to light the shortcomings of the education acquired at school. Likewise, advances taking place in the course of one’s career may also “infiltrate” one’s opinions about the past. What is most important, however, is the fact that the educational systems and the teaching curricula two decades ago and now are not the same, quite understandably. In 20 years, physiotherapy education has seen dynamic changes in both countries, associated with the development of educational structures and facilities and, more importantly, with increasing supervision of the quality of education and changes in educational curricula, in line with the accreditation standards of World Physiotherapy, of which both countries are members. In fact, we hope that educational curricula in the two countries have changed significantly in the last 10 or even 5 years, taking into account newly acquired evidence and epidemiological needs. Overall, the significant difference in years of service suggests that specific participants have had quite different experiences and opportunities. Some of these factors may also explain differences observed in the perceptions of physiotherapists with more experience.Our findings support the need to unify the systems of physiotherapy education across countries in the European Union to maintain high standards of care. In addition, comparable education for physiotherapists across the EU would facilitate their movement to practice in other European countries.Sample representativeness should be improved by applying random selection . Notably, in the current study, potential participants decided whether to respond to the invitation to take part in the survey; therefore, their responses may reflect their variable motivations; due to this, the generalizability of the findings is limited.Objective indicators of the assessed variables should be used, e.g., use of other information in addition to the questionnaire.There should be qualitative analysis of the differences in the functioning of therapists .Other countries should be included in the study.This study presents certain limitations; however, it should be remembered that this is the first research report related to this specific subject matter. We suggest the following ways to expand and enhance further research:Our questionnaire-based study, investigating career-related perceptions of Polish and German physiotherapists, showed certain similarities and differences in their perceptions concerning formal education, professional development and career opportunities. Further research is needed to directly compare formal physiotherapy education systems, as well as professional development requirements, mechanisms, and opportunities in Poland and Germany. Comparative analyses of physiotherapists’ perceptions, educational systems, teaching curricula and professional development opportunities in the two countries will provide information to entry-level physiotherapy educators as well as professional organizations to recommend changes in professional education in both countries.


The diagnostic process for fetal alcohol spectrum disorder (FASD) involves a multi-disciplinary team and includes neurodevelopmental, physical, and facial assessments and evidence of prenatal alcohol exposure during the index pregnancy. With the increased use of virtual care in health care due to the pandemic, and desire of clinics to be more efficient when providing timely services, there was a need to develop a virtual diagnostic model for FASD. This study develops a virtual model for the entire FASD assessment and diagnostic process, including individual neurodevelopmental assessments. It proposes a virtual model for assessment and diagnosis of FASD in children and evaluates the functionality of this model with other national and international FASD diagnostic teams and caregivers of children being assessed for FASD. Over the last decade, there has been a dramatic shift towards physicians providing care virtually, further increased by the COVID-19 pandemic. Virtual care is defined as “any interaction between patients and/or members of their circle of care, occurring remotely, using any forms of communication or information technologies with the aim of facilitating or maximizing the quality and effectiveness of patient care” .Virtual care can reduce wait times for those living in rural and remote regions ,4,5. BadFetal alcohol spectrum disorder (FASD), resulting from prenatal alcohol exposure (PAE), is a condition resulting in variable expression of physical and lifelong neurodevelopmental changes and outcomes for the individual . CurrentThe diagnostic process for FASD is complex and the Canadian Guideline for FASD Diagnosis recommends a multidisciplinary team for assessment . The corThe aim of this pilot study was to improve access to pediatric FASD diagnosis and assessment through the development of a virtual model. Secondary aims included exploration of use of the model with national and international clinicians, specializing in FASD assessment and diagnosis, and survey evaluation of caregiver experiences using the model.A virtual model of FASD assessment for children based on validated assessment tools was developed building upon a previous literature review of FASD assessments . After dThe virtual model was also piloted in practice in four pediatric FASD assessment clinics in Alberta, Canada from June 2020 to June 2021. Clinic coordinators in each clinic consented caregivers to fill out a survey evaluation after a virtual FASD assessment for their child. In this study, caregivers were defined as the individual who assumes the role of providing day-to-day care for a child, including parent(s), foster parent(s), kinship care providers, or other authorized individual(s). The pilot focused on using the virtual model with children aged 7–16 years of age with no severe behavioral issues, and the caregivers’ ability to complete questionnaires and provide consent. School-aged children were chosen because they are often the ones identified as requiring cognitive testing, are readily adaptable to learning and using technology, and are less likely to have face-to-face behavior management issues.The evaluation focused on the virtual aspect of the assessment process and included questions assessing the caregiver’s understanding of the process, the quality of the method, the caregiver and child’s comfort level, their satisfaction, and the acceptability of using a virtual model. The survey was conducted in two rounds, one with a small group of caregivers from June 2020 in one clinic expanding to a larger evaluation in three clinics from April to July 2021. Changes were made to the survey between iterations, but questions that remained the same were grouped together in analysis. Respondents were asked to rate their agreement to statements using a 5-point Likert scale and were provided open text comments to expand on answers that were unsure or on the lower end of the scale.Ethics approval (25 June 2020) was obtained from the University of Alberta Research Ethics Board (Pro00101938 and Pro00101860).Currently, most of the process for diagnosis and assessment of FASD is completed in person and follows the steps outlined in referral and intake, where a referral, usually originating from frontline workers  or family is accepted, as per each clinic’s screening criteria . A clinic coordinator is responsible for the referral, intake, information collection, PAE confirmation, and medical summary report compilation and distribution. Consent forms for the access and release of information are signed by the legal guardians, allowing clinics to obtain health records (including birth records), education reports, child and family services history and information, justice and other relevant reports and documentation, including results of any previous assessments. During this time, reliable and accurate details of PAE are collected in a respectful and non-judgmental manner, in accordance with the Canadian diagnostic guideline recommendations [The first step is ndations . Assistamultidisciplinary assessments are scheduled by the clinic coordinator to be completed by core team clinicians, including a physician, registered psychologist, speech language pathologist and occupational therapist. Parent and teacher questionnaires and rating scales are completed, with the clinic coordinator assisting with this process. Any previous speech–language, occupational therapy, educational, psychiatric, neurodevelopmental, and other pertinent assessments are obtained and reviewed with respective clinicians to ensure history and validity of previous testing protocols .Once the referral process is complete, interview with the caregiver to support and augment information and any history obtained. This is a standard practice in FASD clinics and informs the physician of the caregiver’s concerns, understanding, and expectations of the assessment process. The physician explores the presence and frequency of PAE associated behaviors and clarifies any medical information previously collected. The child is also interviewed, and when appropriate, an adolescent HEADSS history is completed, ensuring confidentiality is maintained [The physician (or nurse practitioner) conducts an intained . An oldeintained .multidisciplinary case conference for diagnostic formulation, and recommendations is scheduled. At this time, the team members review the case history, and other information collected through interviews, reports, and assessments. Each clinician reports their findings on test measures performed. The members discuss and deliberate on the significance of the test results, the degree of impairment of the different domains of brain function and determine whether the criteria for FASD diagnosis and other diagnoses are met. Based on findings, a set of recommendations that will guide post-clinic interventions and services are developed to ensure support for the child and the caregiver.Once assessments are complete, a caregiver/patient debrief. The physician (or nurse practitioner) and other core clinicians communicate the diagnosis to caregivers. The patient may be involved in the debrief process where appropriate and after discussion with the caregiver. A strength-based approach is followed when reviewing assessment results and recommendations with caregivers and the child . On the clinic day, a brief medical report including the diagnosis and recommendations is prepared and given to the family after the debrief, with a final detailed comprehensive report provided a short time later.The final step of this process is the There are few studies that focus on virtual models to complete the full battery of neurodevelopmental and speech–language assessments; caregiver and patient interviews; multidisciplinary diagnostic formulation; and caregiver and patient debriefing sessions specific to FASD assessment and diagnosis . PradhanSpeech–language assessment: A comprehensive speech–language assessment is important in the FASD diagnostic process. Sutherland and Trembath used telehealth to assess 23 school-aged children with known or suspected language impairments . The resMotor skills assessment: An FASD assessment includes an assessment of motor skills by an occupational therapist as children with FASD and PAE have been shown to have deficits in motor skills . AlthougNeurodevelopmental assessments: Neurodevelopmental assessments require objective assessments of the various domains of brain function in FASD diagnosis . Temple,Physical measures and neurological assessments: FASD assessment requires the completion of a physical exam for sentinel facial features, measurement of the patient’s head circumference, and a neurological examination by a trained individual. A piece of evidence-based software, for measurements of the sentinel facial features, is used to complete this by a team member with appropriate training. The University of Washington Fetal Alcohol Syndrome Diagnostic & Prevention Network (FAS DPN) FAS Facial Photographic Analysis Software is used to measure the magnitude of expression of the three key diagnostic facial features of FAS  . The sofTo assess for the presence of FAS facial phenotypes, the coordinator arranges for in-person photographs of the child to be taken either before or after the child’s virtual assessment. Three photographs of each child  are taken and analyzed using the University of Washington facial software. The software generates a detailed report, scoring outcomes of the facial measurements using the 4-Digit Diagnostic Code. In consultation with the multidisciplinary team physician, these outcomes are reviewed to determine the presence (or absence) of the three FAS facial phenotypes assessed. The same team member is trained to carry out the measurements for height, weight, and head circumference and extrapolate the percentiles.Abnormal neurological signs contribute to informing the domain of motor skills, which is assessed in major part by the occupational therapist. A reliable physical neurological exam cannot be conducted virtually; however, gross impairment in balance and some easily performed cerebellar tests can be completed virtually. Fitzpatrick, Latimer, in noting a prevalence rate of microcephaly that was nine times higher in children with FASD than amongst those with no PAE, did not find any difference in neurological signs between the two groups .Support worker: A support worker is required when using a virtual model. This support worker can be from a local community agency or school, or be staff member of the FASD clinic who has received appropriate training in the use of virtual platforms and the necessary equipment and technology. The individual is tasked with setting up the necessary equipment and maintaining test/instrument confidentiality. Prior to the assessment, the psychologist and/or SLP and support worker initiate the virtual meeting to test the equipment before the patient is introduced. During the process, the support worker is responsible for monitoring the patient and ensuring images presented on the computer screen are clearly visible. At various points throughout the assessment, the psychologist may request the support worker to provide and collect documents/worksheets to and from the patient. With experience, the support worker may also provide comments on their observations of the patient during testing. This would provide additional useful information to the clinician conducting the test.Ethics: Virtual care must conform to the rules and regulations of the governing and professional regulatory bodies. It is essential that the caregiver and patient, where appropriate, provide informed consent to the virtual process of assessment. The diagnostic team should be aware of the security capabilities of the virtual platforms to ensure patient confidentiality. The physical environment should enable assessments in a comfortable, quiet, private, and safe location allowing for confidential data gathering, interviewing, and testing.Equipment: Equipment and connectivity should allow for a clear, continuous, and uninterrupted audio-visual connection. Ancillary equipment such as additional cameras with appropriate resolution should be used to ensure clear observation of the patient and testing materials. Training of the support worker for use of facial photographic software, taking appropriate facial photographs, measurement of the sentinel facial features, and growth parameters and participating in caregiver interviews, or supporting clinicians to present test materials to the patient, should be completed and practiced for proficiency. These members may also help the patient navigate equipment use and report issues of connectivity.In addition to assessments, as described previously, there are several other components to the multidisciplinary assessment of children with FASD . These iThe “referral and intake” process including records/information gathering by the clinic coordinator continues to be conducted electronically . When deciding on a virtual assessment, the criterion for accepting a pediatric referral for virtual care is discussed and consensus reached with all clinicians completing the testing. Children with severe behavioral issues or a preschool referral may not be appropriate for virtual assessment. Reports are obtained electronically to obtain accurate PAE documentation, and interviews with birth parents or other reliable sources are conducted by telephone or using a virtual platform. Similar to in-person interviews when collecting this sensitive information, the interviewer should be skilled and trained in motivational interviewing and have a good understanding of trauma-informed practice, especially when speaking with birth families. Virtual assistance is provided to caregivers completing the intake forms, as well as providing a clinic contact for any follow up or questions. Consent forms to access or disclose personal and health information are adapted appropriately when using electronic communication.In the virtual model, the clinic coordinator fully explains the intent and process of the telehealth project, and ensures the legal guardian is well-informed prior to signing consent forms. It is important that the legal guardians understand the process and any risks associated with virtual connectivity, while understanding the security, privacy, and confidentiality measures that are in place.The multidisciplinary case conference, diagnostic formulation, and recommendations are scheduled for the clinic team as soon as possible after the assessments are completed. Logistics for members to connect are organized and shared, such as any passwords required, and finding an appropriate meeting space in the community if multiple members are using the same location. The caregiver–physician interview may take place prior to the team meeting, or this can occur on the same day as the case conference before the team meets. Virtual connections enable community team members to attend the multidisciplinary meeting, allowing individuals to join without taking time from work or having to travel. Representation from education, child and family services, intervention service providers, and other team members attend virtually and contribute to the case review, diagnostic formulation, and recommendations.The clinician(s) debriefing with the caregivers and patient (dependent on the age of the child) is conducted using a virtual mode that is pre-arranged and fully explained to the caregivers. Security and confidentiality are essential, and the caregivers are supported throughout to ensure this meeting occurs in a safe and private space. The debrief is often conducted on the same day as the case conference and diagnostic formulation day or can be scheduled for a date soon after. A short version of the medical summary report, including FASD and other diagnosis, along with recommendations, can be sent electronically through a secure method compliant with standards of practice within each discipline. The full medical summary report should be shared with legal guardians at a date soon after the clinic day. A member of the diagnostic team is responsible for following up with caregivers and ensuring access to support recommendations listed in the final medical summary report.The FASD evaluation process, whether in-person or virtual, may need to occur over several appointments, depending on the comfort of the caregiver and/or patient. Comprehensive assessments can take 45–60 min each, which can be difficult for some children to sit through. Breaks, monitoring signs of disinterest, and spacing of assessments may be required. Not all steps for the virtual model  need to n = 71), 13% were physicians, 41% were registered psychologist/psychometrists, 9.9% were speech language pathologists, 28% were clinic or network coordinators, and 9.9% marked other. Prior to the webinar, 40% (n = 82) were members of clinics that were already using virtual or telehealth platforms for parts of FASD assessment and diagnosis and 57% (n = 81) were considering use of virtual options. After the webinar, 77% (n = 71) were likely or very likely to consider the use of virtual options for at least one part of the FASD diagnosis and assessment process. Pre-webinar, many clinics of attendees had implemented virtual methods for conducting diagnostic formulation and recommendations by the clinic team, as well as debriefs with the caregiver, while post-webinar, most parts of the diagnostic process were being considered virtually by attendees  with some having more than one part of the process completed virtually. The majority of caregivers (93%) received the diagnostic formulation and recommendations by the clinic team and the debrief of diagnosis with the caregiver virtually, while 63% had the interviews with the physician completed virtually. A total of 67% of caregivers had the neurobehavioral assessment completed virtually, and 19% had a virtual speech–language assessment. Prior to the appointment, 100% of respondents thought the process and details of connecting and using virtual technology were made clear to them, and 96% of them felt that they had adequate opportunity to ask questions about their appointments. The majority of caregivers strongly agreed or agreed favorably to aspects of using the virtual method including maintaining privacy, comfort with use, and quality of visual and audio  were very satisfied/satisfied with the quality of services provided with virtual technology and 9% were not sure. The three respondents that were unsure commented that they were satisfied with the services but would have preferred it to be in-person if possible. A total of 77% of caregivers (n = 26) strongly agreed/agreed that virtual methods were an acceptable way to receive an assessment and case conference, while 15% were unsure. The two respondents that disagreed preferred an in-person assessment. A total of 82% of caregivers (n = 33) would have a virtual appointment again, with those who were unsure or declined to answer commenting that they would only do so if face-to-face was not an option.Overall, 91% of caregivers (n = 27) selected that it saved travel time, 55.6% costs savings, 33.3% no missed work time, 33.3% ease of childcare arrangements, and 33.3% increased comfort connecting from home or another setting in their community. When asked if the quality of virtual services is comparable to the quality of in-person or face-to-face services: 52% strongly agreed or agreed, 18.5% were neutral, and 29.6% disagreed or strongly disagreed. Those that disagreed or strongly agreed noted that personal connection would have been more beneficial.The survey also asked how the virtual option benefited the caregiver. A total of 63% of caregivers . Specific to FASD, assessments for neurodevelopmental and language are reliable, and the validity of these tests is equivalent to those conducted face-to-face.Previous studies have shown the benefits to virtual care to include timely access to care, reduced travel time and wait times, and improved convenience for patients . These eA limitation specific to this proposed model was the reliance on a support worker to ensure assessments, and support was available to caregivers. This means that a community support person may need to travel to support the family/patient as a trained individual is required to be present with the patient during testing and for photographic and physical measurements. Regarding assessment, an OT assessment and a physical exam cannot be completed, while only a limited neurological examination is feasible. Not all language tests have been standardized using a virtual presentation. Other limitations include children who may be very active or are uncooperative and may not be engaged as easily. This, however, may not be different from in-person assessment.Further research and studies are required to develop guidelines and best practices to increase success in the emerging field of using virtual models for FASD assessment. There is a need for further research to understand the full benefits of using digital or virtual models, as well as the need to understand the challenges and barriers associated with this technology.Assessing and diagnosing FASD through a virtual model could be an alternative to in-person assessments when necessary. It has multiple benefits, especially for families in rural and remote settings where access to a diagnostic team might not always be convenient and feasible. The use of this virtual model was favorable to clinicians and teams with experience in FASD diagnosis and assessment as well as to caregivers of children being assessed for FASD.