Shifting learning to distant formats especially at the higher education level has been unprecedented during the past decade. Diverse digital learning media have been emerging which allow learner autonomy, and at the same time, require the ability of efficient regulation of various aspects of the learning process for sustainable academic progress. In this context, supporting students in self-regulated learning (SRL) in an optimal way becomes an important factor for their academic success. The present study attempts through a systematic review of 38 studies to provide an overview of the interventions identified as supporting all areas of SRL , in its three phases  in distance education environments at the higher education level. As the study results show, there are a number of SRL support interventions available with proven positive effect on SRL. However, their distribution has been found to be uneven. Whereas metacognition regulation and the performance phase of learning is vastly investigated, the emotion regulation, and the preparatory and appraisal phases of the SRL cycle are somewhat underexplored. As complex and multi-component as the process of SRL is, the combination of various interventions, and specific features, for more comprehensive support has also been found beneficial. Additionally, it has been revealed that the emotion regulation, in most cases, is closely related to motivation regulation, and similar interventions support these two. Future studies can further explore the efficiency and relevance of the identified interventions, taking closer look at the effects of various digital media, learner characteristics as well as different levels of education on learners’ self-regulation needs. Digitalization and shifting to distant modes of operation have affected the 21st century living, studying and working dramatically. However, the start of the COVID-19 pandemic triggered even stronger, irreversible reliance on digital technologies, in general, and the largest “online movement” in the history of education, in particular. The current tendencies in the field of education indicate that operation in the distance learning environment is becoming more and more common and will eventually turn into a new normal beyond the era of the COVID-19 pandemic. Consequently, relevant adaptations and finding new ways to cope with the new reality in the field of education are emerging . In the In this era of unprecedented digitalization and distance learning, reconsideration of the ways that have been used to support learners in their study process has become crucial. Even though self-regulated learning (SRL) is relevant for face-to-face (F2F) learning formats as well, it is distance learning that makes the importance of SRL more pronounced . In the Self-regulated learning becomes even more important at the university level, when studying becomes more intense and complex . Higher Further, engaging in self-regulated learning in an efficient manner, in a digital environment which is open-ended, non-linear and information-rich , and espOver the past two decades, SRL has become one of the major areas of research in educational psychology, and it is often referred to as the driving competence needed for transforming individuals into successful independent learners . SRL hasThe given model is detailed enough to cover all aspects of SRL: all three of its phases  as well as the areas . Exploration of SRL along these lines will allow a comprehensive analysis of the whole process and identification of the targeted support interventions.As repeatedly witnessed during COVID-19 pandemics, where the emergency shift toward online learning became a necessity at each level of education, succeeding academically in distant contexts requires a different set of skills on learners’ part from the ones they were used to in f2f learning formats . In f2f Another important factor to be considered while narrowing down the scope of SRL research is the education level. Learners of different ages differ considerably by the way they learn – the methods that help them prepare for their studies, the ways they process information, stay focused and motivated. The factors that contribute to the initiation and support of SRL learning also differ across different age groups. If in case of children and school contexts it is the teacher who plays the defining role for learners’ successful SRL, in case of adults, the instructional design is seen to be a driving factor . Also, wFor the past decade, an increasing number of literature reviews has been conducted on the interventions supporting SRL in online learning. The focus of the research available has varied, however. Some studies have focused on identifying as many concrete tools/platforms supporting SRL as possible without particularly checking their actual impact  on learnIt was deemed important to keep the scope of the study focused, and explore SRL in the context of distance learning at the higher education level . Such approach facilitates capturing the specific nature of the given contexts comprehensively (see section “Self-Regulation and Distance Learning” and “Self-Regulation and Higher Education Level” above), and making the findings context-specific and readily applicable.Thus, the current study investigates how SRL can be best supported in distance learning environments at higher education level. It aims to identify the interventions, or combination of interventions, that have been found to have a demonstrated effect on supporting each area of SRL at each of its phases. Study further tries to locate the features with which various interventions can be enhanced. To explore the most recent findings, the present literature review looks into studies conducted in the period from 2010 to 2020.Taking into consideration the objectives described above, the following research questions have been formulated:1.Which interventions support various areas of SRL in its three phases in the context of online learning at higher education level?2.Which technical features and representations of SRL support interventions, and which combinations of interventions are effective for SRL support?The present systematic literature review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) approach . ConsequIn an attempt to thoroughly cover all aspects of the research, first, the main concepts covered in the RQ were clearly identified. The table below presents the concepts along with their synonymous terms used under each concept category.Based on the identified concepts and related terms, a relevant search phrase was created, which is presented below:(“support*” OR scaffold*” OR “facilitat*”) AND (“self-regulat*” OR “self-control” OR “SR” OR “SRL” OR “self-regulated learning”) AND .Support/Scaffold/facilitate was expected to naturally lead to the identification of the diverse possibilities of SRL support methods. Further, even though the concept of SRL can be further broken down into smaller constituent categories , such elaboration was considered unnecessary based on the assumption that the term self-regulated learning would be sufficient for locating studies covering various constituents of SRL.Since the aim of the search was to detect any potential SRL support mechanism, no search words such as tool, framework or intervention were specified. Rather, the word The search for studies focusing on the supporting intervention of SRL was conducted in the Web of Science and EBSCO, two of the biggest database platforms focusing intensively, among other areas, on the field of education. The platforms were expected to have the most relevant articles for our study purposes. Advanced search was used in both databases using the search formula presented above.Since the focus of the study was to identify the interventions most up to date in nature, the search was restricted to the period from 2010 to 2020. The studies selected had to come from peer-reviewed journals, conference publications and dissertations. Another limitation applied during the search was with regard to language—only those articles published in English were targeted. Besides other obvious reasons, English is the common language for all authors involved in this study and facilitated the required validation processes involved in the study.The following inclusion criteria were used for the study selection purposes at the abstract as well as full text screening level:1.The study makes an explicit link to SRL and focuses on at least one area of SRL .2.The study is empirical in nature, and attempts to measure the effect of an intervention(s) on SRL.3.The study focuses on distance learning .4.The study is conducted with students at higher education level.Searching Web of Science and EBSCO for relevant articles resulted in identifying 351 and 729 articles in each database, respectively. EBSCO database automatically eliminated the duplicates identified in its search result, leaving the total at 512 articles. EBSCO and Web of Science articles together amounted to a total of 963.MetaTutor, each focusing on the effects of the given platform on SRL from a slightly different perspective. The multifunctional and explicitly SRL support directed nature of the given medium must be the reason of the recurring interest. More information about the articles can be found in When both search result sets were exported to the web version of EndNote, an additional search for duplicates was performed, and 496 articles were eliminated automatically as well as additional 58 ones manually, leaving the total of merged database results at 409. As a result of further screening – browsing the titles and abstracts of the articles – 111 studies were found to be meeting the established inclusion criteria and selected for further eligibility check. In the process of full text screening, 23 additional relevant studies were identified through the references of the selected articles and added to the pool of 111. After the final full text analysis, 33 articles were selected as meeting the inclusion criteria. The reviewed articles include four that describe two or more studies, looking at differentiating effects of certain features and/or combination of features  of an inTwo authors examined the studies separately. The validation was conducted at title and abstract as well as full text level  according to the inclusion criteria outlined. Cohen’s Weighted Kappa test revealed the range of.82 to.92 reliability at the title and abstract, and from full agreement to.88, in the full text level.A frame of analysis was created by the authors to facilitate systematic capturing of the information related to the studies included in the present literature review. The validation was ensured through the rounds of discussions and refinement of the frame, as well as actually applying it to 5 studies before its employment for wider scale study analysis see . For valintervention will be used to refer to all possible methods of SRL support, including the concrete digital tools as well as more general support types such as pedagogical frameworks, platform designs and quality factors explored for SRL support. Another key umbrella term used in the current study is distance learning, which refers to all types of learning not taking place in F2F format and implemented distantly with the help of technology, ranging from Massive Open Online Courses (MOOCs) and Learning Management Systems (LMS) to Hypermedia Learning Environments (HLE).In the context of this study, several terms are of high importance and recurring throughout the study. Firstly, the term self-regulation, it is defined, in general terms, as a process through which self-generated thoughts, emotions and actions are planned and adapted to reach the established goals , in others the course type  or the qualities of the systems working behind the platform were reported . This made clear, broader categorization of the information about the learning media challenging. Thus, the analysis framework captures the information as it is presented in the studies reviewed.Descriptive data about the articles includes the information about the study Longitudinal, referring to the course-long and more extensive studies, and Cross-sectional, referring to shorter studies, conducted during one or more learning sessions.With regard to the research quality related section of the table, the following categories were formed: Micro and Macro— Micro, focusing on helping learners at the task level, and Macro, facilitating SRL throughout the course and/or at the study cycle level, types, which are then further grouped according to the phase and area of SRL they support.Outside the analysis framework, the interventions were further categorized with terms Prompts, which are largely defined as “recall and/or performance aids” , which are embedded instruments facilitating the process of SRL in various ways. (c) Instructional designs built on SRL principles are other interventions providing broader, framework-based support, affecting the whole dynamics of the learning experience. (d) Other interventions include technical features/additions to the system/tool such as visualization, social comparison, as well as video/text enhancement functionalities. Learning environment related quality factors  are yet other components to consider while identifying SRL support mechanisms (e). For more clarity and better understanding of the interventions explored, descriptions of intervention related terminology is provided in effects of the interventions included in As for the more concrete categories related to the interventions, broadly, they fall into following categories (a). ce aids” . They doCohen’s d (d). The effects were calculated based on the presented data in the particular studies: t-value, f-value, χ2-value or p-value of the tests along with sample sizes reported. In a few cases, where not enough analysis data was provided, calculation of the effect size was not possible.To present comparable effects of the SRL interventions explored in the included studies, the effect size of these intervention on learners’ SRL skills , and several from the International Conference proceedings (3) and one dissertation. The study domains involved are mostly from the field of education (14), technology (12), science (7) and medicine (4); thus, the study topics/tasks as well are complex in nature and require intense support in distance learning formats. As for the learning media, they range from MOOCs and Learning Management Systems (LMS) to adaptive multi-agent hypermedia learning environments. Most of the studies are conducted in countries with highly developed educational technologies infrastructure .As for the methods applied, as defined by the inclusion criteria, studies reviewed are empirical in nature. In vast majority of cases data collection tools and data analysis methods were largely reported. The data for analysis was collected through a combination of various sources such as log data, video protocols, observation protocols, archived forum discussions and various types of validated targeted questionnaires  ; PerceivThe interventions identified focus both on micro  areas of SRL. an tutor  have beeMetaTutor, focuses on adaptive prompting and subsequent feedback provision coming from its platform-embedded pedagogic agents covering different areas of SRL strategy support. Agents prompt participants to deploy specific SRL strategies— goals and sub-goal setting and staying mindful of their overall learning goal. The learners are also prompted to activate their prior knowledge, write summaries, assess the relevance of the content, take notes, assess their understanding and re-read sections of the text. The agents then give feedback regarding the accuracy and relevance of the practices employed, which has a positive impact on cognition regulation strategy improvement such as note-taking, summarizing and inferring skills as well as content evaluation ability . Since the study also investigated the effect of the learner goal orientation, as a factor, it revealed that such support is more useful for performance- rather than mastery-oriented learners, the authors speculating that intensive prompting and feedback provision might not be creating a challenging enough learning experience for mastery-oriented students. The Planning and Reflection Protocol, embedded in an LMS, which primarily focuses on metacognition regulation support, helping learners in the process of planning, goal setting and reflection, proved to have a positive effect on cognition regulation strategy use as well. Learners, by setting specific goals and then reflecting on what has been learned and what needs further adaptation, manage to engage in more targeted and conceptual learning  through group awareness mechanisms applied in collaborative contexts include boration . Applicaboration . Collaboboration .Video Mapper and MetaTutor’s reading platforms offer such environments , which allow learners to get actively engaged in the learning process rather than remain in a passive recipient’s role, improves their cognitive regulation strategies. The ronments . Note-taronments  and, ultAnother important factor to be considered while trying to help learners with cognitive processing and avoidance of negative overload is to carefully plan the learning environment using well-structured modes of information presentation as well as efficient use of diverse media formats. Even though there is evidence pointing to the positive effects of multimedia use in the instructional process on learners’ cognitive processing and increased level of learning, overall, inefficient application of the diverse media can have reverse effects. Using multimedia for delivering the content/messages irrelevant to learning and/or providing redundant/overlapping information through various forms of media  leads to diverting learners’ attention from the essential to non-essential information processing. This results in extraneous cognitive workload and confusion on learners’ part, which further hinders self-regulation and is conducive to lower levels of knowledge acquisition .Information about metacognition regulation support interventions is captured in As in the case of cognition, with regard to metacognition as well, prompts have been found to be among the most prominent interventions supporting metacognition regulation. The findings with regard to prompts indicate that specific prompts  are significantly more efficient and conducive to more positive effects on metacognition regulation, especially when combined with feedback , than prFurther, training with regard to understanding and following the prompts has also been found helpful. However, the positive effect of such explicit training can be observed only with less experienced and less motivated learners, whereas almost a reverse influence can be observed on more advanced learners with high intrinsic motivation . SimilarAdaptability and self-directed nature are other features that have been found to make prompts more effective. An adaptable, initially more frequent but progressively fading prompting contributes to the increase of SRL strategy deployment  at macro SRL-phase level, encouraging planning, monitoring and reflection , as well as at micro, learning material level (prompting about how well the videos and/or texts have been understood). The intervention was found effective for metacognitive strategy improvement across all SRL phases. However, the biggest effect was observed with regard to the performance phase.The positive effect of the comprehensive and personified approach adopted with regard to prompting was witnessed in the study by Automated Adaptive Time Management Enabling System , founded on PBL collaborative model, and having instructor support available as needed, was also found to be supportive to learners through the learning process with their metacognition regulation strategies  sending learning monitors (reminder emails about progress) and learning motivators  was found to be conducive to learners spending more time on material and more students completing the course successfully . SimilarMastery Grids system, an intelligent interface for online learning content that combines Open Learner Modeling (OLM), adaptive navigation support and a navigation-oriented social comparison feature, learners can click on any topic cell of the interface and access diverse web-based “smart” practice content. The system can then process learner activity, estimate progress and incorporate feedback based on the log data. The adaptable and interactive nature of the system, possibility of receiving individualized feedback in a visual format and the comparison feature have proven to have a positive effect on learner engagement and overall efficiency (Adaptability achieved through Open Learner Modeling (OLM) and its benefits have been demonstrated in several studies reviewed. In the ficiency . Similarficiency , using tGroup Awareness (GA) functionality, in a somewhat similar way to Learning Tracker, has been found helpful for boosting learners’ motivation regulation  regulation through a learner style-based, individualized approach. It aims at enabling learners to define and manage their learning path by means of providing a set of generic strategies and customized learning activities based on their learning preferences throughout the three phases of SRL  . Especially with novice learners, with less developed technology skills, such factors determine the level of learner engagement and the anxiety level in the study process. Interestingly, factors such as information quality and service quality did not show any significant impact on learner SRL strategies in the same study , which encourages learners to plan and set their learning goals before engaging in the learning practice, which results in better implementation of the learning process and less procrastination related anxiety . To make the raw data more easily digestible, visualization comes into play, which has been proven to have a positive effect on learners’ metacognition as well as motivation regulation  and found a positive effect of radar visualization over the textual one  as well as the advantage of the textual visualization over no visualization option . Interestingly, textual visualization did not have a favorable effect on scheduling, i.e., dividing the work across multiple days—the visualizations did not increase the number of days during which the students worked on the assignments, the difference between the groups being statistically significant (p = 0.031). The authors speculate that the possible explanation could be that the performance-oriented learners may have tried to gain all the exercise points as fast as possible, ignoring the feedback related to spacing out their effort over a longer period of time. Additionally, when it comes to academic performance, the highest performing students, regardless of the visualization, earned the highest scores, giving grounds to speculate that students who have strong task related or self-regulatory skills do not benefit from the external feedback provided by the visualizations as much as students with weaker skills  and found that while beneficial for all types of learners, visualization without such comparison function might even have a reverse impact on performance-oriented students, who draw their motivation from outperforming others  when combined with self-monitoring prompts that encourage students to review their notes before moving on to the next activity have proven to have an enhanced effect on learners’ cognitive strategy use  as well as self-monitoring efficiency. Such combination is especially helpful with least supported  learners and more observable in the case of more complex tasks , . The generic nature of prompting, which, used on its own, was found not to have a significant effect , , a fact , 1.3]),  showed tt effect , seems tpeer-to-peer feedback in collaborative online learning contexts was shown to be enhanced with the detailed assessment guidelines and analytical rubrics. Such rubrics play a key role in supporting students to monitor their peers’ progress, and provide valuable feedback. The process further benefits from tutor supervision.In a qualitative study by The important role of teacher involvement has also been proven with regard to the SRL interventions which are more complex in nature. SRL e-portfolio is a multifunctional and multi-component tool, the functionality and use of which need to be properly understood in order to reach the intended effect . The preOperating efficiently in online learning environments is not an inherent competence that higher education students possess. Rather, it is a skill that needs to be developed in the process of learning and requires explicit support and training at an initial stage. The less experienced the learner and the more conceptually rich the learning domain, the more such help is needed. The present study investigated the SRL interventions that were found helpful for supporting various areas of SRL at its various phases. The study also attempted to identify technical features and a combination of interventions which were found to be effective for SRL support. As a result, the potential inventory of interventions was drawn up in the form of tables see –6.In the current study, the distribution of the interventions explored focusing on various SRL areas has an unbalanced nature, with metacognition regulation scaffolds being by far the most explored, whereas emotion regulation interventions are the least investigated see  above. AAdditionally, SRL is a multi-component and complex construct; it is a cyclical process, and the activities in each phase, which are also non-linear or lacking a subsequent nature, affect one another . Under sHowever, if a single most flexible and comprehensive intervention had to be selected, that would be prompts. As shown in the present study, prompts can come in different forms  and at different times . Various prompts are also presented in combination with other interventions  for an enhanced effect. They can be of varying levels of specificity , and delivered at micro (task-level) as well as macro level (study cycle level). Prompts also vary according to the level of individualization and flexibility , learners’ involvement  and intensity of support they provide. Prompts have been found the most useful for learners with fewer skills and competence as well as for more complex tasks . HoweverTo broadly summarize the findings with regard to the areas of SRL that the identified interventions cover, it can be observed that cognition regulation seems to be supported at the task level in most of the cases and at the performance stage of the learning process; the findings are in line with previous studies . The intThe present literature review revealed a positive association of motivation and emotion regulation with goal setting and planning conducted at the preparatory phase of the SRL cycle. This observation is supported by the Goal Orientation theory, according to which goal setting is a key motivational process . Since tUnlike motivation regulation, which has been well explored at the performance phase of SRL, emotion regulation has been vastly under investigated. Fortunately, it seems that the existing gap has been identified in other studies as well , the reaAs shown by the findings of the current review, the most optimal and feasible way to provide comprehensive support for self-regulated learning in distance learning environments is by accurately and thoughtfully combining various interventions. Additionally, it is important that each intervention is carefully crafted, paying attention to each of its feature as well as taking into account a myriad of factors emerging from the context at hand. Otherwise, potentially very powerful tools might turn into useless or even hindering measures. For instance, directed pre-flection prompts  were fouAs for an impactful combination of SRL interventions, it was found that reflection prompts enhance the effects of planning e-journals by encouraging further reflection on learners’ part with regard to their metacognitive strategy use. Also, a note-taking tool highly benefits from add-on monitoring prompts, and the combination results in more intensive processing and analysis of the notes taken. Generic prompts benefit from being reinforced by monitoring feedback for significant effects, whereas the feedback itself has a stronger effect if delivered in the visual form. In the case of SRL, multidimensional visualizations, such as radar graphs, are of most use, and a further combination of the visual feedback and the comparison feature (see detailed discussion in the paragraph below) makes the interpretation of the results easier and more productive.Another efficient combination of interventions identified is supplementing system delivered SRL support with tutor involvement in the support process, a practice that proves to be useful in the case of complex SRL interventions and, again, particularly with learners lacking experience in operating efficiently in online learning environments independently. Peer-to peer interaction and the provision of feedback, which is a useful SRL practice, can also be further supported by employing well-defined assessment rubrics, which are expected to secure the needed quality of the feedback given and alignment of the feedback with the learning outcomes. This is an especially useful practice in the absence of intensive teacher presence.The “empowering features,” which were found to be contributing to boosting the impact of the SRL support and, in some cases, being a critical determining factor of success, are summarized below.Personalization and adaptability of the distance learning experience can be achieved with the help of designs of the tools and learning environments that involve learners themselves in elaborating support interventions for themselves. Such practice contributes to making learners more engaged and motivated in the learning process , the finProviding students with adaptive scaffolding in the OLM environment then also means measuring learners’ levels of SRL and providing personalized support. Accordingly, clearly defining the indicators related to concrete SRL strategies becomes necessary for the system to be able to accurately deliver targeted support to the learner. The trend of combining the measurement and support of SRL is emerging in the field of self-regulated learning, and is referred to as “the third wave” (and the most efficient) of SRL support, “when measurement and intervention come hand in hand” , p.1, anThe social comparison feature has been explored by a number of studies as a useful feature to have in distance learning environments. The motivational and time management related benefits of social comparison were identified in the studies reviewed  and thisThus, one potential way to go about the comparison issue and to encourage mastery rather than performance orientation among learners is to focus on making the comparison more general in nature. Comparison can be made of a students’ outcomes against a standard expectation level, a ‘neutral average’ rather comparing students’ success to one another, which can have a detrimental effect on low-achieving learners, and result in increased anxiety levels. Another potential approach to help learners stay focused on their own progress rather than worry about being ‘behind’ or being demotivated by progressing too ‘far ahead’ of the others is to follow up the comparative data with the textual feedback focusing on the learner’s own improvement and individual effort as much as possible. Further, to attribute this feature an adaptable nature, it can be offered to learners on an on-demand basis, by making the function optional.The gap observed in the research of the SRL support was with regard to emotion regulation in online learning environments. It can be speculated that the reason for the under-investigation of this area might be due to its highly ‘hidden’ nature. For this reason, the ability to accurately detect the need for emotion regulation becomes important . For theThe fact that the study is limited to looking at SRL in higher education level and distant learning context, implies that the findings of the given study cannot be automatically applied in other settings  and these areas require further investigation. Similarly, learner-related variables might have a differentiating effect on the efficiency of certain SRL interventions. The current review revealed that the studies investigating this aspect in a systematic and thorough manner with regard to concrete interventions are scarce and need more attention.Additionally, the present study does not compare or explore the differentiated effects of the identified interventions in the various identified learning environments. For instance, platforms that are open and non-linear in nature and allow interaction and communication and self-directed choice of materials for learning purposes would benefit more from technology provided step-by-step scaffolding, OLM technology adoption and individualization of the learning process. In contrast, distance learning environments which serve more as repositories of knowledge and leave little space for creativity or autonomy due to their passive and straightforward nature are likely to benefit from different types of support, e.g., feedback on their level of engagement with the course material and learning performance . Hence, Also, since the wider context (countries where the studies included in the current literature review were conducted) is dominated by highly developed countries see , it can The central aim of the present study was to investigate what interventions have been studied as part of the recent research conducted in the area of SRL, with a particular focus on distance learning and higher education level. The cyclical nature of SRL makes the comprehensive, and continuing support necessary for ultimate success. Additionally, since the SRL processes are largely determined by a number of more global, objective factors as well as learner-related characteristics, a careful account of all of these variables need to be taken into account while designing SRL support systems in online learning environments. In this direction, further, more consistent and focused research is needed for more concrete assumptions (for this reason, the relationship between these factors and SRL is presented with a dashed arrow in On a final note, amid the abundance of the SRL supportive interventions, and facing the temptation of adopting multiple technologies while trying to make the online learning environments highly supportive, it has to be born in mind that the systems and designs should stay simple, whereas the learner, their needs and the process of learning always needs to occupy the central part.The original contributions presented in the study are included in the article/NE, KS, MP, and ÄL all contributed to conception and design of the study. KS took an active part in data validation, and together with MP and ÄL, to the development of the framework of analysis. NE wrote the first draft in close collaboration with other authors. KS, MP, and ÄL provided detailed feedback and contributed to the revision process of the manuscript. All authors approved the final version of the manuscript to be published.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Limited evidence exists to help understand the experiences of university students in relation to the long-term lockdown due to the COVID-19 pandemic. For that reason, we conducted a study using a phenomenographic approach in order to understand how university students perceive COVID-19 and the associated lockdown. Data were collected from 25 students in Pakistan. They were asked to demonstrate the psychological effects of the COVID-19 pandemic and lockdown in illustrations. In addition, in-depth interviews were conducted with these students, to gain further insights into their perspectives on the psychosocial effects of the COVID-19 pandemic. The analysis revealed four interlinked directions for understanding students’ experiences. These themes were: 1) escape into peace, 2) hope for personal freedom, 3) fear of becoming a victim of COVID-19, and 4) concerns regarding education, future career, and opportunities. All four themes were analyzed and condensed into an outcome space, which further gathers the perceptions of students under one theme as “Hope for life while paradoxically living with fear”. Studying the psychological impact of the COVID-19 pandemic and lockdown on students not only highlighted their concerns, but also emphasized the importance of starting regular psychological evaluations and stress-releasing sessions, along with online education to overcome growing depression. COVID-19 is a public health emergency of international concern . A rapidDue to this pandemic situation, not only are health-care providers overburdened, but public health departments all over the world initially recommended physical distancing and later on massive lockdowns due to the ongoing spread of the virus within the public . LockdowWhen implemented as a control strategy affecting a massive number of people, lockdowns lead to challenges such as the questions of how long these actions are needed and how to separate suspected cases from healthy individuals . In addiThe mental health of students at universities and professional institutes is anticipated to be influenced by the pandemic and its associated political actions in terms of severe quarantine measures and postponements of the opening of educational institutes throughout the world. There are studies available on the psychological and socio-economic influences of the COVID-19 pandemic on health-care personnel, adults, and children –13. HoweWhen considering the phenomenon of physical distancing or quarantining, it is essential to realize that it comes with a significant personal cost and disrupts the physical and mental wellbeing of those facing it. It involves reduced social contact with friends and family, as well as confinement to a specific space. Even though these precautionary measures are essential for reducing the pressure on health-care systems, the troublesome part is that extended home quarantine due to any infectious outbreak might damage the physical and mental wellbeing of people facing it , 15. It As Pakistan is among the countries most affected by COVID-19 (according to statistics from July 2020), the government is conscious of the urgent need for action. Hence, a nationwide lockdown was initiated on March 23, 2020 , and eduFrom the beginning of the COVID-19 pandemic, feelings of anxiety and fear were common among the community . The misTo gain an insight into the practices and apprehensions of university students during the COVID-19 lockdown, a phenomenographic methodology was adopted. Phenomenography is a type of qualitative methodology that is used to define disparities among people’s understandings and conceptualizations in their own way . It defiPhenomenographic investigations are usually expressed as categories of description or themes which portray the core meaning of concepts and the ways in which they could be analyzed, labelled, and understood. It could also be considered as an abstract tool to symbolize and summarize different understandings of phenomena identified through the analysis of data. An outcome space is then used to represent the logical relationships between different identified themes. According to Marton , an outcThis study uses illustrations to express understandings of lockdown and COVID-19. Although this is an uncommon method, it is an acknowledged research method in phenomenography . The illParticipants were selected randomly from different departments of the University College of Art and Design at the University of the Punjab in Lahore, Pakistan. The selection of these students is justified because: 1) art students studying at this institution come from all over Pakistan, 2) they have diverse socioeconomic backgrounds, and 3) they are skilled enough to convey their message or feeling in the form of an illustration. Thirty-two students volunteered to take part in the study. However, only 25 of them were able both to hand in an illustration and be available for an online-based qualitative interview afterwards.Participating students were asked to define their understanding of the ways in which they acknowledge their feelings related to the COVID-19 pandemic and lockdown through illustrations such as drawings. The artists were free in their choice of art technique, e.g. color/charcoal pencils, pastels, or watercolors. After finishing the illustration, each participant was asked to explain the meaning of his or her drawing in an online session.Further probing questions were asked related to the illustrations. For example, in After taking written consent from the participants, these explanations were recorded. Afterwards, the statements were transcribed and, in conjunction with the associated illustrations, served as information for the phenomenographic investigation.The illustrations, supported by additional verbatim clarifications provided by the students, were analyzed. We compared, grouped, labeled, and contrasted the understandings presented in painted form in order to establish categories of description. In the next step, we condensed the categories into overarching themes. These themes depict the core connotation of each concept and emphasize variations and similarities among participants’ understanding of the phenomenon. This led to four categories of description:Escape into peaceHope for personal freedom: A world without fear of COVID-19 and lockdownsFear of being a victim of COVID-19Concerns regarding education, future career, and opportunitiesThe final themes reflected the diverse understandings of surviving a pandemic and lockdown, which were contextually elucidated in the form of a mutual understanding referred as the outcome space.The research was approved by the Ethical and Research Board of the Department of Public Health, University of the Punjab, Lahore (D/577/ERBPH/ISCS). Individual written consent to contribute was attained after rapport building and explaining the study to the participants.Categories of description recognized through the data–i.e., concepts about surviving the pandemic and lockdown–were analyzed. The conceptual framework originated from respondents’ personal feelings and experiences, which represent a mutual understanding of these phenomena.Being at peace or achieving harmony appears to be the fundamental basis of hope and positivity. One student described her feelings as “quarantine and lockdowns due to corona are not only breaking us apart socially but also psychologically. Eventually causing the fear of death and at the same time having a hope that it will end someday, and we will be out and free with happy souls as we were before” . The col“We often get weak and stressed out, considering there is no way out of the situation. But all we need is to calm ourselves and believe that everything will soon be fine. Better is always on its way and in the end peace always prevails.”The broken window grills can be seen as a way to escape from the prison–which is a symbol for the lockdown–into a world full of freedom, indicated by the birds outside.As a qualitative study explores the world through the participants’ perspectives, one of the participants labelled the pandemic and lockdown as a blessing in disguise. According to him, “this virus has caged the selfish desires of mankind. While our dreams have blown away with the autumn of pandemic, animals and nature are blooming” . The parSimilarly to her illustration, another female participant reflected on optimism, hope and assurance . The sunThe final illustration under this theme  shows thHope is the key to survival and to overcoming any difficult situation, irrespective of the misery one is facing . AccordiAnother respondent described life in quarantine as a new and unexpected way of living. He said that, as a youngster, he felt miserable, being locked in the house without meeting friends or members of his social circle. In his illustration , he has Another illustration  portraysThese illustrations portray misery, articulating with faith in the return of a free life (without the chains that frequently occur in the drawings). Thus, they depict intermittent active and positive coping techniques in participants’ minds.The constant fear of acquiring the disease produces an innate need to be relentlessly alert and defensive. This disease is affecting every single person physically, mentally, and emotionally. In Most of the participants under this theme took a passive coping approach due to the negativity spread through social media. The main cause of depression and poor psychological adjustment was not the pandemic itself, but the fear of death related to COVID-19 that was portrayed on social media.Fear of an uncertain future was the major concern for most of the students. This pandemic has brought a halt not only to education, but also to practical life. Another illustration  shows thIn Another participant  stated:“As this pandemic has kept us away from our goals, my illustration depicts invisible walls between a person and his goals. The more we try to move towards our set goals, the more we are exposed to danger. The red color represents danger, which is getting stronger as we try to break down the physical distance between one another.“Likewise, The next participant  tried toSimilarly, in the next illustration  the partA majority of participants had concerns regarding their education and future career due to increasing depression, loss of social contacts, and economic crises at home. According to them, these issues were creating a pessimistic approach towards the pandemic and lockdowns.An outcome space is a graphic representation of the coherent relations among different ideas or notions defined by a study . The outCOVID-19 is having distinct effects on the lives of students, both physically and psychologically, all over the world. It has not only jeopardized their physical, social, and mental health, but also their education, future plans, and job opportunities. Furthermore, it creates insecurity about the health and lives of their loved ones. Several studies have investigated psychological effects such as anxiety, depression, and stress among university students related to the COVID-19 outbreak and lockdown –25. But In the absence of a vaccine, lockdown was necessary in order to control the unknown and extremely infectious COVID-19 pandemic . This inThe analysis of the illustrations created for this study revealed four different but interconnected approaches to managing the emotional turmoil of lockdowns related to COVID-19. As in other studies, a few of the participants had hope and faith that was stronger than average, while others were more pessimistic about the ongoing situation. Overall, the findings were psychologically more or less similar. They included fearfulness, isolation, apprehension, insomnia, boredom, resentment, annoyance, ambiguity, and stigmatization. Experiencing the lockdown was not stress-free for these university students. They were combating social distancing as well as the turbulent economic and health circumstances their families were facing. Similar to other studies, quarantined participants had doubts about the actual situation due to the hype created within the media and were hesitant about accepting this lockdown as the most effective technique for combatting the pandemic .This study has given us an opportunity to understand the requirements, hopes, and thoughts of young people who are facing these drastic infection-control strategies. Several illustrations undoubtedly depict an appreciation of the worth of living a free and peaceful life, which we took for granted before. Furthermore, the unpredictability of COVID-19 and its enduring effects elevate feelings of improbability and uncontrollability in relation to the future. This augments the sense of agony and helplessness which is evident in the illustrations . COVID-1Our results need to be interpreted with caution due to some limitations. First of all, the sample limits the diversity of understandings that the human mind could relate to a specific situation. Nevertheless, the sample is quite large for such a qualitative study. There have been no further inclusion or exclusion criteria, despite the fact that they were students of arts and design. There was no need to exclude students who seemed to be depressed, although we did not assess their current state of mental health in a standardized way. Including depressed students may have influenced the results, because persons with depressed mood articulate their emotions and thoughts differently in illustrations. The topic of anxiety and depression was frequently addressed in the illustrations. The interpretation would have been different in a sample of students with depression. The choice of only arts students at one university limits their areas of concern. It needs to be kept in mind that students from other disciplines could have different understandings. The diversity related to age groups and professions could not be delineated.This study highlights the psychological impact of the COVID-19 pandemic on students. The qualitative design allows insights into the psychological effects experienced by students during lockdown. The themes, related to fears (such as becoming a victim of COVID-19), concerns , as well as the hope for personal freedom and an escape into peace, emphasize the need for supportive programs for relieving stress. Students need to be better prepared to face and overcome the long-lasting gaps this pandemic has created in terms of economic, educational, and career opportunities.


The value of tourism has been included in studies of active aging, and the existing public health implications of the physical and mental health effects of tourism among seniors are recognized as important issues. This study uses a mixed methods research approach to explore the effects of tourism value on the health and mortality risk of older adults, referred to in this paper as seniors. Survival analysis and cohort analysis are combined with the narrative analysis of in-depth interviews with eight convenience-sampled seniors to construct a narrative framework of seniors’ active aging tourism and its intrinsic drivers. The study found that the intrinsic framework of active aging tourism values for seniors has a three-stage continuum, an interaction, and orientation characteristics. There are six intrinsic key value drivers of tourism value and public health for seniors. In addition, this study identifies the personal characteristics and strengths of seniors as important influences on tourism value practices for active aging and public health. This study provides a positive psychological and behavioral research direction for existing research on the value of tourism in active aging. It provides an empirical basis for exploring the intrinsic mechanisms of tourism and public health. Previous research has identified aging as a problem associated with the decline and loss of physical and psychological health in later life . The devTo date, issues related to senior tourism have been dominated by market segmentation studies, with an emphasis on decision-making and motivation ,7. ExistNegative cultural stereotypes experienced by seniors may hinder the positive impacts of active aging. Fernández-Ballesteros and Sánchez-Izquierd , for exaThe potential value of this study is the use of the developmental cycle of active aging as a lens to explore the value of tourism, as well as the intrinsic linkages between tourism and seniors’ public health. It examines the positive psychological adjustment and personal trait strengths of seniors that promote positive mental health adaptation pathways, and identifies a positive psychological dimension that can contribute to a deeper understanding of the existing relationships between tourism and the public health of seniors. This was achieved by focusing on the public health effects of tourism value and active aging to provide an empirical basis for further clarification of the mechanisms underlying older adults’ travel behavior and active aging.In this research, the study population are described as seniors, in preference to older adults. The literature has yet to offer a universally agreed definition of senior tourists, with definitions ranging from participants in tourism activities who are over the age of 50, to studies that define senior tourists as being over 60, or even 65 . Most stIssues related to senior tourism market segmentation have been widely researched, with the main segments described variously as new seniors, young seniors, affluent seniors, and retired baby boomers . Senior Existing studies on the association between tourism value and senior travelers have identified a number of areas of interest, including the value elements, such as social value, physical and mental value, active aging, and quality of life value, that tourism brings to seniors. Qiao et al. ,23 highlActive aging as an important element in achieving positive value outcomes of seniors’ tourism, and has been explored in a number of recent studies. Yoon et al.  identifiCurrently, the literature on the value of tourism among elderly people is largely oriented toward positive psychology and positive relationship construction, and provides a theoretical reference for the exploration of the key influencing factors of the value of tourism for seniors in this study. However, the empirical arguments of existing studies on the value of tourism for seniors, and the intrinsic mechanism of the process of active aging, are insufficient to explain how tourism assists in active aging, or how tourism can promote improvements to physical and mental health. The lack of research of this type provides a strong justification for the research described in this paper.The survival analysis model, which has been employed to explain the length of tourists’ stay at a destination , is a stExisting research on senior tourism has mainly focused on the “silver-hair market”, with destination marketing as the main topic of research. Research on tourism value segmentation has also explored micro-value influencing factors, such as community, mind and body, and socialization . CollectThis study applied a mixed methods approach, using quantitative data to determine trends and relationships, and qualitative research to explain the mechanisms and reasons behind these trends. The study design was divided into two parts. Study I explored the effects of travel behavior on health risk among seniors by using data representative of Chinese adults aged 65 years and older. The study was based on the survival analysis approach with strong causal validity. Study II recruited respondents through convenience sampling in a snowball format. A total of eight respondents  were interviewed. All respondents were retired, none had underlying medical conditions, and all had some travel experience. Convenience sampling, also known as availability sampling, is a non-probability sampling method that relies on collecting data from members of a population willing to participate in a study . For the2 test and a Cox proportional risk model to describe and statistically test for the risk of death. The results were considered significant at two-sided p < 0.05. Kaplan–Meier curves were used to show the survival time of seniors. Log-rank χ2 was used to test whether the difference in mortality risk was significant among seniors with different basic demographic characteristics, health status, and lifestyle habits. The Cox proportional risk model was used to calculate the risk ratio. The Kaplan–Meier analysis method and the Cox proportional risk model are nonparametric methods/models that do not require any assumptions about the distribution of the dependent variable, and are not affected by the shape of the baseline risk function. These methods are the most commonly used in survival analysis studies. However, the proportional risk assumptions need to be satisfied for analysis using Cox regression models. If they are not fully satisfied, they may reduce the accuracy of the estimation of parameter values. Before conducting formal analysis, the study conducted a Schoenfeld residual method test. The results showed that the proportional risk assumptions were satisfied, and that the Cox regression models can be applied to analyze the effect of tourism on the risk of death in seniors. The mathematical Cox proportional risk model was expressed as follows:x at time t, β is the coefficient matrix of covariate In the Stage I analysis, Stata 16.0 software was used to explore the effect of travel on the risk of death among seniors, based on survival analysis. The study used the Kaplan–Meier method to plot survival curves; and a Log-rank χIn stage II, interviewee transcripts were manually coded and analyzed. A five-factor problem-solving approach proposed by Yussen and Ozcan , and basThe researcher explained the purposeful nature of the study to the senior respondents, reading the study information sheet and informed consent form aloud to participants. All interview notes were treated as confidential, and not disclosed to third parties. The researcher was conscious of the potential for the emergence of a researcher-dominated unequal status and power relationship with the respondents. To mitigate this possibility, the researcher conducting the interviews undertook ongoing reflection to ensure that an unequal power and status did not emerge. To protect the privacy and personal information, interviewees were assigned anonymous code numbers from R1 to R8. All interviewees were made aware of the privacy protection of this study prior to the interviews.Study I explored the effects of travel behavior on health risk among seniors using data representative of Chinese adults aged 65 years and older.Data for study 1 were extracted from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) for the years between 2008 to 2018. Four sets of longitudinal data were obtained, and three prospective cohorts were constructed. The CLHLS survey is representative of the Chinese national senior population, with data covering more than 860 counties, county-level cities, or districts in 23 provinces, cities, and autonomous regions.The study divided the longitudinal data into three cohorts of ten years, namely “2008–2018”, “2011–2018”, and “2014–2018”, to analyze the immediate and long-term effects of tourism on mortality among seniors. The study population in each cohort were adults aged ≥65 years in the base period survey. Study subjects aged ≥105 years were excluded because, according to the data quality assessment of the CLHLS survey project team, the information for the very elderly may be biased . After cThe independent variables adopted for this study were travel participation and number of trips. Combined with the CLHLS questionnaire, the specific number of trips within the last two years were used as variables of interest for the study. A code of 1 means that seniors had traveled within the last two years; otherwise, the code is 0. This study also analyzed the total number of trips as a key independent variable to analyze the health effects of travel.The dependent variable adopted for this study was risk of death . If a person died during the observation period, the length of survival was based on the number of months that had elapsed between the first visit and the time of death. If a person died during the observation period, the survival time was measured as the duration from the first survey to the most recent survey. The survival time of a person who had not died at the time of the last survey was measured from the first survey to the last survey. In the sample, persons who died were defined as “events”, and those who died during the second follow-up visit and those who were alive at the last survey were defined as “deletions”.The control variables adopted for this study were based on existing studies , and incAs seen in Models 1-1 and 1-2, in To test the accuracy of the findings, this study constructed new cohorts for analysis using the eight-year and four-year survey data tracked by CLHLS 2011–2018 and CLHLS 2014–2018, respectively. As seen in Models 2-1 and 2-2, the analysis of the eight-year follow-up data showed that the death rate among seniors with regular travel experience slowed by 36% . Their risk of death was 0.64 times lower than that of seniors without travel experience, and an increase in the number of trips was associated with a 10.7% reduction in the risk of death .In addition, analysis of the four-year follow-up data from Models 3-1 and 3-2 showed that travel reduced the risk of death by 31.3% , and an increase in the number of trips slowed the rate of death by 10.6% .Taken together, the calculated values for the three cohorts were similar, and the results were robust, with all data showing that undertaking regular and frequent travel significantly reduced the risk of death in seniors.The qualitative research in study II discusses the mechanisms and factors that highlight how participation in tourism may have a positive impact on seniors’ health through active aging.The cohort analysis undertaken in Study I indicated that persons with a higher number of trips demonstrated a low risk of death, indicating a causal relationship between tourism and positive long-term health outcomes. However, the underlying mechanisms of how tourism affects the physical and mental health of seniors at the micro-psychological and behavioral levels, and the potential association of tourism with active aging, were not clear. Study II was undertaken to explore the relevance of tourism values on seniors’ physical and mental health, and active aging. Based on the narratives of the eight participating seniors, this study identified a number of factors that constitute the key value elements that influence active aging, and the mechanisms for realizing seniors’ tourism value practices.The eight seniors who participated in this study all maintained a reasonable frequency of travel. The oldest participant was aged 73 and the youngest was aged 65. All were retired and free from underlying illnesses. Finally, I have retired but I still want to enjoy life. I retired first, and my husband is still working. Every day, I awake to a life that seems empty. I miss all the outdoor activities, and my friends feel the same. Suddenly, I understand that I have a lot of time for my favorite outdoor sports and to engage in long-distance travel. I no longer need to worry about my children. They have their own families. My husband is still working.It took me a long time to adapt after retirement. Even still, I sometimes feel abandoned by society. My children have grown up and are busy at work. Before I retired, I traveled quite frequently, and I still need to be mentally prepared to maintain a high frequency of travel after retirement. Some of my friends who used to travel together have minor illnesses, and some have chronic conditions, so they can no longer engage in long-term travel.In the second stage of travel value, respondents talked about their deepening understanding of leisure and freedom. In adapting to post-retirement life, the respondents entered the second stage, centered around strengthening their own identification with travel and health. Some had taken on the role of group travel leader. They had positive experiences of arranging travel itineraries and organizing participation. They were able to coordinate the whole trip and share the value of their travel experience with a group of friends, as described by R2.I retired early and became part of the retired community. After the post-retirement psychological struggle and emotional transformation, I realized that I was still very influential in our outdoor circle. I started to organize short outdoor trips. Anyway, with so much time to spare, I began to persuade my friends to actively participate in the activities I organized. We went camping at Qingshan Lake and hiking at Changle Forest, places that were not too far away. In these short outdoor trips, we could relax, follow our interests, and have a clearer understanding of how to plan retirement life.After experiencing the interactions that typified the second stage, the importance of goal orientation became clear in the third stage. Analysis of the transcripts indicated that, by the third stage, respondents had begun to construct new identities, and explore new travel patterns and activities to maintain the positive emotional experiences that translate the value of travel into daily life. Some of the interviewees in this stage had organized and operated tours in the second stage, and began to engage more frequently in altruistic behavior. Gratitude and altruism become the cognitive characteristics of this stage in terms of positive group relationship building through travel. These characteristics also allowed the interviewees to gradually construct a group identity based on leisure and tourism, which became the basis for realizing tourism value. The interview transcripts of R3 and R5 present the salient features of this stage.Since I retired, for the past 10 years, I have organized big and small, short and long trips, and I am aware of my emotional stability. Through travel, I have slowly resolved the conflicts and contradictions in my family. Travel is like life, filled with ups and downs.I have several interest circles that I joined after I retired. One of them is called Southeast Asia Circle, which is all about island trips to Indonesia, Okinawa, Japan, Thailand, and so on. I divorced my husband many years ago, and I live alone. I travel to cultivate my own interests and to help others to resolve negative emotions and psychological issues. I gained a lot in the process. My shoulder and neck problems were alleviated by the non-stop physical exertion involved in my travels. I also organized the exploration of different destinations for others in similar circumstances to my own. In this way, my circle of friends could feel the charm of travel.Respondents highlighted different stages of tourism value in their aging narratives, interpreting, in turn, the continuity, interaction, and orientation of the aging tourism value narrative. The characteristics and internal mechanisms of the three stages provide a time-series perspective interpretation to reveal the impact of tourism value on active aging, and public physical and mental health.What drives respondents’ value-seeking in active aging? What role does tourism value play in the process of active aging? This study responded to these issues by uncovering the key driving value elements in respondents’ narratives at the level of tourism value output. I have a bad relationship with my family and little contact with my children, but I often travel to Buddhist travel places to keep my inner peace and emotional calmness. I have my own plan to cope with my life after retirement, which is to constantly maintain a positive state of mind, not to have big ups and downs. This is a good way to travel to different travel places according to how I feel.My husband is still on a career path. My daughter is married. I worked in a textile factory and retired early after major surgery. I took up outdoor sports to help my recovery. When I was young, I was argumentative and headstrong. After retirement, I began to believe in Buddhism. Every month I would go to Buddhist travel places to eat vegetarian food, to chant, and to become calm. I also organized a lot of outdoor activities. In an outdoor circle of friends, everyone can be a leader and explore different places with others. Now, I am in good physical condition. My long-term outdoor activities have made me stronger. I can eat and sleep well. I think that is enough.Respondents embodied the value of antecedent travel experiences, the value of belonging to a travel community, and the value of travel well-being in relation to travel value. They generally believed that previous travel experiences and the skills they gained have a significant impact on their life. They cultivated specific travel cognition and experiences that can be used as instrumental behaviors to plan and implement aging travel practices. Community value, as the key to sociability, had a major impact on respondents’ reconfiguration of daily living space and travel space. These spaces now have greater significance, and respondents can maintain an active and positive attitude and state of mind in the community, which can be transformed into their own value-seeking needs. Eventually, the goal of travel well-being value is able to be achieved. The result is positive emotional communication through regular travel and leisure, whereby social support is actively sought and achieved, and every aspect of the aging process is improved and optimized by the psychological capital of a positive mindset.This study found six strengths that promote active aging by identifying a supporting role for seniors’ tourism value practices, and the key factors that explain the mechanisms of tourism value see . The intThe quantitative findings of this study show that the experience of traveling, and the number of trips undertaken, significantly reduce the risk of death among seniors. The cohort analysis undertaken as part of the studies’ survival analysis includes seniors who were highly educated, live in urban households, do not have chronic diseases, and had sufficient disposable income for travel, implying that tourism has long-term health effects. The qualitative findings of this study have identified the underlying mechanisms and relevant correlation arguments to underpin the quantitative results. The key finding of this study is that the health effect of tourism value for seniors lies in the process of active aging. Based on this finding, continuity, interaction, and orientation can be identified as the key issues that govern the extent to which tourism can play a positive role in active aging. Social emotion, spiritual perception, and instrumental support thus become the key driving elements of active aging. The identification of key personal traits and strengths of seniors explains tourism value and the health effect, and provides a strong analytical basis for explaining the health effects of tourism on seniors, translating the effectiveness of active aging and tourism value practices. These findings echo previous research on active aging, including Tung and Ritchie’s  five aspThe findings make several contributions to theory in relation to the role that a positive psychology perspective can play in supporting active aging. The empirical analysis of tourism value and its health effects on seniors utilized the survival analysis model with a time cohort and event type, highlighting the advantages of using tourism value in senior research. This study links the theoretical value of this correlation analysis to the role of positive psychology, deepening and extending the boundaries and conditions of the use of this theory. It thus provides a theoretical framework for identifying positive relationships and the value of positive psychology and emotions in senior research. Unlike the previous use of learned helplessness theory to explore the impact on seniors’ travel health , this stThe practical contribution of this study is mainly at the level of physical and mental health promotion, from the perspective of positive aging; in particular, sensory perception, feelings, emotions, and cognition of senior travelers. Existing media communication channels and government public relations content output could encourage seniors to explore their own traits, to encourage positive psychology and behaviors that maximize their personal strengths, thereby enhancing the value of their tourism experiences. The findings may also be useful in developing strategies that are designed to convince the public of the advantages of supporting physical and mental health programs for seniors. Programs of this type can lead to increased recognition of the individual value of seniors, and the need to fund programs that support the building of positive relationships, and strengthen the transmission of positive psychological behaviors. This study also provides practical implications for the diversified development of the senior tourism market and recreation tourism, reflecting the pursuit of “self-fulfillment” values of seniors, positively reversing the image of senior public health groups, providing more possibilities for active aging, and serving as a model for the unaged . The posThis study also has research limitations. Although the mixed research approach enabled the exploration of tourism value and health effects on seniors in some depth, the qualitative component of the study used a convenience sample, and the interviewees were all experienced in tourism, and had no underlying illnesses. This restricted sample was a major limitation. The narrative process of the positive aging of seniors in the interviews was also a limitation arising from differences in the narrative ability of older adults. The saturation of interview materials was another limitation. Future research could conduct additional dimensional screening of respondents, and a comparative study of the relationship between the presence or absence of underlying illness and frequency of travel on the value of travel and its health effects for seniors. An in-depth investigation through quantitative approaches to assess the tourism value indicators of active aging would also be worthwhile.


Unintentional non-fire related (UNFR) carbon monoxide (CO) poisoning continues to cause fatalities. The narrative verdicts from coroners concerning fatal UNFR CO poisoning in England and Wales, 1998–2019, were collated by the Office for National Statistics. Search terms related to CO exposure were used to obtain information regarding the circumstances of death. Findings were grouped by the location of death, the source of CO, and the reason or behaviour underlying the exposure. There were 750 deaths . The annual number of deaths decreased over the period studied. Two thirds (68%) of the deaths occurred in the autumn or winter. From the records with information, 59% of deaths occurred within a dwelling . Males also predominated deaths within vehicles (91%) and garages or outbuildings (95%). From the deaths with information, domestic piped gas was the most common source of CO (36%) and the most frequent underlying factor was inadequate ventilation of exhaust gases . Despite the decrease in the annual number of deaths over the study period, there remains a clear need for measures that raise awareness of the dangers of CO poisoning, especially amongst men working alone in garages or outbuildings. Education campaigns and fitting and maintaining CO alarms in high-risk areas should be encouraged. Unintentional, non-fire related (UNFR) carbon monoxide (CO) poisoning causes hospital admissions and deaths each year in the UK. Such incidents are largely preventable. CO is formed from the incomplete combustion of fuels, such as natural gas or petrol, but may also arise from more insidious sources, such as wood chip being stored as fuel, an apparently cold and used barbeque, and disused coal workings. Once inhaled, CO binds to haemoglobin (to form carboxyhaemoglobin), myoglobin, and mitochondrial cytochrome c oxidase. Not only is oxygen supply to tissues impaired, but oxidative phosphorylation is also inhibited. This sequence of events can lead to potentially permanent neurological damage or death, depending on the severity and duration of exposure . According to the UK Cross-Government Group’s 2019–2020 annual report . SimilarIn addition to collating data on fatal UNFR CO poisoning, it is also important to consider the morbidity caused by CO poisoning as this is potentially a burden on health care services too. Roca-Barcelo et al.  found anFor each death from UNFR CO, several heath care systems are probably accessed. These may include the emergency services, doctors’ certification of death, family bereavement services, and possibly mental health service interventions. In the post COVID-19 situation, where reducing the burden of preventable illness on health and on health services is essential, when a death can be avoided, the need to access all of these things on an already pressurised health care system can also be avoided. The clinical and public health effects of CO are well known and covered elsewhere ,10. The UNFR deaths in England and Wales, 1998–2019, that were recorded by the Office for National Statistics (ONS) were studied. Within this, the coroner narrative reports of each incident were gathered. The deaths were classified using International Classification of Diseases (ICD) codes .Inclusion criteria for the narrative search on UNFR CO deaths were based on meeting the criteria in ONS staff were asked to conduct a search of the text of the narrative reports to extract specific items that might provide more information on the circumstances surrounding the death. Such items included demographics (including age and sex), the characteristics of the place of death, CO source(s) in the place of death, and the reason or behaviour underlying the exposure, such as “gas ring left on” or “inadequate ventilation in a garage”. The initial text extracts provided by ONS were studied and three fields for summarising and capturing data were defined. These were: the place of exposure, the source of CO, and the reason or behaviour underlying the exposure. In total, 66 text terms for the place of exposure were allocated into 5 categories for analysis, 137 terms for the source of exposure were also allocated into 5 categorises, and 235 terms for the reason or behaviour underlying the exposure were allocated into 7 categories.The certification of the cause of death can be delayed by up to 18 months when an inquest occurs to establish the cause of death. Therefore, it may be several months before the death is registered. We chose to study the date of death as it is more accurate in terms of season and other time-dependent factors compared to the date of registration. To calculate the mortality rate per million population, ONS mid-year population data  were appAs the midpoint of this study period, the English index of multiple deprivation (IMD) scores for 2010 were derived from ONS  and codeFinally, postcode data were used to map the distribution of deaths and derive regional death rates. Postcode data from the usual residence (N = 741) and the place of death (N = 240) were available and both were geocoded, but the latter were excluded from the rates analysis. Data were analysed using MS Excel and STATA.15. We calculated crude average mortality rates per million population with 95% confidence intervals (CI) by country, region, sex, and age. Age standardised mortality rates for England and Wales were calculated using a direct standardisation method. There were 750 deaths, 77% of which were male . Nine deThe median age at death was 57 (IQR 41–74) years. Death rates were highest among those aged 70 and over, specifically among the 80 and over age group, and lowest in the <10 age group. The death rates of males were higher in all age groups except 0–9 and 90+ years, where they were the same as those of females. Deaths were highest in the autumn and winter months  compared to spring and summer .The highest average annual mortality rate from 1998–2019 was in Wales, with 1.25 deaths per million, followed by the Yorkshire and Humber region in England (0.85). The lowest rate was in southeast England with 0.4 deaths per million. After adjusting for age, the mortality rate for England was unchanged but reduced slightly for Wales (to 1.17 deaths per million).In England, there was a clear trend of increasing UNFR CO mortalities with increasing deprivation across both sexes. Half (51%) of these deaths occurred in the two most deprived quintiles of the population (four and five). In England, those in the lowest occupational classification had the highest frequency (32%) of UNFR CO related mortality, followed by the second lowest occupational classification (22%), i.e., 54% of deaths occurred in routine and technical occupations. However, the number of deaths of those in managerial, administrative, and professional occupations was also substantial. The analysis of deprivation and occupational classification among Welsh cases did not provide meaningful data due to the small number of deaths. There was information on the place of exposure in 74% of the deaths  and of these, almost 60% of deaths  occurred inside a dwelling . Of the Around 26% of deaths  occurred in places where CO alarms were unlikely to be present, such as vehicles, garages, sheds or workshops, containers, portacabins, greenhouses, and tents. The number of deaths in places where CO alarms were unlikely to be present increased to 30%  when temporary accommodation, such as campervans, caravans, mobile/park homes, and day boats, were included. There was information on the source of exposure in 63% of the deaths  . Of thesIn Wales, the main source of CO was solid or multifuel appliances (44%) rather than piped domestic gas (24%), which was the main source of CO in England (38%). Of the deaths involving domestic gas, 40% involved a central heating boiler, 20% involved a gas cooker, grill or hob, 18% involved a gas fire for space heating, 16% involved a portable gas heater (using a liquefied petroleum gas cylinder as the source), and 7% involved another source. In 15 (3%) deaths , the source of CO was a charcoal barbecue; these deaths occurred 2004–2019. In four (27%) of these deaths, the exposure occurred inside a tent without proper ventilation.There was information on the reason or behaviour underlying the exposure in 48% of the records. Of these, inadequate ventilation , such as running a vehicle engine inside an enclosed space, was the most frequent cause of poisoning, followed by a faulty appliance being used inside an enclosed space . Amongst the records with information for females, the most frequent reason or behaviour underlying the exposure was a faulty appliance (30%), followed by a blockage, such as a blocked flue or blocked air intake (26%). In England, the most frequent reason or behaviour underlying the exposure was inadequate ventilation (41%), followed by a faulty appliance (19%). However, in Wales, the most frequent reason or behaviour was a faulty appliance (37%) and then a blockage, such as a blocked flue or blocked air intake (26%). We have extracted data from coroners’ narrative reports and described the findings in terms of the place of exposure, the source of CO, and the reason or behaviour underlying the exposure. This was to gain a better understanding of the circumstances under which fatal UNFR CO poisoning occurred, which was the aim of the study and could help in the design of more focused and specific interventions for the prevention of CO poisoning. The study found that between 1998 and 2019, there was a steady decline in the annual number of deaths caused by UNFR CO poisoning. A similar trend has been found in other studies in England and Wales  as well There are many possible reasons for the decline in the annual number of deaths, including increased CO alarm installation. However, it is estimated that only approximately 19% of UK homes have a CO alarm, which is lower than smoke alarm installations . The perDeath rates were highest amongst males and the over 70s, particularly the 80 and over age group. This is consistent with previous studies ,18,22,23Deaths occurred in all months, with the most occurring in winter (42%). This trend has been observed in many other studies ,18,24,25Geographically, Wales was the region with the highest average annual rate per million and the difference between that and the rate in England remained after standardising for age. There were also differences between the regions of England, with Yorkshire and Humber reporting the most deaths per million population and the southeast region reporting the lowest. There could be many reasons for these differences and the reported numbers in Wales were relatively small, making it difficult to draw clear comparisons to the data for England.A study on hospital admissions for UNFR CO poisoning in England found higher rates of admissions in the northeast, with lower rates in the south . Wales wThe clear trend of increasing UNFR CO mortality with increasing deprivation in England likely reflects poorer housing standards and the poorer maintenance of heating appliances. People living in such accommodation may also be less aware of the dangers posed by CO in domestic situations. To reflect the fact that each nation in the UK is responsible for its own health service, efforts were made to analyse the data for England and Wales separately. However, with just 83 deaths in Wales across the study period, deprivation-based analyses were not possible. The greatest number of deaths occurred inside the home. Dwellings contain many potential sources of CO and some individuals (such as the elderly) tend to spend most of their time inside their homes. This is consistent with findings from the NPIS  and in t−3) in properties that were subject to energy efficiency measures where purpose provided ventilation was not included as part of the retrofitting scheme.In recent years, there has been a drive to increase energy efficiency within the home; this has had the knock on effect of reducing ventilation and trapping poisons, such as CO, inside the home . ShrubsoEducation campaigns are essential to also raise awareness of the risk of CO poisoning away from home to ensure that individuals remain alert to potential exposures and consider taking a portable CO alarm with them. The number of men who died in a garage, outbuilding or vehicle points to the need for targeted prevention strategies.Exposure in temporary accommodation accounted for 9% of deaths. Online accommodation rental company Airbnb, as well as other similar companies, include the presence of a CO alarm as one of their features in accommodation listings . The most common source of CO poisoning was exposure from domestic piped gas appliances. This was expected as piped gas is the most common fuel used for heating in the UK. It is reported that around 80–85% of the UK population use gas-fired systems (mains gas or liquid petroleum gas from cylinders), although figures do vary by region and country ,27.Fewer deaths per million population occurred from the incomplete combustion of gas fuels in Wales compared to England and there were proportionately more deaths involving solid or multifuel appliances. This may be because Wales has many rural areas that are not connected to a piped gas supply. Urban areas have higher levels of piped gas supply, with pockets of solid fuel use in Wales and Yorkshire and oil use in Wales, Yorkshire, and the east of England . The BuiOf the reports with data, using an appliance or machine with the inadequate ventilation of exhaust gases was by far the most frequent reason for death.Many accidental CO poisonings and deaths following disaster remediation have been documented . In one Of the data sources that are readily accessible to health professionals, ONS mortality data are relatively more complete and easily accessible in terms of capturing UNFR CO deaths. However, delays of up to 18 months between the date of death and the date of the registration of the death can occur. Thus, it is likely that the UNFR data for CO poisoning deaths that occurred in 2018 and 2019 presented here are incomplete.It appears there is also uneven reporting by coroners on this topic, with some narrative verdicts being more extensive and providing more detailed information than others. Some of the key fields that were analysed had missing data. To obtain the country and region of death, the postcode of the usual residence was used as this information was more complete than the postcode of the place of death. However, the actual location of the death may have been very different from the postcode of the residence. Moreover, when investigating occupational differences, many of the fields for coding SOC90 and SOC20 into NSSEC were incomplete.From these data, we did not have information on other people involved in the incidents, but work by Fisher et al.  demonstrThere is also a lack of comparability between the English IMD and the Welsh IMD as they include different factors, which made it hard to compare the figures for both countries and is part of the reason why the Welsh IMD was omitted from the results. When analysing the occupational status data, there have naturally been significant changes in the meanings or categorisations of some occupations over the study period in terms of the coding differences between SOC90 and SOC20 and also in terms of the coroners’ recording of certain occupations and the translation of these codes into the NSSEC index, which could not be accounted for in the results. It is important to inform coroners of the results of this work and to highlight its value in improving future data collection. For example, it would be important to record how many of these deaths had a CO alarm fitted in the area where the death occurred in order to inform awareness campaigns. Audible CO alarms need to be installed and function correctly to be effective . MoreoveWithin the home, the correct installation, maintenance, and safe use of appliances and the location of CO alarms are important . VehicleDeaths due to UNFR CO poisoning in England and Wales have decreased over time. However, fatalities still occur, especially in certain circumstances, such as in more deprived populations, males working in outbuildings or garages, and amongst the elderly. Prevention strategies should target not only increasing awareness of the dangers of CO, but also the installation and maintenance of CO alarms, especially in garages, outbuildings, and temporary accommodation. The proper installation and regular testing of domestic gas appliances is also important. Coroners have a valuable role in documenting the facts and circumstances associated with UNFR CO poisoning deaths.