The worldwide aging trend requires conceptually new prevention, care, and innovative living solutions to support human-based care using smart technology, and this concerns the whole world. Enabling access to active and healthy aging through personalized digital coaching services like physical activity coaching, cognitive training, emotional well-being, and social connection for older adults in real life could offer valuable advantages to both individuals and societies. A starting point might be the analysis of the perspectives of different professionals  on such technologies. The perspectives of experts in the sector may allow the individualization of areas of improvement of clinical interventions, supporting the positive perspective pointed out by the intrinsic capacity framework.The overall aim of this study was to explore the cross-national perspectives and experiences of different professionals in the field of intrinsic capacity, and how it can be supported by eHealth interventions. To our knowledge, this is the first study to explore geriatric care providers’ perspectives about technology-based interventions to support intrinsic capacity.A survey involving 20 geriatricians or clinical experts in the fields of intrinsic capacity and active and healthy aging was conducted in Italy, France, Germany, and Japan between August and September 2021.The qualitative findings pointed out relevant domains for eHealth interventions and provided examples for successful practices that support subjective well-being under the intrinsic capacity framework . Moreover, eHealth interventions could be used as a bridge that facilitates and enables social engagement; an instrument that facilitates communication between doctors and patients; and a tool to enrich the monitoring actions of medical staff.There is an unexplored and significant role for such geriatric perspectives to help the development process and evaluate the evidence-based results on the effectiveness of technologies for older people. This is possible only when clinicians collaborate with data scientists, engineers, and developers in order to match the complex daily needs of older adults. The challenge of supporting and promoting active and healthy aging (AHA) as “the process of developing and maintaining the functional ability that enables well-being in older age”  concernsEvidence on interventions designed to support the intrinsic capacity framework is of paramount relevance for older people, as they may allow personalized strategies to be put in place to support the independence and resilience of older people. However, numerous studies in the field have identified research trends and gaps that need to be solved to effectively integrate the intrinsic capacity framework with more traditional therapies and treatments .The perspectives of health professionals and stakeholders are essential to understand not only how to design intrinsic capacity–integrated and technology-integrated interventions, but also how to assess the improvement in intrinsic capacity domains after conducting those interventions, as an assessment tool to identify improvements in intrinsic capacity as a whole (not only as a sum of domains) is still missing ,30.A starting point in this sense might be the analysis of perspectives from different professionals, like geriatricians, on such technologies. The perspectives of experts in the sector may allow the individualization of areas of improvement of clinical interventions, supporting the positive perspective pointed out by the intrinsic capacity framework, which is more in favor of a person-oriented approach than a disease-oriented approach, allowing the greater personalization of any clinical intervention. Therefore, the relevance of this study involves the identification of existing research trends and possible gaps with experts in the field, which should be applied in the near future when designing technology-based interventions.The overall aim of this study was to explore the cross-national perspectives and experiences of different professionals in the field of intrinsic capacity, and how it can be supported by eHealth interventions . The specific research goals falling under this aim are as follows: (1) to collect information about which everyday practices can increase and sustain intrinsic capacity in the older population; (2) to identify what kind of technology could support the related practices; (3) to understand which technologies were useful to support the functional ability and quality of life of older people during the COVID-19 crisis; (4) to analyze the gender differences in planning interventions to support the intrinsic capacity and functional ability of older people, even considering eHealth interventions; and (5) to map the positive and negative aspects of the intrinsic capacity framework, even considering the possible roles of technologies. To our knowledge, this is the first study to explore the perspectives of geriatric care providers regarding technology-based interventions to support intrinsic capacity. Therefore, it contributes to the literature by demonstrating that there is an unexplored and significant role for such geriatric perspectives to help the development process and evaluate the evidence-based results on the effectiveness of technologies for older people. However, only when clinicians join forces with data scientists, engineers, and developers and when innovative technologies match the complex daily needs of older adults will we be able to exploit the full potential of these technologies . This stOwing to demographic changes, decreasing numbers of care professionals, and dissolving family structures, all arguments are now turning toward digital solutions to support elderly care and prevention. Innovative approaches can support older people in managing their health and well-being; however, this is only possible if all beneficiaries are consulted and if they have sufficient ICT literacy and can access affordable and interoperable solutions that facilitate collaboration among older adults, their informal and professional health carers, community members, and policy makers.Thus, it was planned to adopt a user-centered and value-sensitive participatory design approach in all phases of the e-VITA project, in collaboration with different stakeholders in all participating countries, considering their engagement as a crucial means to ensure the sustainability, acceptance, and uptake of e-VITA in European countries and Japan.The exchange of good practices and the inclusion of stakeholders in all the countries will support local governments to adopt and adapt policies for AHA in Europe and Japan on a cross-national basis to build a reasonable support system that is sustainable as it fulfills the real needs of older adults, considering different cultural perspectives.In the first phase, the cross-national approach has been applied to the analysis of the attitude toward virtual agents, such as e-VITA, in Italy, France, Germany, and Japan. Italy has a strong emphasis on family-based care for elderly people. Traditionally, Italian families take on the responsibility of caring for their aging relatives. However, with changing societal dynamics and increased mobility, the demand for formal care services has grown. The Italian government provides various support measures, such as financial aid and home care services, to assist families in caring for their elderly members. There are also nursing homes and assisted living facilities available for those who require more specialized care. In France, there is a comprehensive social welfare system that provides assistance to elderly people. The government operates a national health care system that includes coverage for long-term care services. Elderly individuals can receive home care services, such as help with daily activities, nursing care, and domestic assistance. Additionally, there are nursing homes and residential care facilities available for those who need more intensive care. The French government also provides financial aid and benefits to low-income seniors to ensure their well-being. Germany has a well-developed system of social protection for elderly people. The country has a mandatory long-term care insurance program that provides coverage for long-term care services. Elderly individuals can receive assistance with personal care, nursing, and household tasks through home care services. The German government also supports the development of community-based services and encourages independent living for seniors. Nursing homes and assisted living facilities are available for those who require round-the-clock care. In Japan, the care and support provided to elderly people are characterized by a combination of family involvement, community-based care, and formal care services. Similar to Italy, Japan places a strong emphasis on family-based care for elderly people. It is culturally expected that children will take care of their aging parents. Many elderly individuals live with their adult children or nearby, and families often provide primary support and assistance. Moreover, Japan has a well-developed system of community-based care services. Local governments and community organizations provide a range of services to support independent living for seniors. These services include home help, meal delivery, transportation assistance, social activities, and health monitoring.An essential phase of the e-VITA project is linked to the mapping of indicators and practices that facilitate stable good health conditions through consultation with relevant international experts in intrinsic capacity and AHA. Therefore, a survey involving 20 geriatricians or clinical experts in the fields of intrinsic capacity and AHA was conducted in Italy, France, Germany, and Japan between August and September 2021. The survey aimed to collect information on which everyday practices increase the intrinsic capacity and subjective well-being of older adults and how digital coaching can offer support in this process.It was conducted using a semistandardized questionnaire formulated in English and then adapted to the language of the respective country . The survey consisted of the following 5 topic sections populated by open questions see :Topic 1. Clinical expert perspective: This section aimed to collect information about which everyday practices can increase and sustain intrinsic capacity in the older population .Topic 2. Technology enhancement: In this section, experts can indicate what kind of technology they suggest for supporting the intrinsic capacity practice.Topic 3. Supporting intrinsic capacity during COVID-19: This section focused on the identification of which technologies were found useful to support the functional ability and quality of life of older people by experts during the COVID-19 crisis.Topic 4. Gender considerations: This section was devoted to analyze the gender differences in planning interventions to support the intrinsic capacity and functional ability of older people.Topic 5. Aspects of intrinsic capacity: This closing open question aimed to gather information on the positive and negative aspects of the intrinsic capacity framework, and the improvements and future areas of interventions to support older people.An invitation email was sent to invite the experts and to explain the objectives of the project as well as the aim of the survey. An informed letter was attached to the email, and the experts were kindly invited to visit the project website  as a repThe procedures and approaches adopted during all design activities of the e-VITA project are in accordance with the ethical standards and have been approved by the Ethics Committee of Siegen University .Sensitive and private data were covered by informed consent in each participant’s own language, in accordance with the ethical standards on human experimentation , the GDPR  2018, and the national legislations on privacy and data protection.The experts recruited for the survey in Germany are network partners of the Diocesan Caritas Association for the Archdiocese of Cologne. They were contacted by email. The email explained the aims of the survey and contained the questionnaire and an informed consent form. The informed consent form was filled out digitally by the study participants and returned together with the questionnaire.In France, the experts were recruited through the Broca Living Lab network. An email invitation was sent to the experts. The email explained the objectives of the project and the purpose of the questionnaire, and contained the questionnaire. If they agreed to participate, the experts returned the completed questionnaire by email. (INRCA). An invitation email was sent to invite the experts. The email explained the objectives of the project and the aims of the survey. If they agreed to participate, they signed the informed consent form attached to the email and answered the questions on the questionnaire. All participants returned the signed informed consent form and the questionnaire by email.In Italy, the experts were recruited within the hospital units of the National Institute of Health and Science on AgingIn Japan, the experts were recruited within the National Center for Geriatrics and Gerontology (NCGG) and through the network of the eHealth intervention Japanese partner. An invitation email was sent to invite the experts. The email explained the objectives of the project and the aims of the survey. If they agreed to participate, they signed the informed consent form attached to the email and answered the questions on the questionnaire. All participants returned the signed informed consent form and the questionnaire by email. In total, 5 experts were recruited.Individuals who took part in the study were provided with and asked to sign a written informed consent form regarding data.Data were collected and analyzed in the native language of each site, and then, the local results were translated into English and combined cross-nationally. Local questionnaires and the national findings were analyzed using the framework analysis method ,33. The A total of 20 experts in the field were recruited . However, 1 questionnaire had to be excluded from the qualitative analysis of the open-ended questions owing to missing answers. The different topics are presented below. The most frequent sets of codes and findings are discussed in each paragraph and reported in Across all countries, the experts agreed on the value of physical  and social activities  as the main everyday practices that can increase and sustain the intrinsic capacity of older people. Indeed, all physical activities like any kind of sports  as well as the independent performance of household chores and the active pursuit of hobbies can prevent frailty symptoms and preserve physical functioning. Some responses were as follows:In ageing research, the relevance of physical activity is very often pointed out. The empirical studies to date show that regular exercise, for example, reduces the risk of developing frailty symptoms , which in my view greatly influences a person's intrinsic capacity.Participant ID: DE_EXP_04The promotion of lifestyle activities is mandatory to avoid physical decompensation and to sustain physical and mental health.Participant ID: IT_GER_04Moreover, nutrition as well as a healthy and balanced diet  was a significant determinant to have enough energy and strength to participate in physical activities. One participant commented as follows:All the physical activities empower social activities such as going to the cinema, the theatre, the interactions among individuals, family members, and health care professionals.Participant ID: IT_GER_05…having dinner with friends or family, looking after grandchildren, being an active member of an association.Participant ID: IT_GER_05Other ranked activities cited by half of the European experts were cognitive activities  related to intellectual and affective-relational stimuli and self-care . European and Japanese geriatricians  underlined how regular health status monitoring is important to identify any deficits or medical problems at an early stage and thus perform appropriate interventions. In this specific case, health literacy was seen as basic knowledge for self-management.According to the respondents, physical , cognitive , and social  interventions based on technology could improve physical activities and social connections, as well as self-esteem and well-being. This improvement could lead to a general overcoming of the anxiety in performing daily activities that may contribute to the sensation of mental fatigue. For example, the respondents imagined that technology-based interventions could track adequate nutrition and hydration using a daily diary  and physical activities using geolocalization tools  and reminders.These tracking measures could also be shared with other older adults to exchange experiences and support each other as in a virtual community. This could lead to approaching the need for social connections at the same time. Indeed, integrating eHealth interventions into everyday life or using programs to create interactions between humans and virtual coaches could help people fulfill their wishes and enjoy their hobbies. Based on their clinical experience, the experts underlined that individuals often do not know exactly what they like, so it is essential to implement a function that proposes a list of enjoyable activities and assists them in performing the activities. Indeed, the importance of offering support, motivational tips, and suggestions was underlined  as a key to fostering positive engagement. Moreover, the service should be personalized  considering that due to the heterogeneity of the target, some older adults prefer to be “active” users who maintain control and want the feeling of power, while others require more direction.Moreover, the use of virtual coaches, smartphones, and computers would facilitate these activities. Indeed, these devices would make it possible to centralize different applications covering broad areas, for example, by offering gymnastic applications to strengthen muscular capacities and encouraging outdoor activities , which can then improve social links. These tools also help to promote cognitive abilities by proposing personalized activities that can be close to home or remote, such as visiting virtual museums. Additionally, user autonomy can be encouraged through calendars, lists, and banking applications.Regarding e-coach interventions, some experts  underlined the importance of having the easiest interface as a significant component of any kind of technology designed for older adults. This includes the use of clearly understandable icons and control through voice interaction as the most natural way of communication. In addition, suggestions were made to combine technical and human support.For example, 1 participant proposed that supermarkets should be geared to the needs of older people and that shopping should be planned using apps:Supermarkets for older people with products at eye level and large numbers, checkouts with friendly staff who take their time. Apps that suggest products to order through pictures.Participant ID: DE_EXP_05Moreover, physical training should be promoted by supporting technologies where appropriate. One participant commented as follows:…exercises to strengthen the muscles, possibly guided by artificial intelligence (AI) and measurement of the muscle tissue to monitor success.Participant ID: DE_EXP_06To maintain mobility, the experts also suggested using technology to make trips more predictable. This includes the identification of possible barriers that the user might encounter on the way, the use of public transport, and the knowledge of public toilets.To promote social participation in the community, the experts advised social networks to connect users (possibly with similar interests) and mention where people can offer their help in specific areas . One participant stressed the concept of technologies that cooperate with clinicians:I cannot imagine a future in which any electronic device or e-coach will replace humans in supporting older patients. I think that an extremely useful action would be to implement technology‐based services delivered and managed by healthcare and other professionals. To note, I am not saying that technology is not important but some “human functions” cannot be replaced.Participant ID: IT_GER_03During the COVID-19 emergency, the surveyed participants made extensive use of video communication and social apps to establish contact and opportunities with their patients . In Germany, such platforms were used even for online education to support the functioning and quality of life of older people during the lockdown. Indeed, these tools allowed older adults to maintain social links and even promoted physical activities. All the experts reported that the use of such remote modalities was very important to decrease the sense of social isolation, uncertainty, and powerlessness during the period of social distancing. This represented a very important tool to increase mental well-being and social engagement.The surveyed participants underlined that a virtual coach should account first for individual differences and then, in some cases, for gender . The experts usually planned their interventions by accounting for individual differences (characteristics and preferences of the person). Nine of them suggested that empathetic communication, discussions or reactions involving the user, and the different physical abilities between men and women should be definitely accounted for, considering gender differences. Moreover, the user could choose the gender of the coach. The participants commented as follows:I'm not sure if there are really gender differences or if they don't break down more and more in the next years and one should pay much more attention to the individuality of the person and generalized approaches based on gender characteristics don't lead to achieving the outcome. Technological support for crochet can also be interesting for men.Participant ID: DE_EXP_01…make sure to personalize the intervention according to the patient's wishes and interests, their previous lifestyle.Participant ID: FR_GER_01Make a fair assessment. No gender difference but depends on the person's abilities/personalities/ understanding interests.Participant ID: FR_EXP_03One participant described that gender-specific differences should be considered especially against the background of age, culture, and religion:A distinction must be made here depending on age and also in relation to culture. A gender-specific consideration is necessary around age, as gender-related attributions still play a major role here. e.g. for women, domestic activities and handicrafts, and for men, e.g. playing Skat, handicraft-related tasks, early morning hopping. The younger the people are, the more the activities are similar. In general, however, there is always a cultural and religious distinction.Participant ID: DE_EXP_06Another participant commented as follows:Even though women were considered at risk of increased functional capacity with aging, today we are seeing how such differences are becoming less evident, thanks to improvement of lifestyles and social engagement of women.Participant ID: IT_GER_04The following specific suggestions regarding the virtual coach were shared: the language and choice of words could be individually adapted by the user, the gender of the coach could be individually selected, and the difference in physical abilities between men and women should be taken into account.The importance of communicating the information differently was mentioned:Women are often more receptive to prevention advice. For men it seems more important that they understand the direct individual benefit of interventions. When men are in a couple, it is sometimes interesting to go through his wife to get the messages across.Participant ID: FR_GER_02Participant FR_EXP_04 explained that people are addressed and interventions are planned according to the “bio-psycho-social level. From a cultural and developmental point of view,” which explains why sometimes the interventions are not the same according to gender.Other geriatricians commented as follows:Preservation of intrinsic capacity needs to be particularly targeted in women, since they are more prone to develop functional disability over time compared to men of the same age.Participant ID: IT_GER_05Women are more prone to locomotion and cognitive decline, and prefer group activities, while men have general characteristics such as a preference for solo activities, and it is necessary to understand these characteristics while giving consideration to individuality.Participant ID: JP_GER_01Regarding physical activities probably men and women should practice more different domains . Women are more prone to socialization and less close to accept a device like that (I suppose). When trying to implement empathetic discussions or reactions to the user, gender should be definitely accounted for.Participant ID: IT_GER_03The participants commented as follows:The intrinsic capacity framework is full of positive aspects. Indeed, it may improve self-wellbeing through enhancement and preservation of baseline capacities. It would be important to provide patients with appropriate tools and technologies to support choices and to speed up the recognition of individuals at risk of decline.Participant ID: IT_GER_04The intrinsic capacity Framework pushed the importance of prevention compared to treatment and of the preservation of physiological reserve compared to the disease-based approach.Participant ID: IT_GER_05The advantages of the concept were recognized as follows:It considers the person as a whole, ie, psychological as well as physical aspects are included.Participant ID: DE_EXP_04However, the same expert also stated the following:The concept of intrinsic capacity is based on the assumption that all persons have the same  resources to maintain or improve their own intrinsic capacity and mentions that it is often described in the literature as having been developed for the “privileged group” of older persons.Participant ID: DE_EXP_04This is particularly significant in light of the fact that research shows that social and environmental contexts lead to negative health outcomes. Therefore, the development of the e-coach should also take into account people who, for example, have limited financial resources or few digital or health-related skills.For participant FR_GER_02, intrinsic capacities are important to take into account because their decline leads to a loss of autonomy. However, for this expert, these intrinsic capacities are sometimes complicated to understand for elderly people:Intrinsic capacity's definition and evaluation are complicated for the elderly.Participant ID: FR_GER_02Another participant commented as follows:However, this concept is often difficult to understand by the elderly because the decline in intrinsic capacities sometimes goes unnoticed and is only little taken into account by carers. It is also little sought after by carers who are often focused on the loss of autonomy: It would be appropriate to better communicate and raise awareness of the concept of intrinsic capacities among older people and carers.Participant ID: JP_GER_01The promotion could be valuable since “the positive aspects of intrinsic capacity are related to health and longevity and are useful for self-management” [Participant ID: JP_GER_01] and “many elderly people recognize that maintaining their intrinsic abilities is in itself a positive aspect” [Participant ID: JP_GER_03].Another participant commented as follows:In terms of improvements and future areas of intervention to support older people, the implementation of the intrinsic capacity framework should ensure to sensitize both health care professionals and individuals on the importance of intrinsic capacity and functional capacity.Participant ID: IT_GER_05This comment indicates that the promotion of intrinsic capacity is intended for not only older adults and their caregivers but also all clinical staff.Moreover, 1 participant stated:A fair assessment of the functional capacities and the impact on the person's life should refer to the functional abilities and the impact of their loss on the older person, as some people will accept and regulate their living conditions, while others will suffer and may increase this loss.Participant ID: FR_EXP_03If there is a negative aspect to intrinsic capacity, “it is spiritual distress over the fact that actual physical functions are declining compared to the ideal or desired physical functions” [Participant ID: JP_GER_03].On the other hand, another participant commented as follows:Intrinsic capacity is the capacity or ability of an individual person, and a person's sense of value. We had better think of it as a positive or negative aspect, but rather as a way to capture individual abilities.Participant ID: JP_GER_05Furthermore, how intrinsic capacity could be supported by a virtual coaching system is seen in the fact that it could improve the general well-being of users, potentially support people to live independently at home for as long as possible, and support their health safety. The participants commented as follows:It could offer a multitude of activities concerning cognitive stimulation , physical activity  and promoting social contacts . And, the virtual coaching system should take into account ethical considerations, in particular the fact of not infantilizing, of respecting the user's free will, the user's capacity to make choices and of proposing personalized interventions since a human is by definition not a machine, he does not behave in a uniform manner. This system is disturbing in its reduction of humanity to a norm.Participant ID: FR_EXP_04It is questionable whether every person can afford this technology. In addition, isolation in a technology-infused home could occur and social contacts could be pushed into the background.Participant ID: DE_EXP_03The interest of the users could decrease and that suggestions from the coach are not accepted or are perceived as annoying.Participant ID: DE_EXP_05This study aimed at identifying and analyzing (1) which everyday practices can increase and sustain intrinsic capacity in the older population; (2) what kind of technology could support the related practices; (3) which technologies were found useful to support the functional ability and quality of life of older people during the COVID-19 crisis; (4) the gender differences in planning interventions to support the intrinsic capacity and functional ability of older people, even considering eHealth interventions; and (5) which are the positive and negative aspects of the intrinsic capacity framework, even considering the possible roles of technologies.The qualitative findings point out relevant domains for eHealth interventions and provide examples for successful practices that support subjective well-being under the intrinsic capacity framework. From Topic 1 , participants agreed on the value of physical and social activities as the main everyday practices that can increase and sustain the intrinsic capacity of older people. The relevance of supporting physical activities and social connectedness, especially through technology, is in line with the literature in the field of multicomponent interventions to support older people’s well-being, as demonstrated by large clinical studies, such as MyAHA , FINGER Moreover, in the results of Topic 1, it emerged that the eHealth intervention could promote health literacy. Since low health literacy is associated with worse health outcomes -37, the From the main results of Topic 4 (gender considerations), the experts enrolled in this study explained how they usually plan their interventions by accounting for individual differences (characteristics and preferences of the person). They suggested that empathetic communication, discussions or reactions involving the user, and the different physical abilities between men and women should be definitely accounted for, considering gender differences.Various practices were analyzed from a gender perspective through the literature. For example, the high frequency of social participation activities is an important driver of well-being and better health for older women and men, and should be a focus of any technology-based intervention. Even if older men are less involved in social activities, they are more sensitive to loneliness and tend to need a closer social circle . AnotherThe positive effect of physical activities on the health and well-being of older people, regardless of gender, is a known factor, and technologies should therefore be a support in the practice of the activities, offering different formulas and regular monitoring of the completion of the activities. For women, the e-coach system could look at the internal motivations , and for men, it could focus on external motivations such as the competitive aspect and playing sports in a group ,53. FinaIntrinsic capacity can be supported by digital interventions to improve the general well-being of users, but a great effort is needed to promote the concept among clinicians, caregivers, and patients. The goal of supporting the intrinsic capacity of individuals through eHealth interventions is an important one, as it enables people to maintain and enhance their physical and mental abilities, promoting healthy aging and overall well-being. eHealth interventions refer to the use of electronic means, such as digital platforms, mobile apps, and remote monitoring devices, to deliver health care services, information, and support. It is crucial to ensure that eHealth interventions are accessible, user friendly, and tailored to the specific needs and capabilities of the target population. Regular evaluation and feedback from users and health care professionals can help refine and improve these interventions over time. By leveraging the power of technology, eHealth interventions have the potential to effectively support and enhance the intrinsic capacity of individuals, empowering them to lead healthier and more independent lives . NowadayWhile this study benefitted from including a survey for professionals across Europe and Japan, linguistic barriers may have limited the quality of the survey. The data collection was conducted in the national language, and then, the data were translated from the native language to English. Thus, the results could have been impacted by this language switch. The use of software programs for qualitative analyses counteracted this issue. Despite this, the survey captured the main reflections and experiences of the participants from cross-national and multi-language perspectives. On the contrary, the specific national centrality of Italy, France, Germany, and Japan, as well as gender disparities in sample size could have introduced biases and could be seen as significant limitations that do not allow for the generalization of the results. Furthermore, the use of qualitative analysis in combination with a semistandardized questionnaire instead of a mixed-methods approach, which could have guaranteed a broad understanding of thoughts and emotions toward the use of eHealth interventions, could be considered another limitation of this study. The open-ended questions in the questionnaire provided only limited scope for answers, and in-depth enquiries with the experts were not possible owing to the design. Moreover, the data collection was performed during the pandemic period across all countries, and this situation could have impacted the thoughts and emotions of the respondents. Another limitation is related to the sample size. Although there is no commonly accepted sample size in qualitative studies, in this research, purposive sampling -60 was uThis research study explored the opportunities of eHealth interventions designed for older adults according to the perspectives of a sample of professionals in the fields of AHA and intrinsic capacity from Europe and Japan. Indeed, digital coaching seems to be very promising and able to sustain physical activity coaching, cognitive training, emotional well-being, social connection, etc, for older adults in real life. These multicomponent interventions could offer valuable advantages to both individuals and societies, and therefore help in mitigating the need for new prevention, care, and innovative living solutions, as already highlighted by the results collected with older people in a similar study .Through the qualitative analysis discussed in this study, the importance of the perspective of experts was underlined to demonstrate that there is an unexplored and significant role for such a geriatric perspective to help the development process and to evaluate the evidence-based results on the effectiveness of technologies for older people. This is possible only when clinicians collaborate with data scientists, engineers, and developers in order to match the complex daily needs of older adults. This synergy needs to be driven, and there is an urgent need to strengthen data, research, and innovation to accelerate the implementation of eHealth interventions in order to meet the interests and needs of the aging society, especially with the hindsight of the COVID-19 pandemic, which revealed the need for improvement in all health services.Future developments should include the involvement of all stakeholders in the service, such as older adults as potential users and technical or digital health experts in geriatric care. Moreover, implementation approaches and recommendations to specifically translate the conclusions of the study should be planned.


The findings from this study result in a novel consensus-based framework for health-promoting eating behaviors that can form the basis for collaborative work towards the integration of physical and mental health promotion.Eating behaviors and patterns are one of the key behavioral indicators of health, and as such these behaviors are a focus of interest across different areas of scholarship. Yet, to date, work in this area is impeded by the lack of a collective theoretical framework to conceptualize, assess, and intervene upon eating behaviors. The aim of this study was therefore to establish a consensus-based framework for health-promoting eating behaviors using a Delphi methodology. An initial systematic search identified constructs that yielded 150 items grouped into three topic areas: (1) the content, types of food and nutrition provided; (2) eating behaviors; and (3) thoughts and feelings related to eating and foods. Over the course of three iterative rounds of rating by a panel of  Eating behaviors and diet are now well-established as one of the principal contributors to positive physical and mental health status and lower mortality . Indeed,The predominant definition of healthy eating relies on an energy balance model of weight maintenance that targets controlled caloric intake  and energy expenditure  . The eneAlternative models of healthy eating that include other dimensions have recently emerged, notably the intuitive eating ,13, the Thus, the existing models of health-sustaining eating behaviors are limited by their respective narrow focus on certain aspects of eating with either accounting for nutrient content and energy density on the one hand, or solely psychological context on the other. These very separate conceptualizations and different understandings of the mechanisms of action, in addition to different outcomes of interest constitute a barrier to common concerted efforts to better characterize holistic health-promoting eating behaviors and identify modifiable targets with a view to improving intervention efforts. Moreover, an important weakness of all these frameworks is their failure to explicitly consider the perspectives, needs, and values of groups of people who have been framed as “at risk” in terms of healthy eating. These groups may include those experiencing food insecurity, low food accessibility, oppression, or disability, or those who have been engaging in chronic rigid and restrictive eating patterns due to the Western abundant food environment coupled with unattainable appearance ideals ,20. WhilThe current study utilizes the Delphi method by inviting experts across different fields to make independent ratings on a series of statements across several rounds. These ratings were then used to produce a final set of statements that represent a consensus from the group. The process utilized four steps, as previously described . The firn = 26 to n = 47 [Given the observation that discipline-specific conceptualizations and methods were among the major barriers to advancement in this area, experts were sought from a range of areas of scholarship  as well as specializations and trainings . In addition, efforts were made to maximize the diversity of the expert pool in terms of gender, seniority, race/ethnicity, and other identities. Expertise was determined through involvement in research and scholarship and/or clinical practice, the development of previous measures of eating behaviors, and the participation in the development of relevant guidelines or reports. Experts were contacted via email containing information regarding the study goals and procedures as well as a participant information sheet. The goal was to recruit approximately 30 panel experts to allow for diversity and in anticipation of attrition across the study rounds ,24. Indeo n = 47 ,26n = 9), a second group of 44 additional experts was identified and contacted. The second pool of experts was identified with particular concern to diversity as well as more personalized invitations. Together, these efforts yielded a total of 37 experts who participated in the first round of the study. The majority of participants were female (86%) who identified as White (62%), while others identified as African American/Black (17%), Hispanic (12%), and Asian (4%). Some participants reported more than one racial/ethnic background. Participants were aged on average 53.7 years old (SD = 7.88). A total of 24 experts responded to the Round 2 survey (64% of Round 1). The third and final round survey was completed by 23 experts (95% of Round 2).An initial group of 30 expert participants was contacted to complete the first round of the survey. Given the low response rate , Nutrition , Obesity and Overweight , Public health, Governmental Guidelines or Programs , Weight Stigma or Health Disparities , or Other . The 5 individuals reporting “Other” specified their backgrounds, which included professions such as Eating and Dieting Behavior and Epidemiology. Participants indicated their primary field of expertise from a list of five options: Eating Disorders  were searched for key terms, and the first 20 sites for each term on each search engine were recorded. The search terms included: healthy diet, healthy eating, healthy eating behavior, and healthy nutrition. Duplicate websites were removed throughout the process. Relevant books and publications by expert authors were also located via references or knowledge. The search generated a list of concepts and statements that were then utilized to generate the pool of items to be rated by the expert panel participants. Following previous methods , two memThis process rendered an initial pool of 150 statements to be rated in the first survey, that were organized into three overarching themes. The first included items focused on the content, types of food, and nutrition provided. The second theme included items focused on eating behaviors, and the third theme included items focused on thoughts and feelings related to eating and foods. In the first round of ratings, participants were invited to provide feedback on the items and suggestions for changes to wording as well as the inclusion of additional concepts. The online survey asked participants to rate each item on a 5-point scale  indicating how important it was to include the item as contributing definition for “healthy eating”. Survey items were rated according to the widely used matrix in previous studies. The following criteria were used: If endorsement rate was between 90% to 100%, and most experts agree that the item should be retained, it was included for the following rounds. If endorsement rate was between 80% to 89% percent, experts did not reach a consensus that the item should be retained and it would then be included and re-rated in the following rounds. During the final round, items within that range that did not receive full endorsement were excluded from the final consensus. If endorsement rate was below 79%, then the majority of experts did not endorse the item, and hence would be excluded in the following rounds. At the end of the first round, the expert feedback and suggestions for modifications or additional inclusions was reviewed, and modifications were made for the second round. The study was approved by the relevant institutional review board. No compensation was provided. Expert panelists were contacted via email with an invitation to participate as well as the link to the first survey. The survey contained a link to a separate sheet in which panelists were invited to provide their email such that they could then receive the link to the second and third rounds of ratings. Thus, responses were anonymous. With the links to the second and third round of ratings, participants received a report of the results from the previous round of ratings at the group level and were invited to use this information in making their subsequent evaluations. At the end of the study, participants received a final report detailing the items that were ultimately retained. https://www.who.int/news-room/fact-sheets/detail/healthy-diet) (accessed on 15 October 2020) as well as largely unmoderated forums or opinion blogs focusing on weight and shape control  (accessed on 15 October 2020). Of the 150 items presented to the panel, 123 were endorsed by 79% or fewer of the experts and were therefore not moved forward to the next round of ratings (see The systematic review revealed a variety of sources, including international guidelines (e.g., ings see . Based oings see . For a fEating behaviors and patterns are associated with short- and long-term physical and psychological health impacts . As suchThe results of the systematic review conducted to identify the items to be included for rating by the expert panelists led to the identification of three main areas or themes. The first was related to content, types of food and nutrition provided, the second focused on eating behaviors per se, and the third included thoughts and feelings related to food and body image. The inclusion of items from all three of these areas in the final conceptualization highlights their importance as critical elements of eating patterns. In addition, the review led to the identification of 150 initial statements, of which 123 were strongly rejected due to low expert endorsement after the first round of ratings. This is a very large proportion compared to some other studies utilizing similar methodologies in which the majority of items were retained after the first round . AlthougThe final endorsed items focused on diet variety across food groups, with specific focus on vegetable products, attunement to inner signs of fullness and satiety, and flexible positive attitudes towards eating. Together, these items represent an understanding of health-promoting eating patterns and behaviors that is inclusive across food groups and accompanied by a versatile and positive relationship to food. This is interesting in its contrast with perhaps popularized conceptions of health-promoting culture and beliefs that may focus on the avoidance or restriction of appetizing and enjoyed foods, in addition to effortful quantified approach to eating according to authoritative guidelines ,30. In cOne of the guiding concepts throughout the study was the consideration of power and privilege as related to eating patterns and behaviors. It is worth noting that access to a varied, and plant-rich, diet may be inequitably distributed among groups due to financial resources and food scarcity. In addition, barriers to a comfortable relationship with food and reliance on attunement to inner cues may be greater among certain groups due to their current and past experiences of trauma/oppression. In addition, those who experience high levels of preoccupation or concern regarding shape and weight, or difficulty in regulating their eating behaviors according to inner cues may also find such a model difficult to adhere to. Finally, public health messaging that promotes body ideals and eating patterns of the dominant culture reinforce hierarchies and systems of oppression that harm those who are often targeted by public health messaging because of their body size, economic status, or race and ethnicity. If this is indeed a consensual model of health-promoting eating patterns and behaviors, implications exist for the framing of public health messaging, the training of professionals across areas of specialization, and the targeting of interventions aiming to support individual behaviors. Greater focus at the public health level should be placed on the development of a comfortable and positive relationship with food. In addition, common curriculum content might be developed for health providers across areas whose work is relevant to eating behaviors to ensure that this more holistic model is promoted. The model also holds implications for policy and practice, including policies relating to the food industry and food environment. It has been noted that the food environment creates specific barriers to eating in the way upheld by this model. In particular, the focus of the food industry can be viewed as discouraging plant-rich diets through the disproportionate development, marketing, and selling of products that are largely not plant-based ,35. In aThe study includes a number of limitations. Despite concerted efforts, the final panel lacked diversity in terms of expert gender as well as race and ethnicity. While this no doubt reflects some of the systemic difficulties we face as a field in terms of increasing diversity within training programs and providers, it may have led to some perspectives being less represented. While the initial survey items that were produced from this study represent a consensus of the expert panelists, they are highly dependent on the expertise of those respondents and the utility of these items as meaningful measures of health-promoting eating behaviors is unknown. The reliability and validity of these items should be tested in future studies. Despite these limitations, a notable strength of this methodology is that is allows experts of diverse professional backgrounds to participate anonymously and individually, which likely enhances their ability to respond truthfully by minimizing the influence of dominant personalities/perspectives.In conclusion, the findings from this consensus revealed a novel, consensus-based framework for health-promoting eating behaviors that can form the basis for collaborative work towards the physical and mental health promotion. Future work should aim to empirically examine the usefulness of this framework as well as its acceptability among professionals from different areas.


Background. A Cochrane review found that there is insufficient evidence to determine the effectiveness of acupressure for pain relief. One of the problems detected is the methodological variability reported. Objective. To assess the impact of the application of acupressure on obstetric and neonatal outcomes of labor, pain experience, and mother’s satisfaction with the experience. Method. Design of a protocol to carry out a two-arm multicenter single-blinded randomized controlled trial. Intervention  and placebo (application of the technique on points not identified by acupuncture as key points) will be performed by a single researcher. Results. The recruitment began in April 2021 and, to date, there has been the participation of 40 women, divided into 17 included in the experimental group and 23 in the control. Communication of future results will be made in accordance with the CONSORT checklist. Conclusions. The designed protocol could methodologically improve some aspects of previous studies while maintaining adequate statistical power. The effectiveness of acupressure for one or more outcomes proposed (time and pain in labor) could support the inclusion of a new therapeutic tool in the clinical practice of midwives that would allow them to assist pregnant women, improving their experience both physically and psycho-emotionally Childbirth, being a natural phenomenon, encompasses various dimensions, making it a comprehensive and subjective experience in which physiological, psychological, social, and cultural factors come into play . The perIt is noteworthy that women exhibit a keen interest in exploring complementary forms of care that empower them to maintain a sense of control throughout the labor process . MidwiveDifferent techniques developed in traditional Chinese medicine are used as alternative and/or complementary therapies in order to reduce the medicalization of healthcare. Some of these most-used techniques are acupuncture, acupressure, moxibustion (moxa), and transcutaneous electric nerve stimulation (TENS) on acupoints, and all have been applied to pregnant women for this purpose . Within The recent literature has provided affirmations regarding the potential benefits of applying pressure on acupuncture points in improving obstetric and neonatal outcomes. While there is a growing consensus on the effectiveness of this technique in reducing perceived pain during pregnancy, further investigations are still warranted to explore its impact on labor duration, maternal satisfaction, and associated neonatal outcomes. These types of outcomes are less explored and when, they are evaluated, they can be studied with different methods or partial and inconclusive results can be obtained ,8,9,10.Building upon this foundation, Haj and Xiao-Nong emphasized the need for standardized interventions to establish clear guidelines for the utilization of this technique and to demonstrate its utility . NotablyJianjing (GB21): Located in the middle of the imaginary line that joins the spinous process of the seventh cervical vertebra (C7) and the upper part of the shoulder joint . It is a point with sensation of heat or numbness. It is a point that reacts to pressure, and can generate an unpleasant sensation. This point is useful in the stage of fetal dilation and descent, and can stimulate uterine contractions ,12,13.Hegu (LI4): Located between the first and second metacarpals (thumb and index bones). It is at the highest point seen when the thumb rests on the index finger. It acts as a stimulus for contractions if they are irregular, making them more efficient ,16,17,18Sanyinjiao (B6): It is located four fingers of the woman above the prominence of the medial malleolus (inside of the ankle). It is a pressure-sensitive area. This point helps the cervix to dilate more easily. Pressing can be stopped once labor has effective and regular contractions ,16,19,20Yongquan (R1): It is located in the depression found in the upper third of the sole of the foot . It is essential to apply forceful pressure, squeezing inwards and upwards, towards the first toe. It has a relaxing effect .Hand Points: These are located along the creases of the hands where the fingers join the palm. Helps release endorphins, which are natural pain relievers. The woman holds a small comb in the palm of her hand so that the teeth press on these points. She can squeeze the comb during contractions by pressing to get the desired effects .Some of the most-used points in the literature were:In short, labor and the pain associated with this phase is something that worries pregnant women, manifested by the high demand for pharmacological methods for pain relief, so identifying non-pharmacological interventions that reduce or minimize this will allow a significant improvement in women’s satisfaction with the vital experience of childbirth. The midwife constitutes the cornerstone to achieve this purpose .The general objective is to assess the impact of the application of acupressure on obstetric and neonatal outcomes of labor. To achieve the general objective, four specific objectives have been established, each based on the verification or refutation of a specific hypothesis.Objective 1: To analyze the possible statistical association between the use of acupressure and the times of cervical dilation and fetal delivery.Null hypothesis: The dilation time and the expulsive time in the women who receive the intervention is the same as those of the women in the control group.Alternative hypothesis: The time of dilation and the time of expulsion in the women who receive the intervention is not the same as those in the women in the control group.Objective 2: To compare the pain perceived by pregnant women in relation to the use of the acupressure technique.Null hypothesis: The pain experienced by women receiving the intervention is the same as that experienced by women in the control group.Alternative hypothesis: The pain experienced by women receiving the intervention is not the same as that experienced by women in the control group.Objective 3: To study the relationship between the use of acupressure and maternal satisfaction regarding the childbirth experience.Null hypothesis: The satisfaction experienced about the birth process in women receiving the intervention is the same as that in women in the control group.Alternative hypothesis: The satisfaction experienced about the birth process in women who receive the intervention is not the same as that in women in the control group.Objective 4: Assess the safety of the intervention through fetal and neonatal outcomes.Null hypothesis: The fetal and neonatal results of the pregnant women belonging to the intervention group are the same as those in the pregnant women of the control group.Alternative hypothesis: The fetal and neonatal results of the pregnant women who belong to the intervention group are not the same as those in the pregnant women of the control group.The primary investigator leading this study is an experienced and dedicated midwife who actively practices in a private hospital, along with regular rotations through multiple public hospitals. This diverse practice setting offers a valuable opportunity to include pregnant women from at least three distinct health centers, encompassing a wide range of profiles and characteristics among the participants.This study employs a robust multicenter randomized controlled single-blind experimental design. The intervention group will receive acupressure applied to specific points that will be thoroughly explained later in the study. As for the control group, acupressure will be administered to points that, according to traditional Chinese medicine’s energy meridians, are deemed to lack the desired therapeutic effect. Due to the fact that the principal investigator is directly responsible for both administering the intervention and the placebo, the study cannot be designed as a double-blind trial. To ensure transparency and impartiality, the collected data will be provided anonymously to a secondary investigator who will conduct the statistical analysis without any indication of which group represents the control or intervention.The sampling process will be conducted using an intentional or convenience sampling approach, wherein all pregnant women who meet the inclusion criteria and are under the care of the project’s principal investigator will be included until the predetermined sample size is reached. This meticulous approach aims to encompass a diverse range of participants, thereby enhancing the generalizability of the study findings.The calculation was based on the results obtained in a pilot study (unpublished data) with 17 and 23 women in the intervention and control groups, respectively, using the Gpower 3.1.9.4 software. Different calculations were carried out based on the means and standard deviations obtained in the times of the active, passive, and expulsive phases, as well as on the VAS scale (Likert 1–10 points) used to measure pain. From the different calculations carried out, the one that determined the largest sample size (difference of means in time of expulsive phase) was selected with the intention of having sufficient statistical power for all the analyses proposed.The means and standard deviation obtained for the expulsive phase time  in a pilot study were 46 ± 39 min for the intervention group and 65 ± 47 min for the control group. The number of women per group was calculated to determine a difference in the means of independent groups with alpha = 0.05 (type I error), power (1-beta) = 0.8, and allocation n1/n2 ratio = 1, obtaining a total of 166 women (83 in each group) .Recruitment. The selection of participants for this study will adhere to specific criteria outlined as follows:Women with induced, accelerated, or spontaneous labor, both primiparous and multiparous, are included.Women who are 18 years of age or older and in the term of their pregnancy (37–42 weeks).Single gestation (not multiple pregnancies).Absence of associated pathologies or medical conditions.Proficient communication skills in the Spanish language.Inclusion criteria: The study will include pregnant women who meet the following requirements: Women with a fetus in a breech or transverse presentation.Women who have previously undergone caesarean sections.Women with existing skin lesions or wounds.Women with cognitive deficits or impairments.Women who have consumed toxic substances or medications during their pregnancy.Women with diagnoses of placenta previa (previous insertion placenta), fetal pathologies such as Delayed Intrauterine Growth (DIC) or Small for Gestational Age (SGA), or instances of oligo- or polyhydramnios.Exclusion criteria: The study will exclude pregnant women who meet any of the following criteria: These well-defined criteria will ensure that the study focuses on a specific group of pregnant women, enabling researchers to examine the intended effects of the intervention more accurately. Allocation. Assignment to the intervention group will be made by simple randomization of the sample. To do this, a random sequence of numbers will be generated using R software , which is open source and specifically designed for statistical analysis, to assign women to intervention/control groups. For this purpose, the function will be used: sample . The women who are attended in the order of arrival will be included in the intervention group if their order coincides with any of the random numbers generated.Intervention. Intervention will be implemented by a single researcher and it will be based on pressure on the points detailed below:-LI4 of the left hand, SP6 of the left leg, GB21 of the left shoulder, and then the same sequence on the right side. This is intended to generate regular and effective contractions and promote the descent of the fetal head.-Yongquan (R1): For pain relief and relaxation of women, exerting constant pressure for 1 min, as many times as necessary to promote pain control.-Hand points: Also for pain relief, autonomously by the woman, whenever she needs it.It will start by exerting pressure on:The location of the trigger points can be visualized in Constant pressure will be generated for 3 min, alternating points, and repeating the technique every 4 h, after the scans. Digital pressure will be applied until half of the nail turns white  . The HegBased on the research carried out by Dávila Payano and Lazo del Carpio (2016), as for the main researcher, it is essential to maintain a deep and relaxed breath, and to apply deep and lasting pressure, bearing all the weight on the pressure point during the exhalation. Your position will be static, standing, with legs slightly apart, exerting force with your body weight. The manipulation must be constant, energetic, uniform, and delicate, using fingers or knuckles .Control. The control group will receive the application of the technique on points not identified by acupuncture as key points (placebo), but with the same characteristics described above . Different points will be used as placebo points and will be determined using some of the potentially therapeutic points as references; some of these points will be one F-Cun away from the original points with therapeutic effect. The Cun measurement, derived from acupuncture anatomy, represents the width of the thumb at the joint level and serves as an important anatomical unit in traditional acupuncture practices. In traditional Chinese medicine and acupuncture, the concept of Cun plays a vital role in determining precise anatomical locations for treatment. It is a unit of measurement utilized to establish the distances between acupuncture points on the human body. The Cun measurement is unique to each individual and is derived from the width of the thumb at the joint level. By using the Cun measurement as a standardized reference, acupuncturists can accurately locate specific points for therapeutic intervention. In this study, the F-Cun distance will be employed as a reference point for the placement of placebo points, ensuring consistency and precision in the experimental design . The conThe purpose behind administering pressure to different points using fingers in the control group is to eliminate any potential placebo effect associated with “manipulation using a therapeutic instrument”. It is important to note that none of the points pressed in either the intervention group or the control group possess an anatomical location that can induce significant physiological changes when pressure is applied, such as pressing the carotid artery. This precautionary measure ensures the safety of the study participants, minimizing any adverse effects resulting from the applied pressure on the women. Thus, the inclusion of these additional control points not only serves to rule out placebo effects, but also guarantees the well-being and welfare of the participants by preventing any unintended consequences arising from the pressure applied during the study.-Effectiveness of the use of acupressure on labor times in minutes .-Effectiveness of the use of acupressure on women’s perceived pain by recording values on the VAS scale and the need for pharmacological analgesic methods. A Visual Analogue Scale (VAS) is a pain rating scale that was first used in 1921 by Hayes and Patterson. The pain VAS is a one-dimensional measure of pain intensity that is used to record the progression of patients’ pain or to compare the severity of pain between patients with similar conditions. The patient must rate their perceived pain on a scale of 0 (no pain) to 10 (the most severe pain imaginable) ,25,26.-Impact of the use of acupressure on maternal satisfaction expressed about the childbirth experience  .-Impact of the use of acupressure on neonatal outcomes .Outcomes. Variables will be measured in order to assess the efficacy and safety of the intervention:-Sociodemographic: Age (years), country of birth, weight (kg), height (cm), marital status , studies , employment , dysmenorrhea: yes/no , fear of childbirth (yes/no), reasons for fear of childbirth , hospital (public/private).-Clinics: date of last period (FUR) and probable date of delivery (FPP), gestational age (weeks of gestation), obstetric formula , estimated fetal weight (kg), fetal weight at birth (kg), type of delivery termination , special circumstances associated with childbirth , factors associated with the newborn : 60–80 mmHg, blood carbon dioxide (PaCO2): 35–45 mmHg, bicarbonate (HCO3-): 24–26 mEq/L, base excess: ±3.0).-Variables that can affect the effectiveness of the intervention: hospital shift the night before (yes/no), start time of application of the technique (0–24 h), level of saturation of the system (number of women in the service attended by the researcher).Independent variables.Data analysis. The data obtained will be analyzed with IBM SPSS Statistics v23 software; this will allow for the descriptive analysis of qualitative variables through absolute frequencies and percentages, and of quantitative variables through measures of central tendency, dispersion, and position. On the other hand, a statistical inference analysis will be carried out to evaluate the possible differences between the groups; these will be treated as unpaired samples because there are different women who constituted each group.The statistical association between qualitative variables will be analyzed using Pearson’s chi-square test or Fisher’s exact test . Odd ratio will be calculated as size effect measure for this analysis.For the comparison of means between dichotomous variables, the Student t-test and ANOVA test will be performed in the case of dichotomous or polytomous variables, respectively, as long as the parametric criteria are met . If the parametric criteria are not met, non-parametric tests will be performed . For the Student t-test analysis, Cohen’s d will be used as a measure of the effect size. For regression analysis, the Pearson correlation coefficient will be used. In the case of non-normal distributions, Spearman correlation test will be used. Statistical significance at 5% will be established for all tests.Ethical aspects. The present study preserves the well-being of the subject above the interests of science or society and the ethical considerations that support it, as part of the compliance with current international and national regulations for health research studies with human beings, as well as that referring to the protection of personal data and clinical information derived from it. Under these premises, this protocol has been approved by the Regional Ethics Committee .Data collection notebooks will be handled in which only identification codes will appear that will correspond to the personal data in other guarded records. Similarly, electronic database-type records will be designed disaggregated to avoid identification of patients. An Informed Consent document has been prepared. The intervention does not require invasive tests or manipulation of biological samples beyond those implemented in routine clinical practice.The recruitment and inclusion of women in the study began in April 2021 and, to date, there has been the participation of 40 women, divided into 17 included in the experimental group and 23 in the control. Among them, 95% of the women were treated in a private hospital. They are Spanish women , around 33 years of age, married, with higher education, gestation at term and without complications, with an estimated fetal weight around 3330 kg and with fear of childbirth whose stated reasons were: pain (35%), ignorance (20%), epidural, completion of labor, and loss of control, with 2.5% each. To communicate the results, the CONSORT checklist  and its The primary objective of this study’s protocol is to introduce a novel acupressure intervention, incorporating points that have been extensively studied in the scientific literature and have demonstrated their effectiveness. However, certain points located on the back were deemed impractical due to the supine position in which women typically find themselves during childbirth. Consequently, these points were excluded from the intervention. Conversely, we have identified points from Dávila’s doctoral thesis that have not been previously documented . The strBased on the findings, it is anticipated that the meticulously chosen set of points, previously unexplored, will provide a prompt and effective intervention. We expect this intervention to yield improved perinatal outcomes while minimizing discomfort for the mother. By utilizing these previously unexplored points, we aim to optimize the intervention’s efficacy and enhance the overall childbirth experience for women. Therefore, the midwife should position the woman in the standard childbirth posture and can proceed with the intervention, as easy access to the proposed points is ensured in this position. This is crucial from an ergonomic perspective, benefiting both the pregnant woman and the midwife.The outcomes derived from the implementation of this protocol possess the potential to generate significant and applicable insights for clinical practice, thereby enhancing the overall childbirth experience by reducing pain perception and duration. Consequently, such improvements would directly contribute to heightened satisfaction among women undergoing this crucial life event. Furthermore, if the safety of the intervention for both mothers and infants is demonstrated, its incorporation into the healthcare system of our country would carry substantial weight as a valuable tool for future implementation.Nevertheless, it is important to acknowledge certain limitations that may arise in relation to the sample size. The current study is based on a small, unpublished pilot study that was organized ad hoc to collect data for the development of this protocol. However, we firmly believe that our meticulous approach will yield more robust scientific evidence compared with previous studies that lacked explicit mention of sample size calculations ,28 or stIt is noteworthy to highlight that our sample size aligns closely with those observed in other studies published in high-impact nursing journals, reinforcing the methodological robustness of our research . Lastly,If the results of this study confirm the effectiveness of acupressure in achieving the proposed outcomes outlined in the research hypotheses, it would provide substantial support for the integration of this therapeutic modality into the clinical practice of midwives. The inclusion of acupressure as a viable tool would empower midwives to offer comprehensive care to pregnant women, enhancing their overall experience not only on a physical level, but also in terms of their psycho-emotional well-being.By incorporating acupressure as a part of their practice, midwives would be equipped with an additional evidence-based intervention to address various aspects of pregnancy, labor, and childbirth. This holistic approach to care has the potential to optimize maternal comfort, promote a sense of control and empowerment, and foster positive emotional experiences during this transformative journey.Furthermore, the integration of acupressure into midwifery practice aligns with the growing recognition of the importance of complementary and alternative therapies in maternity care. It would provide midwives with a valuable tool that complements their existing knowledge and skills, enhancing their ability to provide personalized and holistic care to pregnant women.Ultimately, the successful implementation of acupressure as a therapeutic intervention within midwifery practice has the potential to positively impact not only the physical well-being of pregnant women, but also their overall satisfaction and emotional connection to the childbirth process. By recognizing and embracing the potential benefits of acupressure, midwives can contribute to a more positive and empowering childbirth experience for women, promoting their overall health and well-being.


To identify barriers to adherence to home oral maintenance chemotherapy in children with leukemia treated at a specialized cancer center.We used the Brief Medication Questionnaire (BMQ) as a tool for screening barriers to adherence. The level of adherence was calculated considering at least one positive response in each BMQ domain, defined as Regimen Screen, Belief Screen, and Recall Screen. A positive screening for belief barriers (PSB) indicates that the caregiver reports not understanding the medication's mechanism of action and adverse effects.Three important barriers to adherence were identified: beliefs, number of children of the caregiver, and age of the caregiver. The primary caregivers included 32 mothers (80%), four fathers (10%), three grandmothers (7.5%), and one unrelated caregiver (2.5 %). Most caregivers with a PSB were mothers. A PSB indicates that the caregiver reports not understanding the medication's mechanism of action and adverse effects. Caregivers with two or more children  had more barriers to adherence. Caregivers with potential non-adherence tended to be older than those with potential adherence, although without statistical significance .The main barriers to adherence to home oral maintenance chemotherapy in children with leukemia identified through interviews with their caregivers, most often mothers, were lack of understanding of the treatment regimen, a greater number of children, and older age. Access to diagnosis of children with leukemia has increased significantly in the last 40 years, and cure rates of children treated in specialized centers reach 80% in high-income countries.Childhood cancer is the leading cause of disease-related death, approximately 8%, in children and adolescents in Brazil. Recent data show that leukemia is the most commonly diagnosed malignancy affecting children and adolescents. Leukemia can be divided into subgroups based on the morphology of the affected cells and speed of disease progression, being classified as acute or chronic. They can be further divided into subgroups according to the type of affected cells, being characterized as lymphocytic leukemia, myeloid leukemia, and nonspecific or combined types.Leukemia is defined as a primary malignancy of hematopoietic stem cells. Because these cells are genetically altered in leukemia, they lose their differentiation ability while maintaining their proliferative capacity, with subsequent reduction in the production of healthy hematopoietic elements. However, despite no visible evidence of disease on cytology, studies have reported residual leukemia cells in the body, which requires further treatment to prevent relapse. The last phase is called maintenance, characterized by continuous treatment for several months.Conventional leukemia treatment is divided into phases. The first phase aims to eliminate the pool of abnormal cells and is called remission induction. Once cytological remission has been achieved, less than 5% of bone marrow cells are expected to be leukemic with restoration of normal hematopoiesis. These factors may hinder treatment adherence, compromising clinical outcomes and potentially leading to relapse that might increase caregiving demands.Multiple factors should be considered during treatment. Examples include the complexity of dosing regimens, the duration and cost of treatment, adverse events, subgroups with poor prognosis, a low health literacy population, cognitive and functional impairment, beliefs, concerns, patients’ and caregivers’ perceptions of health and treatment status, and lack of family and social support, among others.Barriers to adherence can be considered a public health problem because of consequences such as worsening of the disease, increased adverse events, and drug treatment failure, which may lead to disease progression and the need for hospitalization.The primary objective of this study was to identify barriers to adherence to home oral maintenance chemotherapy in children with leukemia treated at a specialized cancer center.The present study outlined the epidemiological profile of the main adherence barriers in children with leukemia treated at a referral hospital in Brasília, Brazil. We conducted a cross-sectional, observational, analytical study of 40 children diagnosed with leukemia between one and ten years of age who reached the maintenance phase of the chemotherapy protocol and were not hospitalized at the time of the study by convenience sample. translated into Portuguese and validated in Brazil as a tool for screening barriers to adherence.Data were collected through an interview with the person responsible for the child's treatment (caregiver) using the adapted version of the Brief Medication Questionnaire (BMQ)A total of 49 children diagnosed with leukemia receiving maintenance chemotherapy were considered eligible for the study. Eight children were excluded from the study because they were older than ten years, and one child was excluded because the caregiver refused to complete the questionnaire. Therefore, the final sample consisted of 40 children.Descriptive and association analyses were performed for levels of adherence and for levels of adherence by BMQ domain. The level of adherence was calculated considering at least one positive response in each BMQ domain, defined as Regimen Screen, Belief Screen, and Recall Screen. Responses to the questionnaire were categorized into levels of adherence according to the number of positive responses in any of the BMQ domains: high adherence (none), probable high adherence (1), probable low adherence (2), and low adherence (3 or more). A positive screening for belief barriers (PSB) indicates that the caregiver reports not understanding the medication's mechanism of action and adverse effects.Qualitative variables characterizing the children and caregivers were expressed as frequency (n) and percentage (%) and associated using Pearson's chi-square test with continuity correction or Monte Carlo simulation if necessary . Quantitative variables were associated using the nonparametric Mann-Whitney U test and Kruskal-Wallis test for independent samples, considering these variables did not present normal distribution by the Kolmogorov-Smirnov test. Data were analyzed using IBM Statistical Package for the Social Sciences — SPSS, version 23, 2015. The significance level was set at 5% for all analyses.The study followed the standards for research involving human subjects, set forth in Resolution 466/12 of the Brazilian National Health Council, and was approved by the Research Ethics Committees of the University of Brasília School of Health Sciences  and Health Science Teaching and Research Foundation . All caregivers provided written informed consent to be interviewed for the study.The sociodemographic characteristics of the children and caregivers participating in the study are shown in The responses to the BMQ questionnaire were associated with qualitative variables  and quanNo qualitative sociodemographic variable of the caregivers was significantly associated with the Belief Screen in children with leukemia receiving home oral maintenance chemotherapy. The degree of kinship of the caregiver showed a strong tendency toward association with the Belief Screen, although without statistical significance . Most caregivers with a PSB were mothers .Adherence barriers identified in the study were associated with beliefs, number of children, and drug regimen in relation to the age of the caregiver. In most cases, the primary caregiver was the mother . Mothers also reported a more PSB than did other caregivers. The results indicate the main areas that should be addressed by the multidisciplinary team to improve medication adherence. conducted a qualitative study based on discourse analysis seeking to identify factors associated with anticipatory grief when caregivers, who most often are mothers, are told that their child has cancer or requires palliative care. The results showed that, while the mother is taking care of her child, she suffers from the belief that her child may die during treatment, leading to distress that may be related to the belief that the treatment is not working.Regarding the PSB, Bastos Our findings are consistent with these results, since there was a PSB regarding the understanding of the treatment regimen among the caregivers who had not completed elementary school .A systematic review of health literacy, conducted at the University of Amsterdam in 2015, showed that people with low health literacy are less likely to understand health information. This may be related to the PSB of mothers, which indicates they do not actually understand the mechanism of action of the simultaneous use of multiple drugs in the treatment regimen.Treating childhood cancer is complex. According to a quantitative analytical study conducted in 2019 in the oncology unit of a public hospital in Pernambuco, Brazil, patients with acute lymphoblastic leukemia are treated with several drugs, suggesting polypharmacy as the main factor leading to potential drug-drug interactions. also showed that mothers were overwhelmed by caring for their sick children, facing problems related to stress and responsibilities inherent in the treatment. Generally, mothers withdraw from their other children, leave their job and social life to dedicate themselves fully to the sick child, and, as a consequence, they often experience mental health problems, high levels of stress, anxiety, and depression, decreased sense of well-being, and decreased quality of life.A qualitative study of ten women conducted in two phases from 2015 to 2018 using structured interviews, in addition to identifying that the mother was the primary caregiver of children with congenital syndrome , Another important issue to be addressed is that having a child with cancer changes the family dynamics, as there is a considerable impact on the spousal relationship and on the care of healthy siblings. The primary caregiver, usually the mother, feels guilty about the series of events that happen to the sick child, in addition to feeling that she is not fulfilling her responsibilities as a mother toward her other healthy children.The number of children of the caregiver had a negative impact on adherence to treatment. Our study showed that caregivers with two or more children  had more barriers to adherence. A possible explanation for this association is that attention was not focused on the sick child, being shared between the sick sibling and healthy siblings. The family daily routine often changes after a cancer diagnosis, which directly affects healthy siblings, who feel they are a burden on parents, and becomes an additional concern for parents, who try to share the attention between all children. However, due to the severity of the disease, parental attention tends to be focused on the child with cancer, which may cause discomfort and psychological problems in the healthy siblings who also need care. Once again, the mother assumes responsibility and feels guilty for not being able to be present in the lives of all her children.A childhood cancer diagnosis can be considered a negative life event that interacts with aspects of personal life, environment, and family system, influencing the daily life of the entire family.The present study also identified that, in the Regimen Screen, younger caregivers showed higher adherence to the prescribed leukemia treatment . It may be suggested that older people have habits, thoughts, and beliefs of their own that make it difficult to follow the physician's and multidisciplinary team's instructions about pill splitting, disposal, and administration as well as drug-drug and drug-food interactions, which are correctly performed by health professionals. Therefore, caregivers’ difficulty following instructions becomes a barrier to adherence that worsens with advancing age. However, a study of six caregivers of older people conducted in Rio Grande do Sul, Brazil, showed that older caregivers were more resilient, that is, better able to adjust to change, which may facilitate adherence to treatment. in this population.This study has limitations. The method used considers polypharmacy a barrier to adherence. However, cancer treatment has multiple therapeutic targets, making monotherapy difficult. Another limitation is the questionnaire used, as the BMQ is not a standardized instrument to screen pediatric patients undergoing cancer treatment. The small number of caregivers interviewed can also be considered a limitation, in addition to the fact that the study was conducted in a single center. Therefore, further studies with a larger sample size are needed. Nevertheless, only a few patients were excluded from the study, and we were able to outline a profile of the pediatric population with leukemia treated at our institution and identify treatment-related factors that need to be addressed. Considering that the main barrier to adherence identified in this study was the understanding of the treatment regimen, additional studies are suggested to assess the level of patient satisfaction Although we analyzed a different population in the present study, we ended up identifying the same problem of lack of caregiver understanding, especially of mothers (80%), as a barrier to adherence to treatment, thus highlighting the urgent need of additional studies to enhance caregiver understanding of leukemia treatment so that they can act as agents in the treatment of these children.In this context, a descriptive cross-sectional study was conducted in a reference outpatient clinic in Brasília between 2017 and 2019 to evaluate the level of satisfaction of adolescents’ caregivers with information received on the use of psychotropic drugs using the Satisfaction with Information about Medicines Scale (SIMS), and the results showed that most caregivers were dissatisfied with the information about treatment.Another important factor to be evaluated in further studies is the follow-up that supports the use of event-free survival and overall survival in pediatric oncology after maintenance treatment of acute lymphocytic leukemia.The main barriers to adherence to home oral maintenance chemotherapy in children with leukemia identified through interviews with their caregivers, most often mothers, were lack of understanding of the treatment regimen, a greater number of children, and older age.