Around 20% of the Dutch population is living with chronic musculoskeletal pain (CMP), which is a complex and multifactorial problem. This complexity makes it hard to define a classification system, which results in non-satisfactory referring from the general practitioner (GP). CMP is often explained using the biopsychosocial model in which biological, psychological and social factors cause and maintain the pain. The presented study investigated the factors related to the GPs’ referral for patients with CMP to further treatment.Using convenience sampling, semi-structured interviews and a focus group were conducted among 14 GPs. The interviews were iteratively analyzed using inductive conventional content analysis.Analysis of the interviews demonstrated that there were 28 referral factors that were mentioned by more than 50% of the interviewed GPs. The results showed that the GPs were mostly focussing on the physical (e.g. pain location) and psychological (e.g. acceptation of pain) factors, indicating that they lack focus on the social factors. Furthermore, unfamiliarity of GPs with treatment options was a noteworthy finding.The referral of patients with CMP by GPs is complex and based on multiple factors. To improve referral, it is recommended to include social factors in the decision-making process and to increase the familiarity of the GPs with available treatments.The online version contains supplementary material available at 10.1186/s12875-022-01743-6. Around 20% of the Dutch population is living with from chronic musculoskeletal pain (CMP) , 2. CMP The complexity of CMP and the frequent presence of comorbidity with psychological complaints complicates the development of one single valid classification system to categorize patients with CMP, which leads to insufficient quality of referring . This reIn the Netherlands, the GP is usually central in the patients’ treatment as the gatekeeper within the Dutch healthcare system . So, to To improve the referral of patients with CMP it is crucial to first get more insight in factors GPs focus on when referring. To accomplish this, the aim of this study was to identify those factors used by GPs when referring patients with CMP for further treatment.This research is part of a larger project called PReferral, that is focused on the design of a decision support tool to support the GPs in the referral of patients with CMP.This explorative qualitative study, analysed using conventional content analysis, took place in the east of the Netherlands (Twente) among practicing GPs. A qualitative design was chosen, because referral of patients (with CMP) to treatment is a complex process  of whichThe Dutch version of the semi-structured interview scheme . Moreover, a rehabilitation doctor of a local hospital (ZGT) (J.B.) contacted GPs that often referred to the ZGT. The GPs for the focus group were contacted by the research coordinator of THOON (P.L.), using convenience sampling. After agreeing to be interviewed or participate in the focus group, the participants answered demographic questions , a question about their professional interest in patients with CMP on a scale from 0 to 10 and their satisfaction with their referral of patients with CMP on a scale from 0 to 10. The interviews were conducted by one researcher (A.M.) and the focus group was conducted by one researcher (S.S.) and moderated by another researcher (J.B.). Because of COVID-19, the conducted interviews and focus group were online via Microsoft Teams and the interviews lasted between 25 and 84 minutes, with a median of 54 minutes and the focus group lasted 79 minutes. All participants were informed about the project goals beforehand and gave verbal informed consent to participate in the study and be recorded. The interviews and focus group were recorded in Microsoft Teams, transcribed using Amberscript software and manually corrected by the researchers. The recordings and transcripts of the interviews and focus group are stored in a secured online environment of the University of Twente.The data of the interviews was analysed in Atlas.ti, using inductive conventional content analysis . This meIn total, 83 factors for referring patients with CMP were stated by the interviewed GPs  factors. A seventh theme was identified, called “external factors”, with factors like social environment and financial situation. However, none of the factors in this theme were mentioned by 50% or more of the GPs and therefore this theme was not discussed in the results. The six identified categories, correspond to previous studies that found that the GPs’ referral is based on (1) GP factors, (2) treatment factors and (3) patient factors , 11.According to the guidelines of the Dutch GP organization, a combination of physical, psychological and social factors is contributing to and causing CMP , 15. AddWithin this study, 90% of the interviewed GPs mentioned their unfamiliarity with treatment options as an influencing factor for their referrals of patients with CMP. This unfamiliarity was either about unfamiliarity with the content of a certain treatment or the presence of this treatment in the region. In relation to the physiotherapy related treatments, it was mentioned GPs often did not seem to make a distinction between the different forms of physiotherapy, because of unfamiliarity with these therapies. For example, it is hard for GPs to make a distinction between manual physiotherapy and regular physiotherapy, resulting in referring towards the more familiar option, regular physiotherapy . PreviouThis study was the first study to identify factors GPs use to refer patients with CMP. Another strength of this study was the sample, with a wide range in age, years of experience as a GP and satisfaction with referring, which increased the representativeness of the factors found within this study. Furthermore, the study design had two phases, where the results of the interviews were verified by the focus group, which increased thoroughness. Also, the interpretation and coding of the interviews by multiple researchers was a strength. Constantly discussing and checking the codes with multiple researchers ensured an open-minded approach for creating codes.The willingness of GPs to cooperate to this research was an important limiting factor in this study. The GPs indicated that their time and focus was on the COVID-19 pandemic, because a lot of changes had to be made within primary care . A largeThis study specifically focused on the referral of patients with CMP by the GPs in the east of the Netherlands. Further research should expand the region and number of the participants to increase the representability. By interviewing more GPs, either using interviews or focus groups, it will be possible to allocate more detailed weight to referral factors and to gain more insight in referrals to different kind of treatments. Specifically, the reason why social factors currently seem to be overlooked in the referral of patients with CMP should be further investigated. Also, this study provides factors GPs use for the referral of patients with CMP, but does not give an explanation as to why these factors are used for referral. Additionally, this study covered patients with both primary and secondary chronic pain, while it might be possible that there are different referral factors for these groups of patients. Further research could specify a patient group to get better insight in referral factors for specific chronic pain conditions.Based on the results of this research, it is evident that GPs should take social factors into account when referring patients with CMP. This could be supported by promoting the use of guideline suggested tools, like the SCEGS  method .Further, unfamiliarity of the GP with the different treatment options seems to be an important factor for their referral. An implication for improving the familiarity of the GPs, would be to support them in their awareness of treatment options for patients with CMP. For example, by developing an easily accessible and usable  tool or eHealth application, in which all treatment options and characteristics in this region are mentioned, including both mono- and multidisciplinary treatment options. On the other hand, there is a public social map in the Netherlands where patients are able to see possible treatments near to them. Therefore, the responsibility of finding the most fitting treatment could also be shared between the GP and the patient.Concluding, this study identified different factors important for the referral of patients with CMP by the GP. The referral factors were most often related to physical, psychological or GP factors. Important results were the apparent absence of social factors used for referral and the unfamiliarity of the GP with the treatment options. The factors mentioned by the participants should be taken into account when setting up a decision support tool for improving the referral process of patients with CMP.Additional file 1.Additional file 2.Additional file 3.


The introduction of digital currency electronic payment (DCEP) by the Central Bank of China is conducive to the central bank's timely grasp of macroeconomic dynamics and the internationalization of RMB. As DCEP is one of the first digital currencies issued by the central bank to be used on a large scale internationally, it is necessary to conduct research on its user adoption. Therefore, this research extends the unified theory of acceptance and use of technology (UTAUT) to explore factors affecting the adoption of DCEP. The researchers cooperated with city banks that have started to use DCEP, and distributed questionnaires to users in the lobbies of these banks. A total of 295 valid questionnaires were empirically examined with Smart-PLS. The results indicate that perceived fairness, habits, social influence and national identity have significant effects on usage, with p values less than 0.05. National identity is shown to be a significant moderator of the relationships between perceived fairness, habit, perceived risk and usage, with p values less than 0.05. National identity is shown to have no moderating effect between social influence and usage, with a p value greater than 0.05. This research provides the central bank and the government with suggestions to increase user enthusiasm and reduce user perceived risks, thereby promoting the widespread use of DCEP. In contrast to Libra, which is issued by Facebook, DCEP is issued by China and endorsed by national credit, so it involves almost no credit risk, whereas Libra is affected by changes in exchange rates between reserve asset currencies and market confidence. From a regulatory perspective, Libra will eventually be completely decentralized, making it difficult to prevent illegal behaviours such as money laundering and tax evasion. The unrestricted cross-border flow of Libra, which has a strong user base, may weaken the country's currency sovereignty. DCEP transactions are completed at the central bank without any other intermediaries, so the speed of these transactions is much higher than that of e-payment transactions, especially with the spread of 5G networks. When the network is interrupted, DCEP can make payments without it, which is also a feature making DCEP superior to electronic payments.Digital currency electronic payment (DCEP) is a digitalized version of RMB and a centralized, legal currency. It is issued by the Central Bank of China, operated by designated state-owned banks and freely convertible to the public. Because DCEP has the credit endorsement of the Chinese government, it is beneficial in terms of future RMB settlement, anti-money laundering and internationalization. The large-scale use of DCEP may become a game changer for the global currency system3, at present, China, the European Union, Japan, Russia and other countries are exploring the construction of their own digital currency payment networks. Another reason that central banks in many countries want to set up their own digital currencies is that they aim to increase consumption and GDP6.Since the collapse of the Bretton Woods system, currency issuance has been based on national credit, and the United States, with its strong economic foundation, made the US dollar the world's main reserve currency. In the context of a high degree of globalization, the economic activities of the United States have profoundly affected the economic changes of other countries. Therefore, the current three major financial systems, namely, SWIFT, CHIPS, and Fedwire, are all dominated by the US dollar economy. Regardless of whether they are conducted using US dollars, euros, yen or RMB, cross-border transactions cannot avoid the supervision of the US government, which has raised many concerns among foreign companies about sanctions. Although some nations’ central bank digital currency programs have proven unsuccessful7, a two-tier operating system has been adopted for the central bank’s digital currency. The central bank releases this digital currency through commercial banks, and these commercial institutions then exchange the digital currency with the public. This behaviour not only makes full use of the mature, complete service systems of commercial banks but also prevents direct competition between the central bank and commercial banks. Although there have been some studies on DCEP, most such works focus on its impact on the macro economy, and few studies have focused on the public's acceptance of this currency. If the government wants to actively increase the public's adoption of DCEP to achieve the central bank's goal, the factors that affect the public's usage of the currency must be carefully considered.To protect the interests of commercial banksSince the Chinese government has many investment projects in Africa, Southeast Asia and South America, it must use foreign exchange regularly and on a large scale. Therefore, problems such as exchange rate loss, payment security, time losses in cross-border remittances and cumbersome procedures lead to massive losses every year. DCEP is intended to improve the efficiency of payments and settlements and greatly reduce transaction costs, which is conducive to promoting the vitality of China's domestic and cross-border trade and finance and increasing commercial value for China. Although DCEP is controlled by the Central Bank of China, the four major state-owned commercial banks , and three communications companies , people are very worried about their own financial and consumer privacy being completely controlled by the central bank; therefore, some users are cautious about using DCEP. When domestic companies and consumers in China accept DCEP and are willing to use it, they will take DCEP abroad and promote DCEP it throughout the world. Since the Chinese government only issues DCEP in some core cities, and due to the closure caused by the epidemic, it is difficult for foreign researchers to obtain the operation of DCEP. The European Union's digital currency named EUROchain anonymizes customers' identities and transaction records. Except for the intermediaries formulated by the customers, the central bank and other intermediaries cannot see the data submitted by customers. EUROchain can improve customer privacy needs, reduce transaction costs and anti-money laundering. DCEP is an alternative to paper currency issued by the central bank and has the right to monitor all transaction information. Thus, this research also attempts to provide researchers around the world with a thorough understanding of the Chinese people's acceptance of DCEP, as well as the steps taken by the Chinese government to try to counter the US dollar and Euro through DCEP. Therefore, the main purpose and research objective of this paper is to conduct empirical research based on the extended unified theory of acceptance and use of technology (UTAUT) and construct a theoretical model involving consumers in cities that have begun to use DCEP to provide an effective empirical reference for the Chinese central bank for their future domestic and cross-border DCEP payment decisions.In this study, empirical research is conducted on users of DCEP to identify the factors that influence the public's acceptance of this currency. The structure of the paper is as follows. The introduction discusses the importance of promoting DCEP in terms of enhancing the global competitiveness of China’s central bank and the difficulties faced in this context, and it introduces an empirical research program intended to help the People's Bank of China address the difficulties it encounters in the promotion of DCEP. The literature review exemplifies the popularity of the UTAUT model in scientific research and shows that the PPM model can help improve the effectiveness of empirical research. The methodology section provides not only the research hypotheses and research model, which are constructed by combining UTAUT theory and PPM theory, but also the analysis software selection and basic information on the survey. The results section provides the results of the reliability, validity and hypothesis tests performed. The discussion section provides suggestions for the Central Bank of China in relation to further implementing DCEP in China and contributes to improving China's competitiveness in the context of international finance based on empirical results. The conclusion suggests specific actions to improve the use of DCEP, providing the Central Bank of China with a reference for the formulation of policies. The limitations of this study and future research directions are also given.8. Researchers can select appropriate variables according to the characteristics of their research objects to add new variables that better explain their research models. When conducting empirical research and testing, researchers often face many theories, and it is difficult to choose one to employ; moreover, they are often forced to choose characteristic variables from among a variety of contradictory models and theories. To respond to this dilemma and unify the literature related to the willingness to accept new technology systems, Venkatesh et al.8 proposed UTAUT2 by adding more variables, including habits, price value, hedonic motivation, age, gender and experience, to UTAUT9. The ability of UTAUT2 to interpret users' adoption behaviours is much better than that of the UTAUT model. Although UTAUT currently has one of the highest explanatory capabilities for user intentions and usage behaviours among the existing models, many researchers still extend UTAUT to better explain specific user behaviours in different research situations. Table UTAUT contains four core dimensions. Performance expectancy refers to the degree to which an individual feels that using the focal system is helpful in their work. Effort expectancy refers to the amount of effort required from an individual to use the system. Social influence refers to the degree to which an individual feels influenced by the group of people around him. Facilitating conditions refer to the degree to which individuals feel that their organizations support their use of the system in terms of related technologies and equipment. UTAUT also recommends some control variablesBecause DCEP is issued by the central bank, it differs in specific ways from other technologies and products. First, since the use of DCEP has a certain legal implication stemming from the government, the use of DCEP may not entail sufficient hedonic motivation. Second, DCEP is the digital form of RMB, so it does not have the speculative value of Bitcoin. Third, because users need certain skills related to operating electronic equipment to be proficient in using DCEP, users who are not proficient in operating mobile phones may experience difficulties. Although the Central Bank of China and the government have implemented incentives to encourage the use of DCEP, such as giving free DCEP distributions to citizens to increase their enthusiasm, some citizens still have a negative attitude towards DCEP. To better explore the factors that promote and hinder users from using DCEP, this research introduces a method that combines push-pull-mooring theory and UTAUT.22 examines users’ switching behaviour between mobile stores using PPM. Fang and Tang23 explore involuntary migration in cyberspaces using PPM. Jung et al.24 test travellers' switching behaviour in the airline industry from a PPM perspective. Li and Ku25 use PPM theory to explain factors affecting e-commerce to social commerce switching. Sun et al.26 apply PPM to test SMEs’ adoption of block-chain-based loan systems. PPM is a useful supplement to other theories, such as UTAUT, because pulling variables can explain factors that encourage users to adopt DCEP, pushing variables could explain the factors that hinder users' enthusiasm for using DCEP, and mooring variables may explain the factors that moderate these pulling and pushing effects.Push-pull-mooring theory (PPM hereafter) is the most important theoretical paradigm for studying population mobility and immigration, and it is often used as an analytical framework for population migration decision-making. The migration decisions made by populations are the result of the interaction of forces from two different directions: one force promotes migration and is called a push, and the other hinders migration and is called a pull. Between these pushes and pulls, there is a moderating factor called mooring. The pushing factor mainly comprises the internal influencing factors that prompt individuals to temporarily leave their places of residence and go to other destinations, while the pulling factor comprises the external influencing factors that encourage individuals to move. Together, the two forces form the motivation underlying population migration. Usually, the pushing factors impacting immigration behaviour include the depletion of natural resources, increased agricultural production costs, unemployment, lower economic income levels and other negative factors. The pulling factors may include greater employment opportunities, higher salaries, higher living standards, better educational opportunities, more complete cultural facilities, better traffic conditions, a more suitable climate and other positive factors. Mooring factors are factors that moderate immigrant behaviour and generally include innovation ability, identity and belonging, cultural and ethnic diet, and emotional commitment. Zhou27, tax compliance28, regulatory policy29, children's behaviour30, market power31, error management training32, reviewer reputation33 and contractors’ potential to dispute34. Therefore, we propose the following:The ability of individuals to acquire knowledge is weaker than that of institutions. Institutions can acquire new knowledge rapidly through paid channels, or they can acquire relatively precise knowledge from replicated information by hiring professionals. Therefore, there is a knowledge gap between individuals and institutions. An important feature of the big data era is that commercial organizations can comprehensively collect and analyse consumers’ payment information and data in real time; thus, these organizations can target and accurately market to consumers according to their different preferences, interests, and buying habits. By using data mining and other technologies to predict the upcoming or deep needs of consumers early, institutions can ultimately achieve the great goal of increasing profits. However, because businesses have strong technological monopoly capabilities, consumers often find that unless they no longer use electronic payments, it is difficult to prevent others from tracking their consumption data. The asymmetry of this technology makes consumers unable to deny commercial organizations access to their consumption data even if they feel such access is unfair. DCEP is a payment method that eliminates third-party payments through intermediaries. All its transaction information exists only in the central bank's database, so commercial institutions can no longer obtain information such as payment monitoring data from consumers. Thus, perceived fairness is one of the most important requirements from the perspective of users. In fact, the application of DCEP makes it difficult for government officials to transfer funds obtained by bribery to foreign countries or to use such funds for consumption. This is because any income that enters a personal account from an unidentified source in the form of DCEP without a valid reason may be detected by the central bank. If DCEP can restrain the bribery behaviour of government officials, the public will be satisfied with the government’s integrity; in this way, DCEP can enhance the public’s sense of fairness. Many previous studies have proven fairness is a significant factor for usage in different research fields, including managementPerceived fairness positively affects the usage of DCEP.8. Unlike existing third-party payments, DCEP payments do not need to be bound to a bank card, and they are made through only a digital wallet. The use of a DCEP digital wallet makes consumers gradually get used to this new payment method through learning and practice. Despite the government’s efforts, DCEP faces competition from third-party payments such as WeChat and Alipay. WeChat and Alipay have many hundreds of millions of users, and these users have used the payment platforms for years. Since the use of DCEP's e-wallet is not particularly different from that of existing third-party payment platforms, hopefully, users can form DCEP consumption habits within a few years. Habit has been proven to be a significant factor in various research fields, such as those of novel mobile adoption35, mapping app usage36 and restaurant app usage37. Therefore, we propose the following:Habit is a key factor affecting usage behaviour in the context of UTUAT2; this factor refers to an outcome of users’ past behaviours or experiencesHabit positively affects the usage of DCEP.38, technology adoption by older individuals39 and mobile shopping40. Therefore, we propose the following:The Chinese government is actively promoting the benefits of DCEP via various media, and these benefits include but are not limited to the ability to make payments without the internet, the ability to avoid payment tracking, anti-money laundering mechanisms, anti-tax evasion mechanisms, anti-telecom fraud mechanisms, and anti-terrorist financing mechanisms. To increase the social influences encouraging the public to adopt DCEP, the Chinese government is also promoting it through administrative channels. In some cities, the salaries and subsidies provided to civil servants are being distributed through DCEP. Additionally, the government requires businesses in some cities to accept DCEP payments. Since there are millions of civil servants in China, the public is bound to be influenced by these policies. When users find that an increasing number of people around them are using DCEP and enjoying its convenience, they may also try to use it. Social influence has been frequently used as a factor in adoption studies, including those on mobile paymentsSocial influence positively affects the usage of DCEP.41, hotel service adoption42, online payments43 and consumer reactions44. Therefore, we propose the following:Although DCEP has many advantages, consumers will find some potential risks. All the information associated with a payment, whether it is individual or institutional in nature, is obtained by the central bank. Not all institutions and individuals are familiar with tax policies. If the central bank strictly evaluates the tax information of individuals and institutions based on their payment information, large-scale tax payments and fines may ensue. Through the monitoring of DCEP payment records, the government can obtain various types of personal, private information, including health care, insurance, and travel information. With the development of the economy, Chinese users increasingly value the protection of personal privacy, and the risk of private data being monitored may hinder the promotion of DCEP. The negative effect of perceived risk is often tested in various studies, including those on e-store adoptionPerceived risk negatively affects the usage of DCEP.45. National identity provides a powerful means by which an individual can be defined and positioned in the world, and it enables people to understand who they are in their globalized and complex environment46. Consumers like to signify their identity by consuming iconic national products47. Considering that DCEP is used to promote the globalization of China's economy, it is clear that DCEP is a typical iconic national product. National identity has been considered in a wide range of research contexts, including national identity in the United States49, national identity in New Zealand50, national identity in Singapore51 and national identity in postcolonial destinations52.Most consumers realize that they belong to a country and may express this belonging to the outside world during the consumption process by exhibiting different attitudes towards products from different countriesThe international promotion of DCEP will bring more investment and trade opportunities to China in addition to promoting domestic employment and sustainable corporate development. Currently, the SWIFT system is still the main payment and settlement system used by most banks worldwide. The leadership of the United States is obvious and powerful, which makes its opponents worried that they may be prohibited from conducting any transactions and international trade related to the US dollar. Therefore, the globalization of the RMB is the core of China's economic interests. DCEP is a possible alternative to SWIFT due to its low cost, traceability and reliability. If it is widely used and adopted on a global scale, China's economy will experience unprecedented development. The Chinese government continues to promote the use of DCEP as a patriotic behaviour, hoping to promote the acceptance of DCEP by increasing a sense of national identity among businesses and individuals. When users’ national identities are enhanced, poor people, rich people and businesses may all feel that they can help China's economic globalization process by using this currency. A strong sense of national identity may also encourage users to form the habit of using DCEP more actively. When this sense of national identity forms a culture in Chinese society, users are more likely to be influenced and more inclined to accept DCEP. To enhance China's competitiveness in the global financial market, users with higher levels of national identity may also have reduced perceptions of risk and actively adopt DCEP. Therefore, we propose the following:National identity positively affects the usage of DCEP.National identity positively moderates the relationship between perceived fairness and the usage of DCEP.National identity positively moderates the relationship between habit and the usage of DCEP.National identity positively moderates the relationship between social influence and the usage of DCEP.National identity negatively moderates the relationship between perceived risk and the usage of DCEP.Figure All the procedures of this research were carried out in accordance with the relevant guidelines and regulations. All the experimental protocols, including those involving all kinds of ethical behaviours, were approved by the Ethics Commission of Jinan University. Informed consent was obtained from all the participating subjects and/or their legal guardians. The Ethics Commission of Jinan University approved all the experiments, including any relevant details.The questionnaire was designed to survey DCEP users in China. We cooperated with banks in cities that had started to use DCEP and issued questionnaires to users in the lobbies of these banks; users who voluntarily completed the questionnaires could obtain movie ticket coupons. Most of the DCEP users were civil servants, professionals and businesspeople. They participated voluntarily and authorized the researchers to disclose the survey content to the public. Most of them were under the age of 50 and had a bachelor's degree or above. Most of them had used DCEP for several months for daily consumption purposes. We conducted a pre-test survey of 47 volunteers to improve the reliability and validity of the survey. According to the pre-test results, we improved the questionnaire and then launched a formal online version in June 2021. A total of 341 completed questionnaires were received within two weeks for a completion rate of 67.3%. After deleting any invalid questionnaires, we used 295 valid questionnaires for the empirical test, as shown in Table 53. Three items were used to measure habits based on Saumell et al.37. Three items were used to measure perceived fairness based on Maqsoom et al.34. Three items were used to measure social influence based on Grob40. Three items were used to measure national identity based on Zhang et al.’s52 study. Three items were employed to measure usage based on Sun et al.54.Three items were used to measure perceived risk based on Wu et al. (2011)5456. Table 21.A seven-point Likert scale was used in the measurement process. Smart-PLS 3.0 was used as the main analysis software because DECP is a new technology. Previous researchers have proven that PLS technology provides some advantages related to testing new technology adoption by optimizing restrictive distributions and potential structural modellingTable 57. All the values in Table 58.Tables 2 means how much the independent variables can explain the proportion of usage variation by regression. Based on the structural model, it shows usage can be explained by all the five independent variables in variance proportion of 35.9%59.Figure 60, with a p value less than 0.05. The government's use of DCEP reduces the cost of tracking and verifying transactions, and more information is thus revealed about users' tax payments; therefore, users face increased difficulty in relation to tax avoidance. The government should adjust its mechanism of taxation on enterprises and individuals and thereby reduce the intensity of taxation imposed on users, as this could help them maintain survival and profitability from the perspective of taxation. Otherwise, most enterprises and individual users will perceive a potential taxation risk in relation to DCEP and may refuse to adopt it.In this study, social influence is proven to be significantly and positively related to usage, with a p value less than 0.05. Professional services and technical teams are required to expand the social influence of DCEP; however, all the current promoters are banks. Payment companies and services have complete service teams specialized in payments, and the provision of these professional services can help enhance the social influence of DCEP. The Chinese government and central bank should bring together payment companies and service providers to improve the coverage of the last mile of payments. In this context, payment companies and service providers could encourage their customers to obtain the corresponding remuneration while expanding the scope of their own businesses to achieve revenue growth. Habits are proven to be significantly and positively related to usage, with a p value less than 0.05. When users are accustomed to using digital payment methods such as Alipay and WeChat Pay on a daily basis, DCEP is easily accepted and habit-forming. Additionally, perceived risk is proven to be significantly and negatively related to usageNational identity is proven to be significantly and positively related to usage with a p value less than 0.05, which indicates that Chinese users proudly believe that DCEP has a global leading edge in the context of technology and that their active use of DCEP can help China take the initiative in international economic competition. The Chinese government and central bank must not only promote the convenience, speed and low cost of DCEP but also explain to users that the true competitors of DCEP are the many digital currencies in the future international market; in this way, users' national identity can be strengthened. It is proven that national identity can positively moderate the relationship between perceived fairness and usage, and this relationship has a p value less than 0.05. The reason for this phenomenon could be that, even when people's wealth and class differ, they are willing to actively use DCEP to clearly demonstrate their national identities. Thus, the government should encourage institutions and individuals to actively use DCEP instead of other currencies in domestic and cross-border transactions to increase the influence of DCEP in the global financial market, which could make RMB receive fairer treatment. It is proven that national identity can positively moderate the relationship between habit and usage with a p value less than 0.05. This could be because the Chinese government's long-term promotion of national identity in the media has made the public more accustomed to accepting new products or technologies on the grounds of safeguarding national interests. Unfortunately, it is proven that national identity cannot moderate the relationship between social influence and usage, and this finding has a p value greater than 0.05. The reason for this could stem from the fact that although many people and media groups emphasize the importance of using DCEP for the good of the country, different people have different opinions. It is proven that national identity can negatively moderate the relationship between perceived risk and usage with a p value less than 0.05. This shows that when people’s national identity is strong, many will actively reduce their perceptions of potential risks and choose to enthusiastically accept DCEP.These findings reflect the ambition of the Central Bank of China in relation to digital technology and financial globalization. This study provides detailed policy suggestions for the Central Bank of China regarding the further implementation of DCEP in China and contributes to improving the country’s competitiveness in international finance. The study not only provides a reference for other countries to implement their own digital currencies in the future but also helps central banks construct a decision-making basis for promoting tax growth and social justice through digital currency. By extending UTAUT, this study incorporates push-pull theory and the national identity factor into its model and proves their importance as modular variables and moderating factors.62. To increase fairness, institutions can grant loans in the form of DCEP to facilitate accurate loan usage tracking and prevent misappropriation, thereby greatly reducing the possibility of the falsification of cash flows, assets and liabilities, profit and other data. To reduce the perceived risk of lenders, banks could give preferential interest rates to companies that provide DCEP loans to enhance the popularization of DCEP in the context of financial activities.The results obtained through this empirical research support the hypotheses well and clarify the objectives of the research. The Central Bank of China can refer to these research conclusions to effectively promote DCEP and thus achieve the original purpose of this research. To improve users’ habits, the government can subsidize the pre-installation of DCEP wallets in mobile phones produced in China to promote the public’s habit of paying with DECP. In addition, for Chinese-funded overseas banks, it is recommended that DCEP users are provided with additional comprehensive foreign exchange services in the future. Third-party agencies such as law firms and accounting firms can review DCEP records to understand the true financial situations of companies and issue more accurate professional recommendations, thereby creating a fair, competitive environment for the public in terms of loan interest rates and tax payments. Due to the low cost and high efficiency of DCEP payments, banks can issue DCEP-based credit cards that offer customers’ higher point rewards, lower annual fees, and instalment fee discounts, thereby increasing the social influence of DCEP. The introduction of DCEP overseas could theoretically expand the scope of RMB usage and promote the cross-border settlement of RMB. Potential DCEP users may include trading partners and people in the countries and regions along the “Belt and Road” who do not yet use banking services. The establishment of another international payment system is also expected to reduce reliance on foreign exchange. Users can have DCEP wallets even if they do not have bank accounts in China. If DCEP can be freely converted into non-RMB currencies and transferred abroad, the number of international users of DCEP may increase. Previous researches have demonstrated that the Chinese government is very good at extending its familiar business models to other developing countriesDespite the contributions of this research, it also has some limitations. First, because the survey was conducted in a few large cities in China, considering the uneven development of China’s cities, the research conclusions may not be fully applicable to small, remote cities. Second, most of the individuals who responded to the questionnaire were middle-class people; therefore, future research should also focus on low-income groups, such as students, farmers, and freelancers. Finally, this research is mainly aimed at users, and it ignores the role of financial institutions in the promotion of DCEP. Future research can conduct questionnaire surveys among financial institutions to obtain useful suggestions from them .Supplementary Information 1.Supplementary Information 2.


The spread and influence of misinformation have become a matter of concern in society as misinformation can negatively impact individuals’ beliefs, opinions and, consequently, decisions. Research has shown that individuals persevere in their biased beliefs and opinions even after the retraction of misinformation. This phenomenon is known as the belief perseverance bias. However, research on mitigating the belief perseverance bias after the retraction of misinformation has been limited. Only a few debiasing techniques with limited practical applicability have been proposed, and research on comparing various techniques in terms of their effectiveness has been scarce. This paper contributes to research on mitigating the belief perseverance bias after the retraction of misinformation by proposing counter-speech and awareness-training techniques and comparing them in terms of effectiveness to the existing counter-explanation technique in an experiment with N = 251 participants. To determine changes in opinions, the extent of the belief perseverance bias and the effectiveness of the debiasing techniques in mitigating the belief perseverance bias, we measure participants’ opinions four times in the experiment by using Likert items and phi-coefficient measures. The effectiveness of the debiasing techniques is assessed by measuring the difference between the baseline opinions before exposure to misinformation and the opinions after exposure to a debiasing technique. Further, we discuss the efforts of the providers and recipients of debiasing and the practical applicability of the debiasing techniques. The CS technique, with a very large effect size, is the most effective among the three techniques. The CE and AT techniques, with medium effect sizes, are close to being equivalent in terms of their effectiveness. The CS and AT techniques are associated with less cognitive and time effort of the recipients of debiasing than the CE technique, while the AT and CE techniques require less effort from the providers of debiasing than the CS technique. Decision making shapes important outcomes for individuals, organisations and societies . If the This paper uses the term ‘misinformation’ to refer to information that is initially presented as accurate but later appears to be false, regardless of any intent to mislead. Thus, misinformation in this context covers everything from timely news coverage of unfolding events requiring occasional corrections of earlier statements (with no intention to mislead the news consumers) over fake news  to retracted research papers .Research has shown that simple retraction of misinformation is insufficient to eliminate its influence. On the one hand, individuals may persevere in opinions and judgements even after the initial information on which the beliefs or opinions were based has been retracted; this phenomenon is known as the belief perseverance bias (BPB) . On the The extant research on reducing the negative impact of misinformation has mainly focused on the CIE and its mitigation –15. ConvBPB is defined in the Encyclopedia of Social Psychology as ‘the tendency to cling to one’s initial belief even after receiving new information that contradicts or disconfirms the basis of that belief’ , p.109. BPB is closely related to confirmation bias , 26, whiResearch on BPB has traditionally used a paradigm in which participants receive information on a specific topic, which is later retracted . When paVarious techniques have been explored to reduce the negative impact of misinformation on individuals. These techniques can be grouped into (a) prebunking interventions and (b) debunking interventions.are applied before encountering misinformation to prevent or reduce later reliance on the misinformation. Among the prebunking interventions, up-front warnings, inoculations and literacy training interventions have received particular attention.Up-front warnings consist of warning people that the information to be presented might be misleading. Research has shown that up-front warnings can reduce but not eliminate later reliance on misinformation  lies well within the equivalence interval .The CG serves as a benchmark for analysing the effectiveness of the debiasing techniques. There was no change in opinions between the measurement times o1 –o4 revealed a significant effect of the debiasing treatments, F = 20.08, p = 1.1E-11, η2 = 0.20. Planned contrasts with Bonferroni correction further showed a significant reduction of the BPB for the CE treatment (t(247) = 2.41, p = 0.017), the CS treatment (t(247) = 7.57, p = 7.5E-13) and the AT treatment (t(247) = 2.50, p = 0.013) compared to the CG. Thus, hypotheses H1, H2 and H3 were supported, i.e. all three debiasing techniques mitigated the BPB. The effect size was medium for the CE and AT techniques  and very large for the CS technique (d = 1.36). o1 –o4 with the corresponding statistics.One-factor ANOVA on the differences t1 and t4 for the CE and AT treatments  after the retraction of misinformation by developing new debiasing techniques with higher practical applicability than the existing debiasing techniques. Based on the literature review, we developed two debiasing techniques and conducted a study to compare their effectiveness in mitigating BPB with an existing debiasing technique. This section discusses the results, reviews the limitations and suggests directions for future research.We developed counter-speech (CS) and awareness-training (AT) techniques and compared them in an experiment with the counter-explanation (CE) technique proposed by Anderson  in termsA prerequisite for examining the effectiveness of techniques to mitigate BPB after the retraction of misinformation in our study was observing BPB by the participants after retraction of misinformation. The study fulfilled this prerequisite. Namely, 85% of the participants in our study became biased by the misinformation, and 68.5% showed BPB after the retraction of misinformation. These high numbers demonstrate how easily individuals’ opinions can be influenced by misinformation and emphasise the importance of techniques for mitigating BPB.1, H2 and H3 were supported). The CS technique was the most effective among the three techniques with a very large effect size. The CE and AT techniques, with medium effect sizes, were close to being equivalent in terms of their effectiveness.All three tested debiasing techniques mitigated BPB after the retraction of misinformation  in support of an alternative claim. Causal thinking has been argued as an essential determinant of BPB, and the availability of causal arguments for an alternative claim has been shown to negatively correlate with BPB . The avaCE technique proposed by Anderson [The Anderson  consistsBecause of this, we see only limited practical applicability of the CE technique in situations where recipients frequently encounter misinformation that is not related to a specific decision problem, such as news consumers encountering misinformation in various media. In media, news consumers are likely to frequently encounter misinformation on various topics that are not necessarily of high importance to them and they may, therefore, not be willing to undergo the high cognitive and time effort related to the CE technique. Contrarily, we see some potential for the CE technique to be applied in situations where recipients encounter misinformation related to a specific decision problem of high importance to them. In particular, we can assume that decision makers encountering misinformation related to an important decision problem are willing to accept the additional effort related to the CE technique to ensure high-quality outcomes of their decisions.CS technique, the recipients of misinformation were asked to read a text with counter-arguments. This technique requires only passive participation of the misinformation recipients and is, therefore, associated with low cognitive and time efforts compared to the CE technique. On the other hand, the CS technique requires higher effort from the providers of debiasing than the CE technique, as they must formulate the counter-arguments. The counter-arguments must be designed for every piece of misinformation or at least for every topic subject to misinformation. For example, one standardised CS text containing arguments for COVID-19 vaccinations might be used to counter misinformation containing arguments against vaccination. Despite the higher effort from the providers of debiasing, we see a high potential for practical applicability of CS to misinformation in various contexts, such as frequent misinformation spread in media or misinformation related to a specific decision problem in which a decision analyst is involved. Indeed, fact-checkers willingly spend substantial effort identifying misinformation in media, and decision analysts put effort into modelling decision problems and eliciting judgemental inputs from decision makers. Therefore, we can assume that both fact-checkers and analysts are willing to exert additional effort to apply the CS technique and enhance the effectiveness of fact-checking and the quality of the decision analysis outcomes.In the Our study’s CS treatment included arguments for an alternative (or opposite) hypothesis. CS can be applied in this form only when an alternative hypothesis or explanation exists. However, there are many situations where an alternative hypothesis is unknown, even when it is clear that the initial information was incorrect . In suchAT technique, the recipients of misinformation were asked to read a short text explaining the BPB effect. Like the CS technique, the AT technique requires only passive participation of the recipients of misinformation and is, therefore, associated with low cognitive and time efforts compared to the CE technique. Additionally, since the general text of the AT technique does not need adaption for a particular piece of misinformation, the effort of the providers of debiasing related to the application of the AT technique is negligible. We, therefore, see a high potential of the AT technique for practical applicability.In the Our study applied the AT technique as a debunking intervention after the retraction of misinformation. Since the AT text does not require adaption for a particular piece of misinformation, it is also universally applicable as a prebunking intervention before encountering misinformation, mitigating or preventing the potential BPB after the retraction of misinformation. This feature further enhances the practical applicability of the AT technique. For example, in information and social media, AT could be automatically attached to all news and claims concerning specific topics identified as susceptible to misinformation. AT on BPB could also be applied as a part of an initiative to raise awareness and improve societal resilience to misinformation.This study used misinformation concerning a topic used in the pioneering experiments on BPB. This topic has a particular feature, as it is supposed to be of low relevance to the experimental participants. Therefore, we can assume that most participants are not involved with this topic and have no pre-formed opinions. We assume that the participants have not been actively thinking about the topic before the experiment and that they ‘form’ their first opinions regarding the topic only at the beginning of the experiment as they are asked for their opinions. This feature might have made biasing participants’ opinions and inducing BPB in an experimental setting easier than other topics. Additionally, care should be taken when generalising conclusions about the effectiveness of the debiasing techniques in mitigating BPB after the retraction of misinformation; the effectiveness of these techniques likely depends on the topic. This study considered a topic of low relevance to the participants. Therefore, we have no information on the effectiveness of the debiasing techniques with topics of high relevance. Moreover, BPB caused by misinformation concerning topics of low relevance is likely to have only limited negative implications for individuals, organisations and society. Contrarily, BPB caused by misinformation concerning topics of high relevance  can have profound implications. Therefore, further research on BPB should focus on misinformation concerning topics of high relevance to individuals.The retraction of misinformation and the debiasing were done in our study shortly after reading misinformation, as it is common in studies on reducing the negative impact of misinformation and mitigating the BPB. However, in practice, the time between reading a piece of information and finding out that it was misinformation is usually longer. Therefore, future research should examine how extending the time between reading misinformation, its retraction and the application of a debiasing technique impacts the strength of BPB and the effectiveness of the debiasing.Future research should also examine adapting the debiasing techniques to specific target groups of the recipients of misinformation . We assume that appropriately adapting the debiasing techniques, particularly the CS and AT, to the specific target group (e.g. illustrating BPB on a simple example from everyday life for people with a low level of education and on a sophisticated example for people with a high level of education) may help to increase their effectiveness.The debiasing source is another factor that could influence the effectiveness of the debiasing techniques, particularly concerning misinformation spread in media, and should, therefore, also be examined in future research. Research has shown that retractions from highly-credible sources are more effective than those from low-credible sources . TherefoAnother interesting question for future research, particularly concerning BPB with topics of high relevance, is whether and to what extent people’s existing views influence the effectiveness of the debiasing techniques.Effort and practical applicability, AT is also applicable as a prebunking intervention before encountering misinformation. Since this study did not examine the effectiveness of such prebunking intervention in mitigating BPB, future research should examine whether AT on BPB, applied as a prebunking intervention, could increase the effectiveness of the retraction of misinformation in mitigating BPB or even prevent bias. There is already some evidence that this might work. Specifically, Ecker et al. [Techniques to mitigate the belief perseverance bias showed to be effective in mitigating  the biases in experimental settings. On the other hand, some studies suggested that prebunking interventions may lead to less accurate identification of and decreased belief in accurate information [This study applied the AT technique as a debunking intervention after the retraction of misinformation in our study. As discussed in Sec: r et al.  showed tormation , 69. FutWe examined the effectiveness of single debiasing techniques in mitigating BPB after the retraction of misinformation. However, we did not determine whether combining various techniques could increase their effectiveness in mitigating BPB. Our follow-up paper, which is currently under preparation, examines, among others, the effectiveness of combined AT and CS techniques.The belief perseverance bias (BPB) makes individuals persevere in their beliefs and opinions even after the misinformation on which they were based has been retracted. In this way, misinformation can negatively impact individuals’ beliefs, opinions and consequently decisions. Despite the high relevance of BPB, only a few debiasing techniques with low practical applicability were introduced.This paper has contributed to the research on reducing the negative impact of misinformation on individuals’ opinions by developing techniques to mitigate BPB after the retraction of misinformation. In developing the debiasing techniques, we focused on practical applicability, drawing from the existing literature on reducing the negative impact of misinformation and mitigating other biases. As a result, we proposed two new techniques for mitigating BPB—counter-speech (CS) and awareness training (AT). We compared the debiasing techniques with the existing counter-explanation (CE) technique in terms of effectiveness in an experiment using the classical BPB paradigm. Furthermore, we discussed the effort of the providers and recipients of debiasing related to the use of the debiasing techniques and their applicability in practice.All three debiasing techniques—CE, CS and AT—mitigated BPB after the retraction of misinformation in our study. The CS technique was more effective in mitigating BPB than the AT and CE techniques, which were close to being equivalent in terms of their effectiveness. The CS and AT techniques are associated with less cognitive and time effort of the recipients of debiasing than the CE technique. On the other hand, the AT and CE techniques require less effort from the providers of debiasing than the CS technique. Therefore, we recommend that the providers of debiasing use the CS technique as the first choice to achieve the best debiasing effect. Contrarily, the AT technique should be used when there is a need to keep the effort of the recipients and providers of debiasing low. Another advantage of the AT technique besides the low effort required from the providers and recipients of debiasing is that it is universally applicable as a prebunking intervention before encountering misinformation. In this form, AT could be used to raise awareness of BPB and improve societal resilience to misinformation.This study has some limitations. The retraction of misinformation and the debiasing were done shortly after reading misinformation, as is common in studies on reducing the negative impact of misinformation and mitigating BPB. Therefore, it is unclear whether or to what extent the effectiveness of the debiasing techniques would change in practice, where the time between reading a piece of information and discovering that it was misinformation is typically longer. Moreover, the effectiveness of the debiasing techniques was studied on a topic of low relevance to individuals. Thus, care should be taken when generalising the conclusions about their effectiveness to other topics, particularly topics of high relevance to individuals.The paper provides several directions for future research. First, the impact of the time between encountering misinformation, its retraction and debiasing on the effectiveness of the debiasing techniques should be studied. Second, the effectiveness of the debiasing techniques should be examined on topics of high relevance to individuals. Third, the focus should be on enhancing the applicability of the debiasing techniques in practice, particularly with misinformation spread to a broad audience through information and social media. Fourth, research should focus on enhancing the effectiveness of debiasing, e.g. by combining various debiasing techniques. Fifth, the effectiveness of the AT technique applied as a prebunking intervention should be examined and compared to the debunking AT intervention. Finally, it should be examined whether and to what extent the effectiveness of the debiasing techniques can be influenced by the source of debiasing, peoples’ existing views and opinions and adapting the debiasing techniques to specific target groups of the recipients of misinformation.S1 Appendix(DOCX)Click here for additional data file.


The COVID-19 pandemic generated a series of profound and unprecedented challenges for health and social care systems and those frontline clinicians responsible for delivering services including nurses. One consequence has been the rapid and widespread introduction of a range of digital tools, solutions, and initiatives. In the United Kingdom, this has required clinical leadership to drive implementation and adoption of digital innovations across the system, ranging from those in senior executive board level positions to those on the frontline.This commentary presents a framework highlighting the breadth of digital transformations which emerged as a consequence of the U.K. health and social care systems’ response to the COVID-19 crisis. The framework outlines the different levels of digital transformation, ranging from what we have termed “ceremonial adoption” to isolated automation, organizational integration, and full systems integration. We reflect on the nursing leadership practices that need to be in place to support these changes.Whilst acknowledging the extraordinary results achieved by the COVID-19 driven tsunami of digital transformation, we reflect on the essential steps required to translate these nascent, isolated efforts into fully integrated, long-term solutions. We also offer recommendations for clinical digital leaders and suggest steps that will be crucial to translate the temporary and/or limited interventions into effective, permanent features of our health and social care systems, while also providing a platform on which to build future digital capabilities. We will inevitably continue to see an increase in the use of technology in everyday clinical practice, and nurses are well positioned to take a lead in its widespread adoption. The U.K. National Health Service (NHS) has traditionally demonstrated inertia towards digital innovation and change. A recent report registered the consensus that digital transformation in the U.K. healthcare sector was “slow, expensive, and challenging” . DespiteThe unanticipated COVID-19 crisis overcame many of these barriers, radically accelerating the adoption of digital tools and technologies within the space of just a few months. The need to urgently triage and treat large numbers of patients with acute respiratory illness, protect the healthcare workforce and ensure they were able to treat the sick, and shield the elderly and most vulnerable from becoming infected, has resulted in the fast adoption of a number of innovations . Nurses among others were rapidly mobilized to adopt new patient management systems, ranging from the widespread use of telemedicine consultation approaches for both primary and secondary care, to more complex video conference-based telemedicine or app-based solutions . As a consequence of the COVID crisis, substantial and pervasive changes have been observed in a number of key areas. These include technology, for example, telephone and online triage , use of Our insights are based on a combination of our own opinions and those of a range of expert digitally orientated clinicians including nurses, who are all alumni of the NHS Digital Academy Leadership Programme . We beliOur first observation is that not all the changes introduced have been material. We have found evidence of superficial changes prompted by the need to align with new digitally oriented care guidelines, whilst also keeping up with the rapidly escalating expectations of the healthcare sector by government, press, and the public. Some of the resources used to implement digital change, for example, were existing resources moved from other areas of the healthcare system to frontline CV-19 activities. The issue of resourcing raises concerns as to whether the progress achieved may be sustainable. The amount of debt accumulated during the fight against CV-19 and the current and projected state of the U.K. economy also raises doubts over the resources that might be directed towards further digital innovation initiatives in the years to come.Secondly, the reality of the extent of change is not in keeping with that has been suggested . The curAnother issue is the uneven distribution of users across different parts of the U.K. healthcare system, due to the limited access to technology and/or lack of basic digital skills. The lack of uniformity also concerns the variable fit of digital tools and interventions across different clinical practices , as well as different health conditions—some being less suitable for remote consultation .More significant is the observation that meaningful digital transformation must go well beyond the straightforward substitution of new technologies and tools for old ones, requiring instead the reconfiguration of how health care is delivered and current practices. Even the most innovative digital intervention will not afford any real advantages unless it is integrated into the flow of work. Looking more closely into the use of e-prescribing during the COVID crisis, for example, our clinical experts observed that some of the perceived change has simply been a matter of performing the practice as before, but with some minor adaptations which, in some cases, have produced complex workarounds and increased paperwork. This is a typical outcome of trying to introduce new tools without also changing practices: if the process is sub-optimal before being automated, it will remain sub-optimal and an opportunity for process improvement will have been missed. A related example is electronic referral, whereby the use of NHS email with word documents appears to have simply replaced manual form filling, faxing or posting. Such cases, only the medium will have changed, not the burden on the clinician, or on the system. To benefit from this, or similar kinds of interventions, digital tools, resources, practices, and capabilities would have to be integrated within NHS sites as well as across the wider healthcare system, to achieve the synergies required for the innovation to realize its potential benefits.ceremonial adoption,” involving either superficial (non-transformative) change, or no real change at all  digital initiatives implementation needs to be captured at all levels of the healthcare system and integrated into policy and practical learning which can guide future interventions. Nurses and other clinicians on the frontline are crucial in this aspect as they can support the translation of learning acquired on the ground into higher-level policy. This calls for distributive leadership across the healthcare system so that leaders at all levels are actively engaged in—and share responsibility for—the digital innovation and transformation strategy objectives.The NHS is a complex adaptive system and an acceptance that digital innovation and transformation in the healthcare system differs from other sectors is required. In healthcare, processes, systems, incentives, and drivers are substantially different from other sectors such as financial services, and they are often not aligned. Part of the problem is the focus on measuring process rather than outcomes . Measuring outcomes across the system, enabled by a higher level of knowledge and process integration, could help align the dispersed incentives, drive transformation, and bring in better products and services that improve utility to the user/patient. The use of a socio-technical model such as that described by Finally, it is important that clinical nurse leaders are educated to acquire a system-level understanding of digital transformation. Digital transformation must start in the minds of the leaders. They need a deeper understanding of how new digital tools and technologies can—and indeed should—be integrated across healthcare processes, practices, organizations, and the overall system in a way to create an effective transformation capability rather than one-off, time-limited, local interventions. To avoid narrow approaches, training should also involve learning from past initiatives such as Connecting for Health , and GloTo future proof digital transformation more comprehensively, both clinical nurse leaders and nursing educationalists need to ensure that digital competencies embedded in practice and educational pathways are available from novice to expert nurse roles. These include pre-registration programs through to specific post-graduate Digital Leadership programs such as provided by the NHS Digital Academy in the United Kingdom. Specialist practice Data capture and use in nursing and midwifery practicePopulation healthRegulation and education standardsPlace-based person-centered care supported by techGeonomics in nursing and midwifery practiceAI in nursing and midwiferyThis multi-strand approach seeks to capture both National and International expert opinion and thought leadership, case studies, benchmarking, crowdsourcing ideas from nurses and midwifes in practice and the opportunity to participate in the consultation process. The findings from the review will provide research-based and critically appraised recommendations to ensure the breadth of ambition and scope of future practice of pre- and post-nursing is captured.Whilst this paper is in press The Phillips Ives Nursing and Midwifery Review is taking place. This year's long review due to report in Summer 2023 builds on the findings and recommendations from The Topol Review  and aimsRecent publications  insightf


BMC Psychiatry Collection on First Episode Psychosis.First episode psychosis remains one of the most critical research areas in psychiatry. Much progress has been made, but more progress is required to translate the ideas and promises into reality. In this Editorial, we provide the context and invite contributions for our  Key concepts such as the duration of untreated psychosis [Early Intervention in Psychiatry journal was published in the late 2000s [In the 1980s, a 10-bed clinical research unit for people with first episode psychosis (FEP) was established in Melbourne, Australia, with two main tasks . Australsychosis , prodromsychosis , and ultsychosis  became wespecially) in Australia, where Professor Patrick McGorry was awarded the Australian of the Year in 2010 for his work in youth mental health [Why do psychiatrists doubt the value of early intervention? The power of illusion by McGorry and Mei [Despite its promises and intuitive logic behind the idea, the FEP paradigm also attracted much criticism. In 2011, Professor Allen Frances, the Chair of the task force overseeing the development and revision of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, expressed his concern that the FEP paradigm was prematurely being implemented into clinical practice without sufficient foundations. Namely, he argued (i) accurate diagnosis, (ii) interventions with proven efficacy and (iii) proven safety had not yet been established adequately for the FEP paradigm . More thl health –17. Pate and Mei .Forty years on, some critical questions remain unanswered in the field of FEP research. First, what are the causes of FEP? Is the onset of FEP one of the earliest signs of a pervasive brain disease, or do cultural, social and environmental factors contribute to FEP? Related to this, is the onset of FEP really the beginning of a critical period for intervention ? If so, The FEP paradigm has given us a unique and valuable foundation to explore and examine mental disorders in general, psychotic disorders in particular. We have come a long way, but we are not there yet. We hope this Collection will provide another step towards a better future for people experiencing FEP and their families. We progress by testing ideas and rejecting ideologies. We must continue to seek effective and safe pharmacological, psychosocial and other interventions that will reduce and resolve the sufferings associated with FEP.


The university stage is a crucial stage that influences the decision-making process of students. At this stage, they acquire dietary habits that are guided by their likes, beauty ideals, biological influences, and economic factors. During the COVID-19 pandemic, universities closed and turned to online teaching, changing their life habits under the duress of confinement. The aim of the present work was to identify the dietary behaviours of nursing and engineering degree students at the University of Huelva during the period of confinement, in addition to identifying the factors influencing these habits. The methodological strategy employed was mixed in nature. In this sense, a cross-sectional descriptive study was first performed, followed by a phenomenological qualitative study that was descriptive in nature. Examination of outcomes revealed the presence of four lines of argument founded on the influence of context, life habits, emotional changes experienced during the COVID-19 pandemic, and the factors facilitating or limiting adaption to this period. Taking into account that confinement, restrictive measures, the absence of family, closeness and affection, and training influenced changes to feeding habits and approaches to consumption, universities could carry out interventions oriented in this line to favour healthy eating habits. In the same way as the rest of the world, Spain experienced substantial changes at all levels due to the widespread infection caused by the outbreak and almost generalised spread of the SARS-CoV-2 coronavirus . In JanuUniversities, along with other educational institutions, were forced to close their doors and turn to online working for both teachers and students. This led them to change their overall approach under duress by the situation enforced by confinement.The population of university students, in itself, is made up of highly vulnerable groups due to physiological processes inherent to their generational age, alongside the sociocultural changes resulting from moving home, independence, and a changing economy . The uniDuring imposed confinement, the Spanish Society of Community Nutrition (SENC) laid out nutritional and physical activity recommendations as a means of helping individuals adapt their nutritional and physical activity behaviours to the new situation. The avoidance of impulse buying, comfort eating and overeating of ultra-processed foods was one of the main objectives of these guidelines. Another objective was to promote different types of physical activity to be performed at home or on terraces and consider sources of vitamin D and specific foods of interest for the immune system .With regards to the mobility restrictions imposed by having to stay at home, various studies ,14 stateOther studies ,17 argueAnother consequence resulting from confinement of the population and, therefore, of the university population, includes alterations to the mood state . SpecifiWithin the proposed context, the aim of the present work was to describe the nutritional behaviours of students undertaking nursing or engineering degrees at the University of Huelva during the period of confinement, whilst also identifying the factors that condition these habits.The methodological strategy employed was mixed in nature, first, employing a descriptive cross-sectional study with students undertaking the last year of nursing or computer science and engineering courses. Following this, a phenomenological qualitative study was conducted via a similar content analysis to that described by Taylor and Bodgan .With regards to the quantitative approach, a survey study was conducted using a representative sample in terms of general data, with a maximum sampling error of 5.35%. Given the high representation of women in the population of students undertaking nursing degrees and the high representation of men undertaking computer science and engineering degrees, it was intended to apply proportional gender allocation methods at each university, obtaining a final sample of 139 individuals, of which 90 were women and 49 were men, and of which 85 were nursing students and 54 were engineering students. However, given the exceptional circumstances imposed by confinement during the period of data collection, an ad hoc questionnaire had to be used via Google Forms during the months of April and May 2020.As can be observed in With regards to the qualitative approach, intentional sampling was performed via a snowballing approach carried out within the overall population, with data being stratified according to university and gender. The sample size was determined progressively over the course of the research study, with the final sample being finalised once saturation of new information was achieved.Inclusion criteria stipulated that participating students were undertaking the final year of a nursing or computer science and engineering degree course, had an active registration during the pandemic, and provided informed consent to voluntarily participate in the research. Sociodemographic variables were considered for all participants.The study followed the international ethical recommendations laid out in the Declaration of Helsinki. Participation in the study was completely free and voluntary. Responses to all questionnaires were anonymous, and all provided personal information  was stored in a manner that complied with legal requisites for the protection of personal data and guarantee of digital rights . The project was approved by the Ethics Committee of the Council of Andalusia (reference number: 183-N/2020 PEIBA).For the preliminary study, the survey administered comprised a validated nutritional behaviour scale  that wasFor the qualitative study, given the exceptional set of circumstances present during the performance of field work, it was impossible for researchers to approach informants in person. As a result, interviews were performed through remote video and audio connection via the program Zoom©, with sessions being recorded from start to finish from the moment at which participants provided consent to participate in the interview. Three research team members participated in the delivery of interviews. The aim of this was to minimise the implicit risk of the absence of physical contact between actors, which can lead to a failure to perceive non-verbal expressions, with resultant effects on analysis. One researcher proceeded to conduct the interview whilst the other two took charge of the technical aspects and took field notes. A total of 6 in-depth interviews and 2 focus groups were conducted. The research team moderated group discussion and interview development, whose progress was based on a number of scripted questions. Interviews lasted approximately 40 min. This analysis enabled the aspects most relevant to elaboration of the interview guide and the question at the heart of focus groups to be examined in greater depth.Survey data was analysed using the software program SPSS version 20 belonging to IBM©. Results are presented in the form of means, standard deviations and distributions. Differences between sub-groups were evaluated using chi-squared analysis for discrete variables. When performing this analysis, a weighting factor was applied, which enabled more proportional representation of examined strata relative to the distribution found in the actual population. This factor was developed in consideration of the distribution seen in the target population according to sex and degree undertaken.With regards to discourse analysis, following the literal transcription of interviews and discussion groups, further analysis was conducted that was based on the model outlined by Taylor-Bodgan . In thisFollowing this, data was triangulated. The different techniques employed provided obtained data with greater validity and reliability.The analysed sample was comprised of 139 individuals, of which 90 were women (64.7%) and 49 (35.3%) were men. Obtained outcomes pertained to 85 nursing students and 54 engineering students. The age of interview informants ranged from 21 to 39 years old, with 95% of individuals being younger than 30 years old and 82% being younger than 25 years old. Average age was 23.73 years, whilst the mode was 22 years.Of the surveyed students studying nursing, 72 were women (84.7%) and 13 were men (15.3%). Of those who were studying engineering, surveys were completed by 18 women (33.3%) and 36 men (66.7%).A total of 22 informants were interviewed . InformaPrincipal component analysis (PCA) revealed the existence of four main lines of argument on which informant discourse was hinged. These lines of argument addressed the aims of the present study and pertained to context, lifestyle habits, emotional changes experienced during the COVID-19 pandemic, and the factors that facilitate or limit the ability to adapt to this period of time .The first line of argument refers to the personal, family, and environmental context in which the COVID-19 pandemic was lived out, alongside the nutritional decisions and approaches to feeding that characterised this time in light of this context.When analysing the family setting, the accompaniment received by students during the COVID-19 pandemic was described with regards to whether they lived with family, alone, or with flatmates, in addition to which of these normally prepared meals.A total of 66.2% lived with their parents and 24.5% lived with flatmates. Of those living with their parents, 41.7% pertained to nursing degree students and 24.5% to engineering students. Of the 66.2% of those who were interviewed who were living with their parents, 53.2% indicated that either their mother or father cooked the food they ate. Likewise, of those individuals who responded that they did not live with their parents, 25.2% indicated that they cooked their meals themselves.p < 0.05).When addressing feeding behaviours, the types of foodstuffs consumed and their preparation , responses revealed that more than half of students (55.4%) preferred roasted or grilled food, relative to 23.7% who preferred stewed or sautéed. When comparing the responses given by students on the two types of degree course, the option “fried” was selected by 14.8% of engineering students relative to only 2.4% of nursing students who opted for this response. These differences were found to be statistically significant  describes the way in which personal beliefs influence the value placed on feeding in daily life. The family setting (12) describes the accompaniment perceived by students during the COVID-19 pandemic  and the changes caused by this accompaniment with regards to their dietary habits. The environmental context (6) described the physical place and circumstances surrounding individuals during confinement. Analysis focused on whether or not a physical separation existed between the settings related with feeding and study, in addition to whether these settings were influenced over time .The second line of argument refers to the lifestyle habits followed by students prior to the COVID-19 pandemic and the way in which they changed or were modified during confinement.Addressing habits related with body image and caring for one’s body, differences found between the two examined student groups stood out. A total of 56.6% of nursing students employed strategies pertaining to taking care of nutrition, exercise, or the acquisition of a healthy diet, relative to 32.4% of engineering students who employed these strategies. This reveals notable gender differences, with 69.7% of women providing this response.When this line of argument is considered from a phenomenological perspective, three codes emerge to describe informant discourse, namely, the physical exercise engaged in (6), the online classes (18) that had to be attended during this time, and the use of social networks and apps (5).With regards to physical activity, it serves to highlight some of the modifications resulting from the pandemic with regards to the location chosen for this activity and the intensity of activity. Two contrasting elements were observed. The first pertained to individuals who engaged in exercise prior to the pandemic and were faced with challenges to continuing with the same routine during confinement. The second pertains to references to sedentary behaviour and the influence of online teaching on the failure to achieve these prior routines.Although some informants referred to being able to continue with their exercise routines via the internet or exercise apps, all informants agreed that differences inherent to this new modality with regards to its effectiveness were related with the challenge of performing exercise at home, lack of resources, etc. Further, rising sedentary behaviour due to learning at home led to an increase in the calorie content of the diet.Another worthwhile dimension to highlight is related with the use and abuse of social networks during confinement. All interviewed informants mentioned that this behaviour had affected their dietary habits, sometimes due to adopting a new routine, in other cases due to anxiety and, sometimes, even due to the challenge itself of following some of the publications they saw on social networks. In fact, the discourse mentioned that the profiles of some influencers dedicated to nutrition had seen in a rise in the number of followers from this target university group .The third line of argument described the emotional changes suffered during this period. Consideration is focused on the three codes proposed to condition these changes, namely, the confinement (10) experienced during the first three months following the decreed state of emergency, uncertainty generated by the pandemic (9), and the social distancing enforced by the health crisis (7) .One of the questions posed was focused on the emotional reaction experienced when feelings of satiety were achieved following food intake. A total of 63.5% of nursing students mentioned that they were able to stop eating when they were full, relative to 11.7% who reported the need to continue eating even after feeling satisfied. When the same question was posed to engineering students, 38.9% reported that they would continue eating despite feeling satisfied.p = 0.038). Nursing degree students preferred to snack on fruit (30.6%), yoghurt (10.6%), and nuts (32.9%), compared with engineering students who preferred to consume sweets (18.5%) and nuts (18.5%) outside of meal times.Questions were also asked with regards to the types of foods consumed when intake occurred between meals as these behaviours are associated with feelings of stress and anxiety. Obtained outcomes pointed to a significant difference between the two examined student groups .Some recorded discourse gave voice to the negative thoughts that were taking over positive thoughts and starting to play a leading role as the pandemic progressed. Both the mass media and social networks were reported to have directly influenced mood states and, at the same time, dietary habits, not only in terms of quality but, also, the quantity of consumption. According to informant discourse, emotional changes directly led to an increase in foods high in sugar and fat.Confinement, restrictive measures, and absence of the family, closeness, and affect, led to changes in the mood state of those interviewed who also mentioned that their habits, lifestyle, and food intake was related to these factors, alongside their opportunities for socialisation .The fourth and final line of argument reflects elements that were identified as facilitating (8) or limiting (9) dietary consumption during the COVID-19 pandemic.With regards to this line of argument, students were asked about the factors they considered to be relevant to their consumption with regards to the type of foods consumed, in addition to the factors that conditioned the following of a healthy diet. Outcomes referred to the way in which academic training had exerted a meaningful influence on the motivation to engage in health consumption habits. A total of 35.3% of nursing students reported that nutritional content was the main conditioning factor pertaining to consumption, relative to just 10.1% of engineering students. Nonetheless, 38.7% of these students attributed more value to characteristics related with the taste of food.Another of the issues addressed by the survey pertained to the elements required by students in their day-to-day lives to equip them to be able to improve their diet. Similar results were obtained between both disciplines (nursing and engineering), revealing values such as commitment and motivation (23.0–15.1%), more information and training (6.5–6.5%), and time (7.2–4.3%), followed by money (4.3–2.9%) and social support (4.3–1.4%).It serves to highlight that this line of argument demonstrated greater variability in the analysis conducted according to student group than those discussed earlier.Training was one of the elements identified as being a facilitator, especially by nursing students, who highlighted that training was fundamental to decision-making at the time of making purchases, consuming foods, and consuming snacks outside of meal times. Engineering students contributed an additional important element to that presented up until now, in that they related the personal characteristics, resulting from family feeding habits, of individual students to this aspect. Some of those surveyed highlighted that the profession of their parents or the individuals with whom they shared the period of confinement had influenced their consumption and feeding habits.With regards to the limiting elements most highlighted by engineering students, obstacles included the lack of training, impact of information received through mass media, advertising, and social networks, behaviour prior to the pandemic, and the internal pressure felt to maintain an expected body image.Nursing students discussed the stress caused by this situation, alongside the previously defined characteristics , as the main limiting element over their ability to adapt their dietary habits during confinement .The aim of the present research was to identify the dietary behaviours of students during the period of confinement, whilst also conducting a comparative analysis of students undertaking nursing and engineering degrees at the University of Huelva. The mixed approach to this issue enabled not only student habits to be uncovered, but also permitted the reasons behind them and the intentions of them to be revealed.The present study identified four lines of argument that describe student behaviour with regards to nutrition. The first of these was related to the individuals with whom students lived, specifically the family or flatmates, with the family context proving to be more protective against unhealthy nutrition given that parents tended to be responsible for preparing meals. This coincides with the outcomes of other research studies ,28 conduWith regards to the lifestyle, the present study closely aligns with other previous research ,30,31,32On the other hand, when habits related with body image and taking care of one’s body, differences were found in the present study in both student groups, although nursing degree students were more concerned about taking care of themselves in this sense. A study conducted by the University of Edinburgh during confinement  describeThe third line of argument to emerge from the present research pertains to the emotional component of nutrition in university students during confinement. Similar studies ,37 have A study carried out at a leading public university in the United States during the pandemic  evaluateThe final line of argument to emerge from the present study pertains to factors considered by the student to be relevant to their consumption with regards to types of food and the individuals who motivate them to follow a healthy diet. It is notable that this line of argument demonstrated greater variability than the others when examined according to student group. In this sense, nursing students viewed academic training as a crucial building block on which to make decisions, form judgements about the nutritional content of foodstuffs, and understand the pathologies derived from poor nutrition. In stark contrast to this, engineering students reported that the overriding factor driving their consumption of a certain food type over another was the taste of the food. A study conducted at universities in Ecuador and Peru  also repThe health status of the university population is built on the synergistic relationship between healthy lifestyle habits and the personal and material resources on hand at any given time. Present findings describe the way in which confinement influenced the dietary habits of university students and the role played in relation to these changes by the acquisition of knowledge of healthy habits. In this sense, nursing degree students were more likely to continue to follow healthy dietary habits than engineering students.Confinement, restrictive measures, and the absence of family and opportunities to experience closeness and affect led to changes in the mood state of those interviewed who, in turn, stated that their habits, lifestyle, and dietary intake were related both with these aforementioned factors and with their opportunities for socialisation. Future lines of research should be aimed at deepening factors such as loneliness and recreational deficits that influence feeding habits.Elements considered to be promotive of healthy habits were deemed to be influenced by student training with regards to the diet and lifestyle. Training was highlighted to provide students with greater confidence at the time of making decisions when making food purchases and choosing the types of foods to eat, in addition to impacting decisions around food consumption outside of regular meal times. Students with less knowledge about nutrition pointed to the personal characteristics of individuals as the main catalyst, with these being born out in perceived family dietary practices. Universities must include training actions not only in food, but in healthy shopping and empowerment and self-esteem to help in decision-making.Based on the findings of the present study, the acquisition of cognitive, attitudinal, and experiential skills by university students with regards to healthy habits will enable the development of strategies targeting the adoption and maintenance of healthy habits in the university community.A limitation of this research implies the ability to generalize the results obtained to other universities and even to other disciplines not included in the study, although it has allowed us to establish actions that can be extrapolated to other university communities.