Minimal, low-cost approaches can be effective in delaying child marriage and increasing school attendance. Program managers should consider the cost, quality, and coverage of interventions, especially because child marriage persists in the most hard-to-reach, rural areas of many countries. Minimal, low-cost approaches can be effective in delaying child marriage and increasing school attendance. Program managers should consider the cost, quality, and coverage of interventions, especially because child marriage persists in the most hard-to-reach, rural areas of many countries. A significant number of girls are married as children, which negatively impacts their health, education, and development. Given the sheer numbers of girls at risk of child marriage globally, the challenge to eliminate the practice is daunting. Programs to prevent child marriage are typically small-scale and overlook the costs and scalability of the intervention.This study tested and costed different approaches to preventing child marriage in rural Burkina Faso and Tanzania. The approaches tested were community dialogue, provision of school supplies, provision of a livestock asset, a model including all components, and a control arm. A quasi-experimental design was employed with surveys undertaken at baseline and after 2 years of intervention. We examined the prevalence of child marriage and school attendance controlling for background characteristics and stratified by age group. Programmatic costs were collected prospectively.Among those in the community dialogue arm in Burkina Faso, girls aged 15 to 17 years had two-thirds less risk  of being married and girls aged 12 to 14 years had a greater chance of being in school  compared to the control site. In Tanzania, girls aged 12 to 14 years residing in the multicomponent arm had two-thirds less risk of being married , and girls 15 to 17 in the conditional asset location had half the risk . All the interventions tested in Tanzania were associated with increased risk of girls 12 to 14 years old being in school, and the educational promotion arm was also associated with a 30% increased risk of girls aged 15 to 17 years attending school . Costs per beneficiary ranged from US$9 to US$117.The study demonstrates that minimal, low-cost approaches can be effective in delaying child marriage and increasing school attendance. However, community dialogues need to be designed to ensure sufficient quality and intensity of messaging. Program managers should pay attention to the cost, quality, and coverage of interventions, especially considering that child marriage persists in the most hard-to-reach rural areas of many countries. Several meta-analyses and evaluations of individual programs have examined what works in delaying child marriage. In 2012, Lee-Rife et al undertook a systematic review of evaluated child marriage interventions in developing countries. Among the 23 evaluated programs, only 4 focused on preventing child marriage as the primary objective and only 5 studies were undertaken in sub-Saharan Africa. Although evidence was limited, the review found that the most effective approaches in delaying child marriage were those that offered incentives and those that are directed at girls, providing them knowledge, skills, and opportunity to expand their social networks.–Given the sheer numbers of girls at risk of child marriage globally, the challenge to accelerate elimination of the practice is daunting. Pilot programs to prevent or reduce child marriage, whether evaluated or not, typically overlook the costs and scalability of the intervention design.Berhane Hewan (Amharic for “Light for Eve”) was one of the early child marriage prevention programs to include a rigorous, quasi-experimental evaluation. The program was a multicomponent package that included (1) community conversations to address social norms related to child marriage; (2) provision of school supplies to encourage school enrollment and thereby protect girls from marriage; (3) a conditional asset transfer, promising girls and their families a goat if they remain unmarried and in school; and (4) girls' groups led by adult women mentors that were mainly attended by married girls. After 2 years of intervention, girls aged 10 to 14 years in the Berhane Hewan site were one-tenth as likely to be married and 3 times more likely to be in school compared to girls residing in the control area.In Ethiopia, Given the success of Berhane Hewan in delaying marriage age, it was anticipated that government and NGO partners would scale up the approach to other locations in Ethiopia where child marriage was prevalent. However, in-country partners questioned the feasibility of scaling up the project given the complexity of its multicomponent design and wanted more information about the costs associated with scaling up the program over larger populations.As a result, a second generation of research was designed related to child marriage prevention. We sought to examine if streamlined, low-cost interventions could be effective in delaying marriage in sub-Saharan Africa, and at what cost? In this phase, we adapted the interventions used in the original Berhane Hewan project but implemented them separately in different geographical areas, with the intention to isolate the specific impact of streamlined interventions. During this research phase, costing data were collected for all interventions, and the program was expanded beyond Ethiopia to include the Cascades province of Burkina Faso and the Tabora region of Tanzania.In this article, we present implementation, impact results, and costing data for child marriage prevention schemes in Burkina Faso and Tanzania only. Although we included research sites in the Amhara region of Ethiopia, where the Berhane Hewan project had been tested, we had to eliminate the control site because it became a resettlement area for people from other parts of the country. As a result, the population in this area was frequently unfamiliar with each other, making it significantly different from the other intervention sites. Marriage arrangements in Ethiopia are rooted in family ties and the desire to strengthen bonds between families who are essentially known to each other and/or neighbors. The control site included a resettled population, many of whom were strangers to each other or from different religions, inherent differences that could not be captured in the survey. As such, the marriage market in this area was compromised and rates of marriage were extremely low and uncharacteristic of the region.Burkina Faso is a francophone West African country where the prevalence of child marriage is the eighth highest in the world (52% married by age 18 years).The Tabora region is located in the central-western part of Tanzania and has a population of more than 2.2 million. The largely agricultural region has tobacco production as a major economic activity. Based on the 2010 Tanzania DHS, 63% of Tabora girls are married by age 18 years and 16% are married by age 15 years. Among girls aged 20 to 24 years, 42% have never been to school and only 9% have reached the secondary level.This study tested and costed streamlined interventions to delay the age at marriage in Burkina Faso and Tanzania. Local NGO partners implemented different child marriage prevention strategies derived from the Berhane Hewan program in Ethiopia in different geographical areas of the project regions. In each country, 4 approaches were implemented: (1) addressing community attitudes related to child marriage through community dialogue (2) providing unmarried girls aged 12 to 17 years with school materials, (3) offering a conditional asset transfer in the form of a goat, both conditioned on the 12-to-17-year-old girl remaining unmarried and in school for the duration of the pilot period (27–28 months), and (4) offering all components: community dialogue, school supplies and a conditional asset transfer. A fifth area served as a control where no intervention took place.This study tested and costed streamlined interventions to delay the age at marriage in Burkina Faso and Tanzania.The interventions were similar between regions but not identical. In each of the countries, modest modifications and adaptations were made by local implementing partners based on experiences and preferences as well as local circumstances, and so as not to impose approaches that might not be appropriate to the context . InterveApproaches to community dialogue differed in Burkina Faso and Tanzania with the approach in Burkina Faso being more systematic. In Burkina Faso, community facilitators were recruited from project communities and trained for 5 days using a facilitation manual. The manual contained information on facilitation techniques and on child marriage and girls' education. After training, facilitators mobilized community discussion groups composed of roughly 30 members containing a cross-section of the community: adult men, adult women, adolescent men, and adolescent women. Groups were taken through a 16-week curriculum that included both educational and action-oriented sessions. Education sessions provided information on the negative impact of early marriage and the value of girls' education. The action-oriented sessions provided a space for group members to devise home-grown solutions to child marriage and develop strategies to address it. Strategies could include house-to-house campaigns or systems of punishments or rewards for community members. Following the completion of the 4-month period, groups could have continued to meet on their own, if they desired. However, facilitators moved to additional areas to form new discussion groups. By the end of the program, 495 individual community members had taken part in the dialogues in Burkina Faso.In the Tanzania community dialogue locations, community and religious leaders received 2 days of training on the benefits of delaying marriage and promoting girls' education. Leaders were trained on how to facilitate discussions and deliver messages and were asked to pass messages in their villages or places of worship. In contrast to the approach in Burkina Faso, the community dialogues in Tanzania did not include sustained and systematic contact with community groups but rather ad hoc contact with community members who attended routine community or religious meetings. Leaders in Tanzania did not record the number of community members who received their messages.Both in-school and out-of-school girls aged 12 to 17 years who were unmarried were eligible for the provision of school supplies, with out-of-school girls encouraged to return to school or join nonformal education. In school promotion locations, community-based mentors who were recruited and trained by the project identified eligible girls by going house-to-house. Once identified, project staff explained the scheme to girls and parents/guardians in the household and invited them to register for the scheme at a central location  on a designated day. These explanations of the scheme were scripted so that information provided about the school promotion scheme was complete and uniform across households. On the day of registration and at the designated location, both the registering girl and her parent/guardian would sign the registration form in the presence of other community members and local leadership and take school materials with them with the agreement that the girl would remain unmarried and in-school for the duration of the pilot. Once it was confirmed that girls were attending school and remained unmarried, they were given her subsequent allocation of supplies in public ceremonies acknowledging their achievements by local leadership and school officials. These public ceremonies were also used as occasions to educate the community on the value of educating girls and keeping them unmarried.Girls were given supplies once per year at the beginning of the school year, but the support differed by country. In Burkina Faso, registered girls received school supplies . In addition, they received a subsidy for school fees equivalent to US$3.50. In Tanzania, girls were given the choice of receiving a school uniform or school supplies. Tanzanian girls could attend Smart Girls' Clubs, which were after-school clubs that included life skills, reproductive health information, and tutoring. In all, 1,055 girls registered for the schooling program in Burkina Faso and 1,617 registered in Tanzania.Girls were recruited for the conditional asset transfer through community-based mentors going house-to-house to identify unmarried girls aged 12 to 17 years. Girls and their parents/guardians were sensitized on the scheme through a scripted narrative and asked to come to a central registration site on a specified day, if they wanted to enroll. In both countries, families and girls were awarded a goat at the end of the pilot period if the registered girls remained unmarried and in-school throughout the intervention period. In Tanzania, a pregnant goat was preferred because project partners perceived that such an asset would be further incentivizing to project communities. At the end of the pilot period, girls who remained unmarried and in school were awarded their livestock in a public ceremony with all the community members and local officials. As with the school material ceremonies, these occasions were used to educate the community on the value of girls' education. Seven hundred and thirty-two girls registered in Burkina Faso compared to 805 in Tanzania.In both countries, 1 location included all the project interventions: community dialogue, school promotion, and conditional asset transfer. All interventions we tested were designed to change social norms related to child marriage in different ways. The community dialogues directly addressed attitudes and beliefs related to child marriage and the status and value of girls. In addition, promotion of schooling and provision of conditional asset transfers were all implemented through public events under the auspices of local community leadership. These events raised the visibility and status of girls in the community and included messages from local leaders emphasizing the value delaying marriage and girls' education.This was a quasi-experimental study design with cross-sectional baseline and end line surveys undertaken among girls aged 12 to 17 years. These surveys were used to measure population-level prevalence of child marriage and school attendance associated with the different interventions, using the control to measure changes that would have taken place without the interventions. Separate, cross-sectional baseline and end line surveys were undertaken before the interventions were established and after 27 to 28 months of intervention implementation.The sample size was calculated to detect a 10-percentage point change in the prevalence of child marriage and adjusted for nonresponse and design effect. In each country, 2,500 girls aged 12 to 17 years were sampled, 500 per intervention area, at each round of survey. In each study commune (Burkina Faso) and ward (Tanzania), we randomly selected 17 enumeration areas from the existing national sampling frame. Each selected enumeration area underwent a household listing to establish a sampling frame. All members of the household were listed. Using the random number function in SPSS, we selected 30 girls aged 12 to 17 years per enumeration area. Only 1 respondent was interviewed per household. Where there was more than 1 eligible respondent per household, we used a Kish grid to select just 1 respondent.Female interviewers were recruited from the project regions, ensuring that they were familiar with local languages and customs. At each survey round, interviewers received a 5-day training that included review of the questionnaire, review of ethical procedures, and practice interviews between interviewers and with girls recruited from outside the study areas.Interviewers approached sampled respondents for a one-on-one interview. Similar to the DHS, interviewers made up to 3 visits to the household to locate and interview the sampled respondent. There was no replacement if the sampled respondent could not be located or refused to participate. Informed consent for the interviews was obtained from the parent or guardian of the sampled adolescent, and informed assent was obtained from the girl. If a girl was married, we considered her as an emancipated minor who could provide her own consent.The questionnaire used in the study was a structured instrument covering areas such as demographic characteristics and living conditions, education, families and parent-child relationships, livelihoods, attitudes toward marriage and the experience of marriage, sexual experience, family planning, maternal and child health, and HIV and AIDS. A separate, abbreviated questionnaire was administered to younger respondents aged 12 to 14 years. This questionnaire omitted especially sensitive or potentially upsetting questions such as those related to violence or sexual coercion. The questionnaires were the same across countries at baseline and end line, except for country-specific modifications such as response codes for ethnic groups or religion. However, at end line, an additional section was added at the end to measure exposure to the interventions. The study received ethical clearance from the host institution's review board as well as local review boards in each of the study countries.The main outcome indicators measuring the impact of interventions was the percentage of girls who had ever been married and the percentage of girls in school in the current or previous year. Marriage was measured by asking the question, “Have you ever been married or lived with a person as married?” and a follow-up confirmatory question, “Have you ever been married but later divorced?” Girls who answered yes to either of these questions were coded as having been married and were asked a series of follow-up questions related to their husband and the timing and nature of their marriage.To indicate whether girls had attended school in the last year, we asked respondents if they had ever been to school, if they were currently in school, and, if not, the age at which they left school. We used these 3 variables as well as the respondent's current age to construct a dichotomous variable reflecting school attendance in the previous year. We considered not only girls who were currently in school but also those who recently dropped out from school. This was because school supplies were only provided once per year at the beginning of the school year. Our field reports suggested that some girls in the 2 project countries dropped out of school in the second year of implementation after receiving their supplies because they knew no further supplies were forthcoming.Multivariate models controlled for age, ethnicity, household assets as a reflection of socioeconomic status, and religion. Household socioeconomic status of respondents was measured based on ownership of a list of assets derived from DHS surveys. Each of these assets were given weights varying from 1 to 5, with the larger weight indicating greater value of the asset. Hence, car/truck was given a weight of 5; motorcycle/scooter was given a weight of 4; television, refrigerator, bicycle, and animal drawcart were given weights of 3; clock or watch, radio, telephone, mobile phone, and solar panel were given weights of 2; and table, chair, bed, and mattress were given a weight of 1. In each country, a weighted asset score was calculated after which respondents were scored as low-, middle-, or high-economic status. For religion, a dichotomous variable was created in both countries to reflect if the respondent was a Muslim or another religion.Exposure and participation in the interventions were measured by asking respondents 2 separate questions. First, they were asked if they had heard of a project in their area offering community dialogues, school supplies, or a goat. In Tanzania, we also asked if girls had heard about a program offering girls' clubs in school. The second question asked if they had participated in the program including community dialogues, school supplies, or a goat. Those who had heard of and reported participation were coded as having participated in the project. Because the community dialogue arm included interventions that were targeted to both girls and the community at-large, respondents who had either heard of or participated in community dialogue were coded as having been exposed to the project. As the intervention was targeted to the community and not necessarily intended for the girl, it was assumed that those who had heard of the community dialogue had family and community members exposed to its messages. To measure exposure to the comprehensive model, we considered only residents of the study cell who had been exposed to all 3 project components as having been exposed to the comprehensive model. Follow-up questions were asked to assess levels of exposure to the interventions such as how many times they received school materials and how many community meetings they attended.,The analysis of the demographic characteristics was based on the unweighted sample. All other analyses were adjusted for the number of eligible females in the household to compensate for unequal probabilities of selection. Weighted numbers were reported. Exposure to the interventions is reported for each of the respective project sites at end line. In each of the countries, 1 study area was assigned to each model tested, due to logistical constraints. We undertook tests of equivalence using a confidence interval approach to understand the comparability of the study cells in each country.To estimate the impact of the interventions, we use Poisson regression to model risk ratios (RR) of having been married and having attended school in the last year, controlling for age, religion, ethnicity and low-, middle- or high-socioeconomic status. We stratified analysis by younger (aged 12 to 14 years) versus older (aged 15 to 17 years) adolescents. This stratification was done because the Berhane Hewan study demonstrated that interventions may operate differently among younger versus older adolescents, reflecting the divergent experiences and circumstances of older versus younger adolescents. At the same time, our sample was not powered to account for stratification. Separate models are presented for each intervention site, with reference to the control site, presenting RRs and 95% confidence intervals (CI) for residence in the intervention sites versus the control site, at end line. In addition, we did not assess the child marriage outcome for girls aged 12 to 14 years in Burkina Faso because there were too few cases of marriage among this age group at both baseline and end line.Management information systems in each country tracked information on girls' participation in each of the study arms. When registering, basic demographic information about each girl was entered into the database including age, school attendance, and highest year of education attained. Girls participating in the community sensitization arm were not registered as this approach targeted the community at-large. Management information systems data were entered in each country in an Epi-data file and converted to SPSS for analysis.At the beginning of the study, a Microsoft Excel spreadsheet was developed by a costing expert to enable systematic compilation of all project costs. Cost categories included staff time, office expenditures, training and meeting costs, travel expenditure, and purchase of commodities. Costs associated with evaluation were not included. Cost data were updated in the spreadsheet on a monthly basis by project staff and our in-country partners. On a yearly basis, costing data were validated by the costing expert.At the end of the intervention, total costs were calculated by country and model. Using data from the management information system on the number of girls served per model, we calculated the cost per girl served, per year. Because the community dialogue did not include only girls, we estimated the population reached using population estimates and the percentage of girls at end line hearing about or participating in community dialogue.We modelled the RRs at end line associated with being married in each of the study communities in Burkina Faso and Tanzania, with reference to the control site. In Burkina Faso, we did not examine the impact on marriage age among younger girls aged 12 to 14 years, as too few girls were married at both baseline (12 married girls) and end line (5 married girls). As previously mentioned, the conditional asset transfer arm was removed from analysis because of incomparability of that site, even after controlling for background factors. In Burkina Faso, girls aged 15 to 17 years who were enrolled in the community dialogue arm were one-third as likely to be married as those in the control site  .In Tanzania, girls 12 to 14 residing in the comprehensive site had two-thirds less risk of being married compared to girls in the control site . Tanzanian girls 15 to 17 residing in the conditional asset transfer site had roughly half the risk of being married compared to girls in the control site .We re-analyzed data to model RRs among Burkinabe and Tanzanian girls who reported that they had been exposed to the intervention at end line, with reference to the control site. Although selectivity issues undoubtedly impact upon results, the results of these analyses are consistent with the findings presented above . In Burkina Faso, girls exposed or aware of the community dialogue had three-quarters less risk of being married (RR=0.27) compared to girls in the control site. Tanzanian girls aged 15 to 17 years residing in the conditional asset transfer arm and the comprehensive model had 90% less risk of being married compared to those in the control. This analysis demonstrates similar results among the exposed compared to the intention-to-treat analysis design, giving us confidence in the findings from our earlier analysis.We examined differences in the risk of girls attending school in the current and previous years. We included attendance during the current year and previous year because school material was provided only once per year. We received information from staff in the field that some participants left school after receiving the second tranche of school supplies, knowing that additional supplies would not be provided in the next year. Burkinabe girls aged 12 to 14 years residing in the community dialogue site had a greater chance of being in school  compared to their counterparts in the control. This finding is consistent with the fact that girls in this site were also less at risk for child marriage, which supports the effectiveness of this intervention in Burkina Faso. In Tanzania, all the interventions tested were associated with increased risk of girls aged 12 to 14 years being in school. The educational promotion arm was also associated with a 30% increased risk of being in-school among girls aged 15 to 17 years .Child marriage is considerably more common in rural areas compared to urban areas. Sites for this study were all rural and difficult to access. As such, the cost to deliver interventions in these rural areas was undoubtedly higher than similar efforts in urban areas. The coverage or reach of interventions varied. A much lower proportion of girls was exposed to the comprehensive model in both countries, likely reflecting the increased difficulty in implementing complex, multicomponent programs, exacerbated by the fact that interventions are being implemented in remote rural areas, where households are dispersed, isolated, or inaccessible. Although it had been expected that the comprehensive model would be more effective than simpler or single-component models in bringing about improved outcomes, the difficulty in implementing multicomponent programs in remote areas may have undermined the effectiveness of the intensive program model. Therefore, program implementers should closely monitor the coverage and quality of child marriage interventions. Specifically, they should weigh the trade-offs between more comprehensive program design that may be difficult to implement at scale in remote areas against simpler models that can more easily achieve coverage and scale and maintain quality.Child marriage is commonly perceived as an intractable traditional practice. Many practitioners assume that complex and cost-intensive interventions are needed to achieve a tipping point. Our study results suggest that streamlined minimal approaches can be effective in delaying child marriage and encouraging school attendance. Community dialogue was effective in Burkina Faso, both in delaying child marriage and in increasing school attendance; however, the approach did not bring about measurable change in Tanzania. Community dialogue in Burkina Faso was systematically implemented using dedicated, paid facilitators who implemented a set curriculum among representatives of the community recruited for the dialogues. The approach in Tanzania was less rigorous and used existing community leaders to pass messages during routine community meetings. The ad hoc nature of the approach in Tanzania probably weakened the quality and intensity of messaging, as well as, possibly, cultural differences or differential receptivity to messages. This suggests that efforts to promote social norm change need to be implemented in a rigorous and systematic manner and not simply delegated to community members or religious leaders without rigorous training and follow-up.Our study results suggest that streamlined minimal approaches can be effective in delaying child marriage and encouraging school attendance.Finally, this is one of the few studies on child marriage prevention to include rigorous costing data. The study demonstrated that streamlined interventions can be effective to both delay marriage and contain costs, thus maximizing the likelihood for scale-up to large numbers of at-risk girls. Community dialogues in Burkina Faso cost only US$12 per person reached per year; schooling promotion in Tanzania cost only US$18 per girl supported per year. However, the cost of providing goats as a conditional asset transfer ranged from US$33 per girl served in Burkina Faso to US$107 per girl in Tanzania. The higher cost of purchasing pregnant goats in Tanzania compared with purchasing less expensive younger goats in Burkina Faso coupled with the delivery cost to remote areas of Tabora region drove up the cost of the conditional asset transfer in Tanzania. The high unit cost in Tanzania underscores the fact that decisions about programs and purchases should take cost into careful consideration to avoid excessive costs that undermine the chances of scalability. In addition, programmers should carefully consider the choice of economic incentives. A more recent program in Ethiopia eliminated livestock and introduced solar-powered lanterns as incentives to delay child marriage.This is one of the few studies on child marriage prevention to include rigorous costing data.Child marriage affects a large number of developing country girls, mainly in the poorest, most remote, and hard-to-reach locations. Programs designed to reach the greatest number of girls possible will require a greater number of impact evaluations coupled with costing studies. This study demonstrated that cost-contained interventions are feasible and can be effective in preventing child marriage. However, interventions need to take into account the quality and coverage of interventions, especially considering the difficulty of implementation in remote areas, where child marriage tends to persist.The study had a number of limitations. Due to logistical and budgetary constraints, only 1 location was used to test and compare each model implemented. Including multiple sites per model tested would have likely increased comparability between sites and our confidence in the study results. Unfortunately, the control site in Ethiopia was found not to be comparable to the experimental sites, which weakened our ability to detect changes associated with interventions. In addition, the conditional asset transfer site in Burkina Faso was not comparable to the control site, even after controlling for background factors. As such, we could not assess the effectiveness of this approach. Lastly, based on past experience, it was necessary to stratify the analysis by age group. At the same time, the sample was not necessarily powered to accommodate this subgroup analysis.This study demonstrates that minimal, low-cost approaches can be effective in delaying child marriage and increasing school attendance. However, community dialogues need to be designed to ensure sufficient quality and intensity of messaging. Program managers should consider the cost, quality, and coverage of interventions, especially because child marriage persists in the most hard-to-reach, rural areas of many countries.


In the last few years, a wide range of pharmacologically active substances entered the legal and illegal market of abused compounds creating new challenges for health professionals dealing with users and their health threats –6. AmongChemsex drugs are a group of psychoactive substances  and non-psychoactive drugs  intentionally or non-intentionally used in the context of sexual intercourses, most commonly among gay and bisexual men , 8. The Similarly, cognitive enhancers are used in medical practice as medication to treat specific cognition deficits in mental diseases, such as attention deficit hyperactivity disorder and Alzheimer's disease. In contrast, their non-medical use has been spreading worldwide due to their alleged capability to increase mental alertness and concentration, as well as to boost memory and energy levels. Although the psychostimulant effects of these substances are necessary to treat cognitive impairment, the psychiatric/psychotropic effects of their misuse, and the consequences for mental health, are poorly described , 10.Generally speaking, unlike what happened in the past century, every year a non-negligible number of new psychoactive substances appear in the illegal market. Their permanence both on the market and on web-based channels only depends on “consumers' satisfaction”: a balance between number and length of positive subjective effects vs. acute side effects . WhereasThis Research Topic seeks to provide updated studies, reviews, mini reviews, opinion papers, perspective articles, and case reports on psychiatric and psychotropic effects of chemsex drugs, cognitive enhancers, and more generally on new psychoactive substances. This collection aims to shed light on this incoming hazard to scientists and health professionals operating in the field of psychiatric damages caused by drug abuse.Bohn et al.. The research group administered to volunteers from the German MSM community a survey concerning recreational substance use, substance use in a sexual setting, mental health, adverse consequences of Chemsex behavior, and others. They concluded that the consumers of methamphetamine, mephedrone, GHB and or ketamine in sexual settings presented several more symptoms of depression, anxiety and somatization than the non-chemsex abusers and German general population.As above reported, evidence on the Chemsex drugs' influence on mental health were provided by Pereira et al. investigated the effects of regular GHB consumption and GHB-induced comas on the human brain structure and impulsivity. The study showed that only multiple GHB-induced comas could affect the microstructural tissue in the white matter, that is alleged to be the cause of the higher self-reported impulsivity.Besides, Schreck et al. with the aim to evaluate the presence of the cathinone use disorder. Based on 39 “slam” notifications, Cathinone related disorder appeared particularly important in this population of users due to the negative consequences of slam practice.An emerging phenomenon associated to Chemsex is the so-called “slam,” being the practice of injecting drugs in Chemsex contests. A study on the cathinones injection in slam context was presented by Brown. After an historical overview of main drug related social issues, the author identified in the emerging phenomenon of Chemsex the chance to do better, preventing the dehumanization of the MSM communities which could feed the drug abuse among MSM communities.The problem of stigmatization of drug addiction and the consequent social exclusion is discussed by Napoletano et al. outlined the online availability of cognitive enhancers, comparing the information on online fora and the EMCDDA and UNODC NPS databases. Through the website NPSfinder®, 142 cognitive enhancers not reported in the official databases were individuated.The marked increase of the prescription of substances like methylphenidate has recently raised concerns, suggesting a possible misuse of these substances to obtain mind-booster effects and create new niches in the NPS market . In factKexel et al. in a sample of 42 cocaine users, divided into a non-social motive group and a social motive group. Then, the social motive group was compared to a control group to assess their cognitive functioning through a comprehensive neuropsychological test. The study confirmed that people who use cocaine as a cognitive enhancer have considerable deficits in cognitive empathy and working memory. Currently, different treatments for cocaine addiction have been proposed in the literature. The long-term outcomes of an alternative approach were evaluated by Madeo et al. in their retrospective observational study. A large cohort of cocaine addicts who underwent repetitive transcranial magnetic stimulation (rTMS) for 3 months were observed and regular toxicological analysis of urine were conducted. As already observed in smaller samples, the rTMS shows promising results in the treatment of cocaine addiction.Besides recreational consumption, cocaine is also abused for social or cognitive enhancement. The motivation pushing people to take cocaine to self-medicate deficits in cognitive abilities was assessed by Zaami, Tagliabracci et al. and Ricci, who both focused their attention on the effectiveness of cosmetic neurology and the possible misuse to obtain “super-human” performances in healthy subjects. Although several opinions have been expressed by the international bioethical committee, the issue is still controversial and official guidelines are required by physicians. On the other hand, Schleim proposed a different approach to the cognitive enhancers issue, defining it as instrumental drug use. To this purpose, a brief discussion on the most relevant research and anecdotal evidence was reported by the author to corroborate his thesis.The ethical implications of cognitive enhancers prescription were discussed by Specka et al. showed that polydrug consumption was common in that population, especially in opiate abusers, but NPS use in particular was infrequent and only short-term. The most commonly used NPS class in this population were synthetic cannabinoids. It is interesting to note that the most frequent reason for NPS use according to the participants, was that NPS were not included in the usual toxicological tests. Although this study shows that the NPS consumption is not so common. Giorgetti et al. drawn the attention toward the fact that a concerning number of NPS related deaths are reported in the literature. The research group focused on the post-mortem toxicology of synthetic cannabinoids-related fatalities. According to their research, the 26 cases reported are not sufficient to identify a typical toxic range for this class of substances and further analysis of post-mortem findings should be conducted to elucidate the toxicological profile of synthetic cannabinoids.The NPS issue is an everchanging reality, always posing new challenges to the scientific community and professionals working against this phenomenon. Investigating the NPS and other drugs use among patients in detoxification treatment in Germany, Corazza et al. conducted a phenomenological qualitative study to investigate the experiences of prisoners and professionals on “spice” consumption in prison, with the aims to elucidate the impact of NPS abuse on workers and people in custodial settings. Due to the frequent violent events experienced, the professionals involved in this study suggested to improve detection and treatment and support services in prisons together with enhanced training and education to face the problem.Martinotti et al., who administered a questionnaire to a sample of inpatients hospitalized in Psychiatric Ward in Ibiza confirmed to have recently abused substances by toxicological analysis. According to their research, stimulants and psychodyspleptics drugs are the most popular club drugs and the polydrug consumption is a common practice of party goers. It is interesting to notice that the largest part of the considered population has already had a Bipolar Disorder diagnosis.Also, the psychiatric disorders caused by NPS abuse were investigated by Nagy et al. assessed intake patterns of the cathinone alpha-pyrrolidinopropriophenone (a-PPP) in condition of prolonged free access to the drug, in an animal model. The authors concluded that a-PPP shows a limited abuse potential and/or support only recreational use patterns in rats.Hassan et al. to treat morphine withdrawal symptoms in rats. After inducing morphine abstinence in the animals, the rats that showed withdrawal syndrome were treated with buprenorphine, methadone, or mytraginine and the effects were monitored and measured for 28 days. Although a high intraperitoneal dose of mytraginine was required (3–50 mg/kg), the substance showed a good potential as opiate withdrawal treatment compared to medication usually used in detoxification treatment.On the other hand, NPS are also studied as safer alternatives to current therapies, such as in the case of mytraginine studied by Zaami, Marinelli et al. analyzed the possible consequences of this unprecedent situation on the abusers' health, concluding by drawing the attention of the scientific community toward the importance of the psychiatric and psychological assistance to this fragile part of population.Since the beginning of 2020, the COVID-19 pandemic has been changing the habits of the global population at every level. In conclusion, this Research Topic is providing updated studies and reviews concerning the psychiatric and psychological implications of Chemsex drugs, cognitive enhancers and NPS abuse, highlighting the importance to continuously investigate this still unclear field by the scientific community and health professionals.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


China has experienced frequent food safety incidents that have undermined consumer trust in the food supply chain. To overcome this problem, China requalified the legislative framework and adopted a comprehensive food certification system over the years. Here, we investigated the influences of food traceability and Chinese certifications  on Chinese consumer trust of food safety for different types of products: fish, meat, milk, eggs, and rice. Data were collected through face-to-face surveys conducted in rural and urban Chinese areas. With a sample of 757 questionnaires, we ran a logit model. The results show consumers’ uncertainty and skepticism of certifications guaranteeing food safety attributes, especially for animal-based products. We found that price is used as a cue of safety by Chinese consumers. Individuals with higher education seem less influenced by certifications and other cues included in the analysis. The findings demonstrate that Chinese policy makers should implement new strategies to enhance consumer food safety trust, and design policies by considering different categories  of food. The fast development of the Chinese food industry has been accompanied by frequent food safety incidents ,2 that hAs declared in 2015 by China’s State Council, food safety is a top priority; the government has tried to improve the legislative framework and its implementation. In 2015, the food safety law was rewritten, revised in 2018, and published in October 2019 as the Regulation on the Implementation of the Food Safety Law , principAs argued by Ni , productLiu et al.  defined Organic food is “certified to international standards such as the International Federation of Organic Agriculture Movements (IFOAM) and hence genetically modified ingredients are shunned on ideological grounds” . DescripThese certifications have been widely used in Chinese academic studies as representative of safe food ,32,33, iHere, we investigated the influences of product certifications on Chinese consumers’ choices of safe food products, analyzing their impacts on different types of products. The preference of Chinese consumers for other food-related attributes, such as traceability information or price, as well as their preferred place of sale  for purchasing safe food, were also studied to compare these attributes with certifications.This article is organized as follows: Consumer knowledge of safe food concept is still quite low in China . Indeed,Despite the importance of the Chinese food industry and policymakers understanding Chinese consumers’ awareness of food safety and their preferences for food safety information attributes, few studies focused on Chinese consumers’ preferences and behavior with regard to food safety attributes ,41.The literature shows that Chinese consumers use the safe food logos on products to identify safe food . DespiteZhang and Wu  reportedThe literature also describes different attitudes (sometimes positive and sometimes negative) among Chinese consumers about the quality of safe food and the certification labels. Zhang and Wang  reportedGreen and organic food labels are associated with reports of fake organic products, false labels, and bribing of inspection officials ,52. SimuOther authors found a different attitude of consumers toward certifications. Bekele  reportedIn a large-scale study of the adoption of organic food by Chinese consumers, healthiness, taste, and environmental friendliness were found to be important attributes. Health concerns outweigh environmental concerns in terms of influencing the purchase intentions of Chinese consumers . ConsumeOrtega et al.  found thThe questionnaire was administered to a sample of Chinese consumers in Zhejiang province. Nine of the 11 cities (and surrounding areas) in the province were selected: Hangzhou, Ningbo, Shaoxing, Jinhua, Quzhou, Taizhou, Jiaxing, Huzhou, and Lishui. Two cities were excluded: Wenzhou was excluded because of the high proportion of immigrants, and Zhoushan was excluded because it is built on several islands, which would have complicated the data collection, as fish is as the food mainly consumed in the city.The questionnaires were administered in January 2017 by specially trained students through random sampling of residents. A total of 1000 questionnaires were collected, of which 757 (75.7%) were used in the analysis; 243 (24.3%) questionnaires were excluded due to incomplete answers. Considering recent similar studies ,59, thisTo achieve the maximum possible variation, the survey was administered on different days and at different times and places. The interviewers approached the respondents in 3–5 residential districts in the main urban areas and 3–5 villages of the selected cities. According to the proportion of urban and rural population in Zhejiang province, the sample included 30% rural households and 70% urban households. Participants were voluntary, and they did not receive any kind of compensation or gift. Participants when started their interviews were not informed about the final aim and the topic of research.The first part requested the socio-demographic information of the respondents;The second part asked questions regarding eating habits ;The third part asked about the safety perception of different categories of food such as rice, milk and milk products, eggs, meat, fish, vegetables, and fruit. Questions regarding certifications were asked in this section as well;The fourth part queried regarding the quality of food (same categories as above).The questionnaire , created in collaboration with faculty members of the Zhejiang University of Finance and Economics, was divided into the following phases for a total of 36 questions:In the last two sections, questions regarding the willingness to pay a higher price for safer or higher quality staple food were asked. As WTP is the maximum amount an individual is willing to pay to receive an improvement or to avoid a loss in their level of well-being ,61,62,63Specifically, concerning the variables used in the analysis we asked the following questions: (i) How much confidence do you have in the safety of the following food categories ? (ii) What is the meaning of this mark (SC) for you? (iii) Which of the following certifications  do you know? (iv) Where do you usually buy food? (v) How often do you read the list of ingredients of the products that you buy? (vi) how much do you think that the price of a product is related to its safety? For more details, see the In this analysis, we only used a part of the data gathered with the survey, as some were already published in .jth food category as safe is given by the logit of the multiple logistic regression model:j is fish, meat, milk, eggs, or rice, and:In our analysis, we modelled the probability of perceiving a certain category of food as safe according to eight covariates: if the respondents know green, organic, and hazard-free certifications and if the respondents associate foods with the SC logo as safe. As control variables, we included the place where respondents usually complete their food purchasing, if respondents usually read the ingredients of foods, and if they perceive price as a cue of food safety. We ran our model for five food categories: fish, meat, milk, eggs, and rice. The first four categories are animal-based food and represent risky food in terms of contamination and disease contagion. We also included rice since it is the basic staple food for the large part of Chinese and Asian consumers. The probably of perceiving the SC was equal to 1 if the respondent perceived food with SC as safe; green, organic, and hazardfree were equal to 1 if the consumer knew the green, organic, and hazard-free certification, respectively, and was 0 otherwise; supermarket, ingredient, traceability, and pricecue were equal to 1 if the consumer usually purchases food in supermarkets, usually reads food ingredients, knows the certification for traceability, and perceives higher price as a cue of food safety, respectively; and ε is a random error term.All the variables in Equation (2) are dummy variables; ingredient to control for respondents who pay more attention to food and so may behave differently compared with other consumers. For the same reason, we included the place where respondents usually purchase their usual food as a control variable. Supermarkets and supermarket chains should have well-established procedures and controls to ensure food safety. Therefore, we hypothesized that the supermarket consumers would have less need for certifications.We included the variable We repeated the models in Equation (2) including interaction variables between the covariates and two sociodemographic variables, age and level of education, to detect consumer heterogeneity according to respondent features. Age and level of education were also dummy variables. Age was equal to 1 if the respondents were under 30 years old and 0 otherwise. Finally, education was equal to 1 if the respondent had at least graduated and 0 otherwise. The hypothesis was that more educated people have higher cognitive ability and thus are more likely to use formal certification system, as are younger individuals.The sample was slightly oriented toward younger and more educated individuals, with an acceptable variation between the panels (groups) in the sample. Almost two-thirds of respondents reported they usually read the ingredients but, in general, few knew the certifications. Less than half of the sample knew the organic certification, and only 12.17% knew traceability. Hazard-free certification and traceability never influenced the probability that consumers perceive the selected foods as safe. None of the rest of the certifications included in the models affected this probability for all selected products. Therefore, when a certification plays a role in influencing consumer perception of food safety, it is product specific.Two factors seemed more effective as a safety cue: SC and price. The first one was significant for all the five models but with a lower degree of statistical confidence for fish and milk. The latter is the tool that had the greatest impact on food safety because it was the predictor with the largest coefficient, and it was always statistically significant. Finally, control variables, traceability, place of usual shopping, and reading the ingredients never impacted food safety perception.Looking at the results for each product category, we found that for fish and milk none of the examined certifications had statistically significant coefficients with a confidence greater than 90%. Estimates for meat and eggs revealed that the presence of the organic certification was synonymous with safety for respondents, despite the coefficient being statistically significant only at 90% for eggs.R2 values were all very low, ranging from 0.02 to 0.03 for fish, meat, milk, and eggs. The pseudo 2R for rice was almost double, with a value of 0.07. This result confirmed that certifications play a small role in determining food safety trust amongst Chinese consumers, especially for animal-based products.The pseudo To detect if the role of certifications was heterogenous between different groups of the population, we ran logit models including a set of interaction terms between the covariates and age and education level. The results are shown in Organic certification had a statistically significantly influence with a positive sign for the safety perception for fish, rice, and eggs. The safety perception of meat and milk was never influenced by any of the selected certifications. This model specification confirmed that for all food categories, the price strongly influenced the safety perceived by respondents. However, the interaction terms with age and education were statistically significant with a negative sign. This implied that educated people as well as younger individuals are less oriented toward use price as a safety cue.Considering the individual food categories, organic certification produced a low perception of buying safe fish and eggs. For those with a high educational level, the organic certification had an opposite effect as the interaction coefficient was negative and statistically significant. Therefore, educated individuals perceive organic fish and eggs as less safe than conventional products. Meat and milk were not influenced by any of the certifications. We found no statistically significant interactions for milk and meat. This indicated that no certifications had a positive impact on consumer safety perception for these products, and this conclusion did not vary according to age or educational level.The model specifications in In general, education was a more discriminant factor than age. The interactions with this last variable were almost not statistically significant, except for the green certification for eggs, which had a stronger impact on younger individuals.The food where the certification logos was most related to the perception of safety was rice, whereas certification logos on fish and milk were least related to the perception of safety. After the interaction variables of age and level of education were introduced, almost all the certification variables were not significantly positive related to the dependent variable.In this study, we investigated the determinants of food safety perception of Chinese consumers. In particular, we examined the role of food certifications to better understand consumer awareness of their existence and consumer preferences for food safety information attributes. The limited literature ,64 and iIn general, however, we found heterogeneous consumer reactions, focusing more on products rather than certifications; in particular, we found a greater mistrust of food of animal origin as confirmed by the low or lack of interest in certifications in meat, fish, and milk, as already found by other authors ,67.This finding led us to think of a certain skepticism rather than disinterest in safety attributes and, consequently, that there is a strong need for the government to review the food certification policy and to identify specific solutions for animal-origin food, which are more often the source of major food scandals.We found that the food with certification logos most related to the perception of safety was rice. This could be due to rice being the staple food in China; therefore, consumers have considerable familiarity with this kind of food. As mentioned previously , plant pIn general, SC certification seems to be the most statistically significant, even if, in some cases, with a low level of confidence, confirming that the government should be the central actor in this requalification of the certification systems, which should also include control of their correct application and transparent communication to consumers.However, some of our results appear contradictory, for example, by comparing the response to the SC certification with respect to the certified product. Although consumers considered the SC brand safer and more trustworthy, this trust decreased when directed toward the product, preferring other certifications. This can be explained by the fact that in a country with frequent scandals and accidents, it is normal for the consumer to identify the government as the authority that guarantees their safety against producers .Specific concerns arise from multiple factors. Rice’s example is particularly explanatory. Zhu et al.  explaineFood incidents and widespread information asymmetry discourage consumers from purchasing certified products, especially for those involved in large food scandals. Trust is the most important factor that hinders the functioning of the food certification system , and theNotably, this study was addressed to a wide audience such as citizens, academic researchers, and policymakers, as we explored a transversal theme of common interest. In particular, the lack of strong relationship between brands and animal-based products may be of interest both to researchers  of products) and citizens, as it is an increasingly important and timely topic. At the same time, the findings offer policy makers guidance for orienting their efforts toward the activation of specific brands. Our findings can be therefore useful for further research and to guide the government and industry in the actions they have to undertake. According to our results, to associate food safety perception with certifications, institutions need to regain trust from citizens, and the credibility and transparency of food certification bodies need to be increased. Simultaneously, the food industry needs to increase its responsibility and open a proactive dialogue with the government and consumers. The 2019 Regulation on the Implementation of the Food Safety Law demonstrates the government’s awareness of these needs and offers a chance to requalify the sector. The new regulation emphasizes and strengthens the main responsibility of the enterprises and elevates the deliberate release of false information or the concealment of the truth about food products to the grade of severe breach. The new regulation gives the government the responsibility to integrate food safety knowledge into national education and establish a food safety risk exchange mechanism to clarify the contents, procedures, and requirements of information exchange on food safety to raise food safety awareness in society and avoid misleading concerns.In conclusion, in the context we described, Chinese consumers demand safe food but do not completely trust food certifications as a guarantee of safety. This mistrust could be overcome by the current legislation that has created the premises for a responsible, fair, and transparent food market environment; regulatory enforcement and its implementation remain the challenges.


Mindfulness-based stress reduction is an efficacious treatment for people with chronic health problems; however, it is highly intensive and time-consuming, which is a barrier for service provision.This study aims to develop an internet-delivered adapted version of mindfulness-based stress reduction for people with multiple sclerosis to make the intervention more accessible.We co-designed a web-based mindfulness program with end users, that is, people with multiple sclerosis (N=19). Iterative feedback was also collected from a subsample of the initial group of end users (n=11), and the program was reviewed by experts (n=8).We identified three main themes common to people with multiple sclerosis: dealing with uncertainty and fears for the future, grief and loss, and social isolation. These themes were incorporated into narratives throughout the program. People with multiple sclerosis who reviewed the program gave feedback that the program was relatable, feasible, and acceptable. Experts agreed that the program appropriately represented the main tenets of mindfulness. Iterative feedback was used to further refine the program.The web-based mindfulness program that we developed was viewed positively by both experts and end users. The program reflects common concerns for people with multiple sclerosis and has the potential to meet important unmet psychological needs. A randomized controlled trial was planned to determine the efficacy of the program. People with multiple sclerosis live with high rates of depression and anxiety, with prevalence rates of approximately 31% , respectd=0.570).A recent meta-analysis of 13 studies in multiple sclerosis (MS)  revealedd=0.8) and anxiety (d=0.6). This was a high-quality randomized controlled trial (RCT) of 150 people with multiple sclerosis, showing that face-to-face MBSR was effective across a range of outcomes compared with treatment as usual. Indeed, mindfulness has been shown to have significant mental health benefits for people with a range of physical health conditions, including chronic pain, fibromyalgia, arthritis, and cancer [A single study of mindfulness-based stress reduction (MBSR)  demonstrd cancer ,11. Howed cancer -7. Thered cancer .Both RCTs in MS were based on the traditional MBSR program  and invoThe aim of this study is to develop a web-based mindfulness program tailored specifically for people with multiple sclerosis via a qualitative investigation of (1) the psychological experiences and unmet needs of people with multiple sclerosis, (2) attitudes toward a proposed web-based mindfulness program designed to address such needs, and (3) iterative feedback from people with multiple sclerosis and experts in the field.Participants were recruited from the MS Clinic, Brain and Mind Centre, Sydney, Australia, between August 2017 and July 2018. Ethics approval was obtained from the University of Sydney Human Research Ethics Committee (2016/049). Potential participants were approached at the MS Clinic waiting room consecutively and given an invitation letter with the opportunity to fill out their contact details. We did not exclude participants with comorbid physical or mental health conditions. Participants were required to be older than 18 years and to have a neurologist-confirmed diagnosis of MS. Interview times were arranged via telephone and were conducted face-to-face at the MS Clinic at an appointed time, with written consent, by a registered psychologist (AS).Demographic data were collected via interviews and self-report questionnaires. To characterize the sample, we administered valid and reliable measures of depression, anxiety, and pain. Depression symptomatology was measured using the Center for Epidemiological Studies for Depression questionnaire  CES-D;  with appData were analyzed using NVivo Qualitative Data Analysis Software , via indThe web-based mindfulness program was developed on the basis of core components from the MBSR program by Kabat-Zinn , with thThe 5 modules were scheduled as follows: module 1 at the start of week 1 and module 2 at the start of week 2. The remaining modules contain instructions for the next 2 weeks, that is, module 3 would be delivered at the start of week 3 and again for the option of repetition, at the beginning of week 4, etc. The amount of time  dedicated to each module was decided based on the complexity of the mindfulness concepts and strategies described. It was written by a registered psychologist (AS) with clinical psychology and mindfulness training in collaboration with a clinical psychologist with experience in the development and evaluation of evidence-based psychological interventions for people with chronic health conditions (LS) and a clinical neuropsychologist with experience in the delivery of web-based therapeutic interventions (SN).Direct, face-to-face feedback on the program was provided by a subsample of the original participants interviewed (n=11), who indicated that they were interested and willing to review the modules of the program. In total, 8 women and 3 men with MS  took part in the review process. Two neurologists and 4 mindfulness experts including 2 clinical psychologists, 1 emergency care physician and 1 general practitioner provided written feedback on the program. Feedback was then coded and analyzed inductively, forming subheadings with overarching themes. Feedback from both people with multiple sclerosis and experts was discussed in team meetings among the 3 lead authors . Further iterations of the program were cocreated where there was consensus and scope to make the suggested changes.All participants had a neurologist-confirmed diagnosis of MS (N=19). There were 6 males and 13 females. A total of 63% (12/19) of participants had clinically significant depressive symptoms according to a cut-off score of 16 on the CES-D . MoreoveThe thematic analysis of this qualitative study was divided into 3 parts, in accordance with the research aims. For detailed thematic maps, including illustrative example quotations, please see Most participants reported that their psychological experiences were characterized by uncertainty, worry about the future and possible disease progression, and difficulty grappling with unknowns surrounding the disease. The inability to predict possible relapse was a major source of continual stress and anxiety, and it interfered with planning, for example, whether and when they should have children, how long their physical capabilities would allow them to stay in the workforce, and the potential financial burden that they would place on their families. Going to neurologist appointments and having to face the possibility of receiving bad news, such as the identification of new lesions in the brain or spinal cord, or changing treatments, was a source of excessive worry and distress. Some participants worried about whether their physical or cognitive problems were part of their MS or due to other factors, such as the natural process of aging.normal life and preserve their sense of self and identity, which many feared was at risk of erosion.An overarching theme was the participants’ experience of grief and loss due to the gradual decline in their physical and cognitive abilities and their sense of independence and identity. They also expressed anguish and sorrow over the loss of their illness-free life. Many people with multiple sclerosis reported that they were faced with having to give up on future plans and accept changes to their ability to travel and participate in family life. This process of adjustment experienced by people with multiple sclerosis was depicted as challenging and repetitive, as people developed new or worsening symptoms over time. People with multiple sclerosis experiencing cognitive difficulties described experiences of memory loss and how this impacted their daily functioning as well as their ability to recall cherished memories , which reinforced feelings of disconnection from family life. Those experiencing physical challenges, such as ataxia, muscle weakness, and bladder dysfunction, reported feelings of helplessness and a great sense of vulnerability, as they gradually lost confidence in themselves. Participants across all ages, genders, and types of MS emphasized the need to separate themselves from the disease, to try to lead a Participants reported experiencing social isolation and difficulties communicating with people in their support networks about their MS. Barriers to receiving social support included difficulties with participating in social activities due to loss of function and emotional avoidance when faced with opening up to people about their MS as well as other people’s failure to respond appropriately. Some participants reported that they were given unsolicited and often ill-informed advice from friends and family, which was perceived as highly distressing and alienating. Many participants reflected a sense of apathy and disinterest on behalf of their wider social circles and work environment and others’ general lack of understanding that MS is largely an invisible disease. Two participants reported facing blatant rejection from others because of stigma and unfounded beliefs about MS being contagious.Most participants reported an unmet need for psychological support, which they attributed to a lack of follow-up, lack of funding or resources, lack of knowledge regarding where to go for psychological support, and lack of psychologists or therapists specializing in MS. Of the 63% (12/19) participants with clinically significant symptoms of depression, only half reported that they were either currently seeing a psychologist or had seen one in the past.A major barrier to receiving psychological support was that the overwhelming majority of participants did not want to meet other people with multiple sclerosis in a face-to-face therapeutic setting, despite wanting to know how others cope. This was largely because meeting people with more severe symptomatology or disability generated feelings of uncertainty and fear around their own illness progression. For representative participant quotations for each subtheme, please see These main themes underlying the psychological experiences of people with multiple sclerosis were incorporated into the program development through the use of fictional characters featured in each module, whose stories and case examples reflected the common challenges, and mental-health related difficulties that participants reportedly faced. For screenshot examples, please see Participants reported positive attitudes toward seeking psychological support online. It is widely regarded as convenient, easy, and allowing access to therapeutic support with a sense of anonymity, in the privacy and comfort of their homes, without the need for travel. Reservations toward the use of an internet-delivered psychological intervention were noted by 11% (2/19) participants. One experienced MS-related vision problems and another expressed apprehension surrounding internet security.Participants’ experiences and knowledge of mindfulness varied from having no understanding of what it was to having years of experience. Potential barriers to participating in the proposed mindfulness program included not having enough time in the day to meditate, difficulties getting in a routine, problems with attention and concentration, low mood, and inability to find a quiet space to meditate, particularly for those with young families.Methods section). People with multiple sclerosis with more experience with mindfulness meditation tended to advocate for longer meditation practices. Features that were identified to engage participants in the program and reduce dropout included incorporating case examples, email reminders, and guiding participants through the program via weekly telephone calls. Three participants reported that they would be more likely to participate in the program if their neurologist or psychiatrist recommended it. Many reported that a program tailored to people with multiple sclerosis was preferable compared with a generic web-based mindfulness program. For representative participant quotations, please see Most participants reported that they would be interested in participating in the proposed web-based mindfulness intervention  who commented that the program was too simplistic and could be perceived as patronizing. Following this feedback, participants and experts were explicitly asked about their views in this regard, and these concerns were not widely shared by other respondents. Some changes to the program graphics and language were incorporated to further improve the relatability of the program: graphics were changed to make the characters look older and the scenes more realistic, and some of the language was edited to be less repetitive and more direct.monkey chatter) and how the mindfulness concepts were presented. Experts in mindfulness commented that the concepts were well explained and consistent with MBSR principles; however, some suggested involving a mindfulness expert, which we did. One area in which there was disagreement among experts was on the degree to which more reference to research should be included. Some experts recommended integrating scientific evidence on the efficacy of mindfulness into the program to improve treatment adherence, whereas others disagreed. We decided that including specific scientific research and results of studies was not necessary. For representative quotations of the feedback provided by participants and experts in the field, please see In terms of the program content, 8 participants gave specific, positive feedback on the analogies used to explain mindfulness concepts (eg, Participants reported psychological support as a common unmet need and were generally positive about the idea of an MS-specific, web-based mindfulness intervention. Among the participants, the anticipated use of such a program was high, particularly if it was endorsed by treating physicians. A thematic analysis of 19 face-to-face interviews with people with multiple sclerosis revealed 3 overarching themes characterizing their psychological experiences: uncertainty, grief and loss, and social isolation. These themes were used in the development of narratives throughout the mindfulness program.The first theme of uncertainty is unsurprising, considering that MS is an unpredictable illness. Participants indicated that they were fearful of progression, worried about whether symptoms might indicate deterioration, and worried about relapse. The lack of knowledge about the causes of MS exacerbated the uncertainty and worry and made attending medical appointments the source of anxiety. For some, the fear of progression was related to fear of becoming a burden on their family. Fears of progression have been previously documented in MS and found to be associated with poorer psychosocial outcomes ; therefoThe second theme was grief and loss. Participants described the struggle to accept the limitations imposed on them by MS. They experienced losses of their future plans, which led to a loss of independence. Specific losses such as loss of cognitive abilities and loss of confidence led to a loss of a sense of self and identity. The importance of loss and its impact on self and identity have been previously described as important in the context of adjustment to illness . Hence, The third theme was social isolation. In terms of social isolation, people with MS felt that family and friends could not understand their difficulties, which sometimes led to inappropriate responses or apathy from others. Some people with MS described having lost friendships, which they experienced as rejection due to the stigma of having MS. Many people with MS described emotional avoidance, which allowed them to not express their emotions to others as a way of trying to avoid negative responses from others. However, this led to an overwhelming feeling of social isolation, which has been previously recognized in the literature .We used these qualitative results to provide narratives to supplement the mindfulness content of our program. Once a draft version of the program was available on the basis of early interviews, we also gained feedback from both the people with multiple sclerosis and experts in MS and mindfulness. Iterative feedback allowed modifications to be made to the program content and graphics to improve relatability and ensure adherence to MBSR principles. However, overall feedback from mindfulness experts, neurologists, and people with multiple sclerosis were positive. The adapted mindfulness program appeared to be an acceptable and highly relatable program, tailored to the unmet needs and experiences of people with multiple sclerosis, and consistent with the basic principles and teachings of MBSR by Kabat Zinn .illness uncertainty has been found to predict adjustment problems for people with multiple sclerosis, over and above demographic and disease characteristics [As previously described, the primary reason for including the psychological experiences of people with multiple sclerosis was to ensure that the narratives included in our program were relevant to the end users of the program. It seems that the issues raised in our sample were similar to those previously raised in the literature. Prior research has shown that there is a lack of psychological support and continuity of psychosocial care after receiving the initial diagnosis ,34. Preveristics , and theeristics  as well eristics ,39,40. Feristics . Previoueristics . This maeristics ,44. Commpresent moment, cultivating acceptance and letting go, seems an appropriate intervention for reducing psychological distress and improving HRQoL. Furthermore, the delivery of a mindfulness intervention, tailored to the needs and experiences of people with multiple sclerosis via the web, can be used to normalize the challenges of living with the disease and decrease feelings of isolation while maintaining anonymity and increasing access to psychological support.Given the difficulties with anxiety and uncertainty about the future and the experiences of grief and loss experienced by people with multiple sclerosis, a mindfulness-based approach that focuses on the Although we attempted to interview a range of people with multiple sclerosis with various demographic and disease characteristics, we acknowledge that the experiences of people with multiple sclerosis reported here were a reflection of a small sample from one recruitment center. Another limitation of this study was that the reviewers were shown PowerPoint versions of the modules and not the web-based multimedia versions, which would have allowed for further analysis of the program’s usability. Finally, the evaluation of efficacy was beyond the scope of this study. A study protocol for an RCT evaluating the efficacy of the mindfulness program described in this study has been developed . ClearlyIn summary, we have developed a web-based mindfulness intervention using an iterative co-design process that reflects the common challenges reported by people with multiple sclerosis. We included narratives that were developed from the themes derived from a qualitative study. The modules appropriately reflected the principles of MBSR, and the included narratives were viewed as relatable by people with multiple sclerosis. Future research will determine whether the developed intervention is effective. If it proves to be beneficial, the developed program would likely meet an important need for people with multiple sclerosis.