Given the increased use of smart devices and the advantages of individual behavioral monitoring and assessment over time, wearable sensor–based mobile health apps are expected to become an important part of future (forensic) mental health care. For successful implementation in clinical practice, consideration of barriers and facilitators is of utmost importance.The aim of this study was to provide insight into the perspectives of both psychiatric outpatients and therapists in a forensic setting on the use and implementation of the Sense-IT biocueing app in aggression regulation therapy.A combination of qualitative methods was used. First, we assessed the perspectives of forensic outpatients on the use of the Sense-IT biocueing app using semistructured interviews. Next, 2 focus groups with forensic therapists were conducted to gain a more in-depth understanding of their perspectives on facilitators of and barriers to implementation.Forensic outpatients (n=21) and therapists (n=15) showed a primarily positive attitude toward the addition of the biocueing intervention to therapy, with increased interoceptive and emotional awareness as the most frequently mentioned advantage in both groups. In the semistructured interviews, patients mainly reported barriers related to technical or innovation problems . In the focus groups with therapists, 92 facilitator and barrier codes were identified and categorized into technical or innovation level , individual therapist level , individual patient level , and environmental and organizational level . The predominant barriers were limitations in usability of the app, patients’ motivation, and both therapists’ and patients’ knowledge and skills. Integration into treatment, expertise within the therapists’ team, and provision of time and materials were identified as facilitators.The chances of successful implementation and continued use of sensor-based mobile health interventions such as the Sense-IT biocueing app can be increased by considering the barriers and facilitators from patients’ and therapists’ perspectives. Technical or innovation-related barriers such as usability issues should be addressed first. At the therapist level, increasing integration into daily routines and enhancing affinity with the intervention are highly recommended for successful implementation. Future research is expected to be focused on further development and personalization of biocueing interventions considering what works for whom at what time in line with the trend toward personalizing treatment interventions in mental health care. Over the last years, services that use information and communication strategies to improve and support health—eHealth—have grown tremendously owing to rapid technological changes ,2. In meMany eHealth interventions have been demonstrated to be feasible and acceptable . PositivIn forensic psychiatry, personalized treatment interventions are highly relevant as a considerable number of forensic patients do not benefit from current treatment programs ,12. LimiConsidering the needs and preferences of intended users is one of the main prerequisites to bridge the gap between promising results of eHealth and mHealth studies on the one hand and actual deployment of these interventions in (forensic) mental health care on the other . In addiGiven the scarcity of information on the deployment of sensor-based mHealth interventions in (forensic) mental health care, we aimed to provide more insight into the perspectives of both forensic outpatients (study 1) and therapists (study 2) regarding the use and implementation of a new sensor-based mHealth intervention, the Sense-IT biocueing app, in aggression regulation therapy (ART). More specifically, we focused on facilitators of and barriers to implementation, as identified by previous models. As we expected the feedback of forensic outpatients to be mainly centered on the technical or innovation level and the individual patient level, we included forensic therapists to provide us with information on all levels of the implementation model.The perspectives of forensic outpatients on the use of the Sense-IT biocueing app were explored using qualitative semistructured interviews. In addition, usability was determined using a quantitative usability score. Data were collected at the postmeasurement assessment (T1) within a larger quasi-experimental study in which patients used the Sense-IT app for 4 weeks. More specific information on the design of this study can be found in another paper .Forensic outpatients who received ART at Inforsa, a forensic mental health care organization in Amsterdam, the Netherlands, were recruited for participation between January 2020 and March 2022. First, patients were screened for eligibility by a research assistant, consulting the patients’ therapist. Patients were eligible for participation if they lacked anger management skills, were assigned to individual ART, had a basic understanding of mobile apps, and were aged ≥16 years. Patients were excluded if they had acute manic or psychotic symptoms, a high risk of suicide, severe physical conditions requiring immediate intervention, or insufficient understanding of the Dutch language. If a patient turned out to be eligible and interested in the research project, study participation was offered in a face-to-face appointment in which a brief oral description and full written information were provided.After screening and informing the patients about the research project, 25 patients were eligible and willing to participate. All patients participated in a baseline measurement (T0) in which demographic characteristics, attitudes toward new technologies, and perceived proficiency in using new technologies were assessed. Next, they were provided with the Sense-IT app for 4 weeks, in which they received biocueing for 2 weeks. Using the photoplethysmography sensor of a smartwatch, this app compares the users’ current heart rate (HR) to their individual mean HR at rest, calculating a level between −3 and 5 using the SD of the baseline measurement. The app provides a visual display of the real-time HR level on the smartwatch and smartphone and notifies the users when their HR exceeds a predefined level using notifying vibrations and behavioral support messages. Screenshots of the Sense-IT app can be found in This study was part of a larger study approved by the Medical Ethical Committee (NL63911.029.17) and registered in the Netherlands Trial Register (NL8206). Patients were carefully informed about the anonymous use of data, the voluntary nature of the study, and the absence of any negative consequences in case of refusal or early termination. All patients provided written informed consent before participation. Participating patients received a gift card of €10 (US $10.81) and an additional €10 (US $10.81) at T1 when at least 75% of the repeated experience sampling questions (not further reported here) were answered.We organized the qualitative data of the outpatients using Microsoft Excel (Microsoft Corp). For categorical responses, cumulative frequencies were calculated using SPSS . For open responses, content analysis was used. First, textual responses were inspected by the first author (JFtH) to gain familiarity with the data and establish a coding scheme. Next, the first and second authors (JFtH and LMS) independently coded the responses into predefined categories. Discrepancies were discussed between both authors until a consensus was reached. Discussion was also used to refine the categories and code descriptions to increase the interpretation of the codes. Quotes were jointly selected by both authors considering their informative value and ability to illustrate the category. Finally, selected quotes were translated from Dutch into English by JFtH and LMS.The perspectives of forensic therapists on the implementation of the Sense-IT biocueing app were explored using focus groups. This study was designed to investigate the added value of the app from a therapist’s point of view, gain a better understanding of the perceived facilitators of and barriers to implementation, and collect suggestions for implementation.Forensic therapists working within outpatient teams at Inforsa were recruited by email in February 2022. Therapists were eligible and invited to participate if they were trained in ART. No other inclusion or exclusion criteria were applied.In total, 2 focus groups were conducted in February 2022 and March 2022. Both focus groups were scheduled within the existing structure of team meetings to avoid time burdens and added workload, thereby enhancing the chances of participation. In line with this structure , separate focus groups were organized for therapists working with young adults and therapists working with adults. Owing to COVID-19 regulations, some therapists participated on site, and others participated on the web. The planned group size was 6 to 8 participants to allow for optimal interaction between them . The focAt the start of the focus groups, a brief overview of the Sense-IT project was presented, including background information, screenshots of the app, and some qualitative results of earlier studies. After that, therapists completed a short form assessing demographic characteristics, attitude toward both mHealth in mental health care and new technologies, and perceived proficiency in using new technologies. In both focus groups, the same questioning route was used . The modFor this study among therapists, no ethical board review statement was applicable given the embedding in regular care routines and the low burden of participation. Therapists were informed that participation was voluntary, that information would be processed anonymously, and that the data would be used for research and policy purposes as well as for enhancement of the implementation process of the Sense-IT biocueing app. Before participation, therapists received an informative email and an informed consent form. All participants provided written informed consent. Participating therapists did not receive any financial reimbursements.The focus groups were video- and audiotaped, transcribed in full by LMS, and analyzed by JFtH and LMS using content analysis. We used a combination of open and axial coding in a process of constant comparison . First, In total, 21 forensic outpatients  filled out the SUS and participated in the interview at T1. Most participants  received mandatory treatment as a part of a conditional sentence. The main psychiatric disorders most frequently classified according to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, criteria were disruptive disorders  and personality disorders . Some participants were diagnosed with intellectual disability or scored below the cutoff on a screener for mild intellectual disability . At posttest measurement, forensic outpatients evaluated the usability of the Sense-IT biocueing app as acceptable . System usability was not significantly correlated with age, attitude toward new technology, or perceived proficiency in using new technologies. Notably, all patients returned the borrowed materials except for 10% (2/21), who reported that they had lost their smartwatch because of robbery. All descriptive characteristics are summarized in Forensic outpatients identified a wide range of advantages and disadvantages of the Sense-IT biocueing app. Responses mentioned more than once that could be grouped into categories are presented in Clarity and simplicity of the app as well as support in interoceptive and emotional awareness were most frequently reported as advantages. Most patients  reported no difficulty in understanding how to use the app, and some  explicitly indicated that the app was clear and well organized. Furthermore, patients indicated that the app helped them become more aware of physical tension and that the questions in the app assisted them to reflect on their emotions and behavior during the day. A participant reported the following:[The app helped me] to reflect on how things were going; I never really did that, but now I was aware whether I had a good day or a not so good day.Participant 10Connectivity issues, notification issues, and perceived inaccuracy were mentioned the most as disadvantages. Regarding connectivity issues, patients reported disturbance via interruptions in the Bluetooth connection, for example, when the distance between the smartphone and smartwatch was too large. As a potential solution, a patient suggested running the app stand-alone on the smartwatch itself so no Bluetooth connection would be needed. Furthermore, a substantial number of participants  reported that they received too many notifications or notifications that they perceived as either too soon or too late. In addition to the ability to adjust the (maximum) number of notifications, patients suggested sending notifications only when a higher HR was registered over a longer time. A participant recommended the following:Add a button to put the app on pause, as a time-out, when you get irritated by the number of notifications, or when you already know [that you are tense].Participant 21Related to this, several patients  indicated that they would have preferred to customize the settings of the app themselves; their ability to do so was restricted in this study. For example, they would have liked to be able to adjust the number of notifications as well as the frequency and content of the daily questions according to their preferences. Furthermore, patients questioned the accuracy of the feedback provided by the app. Patients mentioned both elevations in HR when they did not subjectively experience stress and subjectively experiencing stress without detected elevations in HR. Patients reported that their activity profiles were not always recognized correctly by the app. Furthermore, patients reported missing specific design features such as the use of colors , graphical overviews, and more variety in watch faces . Other frequently mentioned disadvantages were the use of a study-provided smartphone and the limited battery life of the smartwatch.Furthermore, we assessed in which specific situations the app was described as (not) pleasant or useful. Half  of the patients reported no specific situations or no situations at all in which they perceived the app as pleasant or useful. In retrospect, the app was perceived as most useful  in or shortly after discussions, confrontations, and other situations with a lot of tension to support awareness and emotion regulation. Related to this, the app was judged as not pleasant or useful in relaxed settings in which notifications perceived as inaccurate were reported as disturbing , during exercise or other physical activities , or when patients already felt too stressed or tired . A participant summarized this as follows:In places where you have a lot of tension: it is good to put it [the smartwatch] on just then, and not in situations when you are calm.Participant 25In total, 21 forensic therapists were invited to participate in the focus groups. A total of 24% (5/21) of the therapists preannounced that they were unable to participate for practical reasons. One new therapist, who did not receive the invitation, indicated willingness to participate and joined one of the focus groups. Eventually, another 10% (2/21) of the therapists did not participate. In total, 2 focus groups were conducted: one for therapists working with young adult patients  and one for therapists working with adult patients . In In the first step of our analysis, we retrieved 39 codes from the 2 focus groups related to the added value of the Sense-IT biocueing app from the therapists’ perspective. These codes were categorized into themes and linked to the predefined levels in the questioning route. An overview of the results of this part of the coding process is shown in At the therapist level, using the app to open up conversations was mentioned most frequently. A therapist noted the following:I believe it’s great to be able to discuss with patients, who sometimes already forgot what they did yesterday...to zoom in on specific moments, to start talking about it.Therapist 1, focus group 1At the patient level, increasing interoceptive and emotional awareness was mentioned the most. Therapists supposed that the app could help patients learn and experience how their body and mental state are connected and that reminders could help them be aware of the signals the body gives in everyday life. Furthermore, a therapist stressed the importance of these basal skills in the first stages of treatment:I realize that body awareness precedes all those cognitive things.Therapist 4, focus group 2At the level of treatment itself, therapists most frequently mentioned the impact on out-of-session practice, thereby increasing the transfer to everyday life. Therapists noted that wearing the smartwatch and using the app might also function as reminders for patients that they are in a process of learning to control their aggressive responses. They reported the following:I suppose it can also help patients to be engaged in their treatment outside the therapy session. So it’s easier to generalize what you are doing [in therapy].Therapist 4, focus group 2The therapy does not end in the room, but continues in daily life. The watch could also be a reminder for patients.Therapist 1, focus group 2In the second step of our analysis, 92 codes were retrieved on facilitators of and barriers to the implementation of the Sense-IT biocueing app in current treatment. The coded subthemes as well as the later defined themes were linked to the previously described levels ,22. An oUsability was identified as an important issue for implementation. The limited ease of use of the app on a research-owned smartphone was discussed as a barrier in both focus groups. The use of the app on the patients’ own smartphones was explicitly mentioned as a facilitator by the therapists in the young adult group. They explained that these patients almost never lose sight of their own phones. Therapists in this group also reported potential problems with the materials, such as loss or damage to the devices or charging cables. Furthermore, the simplicity of the rationale of the app—delivering concrete, real-time physiological feedback—was mentioned as a facilitator. Both groups discussed whether the design of the app was easy enough for patients with intellectual disabilities. However, the therapists did not reach a conclusion regarding the ease of use for this group, indicating that the accessibility of the app for patients with intellectual disabilities might need further investigation.Perceived accuracy of the app was also discussed as an essential factor. In the focus group of therapists working with adults, limitations in the perceived accuracy of the feedback were mentioned as barriers. One of the therapists mentioned that receiving too many notifications or notifications perceived as inaccurate may reduce the likelihood of continued use of the app:The app should provide notifications at the right moments...so that patients continue to take the app seriously.Therapist 1, focus group 2Workload was expected to be increased by implementing the app and, therefore, was identified as a barrier in both focus groups. Therapists expressed some concerns regarding the time and continuous attention needed for implementation of the app in their current routines. Therapists noted that there are already a lot of other topics to discuss during a therapy session. To maintain the use of a new intervention by patients, therapists reported that they would need to address this frequently during sessions. A therapist explained that the investment of time would be large in the beginning but probably less over time when therapists can take a more distant position.Integration into treatment was mentioned as a facilitator of implementation in both focus groups. A therapist explained that it would be valuable to view a graphical overview of the patients’ physiological values and notes over the last week, before or at the start of a therapy session, and discuss this with the patient. In the group of therapists of the adult population, integration of the app in the process of creating a personal monitoring plan was suggested. Furthermore, therapists mentioned that the use of the app should be an integral part of their treatment plan. These therapists indicated a need for criteria and guidelines helping them indicate whether the intervention would be beneficial for a particular patient.Knowledge and skills of therapists were also identified as important factors. Limited proficiency in using technological interventions was mentioned as a barrier in both groups. In the focus group of therapists of young adults, the facilitating impact of technological skills and a positive attitude toward new technologies were also mentioned. In both groups, therapists expressed interest in and supported the relevance of becoming more familiar with the app by using it themselves. A therapist explained this as follows:I can imagine that it helps if you can say, from your own perspective, that using the app can be a bit irritating at times. It might be useful to relate from your own experience.Therapist 6, focus group 2motivation were discussed in both groups. A lack of problem insight or disagreement on the aggressive nature of specific behaviors was identified as a barrier to implementation in one of the focus groups. Both focus groups mentioned a certain amount of motivation  to change as a facilitator, and the lack thereof was mentioned as a barrier. In one of the focus groups, using the app to increase motivation and problem insight was also discussed. Therapists also mentioned the ability to be open and receptive to feedback, which could be confronting or annoying, as an important issue. A therapist explained this as follows:Factors related to You need to have the courage to start looking at yourself.Therapist 3, focus group 1Specific problems may also complicate implementation. In both groups, the feeling of being controlled by others was seen as a contraindication for the use of the app. In addition to delusional and other psychotic disorders, disorders that involve an excessive focus on physiological sensations, for instance, hypochondria, were also mentioned as barriers. Furthermore, therapists perceived the app as most useful for patients with reactive aggression and not indicated for patients with predominantly instrumental or proactive aggression.Knowledge and skills of the patients were also discussed as important issues. Proficiency in using technological interventions was mentioned as a facilitator in both groups, and the lack thereof was mentioned as a barrier. Cognitive problems or intellectual disabilities were identified as barriers in both groups, although the app was also perceived as particularly helpful for this group of patients as they often lacked insight into the  signals that precede aggressive behavior. Therapists in both groups expressed some concerns that patients would lose or sell the devices. Therefore, they discussed the ability to take adequate care of the devices and a certain degree of responsibility for others’ belongings as prerequisites for borrowing materials. In the young adult group, practical issues related to unstable circumstances such as homelessness were also mentioned as barriers.Expertise within the team was seen as an important facilitator (and the lack thereof was seen as a barrier) for sustainable use of the app in both groups. Therapists discussed the risk of dilution in case no one within the therapists’ team felt ownership of the app. A therapist suggested a special interest group, whereas another proposed appointing one therapist per team as an expert in using the app. This last suggestion was supported by the members of the other focus group. A therapist stressed the importance of expertise by reporting the following:If all therapists just occasionally use the watch, then all will lack expertise.Therapist 3, focus group 1Time to become familiar with the app was explicitly mentioned as a facilitator in one of the focus groups. This was related to the expectation of added workload associated with the addition of the app to current therapy. A therapist reported the following:If spending a lot of time on the app at the start is facilitated at the organizational level, then it can be done.Therapist 4, focus group 1Materials were also discussed in both teams. Therapists working with young adults stressed the facilitating impact of having the devices directly available in their offices. They explained that this is not only helpful to introduce the app to their patients but also to initiate using the app when the moment is right. Therapists made it clear that they had no desire to fill in (extensive) application forms; they would like the organization to provide them with materials in an uncomplicated way. Furthermore, both groups discussed the lack of clear agreement on the use of devices by patients as barriers. Therapists in both groups explained that it would be helpful if the organization provided a kind of contract in which agreements on loss, theft, and liability were included.Knowledge and insight were briefly mentioned in both groups. Knowledge of effectiveness was mentioned as a facilitator in one group, whereas insight into costs and benefits was discussed as a facilitator and barrier in the other. These therapists explained that more proof of the effectiveness of the app and more information on the costs compared with treatment as usual would increase their willingness to use the app and, thereby, the likelihood of successful implementation.The therapists provided us with many other valuable suggestions regarding the use and implementation of the Sense-IT biocueing app, which will be used to inform the future process. In the context of this paper, 2 topics were highlighted. First, several therapists  recommended the use of the app in the first phases of treatment to increase awareness of physiological signals that precede aggressive behavior. Other therapists  suggested the use of the app in later phases of treatment; one therapist reported focusing on motivation first, whereas another suggested using the app during therapy sessions to evaluate different emotion regulation strategies. Second, therapists working with young adults explored opportunities for a more systemic approach. Therapists mentioned that the use of the app could probably increase awareness among system members as well and might help enable system members to adequately support the patient in moments when physiological tension is elevated.technical or innovation level mentioned by both patients and therapists were several usability issues  as well as limitations in the perceived accuracy of the feedback. For the individual therapist, added workload and limited technological skills were perceived as barriers, whereas integration into treatment and familiarity with the app were mentioned as facilitators. For the individual patient, motivation and knowledge and skills were discussed as both barriers and facilitators of implementation success. Specific psychiatric problems  were identified as barriers.The aim of this study was to provide insight into the perspectives of both forensic psychiatric outpatients and therapists on the use and implementation of a new sensor-based mHealth intervention for ART. More specifically, we aimed to obtain a more in-depth understanding of the facilitators of and barriers to implementation, which could be used as guideposts for future research and clinical practice. Findings from both studies indicate an overall positive attitude toward the addition of a biocueing intervention in forensic therapy, with increased interoceptive and emotional awareness as the most frequently and commonly mentioned advantage. The main barriers at the environmental and organizational level, sufficient expertise within the therapists’ team was seen as a prerequisite for implementation. For organizations, providing time to become familiar with the innovation and providing (clear agreement on the use of) materials were identified as important facilitators. More knowledge of and insight into the effectiveness and cost-effectiveness of the intervention were identified as political or economic factors influencing uptake by therapists.At the The findings regarding the perceived advantages of this sensor-based biocueing app resonate with the results of previous mHealth studies. Increased awareness (mentioned by both patients and therapists) and the ability to open up conversations by zooming in on specific situations (mentioned by therapists) align with previously described benefits of mHealth ,29. ExteBarriers and facilitators identified in the focus groups were linked to the 3 factors associated with eHealth implementation  and the technical or innovation level discussed by the therapists. Although the overall usability of this particular biocueing app turned out to be acceptable, frequently mentioned problems in using a biocueing intervention  need further attention as end users tend to stop using a health app when their preferences and goals are not met [The disadvantages mentioned by the patients corresponded, to a large extent, to the barriers at the  not met . Usabili not met . As sugg not met ,34, a moindividual therapist level—added workload and limited technological skills—have been identified in earlier reviews [The barriers identified at the  reviews ,30. Inte reviews ,30. Thes reviews . Accordi reviews .individual patient level, therapists indicated a certain amount of motivation and problem insight as a prerequisite to benefit from the biocueing intervention. However, other therapists also saw potential to use the app as a means of increasing problem insight. This difference might be related to the 2 components of this biocueing intervention: increasing interoceptive awareness and delivering just-in-time behavioral support. Although the second component might require some problem awareness and receptivity to feedback, as demonstrated in another biocueing study [At the ng study , this ming study -40. Concng study  and healng study . In our environmental and organizational level, most barriers were addressed in the organizational context. The need expressed by therapists to be provided with sufficient time and material by their management was also identified as an important implementation factor in the literature [Finally, at the terature ,30. To aterature .This study has several strengths. First, we were able to assess the experiences and perspectives of forensic outpatients, who are often hard to engage in clinical research. Most participants seemed to enjoy delivering feedback on how to improve this new sensor-based mHealth intervention. Second, we combined the information of forensic outpatients with the input of forensic therapists to obtain a more complete overview of the barriers and facilitators associated with implementation. To do so, we combined a more general implementation model with a more specific eHealth implementation model. Finally, this study was well embedded in daily clinical practice, thereby enhancing the ecological validity and translation of these research results into real-world situations.Our study also had several limitations. In both studies, attitudes toward new technologies  as well as perceived proficiency in using those technologies were assessed using self-developed Likert-scale questions. The use of recently developed and validated scales such as the eMental Health Adoption Readiness scale  could haIn addition to suggestions for further improvement of this particular biocueing app and other issues requiring attention , this study provided valuable information to guide the implementation of sensor-based mHealth interventions in (forensic) mental health care. As the implementation of eHealth and mHealth largely depends on the providers of these interventions , the indTherapists and patients provided several suggestions for using a biocueing app in clinical practice. Although these suggestions specifically apply to the studied intervention, they might also be informative for other researchers developing and implementing similar sensor-based mHealth interventions in (forensic) mental health care. According to the therapists, the addition of a biocueing intervention would be most useful in the first phases of treatment to increase interoceptive awareness. When patients display a certain amount of motivation to change and receptivity to feedback, they might also benefit from the just-in-time behavioral support delivered by the biocueing app. As this involves a reminder to use coping skills to reduce stress, it is necessary that the therapist has already discussed emotion regulation strategies with the patient and that the behavioral support message is prepared in collaboration. Patients indicated that the app was most helpful in difficult situations, and it was perceived as disturbing in relaxed situations, during exercise, or when they already felt too stressed or tired. This emphasizes the need to further adapt these new interventions to deliver mental health support at precisely those moments, when they are most likely to be effective . TherefoForensic outpatients and therapists demonstrated a positive attitude toward the addition of a wearable sensor–based mHealth intervention, the Sense-IT biocueing app, to ART. Increased interoceptive and emotional awareness were mentioned as advantages by both patients and therapists. However, to maximize the potential of these interventions, several important barriers and facilitators should be addressed. Forensic outpatients mainly reported technical or innovation-related barriers, whereas therapists provided us with a more in-depth understanding of barriers and facilitators at the individual and organizational levels. A substantial part of the technical or innovation-related barriers is related to the developmental stage of the app and its use in a research context, and therefore, quite easy to address. Furthermore, although some individual patient barriers apply specifically to forensic patients, most factors should also be carefully considered in other populations with emotion regulation difficulties. At the individual therapist and organizational level, providing time and materials supporting integration into daily routines and enhancing affinity with the new intervention were identified as important facilitators of implementation and, therefore, are highly recommended. In the future implementation process, individual and team differences in readiness for adoption of mHealth should be considered, assigning a central role to active users as experts within the teams. Finally, as further development of biocueing interventions is expected, new and personalized app possibilities might be discovered and investigated at the individual patient level, aligning with the trend of personalizing treatment interventions in mental health care.


N = 129). Participants completed the 20-item Toronto Alexithymia Scale and the Autistic Spectrum Quotient and then performed an emotion-recognition task that involved face stimuli wearing a mask or not, and displaying full or subtle expressions. Each face stimulus was presented alongside the Geneva Emotion Wheel (GEW), and participants had to indicate what emotion they believed the other person was feeling and its intensity using the GEW. For each combination of our variables, we computed the indices of ‘uncertainty’ , ‘bias’ , and ‘perceived intensity’ . We found that face masks increase uncertainty for all facial expressions of emotion, except for fear when intense, and that disgust was systematically confused with anger . Furthermore, when faces were covered by the mask, all the emotions were perceived as less intense, and this was particularly evident for subtle expressions. Finally, we did not find any evidence of a relationship between these indices and alexithymic/autistic traits.With the advent of the severe acute respiratory syndrome-Corona Virus type 2 (SARS-CoV-2) pandemic, the theme of emotion recognition from facial expressions has become highly relevant due to the widespread use of face masks as one of the main devices imposed to counter the spread of the virus. Unsurprisingly, several studies published in the last 2 years have shown that accuracy in the recognition of basic emotions expressed by faces wearing masks is reduced. However, less is known about the impact that wearing face masks has on the ability to recognize emotions from subtle expressions. Furthermore, even less is known regarding the role of interindividual differences  in emotion processing. This study investigated the perception of all the six basic emotions , both as a function of the face mask and as a function of the facial expressions’ intensity (full vs. subtle) in terms of participants’ uncertainty in their responses, misattribution errors, and perceived intensity. The experiment was conducted online on a large sample of participants ( Communicating one’s emotions and recognizing the emotions of others are crucial skills that allow an understanding of other people’s affective states and intentions and help build/foster interpersonal relationships.In this respect, humans, along with other primates, have developed a complex facial musculature that allows a rich variety of configurations, thereby enabling them to convey a multitude of possible emotions: muscles distributed in different areas of the face contribute to the production of different expressions. Conversely, an observer will use the visual information distributed over another person’s face to recognize the emotion being expressed. Thus, it is clear that any circumstance that prevents a person from seeing another person’s entire face will also reduce the degree of correct recognition of that person’s expression and, therefore, of their emotion.The advent of the COVID-19 pandemic and the introduction of face masks as a protective device to limit the spread of the infection has raised considerable interest in the context of studies on face processing, as masks made it impossible to view the entire lower half of the face. Several studies conducted after the beginning of the pandemic (and the use of face masks) have investigated potential patterns in the recognition of emotions by comparing conditions in which the faces were entirely visible with conditions in which the faces were covered by a mask . PreviouIt should be noted that the degree of such interference has been found to vary according to the different emotions expressed. For example, it appears that the recognition of anger is not always affected by the occlusion caused by face masks. This would seem to indicate that access to the visual information conveyed by the upper portion of the face is sufficient for its correct recognition . SurprisSo far, almost all of the studies conducted have investigated the perception and recognition of intense facial expressions using static images as stimuli . The fewIt has been observed that the presence of masks tends to impact the perception of an emotion’s intensity. More specifically, when covered by masks, facial expressions tend to be perceived as more subdued. It has been observed that the same facial expression has been judged to convey an emotion less intensely when covered . It has The lack of in-depth knowledge regarding how the presence of face masks affects the perception of emotions’ intensity may be due to the fact that the majority of studies conducted so far have employed tasks requiring participants to assess a person’s emotional state from a limited list of given emotions . AlthougTo date, most published studies have chosen to select stimuli representing only a limited variety of emotions (a range of three to four emotions) . In the Finally, very few studies have investigated the associations between the presence of clinical traits and difficulties in recognizing facial expressions of emotions covered by masks . Many stThe present study aimed to clarify how the perception of all the six basic emotions  varies both according to whether the face observed has been covered by a face mask and according to the intensity of the facial expression represented (full−100% vs. subtle−40%). We also explored whether individuals’ autistic and alexithymic traits may have an impact on facial-expression recognition.We used the GEW  to colleall facial expressions. That is to say, we hypothesized an increased uncertainty in the participants’ responses relating to facial expressions covered by a mask, compared to those relating to uncovered facial expressions. If this is the case, this effect would offer an index for quantifying more precisely the impact of face masks on participants’ confidence in their judgment, which is reduced as a function of face masks  as diagnostic information for the correct recognition of emotional expressions, the basic emotions conveyed primarily by the lower portion of the face are disgust (characterized by wrinkling of the nose and lifting of the upper lip) and happiness (mainly characterized by the raising of the corners of the mouth). With regard to disgust, the only additional secondary AU possibly available when the face is covered is AU7 (tension of the inferior eyelid). It should be noted that the only expression distinctively characterized by AU7 is anger. Therefore, it may be hypothesized that, when observing a face covered by a mask, the expression of disgust may be confused with anger. On this basis, we expected to observe a response bias toward anger in cases where expressions of disgust were subject to face-mask manipulation. With regard to happiness, there are many additional AUs that can be activated, so we did not make any specific hypotheses about whether the presence of face masks could impact the response bias.Applying Action Units AUs; 1 as diagWe expected to replicate previous results regarding the degree of intensity perceived as a function of the mask e.g.,  and, theFinally, we expected to find that all the hypothesized effects described above would also correlate with alexithymic and autistic traits assessed by means of the 20-item Toronto Alexithymia Scale  and 13 were men .We recruited a total of 139 volunteers to participate in this study. The data obtained from 10 participants were not included in our analyses because the level of accuracy of the responses registered in the catch trials was not deemed sufficient, which is <75% accuracy. We arbitrarily decided that performance above 75% accuracy on catch trials was sufficient to ensure that the participants had focused on the main task. Thus, our final sample size consisted of 129 participants, of whom 116 were women . The study was created to be administered online, and volunteers were mainly recruited Participants were asked to complete a questionnaire providing their demographic data and contact information. They also completed the TAS-20 questionnaire to investigate the presence of alexithymic traits  and the 2; A total of 260 experimental stimuli and 14 catch trials were administered during the test phase, which was preceded by a familiarization phase involving 10 stimuli and 1 catch trial. Seventy face stimuli were selected from the Karolinska Directed Emotional Faces database KDEF2; , for a t3 by morphing each of the six emotional expressions with the neutral expression to obtain a realistic facial conformation with an intensity of the expressed emotion equal to 40%. This allowed us to obtain full and subtle expressions of each of the six basic emotions. Given that the background of each image was removed and replaced by a black backdrop, each stimulus consisted solely of a face portraying the target emotion. Each stimulus was then duplicated and an N95 mask was affixed to each copy, using the MaskTheFace script4. As a result, each facial expression was represented by an unmasked and a masked face expressing both a full and a subtle manifestation of intensity. Each catch trial consisted of an image of the same size as those containing faces, with a sentence written in white color  on a black background asking the participant to click on a specific position of the Geneva Emotion Wheel. The request was different for each of the 14 catch trials, and they were randomly presented during the experimental phase (7 per block). Each facial stimulus was presented to participants only once, and each participant saw all of the ten identities with block randomization across subjects. Trails were randomized within each block but they were not randomized between blocks. To summarize, we administered 240 emotional faces , plus 20 neutral faces (10 masked and 10 unmasked), plus 14 catch trials, for a total of 274 trials.The images were modified with a Face Morpher scriptWe used the Geneva Emotion Wheel GEW 1.0;  to gathe5 to create and host our experiment  and the angle of the presented emotion . The correct angle was computed by dividing the GEW into equal parts and then centering each emotion. For better interpretability, we transformed the angles into degrees. In this way, we centered participants’ responses on the displayed emotion with errors that ranged between −180° and 180°. Values around 0 mean correct responses while negative and positive values represent, respectively, an anticlockwise and clockwise shift of responses on the wheel.To assess participants’ perception of the facial expressions they were presented with, we transformed their responses into polar coordinates. The Euclidean distance from the GEW center (measured in pixels) indicates the bias. When the bias is different from zero, there is evidence of a systematic response shift to another location on the GEW.This measure allowed us to extract two important indices. The circular mean of responses representing the average direction on the circle, relating to the displayed emotion, constitutes the uncertainty and, independently of the bias, it provides information about the amount of spread in participants’ responses. For example, an emotion could be systematically confused with other emotions , but this misattribution may be characterized by a low level of uncertainty, or, in another scenario, there could be no systematic bias toward a specific direction but a high-response uncertainty .The circular variability constitutes the bias and the uncertainty. The Von Mises is the circular version of the Gaussian distribution where parameters (μ and k) are directly associated with our bias and uncertainty indices. The parameter μ (the circular mean) represents the bias and the k parameter (the Von Mises concentration) represents the uncertainty. To facilitate interpretation, we transformed k into circular variance  and 1 . Given the relevance and the independence of bias and uncertainty, we decided to analyze both aspects in the same model. Using the so-called location-scale modeling (bias) and k (uncertainty) can be predicted within the same model. To model the perceived intensity, we used a standard general linear mixed-effects model. In dealing with the multilevel data structure, we added the participants’ random effect in each model.Given the shape of the GEW, to analyze our data, standard statistical models were not appropriate . Therefovariance , 191–192modeling , both μ Mask , Facial Expression Intensity (full and subtle), and the displayed Emotion .As predictors, we used bias, uncertainty, and perceived intensity. Given that the Mask effect could be different according to the Facial Expression Intensity, we fitted the same model considering only the subtle facial expressions.As an exploratory analysis, we also analyzed the impact of alexithymia and autistic traits using the TAS and the AQ questionnaire. In this case, we fitted a model with the interaction between Mask and TAS/AQ for priors) with empirical data  to compute the posterior probability. We decided to use a Bayesian approach for several reasons. Firstly, compared to the frequentist approach, each parameter in a Bayesian regression model is represented by a probability distribution of plausible values after combining data with prior knowledge, instead of a single estimated value . All models converged according to the 6.For the model fitting, we used the  package , 2018 ba package  and R (R package . We deci package . These pyes−Maskno) for each displayed emotion. This allowed us to directly assess the impact of the facial mask on facial-expression perception in terms of bias and perceived intensity. For the uncertainty, the Mask effect is computed using the ratio between conditions (Ratio Mask = Maskyes/Maskno), as commonly used for variance-like measures . The PSIS-LOO is a more robust variant of the WAIC index  that can be used for model comparisons  in relation to the bias and the perceived intensity. For the uncertainty, we calculated the ratio between Mask ratios (Ratio Intensity = Ratio Maskfull/Ratio Masksubtle).Next, we tested whether the Mask effect differs when considering parisons . In thisperceived intensity and bias, each relevant contrast  is bidirectionally tested against 0, whereas for the uncertainty, we tested the contrasts  against 1. If possible, we reported the Bayes Factor calculated using the Savage-Dickey density ratio . The 95% HPDI is the interval of the posterior distribution that contains 95% of the most plausible values . We consty ratio  to suppoParticipants’ responses as a function of Mask, Facial-Expression Intensity, and Emotion, expressed through the GEW location, are depicted in bias with Mask, Emotion, and Facial-Expression Intensity as predictors. Posterior distribution summaries for the Mask effect and the interaction between Mask and Facial-Expression Intensity are presented in The first model predicts the bias different from 0. For disgust, the bias is only present when the face is presented with a facial mask. In terms of the Mask effect, facial expressions of sadness and disgust are associated with different bias values. With disgusted faces, in particular, the presence of the mask clearly increases the response bias. Despite being smaller, the Mask effect for sad faces is reversed where the presence of the mask reduces the response bias. We did not find a Mask effect for a surprise.Facial-Expression Intensity (see model = 0.723) is 2.6 times more likely than the model without the three-way interaction . The Mask effect differs in relation to subtle and full facial expressions only for facial expressions of sadness and happiness. More specifically, for facial expressions of happiness at full intensity, the bias is greater with the mask. For subtle facial expressions of sadness, the effect is reversed, with greater bias in the condition without the Mask. We did not find a difference in the Mask effect between subtle and full facial expressions when considering faces with a facial expression of surprise.We assessed the Mask effect for the subtle and full sity see . The moduncertainty with Mask, Emotion, and Facial-Expression Intensity as predictors. Posterior distribution summaries for the Mask effect and the interaction between Mask and Facial-Expression Intensity are presented respectively in The first model also predicts the uncertainty  is 3 times more likely than the model without the three-way interaction . With the exception of sadness, the Mask effect is greater for subtle facial expressions for each displayed emotion . The model with the three-way interaction  and 52.1 .bias . Furthermore, there is no interaction between TAS and the presence of the mask .We centered TAS and AQ scores and set sum contrasts on the Mask predictor for better interpretability of model parameters . The TASuncertainty parameter either for the TAS main effect  or for the interaction between TAS and Mask .There is also no evidence of a TAS effect on the bias and TAS scores  and no interaction between TAS and the presence of the mask . For the uncertainty, we found no main effect of TAS , and no interaction between TAS and the presence of the mask .When considering only the subtle facial expressions, there is no relationship between bias  or for the interaction between AQ and Mask . Similarly, concerning uncertainty, we found no evidence for the AQ main effect  or for the interaction between AQ and Mask .Similarly, we found no evidence either for the relationship between AQ scores and response bias , and no interaction between AQ scores and the presence of the Mask . For the uncertainty, we found no AQ main effect , and no interaction between AQ and the presence of the Mask .When considering subtle facial expressions, we found no relationship between AQ scores and response perceived intensity, we found no evidence of a main effect of TAS scores  or of an interaction between TAS and Mask . When considering only the subtle facial expressions, we did not found a TAS effect  or the interaction between TAS and Mask .In relation to the logBF01 = 2.3) or of an interaction between AQ and Mask . When considering only subtle facial expressions, again, we did not find a AQ effect  or the interaction between AQ and Mask .We found the same scenario for the AQ scores. There was no evidence of a main effect of AQ scores  uncertainty, i.e., the tendency to provide responses associated with different emotional labels without this necessarily being associated with a systematic misattribution of emotional expressions; (2) bias, i.e., the systematic error of confusing one emotion with others; and (3) perceived intensity.all facial expressions (except for fear) when faces are covered by a mask. However, when considering the intensity of the expression, subtle expressions of fear are also associated with an increase in uncertainty. Interestingly, in the study by Notably and not surprisingly, the uncertainty in the participants’ responses  increases for disgust with other emotions  as a function of the mask. As far as surprise, fear, and anger are concerned, this result seems in line with the observation that most distinctive information remains available despite the mask covering the face. The eye region is the most important of all three of these expressions. On the other hand, the result relating to happiness is unexpected since the mask hides the mouth and the contraction of the zygomatic muscle that is markedly associated with this expression. However, the mask leaves another diagnostic element visible, namely, that relating to the eyes and the contraction of the orbicular muscle in its external part, which may be sufficient for the correct detection of the expression. It should be noted that, when also considering the expression intensity as a function of the impact of the mask, full-intensity expressions of happiness are associated with a slight response bias, particularly toward the categories of interest and surprise.We did not observe an increase/decrease in response bias for the remaining emotions  were perceived as less intense when covered by a mask. This finding aligns nicely with previous studies  regardless of their level of intensity. The one exception is intense fear, which is not subject to this increment of uncertainty as a function of the face mask manipulation. Overall, these findings indicate that face masks reduce diagnostic information for recognizing facial expressions. Moreover, when they do not induce systematic errors of emotion misattribution, they increase uncertainty in observers regarding which emotion the other person is feeling/communicating. The observation that this uncertainty also increases for subtle fear when the face is masked supports our hypothesis that the processing of subtle expressions may be more markedly affected by face masks.On the other hand, an increase in systematic misattribution errors  when the faces are covered by a mask (vs. uncovered) seems to be minimal and mainly concerns the expression of disgust, which is primarily confused with anger. This is so, regardless of the degree of the expression’s intensity. To a lesser extent, the full expression of happiness is also confused with interest and surprise, and the subtle expressions of sadness are misinterpreted as fear and anger. Thus, these misattribution errors seem to concern only those expressions that are distinctively conveyed by the (covered) lower portion of the face .Finally, all the emotions were perceived as less intense, especially when subtle.Overall, these findings suggest that face masks affect the recognition of emotions differently according to the availability of the diagnostic information distributed over the face. Thus, the emotions mainly conveyed by the lower portion of the face are more likely to be subjected to misattribution errors, while all emotions, especially those conveyed by the upper portion of the face, are associated with a general increase in uncertainty.Although the present study did not directly investigate the neural basis of expression perception in conditions of mask covering , we believe some considerations may be helpful to future studies interested in investigating such neural underpinnings.In particular, we expect that uncertainty - as we have measured it in the present work - could have a neural counterpart, since there is evidence that uncertainty of participants’ responses is linked with variability in neural responses .What kind of neural responses could present this kind of variability? To provide an answer to this question, we need to consider neural markers of face processing and the most accredited neural model for processing faces and facial expressions. Three principal posterior brain areas are involved in the visual processing of faces , the fusWhen the mask covers those features that strongly characterize an expression of emotion, any features still available in the upper portion of the face can induce misattribution errors if they are a diagnostic of other primary emotions. This would seem to be precisely what was observed for the expression of disgust. The only additional secondary feature available when the face is covered is the tension of the inferior eyelid , a diagnostic feature of anger. In this case, these misattribution errors would not be primarily associated with increased variability in neuronal responses in the OFA and pSTS but, rather, with the “correct” analysis of the available relevant—but misleading—information.Finally, the most recent sensorimotor simulation model considers that the involvement of a distributed emotion system during the processing of expressions of emotion supports their recognition . This syWe also expected to observe a relationship between alexithymic and autistic traits assessed by means of the 20-item TAS  and the Regarding the present study’s limitations, we note that due to the safety regulations introduced to prevent exposure to the SARS-COV-2 virus, most studies on this topic (including ours) have, to date, been conducted online. While this has allowed larger numbers of participants to collaborate in the different studies, it is also true that it has allowed only limited control over the experiments’ settings. Another limitation concerns the nature of the stimuli presented. More often than not, the facial expressions portraying the targeted effect displayed it in a stereotypical manner and with exaggerated intensity, using photographs of actors who have received instructions regarding which muscles to contract to achieve the desired expression. In everyday life, however, the facial expressions people are confronted with may be different, more sophisticated, less obvious, and therefore, harder to categorize. We tried to overcome these limitations, at least in part, by manipulating the expressions’ intensity (full vs. subtle), demonstrating that the processing of subtle expressions is even more compromised by face masks. It must also be stressed that many studies had higher numbers of female than male participants, making it difficult to carry out gender comparisons. Our study, too, is subject to this limitation, as most of the participants were women. It is not clear how this gender unbalance could have influenced the results of our and previous studies. We imagine two alternative scenarios, both based on experimental evidence: We see two possible and opposite scenarios: (1) Since it is known that women are more expressive than men e.g., , more acAnother possible limitation is based on the knowledge about neural models of face processing: When processing expressions of emotion, the activation would further propagate throughout the dorsal pathway to more anterior regions . Furthermore, thanks to the use of the GEW’s complex space, we were able to compute an objective index of uncertainty in the participants’ responses: one which seems to correspond to the results regarding response confidence found in previous studies . In genehttps://osf.io/e2kcw/.The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found below: Open Science Framework; The studies involving human participants were reviewed and approved by Comitato Etico Della Ricerca Psicologica—Area 17—Università degli Studi di Padova. The patients/participants provided their written informed consent to participate in this study.PS developed the study concept. AV programmed the experiment and prepared the stimuli. AV and CR gathered the data. FG performed the data analysis, while PS and FG interpreted the data. All authors contributed to the study design, drafted the manuscript, and approved the final version for submission.


This research analyzed the influence of comic as the communication media to the knowledge and attitude of the respondent in the various determinant of smoking behavior.this research measured the knowledge and attitude of the respondent after they have been given comic as the educational media. It also explored the information about smoking status and social context of the smokers, such as smoker parents, friends, and teachers. The population was the students. The sample size was 1000 students of junior high school. The research aimed to find out the difference of knowledge and attitude based on the smoking status, social context, and training experience.the mean score of knowledge between the respondents who had trained was higher than respondents who had no trained was significantly different (p<0.05). There was also significantly different of the mean score of knowledge and attitude (p<0.05) between the respondents whose family were smoker and non-smoker. The mean score of knowledge and attitude between the smoker and non-smoker respondents was also significantly different (p<0.05).the comic is more effective as an educational media for non-smoker adolescents, adolescents who have not smoker family, and health educated adolescent. Smoking is the largest preventable cause of death in the world . It is nIn the era of multimedia, the innovative interventions to promote smoking cessation behaviors is required to attract the teenager attention. Some behavior intervention such as edutainment and storytelling related to the health topic have provided to the teenager recently . Manga cThe educational comics of disease are varied, such as acquired immunodeficiency syndrome (AIDS) and sexual health, primary immunodeficiency, hepatitis B and tuberculosis . Health Comic as the media to give the information about smoking risk for the teenager was very limited. In this research, the researchers analyzed the influence of comic as the media to the knowledge and attitude of the smokers in the various levels of smoking behavior.Study area: this research was conducted in the Pontianak City, which is one of 14 cities in the province of West Kalimantan. Pontianak City has a population of 607,021 persons, and the largest city in the province. It is well planned, multicultural, cosmopolitan and the healthiest city in the province. It has established local regulations on non-smoking areas since 2010. But 14.7% of its teens are regular smokers, and surrounded by social environments that support these unhealthy behaviors.Study design: this was an experimental study.Study population: the population of the study was the students of junior high school in Pontianak City. They were 35,639 students aged 13-15 years old. Population data was obtained from basic education data published by the Ministry of Education and Culture of the Republic of Indonesia.Sample size: this study took 1000 students as the sample.Sample technique: a multistage sampling was employed. The sample was chosen from 4 different kind of schools, they were public junior high school, private junior high school, Islamic private junior high school, and Christian or Catholic private junior high school. The students were chosen randomly in those schools. The students who fit the requirements of this research were chosen to be the sample of this research.Study instruments: a structured self-administered questionnaire with the following sections: sociodemographic, opinion toward comic, knowledge, attitude and practice was employed.Data collection method: the questionnaire was pretested in one of the school in the study area that was not selected for the study. The questionnaires were then analyzed and changes were made based on the feedback received. Thereafter, ten trained data collectors were assigned to each of the selected districts to administer the questionnaire. They sought sociodemographic data and sections sought information on the opinion, knowledge, attitudes and practices about smoking cessation. The variables; knowledge, attitudes and practices were graded on a scale into five domains, a point was scored for correct.Study experiment: this research experiment used manga style comic with color pages. The title was “Cool Teen Smoke-Free”. The comic content was about the harmful effect of smoking which were explained in 27 pages. The contents were: a) definition of smoking behavior; b) type of smoker (active and passive smoker); c) harmful chemical in cigarettes; d) diseases of smoking; e) quit-smoking tips.Study analysis: data was entered, cleaned and analyzed using Microsoft Office Excel and Predictive Analytics SoftWare (PASW) Statistic version 18. Univariate analysis was performed for frequencies, means and proportions of sociodemographic characteristics of respondents and knowledge, attitudes, and practices (KAP) of respondents towards smoking cessation. Independent T-test (2-tailed) was used, as appropriate, to evaluate for significance of differences in responses between smoking status and knowledge and attitude of respondent towards smoking cessation and differences between social environment and knowledge and attitude of respondents toward smoking cessation. A p value of <0.05 was considered to be significant.Ethical clearance: approval was obtained from the Research and Ethics Committee of Universitas Muhammadiyah Pontianak, Pontianak, Indonesia. Informed consent of the participants in the study were obtained and respondents were assured of confidentiality of information supplied.This research aimed to find out the characteristic and attitude of teenage smoking in Pontianak. The data was collected according to the sex, experience after being educated, smokers´ family, smokers´ teacher, smokers´ friends, and smokers´ experience about smoking.A total of 1,000 respondents were interviewed. According to Analyze showed the impact of comics on the knowledge of respondents at various levels of smoking status. In fact, there was significant difference in the mean score of knowledge at smoking status . And, the impact of comics on the attitude of respondents at various levels of smoking status was significantly different . The mean score showed that the knowledge and attitude of respondents who did not smoke were higher than the knowledge and attitude of smoker respondents .There were 62.3% respondents strongly agreed that the material presented in the comic interesting. More than 69% of respondents stated that the story in the comic did not offend. Respondents also argued that the stories in comics were relevant to their conditions and background (51.6%). They also strongly agreed (66.7%) that comic content could prevent people to smoke .As a communication medium, comics are associated with teenagers. However, last research suggests there may be benefits for health education. The comics were largely used to raise awareness about an issue and facilitate behavior change ,14. OtheIn this research, comics were designed and tested for the prevention and cessation of smoking. There is a difference in the effectiveness of information in several audience groups. The information about the harmful of smoking through comic is difficult to be accepted by the smokers. This comic is potential to convey the facts about disease of smoking and affect the audiences´ psychology. Some smokers are not ready to accept the fact that their smoking behavior is harmful to their health status. Comic help the patients to deal with the fear, anxiety, hope, and problem that they might be faced .Respondents who have the intention to quit smoking have the bigger chance than the respondents who do not want to quit smoking . It showThis research also found the fact that the effect of comic on audience knowledge (students) are influenced by social context. The students are surrounded by the smokers, such as smoker father, smoker brother, and smoker friend ,21. The Knowledge of risks and benefits of health behaviors associated with lifestyle are the prerequisites of performing a behavior. If people lack relevant knowledge, they will not accept reasons for enduring difficulties associated with that behavior. Comic as media are capable of providing information in the shortest possible time and maximum efficiency, and have a huge impact on knowledge, literacy, and attitudes of their audience .There are several things that must be considered, when using comics as health education medium. Comics have a stigma as a medium for children and lower educated/lower income adult audiences . Comics Based on the results and discussion, it can be concluded that comic is more effective in increasing the knowledge of adolescents who have anti-smoking training. This comic is also more effective in increasing the knowledge and attitudes of adolescents who do not have smoker family compared to adolescents who have smoker family. This comic is also more effective in increasing the knowledge and attitudes of non-smoker adolescents compared to smoker adolescents. It can be concluded that there is the impact of the comic as the media to the students' knowledge and behavior. In order to improve the efficiency of health education, it is better to use media to make the students interesting, such as comic. Comic can be used as learning media at school. The public health office can also build the cooperation with the schools to make the health promotion program, especially the harmful of smoking and they also have monitoring the program. Then, the school can have counselling program to help the students to quit smoking.Tobacco smoking is one of the main killers in the world and Indonesia;The prevalence of youth tobacco smokers continues to increase in poor and middle-income economies countries;The cause of this prevalence increase is the lack of specific youth tobacco smoker interventions.Smokers exist in youth age groups, they smoke 1-6 cigarettes regularly every day, even a small percentage smoke more than 6 cigarettes;Anti-smoking training and education experiences affect the level of knowledge after intervention by comic; smoking status also affects the level of knowledge after intervention; so the effectiveness of comics as a health education media for smoking cessation is influenced by smoking status and anti-smoking training experience of youth;Comic is an interesting health education media, because it consists of composition of colors, pictures and stories; the audience believes that the messages and stories conveyed through comic media are also relevant to the lives of youth, they also feel the message given motivates them to stay away from tobacco cigarettes.


The main purpose of this study is to investigate the impact of green product and process innovation on the competitive advantages of the Chinese automobile industry during coronavirus disease 2019 (COVID-19). This study also examined the mediating role of corporate environmental ethics (CEE) and the moderating role of corporate environmental management in the relationship between the green product and process innovation on the competitive advantages of the Chinese automobile industry during COVID-19.This study used a quantitative approach of research with the cross-sectional method for the collection of data. This study also used purposive sampling for the collection of data from the production managers of the automobile industry of China. The structural equation modeling-partial least squares (SEM-PLS) is used to analyze the data.t = 2.868) and green process innovation also has a significant and positive effect on the corporate advantages . Moreover, green product innovation has also a significant effect on corporate advantages  and green product innovation has also a significant effect on corporate advantages .The results of direct effects indicated that green product innovation has a significant and positive effect on the corporate advantages (β = 0.294, The research in this domain about the antecedents of green innovation is still minimal in the previous literature. One of the antecedents of the green innovation, corporate environmental ethics is discussed in this study; thus, it provides the understanding of green innovation as the mediator which would mediate the relationship between corporate environmental ethics and competitive advantage in the auto manufacturing industry of China.This study is among very few to examine the relationship between green innovation, corporate environmental ethics, corporate environmental management, and competitive advantages of the Chinese automobile industry during COVID-19. Green innovation is considered now as one of the crucial and effective strategies for sustainable development of manufacturing industries due to the increasing stress on environmental issues. The investment in environmental projects was considered as a wastage of resources in the earlier period. But now, new trends for the firms have been set as new strict rules and regulations have been formulated for environmental issues, which have completely rotated the concepts of competitiveness for organizations . Green pAccording to the definition of Chinese automobile during the last two decades has emerged as one of the world’s leading automobile industries. According to the annual production report 2009 of the Chinese automobile industry in terms of the total number of units produced, the Chinese automobile industry has outnumbered the combined production of the European Union or that of the United States and Japan combined. China became the largest automobile market in the world. China is the biggest market to the automobile industry as around 80% of the auto supply chain is connected to China. During coronavirus disease 2019 (COVID-19), the Chinese auto sale has declined by 18%. According to the Chinese passenger association, the sale could further decline by 40%.Coronavirus disease 2019 spreading the globe, vandalization lives, business, and economies. Consequently, placing an enormous pressure on the public health as well as on corporations and organizations for being socially, and environmentally reasonable. Today, CEE and CEM are the new tools for hoteliers when they encounter an irresistible force of urgent nature, which demands an urgent and timely investigation to explore the external factors. Mentioning the argument of In today’s competitive world, businesses have been using innovation as a key tool for increasing market share and their survival in the market. Innovation facilitates firms in attracting potential customers, achieving a competitive advantage, and improving the firm’s position in the market . Due to External environmental pressures may lead firms toward implementing environmental management. According to the Neoclassical economists, the main goal of companies is to maximize the wealth of the shareholders , while tMany small and medium enterprises (SMEs) share a common goal, i.e., aiming to achieve a strong competitive advantage. SMEs tend to pay more attention to competitive advantage, as it leads the firm toward higher performance . AccordiCorporate environmental ethics refers to the firm’s fundamental ethical attitude, belief, and mindset about the environmental aspect . A firm’Competitive advantages are referred to those strategies executed by an organization that is not imitable by any of the competitors of the firm, even the competitors are not capable of achieving those advantages which are achieved by the competitive strategy executing company . The uniProductivity of the resources is boosted from GPrsI through energy decreasing, material saving, reduction in resources, and waste recycling . The benHypothesis 1 (H1) GPrdI has a positive impact on competitive advantages.Hypothesis 2 (H2) GPrsI has a positive impact on competitive advantages.Corporate environmental ethics is the complete belief of ethical practices, values, and environment concerning rules within an organization. There are six elements of CEE: ethics committees, ethics officers, ethics codes, ethics communication systems, disciplinary processes, and ethics training programs . Firms mHypothesis 3 (H3) CEE has a positive impact on competitive advantages.Hypothesis 4 (H4) CEE mediates the relationship between the greed product innovation and competitive advantages.Hypothesis 5 (H5) CEE mediates the relationship between the greed product innovation and competitive advantages.The external pressures of the environment may be a vital cause to adopt CEM. Nevertheless, it has been stated by neoclassical economics that the maximization of wealth should be the prime objective of an organization , But theHypothesis 6 (H6) CEM moderates the relationship between the greed product innovation and competitive advantages.Hypothesis 7 (H7) CEM moderates the relationship between the greed product innovation and competitive advantages.As this study concerns competitive advantages and environmental ethics in the automobile industry in China, the sample contains employees of the automobile industry. The targeted respondents were the production managers of the automobile industry. In the selection of sample size, this study used the inferential statistics of The scale item for all the constructs were adapted from the previous studies and measured on a 5-point Likert scale. The scale of CEE, competitive advantages, and green innovation are adopted from the study of “Partial least squares” (PLS) method of analysis was employed for the analysis of research model using the smart-PLS . This stTwo forms of validity were estimated by the examination of the measurement model, i.e., convergent and discriminant validity. In a measurement model, convergent validity is generally discovered by investigating the outer loadings, average variance extracted (AVE), and the composite reliability (CR) . To estaAccording to Heterotrait-monotrait ratio also shows that this study established the discriminant validity because all the values of HTMT ratio are lower than 0.85  and GPrsI also has significant and positive effect to the corporate advantages . Moreover, GPrdI has also a significant effect on corporate advantages  and GPrdI has also a significant effect on corporate advantages . Hence, H1, H2, H3, and H4 are supported.t = 3.276). It also shows that CEE has significant mediation role between the relationship of GPrsI with corporate advantages .t = 4.348). Moreover, results also indicated that CEM has significant moderation role on the relationship of GPrsI and corporate advantages .The results are in line with the propositions of the RBV theory; according to the RBV, businesses achieve a competitive advantage due to their resources and internal capabilities. Besides, the results of this study also suggest that internal capabilities also bring about sustainable development, pollution control, and provide firms with the solution to several environmental issues. It implies green innovation as the capability, which allows the automobile companies to gain a competitive advantage. In addition, green innovation also provides firms with lower cost and differentiation advantages. The results also highlight that during COVID-19, by improving the quality and design of the product, automobile companies can create differentiated products and services through green innovation, thereby making them unique from their competitors in the market. Consequently, products are sold with a higher profit margin by charging higher prices . FurtherIn addition, the findings of this research indicate that during COVID-19, green innovation contributes to the development of isolation mechanisms that are concerned with the firm’s increased profitability and successes. This research classifies GPrsI and GPdI as the two primary categories of green innovation. Low cost and differentiation are the two sources of competitive advantage that have been identified . DiffereEnvironmental ethics led resource productivity results in increased productivity for the firm. The current study found natural environment as the key criterion for evaluating official promotion in China and firms which consider green aspect are likely to receive the required financial resources from the government because of their good relationship with the government. With regard to resource allocation, Chinese government imposes interventions in the form of natural resource distribution, price setting for the scare resources and assets, distributing bank loan, and exemption and tax reductions. Furthermore, CEE also enable to obtain lower cost capital, tax preference and bank loan, and natural resources. Hence, environment ethics present cost advantage firms with the benefit of enjoying cost reduction in obtaining financial capital and natural resources and cutting the punishment expenditure.With an intent to become socially responsible, companies tend to adopt environmental management. In the short run, environmental management does not ensure profit gains; however, in the long run it may result in economic payoffs. Furthermore, according to the stakeholder theory, firms are required to consider their stakeholders’ interests while developing strategies as it helps in gaining support and trust from the stakeholders. The results argue that solely emphasizing the economic goals makes it impossible for the firm to adopt environmental management. Therefore, a sustainable long-term approach must be adopted by the firms concerning the stakeholders’ and institutional pressures and non-economic goals.This study has broadly studied innovation, but still less attention has been paid to green innovation. Thus, the aim of this study is to study the concept of innovation in context to the green perspective. With regard to the Schumpeterian view, process and product innovation can successfully be implemented to the green innovation. In the manufacturing industry, green innovation can be broken down into process innovation and product innovation; however, in the case of the Chinese automobile industry, it is somehow difficult for separating the consumption and production of the Chinese auto industry. Hence, the results of this study explain that during COVID-19 green innovation as integrating innovation into the product and processes to minimize ecological footprints and achieve environmental objectives . In thisThis study deals with the topic on issues of green innovation, competitive advantages, and CEE, together, which makes them emerge into a new subject of “green management” considered about the issue of economic development as well as the protection of the environment. Many manufacturing firms in China have lack of resources and, hence, they are not up to mark for maintaining their standards according to the environmental protection policies. As the organizations in China cannot hold any compliance with the international environmental regulations, it would harm them in every possible way. Nonetheless, the present study found out that if a firm is consistent about investing more in CEE, Chinese manufacturing industry would witness improvement in their GPrdI and competitive advantage . Thus, tThis study has made China as its center of research, the future researchers can make their studies more contextual by focusing on other areas as well. To test the similar hypotheses in other countries according to their context would be a captivating issue. The future studies may make other countries as their context of research which may be helpful in generalization of the findings around the globe. This study is only demonstrating the cross-sectional data through employing survey methods comprising of questionnaires, so no vigorous changes of green innovation, environmental ethics, and competitive advantages have been shown in different developmental stages of industry in China through longitudinal data. Thus, variations in environmental ethics, green innovation, and competitive advantages can be observed through longitudinal study by future researchers in various developmental stages of auto manufacturing industry of China. Finally, this study intends to fulfill the purpose of contributing to managers of auto manufacturing industry of China, their researchers and policy formulators which may further contribute to their respective areas.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.All authors listed have made a substantial, direct, and intellectual contribution to the work, and approved it for publication.