Although prehospital stroke management is challenging, it is a crucial part of the acute stroke chain to enable equal access to highly specialised stroke care. It involves a critical understanding of players usually not specialized in acute stroke treatments. There is contradictory information about gender inequity in prehospital stroke detection, dispatch, and delivery to hospital stroke centers. The aim of this narrative review is to summarize the knowledge of gender differences in the first three stages of acute stroke management. Information on the detection of acute stroke symptoms by patients, their relatives, and bystanders is discussed. Women seem to have a better overall knowledge about stroke, although general understanding needs to be improved. However, older age and different social situations of women could be identified as reasons for reduced and delayed help-seeking. Dispatch and delivery lie within the responsibility of the emergency medical service. Differences in clinical presentation with symptoms mainly affecting general conditions could be identified as a crucial challenge leading to gender inequity in these stages. Improvement of stroke education has to be applied to tackle this inequal management. However, specifically designed projects and analyses are needed to understand more details of sex differences in prehospital stroke management, which is a necessary first step for the potential development of substantially improving strategies. Acute stroke care and access to timely treatment strongly depend on efficiently organized prehospital management. The stroke chain of survival with its first 3 “Ds”, detection, dispatch, and delivery, based in the prehospital setting emphasizes the importance of optimal pathways before the patients arrive at the hospital . There iIdentification of acute symptoms of stroke can be challenging even for specialists. However, this is the first crucial step in gaining access to modern stroke treatment, especially to recanalizing therapies with a time-limited treatment window for the best outcome. Most of the current literature describes a better recognition and identification of acute stroke symptoms by women, but there are also publications emphasizing their lack of stroke understanding.A meta-analysis of 22 studies, of which 20 were cross-sectional and 2 pretest–posttest design surveys, mainly conducted in the USA and Canada, identified a greater knowledge of stroke symptoms and related risk factors in women compared to men . In a SpIn addition, the overall perception of stroke knowledge in women is poor. A survey of 1,024 women contacted by randomly selected telephone numbers in the USA in 2003 identified that only one-fourth of all women felt well informed about stroke and stroke risk and just below a quarter reported to be very concerned about the disease. Standing out was that younger women aged 25–34 years had the highest rate of nescience (37%). Hispanic or Black ethnicity was associated with less knowledge, but correct identification of acute stroke symptoms was low for all age groups and independent of racial backgrounds .The above examples of available evidence  and that this led to all of them arriving 3 h or later after onset .If the onset of stroke symptoms is witnessed, it is most commonly by the patient's partner ; howeverAnother reason adding to the gender difference in EMS activation might be that women are older than men at the time of stroke, particularly in Europe, Australia, and South America . This reThe identification of stroke symptoms at the point of EMS dispatch is key in optimizing the chain of survival in acute stroke and this remains one of the least investigated elements of the chain . It is cIn some countries, the Medical Priority Dispatch System (MPDS) is used for EMS dispatch. This system is based on a structured caller interrogation with additional instructions on what to do until EMS arrival. In a Los Angeles study of 871 patients, 58 were assigned the stroke MPDS code by the dispatcher, but only 45% received a confirmed in-hospital stroke diagnosis . A totalThere are many reports on differences in clinical presentation between men and women [Women are reported to often present with unusual stroke symptoms such as generalized weakness, fatigue, and mental status change. In an analysis of 461 patients, 52% of women compared to 44% of men presented with a non-traditional stroke symptom . This reThese reported differences in the clinical presentation of stroke between genders can therefore be of challenge for the EMS when diagnosing stroke in the prehospital environment with only limited diagnostic tools available. This is supported by multiple studies . A recenVarious measures have been previously discussed to enhance prehospital stroke recognition, including the use of validated stroke scales . A retroIt is likely that different presentations of women with acute stroke lead to a wrong working diagnosis by the EMS in the prehospital phase, which could impact further stroke management. However, more prospective studies are needed to understand the real impact.via the EMS was slightly longer in women (mean 337 min vs. 297 min in men); however, they subsequently found that gender was not associated with a delayed time to arrival when considering age and National Institute Of Health Stroke Severity (NIHSS) score. It was demonstrated that 30% of women in the study (324/1097) lived alone compared to 22% of men (200/894), and that this was a factor in delayed arrival at the hospital, potentially due to the lack of self-recognition of symptoms  scan in patients presenting within 3 h of symptom onset but also a shorter door-to-needle (DTN) time. This study comprised of 928 patients, of whom 727 received pre-notification to the hospital. There was a significantly higher number of men who were transported with pre-notification (64.5%), and more pre-notified patients had a DTN of <60 min (45.1 vs. 28%) compared to those not pre-notified . A similAn analysis of the American Get-with-the-Guideline stroke registry of 371,998 enrolled patients with stroke in 1,585 hospitals over 8 years showed a pre-notification rate of 67%. Patients with EMS pre-notification to the hospital were more likely to be younger, white, and male. In the 122,791 patients eligible for pre-notification where none was given, 54.3% were women (These differences in prehospital management of women with acute stroke might be caused by a higher number of misdiagnoses, subsequently leading to lower numbers with accurately initiated stroke alert to the hospital. But clearly, further research is required to understand unbiased differences in prehospital treatment and outcomes.This review addresses gender differences in the very first stages of acute stroke management, the detection of disease symptoms to the delivery of the suspected stroke patient to the specialized center. It highlights some of the available evidence with the aim to raise awareness and identify a pattern, hinting toward areas of necessary improvement to guarantee gender equity in prehospital acute stroke treatment.Detection of acute stroke and initiation of the necessary steps, which enable health care specialists to administer up-to-date and high-quality stroke care, is incumbent to the patient and or relatives or bystanders. There is a lot of evidence coming from different countries that women have a better knowledge about acute stroke symptoms, risk factors, and the necessary actions to take than men. However, the overall public level of knowledge about stroke, the number three disease cause for disability is still poor , 53. GenDespite often having a higher and better knowledge about stroke, women seem to feel uncertain about many aspects of the disease. Women's confidence in their own knowledge differs from that of men , which nThe idea to implement health education in standard school programmes would be one possibility to establish gender-independent knowledge transfer in the future. But, to reach girls and young women in countries with relevant sex inequity would need strong collaboration between health services and educational sectors with strong political and governmental support.It is well described that public campaigns do not lead to a sustainable solution to improve health awareness ; howeverHowever, equal knowledge and awareness alone do not lead to equal acute stroke care. The available evidence suggests that women arrive at the hospital later than men, indicating an inequity in dispatch and delivery of acute stroke care. Relevant confounders like social disparity with more women living alone at an older age, when the risk of stroke increases, have to be considered. Management of women seeking help at an emergency medical dispatch center does not seem to show any gender-based differences. But many countries use systematized interrogation programmes, like the Medical Priority Dispatch System to identify stroke suspects, which could be prone to errors and disadvantageous to women with stroke, who often present with non-traditional symptoms .There is no information available on whether a criteria-based dispatch, used in many Nordic and European countries , which rThe differences in the clinical presentation of women compared to men can make it difficult for paramedics to quickly conclude a stroke working diagnosis at the emergency site. This likely presents the biggest challenge in the delivery of equal care. There is evidence for an inequity in pre-notification of cases to the receiving hospital. To tackle this, paramedic and EMS stroke-specific training have to be considered and addressed. A correlation between high-quality medical education and patient outcome has been demonstrated for nurse care , 58, butTo conclude, more structured data and results from specifically designed clinical trials are needed to understand gender inequity in the first stages of acute stroke care and to develop solutions to overcome potential gender disbalances. Identified gender inequity is mostly caused by unawareness of gender-specific aspects of stroke, which are not considered in acute prehospital pathways.SW, BW, RM, and KF contributed to the conception and design of the review. SW, BW, and RM wrote the first draft of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Needs and demands of contemporary engineering stimulate continuous and intensive development of design methods. Topology optimization is a modern approach which has been successfully implemented in a daily engineering design practice. Decades of progress resulted in numerous applications of topology optimization to many research and engineering fields. Since the design process starts already at the conceptual stage, innovative, efficient, and versatile topology algorithms play a crucial role. In the present study, the concept of the original heuristic topology generator is proposed. The main idea that stands behind this proposal is to take advantage of the colliding bodies phenomenon and to use the governing laws to derive original Cellular Automata rules which can efficiently perform the process of optimal topologies generation. The derived algorithm has been successfully combined with ANSYS, a commercial finite element software package, to illustrate its versatility and to make a step toward engineering applications. Based on the results of the tests performed, it can be concluded that the proposed concept of the automaton mimicking colliding bodies may be an alternative algorithm to other existing topology generators oriented toward engineering applications. As it has been observed over the years, topology optimization has been a dynamically developing research area with numerous applications to many research and engineering fields. The researchers community continuously works on innovative, efficient, and versatile topology optimization approaches, methods, and algorithms, whereas the spectrum of numerous solutions of topology optimization problems ranges from classic Michell structures to sophisticated contemporary engineering ones. The various approaches to the generation of optimal topologies have been presented along with emerging concepts which have been implemented in a broadly understood engineering area. The comprehensive discussion on various aspects of topology optimization has been provided by many survey papers: e.g., ,2,3,4 reAlong with the research issues of topology optimization, the practical aspects of engineering implementation of topology optimization techniques have become more and more important. As a result, the topology optimization tools are nowadays present in commercial engineering software. However, the black-box topology generators implemented into commercial software do not guarantee that the final results are the best available. Therefore, although remarkable achievements have been already made toward topology optimization application in engineering, there is still room for further investigations. Recently published papers ,9,10,11 In the present study, the concept of the original heuristic topology generator is proposed. The main idea that stands behind this proposal is to take advantage of the colliding bodies phenomenon, and use the governing laws to derive original Cellular Automata rules which can efficiently perform optimal topologies generation process. The inspiration for this proposal was the series of papers by Kaveh and co-workers ,13,14,15As mentioned above, the applied approach is based on the concept of Cellular Automata (CA). Cellular Automata are built so as to mimic the behavior of complicated systems in a relatively easy way. From a computational point of view, the special local rules are implemented with a view to control the performance of a system under consideration. Hence, the local physical quantities are respectively updated, which allows us to describe the global behavior of the system. The concept of Cellular Automata has been known since the late 1940s when von Neumann and Ulam proposed this idea. Henceforth, this approach has been found interesting by researchers representing various fields but probably for the first time topology optimization has been discussed within the CA approach only in the paper by Inou et al. . Many paThe outline of the paper is as follows. In In this section, the topology optimization problem is formulated, the concept of Cellular Automata mimicking colliding bodies is introduced, and the algorithm built based on this idea is described. The introductory example illustrates the implementation of the proposed concept into the topology generation process.c, Equation (1). Hence, one can follow the optimization problem formulated in a widely recognized paper by Sigmund [κ is defined and treated in the optimization process as the constraint imposed on structure volume V, Equation (2). The finite element approach has been applied:The most commonly formulated structural topology optimization problem is to generate material layout which within a design domain leads to a minimal value of the structure compliance  Sigmund . The avaN elements. The design variable −9) as a non-zero minimum value of relative density, singularity is avoided.The quantity The SIMP  approach  in the p  is responsible for penalization of intermediate densities. This allows controlling the design process and leads to obtaining black-and-white resulting structures. During the topology generation process, a material is redistributed within the design domain, which results in removing parts unnecessary from design criteria viewpoint.In Equation (5), the quantity The selection of a proper method of topology generation determines the effectiveness of the topology optimization process. Heuristic optimization techniques become popular among researchers because they are easy to implement numerically, gradient information is not required, and one can easily combine this type of algorithm with any finite element structural analysis code.In this paper, the original heuristic topology generator built as Cellular Automaton which mimics Colliding Bodies (CAmCB) is proposed. The idea is that the design domain of the structure is decomposed into a lattice of cells which are usually equivalent to finite elements. For each cell, the surrounding cells form a neighborhood. The bodies are distributed within this lattice .Let us assume that the bodies have masses and velocities. Masses are proportional to cell areas whereas velocities are related to cell compliances. Furthermore, let us imagine that the neighboring bodies collide with the central one, which results in changing its status. In what follows, the central body can either be forced to remain in its position, or is pushed away .From a topology generation point of view, the interpretation is that the central cell remains solid, or is driven to become a void one .While building Cellular Automaton, it is assumed that the interactions between bodies/cells take place only within the specified neighborhood, where they are governed by local rules which are identical for all cells, and are applied simultaneously to each of them. According to the concept of the paper, the local rules are derived so as to mimic collisions taking place between bodies/cells within each neighborhood. The governing equations based on the physics laws of momentum and energy are applied. Let us consider the central cell and a neighboring one colliding with it .The governing equations are as follows:Based on the above, the velocity of the central cell after collision equals:As stated earlier, velocities are related to cell compliances and masses are proportional to cell areas. Equation (8) can be rewritten in the form of Equation (9):Based on the results obtained from a structural analysis, the values of local compliances are calculated for all cells/elements. The compliances are sorted then in the ascending order, and those having the lowest and the highest values are identified. In the next step, A monotonically increasing function representing cell compliances is selected for the intermediate interval The quantity  also in .Having finished with data preparation, the update rule can be built. Hence, repeating collisions for all neighboring cells, the average quantity Finally, the design variables can be updated according to Equation (13):In order to implement the above-proposed design rule, a numerical algorithm was built. The sequential approach was adapted for the optimization procedure, meaning that for each iteration, the structural analysis performed for the optimized element is followed by a local updating process. Simultaneously, for a specified volume fraction, a global volume constraint is applied. As a result, during the optimization process, the generated topologies preserve a specified volume fraction of a solid material.The issue to discuss regards the form of Equation (9). In the case of a regular lattice of cells/elements, the first component of the numerator vanishes. In order to preserve the influence of the central cell compliance on the final result during the iteration process, it is proposed to modify the cells area representation:In Equations (14) and (15), In order to control the topology generation, the threshold values The rectangular structure shown in The CAmCB algorithm found the final topology, which is shown in The compliance value found for this structure is equal to 13.62 Nmm. This outperforms the solution reported in  where coThe original examples of topology generation are discussed in this section, presenting the performance of the algorithm. With a view to cover a broad area of implementations, the discussed tasks regard plane and spatial structures. The case of irregular cell lattice is also considered.In what follows, to illustrate more thoroughly how the proposed CAmCB algorithm works, some numerical examples have been selected. The algorithm performance is presented first for plane test structures, and then for plane and spatial engineering structures. For the test structures, a Matlab-based algorithm has been applied, whereas for engineering structures, the topology generator has been combined with the ANSYS system, which was responsible for performing the structural analysis.The results of topology generation performed for four plane test structures are presented below.To perform the first test, the structure shown in The algorithm found the final topology, which is shown in For the structure shown in The final structure topology found by the algorithm and the illustration of the compliance history are given in To perform the third test, the structure shown in The algorithm found the final topology, which is shown in For the structure shown in The final structure topology found by the algorithm and the illustration of the compliance history are given in As can be seen from the above, the original CAmCB algorithm can effectively generate minimal compliance topologies. It is also worth comparing the obtained results with the ones which can be found for the considered structures when using other existing and popular approaches. The top88 algorithm  based onOne can observe that the CAmCB algorithm proposed in this paper allows us to find results which can be better in terms of objective function values than the ones obtained with the use of other approaches selected for this comparison.A series of illustrative engineering examples has been selected to examine the effectiveness of the introduced concept of the CAmCB topology generator. Both regular and irregular cell lattices are considered to show the algorithm performance and the versatility of the approach. As mentioned earlier, the proposed topology generator can be easily combined with any solver built on finite element methods. Hence, the optimization module has been linked to the professional system ANSYS to perform structural analyses. It is worth noting that the proposed algorithm does not require additional density filtering, the so-called gray elements are eliminated, and the checkerboard effect has not been observed for generated topologies.The model of a control arm structure presented in As for the strategy of The algorithm found the final topology, which is shown in The CAmCB algorithm codes for the example considered in this section are provided in the The aim of this example is to extend the presentation of the proposed algorithm toward an irregular grid of cells related to a non-regular mesh of finite elements. Resizing a traditional uniform grid of cells allows us to obtain flexible solutions, for e.g., extremely irregular design domains where it is difficult or impossible to cover them with uniform cells. Additionally, regions with stress concentrations, such as around holes or sharp edges, should be covered with a fine mesh, which is not necessary for the structure as a whole. The procedure of refining a mesh in selected regions can be used in order to achieve an accurate solution without an excessive increase of the number of elements caused by using a fine mesh implemented for the whole structure.−3 Nmm.The example illustrating this case is the portal frame presented in The algorithm found the final topology, which is shown in The box tube shown in The algorithm found the final topology which is shown in The algorithm performance was additionally tested based on the same example, repeating computations for low volume fraction The discussion regarding the proposed algorithm and its performance is summed up in this section. In the presented study, the original concept of Cellular Automaton mimicking Colliding Bodies (CAmCB) has been applied for topology optimization using the minimum compliance as the objective function. The CAmCB algorithm combines Cellular Automata heuristic with Colliding Bodies phenomenon to create a fast convergent technique which provides black-and-white topologies, without gray regions and the checkerboard effect. Moreover, additional density filtering is not necessary and there is no need to calculate gradients. In order to illustrate the effectiveness of the proposed CAmCB algorithm, selected numerical examples have been investigated. The algorithm performance is presented for plane test structures and for plane and spatial engineering structures. In the latter case, the proposed optimizer was combined with professional FEM analysis codes. The advantage of the developed algorithm is that it is a versatile technique which allows implementation of rectangular or triangular lattices, adaptation to highly non-uniform finite element lattices, as well as consideration of the total volume constraint with large and small volume fraction which is important especially for lightweight topology optimization. Preliminary studies reveal the possibility of applying CAmCB algorithm into uncommon but interesting issues such as the consideration of design-dependent loading (self-weight) or topology optimization of multi-material structures. The results of the tests performed so far are encouraging, which allows us to consider the proposed concept of the automaton mimicking colliding bodies phenomenon as an alternative algorithm to other existing topology generators suited for engineering applications.


This paper aims to explore the change of learning mode of college students from physical courses to online courses due to the impact of the COVID-19 pandemic. The questionnaire survey method is used to conduct research on the behavior intentions of college students in online teaching under the pandemic. A total of 600 questionnaires are distributed, and 530 questionnaires are collected, for a recovery rate of 88%. A total of 493 supported questionnaires are received, for an effective recovery rate of 93%. Descriptive statistics of data analysis are used to analyze the distribution of background variables of college students, and a structural equation model is used to analyze and verify the impact of external variables  on the technology acceptance model . The results found no significant impact of the trust of college students in online teaching on the perceived usefulness, and significant impact of trust on the perceived ease of use. There is significant impact of convenience on perceived usefulness, and no significant impact of convenience on perceived ease of use. There is no significant impact of perceived critical mass on perceived usefulness, and significant impact of perceived critical mass on perceived ease of use. There is significant impact of perceived ease of use on perceived usefulness, and significant impact of perceived usefulness on attitude. There is significant impact of perceived ease of use on attitude, and significant impact of attitude on behavior intention. Based on the research results, practical suggestions and research suggestions are proposed in this research, which can be used as a reference for college students to use online courses for learning. In December 2019, a number of viral pneumonia cases of unknown origin were identified in Wuhan, Hubei Province, followed by imported cases from Wuhan into Thailand, Japan, and South Korea. The pandemic then spread rapidly to the whole world. The first imported confirmed case from abroad was discovered in Taiwan on January 21, 2020. As the pandemic intensified, all countries took strict measures to prevent the spread of COVID-19. Nevertheless, the COVID-19 pandemic spread so fast that it had a huge impact on education, the economy, society, and entertainment world wide. Later, after successive infection cases of unknown origin and cluster events occurred in Taipei City and New Taipei City, the Central Epidemic Command Center began to increase the epidemic alert to Level III on May 15, 2021 after analysis showed that the cases of infection in communities would spread broadly. Various restrictions were employed, such as the suspension of opening elementary and junior high schools nationwide to the outside world and the suspension of activities of associations nationwide . As educMoreover, students’ digital divide and the differences in hardware equipment may also cause the learning effect to be less than expected. For example, if the internet connection is not smooth during online teaching, the operation interface of the online teaching platform will be difficult to use. Whether these problems generated in the online teaching process affect students’ attitude regarding the online teaching system is worthy of further discussion. Therefore, the third research motivation of this paper is to explore the impacts of perceived usefulness and perceived ease of use on students’ attitudes toward online teaching systems.It can be seen from relevant literature that the technology acceptance model is often used to explore the use of new technologies , thus, tConsumers’ consumption of a certain product or acceptance of a certain service is often based on their trust in merchants or enterprises. Especially in contemporary society, both the complex information of goods and services and information asymmetry make consumers focus more on their purchasing decisions. Therefore, trust is often the basis for a transaction between a buyer and a seller. The concept of convenience can be used as an entry point to determine how much time and effort consumers spend in obtaining a product or using a service. With the prosperity of We Media, the flow of goods and services has largely broken the restrictions of time, space, and territory, especially at a time when the interactivity of new media has become a phenomenon that cannot be ignored. In 1983, Oliver proposed the concept of critical mass and held that critical mass means that people would have a certain social tendency after the number of participants exceeds a certain threshold. Theories that explore people’s usage behavior are constantly developing with the times. From the theory of reasoned action (TRA) proposed by In the model constructed in this research, the relationship between variables is supported by previous relevant researches: There is a positive impact of trust on perceived usefulness and perceived ease of use ; there iTrust is the user’s belief that the system is reliable and upright in the process of using the network system; Convenience is the degree to which users feel that the operation, method, time and other processes are convenient when using online teaching; Perceived critical mass (PCM) is used to perceive the degree to which new technologies are adopted by the general public; The Technology Acceptance Model (TAM) is used in conjunction with the application context of the new technology information system, and is suitable for explaining and predicting the behavioral intention pattern of users’ acceptance of the new information technology system.This study the impact of online teaching in behavior intention for college students. According to the research purpose and related literature, the research structure proposed is shown in H1: trust has a significant impact on perceived usefulness.H2: trust has a significant impact on perceived ease of use.H3: convenience has a significant impact on perceived usefulness.H4: convenience has a significant impact on perceived ease of use.H5: perceived critical mass has a significant impact on perceived usefulness.H6: perceived critical mass has a significant impact on perceived ease of use.H7: perceived ease of use has a significant impact on perceived usefulness.H8: perceived usefulness has a significant impact on attitude.H9: perceived ease of use has a significant impact on attitude.H10: attitude has a significant impact on behavior intention.This study was investigate the behavior intention of college students regarding online teaching under the influence of the COVID-19 pandemic. The research subjects were college and university students. The survey was conducted with questionnaire. A total of 600 questionnaires were distributed, and 530 questionnaires were collected with a recovery rate of 88%. A total of 493 supported questionnaires were received with an effective recovery rate of 93%.The content of this research questionnaire were revised and complied mainly based on the relevant literature of questionnaires by After the questionnaires being collected, invalid questionnaires were eliminated according to the criteria of valid questionnaires. SPSS 22.0 statistical software was used to establish the data file. Then, AMOS 22.0 statistical software was used to analyze the correlations between variables.This study took students from colleges and universities as the test samples. There were a total of 493 valid samples. Among them, in terms of gender, there were 297 females, accounting for 60.2% of the valid samples, and 196 Male, accounting for 39.8% of the valid samples. In terms of grade, most of them (106) were in junior, accounting for 21.5% of the valid samples, and only others 15 people were in others, accounting for 3.0% of the valid samples. Regarding school, 294 people were in the public university, accounting for 59.6% of the valid samples, and the least number of subjects (37) was in the private university, accounting for 7.5% of the valid samples. In terms of Location of schools, there was a total of 256 people were in the central region, accounting for 51.9% of the valid samples, and only 14 people with South, accounting for 2.8% of the valid samples. In terms of the most frequently used video software, Google Meet had a maximum of 400 users, which accounted for 81.1% of the valid samples, and only 14 people with others, accounting for 2.8% of the valid samples. The details are shown in CFA was adopted to examine the reliability and validity of the questionnaire. Modifications were made based on the Modification Indices MI; . B4 of tThe discriminant validity of the study was tested with the confidence interval method (Bootstrap). The questionnaire dimensions were correlated depends on the value of the Pearson correlation coefficient confidence interval among the questionnaire dimensions of this study. The value should not contain 1. The results showed that the confidence interval between the questionnaire dimensions was missing the value of 1, indicating that the questionnaire dimensions of this study have significant discriminant validity , as showThe structural model analysis of In the results of this study shown in This paper draws the following main conclusions through empirical analysis:H1 is not supported, which means that there is no significant impact of trust on perceived usefulness.H2 is supported, which means that there is significant impact of trust on perceived ease of use.H3 is supported, which means that there is significant impact of convenience on perceived usefulness.H4 is not supported, which means that there is no significant impact of convenience on cognitive usability.H5 is not supported, which means that there is no significant impact of perceptual critical mass on the perceived usefulness.H6 is supported, which means that there is significant impact of perceptual critical mass on perceived ease of use.H7 is supported, which means that there is significant impact of perceived ease of use on perceived usefulness.H8 is supported, which means that there is significant impact of perceived usefulness on attitude.H9 is supported, which means that there is significant impact of perceived ease of use on attitude.H10 is supported, which means that there is significant impact of attitude on behavior intention.Based on the above research results, this paper puts forward some suggestions for reference:It can be seen from the results of this paper that trust has significant impact on perceived ease of use. Therefore, it is suggested that students should first understand the operational interface of the online teaching platform before using the platform. In particular, there are different operational characteristics in different online teaching platforms, and the products with a certain quality can make consumers generate a sense of trust. As a result, if students can become familiar with the operational interface in advance, it is easier for them to find the course and join the video conference, if the login screen of a laptop is different from that of a phone, prior knowledge can help solve this problem in a timely manner, and students can more easily use the online teaching platform when they have prior knowledge of platform use. However, the results also show that perceived critical mass has significant impact on perceived ease of use, thus, students are suggested to ask seed teachers of the platform for help using the system, as well as the steps for learning in the early stages before teaching. Such prior knowledge helps students to understand the course content in advance, which facilitates discussions with teachers and peers through the online chat room during formal teaching, and reduces the challenges faced by students in remote teaching. In other words, the more successful role that critical mass plays, the more students will recognize the learning effect and smooth operation brought by the online teaching system. In addition, the results of this paper show that attitude has significant impact on behavior intention. Consequently, students are suggested to build an environment where they can focus when using the online teaching system, meaning they should avoid excessively noisy spaces and cultivate their spirit of independent learning by concentrating on learning. At the same time, when learning is supplemented by teachers’ diversified teaching materials to stimulate interest-oriented learning, and learning is not completely limited by the curriculum structure, it means students can achieve their learning goals faster through an online teaching system, and have a positive attitude toward completing the learning activities more easily and efficiently, which makes students more willing to adopt the online teaching system.The results of this paper demonstrate that perceived ease of use has significant impact on perceived usefulness. Therefore, school-related units are suggested to adopt online teaching software or interfaces suitable for teachers and students, avoid messy interface designs, complex system operations, and unfriendly interface designs, and consider the compatibility between mobile phones and different operating systems. In particular, more attention should be paid to the technical support services of traffic and troubleshooting on the online teaching platform. With all these strategies, students will feel the online teaching platform is easy to use, and then, recognize the learning experience and teaching results brought by it. In addition, the results show that perceived usefulness and perceived ease of use have significant impacts on attitude. Therefore, teachers are suggested to make good use of the functions and advantages of the online teaching platform; for example, teachers can increase the flexibility of teaching by making use of media technology, and remote teaching can present diversified teaching styles to further improve students’ learning motivation and learning responsibility through interactions on various media . In addition, an online teaching platform can help enhance students’ willingness to learn through interactions and receiving real-time feedback during class; for example, students’ class assignments through traditional teaching methods can only be read by teachers, while the online teaching platform allows teachers and students to exchange ideas and learn from the questions raised by other students during class, which can improve both teaching and learning. When students are satisfied with the teaching content and interactive process provided by the online teaching platform, they will be more willing to use the platform. In addition, the results show that convenience has significant impact on perceived usefulness; therefore, teachers are suggested to help students understand the operation of the platform interface through many methods, such as recording an operational video and providing it to students to watch repeatedly. All these suggestions can further reduce students’ troubles caused by the unfamiliar operations and enhance their recognition of the learning effect of the online teaching platform.It can be seen from the results that three research hypotheses in this paper are not supported. In particular, the hypotheses regarding trust and convenience for perceived usefulness are not supported. It is suggested that in future research, the cognition and usage behavior of college students regarding online teaching software or platforms can be further explored; for example, exploring the important aspects and cognitive aspects of students for an online teaching platform can be conducted through analysis of the important attributes, or exploring the actual process of students’ use of online teaching software through in-depth interviews, on-site observations, and other diversified methods, and recording the problems that students often meet in the process of online teaching, which can be provided to students, in order that questionnaires for future relevant research can be improved. In addition, some specific situations can be considered by future research; for example, studies should explore the possible gaps between teachers and students during digital learning, as caused by the urgent use of online teaching under the pandemic, as well as other factors  that may affect students’ perception of the usefulness of online learning platforms. Future research results are expected to be enriched through the above-mentioned related strategies.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


When high-grade gliomas recur, patients, their families, and clinicians face difficult medical decisions. There is no curable treatment, and the treatment options all come with a risk of complications and adverse effects. The patients are often cognitively affected, and they need tailored decision support. The objective of this study was to develop a patient decision aid (PtDA) targeted at patients with recurrent high-grade gliomas. Based on existing knowledge and the International Patient Decision Aids Standards, the PtDA was developed through an iterative process. The PtDA was alpha-tested by potential users to assess its acceptability and usability. The development team comprised three clinicians, two patients, two family members, and a researcher. The fifth version of the PtDA was submitted to the alpha test. Eleven patients, nine family members, and eleven clinicians assessed the PtDA and found it acceptable. Three changes were made during the alpha test. Most participants perceived the PtDA to prepare patients for decision making and improve consultations. The involvement of potential users was emphasized during the development and alpha test process. The PtDA was assessed as useful and acceptable by patients, family members, and clinicians in the decision-making situation of recurrent high-grade glioma. High-grade gliomas (HGG), classified as WHO grade III and IV tumors, are the most aggressive brain tumors . The priClinical decision making concerning which treatments the individual patient can be offered at disease recurrence depends on the specific characteristics of the tumor, the tumor location, previous treatment responses and side effects, age, and the patient’s performance status . ResearcThe uncertainty concerning treatment outcomes and the trade-offs between benefits and disadvantages make it essential to involve patients and include their values and preferences in the decision-making process . Based oSDM is an approach that combines professional expertise and scientific evidence with the subjective values and preferences of the individual patient in a shared decision ,16. PatiFor patients with recurrent HGG, involvement in SDM can be challenging due to reduced cognitive abilities, such as memory, concentration, understanding, and information processing ,20,21. NTo increase decisional support for HGG patients and acknowledge the critical role of family support, the objective of this study was to develop a PtDA that was considered useful and acceptable by patients, their families, and the involved clinicians.The study design was guided by the “Systematic development process for patient decision aids”  in accorA multidisciplinary development team was established, and they selected the content for the PtDA through an iterative process. After developing the PtDA, we alpha-tested it with potential users to assess its acceptability and usability. We established a multidisciplinary developmental team to provide a balanced representation of relevant clinicians, patients, and family representatives. The patient and family representatives were recruited through the Danish Brain Tumor Association. The team comprised two HGG patients, two family members of HGG patients, one neurosurgeon (FRP), one oncologist (RD), one neurologist, and one nurse researcher (HSE). The clinicians involved were well recognized within their areas of expertise. Due to the COVID-19 pandemic, it was unfeasible for the development team to hold physical meetings with all participants. Instead, the collaboration took place through online discussions and one-on-one meetings. The PtDA presented in this article is based on a generic PtDA template, the “Decision Helper”, which was developed by the Centre for Shared Decision Making at Lillebaelt Hospital, Denmark . The temThe five steps described in the template function as a guide for the clinician and help structure the consultation to increase patient and family involvement, support the clinicians’ verbal information, and strengthen SDM  26]..26].Step 1. To support future patients when they are considering treatment and care, we identified a list of questions typically asked by patients and family members. We selected the questions by recording, transcribing, and analyzing 10 decision-making consultations in the neurosurgical outpatient clinic. By applying a directed content analysis  carried Step 2. The possible treatment options for patients with recurrent HGG were identified in collaboration with relevant clinicians based on international treatment guidelines elicited from the European Association of Neuro-Oncology (EANO) . We thenStep 3. In the first round of the developmental process, the development team was presented with the empty option cards identified in step 2 and asked to suggest the most relevant benefits and disadvantages for each treatment option. The patient and family representatives then evaluated the clinicians’ suggestions and vice versa. All members assessed the 12 patient narratives and the list of preparation sheet questions and selected six patient narratives and six questions. Step 4. During the subsequent rounds of processing, the development team members, either individually or in groups, discussed, and refined which preparation sheet questions, patient narratives, and benefits and disadvantages should be presented in the PtDA. This included discussions about wording and pictograms. Before moving forward to the alpha test, we invited a neuropsychologist, a clinical nurse specialist, and two Danish Brain Tumor Association representatives to assess the developed PtDA and preparation sheet. The objective of the alpha test was to assess the acceptability and usability of the PtDA in preparing patients and family members for decision making and supporting clinicians in SDM. The alpha test followed three phases: Phase 1: First round of alpha test with clinicians, patients, and family members. Phase 2: Adjustment of the PtDA based on the answers and comments received during the first round of the test. Phase 3: Second round of alpha testing with new clinicians, patients, and family members. Eligible participants were adult patients with HGG, family members of HGG patients, and clinicians experienced in treating and communicating with HGG patients and their families. Additional inclusion criteria were the ability to speak and understand Danish and the capacity to talk in sentences. Patients with severe aphasia and otherwise eligible participants who had been involved in the development of the PtDA were excluded. Participants were recruited at a large academic hospital through convenience sampling at the oncology and neurosurgical outpatient clinics and through advertising for eligible participants via the Danish Brain Tumor Association’s webpage. At the outpatient clinics, potential participants were screened against the inclusion criteria and informed about the study aim and the subsequent publication of the results by the HSvE. After receiving the information, the participants provided informed consent to participate in the alpha test. The interviews were conducted face-to-face. The participants responding to the online advertisement were informed, and after providing consent, they were interviewed by telephone. All interviews were carried out by the HSvE.We aimed to include 30 participants, which is equivalent to the “Maximal Process” described in the recent IPDAS update on the development of PtDAs . AdditioPatient and family demographic data were collected concerning sex, age, diagnosis, disease state, and education. For the clinicians, data were collected regarding employment and experience with HGG patients. Data were managed using REDCap electronic data capture tools hosted at OPEN  ,30.To assess the acceptability and usability of the PtDA, we adapted a method proposed by Stacey et al. , buildinThe PDMS was forward-backward translated into Danish in a previous study . It contThe participants were introduced to the PtDA and guided through the decision-making steps, mirroring a natural consultation. Patients and family members could be informed together. After the presentation, the participants responded individually to the structured interview and the PDMS. The interviews were audio-recorded and transcribed verbatim. The PDMS could be answered as either a structured interview or a paper-based questionnaire, depending on the participants’ preferences.The demographic data were analyzed in REDCap using descriptive statistics. The results from the PDMS were transferred to Microsoft Excel (2016), where a two-sided T-test was performed to assess the potential difference between the clinician scores and the patient-family scores. A medical statistician from OPEN-Statistics guided the analysis. The transcripts from the structured interviews were transferred to NVivo to ensure rigor and transparency in the analysis. A directed content analysis  was carrIn the consultations analyzed to identify preparation sheet questions, 6 of the 10 patients decided on surgery, 4 on chemotherapy without surgery, and 1 on no active tumor treatment. One or more family members were present in 9 out of the 10 cases. During the analysis, seven overall themes were identified : questioFor the in-consult part of the PtDA, six possible treatment options for patients with recurrent HGG were identified: (1) surgery, (2) surgical biopsy, (3) no active tumor treatment, (4) temozolomide, (5) lomustine, and (6) bevacizumab-irinotecan. The majority of the six different option cards presented three benefits and three disadvantages. On the lomustine card, two benefits and two disadvantages were presented, and on the surgical biopsy card, two benefits and three disadvantages were presented. Care was taken to ensure that each option card presented balanced information.Three option cards were specifically designed for use in the neurosurgical clinic: surgery b, surgicA total of 36 potential participants were approached during the two rounds of the alpha test. Three eligible patients and one family member declined participation due to emotional distress, and one patient was excluded because he did not speak or understand Danish. Thirty-one participants  were incAmong the 11 clinicians, 8 were doctors, and 3 were nurses. Six participants were employed at the Department of Oncology, and five at the Department of Neurosurgery. All clinicians were involved in medical decision making concerning HGG patients every week, and their overall experience with HGG patients ranged between 6 months and 25 years.The age range of all participants was between 28 and 77 years, and the gender balance was equally distributed. Ten patients were diagnosed with glioblastoma and one with anaplastic astrocytoma. Six patients had experienced recurrence, while five were in their primary treatment or follow-up period. Of the family members, seven participants were partners with the patient, one was a sister, and one was a mother. All participants completed the interview, which lasted 21 min on average .The first round of alpha testing involved five patients, five family members, and six clinicians; the second round involved six patients, four family members, and five clinicians.Twenty-six participants assessed that the PtDA could be used in consultations as it was. Five participants thought that the PtDA could be used with a few changes. The suggested changes in the first round of the alpha test were as follows: (1) Ensure a visual balance between the benefits and disadvantages by changing some colored details; (2) Create an option card that covered experimental treatment; (3) Remove “treatment in outpatient clinics” from the benefit side of the chemotherapeutic option cards, as transportation time and hospital visits could be considered a disadvantage; (4) Change the pictogram related to “do not prevent progression”.During the second round, further suggestions were to change the PtDA to an app and let the clinical nurse specialist hand out the patient narrative card to patients and family members instead of having the doctor present it during the decision-making consultation. No changes to the PtDA were made at the end of round two.Only minor changes were made to the PtDA between rounds one and two, and the participants’ perceptions of acceptability and usability were comparable in the two rounds. Thus, the results from the two rounds of the alpha tests were summed. All participants found the PtDA to be balanced and neutral, and expressed that it did not favor any option over the other. The text and pictograms used in the PtDA were understandable to 30 participants, while one suggested changing one of the pictograms. Twenty-nine participants believed that the amount of information was appropriate. One participant thought that the PtDA had too little information, and another thought that there was too much. Sixteen out of 20 patients and family members believed that the PtDA could make it easier to make the right decision, and four thought it would make no difference. Ten clinicians were interested in using the PtDA in future decision-making consultations, while one assumed it would be a barrier to communication.p = 0.05).Regarding the PDMS, the converted scores on a 0–100 scale  were 65.The participants’ qualitative comments concerning the acceptability and usability of the PtDA were divided into four themes.1. A simple design is essential: The visual and tangible format and the simplicity of the PtDA were crucial, especially for cognitively impaired patients. Some participants preferred larger text or more colorful pictograms, while others preferred an all-digital solution.“At the third recurrence, your brain is affected pretty bad, so it has to be as simple as possible.”(Patient)2. The PtDA might support family involvement: Participants believed that the PtDA, especially the preparation sheet, could encourage discussions between patients and families and prepare them for the consultation. The fact that the in-consult PtDA could be brought home after the consultation was also highlighted as an advantage. One patient, however, emphasized that family involvement was not desirable to all patients and that taking the PtDA home could create difficult conversations.“I think it [the PtDA] is a tool for the family as well.”(Family member)3. The PtDA must be used correctly: Participants emphasized that the most critical aspects were that the clinician was present and attentive. Several clinicians raised the concern that the PtDA could complicate the consultation, that they did not feel sufficiently equipped to use the PtDA, and that they needed practice. Clinicians who had previously used PtDAs were generally more positive than clinicians with no experience. Most participants believed that if clinicians used the PtDA correctly, it would improve a person-centered approach and strengthen communication between patients, families, and clinicians.“I definitely see the advantages. Because it is hands-on. Though I am also a little worried that some clinicians could focus too much on the cards.”(Clinician)4. The no-treatment card is important: The no-treatment option card was highlighted to ensure that the option of foregoing treatment was discussed equally with the other options.“I think the PtDA might encourage us to make the patients aware that even though we offer them this treatment, they also have the option of saying no to it. And then provide them with the adequate amount of information to decide.”(Clinician)We developed a PtDA following the development steps suggested by IPDAS, and then alpha tested it with potential users. To our knowledge, this is the first PtDA that has been developed to support patients with HGG and their families in decision making at disease recurrence ,12,17,23Most of the clinicians involved in the alpha test had no experience with SDM or PtDAs, and the SDM steps outlined in the PtDA required clinicians to change their approach to patient communication. Some expressed worries that the PtDA might complicate consultations. The few clinicians with previous experience using PtDAs were more positive toward the PtDA than those without it. These results indicate that a lack of clinical experience and the challenge of having to change the course of consultations might have contributed to clinicians perceiving the PtDA to be less useful than patients and family members perceived it to be. The results also reflect known barriers to SDM implementation . For patThe findings are supported by previous research concerning decision support interventions for patients with low health literacy and decision-making challenges due to causes other than brain tumors, which found that pictures increased patients’ understanding of the information provided . A studyParticipants highlighted the PtDA for its perceived ability to generate and qualify conversations between patients and their families regarding the values and preferences related to the options. This could imply that both patients and family members prefer the family to take on an active and supportive role in decision-making . Thus, cOne of the option cards in the PtDA presents the option of “No active tumor treatment.” In contrast to the other option cards designed to be used at either the oncology or the neurosurgical outpatient clinic, the “No active tumor treatment” card is designed to be used at both sites. An emphasis on no treatment as a valid option in every treatment discussion is essential in PtDAs and SDM in general ,46. PrevThe PtDA in the current study was developed based on a pre-designed Decision Helper template, and this approach offers both strengths and weaknesses. The obvious strength is that the template was developed through a rigorous research process that adhered to the IPDAS criteria and involved a wide range of patient and clinician representatives and designers . The weaThe alpha test with potential users was performed face-to-face by the main author and neurosurgical nurse, HSE. This offers the strength that the interviewer is experienced in communicating with HGG patients and family members and a bias in that the included clinicians are colleagues. The clinicians’ answers might have differed had the alpha test been conducted as an anonymous survey or by an unknown researcher. This bias can also be extended to the patients and family members who might have answered the PDMS questionnaire differently in face-to-face encounters than they would have done anonymously. The sample size was limited, and another participant sample might have provided other perspectives. Nevertheless, the 31 participants included in the alpha test equaled the IPDAS’s description of maximal effort, and the variety of the participants strengthened the transferability of the results. By chance, no patients with aphasia were included in the study, and four eligible participants declined participation due to emotional distress. These aspects limit transferability to participants in a relatively good cognitive and emotional state.Concerning the PDMS, only the 10-item patient version was tested for its psychometric properties. Additionally, we removed one item that was irrelevant to the study objective, and this alteration of the PDMS might have affected its validity. The credibility of the findings was strengthened by data triangulation, with the qualitative data supporting the quantitative results of the PDMS.The implementation of SDM often requires a change in culture and clinician attitude, and the role of “clinical champions” has been emphasized in previous studies ,49,50. HAccording to the IPDAS recommendations, the alpha test performed in this study should be followed by beta (field) testing before implementing and evaluating the PtDA in larger-scale real-life settings ,25. The This article describes the development and alpha test of a PtDA developed for use in clinical practice to support SDM and increase decision quality. The PtDA was developed by a multidisciplinary development team and designed for both neurosurgical and oncological consultations. Alpha tests with potential users were carried out in two separate rounds, allowing for changes from the first round to be tested in the second round. Patients, family members, and clinicians were generally positive about the design and use of the PtDA. They expected this to improve decision support and increase SDM for patients with recurrent HGG and their families. It is essential to train clinicians in SDM and on how to use the PtDA. Further evaluation of SDM and the PtDA in real-life decision-making consultations is essential before practice recommendations can be made.


Schools provide a big opportunity for promoting the student’s health, life skill, and behavior. Teachers play a fundamental role in the promotion and successful implementation of school health services. This study aimed to assess the level of involvement in the Health Promoting School program and its associated factors and to explore the benefits and barriers to involvement among high school teachers in Myanmar.A mixed methods explanatory sequential study was conducted among 194 high school teachers in Thanlyin Township, Yangon Region, Myanmar, from June to August 2020. Quantitative data were collected with the pretested structural questionnaire and analyzed by Chi-square tests and Fisher’s exact tests. A qualitative strand was added by conducting in-depth interviews , analyzed by thematic content analysis.Of the 194 teachers, 23.7% had a good level of involvement in the Health Promoting School program. The factor associated with involvement in Health Promoting School program were age , duration of services , and a number of accomplished training-related school health . Qualitative data revealed that improvement of the health knowledge and awareness on health problems, the progress of healthy behaviors, development of physical and mental health, prevention of the disease spread, achievement of healthy and productive learning environment, and development of academic achievement were major benefits of teachers’ involvement. Moreover, the main barriers to involvement were insufficient materials and human resources, time constraints, incompetence of the teachers, poor cooperation of school health partnerships, and insufficient awareness of parents.The proportion of good involvement in the Health Promoting School program among high school teachers was low in this study area. Providing sufficient human resources and material, conducting the on-the-job and refresher training, enhancing parent-teacher cooperation, and strengthening the community partnerships were crucial to improve the level of involvement and reduced the barriers for the achievement of the Health Promoting School program. Education, a primary driver of sustainable development, improves the skills, values, and attitudes that enable people to achieve healthy and fulfilled lives . Health The 1.2 billion adolescents in the world today represent more than one-sixth 18%) of the global population. Globally, over 80% of children in the lower secondary school age are enrolled in school where they spend one-third of their time. It makes the school a unique setting for preventive interventions, and school years as an important period to establish healthy behaviors that will contribute to a lifetime of health promotion . Infecti% of the As the school is a place where education and health programs can have their greatest impact on the students at influential stages in their lives, it provides a great opportunity for promoting the student’s health , 10. SchA HPS is a school that is constantly strengthening its capacity as a healthy setting for living, learning, and working , 14. By School teachers have the capability of influencing the future, knowledge, attitude, and behavior of school children. They are considered to be an important target group for various health educational activities with the underlying objective of inculcating healthy lifestyle practices into children for a lifetime . In addiIn Myanmar, since 1920, the Ministry of Health and Sports (MOHS) in collaboration with the Ministry of Education (MOE) has implemented school health services. The MOHS and the MOE of Myanmar were jointly reforming the school health program with a greater emphasis on comprehensive health services and health literacy, environmental health and sanitation, school-based disease control and mental health as well as injury and violence prevention. In 1996, Myanmar has adopted the HPS program with the concept of WHO School Health Initiatives. As stated by the report of Myanmar Health Management Information System, in 2015, only 38.8% of schools covered the HPS activities .This survey also revealed that poor nutritional status, poor dietary habits and low levels of physical activity, high levels of tobacco use, relatively high incidence of injuries, physical violence and bullying, and poor mental health indicators were the worrisome findings among schoolgoing adolescents in Myanmar . These fEnhancing personal knowledge and involvement of the school teachers in school health activities are essential in ensuring the effectiveness and overall success of the HPS program. Although school teachers have the full authority for the promotion and successful implementation of the school health services, challenges remain in the involvement of school teachers in the HPS program with the contributing factors of inadequate resources for school health services, insufficient facilities in schools, low accessibility of training related school health services, low knowledge, and poor awareness and involvement on school health services , 22–24. For the involvement of school teachers in the HPS program to be satisfactorily improved in Myanmar, it is necessary to assess the level of involvement in the HPS program and its related factors among high school teachers. However, there is limited information regarding the involvement of school teachers in the HPS activities in Myanmar. One cross-sectional study investigating the reported practices on specified school health activities was conducted in primary school teachers . This stThe study was adopted as a mixed methods explanatory sequential design incorporating a cross-sectional survey of high school teachers and in-depth interviews of selected participants . Mixed mIn Myanmar, there were 38.7% of schools with HPS activities in 2016. More discrepancy among states and regions was occurred in HPS activities and it was 78.8% in Yangon Region . This stFor the quantitative strand, the sample size was determined by using the single population proportion formula , with anFor the qualitative strand, In-depth Interviews (IDIs) were conducted in the Burmese language to underscore and contrast opinions, benefits and barriers on the HPS program. Based on the quantitative data analysis, a total of fifteen teachers  were selected by simple random sampling.S1 File): personal characteristics, knowledge, attitudes, and involvement on the HPS program. The first part was the personal characteristics . The second part consisted of 20 knowledge questions towards activities of the HPS with the option of “yes”, “no”, and “don’t know”. The scoring for the knowledge questions was one points for correct response and zero point for incorrect and “don’t know” responses.The quantitative data were collected by face-to-face interview method using the structured questionnaire. The questionnaire was constructed to assess the level of knowledge, attitude, and involvement on the HPS program. It was developed based on an extensive literature review  and alsoAs the third part, attitudes of the high school teachers towards HPS program was assessed with 27 statements including negative and positive aspects. A five-point Likert’s scale was used for the scoring of the attitude statements: strongly agree (five points), agree (four points), uncertain (three points), disagree (two points), strongly disagree (one point) for positive statements, and reverse scoring for the negative statements. The fourth part comprised 43 questions to assess the involvement of high school teachers on the HPS program. The scoring was one point for each involvement in multiple responses and the more frequently involved teachers got more scores in a single response.The English questionnaire was translated into the Burmese language, local language, and translated back to English. Before the data collection, content validation was performed based on expert review. A pretest was conducted among 15 high school teachers (5% of the sample size) in No.5, Basic Education High School, Mingaladon to assess the reliability. The pilot study data were not included in study results but served for adjusting minor modifications to the questions. The reliability was assessed by calculating the Cronbach’s α coefficients, which were found to be satisfactory for the second part (0.81 for knowledge), the third part (0.73 for attitudes), and the fourth part (0.85 for involvement) of the questionnaires. After refining according to pretest results, the questionnaires with the Burmese language were used for data collection. The two interviewers were trained for data collection, however, they were not informed about the correct answers in order to avoid interviewer bias during data collection. Before the data collection, the interviewers explained the purpose and procedure of the study to the participants. The face-to-face interviews were performed in the teachers’ restroom after receiving the written informed consent from all participants.The IDIs aimed to explore the benefits and barriers to involvement in the HPS program. Following the explanatory sequential design, and reviewed by literature , 27, theth percentile), medium (25th -75th percentile), and high (> 75th percentile). The attitudes were a way of feeling, beliefs, and behaviors towards a HPS program by the high school teachers, and the summarized attitudes scores were categorized as three: negative (< 25th percentile), neutral (25th -75th percentile), and positive (> 75th percentile). Involvement of the high school teachers was defined as practices or performance of activities in the HPS program. Based on the overall scores, and the level of involvement was considered as poor (< 25th percentile), medium (25th -75th percentile), and good (> 75th percentile).School health training is the act of increasing the knowledge and skill of teachers for performing the school health services. Life skill education was a group of psychosocial competencies and interpersonal skills that help people make informed decisions, solve problems, think critically and creatively, communicate effectively, build healthy relationships, empathize with others, and cope with and manage their lives in a healthy and productive manner . KnowledThe two interviewers were provided the two-day training related to the clarity of the questionnaire, objectives of the study, confidentiality of information, and voluntary participation (informed consent) of the participants. The daily recorded data of IDIs were transferred to storage devices after data collection to ensure data security and back-up on a regular basis. Supervision was taken throughout the data collection period by the supervisor. The principal investigator closely monitored the interviewers for incompleteness, non-accuracy, and inconsistency of data.2) test and Fisher’s exact test were used to assess the associations of personal characteristics, knowledge, and attitudes with outcome variable, level of involvement in the HPS program. All p values were considered as the level of statistical significance was at <0.05.Data were entered into the Microsoft Excel sheet. After checking the errors, data were transferred into IBM SPSS Statistics for Windows, Version 25.0  for analysis. The normality of the continuous data was viewed by using the Kolmogorov-Smirnov test and the data distribution was non-normal. Categorical variables were presented as frequency (percentages) and continuous variables were described as median . Chi-square . The high school teachers with 20 years and more service duration were more likely to have good involvement than their counterparts. The association between duration of service and level of involvement in HPS program was statistically significant . The high school teachers who accomplished three trainings regarding school health services were more likely to have a good level of involvement than those who accomplished one and two training. The association between the number of accomplished training and level of involvement was statistically significant .The associated factors of involvement in HPS program among high school teachers were described in The qualitative strand explored the benefits and barriers to involvement in HPS program among high school teachers. The personal characteristics of in-depth interviewees were summarized in The majority of school teachers reported that by increasing health education activities in school, children could aware of health problems and improve their health knowledge. A small number of interviewees indicated that the students could share health knowledge with others. As one interviewee put it:“Improvement of health knowledge can provide the behavior change for healthy lives… Some parents can’t provide health education to their children well due to their low knowledge …. So, providing health education at the school can promote the level of health knowledge." As a concern of the barriers, the majority commented that some students did not want to follow the teachers’ instructions or directives and they did not interest in some health education topics such as smoking, betel chewing, and substance misuse. Time constraint is another barrier for school teachers to provide health education. One participant reported:"Some children are in delayed growth…here, the one had a problem in hearing, and he can’t catch up with what the teacher taught. Although health education can improve the health knowledge of students directly, it may be better if it’s extended to the parents, caregivers and family members indirectly…." environmental sanitation affected the physical and mental wellbeing of the students and a healthy learning environment. Fresh in mind and keeping the focus in teaching could create a productive learning environment. Some interviewees suggested that a healthy school environment could help to improve concentration in learning. Commenting on the benefit of school environmental sanitation, one of the interviewees said:Clean classrooms, proper refuse disposal, water sanitation, and cleanliness of school toilets, healthy space for physical activities, and canteens were basic hygienic requirements for safe school environments. As the benefits, the high school teachers reported that school "We must establish our school as a garbage-free school. And we should involve in activities like spraying for insect and pest control and proper waste disposal to promote the positive image of the school… You know… It’s a benefit of health-related practice for the students not only during their school time but also for the time at home." Concerning the barriers, insufficient human resources, low teachers’ involvement, and poor community participation were the limitations to involve in environmental sanitation. A small number of interviewees remarked that in the urban schools, the waiting for municipal garbage trucks to discard the wastes was the main problem in disposing of the refuse. One informant described:"Sometimes…, we can’t provide cleaning equipment such as hand diggers, rough broom, lawnmowers, etc., to the volunteers for doing school environmental sanitation… I mean… we have financial and human resource problems for doing these activities. So, we can do more for school environmental sanitation if we have efficient resources, both financial and human resources." The majority of interviewees suggested that dengue hemorrhagic fever, lymphatic filariasis, acute gastroenteritis, food poisoning, and worm infestations were the diseases that could be prevented by involving in school-based disease control activities. They believed that effective preventive measures in the school compound were crucial to prevent and reduce the spread of the diseases to the community. As one interviewee commented:“The preventive activities of communicable diseases are important to perform at the schools because the diseases can spread easily to other students at the school. If we check personal hygiene and health status of the students daily and the students also follow our instructions, the spread of diseases can be controlled.” As some difficulties, most interviewees commented that some obstacles such as low perception of students, poor participation of the students, and low family economic status affected the involvement of communicable diseases control activities. An interviewee commented:"It should be well-adjusted in the curriculum of teaching times and preventive activities of communicable diseases like checking personal hygiene and school canteen sanitation. The main difficulty is to argue the disobedient students to perform the disease control activities at the school." The main activities were checking for unhealthy food selling at the school canteens and providing health education related to healthy food, and the lunch box method. The overwhelming majority of interviewees reported that eating nutritious food could not only promote immunity and physical growth but also diminish health problems. As one interviewee put it:Nutritional promotion and food safety were the main activities to promote healthy eating habits and lifestyles of the students. "Sure…, we can get many benefits. Healthy children can learn better. The well-nourished students are more productive and can also create a healthy lifestyle in future." There were some suggestions that parent’s socioeconomic status and education level influenced on nutritional promotion activities of teachers such as providing nutritional knowledge and healthy school lunch box. A few interviewees indicated that some of the school canteen owners were poor in coordination with school health activities such as medical examinations for food handlers. Selling food and drink outside the school compound was also a challenge to food safety. One teacher stated:"Some students more prefer junk food or snack than the healthy food. And, it’s difficult to carry out the healthy school lunch box method because of the economic status of their families." The high school teachers supported the school health team in medical examinations such as primary oral care, personal hygiene, and BMI measurement of the students. The majority of interviewees reported that medical examinations in the school were checking the school canteens, measuring BMI, monthly vitamin supplementation, and transfer to the clinic when the students got sick. By ensuring medical examination as a pre-screening activity, diseases could be early detected. One participant reported:"It can support to reduce the chance of getting diseases and to be healthy students both physically and mentally." It was possible to challenge the teachers’ involvement in the medical examination due to human resource limitation, time constraints, poor experience, and imbalance of the teacher-student ratio. Some schools did not have emergency first aid kit boxes for treating minor injuries. As one interviewee said:"As for me…, one difficulty is that some students don’t like examining their personal hygiene and… another one is the time limitation. So…, we can’t do it daily although we concern that it should be done daily." The majority of teachers commented that regular exercise could promote the physical development of the students, strengthen stamina, increase the circulatory flow, and refresh the mind and the body. Regular exercise and physical activities also helped the students to increase mental toughness and confidence to participate in collaboration or teamwork. Mental wellbeing, physical development, reduced stress and anxiety, minimize the risk of childhood obesity, and a sense of unity and teamwork were the benefits of doing regular physical activity. Another interviewee thought:"Regular physical activities help the children to achieve the physical and mental health. It promotes a sense of unity and enhances their educational performance. We want our students to create healthy behavior throughout their future lives." Regarding the difficulties of sports and physical activities, most of the teachers expressed that times for physical education were not enough for the students. Insufficient space for playgrounds, and limited material and human resources for physical education were also problems in carrying out this activity. One teacher stated:“In these days, some parents don’t allow their children to play outside or playground and want them to play indoor games to avoid getting an injury. So…, we are going to provide health education on awareness of sedentary lifestyle and its negative impact on health.” Some interviewees reported that counseling and social support could assist to develop a positive attitude and solve the social problems of the students through parent-teacher cooperation. Moreover, the whole community might receive many benefits from healthy behavioral changes. It could promote the healthy behavior and communication skill of the students. One participant commented:"Children from broken families can have mental trauma, and we must do counseling to find the ways for dealing with emotional issues. I enforce the students to work hard and it is the main thing to achieve their goals." As the barriers, the students could not follow the directives of the school health team and their parents could not cooperate with the teachers in the implementation of the school health activities. For a small number of interviewees, the students’ negative behavior, poor communication between students and teachers, and poor awareness of the students on the counseling activities were the main obstacles in successful implementation. One interviewee reported:"The language barrier is the main problem to carry out the counseling to the students who have varying cultural and ethnic backgrounds." The majority of teachers replied that involving the community outreach to improve school health could be achieved by coordination with parents and community leaders. Community outreach of school health services could improve the effectiveness of life skill programs by changing the students’ negative school experiences and behaviors. It could also raise the parent awareness on health-related issues and opportunities to change for their healthy lifestyle. For example, one interviewee stated:"For the implementation of community outreach, we need to invite the parents, community leaders, and other administrative authorities to persuade in school health services. So, the positive behaviors could be adopted in the community by the initiation of school-based activities." Most teachers indicated that poor awareness of parents on school health services, low level of socioeconomic status of the parents, and lack of school health partnership by the community were the main barriers to involvement in community outreach. For the barriers on community outreach, one of the interviewees reported:"When we want the parents to come to the school for discussion the academic performant of their children, some parents gave a reason that they were working at that time or they couldn’t take a leave from the job. So, they couldn’t attend the Parent-Teacher meeting.” The majority of interviewees suggested that updated information and skills regarding school health could be achieved by conducting research and training and they could precisely provide to the students in time. A small number of interviewees reported that involving in school health research was an activity finding practical ways for healthy behavior changes, improved social skills, and higher academic achievement for the students. As one interviewee said:"In the training, I got the opportunity of sharing and discuss the information that we haven’t known yet. Besides, I think we can report and advocate the difficulties to the upper level by doing researches related to school health promotion." Most of the teachers responded that as the difficulties for training and research, they have time constraints for conducting research, and some had poor skill and experience in doing research. Conducting an interview about this issue, an interviewee stated:“If I have a chance, I want to do the research related to dengue hemorrhagic fever, a common disease that mostly occurred during the rainy season." Schools play a particularly important role in establishing a safe and supportive environment with policies and practices to improve healthy behaviors among school children . To prevAmong the 194 participants, most were female (94.8%) and the male-female ratio was 1:18. It was consistent with the studies done in Myanmar , Sudan , India , 40, andOf all high school teachers, most of them (59.3%) were younger than 40 years and it reflected the finding of a previous Myanmar study, reported that the majority of participants were younger than 40 years . The stuSchool-based health programs could offer a highly effective platform for improving access to care and the health status of school-age children . The schIn order to make sincere efforts at implementing the HPS program, not only the program must be acceptable but also the teachers should have a positive attitude towards the program . In the For the teachers’ involvement, the proportion of good involvement in the HPS program among high school teachers was 23.7% in this study. This finding was lower than the previous Myanmar study with 52.6% of high reported practices in specified school health activities  and NigeThis study confirmed that the age of the high school teachers was a significantly associated factor of good involvement in the HPS program. In accordance with this result, the previous Myanmar study had demonstrated that 50 years and older school teachers were more likely to had a good level of reported practices than younger school teachers and its association was statistically significant . This reIn the current study, the high school teachers with 20 years and more duration of service were more likely to involve in the HPS program than the other categories of service duration. It confirmed the results of an earlier study conducted in Myanmar that duration of service was significantly associated with reported practices in school health activities among school teachers . This alSome of the factors influencing against effective implementation of the school health program were low levels of health knowledge and high levels of negative attitudes among the school teachers, and lack of resources . The traThe school location was not an associated factor of involvement in the HPS program in this study. In contrast to earlier studies, it supported the evidence of previous Nigeria study  but diffSchool health service is an appraisal of not only the contribution of health services to the school children and the members of the school family but also promoting health and providing security to the students . The higSchool teachers could serve as reliable sources of health information and therefore, they could provide an appropriate vehicle for more integrated preventive health education . A studyAs regards community outreach, a Hong Kong study described that the schools under Healthy Schools Award scheme were more likely to be better school health policy, higher degrees of community participation, and better hygienic environment . CommuniWhile implementing the school health program, there were some challenges such as poverty’s effect on rural education, lack of resources especially in rural schools, lack of qualified teachers, transportation and communication problems, and low government investment . In thisThe results of the current study should be considered in taking note of the strengths and limitations. Using mixed methods study was one of a strength of the study and consequently, the results could support to evaluate the in-depth insights of benefits and barriers to involvement in the HPS program among the high school teachers. It also revealed potential factors that influenced on implementation of school health services. However, the results of the study might be varied depending on the diversity of demographic (other States and Regions) and personal characteristics, although they might be generalized to those who were with the same background characteristics and setting. Additionally, the interviews were made only among high school teachers, and therefore, the results were in a lack of reflections by the primary and middle school teachers, headmaster or headmistress, school health officer, school nurses, school health partnerships, and community leaders regarding the involvement in the HPS program.The proportion of high school teachers with a high level of knowledge, positive attitude, and a good level of involvement in the HPS program were relatively low in the study area. Age, duration of service, and number of accomplished training regarding school health in high school teachers were associated with the level of involvement in the HPS program. As regards the benefits, the high school teachers believed that the HPS program could increase the health awareness of students and their parents, promote healthy behavior, diminish the health problems, create healthy and productive learning environments. This study suggested the key drivers that the major barriers to involvement of high school teachers in the HPS program were limitation of material and human resources, time constraints, lack of school health partnerships, poor coordination of parents and community, and low experience of teachers. It could be reduced by providing sufficient human resources and material, conducting on-the-job and refresher training to promote the skill, knowledge, and experience on school health activities such as providing health education, physical education, and research development, enhancing cooperation between school teachers and parents, and strengthening the continuation of school health services with the partnerships and community.S1 File(PDF)Click here for additional data file.S2 File(PDF)Click here for additional data file.S3 File(XLSX)Click here for additional data file.