The bootstrapping mediating effect test was used to determine the overall mediating effect of occupational identity. Occupational identity was a complete mediating effect between organizational support and emotional labor. The results show that a strong sense of organizational support can promote higher emotional labor among medical workers in Hubei Province. A strong sense of organizational support will also promote a stronger professional identity; further, a strong professional identity completely mediates the effect of perceived organizational support on emotional labor. These results infer that in emergency medical and health services, medical personnel can realize a high sense of organizational support, which could enhance their professional identity; this enables them to combine their professional goals with organizational goals more actively and to finally pay higher emotional labor to achieve organizational goals.At the outbreak of coronavirus disease in Wuhan, China, 42,322 medical personnel from other provinces and municipalities in China volunteered to rush to Hubei to assist their colleagues. Their all-out efforts contributed to Hubei finally winning the fight to prevent and control the pandemic. The aim of this study is to explore the influence of perceived organizational support on the emotional labor of medical personnel in Hubei Province. A group of 170 medical personnel from (tertiary) hospitals who participated in the pandemic aid operation in Hubei completed self-administered questionnaires, including the perceived organizational support scale, emotional labor scale, and professional identity scale. This study used Pearson's correlation in SPSS to analyze the three variables of organizational support, emotional labor, and professional identity. Organizational support and emotional labor ( To win the battle against coronavirus disease (COVID-19), 42,322 medical workers from various provinces and cities in China went to Hubei Province to support their colleagues. When treating COVID-19 patients , doctors and nurses rely on their beliefs and empathy to curb their own anxiety and fear; when faced with dying patients with severe infection, medical personnel must regulate their own emotions to accept the limitations of treatments and avoid excessive empathy, which may impact their performance in the battle against the disease. These circumstances require medical workers who are highly professional and who are able to work in these circumstances while investing appropriate emotional labor.Existing studies show that emotional labor is the manner in which medical personnel express emotion according to the established requirements of the organization or the emotional expression of the organization's needs  hospitals in Beijing, Jiangsu, Shanghai, Hunan, Guangdong, Sichuan, and other towns or cities who participated in the pandemic aid operation in Hubei. Electronic questionnaires were distributed to respondents and each questionnaire included an agreement of informed written consent. A total of 170 questionnaires were distributed and all 170 valid questionnaires were returned, a response rate of 100%. There were no missing answers in the questionnaires and no repetitive answers. Written informed consent was obtained before the experiments, and the study was approved by the committee of the ethnic board of Nanjing University of Chinese Medicine and the latest revision of the Declaration of Helsinki.This study adopted the perceived organizational support scale  to test whether they impact organizational support, emotional labor, and professional identity.t-test on the organizational support, emotional labor, and professional identity of medical personnel assisting Hubei. The test results are shown in To examine differences based on gender, this study conducted an independent sample T-value was −2.259, and it was significant at the level of P < 0.05. This shows that women's emotional labor is significantly higher than men's, which may be due to differences in thinking, behavior, and empathy between the sexes.According to the statistical results, the differences based on gender for the two variables of organizational support and occupational identity were not significant. However, for emotional labor, the mean for men was 3.833, the mean for women was 4.412, the To examine differences based on working years, this study conducted a one-way analysis of variance test on the organizational support, emotional labor, and professional identity of medical personnel assisting Hubei. The test results are shown in According to the statistical results, the differences based on working years for the two variables of organizational support and emotional labor were not significant. However, there were significant differences in occupational identity among medical personnel based on working years. Among the medical personnel assisting Hubei, generally, as the number of working years increased, there was a stronger recognition of their work and professional roles. This may be because as work experience increases, medical personnel deepen their understanding of their work and are more able to integrate into the job role, leading to a higher understanding of the professional role.To examine differences based on professional level, this study conducted a one-way analysis of variance test on the organizational support, emotional labor, and professional identity of medical personnel assisting Hubei. The test results are shown in According to the statistical results, there were no significant differences based on professional level for the three variables of organizational support, emotional labor and professional identity.The study involves three variables—perceived organizational support, emotional labor, and professional identity—and we focus on descriptive statistics to determine the overall performance of these variables. We conducted descriptive statistics analyses for each variable; the results are shown in To determine the relationships among perceived organizational support, emotional labor, and professional identity, we must first determine whether correlations exist among the three variables. We utilized a Pearson's correlation analysis to analyze the three variables; the results are shown in r = 0.443, p < 0.01), perceived organizational support and professional identity , and emotional labor and professional identity —were all significantly positively correlated. We can therefore state that the perceived organizational support, emotional labor, and professional identity of medical workers in Hubei Province are pairwise correlated.The above empirical analysis verified the influence of perceived organizational support on emotional labor; these results confirm our hypotheses. In terms of the pandemic aid operation, perceived organizational support has a positive impact on emotional labor. Further, this conclusion applies equally to the causal relationship between perceived organizational support and professional identity and the causal relationship between emotional labor and professional identity. Next, we need to verify the mediating effect of professional identity on perceived organizational support and emotional labor. Considering that the test for mediating effect using the SPSS regression method may not be sufficient, this study uses the Amos path analysis method for further testing and obtains the final test results. First, the path test method is used to determine whether the path is significant; next, bootstrapping is used to observe whether the upper and lower limits contain zero.p-values were significantly lower than 0.01, except for the path between perceived organizational support and emotional labor, which was not significant (p = 0.252). This shows that perceived organizational support has a significant influence on professional identity, which, in turn, has a significant influence on the path of emotional labor.The mediating effect of professional identity was tested and a model diagram was drawn . The resNext, we used a bootstrapping mediating effect test to examine the mediating effect of overall professional identity .The path coefficient of the indirect effect of professional identity on the relationship between perceived organizational support and emotional labor is 0.080, and the upper and lower limits of the confidence interval are 0.029 and 0.179, respectively. These are both positive and do not contain zero, indicating that there is an indirect effect. The path coefficient of the direct effect of professional identity between perceived organizational support and emotional labor is 0.031 and the upper and lower limits of the confidence interval are−0.027 and 0.112, respectively, including zero. This means that there is no direct effect. The total effect path coefficient of professional identity on the relationship between perceived organizational support and emotional labor was 0.111 and the upper and lower limits of confidence interval were 0.038 and 0.193, respectively, excluding zero. We can therefore conclude that professional identity has an absolute mediating effect on the relationship between perceived organizational support and emotional labor.During the national pandemic aid operation to Hubei, medical personnel represented the main force of the hospital organization. The main goal of the aid operation was to control the outbreak and successfully offer aid to Hubei as soon as possible. Realizing the maximum value of medical personnel was an important part of the success of the pandemic aid operation. By considering the emotional labor of medical workers in Hubei Province as the breakthrough point and taking professional identity as the intermediary, this study examined the effect of perceived organizational support on the emotional labor of medical workers in Hubei Province. We constructed a theoretical framework with professional identity as the mediating variable and conducted a questionnaire survey on a sample of 170 medical personnel in Hubei Province. We used the empirical method to verify the hypotheses and obtained the following conclusions:(1) A strong sense of organizational support will encourage medical personnel to invest more emotional labor.(2) A strong sense of organizational support will promote a stronger professional identity among medical personnel.(3) A strong professional identity is helpful in encouraging medical workers to invest more emotional labor.(4) Professional identity completely mediates the influence of perceived organizational support on emotional labor.This study found that medical personnel in Hubei felt great support from the hospitals they were working at and that they would show more recognition and understanding of their own work. They were also willing to work hard to achieve the requirements and goals of the hospital and link the achievement of self-goals with the achievement of hospital goals. This means that there is a great sense of organizational support among medical workers in Hubei Province. This psychological perception, enhanced by professional identity, encouraged medical personnel to fight harder in the front lines of pandemic prevention, invest more emotional labor to cure COVID-19 infected patients, and finally defeat the pandemic. Based on our results, in modern hospital management, managers should enhance workers' sense of organizational support and their professional identity. This would enable medical personnel to combine their own career goals with organizational goals. Further, in the event of public emergencies, such as the COVID-19 pandemic, they are willing to invest more emotional labor to achieve organizational goals.The original contributions generated for the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.Written informed consent was obtained before the experiments, and the study was approved by the committee of the ethics board of Nanjing University of Chinese Medicine and the latest revision of the Declaration of Helsinki.ZZ and SG designed the study. XW, HB, SY, and YL performed the experiments. XW, GX, and HB analyzed the data. ZZ, GX, and SG wrote the paper. All authors contributed to the article 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.


Tool performance will be assessed, including external independent validation on hallmark clinical decisions in response to some of the currently most important clinical end points in cancer. The project brings together a consortium of 18 European partners including hospitals, universities, R&D centers and private research companies, constituting an ecosystem of infrastructures, biobanks, AI/in-silico experimentation and cloud computing technologies in oncology.The CHAIMELEON project aims to set up a pan-European repository of health imaging data, tools and methodologies, with the ambition to set a standard and provide resources for future AI experimentation for cancer management. The project is a 4 year long, EU-funded project tackling some of the most ambitious research in the fields of biomedical imaging, artificial intelligence and cancer treatment, addressing the four types of cancer that currently have the highest prevalence worldwide: lung, breast, prostate and colorectal. To allow this, clinical partners and external collaborators will populate the repository with multimodality  imaging and related clinical data. Subsequently, AI developers will enable a multimodal analytical data engine facilitating the interpretation, extraction and exploitation of the information stored at the repository. The development and implementation of AI-powered pipelines will enable advancement towards automating data deidentification, curation, annotation, integrity securing and image harmonization. By the end of the project, the usability and performance of the repository as a tool fostering AI experimentation will be technically validated, including a validation subphase by world-class European AI developers, participating in Open Challenges to the AI Community. Upon successful validation of the repository, a set of selected AI tools will undergo early  The use of Artificial Intelligence (AI) on health data is generating promising tools to assist clinicians in cancer management, as an increasing number of health imaging-based AI approaches are proving to have vast potential to become useful clinical tools in different areas of application . These iDespite these major advancements, the development of imaging-based AI tools relies on the availability of large, quality-controlled datasets , which cDespite these limitations, several health imaging repositories have been created to date –16, suchTo address the lack of data availability as well as the interoperability limitation of currently existing initiatives, the CHAIMELEON project aims to set-up and populate a cancer imaging repository facilitating access to large, high-quality sets of anonymized data. This will be achieved through the creation of a distributed data repository that will be made interoperable with other existing repositories and biobanks, enabling secure share and reuse of data as an intuitive sustainable single-access point resource for the community of developers working on AI-powered cancer management solutions. The repository will use a controlled access policy, whereby registered users will have access to datasets upon acceptance of the terms and conditions of use. These conditions, albeit still under definition by the governance bodies, will include the contracting of non-identification commitments as well as others related to the purpose of use of the data. Since imaging datasets contain images acquired at different centers with different scanners (cross-vendor/cross-institution datasets), quantitative image features, parameters, values and ranges extracted from images acquired at one center may not be reproducible from once center to another. This is due to a lack of consistency of medical images, as they generate from different equipment vendors, models and software versions. To ensure the reproducibility of quantitative imaging biomarkers (QIB) and allow scientific reuse of retrospective imaging data from multicenter acquisitions, CHAIMELEON has set the development and testing of imaging data harmonization protocols as one of its main objectives. Different harmonization approaches have been proposed, including a disruptive one for the generation of synthetic images adjusted to a common harmonization framework, ensuring that the authenticity and integrity of each synthetic coherent image is properly secured.The project will involve the setup of the IT infrastructure, the creation of protocols for legal compliance, the development of tools for agile data ingestion and curation and processing pipelines for imaging data annotation and harmonization, as well as methodologies and tools for enhanced interpretability of AI models among others. Since the repository will be targeted to AI developers as end-users, it will not be designed as a simple data warehouse but as a complete AI-powered solution that will provide integrated quality data. To do so, AI-powered pipelines for data annotation, multicentric data harmonization, integrity securing of synthetic AI-generated images and clinical decision prediction will be implemented, aiming to enhance the interpretability of the tested AI models. An overview of the project execution steps is summarized in Ethics, integrity and compliance with data protection regulatory frameworks will be integral and critical to the project, guaranteeing regulatory compliance in all aspects of the work performed both at the technical and clinical level. To ensure this, all project actions will be carefully guided and supervised by legal experts on data privacy.The successful execution of this project will make multiple resources available to the research community. These will include data infrastructures, legal protocols, new AI models and tools, and methodologies for performance validation and enhanced interpretability of AI solutions. All these resources will be ultimately validated in the context of lung, breast, colorectal and prostate cancer. Given that these are such complex and heterogeneous diseases, this will allow to demonstrate the versatility and scalability of the repository and tools across a range of heterogeneous cancer applications. The final aim is to design the repository as a transversal resource with the required versatility and scalability to incorporate data for other types of cancer and imaging modalities in the near future.In-silico experimentation and cloud computing. The partner institutions include 9 hospitals, 3 universities, and 6 R&D centers and private companies. An advisory board consisting of a recognized group of experts in the fields of oncology and AI applied to cancer management has been designated to give general advice and guidance to the consortium.To bring this project to fruition, an interdisciplinary consortium was recruited, bringing together experts in the fields of IT systems, automated health data management, data privacy and legal compliance, and researchers with experience in the design, set-up and management of imaging repositories and radiomic features. The CHAIMELEON consortium involves 18 partners from 9 European countries  constituting a pan-European ecosystem of knowledge, infrastructures, biobanks and technologies in oncology, AI/The CHAIMELEON project is a 4-year long, EU funded project that started in September 2020 and will finalize in August 2024. Currently in its second year of execution, the project results already include a first complete version of the repository design, a selected set of standards to be used to ensure the repository’s interoperability and the first proposal for its legal operating model among others. To ensure its correct implementation, the project has set 13 different milestones to be met over its entire duration. A final, populated version of the repository is expected to be available to the public on project month 34 (June 2023). A summary of relevant project milestones indicating dataset availability of the repository can be found in To facilitate its scalability and promote cooperative work with the rest of the scientific community, the repository is cloud-based and built upon open standards. Likewise, the use of free, open-access services has been prioritized, to keep maintenance and running costs to a minimum while implementing a robust software infrastructure. In particular, CHAIMELEON uses European Open Science Cloud (EOSC) services to join the projects currently contributing to this initiative. Medexprim Suite™ framework to allow cohort selection, image extraction, collection, extraction and mapping of clinical data, as well as data curation, quality control, anonymization and transfer to the central repository  uses a set of horizontal technologies that enable the distributed storage of medical images and associated clinical data, along with a processing environment where different applications can run. In particular, the storage has been implemented through CEPH  running The repository design has been built under the principles of legal compliance and privacy and security by design and by default. To do so, the consortium’s data protection officer has performed a risk analysis and data protection impact assessment, identifying security, ethics, and regulatory compliance risks, as well as those associated with the re-identification of patients and the potential impact of the use of AI.The long-term sustainability of the repository is being promoted by design, as it is being established as a controlled access cloud-based repository hosting reusable methodologies and protocols which will be interoperable with similar existing initiatives. Other means for the continuity of the repository will be assessed over the project lifetime, including creating synergies with new repositories and biobanks and incorporating data for other types of cancer and imaging modalities. Methodologies and protocols, including image processing tools, automatic annotation pipelines, and tools promoting interpretability of the AI models will be made available for reuse by similar research initiatives in the health imaging community.The data to be made accessible in the repository will include imaging data  in DICOM format, linked to the correspondent e-form including relevant clinical features on the patient´s profile , tumor data , treatment details and outcome.These data will be provided by the clinical partner institutions in the consortium which will populate the repository with retrospective cases during the project lifetime over two data recruitment periods. All cases will correspond to real world data, meaning the study subjects will be patients diagnosed in the participant hospitals for the 4 targeted types of cancer, collected through the routine delivery of healthcare with no enrolment conditions. Local imaging protocols will be used all over the data recruitment period. All cases included will be fully closed cases, that is, those for which all the required data, as specified in the project requirements, are already available for a given patient. More specifically, both clinical and imaging data will be collected over the period comprised between the date of diagnosis and a 12 or 24 month follow up, depending on the type of cancer.It is estimated that de-identified medical imaging data and related clinical data for a total of 11.500 cases of lung cancer, 6.000 of breast cancer, 6.000 of colorectal cancer and 10.000 of prostate cancer approximately will be accessible from the repository. To further accelerate the Repository´s population and to evidence its scalability and adaptability, during project Stage 2 (years 3 and 4) external collaborator hospitals from 5 additional countries will join the data provision efforts. These independent cases will be used for the external validation of the AI tools within the repository architecture. With both internal and external cases incorporated, the total size forecasted for the repository by project end is of nearly 40.000 cases, corresponding to approximately 20 million images .To address the data inhomogeneity derived from the multiple sources the images will originate from, computational data harmonization methods such as self-supervised learning and GAN based models will be developed, in an aim to merge the data from the different sources into a single coherent data set by modifying data formats, terminologies, and measurement units , 13, 26.Lastly, and so as to ensure that CHAIMELEON will offer only high-quality datasets, a data submission process will be implemented, involving the performance of quality assurance tests and the assignment of data set quality scores upon data submission onto the central repository. A detailed description of the quality check process is described in the CHAIMELEON’s approach to image metadata is oriented at enabling data interoperability following FAIR data principles. As such, the data model to be implemented will refer to the current DICOM-MIABIS joint model , which pRegarding the Common Data Model (CDM) to be used for clinical data across clinical centers, the use of the OMOP  CDM  was agreAs curated, annotated, and enriched datasets are being constituted, the MIABIS model will be used to label these collections and promote their reuse. Findability, on the other hand, will be provided through the use of persistent identifiers that will be assigned to the datasets and persisted on the Blockchain. Accessibility will be ensured through the use of an open Application Programming Interface (API) to query the dataset service. Reusability will then be enhanced by the provision of virtual processing environments.The project will contribute to the development, refining, testing and early clinical validation of AI tools targeted to reproducibly assist clinicians in the precise estimation of some of the currently most relevant Clinical End Points (CEPs) in cancer Table 4 This project will follow a methodological approach of continuous learning, allowing a smooth update of the models including new data annotations and training to progressively improve performance over time. It is expected that this continuous learning will provide the repository infrastructure with large scalability in terms of algorithm performance and management of datasets.Although many AI models that predict factors related to both disease phenotyping and treatment effects have recently been published –45, impoThe cancer management solutions to be developed in the context of this project include those assisting radiologists in image processing and analysis, impacting diagnosis and follow up capabilities, helping predict tumor behavior, as well as aiding patient’s stratification, therapy allocation and tumor response to treatment.via Open Challenges to the AI community.By the end of the project, the performance of the repository as tool fostering AI experimentation will be validated. This technical validation phase will assess the usefulness of the repository for accelerating experimentation of AI solutions and contributing to better training and testing of the AI models. This process will occur in two subsequent steps. First, AI developers of the consortium will undertake training and testing of a selected set of their proprietary AI tools using the data provided by consortium partners. Secondly, an external validation subphase will be done by other world-class European AI developers, initiative that will be articulated In-silico studies will be designed by cancer experts to assess the capacity of these tools to aid clinical decision-making in cancer management in terms of diagnosis, prognosis, treatment selection and treatment follow-up. Cases provided by external collaborator centers will be used for this clinical validation phase to ensure the reproducibility of the results on real world cases.Lastly, a clinical validation phase will assess how the technically validated tools can assist clinicians in addressing the selected CEPs for lung, breast, colorectal and prostate cancer. To do so, observational The CHAIMELEON repository along with its related AI-powered tools are being designed to impact the management of the four most prevalent types of cancer worldwide. Due to the social and economic burden these imply, we expect the outcome of this project to have an EU-wide impact both at the social and economic level. Upon successful validation on how the proposed AI tools can assist clinicians in daily decision making, we expect the repository infrastructure, legal operational model, analysis tools and web-based user interfaces to have the potential to be adapted to the management of other types of cancer .The project will contribute to the current state of the art of AI for health imaging by defining a framework for legitimate access to anonymized imaging and related clinical data provided by hospitals in different European nations, making these more openly accessible across the EU for secondary use in research. From image acquisition to image evaluation and QIB reporting, our work is aligned with exciting research on the use of AI for improving image quality and interpretation. At the technical level, we hope to contribute to the advancement in robustness of AI systems against malicious attacks, interpretability of AI-based models, and validation of AI tools in clinical observational studies. We also aim to impact the fields of standardization of radiological procedures for image acquisition and analysis, as well as harmonization for extraction of reproducible imaging biomarkers.From a legal perspective, this project will contribute to the creation of ethical standards for the use of health imaging data in the context of AI tool development. All in all, we expect CHAIMELEON to generate resources that facilitate faster and more successful development of AI-based solutions for cancer management, while promoting actions to foster the evolution of European laws in the reuse of health data for research purposes . By doinThe EU-funded CHAIMELEON project aims to set up one of the most ambitious health imaging repositories across the EU, contributing to major advancements in the field of cancer management at a global scale. Once implemented, it will have the potential to generate innovative products and services beyond the direct outcomes planned for the project. The developed methodologies and protocols will pave the way for the use of this type of repository, not just in other fields of biomedical research but also in any other disciplines where public interest is the main driver.Upon successful demonstration of the disruptive analysis approaches used in this project, such as those related to the improvement of the interpretability of AI models, these will have the potential to be used in other currently prevalent pathologies, such as cardiovascular, neurological or psychiatric diseases. The developed AI-powered tools may be used as clinical support systems for complex diagnosis, and contribute to new diagnostic approaches based on telemedicine or second opinion.To further ensure future interoperability across repositories of the same nature, the CHAIMELEON is taking part in the AI for Health Imaging (AI4HI) league, a collaborative network of similar projects funded under the same topic. The main goal to this collaboration is to ensure the long-term sustainability of these kind of repositories, and to promote cooperation and data sharing among users.Further information on the main project objectives, partners and contributors, work progress and latest updates on project results can be found on the project website (chaimeleon.eu) and social media platforms.marti_lui@gva.es.The data collected for this project will be real world patient data, collected retrospectively through the routine delivery of healthcare with no enrollment conditions. This is a purely observational, non-interventional study. Requests to access these datasets should be directed to LM, The studies involving human participants were reviewed and approved by Comité de Ética de la Investigación con Medicamentos (CEIM), Hospital Universitario y Politécnico La Fe. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.AM and LM wrote the manuscript. AS and MA conceived the project idea and wrote the proposal for funding with the support of LM. The rest of authors contributed to the conception of the project idea and the project proposal preparation.CHAIMELEON has been funded by as a Horizon 2020 project .Authors AS, MA were employed by Matical Innovation SL. MM was employed by GE Healthcare. KS was employed by Medexprim. SF way employed by Bahia Software S.L.U. AA-B way employed by QUIBIM SL.The remaining 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.The reviewer KL declared a past co-authorship with several of the authors LM, PL to the handling editor.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.


Moreover, experienced teachers proved to have a significant difference from novice teachers regarding their TPIs. The findings of this study would hopefully be advantageous for teacher educators to educate pre-service teachers by ways of constructing identity, and they may be applicable for Iranian EFL teachers to know and focus on different aspects of their professional identity. Moreover, they learn how to manage the intervening factors and shape and empower different domains of their PI, such as teaching experience, by means of exploring and knowing their ASs.Teacher professional identity (TPI) is a characteristic of a teacher, which should be developed in a long, consistent, and progressive process and usually shapes in any specific educational and social context. In addition to several factors influencing TPI, such as university education and empowerment courses, experience seems to play a significant role. Moreover, the role of psychological factors is highly undeniable in the formation and development of TPI. Attributional style (AS) is defined as the consistent way by which people can explain the reasons for the occurrence of good or bad events. Besides considering ASs as one of the crucial variables for academic success, it can be regarded as one of the aspects of shaping one’s identity in general and the teacher’s identity in particular. In order to study the relationship between AS and TPI of teachers regarding their experience, two questionnaires were distributed among 317 Iranian English as foreign language (EFL) teachers, and about 80% returned them. The researchers ran correlational analyses and they came up with a positive and significant relationship ( Among the multiple roles any teacher is required to play in the classroom is an individual with the high level of proficiency, strong and updated tools, and information necessary to empower learners in different levels . One of Professional identity can be considered as an important dimension of teachers’ characteristic, which has to be developed in a long, continuous, and ongoing process, and usually happens in contextual settings. The connection between professional identity and some personality and contextual factors has been found by Among the factors, which highly influence forming beliefs, professional images, knowledge, and skills, previous and current experiences are of high priorities. All of these factors can be developed, challenged, and changed during university studies and respective field practice. As one of the psychological factors affecting teacher identity, it is possible to mention teacher attributional style (TAS) . SeligmaRegarding the role of gender, The present investigation aimed to explore the relationship between the professional identity of Iranian English as foreign language (EFL) teachers and their AS and compared experienced and novice teachers in shaping their professional identity and sought to find the answers of these research questions:1: Is there any significant relationship between the professional identity of Iranian EFL teachers and their AS?Q2: Is there any significant difference between experienced and novice teachers’ professional identity regarding their AS?QIdentity as a general term defined by In the field of EFL/english as a foreign language (ESL) education, the subject of teacher identity is considered as a crucial factor affecting their performance and consequently receive and attract the attention of numerous prominent researchers . Moreove“Incorporates the cognitive, the emotional, the bodily, and the creative, such that to not allow (pre-service) student to talk about such issues, to not teach them how and why such issues are important to their teaching lives, to not give them the opportunity to speak and take the time to hear them are doing pre-service teachers and in-service teachers a disservice—we are leaving out, we are forgetting or choosing to forget, an important (if not the most important) part of being a teacher: the teacher identity.”Even so, the development of teacher identity has been seen, at best, as a by-product of teacher education programs rather than as a targeted outcome , and thiAlthough it is a dominant belief that roles are externally shaped by others’ expectations, In conclusion, personal and social identities are simultaneously considered as both integrated and separated issues. it seems unlikely that the core of the personal will not impact the core of the professional”  and social  by any teacher . To highTeacher professional identity in the Iranian context has been extensively researched regarding germane variables by means of different designs . The rolThe most agreed definition of AS is provided by The recent investigations of positive psychology in second language acquisition (SLA)  have rooTo calculate the population of Iranian EFL teachers for selecting the participants, the researchers estimated the total number of EFL teachers from the head offices of more than 10 provinces as 13,000. The proper number of participants for valid generalization of the results was calculated as 380 teachers teaching in different cities of all provinces of Iran, such as Khorasan Razavi, Tehran, Fars, East Azerbaijan, Lorestan, and Boushehr, teaching in junior and senior high schools. They were in different age range (22–47), selected regardless of their gender with academic degrees from AD to Ph.D., and they taught English at different levels with different proficiency and performance. They spoke Turkish as their native language in West and East Azerbaijan and Ardebil and the rest spoke Farsi as their first language.A highly demanding questionnaire in the realm of personality traits has been proposed, developed, and validated by a team of researchers  to measuTo measure Iranian EFL teachers’ index of professional identity, the researchers employed a TPI questionnaire, which has been first developed and validated by ASQ (t-test.Along with many problems of the pandemic of the Coronavirus Disease-2019 (COVID-19) virus all over the world, there was a big limitation for collecting the data by attending, visiting, and having face-to-face interaction for most of the research in education. To avoid the danger of infection, the TPI and AS questionnaires were converted to Google forms, and the links of the questionnaires were sent to EFL teachers in different provinces of Iran. At the beginning of the questionnaires, the explanations of the research aim and scope accompanied with the demographic information items of the respondents, such as their age, gender, academic degree, and years of teaching experience, were presented. The ASQ  was sentASQ . CollectTwo major variables of the present study were TPI and their AS, thus the design of the present study was a correlational design to measure their relationship. Moreover, this research sought to investigate the differences between the professional identity of Iranian EFL novice and experienced teachers. Since the purpose was to find the difference, independent samples tests were also used.t-test was run. The following presents the tables and descriptions for data analysis.Before analyzing the collected data to answer the research questions, the researchers measured the reliability indices of both questionnaires by running Cronbach’s alpha. Moreover, a Kolmogorov-Smirnov test was performed to measure the normality of data distribution. In order to answer the first research question, a Spearman correlation coefficient  was calculated. The main concern of the second research question was to compare TPI of novice and experienced teachers, thus, an independent samples One of the problems each researcher may face with every set of data is to have unengaged participants who carelessly answered the items with marking only one option for all items. To clean the data, the answers provided by these participants should be removed. After cleaning the data collected from 317 participants who returned the questionnaires, the answers of 40 participants were removed and 277 teachers were kept in the study. It is worth mentioning that one of the reasons why this happened to AS questionnaire could be the number of items (36). As mentioned above, since the data were not normal, the researcher analyzed the data non-parametrically. t-test was run. The results of the germane analyses were shown in the following tables:The second research question deals with the possible significant difference between novice and experienced teachers regarding their professional identity. To answer this question, teachers were grouped based on their years of teaching experience. The first group was composed of those teachers with more than 5 years of teaching experience (labeled as experienced), and the second group was composed of those teachers with less than 5 years of teaching experience (labeled as a novice). In order to compare teachers’ professional identity based on their teaching experience, an independent sample N = 178, 99) teachers’ data of their professional identity. Moreover, their mean scores on the TPI questionnaire , their SDs = 8.04, 11.76 were shown.t-test is to check the value of p. The results of the F-test determined whether to use the equal variances assumed rows or the equal variances not assumed rows in evaluating the t statistic. Since the significance level (Sig. = 0.000) for the F-value is less than 0.05, thus, the variances of the two groups are not equal, and therefore, the output in the equal variances not assumed row should be used. The results of t(149) = 12.02, p = 0.000. That is, the average performance score of experienced teachers  was significantly different from that of novice teachers .The prerequisite for considering the output of data in the independent sample The main purpose of this study was to explore the relationship between Iranian EFL teachers’ ASs and their professional identity. Moreover, the researchers aimed to compare the novice and experienced teachers’ professional identity. The results obtained from the correlational analysis revealed that there is a positive (0.12) and significant (0.04) relationship between teachers’ ASs and their professional identity. The history of TPI studies shows that it has been researched from various angles considering dimensions related to personal and educational factors, such as motivation and autonomy , goal orThe results of this study are in line with a similar study in the Iranian context conducted by The other variable investigated in this study was years of teaching experience. Novice and experienced teachers were compared in terms of their TPI index and the results revealed that experienced teachers enjoyed a higher index of TPI. The impact of experience has been investigated in many studies about teachers, such as teaching quality ; teacherThe main concern of the first research question was to investigate the relationship between teachers’ ASs and their professional identity, and the results of the Spearman index revealed a positive and significant relationship between teachers’ ASs and their professional identity. Identity construction in a specific profession needs to create a self-image, which is personally constructed and socially co-constructed. This can be achieved through the early stages of teacher education and developed through teaching empowerment courses. The undeniable role of teachers in shaping the future of the society suggests that TPI construction should be assessed continuously, which helps teacher educators design materials in harmony with their needs in teacher education programs and update their demands based on the twenty-first century principles . Developt-test were shown that experienced teachers enjoy a higher index of TPI. It can be concluded that teachers construct and reconstruct their TPI through the years of teaching experience. The mixed findings of studies about teaching experience suggest that pre-service teachers need education in the realm of the positive and negative psychological  factors for constructing and shaping their identity to have adequate readiness for the real classes. This can be operationalized in having classes with experienced teachers to help novice ones to understand challenging circumstances to decide what factors can be beneficial for learners to look upon. They can also give novice teachers insights about how they can analyze events in the real classes and overcome probable difficulties.The second research question dealt with the impact of experience on Iranian EFL teachers’ professional identity. The results of the independent samples The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study.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.


During brain tumor resection surgery, it is essential to determine the tumor borders as the extent of resection is important for post-operative patient survival. The current process of removing a tissue sample for frozen section analysis has several shortcomings that might be overcome by confocal laser endomicroscopy (CLE). CLE is a promising new technology enabling the digital in vivo visualization of tissue structures in near real-time. Research on the socio-organizational impact of introducing this new methodology to routine care in neurosurgery and neuropathology is scarce. We analyzed a potential clinical workflow employing CLE by comparing it to the current process. Additionally, a small expert survey was conducted to collect data on the opinion of clinical staff working with CLE. While CLE can contribute to a workload reduction for neuropathologists and enable a shorter process and a more efficient use of resources, the effort for neurosurgeons and surgery assistants might increase. Experts agree that CLE offers huge potential for better diagnosis and therapy but also see challenges, especially due to the current state of experimental use, including a risk for misinterpretations and the need for special training. Future studies will show whether CLE can become part of routine care. In brain tumor surgery, the extent of resection is essential for post-operative patient recovery and survival ,2,3. To However, the described process has several disadvantages. As it is an invasive method, usually only one sample is removed and analyzed. Additionally, damage to the brain tissue is possible. Preparing and freezing the tissue sample in the lab can change or destroy structures which are important for diagnosis. Additionally, it can take up to 45 min until the results are ready and can be communicated to the neurosurgeon ,4,6.The last couple of years have seen the emergence of a new technology that has the potential to digitize and improve intraoperative tissue analysis and decision making. Confocal laser endomicroscopy (CLE) is a promising digital biopsy approach using a high-resolution microscope located in a handheld probe. By placing the probe directly on the surgical site, tissue structures can be visualized in vivo in near real-time . The proSeveral CLE devices from different manufacturers and optimized for different medical fields are available on the market. In neurosurgery, the technology is still in an experimental phase and not yet part of the current treatment regime. In order to introduce this promising technology into daily routine, it is essential to properly understand the underlying clinical processes . As statRQ1: What could a workflow employing CLE in neurosurgery look like compared to the current clinical process analyzing frozen sections?RQ2: What are the opinions of clinical staff working with CLE regarding its socio-organizational aspects?®, a second-generation CLE device optimized for neurosurgery that has been on the market since 2018. The intraoperative use of this device has been described in recent studies [To investigate the potential of CLE for neurosurgery and neuropathology and answer the research questions, we (1) modelled and analyzed the current process of frozen sections, (2) modelled a digital process visualizing the possible procedure with CLE, (3) compared both process models, and (4) conducted a survey among medical experts working with the new technology. Our study was conducted based on the ZEISS CONVIVO studies ,22. In 2 studies .The case of surgical brain tumor resection has been used as the basis for the process analysis. Both processes (current and CLE) were modelled using Business Process Model and Notation (BPMN 2.0), a high-level standard used to graphically document the steps in a workflow . BPMN isData collection for the current process of tissue diagnosis using frozen sections took place in a large clinic for maximum care located in Southern Germany. To model the process, non-structured expert interviews were conducted with two neuropathologists who guided the interviewer through the clinical and laboratory process. Additionally, observations and time measurements for the biopsy resection, the transport, and the frozen section analysis were conducted on site. To collect data and model the digitized process with CLE, engineers and project managers from the manufacturer of the microscope were interviewed. Additionally, presentation material, manuals, and other documents such as visual boards depicting the envisioned workflow were consulted. The resulting CLE model shows what the process could look like once CLE has been established. After introducing the experts to the BPMN syntax, both models were refined in several cycles to ensure accuracy and completeness.An online questionnaire was developed consisting of 16 questions in four sections: general information, work with the CLE device, opinion of the microscope, and biggest advantages/disadvantages. The questionnaire was written in German, and a translated version can be found in Two process models were created using the BPMN 2.0 notation, one depicting the current process of frozen section analysis and the other one visualizing a process using CLE. In the following section we present and describe collapsed and simplified versions of the process models. The process comparison is based on the detailed models, which can be found in the The process starts with the need for an intraoperative histology. Once the surgical site is prepared, the neurosurgeon takes a tissue sample, which is then sent to the neuropathology laboratory together with the request form including all necessary information via a tube system. At the reception, the request form is processed, and relevant information is added. A laboratory technician and the Jr. neuropathologist are informed, and the sample is transported to the laboratory. Macroscopic analysis is performed, and the first impressions are dictated by the Jr. neuropathologist, possibly supervised by a Sr. neuropathologist. After embedding and freezing, a laboratory technician prepares the frozen sections (slicing and staining with hematoxylin and eosin (HE)). After having checked the quality and potentially requested a new section, the microscopic analysis is performed by a Jr. neuropathologist alone or together with the Sr. neuropathologist. They record the results and report them back to the surgery room using a regular phone call. The final report is typed by the secretary a.In addition to modelling the process, the time needed for the analysis of frozen sections was measured. Three sections were timed separately: (1) the resection and packing of the biopsy, (2) the transport to the laboratory, and (3) the preparation of sections, analysis, and report of results. On average, 4:25 min were needed to extract and pack the biopsy (four measurements ranging from 2:28 to 6:52 min). For the tube transport, three measurements were taken, resulting in an average duration of 1:40 min. Four measurements were taken for the tasks conducted in the laboratory. The average duration was 11:57 min, with a range from 08:53 to 15:04 min. On average, 18:02 min passed from biopsy resection to the reception of results in this clinic.When working with the CLE device, the surgery assistant logs into the device and establishes a connection. Then, the case is created by importing data from a radiology system  or by entering the information manually. The neuropathologist or a team of neuropathologists receive a consultation request and the neuropathologist scheduled to participate in the surgery can log in to review the available patient information in an anonymized format. Once the live stream is established by the surgery assistant, different image capturing modi are available. A continuous audio communication can be made available via the traditional channels . Thus, the neurosurgeon and neuropathologist are able to cooperate and jointly assess the tumor region. Images that are considered important by the neuropathologist can be edited, annotated, and saved for the final report. While the surgery continues, the neuropathologist finishes entering the diagnostic information and selecting images. The final report is created automatically and can also be accessed by the neurosurgeon. After logging off, the device is cleaned by the surgery personnel b.In both processes, two parties are involved, the clinic for neurosurgery and the department of neuropathology. However, while the current process requires up to seven people , the digital process using the CLE device only requires three people . Different indicators comparing the two workflows are listed in Fifteen experts were contacted for the online survey of which twelve responded (80% response rate). The characteristics receiving the highest number of positive votes were usability, integration into daily routine, and patient safety (N = 10 each). The images provided by the CLE device were voted to be of medium quality by six people versus five who found them to be good. The tasks conducted with the device include patient education (N = 4), appointment planning (N = 4), preparation in the operating theatre room (N = 6), login (N = 6), preparation of the sterile scanner probe (N = 6), selection/alternation of the modus (N = 7), placement of the probe on the tissue (N = 6), interpretation of images (N = 4), editing the images (N = 4), logoff (N = 5), and cleaning (N = 2).Five participants  expressed an increase in their workload due to the use of the CLE device. They explained this with the fact that the methodology is currently used as an addition to the frozen section analysis, not as a replacement. Preparation, operation, and cleaning were mentioned as other reasons. However, nine experts (75%) think that the surgery time can be reduced once the device is used in standardized clinical routine.In general, the faster diagnosis and shortened surgery duration is the biggest advantage of CLE, mentioned by seven experts (58.3%), four of them neurosurgeons. This is followed by an improved diagnosis and resection when using the device. The training and experience needed to effectively use CLE are current disadvantages mentioned six times by neurosurgeons, neuropathologists, and medical students in even measure. The issue of user dependency was only mentioned by neurosurgeons. All advantages and disadvantages mentioned by the experts are listed in To our knowledge, this is the first study investigating the impact of CLE on the clinical workflow and staff in neuropathology and neurosurgery. Other studies have cursorily discussed potential implications of CLE for workflows and staff but have not explicitly analyzed these issues ,2,22,25.BPMN proved to be feasible to model and compare clinical processes. A clinical workflow relying on CLE in neurosurgery and neuropathology could be successfully represented. Several advantages have been shown. Particularly, administrative and laboratory staff in the neuropathology can be relieved. Neuropathologists benefit from a streamlined workflow without interruptions and the fact that they can conduct diagnoses remotely from their desk. Additionally, a continuous communication, directly involving both experts in the diagnosis and treatment process, is possible. The neuropathologist can provide guidance while images can be analyzed in real-time  . The teaMore than 80% of the interviewed experts were satisfied with the device, and no survey participant voiced general dissatisfaction. The potential to shorten surgery time from incision to closure and improvement of resection were confirmed. Our measurements resulted in an average time of approximately 18 min for the frozen sections (including biopsy resection and transport), other authors report average durations of 30 to 45 min ,5. LongeTen experts highlighted the need for training and experience for both the neurosurgeon and the neuropathologist before reliable diagnoses can be performed ,28. ImagThe use of CLE in clinical settings is still in a preliminary phase leaving many blank spots to be investigated further. Potentially groundbreaking for future clinical research and diagnostic is the chance to visualize live tumor cells with CLE. The realization of telepathology, or teleneuropathology, is another promising aspect associated with the implementation of CLE. As CLE produces digital images of tissue structures, remote analysis by neuropathologists from other clinics or laboratories is possible ,29. A smThis study has limitations. The experimental nature of CLE implementation limits the applicability of the results from this study. The current process for the analysis of frozen sections modelled here is based on the workflow in a German clinic. Even though the analysis of frozen sections is a standardized routine, the results might not be generalizable to other countries. The CLE device is stored in another room and needs to be transported to the operating theatre before performing the surgery and back again after surgery. These tasks are not represented in the model as both processes start with the intraoperative histopathological analysis to limit complexity. Additionally, an anesthetist administers NaF directly after the first incision. Albeit important for the tissue analysis, this task is negligible regarding the overall process complexity as the anesthetist is present during the entire surgery to monitor vital signs and narcosis. CLE is not yet integrated into standardized care, therefore the number of experts with experience using the methodology is limited. The results of the small sample included in this survey lack reliability. In light of other positive research results regarding the use of CLE in neuropathology and neurosurgery, this study provides additional confirmation for the potential of this methodology and presents a first insight into the socio-organizational consequences of CLE. Additionally, it can serve as the basis for future research, e.g., a thorough economic evaluation of CLE in the form of a dynamic investment calculation for the setting of neuropathology and neurosurgery.This study confirms the potential of CLE for the improvement of intraoperative tissue analysis and decision making in neurosurgery, specifically during brain tumor resection. The streamlining of processes, faster and better diagnosis and tumor resection, and workload relief for neuropathologists are some of the main advantages. Training experts to interpret CLE images will be of the utmost importance for an establishment of CLE. The results of future studies, in particular economic evaluation and larger clinical trials, will determine whether the technology can become part of standardized care. Many possible applications of CLE in clinical care have yet to be studied. The visualization and analysis of live cancer cells, telepathology, and the combination with deep learning methods hold large promise for the safe, effective, and efficient delivery of care in the future.


Information and communication technologies are tools that are able to support cognitive functions, monitor health and movements, provide reminders to maintain residual memory abilities, and promote social support, especially among patients with dementia. Among these technologies, embodied conversational agents (ECAs) are seen as screen-based entities designed to stimulate human face-to-face conversation skills, allowing for natural human-machine interaction. Unfortunately, the evidence that such agents deliver care benefits in supporting people affected by dementia and their caregivers has not yet been well studied. Therefore, research in this area is essential for the entire scientific community.This study aims to evaluate the usability and acceptability of the virtual agent Anne by people living with dementia. The study is also designed to assess the ability of target users to use the system independently and receive valuable information from it.We conducted a 4-week trial that involved 20 older adults living with dementia and 14 family caregivers in home environment settings in Italy. This study used a mixed methods approach, balancing quantitative and qualitative instruments to gather data from users. Telemetry data were also collected.Older users were particularly engaged in providing significant responses and participating in system improvements. Some of them clearly discussed how technical problems related to speech recognition had a negative impact on the intention to use, adaptiveness, usefulness, and trust. Moreover, the usability of the system achieved an encouraging score, and half of the sample recognized a role of the agent Anne. This study confirms that the quality of automatic speech recognition and synthesis is still a technical issue and has room for improvement, whereas the touch screen modality is almost stable and positively used by patients with dementia.This study demonstrated the ability of target users to use the system independently in their home environment; overall, the involved participants shared good engagement with the system, approaching the virtual agents as a companion able to support memory and enjoyment needs. Therefore, this research provides data that sustain the use of ECAs as future eHealth systems that are able to address the basic and higher-level needs of people living with dementia. This specific field of research is novel and poorly discussed in the scientific community. This could be because of its novelty, yet there is an urgent need to strengthen data, research, and innovation to accelerate the implementation of ECAs as a future method to offer nonpharmacological support to community-dwelling people with dementia. The aging population around the world is growing rapidly, and dementia, as an age-dependent condition , has becIn this scenario, information and communication technologies, especially touch screens, are seen as tools that can support cognitive functions, monitor health and movements, provide reminders to maintain residual memory abilities, promote social support, improve communication with caregivers, and provide useful information concerning health conditions .Among these technologies, embodied conversational agents (ECAs) or personal virtual assistants are seen as screen-based entities designed to stimulate human face-to-face conversational skills and thus allowing for natural human-machine interaction ,5. Unfora 5-year-old grandchild [These include a tool for real-time streaming to a television of a realistic female avatar, previously programmed by a caregiver . This avandchild . This syandchild -11, dispandchild . The chaAnne in home environment settings in Italy.All the examples mentioned above prove that the ECA research area in the eHealth sector is still immature , but thiThis study aims to evaluate the usability and acceptability of the ECA Anne by older adults living with dementia. The study is also designed to assess the ability of target users to use the system independently and receive valuable information from it.First, Anne was developed along the MyLifeMyWay project to enable seniors to live at home independently for as long as possible. The system was then adapted for seniors with forgetfulness, as is typical at the beginning of dementia, during the Living Well With Anne project.The virtual character works on a Surface Pro tablet with the Microsoft Windows 10 operating system. The following languages are currently available: Dutch, English, German, Italian, and French. Anne can support people with dementia in all aspects of daily life  and 2: cUsers can interact with Anne through 2 channels: (1) a visual and haptic channel, via a Material–user interface graphical user interface (looking at the screen and touching the screen) and (2) an acoustical channel, via a voice user interface (listening to the avatar’s voice and speaking to the avatar). Anne’s voice user interface consists of automated speech recognition and text-to-speech functions. The user can always select which channel to use; that is, all commands must be accessible through touch and speech. During the requirements analysis, the clinical staff involved in the project suggested a suitable target group for the system—active and independent users able to interact with the avatar, discuss their thoughts, and express their opinions about Anne and who are competent and able to answer the protocol used for gathering data before and after the trial. Moreover, for safety reasons, individuals in the advanced stage of dementia were excluded from this study because dramatic swings in mood and behavior can be frequent, and it is not predictable how they can react in front of an unknown virtual assistant .We enrolled 20 volunteers diagnosed with dementia in the study. Inclusion and exclusion criteria for enrollment have been presented in In total, 14 family caregivers  were involved in the study.This study was approved by the local ethics committee, and informed written consent was obtained from all subjects.Inclusion CriteriaAge of 65 years or olderLiving independentlyMini-Mental Status Examination  score beAbility to understand and sign the written informed consentExclusion CriteriaThe presence of at least one of the following criteria excluded the user from enrollment:Lack of written informed consentPresence of an unstable chronic condition, with a Mini-Mental Status Examination score <24Presence of severe physical illness or disabilities that could be aggravated through the use of AnneThe enrollment and recruitment strategy was implemented in the city of Ancona at the Neurology Unit of the National Institute of Health and Science on Aging . According to the Living Well With Anne project activities, a staff composed of 2 psychologists identified 25 eligible participants among those who had regular access to the Alzheimer daily center. Each participant was invited to test the virtual agent, Anne. The 20 users who voluntarily participated in the study and used the system were enrolled. Their caregivers were also invited to participate in the research. Five family members refused to participate in the study because of a lack of time and effort in providing care.The field trial ran for 4 weeks in participants’ homes. The entire study was managed by skilled personnel and researchers who ensured the supervision of tests and technical assistance during the period of interaction with the system. Each enrolled subject was introduced to Anne, received general training on its correct use, and returned home with a printed user manual with step-by-step instructions and a dedicated phone number to call in case of technical problems or doubts.This study used a mixed methods approach, balancing quantitative and qualitative instruments to gather data from users.Users responded to the following tests at the beginning and end of the 4 weeks of use:Quality of life in older adults with cognitive impairment  questionnaire ,19. The The Almere model , which iAt the end of the period, users also responded to the questionnaires below:The System Usability Scale (SUS) , a questThe closeness scale , which iSome unstructured short questions that were asked to users to record the general impression of the system  and the major discomfort issues perceived during the use period.Except for the closeness scale and unstructured short questions, family caregivers responded to the same scales. However, because of the overburden of caregivers, time-consuming qualitative data were not gathered from them.Each instrument was verbally administered in a face-to-face session by a trained psychologist who entered the response on a paper version of each instrument.During the 4 weeks of use, telemetry data were collected to track every event caused by an activity of the user on the tablet. Telemetry is the process of collecting data about remote objects and sending it to a computer electronically. These activities include clicks on the touch screen or voice interaction. Moreover, the used feature types such as games or medication reminders, were also recorded. All these activities were timestamped and therefore enabled a comprehensive analysis of the user’s behavior throughout time. Compared with surveys, this usage data is especially suited to detect problems and evaluate the status quo .Continuous variables were reported as mean and SD, whereas categorical variables were expressed as absolute numbers and percentages. The Almere model  was usedt tests were conducted to compare the acceptability of Anne by older adults and caregivers throughout time (pretest and posttest). Closeness and perceived relations were reported as absolute numbers and percentages. Finally, usability was measured with the SUS [Changing of the acceptance level from pretest to posttest for both users and caregivers were reported as mean and SD of each item of the Almere model. Two-tailed paired samples  the SUS , with itRecruitment began in October 2019, and the trial was initiated in December 2019. Enrollment was completed in January 2020. The sample of older adults comprised 20 users , of whom 30% (6/20) were male and 70% (14/20) were female. A large percentage of participants were married  with a medium or high level of education. Only 6 participants had previous experience using tablets for leisure activities. The caregivers  were proportionally male and female and had a medium or high level of education. The general quality of life was in between the fair and good perception and maintained this level during the 4 weeks of the study .P=.007) during the 4 weeks of use. Positive changes among constructs were observed for PENJ (P=.04) and SP (P<.001). Other constructs such as ATT, PAD and FC did not change or nearly changed during the period of use. In contrast, PU (P=.02) and trust registered a negative change during the time of use.As reported in P=.15), PAD (P=.02), PENJ (P=.005), perceived sociability (P=.005), PU (P<.001), and trust (P=.01).For informal caregivers, the constructs of anxiety, FC, SP, and PEOU did not change or nearly changed during interactions with Anne. The constructs that registered negative changes were ATT  or no overlap . Minor percentages are attributed to strong, equal, or little overlap .All participants successfully completed the SUS. The SUS is scored out of 100, with a higher score indicating greater perceived usability. Anne received a mean score of 67.1 among older adults and 71.4 among caregivers. Both scores were compared and interpreted considering the acceptable average value of 68 (SD 12.5), which was determined for a variety of products and tools, including websites and technologies, provided by Sauro and Lewis  after thSome discomfort issues related to the speech command were pointed out in the unstructured short questions asked to users:The speech command does not work well. Sometimes Anne answers other questions, and this is very frustrating, making me feel insecure. Maybe this is because of me as I have no tech skills.About the news service, a participant mentioned the following:Anne’s speech is poor, does not stop for punctuation when reading, always the same monotonous tone. Moreover, Anne only reads the title and it is not possible to listen to the full article.Medication and gaming functions were the most successful services:I often take it at the wrong time. I was very precise in my medicine intake thanks to Anna.I think that having an assistant who reminds me is a great help.The games help me keep my mind active.I used to play memory games and puzzles every night. I think it is perfect to stimulate my memory.Games helped me feel less lonely.In addition, caregivers also really appreciated these functions:I was glad to see my mother-in-law doing something new during the day.The general impression was good among older users:Anne kept me company when I was bored or alone.I enjoy talking to Anna. Every day I say ‘good morning, Anne.’When I was lonely, I used to talk to Anna.Most older adults perceived Anne as a friend  or did not perceive any role to attribute . The remaining 30% (4/14) perceived the ECA as an assistant  and secretary .When asked if Anne was seen as a way to improve their well-being, seniors responded positively , with a slight difference detected between male  and female  users. Among these users, the sense of well-being was related to the match with memory , ability to do things for fun , and mood . Female users mostly associated to the match with memory, whereas males identified a match with mood. The remaining 30% (6/17) did not find any connection between quality of life and Anne.Two distinct classes of events were established to meaningfully analyze telemetry data. Transition events describe events for navigating through Anne, which are mostly events caused by touching on the device’s touch screen, and target events that include using Anne’s actual features, such as reading the news and listening to the radio. Because of the similarity with the mouse navigation, a touch on the device’s touch screen is called a click in the sequel. Let us illustrate the target and transition events in a realistic example. A user would like to read a news article. Because he just started using Anne, he navigates by mistake to the game menu, realizes that and then navigates back to the main menu. Now, he navigates to the news menu and clicks on a news article that he intended to read. Each navigation caused a transition event as well as a click on the news article, resulting in 4 transition events and 1 target event. The number of transition events required to reach a target event depends on the target event itself. However, because of the user-friendliness of Anne, a target event usually requires only 1 to 2 transition events. Moreover, we see from the example how the distinction between transition and target events helps us assess the usability and learning effects of handling Anne.During the observed trial period, 20 users actively performed 93,299 events. The most popular feature was games , followed by medication (2205 events), news, and radio . The high number of events for games is because of Anne’s design. A new event is created every time a user starts, quits, and restarts a game. These user actions are rather common in a game, and consequently, game events were very common. Nevertheless, as previously mentioned, games were a very popular feature.From a telemetry perspective, the number of touch screen clicks before a target event can be seen as a measure of usability. Struggling users intuitively require many clicks because they try many different possibilities; hence, purposeful and quick handling is not possible. Furthermore, 80% (16/20) of the sample, that is, 16 users, only required one click on average for their target event. Thus, users seem to handle Anne very well.Usability also has an impact on user behavior throughout time. At the beginning, a user using a new device is in an exploratory period, trying out the many features and not knowing how to handle the device very well. After some time, a user masters use and knows exactly how to handle the device. Hence, actions become very efficient and purposeful, and the efficiency in handling the device increases meaningful use. This user journey was also detected in the case of Anne.As previously defined, transition events mainly consist of touch screen clicks and on comments provided by Anne. Thus, a large number of transition events indicate problems with handling Anne, whereas a large number of target events show actual increased purposeful activity and interest. To capture user behavior, we decomposed the active field trial time range into 4 periods. The first period lasted from day 1 to day 6, the second from day 7 to day 13, the fourth from day 14 to day 20, and the final period from day 21 to day 27. We then analyzed the number of target and transition events during these periods. As the number of users varied in these periods, the number of target and transition events was adjusted according to the respective number of users. The corresponding visualization is shown in In the first and second periods, the number of transition events was 767 and 639, respectively, whereas the number of target events was 562 and 928. In these periods, the number of transition events was comparatively high, whereas the number of target events was rather low. Consequently, user exploration took place during the first 2 periods; this contrasts with the 2 subsequent periods. In the third and fourth periods, the number of target events was 1098 and 1140, respectively, whereas the number of transition events was 404 and 444, respectively. Thus, we detected a sharp increase in target events and a decrease in transition events with time. Here, the users efficiently handled Anne and had many meaningful interactions, that is, target events.Using similar measures, weekly reports were automatically generated to summarize the usage and detect potential technical problems of users with Anne. For example, if a user stopped using Anne because he was overwhelmed. Caregivers could respond to these problems with suitable assistance and thus prevent users from becoming frustrated with Anne. This was especially helpful for the typology of users involved in this study.Voice interactions were also assessed. Compared with 853 successful voice interactions, users still preferred the touch screen in 55,442 cases to realize their purposes. Within voice interactions, users primarily preferred the feature news in 342 cases, followed by medication in 175 cases. Touchscreen interactions were dominantly used for game features, with 52,008 cases. For example, playing a puzzle or card game really requires touch screen interactions. In this context, voice interactions are inefficient and would be very unintuitive. As games were the most popular feature by far, this had a significant impact in favor of touch screen interactions. Another possible reason for the prevalence of touch screen interaction could be that users may not be natively familiar with such a new and innovative technology; in particular, if we consider the advanced age of users.Overall, participants involved in this study demonstrated a positive approach to Anne: after 4 weeks of use, they were less anxious about interaction with Anne and more skilled in basic functionalities, and half of them perceived a role for the ECA. None of the participants withdrew from the trial, and they all provided useful feedback to facilitate the understanding of the data gathered. On the basis of these findings, it was found that older users were particularly engaged in providing significant responses and participated in improving the system. Some of them clearly discussed how technical problems related to speech recognition had a negative impact on intention to use, adaptiveness, usefulness, and trust. This impact emerged from the qualitative data reporting discomfort issues related to speech commands. The innovative aspect of Anne, as well as of other ECAs, is that users can interact with the system through voice and by stimulating a more human-like interaction rather than just navigating with the touch screen. Unfortunately, our study confirms that the quality of automatic speech recognition and synthesis is still a technical issue and has room for improvement -11, wherDespite this issue, the closeness scale  analysisOur study recruited 20 users in the early stages of dementia who scored between 24 and 27 in the Mini-Mental State Examination , as the dementia-friendly versions of household gadgets) and tools promoting the self-management of health [It is well known that the abilities and needs of people with dementia and those who provide care for them change along the path defined by the progression of symptoms, as does the ability to cope with them. These changing needs also mean that some technologies will be more appropriate or effective at different stages of dementia . Most inf health . For peof health . MoreoveWe cannot achieve the challenge of targeting the disease process from its earliest stages without changing the way of thinking, feeling, and acting toward people living with dementia and their complex needs. Thus, the second challenge is to support people living with dementia in doing what they need and decide, recognizing their purpose, identity, and independence. The key point is to avoid any type of stereotype about the experience of living with dementia and the opportunities that ECAs could offer to really address individuals’ medical, cognitive, psychological, environmental, cultural, and social needs . AccordiOlder adults are bearers of value for the design of technologies and beneficiaries of such systems. If the meaningful engagement of patients with dementia is essential for setting the future of ECAs, the two challenges depend on how much researchers, medical scientists, technology developers, and social and business innovators are ready to agree on a common vision concerning healthy aging as the way of developing and maintaining functional ability enabling well-being in old age -36. In tLonger trials are needed to measure changes in user experience and familiarity with the system. This research focused on 4 weeks of interaction between 20 seniors with dementia and the agent Anne in a home setting. This framework is rare in ECA research, which mainly comprises studies on short-term interaction in a controlled environment  and smalThis study aimed to evaluate the usability and acceptance of the ECA Anne by people living with dementia. It demonstrated the ability of target users to use the system independently in their home environment and receive valuable information from it. Overall, participants shared good engagement with the system, approaching the virtual agents as a companion able to support memory and enjoyment needs. Therefore, this study provides evidence for using ECAs as future eHealth systems to address the basic and higher-level needs of people living with dementia. This specific field of research is novel and poorly discussed in the scientific community. This could be because of its novelty, yet there is an urgent need to strengthen data, research, and innovation to accelerate the implementation of ECAs as a future way of offering nonpharmacological support to community-dwelling people with dementia. In our vision, this primarily means collaboration among interdisciplinary research networks, medical scientists, technology developers, and social and business innovators and the direct engagement of older adults and their formal and informal caregivers. Furthermore, sharing the strengths and weaknesses of research is fundamental for building common knowledge from previous studies. In the midst of the COVID-19 pandemic, these key points could prove significant in improving health care services. eHealth technologies have considerable challenges to overcome, but the opportunity to increase the quality of services and access to health information for users can really make a difference in these times of the pandemic.